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OB/GYN Chief Clinical Consultant's Corner

Volume 3, No. 12, December 2005

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

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

**Routine screening for protein and glucose at each prenatal visit
should be abandoned**

#### From your colleagues: page 6 {#from-your-colleagues-page-6 .Style-Heading-4-+-Arial-14-pt-Underline}

Carolyn Aoyama

#### Breast cancer in Native American women treated at an urban-based Indian health center {#breast-cancer-in-native-american-women-treated-at-an-urban-based-indian-health-center .Style-Heading-4-+-Arial-14-pt-Underline}

Burt Attico:

Asian Descent: Diabetic Women Have High Rates of Adverse Pregnancy
Outcomes

Bonnie Bishop-Stark

How do you know when you have a false positive HIV test in pregnancy?

Terry Cullen

Northwest Portland Area Indian Health Board recruiting new EpiCenter
Director

Lani Desaulniers

5th International Workshop-Conference on Gestational Diabetes

Kate Landis

HPV and Cervical Cancer: Update on Prevention Strategies, is now
available on DVD

Leslie Randall

#### PHN visits, maternal EtoH use, and layers of clothing are important risk factors for SIDS among Northern Plains Indians {#phn-visits-maternal-etoh-use-and-layers-of-clothing-are-important-risk-factors-for-sids-among-northern-plains-indians .Style-Heading-4-+-Arial-14-pt-Underline}

Ty Reidhead

Updated and revised IHS Clinical Guidelines, IHS Clinical Forms, Patient
Education sites

Judy Thierry

-What a great library resource! ...and it is available to *ALL* ITU
staff for free

-Do you want to increase your funding for the care of children?

-MCH tribal epidemiology on WIC data

-Sudden Infant Death Syndrome (SIDS), Sudden Unexplained Death in
Childhood (SUDC)

-Upcoming Theme: Health Care Systems -- The Key to Complete Women's
Health Care

...and more

**Myra Tucker**

An invitation to Submit Manuscripts to the Maternal and Child Health
Journal

**Alan Waxman**

Vaccine prevents cervical cancer, Gardasil: Preliminary results 100%
effective

**Judy Whitecrane**

Teen Birth Rate Continues to Decline, but Slowly

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

##### Obstetrics: page 12

Paroxetine's pregnancy category changed from C to D

Do you work with a low HIV prevalence population? Here is a strategy to
keep it that way

Evidence-based surgery for cesarean delivery

Umbilical cord blood is a proven source of hematopoietic stem cells: You
can bank on it

#### Women with a prior cesarean should be offered VBAC, esp. with prior vaginal delivery  {#women-with-a-prior-cesarean-should-be-offered-vbac-esp.-with-prior-vaginal-delivery .Style-Heading-4-+-Arial-14-pt-Underline}

...and more

**Gynecology: page 20**

#### -Urinary incontinence: Familial association stronger than that of vaginal delivery {#urinary-incontinence-familial-association-stronger-than-that-of-vaginal-delivery .Style-Heading-4-+-Arial-14-pt-Underline}

-Handle abnormal Pap smears differently in adolescents

-Simplifying the Diagnosis of Bacterial Vaginosis

-Certain factors predict chronic pelvic pain after pelvic inflammatory
disease

#### -Uterine artery embolization: Low complication rate, reduced length stay {#uterine-artery-embolization-low-complication-rate-reduced-length-stay .Style-Heading-4-+-Arial-14-pt-Underline}

...and more

**Child Health: page 22**

-Two RCTs show promising results with hypothermia for neonatal
encephalopathy

-Guidelines for Identifying and Referring Persons with Fetal Alcohol
Syndrome

-National Conference on Juvenile Issues

-AAP Report on Assessment of Sexual Abuse in Children

-Heads Up: Concussion in High School Sports

...and more

**Chronic Illness and Disease: page 25**

-Quick Assessment of Literacy in Primary Care: The Newest Vital Sign

-Stroke preventive treatments are well understood and widely available:
Why isn't it used?

-USPHS Releases Updated Guidelines for Management of Occupational
Exposure to HIV

-Moderate Exercise Improves Breast Cancer Outcomes

-Management of Active Tuberculosis

...and more

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

##### American Family Physician

-Duration of Therapy for Women with Uncomplicated UTI: Cochrane Briefs

-Metformin Increases Fertility in Patients with PCOS

American College of Obstetricians and Gynecologists

-Intrapartum fetal heart rate monitoring. ACOG Practice Bulletin

-Inappropriate use of the terms fetal distress and birth asphyxia

-Vaginal Birth Not Associated With Incontinence Later in Life

-Update on Carrier Screening for Cystic Fibrosis: Committee Opinion

**Agency for Healthcare Research and Quality**

-Two American Indian tribes with different rates of smoking, but
similarly high life traumas

-Shortage of radiologists and certified mammography technologists in
U.S. communities

**Ask a Librarian**

Obesity Before Pregnancy Linked to Childhood Weight Problems

**Breastfeeding**

-New studies shows a 15% reduction for the risk of diabetes for every
year of lactation

-Infant feeding choice collection tool

-Women in the US Need More Breastfeeding Support

**CCC Corner Digest**

\-[Evidence does not justify routine use: Magnesium sulfate
prophylaxis - mild
pre-eclampsia](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_AOM.cfm)

\-[Medical Staff Credentialing and Privileging Guide, 3rd Edition: Now
available](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Coll.cfm)

\-[Two handy 'Best Practice' checklists now available: DM or HTN in
pregnancy](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_HT.cfm#ob)

\-[Have you ever had problems with a stenotic cervix? Here's an easy
solution](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_HT.cfm#gyn)

\-[Advanced skills practitioner not needed at uncomplicated elective
cesarean
delivery](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_HT.cfm#child)

\-[Beyond Red Lake - The persistent crisis in American Indian Health
Care](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_HT.cfm#chrIll)

\-[Low Testosterone Not Linked with Female Sexual
Dysfunction](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Feat.cfm#afp)

\-[USPSTF Releases Updated Guide to Clinical Preventive
Services](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Feat.cfm#ahrq)

\-[Exciting news: All clinicians involved with Indian Health are now
invited: Tribal, urban,
etc..](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Feat.cfm#AskLib)

\-[We need your expertise: Breast Feeding Best Practices in Indian
Country](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Feat.cfm#breast)

\-[FDA Updates Labeling for Ortho Evra Contraceptive
Patch](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Feat.cfm#fp)

\-[DMPA bone mass loss is
reversible](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Feat.cfm#fp)

\-[The HCG curve has been redefined. How about
ultrasound?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Feat.cfm#mmtour)

\-[Bioidentical Hormones: No scientific evidence to support claims of
increased
efficacy](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Feat.cfm#mscape)

\-[Trends in umbilical cord care: Scientific Evidence for
Practice](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Feat.cfm#MidWives)

\-[Once a day gentamicin dosing intrapartum may provide better coverage
for the
fetus ](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Feat.cfm#navajo)

\-[Stressful workplaces and unfair bosses can raise cardiac
risks](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Feat.cfm#nurseCorner)

\-[Shoulder
dystocia](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Feat.cfm#okie)

\-[Many new additions to the Indian Health Guidelines / Patient
Education web
page](http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-guidesA-Z.cfm)

\-[Estrogen supplementation may be protective of BMD in adolescents who
use
DMPA](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Feat.cfm#oste)

\-[Medical Management of Early Pregnancy Failure -- Use
Misoprostol](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Feat.cfm#periPicks)

\-[Daily suppressive therapy is recommended for HSV-2 seropositive
individuals](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Feat.cfm#std)

\-[Just an additional 3200 steps a day, not 10,000 shows fitness
gains](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Feat.cfm#stillW)

**Domestic Violence**

-"Dating & Violence Should Never Be a Couple" Preventing Teen Dating
Violence

-Funding for Legal Services to Victims of DV, Sexual Assault, Stalking &
Dating Violence

-Project about Adult Native American and Alaska Native Women and Sexual
Assault

**Elder Care News**

-Women with DM had about 25% higher prevalence of incontinence

-Treatment of Constipation in Older Adults

-Older Patients with Caregivers and Assistance for Activities of Daily
Living: 1998 and 2000

**Family Planning**

-Women who attend a postpartum visit 3x more likely to use postpartum
contraception

-Ortho Evra Contraceptive Patch Linked to Increased Estrogen Exposure

**Featured Website**

The Indian Health Women's Health pages are getting a facelift and needs
input

**Frequently asked questions**

Should we perform a routine urine screen at each prenatal visit?

**Indian Child Health Notes**

-Antibiotics: Everyone says there overused in America: strep throat
infections, otitis media

-Dr Singelton: Prevnar vaccine may increase of non vaccine serotypes of
Strep pneumoniae

-Dr.Esposito: MVA rates in AI/ANs and increased risk of retinopathy of
prematurity in AI/AN

**Information Technology**

National Release Notice - Clinical Reporting System, Version 6.0

International Health

Cross-Cultural Medicine

#### MCH Alert

New cigarettes with flavors that appeal to youth

#### Medical Mystery Tour

#### I feel really cold and my side hurts, plus I am shaking all over {#i-feel-really-cold-and-my-side-hurts-plus-i-am-shaking-all-over .Style-Heading-4-+-Arial-14-pt-Underline}

#### Medscape

**Menopause Management**

-WHI clinical trial revisit: imprecise methodology disqualifies the
study\'s outcomes

#### -WHI response to Ostrzenski and Ostrzenska {#whi-response-to-ostrzenski-and-ostrzenska .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Mechanisms of Premature Menopause {#mechanisms-of-premature-menopause .Style-Heading-4-+-Arial-14-pt-Underline}

**Midwives Corner**

-Liability in Triage: Management of EMTALA Regulations and Common
Obstetric Risks

-Post Partum Hemorrhage is the most common cause of maternal mortality
worldwide

-Motherhood a \"rite of passage\" for some teens

-A trial should focus on women at low risk for failed trial or uterine
rupture and should not be

limited to a restrictive evaluation of short-term complications

-Midwifery Measures in Stage Two: Reduction of Genital Tract Trauma at
Birth

**Navajo News**

MRSA presents new challenges in treating soft-tissue infections,
including in pregnancy

**Nurses Corner**

#### Seeking Executive Nurse Leaders  {#seeking-executive-nurse-leaders .Style-Heading-4-+-Arial-14-pt-Underline}

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

Cigarette Smoking in the United States, 2004

**Oklahoma Perspective**

-Who do you contact in Oklahoma for MCH issues?

Osteoporosis

Screening and treatment for osteoporosis low among patients taking
glucocorticoids

Patient Education

-FDA Patient Education page- paroxetine changed for Class C to Class D

-The Eagle's Nest: Safe (online) place for youth to learn more about
living healthy with DM

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

#### -Taking Care of Yourself After Having a Baby {#taking-care-of-yourself-after-having-a-baby .Style-Heading-4-+-Arial-14-pt-Underline}

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

Perinatology Picks

-Meconium Happens

#### -Since the amnio is immature today, should we re-tap in a week or just deliver then? {#since-the-amnio-is-immature-today-should-we-re-tap-in-a-week-or-just-deliver-then .Style-Heading-4-+-Arial-14-pt-Underline}

Primary Care Discussion Forum

Cardiology Topics for Primary Care Providers -- February 15, 2006

STD Corner

## -High-Risk HPV Associated with Chlamydia trachomatis with Female Adolescents 

#### -Financial support for I/T/U staff to attend STD/HIV training in FY2006 {#financial-support-for-itu-staff-to-attend-stdhiv-training-in-fy2006 .Style-Heading-4-+-Arial-14-pt-Underline}

-Screening for HIV: Recommendation Statement USPSTF

-HIV-Prevention Research in Minority Communities Program Accepting
Applications

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

-Type 2 diabetes mortality in women: Same as a \"coronary heart disease
equivalent\"

-Homocysteine: Risk factor for the development of diabetes in women with
previous GDM

-Protein and Unsaturated Fats Lowers BP, Improves Lipids, and May Reduce
CVD

-Glycemic Index online

###### Save the Dates: Upcoming events of interest page 46

#### What's new on the ITU MCH web pages page 47

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

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

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

**Routine screening for protein and glucose at each prenatal visit
should be abandoned**

OBJECTIVE: More than 22 million prenatal visits occur in the US each
year. Each pregnant woman averages 7 visits. Most include urine testing
for glucose and protein to screen for gestational diabetes and
preeclampsia. Is there sufficient scientific evidence to support this
routine practice?

METHODS: We searched Medline (1966-2004), the Cochrane review, AHRQ
National Guideline Clearinghouse, the Institute for Clinical Systems
Improvement, and Google, searching for studies on proteinuria or
glycosuria in pregnancy. The reference list of each article reviewed was
examined for additional studies, but none were identified. We found 6
studies investigating glycosuria as a predictor for gestational diabetes
mellitus, or proteinuria as a predictor for preeclampsia (1 examined
both). Because every study used different dipstick methods of
determining results, or definitions of abnormal, each was evaluated
separately.

RESULTS: Glycosuria is found at some point in about 50% of pregnant
women; it is believed to be due to an increased glomerular filtration
rate. The renal threshold for glucose is highly variable and may lead to
a positive test result for glycosuria despite normal blood sugar. High
intake of ascorbic acid or high urinary ketone levels may result in
false-positive results. Four published studies assessed the value of
glycosuria as a screen for gestational diabetes. All used urine
dipsticks. Three of the 4 most likely overestimate the sensitivity of
glycosuria for predicting gestational diabetes.

CONCLUSIONS: Routine dipstick screening for protein and glucose at each
prenatal visit should be abandoned. Women who are known or perceived to
be at high risk for gestational diabetes or preeclampsia should continue
to be monitored closely at the discretion of their clinician.

[Alto
WA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Alto+WA"%5BAuthor%5D)
No need for glycosuria / proteinuria screen in pregnant women. [J Fam
Pract.](javascript:AL_get(this, 'jour', 'J Fam Pract.');) 2005
Nov;54(11):978-83.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16266604&query_hl=1>

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

**Routine screening at each prenatal visit should be abandoned**

Routine urine screening is both insensitive and non-specific in
screening for pre-eclampsia, diabetes, and asymptomatic UTI. Routine
prenatal urine is a needless drain on clinic resources and is not a
value added procedure.

ACOG does not recommend routine urine dipstick screening because it is
not "reliable and cost-effective" (ACOG Practice Bulletin No. 33)

***Are there effective methods for identifying women at risk for
preeclampsia?***

No single screening test for preeclampsia has been found to be reliable
and cost-effective. Uric acid is one of the most commonly used tests but
it has a positive predictive value of only 33% and has not proved useful
in predicting preeclampsia. Doppler velocimetry of the uterine arteries
was reported not to be a useful test for screening pregnant women at low
risk for preeclampsia . "

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

Practitioners should be aware that although various laboratory tests may
be useful in the management of women with preeclampsia, to date there is
no reliable predictive test for preeclampsia.

## Screening for Pre-clampsia

-Screening for preeclampsia is recommended for all pregnant women at the
first prenatal

visit and throughout the remainder of pregnancy.

-To screen for preeclampsia, measure an upright sitting blood pressure
after a 10 minute rest. The BP should be repeated in a similar manner
4-6 hours later to confirm the diagnosis.

**[Gestational diabetes]{.underline}**

Although measuring urine glucose may be much easier than measuring blood
glucose, it has potential errors that limit its accuracy as a reflection
of glycemic control and is rarely used. Detection of glucose on a
semi-quantitative urine dipstick (anything regarded as trace positive or
more) or Clinitest tablets is a fairly specific but insensitive means of
screening for type 2 diabetes. The high rate of false-negative results
suggests that the urine dipstick is not adequate as a screening test.

**[Asymptomatic urine infections]{.underline}**

Screening for asymptomatic bacteriuria is standard practice at the
[first]{.underline} prenatal visit. Re-screening is generally not
performed in low risk women, but can be considered in women at high risk
for infection (e.g., presence of urinary tract anomalies, hemoglobin S,
or preterm labor).

**What should you perform urinalysis in pregnancy for?**

It is reasonable to perform prenatal urine testing in these cases

-BP greater then 140/90 mm Hg or mean arterial pressure greater than 105
mm Hg

-Symptoms of pre-eclampsia

-Multiple gestation

-Symptoms of UTI

-Chronic hypertension by history or currently on hypertension medication

More resources available:
<http://www.ihs.gov/MedicalPrograms/MCH/M/UVfaqs.cfm#urineScreen>

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

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

#### Breast cancer in Native American women treated at an urban-based Indian health center {#breast-cancer-in-native-american-women-treated-at-an-urban-based-indian-health-center-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### BACKGROUND: Breast cancer incidence and survival varies by race and ethnicity. There are limited data regarding breast cancer in Native American women. METHODS: A retrospective chart review was performed of 139 women diagnosed with breast cancer and treated at Phoenix Indian Medical Center in Phoenix, AZ between January 1, 1982 and December 31, 2003. Data points included tribal affiliation, and quantum (percentage American Indian Heritage) along with patient, tumor, and treatment characteristics. RESULTS: Most patients (79%) presented initially with physical symptoms. There were no significant differences based on tribal affiliation; however, higher quantum predicted both larger tumor size and more advanced stage at diagnosis. Obesity also significantly correlated with larger tumor size and more advanced stage. Treatment was inadequate in 21%; this was attributed to traditional beliefs, patient refusal, or financial issues. CONCLUSIONS: When compared to national averages, Native American women presented at a later stage, underutilized screening, and had greater delays to treatment. {#background-breast-cancer-incidence-and-survival-varies-by-race-and-ethnicity.-there-are-limited-data-regarding-breast-cancer-in-native-american-women.-methods-a-retrospective-chart-review-was-performed-of-139-women-diagnosed-with-breast-cancer-and-treated-at-phoenix-indian-medical-center-in-phoenix-az-between-january-1-1982-and-december-31-2003.-data-points-included-tribal-affiliation-and-quantum-percentage-american-indian-heritage-along-with-patient-tumor-and-treatment-characteristics.-results-most-patients-79-presented-initially-with-physical-symptoms.-there-were-no-significant-differences-based-on-tribal-affiliation-however-higher-quantum-predicted-both-larger-tumor-size-and-more-advanced-stage-at-diagnosis.-obesity-also-significantly-correlated-with-larger-tumor-size-and-more-advanced-stage.-treatment-was-inadequate-in-21-this-was-attributed-to-traditional-beliefs-patient-refusal-or-financial-issues.-conclusions-when-compared-to-national-averages-native-american-women-presented-at-a-later-stage-underutilized-screening-and-had-greater-delays-to-treatment. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**Tillman L**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Tillman+L"%5BAuthor%5D), et al Breast cancer in Native American women treated at an urban-based indian health referral center 1982-2003. [**Am J Surg.**](javascript:AL_get(this, 'jour', 'Am J Surg.');) 2006 Dec;190(6):895-902. [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16307942&query_hl=1**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16307942&query_hl=1) {#tillman-l-et-al-breast-cancer-in-native-american-women-treated-at-an-urban-based-indian-health-referral-center-1982-2003.-am-j-surg.-2006-dec1906895-902.-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids16307942query_hl1 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Burt Attico, Phoenix {#burt-attico-phoenix .Style-Heading-4-+-Arial-14-pt-Underline}

**Asian Descent: Diabetic Women Have High Rates of Adverse Pregnancy
Outcomes**

CONCLUSION: Ethnicity has a significant impact on the outcome of
diabetic pregnancies, with worse outcomes for babies born to Asian
mothers compared with Caucasian mothers. The use of insulin
pre-pregnancy rather than type of diabetes appears to predict adverse
outcome.

[Verheijen
EC](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Verheijen+EC"%5BAuthor%5D),
et al Outcomes of pregnancies in women with pre-existing type 1 or type
2 diabetes, in an ethnically mixed population.
[BJOG.](javascript:AL_get(this, 'jour', 'BJOG.');) 2005
Nov;112(11):1500-3.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16225569&query_hl=15>

**Bonnie Bishop-Stark, ANMC**

**How do you know when you have a false positive HIV test in
pregnancy?**

Bonnie asked that question to the ANMC HIV Program Director.

**Q.** I am requesting your input regarding a prenatal patient who has a
positive HIV screen and positive Western blot (weakly positive P55) and
a HIV viral load of \<75. The first test results were done at 18 weeks
and were repeated 23 weeks. We are still waiting on the Western blot
repeat but she continues to be HIV screen positive and her viral load
continues \<75. The patient states her partner has tested negative.

**A.** Here is an explanation for what we see on Western Blot:

The pattern of antibodies to the different viral protein bands provides
useful diagnostic information. Antibodies to the HIV-1 major group
specific antigen (Gag) protein, p24, and its precursor, p55, are the
first to appear, but their levels decline during the later course of
infection.

There can be cross-reacting alloantibodies from pregnancy. Antibodies to
the envelope (Env) precursor protein, gp160, and the final Env proteins,
gp120 and gp41, are present throughout the course of disease. Antibodies
to the polymerase (Pol) gene products---p31, p51, and p66---are also
used.

To diagnose HIV, the Western Blot needs to have a combination of p24 and
p31 with gp41 or gp 120/160.  So, this is likely a false positive,
especially having been unchanged over a one month period with an
undetectable viral load.  Reassurance and a recheck at the beginning of
the 3^rd^ trimester and in 6 months thereafter would be a fine plan.

**Resources**

**H.I.V. Infection in Pregnancy, IHS C.E.U./C.M.E. Module**

<http://www.ihs.gov/MedicalPrograms/MCH/M/HV01.cfm>

**Primary HIV-1 infection: Diagnosis and treatment, UpToDate**

<http://www.uptodateonline.com/application/topic.asp?file=hiv_infe/17081&type=A&selectedTitle=4~577>

**Women's Health HIV / AIDS web page**

<http://www.ihs.gov/MedicalPrograms/MCH/W/WHhiv.asp>

**The Indian Health HIV Center of Excellence**

The HIV Center of Excellence (HIVCOE) is a clinically based center for
HIV care, treatment, research, and intervention. The center is an Indian
Health Service program at the Phoenix Indian Medical Center serving the
tribal and IHS facilities in the Area.

<http://www.ihs.gov/MedicalPrograms/aids/index.asp>

**AIDS*info*** is a U.S. Department of Health and Human Services (DHHS)
project that offers the latest federally approved information on
HIV/AIDS clinical research, treatment and prevention, and medical
practice guidelines for people living with HIV/AIDS, their families and
friends, health care providers, scientists, and researchers.

[Clinical Trials:]{.underline} AIDS*info* offers information on
federally and privately funded clinical trials for AIDS patients and
others infected with HIV. AIDS clinical trials evaluate experimental
drugs and other therapies for adults and children at all stages of HIV
infection \-- from patients who are HIV positive with no symptoms to
those with various symptoms of AIDS.

[Medical Guidelines:]{.underline} AIDS*info* serves as the main
dissemination point for federally approved HIV treatment and prevention
guidelines, AIDS*info* provides information about the current treatment
regimens for HIV infection and AIDS-related illnesses, including the
prevention of HIV transmission from occupational exposure and
mother-to-child transmission during pregnancy.

The AIDS*info* project is 100% federally funded. This project neither
allows advertising on this site nor endorses any company or products.\
All of the information from the AIDS*info* staff, Web site, and other
project resources is from federal government agencies, including the
National Institutes of Health, Centers for Disease Control and
Prevention (CDC), Health Resources and Services Administration (HRSA)
and others. <http://www.hivatis.org/>

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

**Northwest Portland Area Indian Health Board recruiting new EpiCenter
Director**

The Northwest Portland Area Indian Health Board is recruiting for an
Epidemiology Center Director. The position description is available.
Further information, including a downloadable (PDF or Word) application,
is available on the NPAIHB website:

<http://www.npaihb.org/Employment.htm>

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

#### Lani Desaulniers, ABQ {#lani-desaulniers-abq .Style-Heading-4-+-Arial-14-pt-Underline}

#### 5th International Workshop-Conference on Gestational Diabetes November 11-13, 2005 Chicago, Illinois {#th-international-workshop-conference-on-gestational-diabetes-november-11-13-2005-chicago-illinois .Style-Heading-4-+-Arial-14-pt-Underline}

#### Webcast of major elements: Management, physiology, post partum {#webcast-of-major-elements-management-physiology-post-partum .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://webcasts.prous.com/ADA2005%5FGDM/**](http://webcasts.prous.com/ADA2005_GDM/) {#httpwebcasts.prous.comada20055fgdm .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Kate Landis, ANMC {#kate-landis-anmc .Style-Heading-4-+-Arial-14-pt-Underline}

#### HPV and Cervical Cancer: Update on Prevention Strategies, is now available on DVD The CDC's Provider Webcast DVD includes a one-hour presentation and slide set, intended to increase provider knowledge of HPV and its clinical manifestations, and to update clinicians on strategies to prevent genital HPV infection and cervical cancer. Target audiences include obstetricians, gynecologists, physicians in family and general practice, general internists, advanced practice nurses, physician's assistants, and nurses. For free online ordering, visit  {#hpv-and-cervical-cancer-update-on-prevention-strategies-is-now-available-on-dvd-the-cdcs-provider-webcast-dvd-includes-a-one-hour-presentation-and-slide-set-intended-to-increase-provider-knowledge-of-hpv-and-its-clinical-manifestations-and-to-update-clinicians-on-strategies-to-prevent-genital-hpv-infection-and-cervical-cancer.-target-audiences-include-obstetricians-gynecologists-physicians-in-family-and-general-practice-general-internists-advanced-practice-nurses-physicians-assistants-and-nurses.-for-free-online-ordering-visit .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**https://www2.cdc.gov/nchstp_od/piweb/stdorderform.asp**](https://www2.cdc.gov/nchstp_od/piweb/stdorderform.asp) {#httpswww2.cdc.govnchstp_odpiwebstdorderform.asp .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Leslie Randall, Aberdeen {#leslie-randall-aberdeen .Style-Heading-4-+-Arial-14-pt-Underline}

#### PHN visits, maternal EtoH use, and layers of clothing are important risk factors for SIDS among Northern Plains Indians {#phn-visits-maternal-etoh-use-and-layers-of-clothing-are-important-risk-factors-for-sids-among-northern-plains-indians-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSIONS: Public health nurse visits, maternal alcohol use during the periconceptional period and first trimester, and layers of clothing are important risk factors for SIDS among Northern Plains Indians. Strengthening public health nurse visiting programs and programs to reduce alcohol consumption among women of childbearing age could potentially reduce the high rate of SIDS. [**Iyasu S**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Iyasu+S"%5BAuthor%5D), [**Randall LL**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Randall+LL"%5BAuthor%5D), et al Risk factors for sudden infant death syndrome among northern plains Indians. [**JAMA.**](javascript:AL_get(this, 'jour', 'JAMA.');) 2002 Dec 4;288(21):2717-23. [**http://www.ihs.gov/MedicalPrograms/MCH/M/Pr01.cfm#piRisks**](http://www.ihs.gov/MedicalPrograms/MCH/M/Pr01.cfm#piRisks) {#conclusions-public-health-nurse-visits-maternal-alcohol-use-during-the-periconceptional-period-and-first-trimester-and-layers-of-clothing-are-important-risk-factors-for-sids-among-northern-plains-indians.-strengthening-public-health-nurse-visiting-programs-and-programs-to-reduce-alcohol-consumption-among-women-of-childbearing-age-could-potentially-reduce-the-high-rate-of-sids.-iyasu-s-randall-ll-et-al-risk-factors-for-sudden-infant-death-syndrome-among-northern-plains-indians.-jama.-2002-dec-4288212717-23.-httpwww.ihs.govmedicalprogramsmchmpr01.cfmpirisks .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Charles (Ty) Reidhead, Whiteriver, Internal Medicine CCC {#charles-ty-reidhead-whiteriver-internal-medicine-ccc .Style-Heading-4-+-Arial-14-pt-Underline}

#### Updated and revised IHS Clinical Guidelines, IHS Clinical Forms, Patient Education sites {#updated-and-revised-ihs-clinical-guidelines-ihs-clinical-forms-patient-education-sites .Style-Heading-4-+-Arial-14-pt-Underline}

#### Ty has been updating and revising the IHS Clinical Guidelines, IHS Clinical Forms, Patient Education pages. Take a look. {#ty-has-been-updating-and-revising-the-ihs-clinical-guidelines-ihs-clinical-forms-patient-education-pages.-take-a-look. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [[http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-patEd.cfm]{.underline}](http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-patEd.cfm) {#httpwww.ihs.govnonmedicalprogramsnc4nc4-pated.cfm .Style-Heading-4-+-Arial-14-pt-Underline}

#### [[http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-forms.cfm]{.underline}](http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-forms.cfm) {#httpwww.ihs.govnonmedicalprogramsnc4nc4-forms.cfm .Style-Heading-4-+-Arial-14-pt-Underline}

#### [[http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-formsOrgSys.cfm]{.underline}](http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-formsOrgSys.cfm) {#httpwww.ihs.govnonmedicalprogramsnc4nc4-formsorgsys.cfm .Style-Heading-4-+-Arial-14-pt-Underline}

#### [[http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-patEd.cfm]{.underline}](http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-patEd.cfm) {#httpwww.ihs.govnonmedicalprogramsnc4nc4-pated.cfm-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [[http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-guidesA-Z.cfm]{.underline}](http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-guidesA-Z.cfm) {#httpwww.ihs.govnonmedicalprogramsnc4nc4-guidesa-z.cfm .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### [[http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-ihcgOrg.cfm]{.underline}](http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-ihcgOrg.cfm) {#httpwww.ihs.govnonmedicalprogramsnc4nc4-ihcgorg.cfm .Style-Heading-4-+-Arial-14-pt-Underline}

#### [[http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-guidesA-Z.cfm]{.underline}](http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-guidesA-Z.cfm) {#httpwww.ihs.govnonmedicalprogramsnc4nc4-guidesa-z.cfm-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### If you want other guidelines, forms, or patient education materials added, please let Ty know {#if-you-want-other-guidelines-forms-or-patient-education-materials-added-please-let-ty-know .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**Charles.Reidhead@ihs.gov**](mailto:Charles.Reidhead@ihs.gov) {#charles.reidheadihs.gov .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

**What a great library resource! ...and it is available to *ALL* ITU
staff for free**

Diane Cooper briefed the OCPS staff today and gave this tip:

If you are tribal you too can now access this web site.
[[http://hsrl.nihlibrary.nih.gov/]{.underline}](http://hsrl.nihlibrary.nih.gov/)

Contact Diane for a password and access to journal articles and
librarian services

<cooperd@ors.od.nih.gov>

**Do you want to increase your funding for the care of children?**

If you could please look at the National Children's Study web site and
the counties as to which counties you identify as having an AIAN
population and or ITU services. This will be helpful as we make a case
for support (\$) to assist in the enrollment eligible AIAN women, to
inform communities within and beyond these counties.
<http://www.nationalchildrensstudy.gov/about/locations/index.cfm>

<Judith.Thierry@ihs.gov>

**MCH tribal epidemiology on WIC data**

You are invited to discuss the progress of the IHS patient care
documentation or Pcc+ activity on infant feeding practices
documentation.

**888-677-1324 passcode 80603 - Wednesday January 18^th^ 4 pm ET.**

The DM breastfeeding best practices input has also widened the
discussion and I have added some members to the breastfeeding
distribution group because of this. Thank you for your input. I would
like to use the call to consolidate some of the discussion we have had
around these two activities.

In addition...!

The MCH tribal epidemiologists have been discussing WIC and data
collection. A separate call that you are free to join will take place on

**Wednesday, January 11^th^ at 2 pm ET 888-677-1324 - passcode: 94498**

Intertribal Council of Arizona will discuss their work along with CDC's
DNPA/MCNB Branch -- Dietetics Nutrition and Physical Activity
<Judith.Thierry@ihs.gov>

**Sudden Infant Death Syndrome (SIDS), Sudden Unexplained Death in
Childhood (SUDC)**

National Conference: February 23-26, 2006

Philadelphia, Pennsylvania. ** **

Parent track and Professional track\
The Caring Connection: Caring Today with Hope for Tomorrow, a 2006
National Conference dedicated to bringing together professionals and
families to address Sudden Infant Death Syndrome (SIDS), Sudden
Unexplained Death in Childhood (SUDC) and Sudden Unexpected Death in
Infancy (SUDI). Plenary sessions, workshop presentations, panel
discussions and other program activities will enable those in attendance
to gain the tools, skills and resources necessary to educate, advocate
and heal. CJ Foundation for SIDS, Inc & CMI Education Institute\
[[http://www.cjsids.com/]{.underline}](http://www.cjsids.com/)

**Upcoming Theme: Health Care Systems -- The Key to Complete Women's
Health Care**

As we are unfolding the new women's health package, DM best practices
around GDM and breastfeeding in Diabetics, there are complementary
health considerations that impact on women's health and inter-conception
care. Here is one example of a facility's comprehensive approach to
Women's Health:

At Chinle the Women\'s Health Coordinator\'s position was modified from
the original position created in 1998 to encompass an added clinical
role of a CNM or NP. It was determined that a person in the role who was
part of medical staff would have more \"clout\".

-I am the Women\'s Health Program Coordinator since April of 2002.

-I supervise a Registered Nurse High Risk OB Case manager, who works
closely with the OB/GYNs to manage all the patients whose pregnancies
are complicated by factors placing them in a higher risk category: DM
especially.

-Three staff of the Breast and Cervical Cancer Prevention Program, the
Case Manager, the Data Entry Clerk and the Health Educator.  This
Program is CDC Funded through the Navajo Nation Division of Health.  We
work with them through MOU.

 -All Breast Imaging, pathology and cytology reports, as well as all Pap
smear, Colposcopy, Cryo, Leep and endometrial Biopsy Reports are
maintained by WH Staff through the Women\'s Health Package.   

 -I am on site liaison (supervisor) for Navajo family Health Resource
Network Family Planning counselors.

 -I supervise the Women\'s Health Program Assistant, (secretarial,
administrative, and assistant case management work for the Breast Clinic
case load) 

 -My programs work closely with the newly created surgical case
management position (training that person to case manage the Breast
Clinic patients), radiology (for breast imaging), scheduling breast
clinic appointments, off site diagnostic procedures for abnormal breast
exams (clinical or imaging); medical and radio logic oncology.

 -As the Women\'s Health Coordinator I established the Chinle Breast
Cinic in 2002 with Women\'s Health Staff and a surgeon.  As WHC I
created the case management model for the Breast Clinic in
2002/2003.  The Breast Clinic is now managed by the Surgeons and the
Surgical Case Manager with the assistance of and coordination with
Women\'s Health Program staff and the Mammography Tech.

 -I lead the work of and Chair the Chinle Interpersonal Violence
Prevention Committee.  Chinle is one of the fifteen DV
Demonstration Pilot Project Sites of the IHS/ACF Grant.  This is
largely, coordination, staff training, policy creation and revision.

 -I am active in the GPRA Committee of Chinle Hospital, responsible for
the DV indicator and share responsibility for the other WH Indicators,
Pap, Mammogram, FAS and HIV screening.

 -I Co-Chaired the STD Task Force formed in 2002 in response to the
Syphilis epidemic.  However, we are now considering reincorporating this
work into the Infectious Disease/ Preventative Medicine office and
disbanding the STD Task Force. 

 -I started a weekly evening clinic for WH (OB and GYN) in October of
2002.  I also see the walk in patients Monday and Wednesday mornings. 
However, we have modified our scheduling capabilities with same day and
two day urgent appointments.  The numbers of \"walk ins\" has
diminished.

 -I have not done inpatient since 1/2002.  I miss it but am otherwise
busy.

 

Hope this is helpful.

Yohanah B. Leiva, CNM, MS

Women\'s Health Program Coordinator

Chinle IHS

928  674 7420 <yohanah.leiva@ihs.gov>

**HIV in New Mexico: Distribution of Reported AIDS Cases by
Race/Ethnicity, 2004**

This link opens to New Mexico stats but you can access all states and by
race.

[http://www.statehealthfacts.org/cgi-bin/healthfacts.cgi?action=profile&area=New+Mexico&category=HIV%2fAIDS&subcategory=Cumulative+AIDS+Cases&topic=Cumulative+AIDS+Cases+All+Ages+by+R%2fE](http://www.statehealthfacts.org/cgi-bin/healthfacts.cgi?action=profile&area=New+Mexico&category=HIV%2FAIDS&subcategory=Cumulative+AIDS+Cases&topic=Cumulative+AIDS+Cases+All+Ages+by+R%2FE)

**Myra Tucker, CDC**

**An invitation to Submit Manuscripts to the Maternal and Child Health
Journal**

Although research has documented substantial disparities in maternal and
infant outcomes between American Indians and Alaskan Natives and the
white population in the United States, knowledge is limited regarding
contributors to these disparities and, more importantly, public health
interventions that can eliminate them. Investigators who have conducted
research on these topics are invited to submit manuscripts for
consideration for a special, forthcoming supplemental issue of the **MCH
Journal**, titled "*Research for MCH Practice in American Indian and
Alaskan Native Communities*".

> **Manuscripts** may report epidemiologic studies, research on health
> services, intervention trials, and program evaluations.
>
> **Submissions** that are authored or co-authored by American Indians
> and Alaskan Natives are especially encouraged.

**A special Advisory Committee**, whose members are listed below, has
been convened to assist with review of submissions and the final
composition of the supplement.

Melissa Adams will serve as theme editor for the supplement.

**Submissions received by March 1, 2006** will have the greatest
likelihood of acceptance in this special supplement. Please follow the
[MCH Journal']{.underline}s instructions for authors and submit
manuscripts to the Editorial Manager
([https://maci.edmgr.com](https://maci.edmgr.com/) ). When submitting a
manuscript, include a cover letter stating your request for it to be
considered for the supplement.

**Prospective authors** are encouraged to consult Myra Tucker, associate
editor for the supplement, by email or telephone regarding their
submissions.<mjt2@cdc.gov> 770-488-6267

**Advisory Committee:**

George Brenneman, J. Chris Carey, Bette Keltner, Everett Rhoades

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

#### Alan Waxman, Albuquerque, Retired CCC OB/GYN {#alan-waxman-albuquerque-retired-ccc-obgyn .Style-Heading-4-+-Arial-14-pt-Underline}

**Vaccine prevents cervical cancer, Gardasil: Preliminary results 100%
effective**

I agree with Dr. Stoler\'s comments.\* There are several points that
deserve amplification. The vaccine will guard against HPV 16 and 18, but
not the other 13 known oncogenic HPV types. 'Having said that, HPV 16
and 18 account for the majority of cases of CIN 3 and cancer.

Screening with Pap or perhaps HPV will have to continue as a part of
women\'s health maintenance exams to detect dysplasia caused by the
other high-risk HPV types. We don\'t know whether dysplasia will become
less common after the vaccine or if the other HPV types might move in to
fill the void left by 16 and 18. We also don\'t know whether screening
recommendations will change as a result of the decrease in frequency of
HPV 16 and 18.

One of the public health uncertainties is how eagerly child health
providers will adopt an HPV immunization protocol - it will be one of
the more expensive vaccines, at least in the near future- or whether
parents of preadolescent children will go for the vaccine. As a
prophylactic vaccine it must be administered before the first encounter
with the virus which means before the first sexual encounter. As Stoler
says in his comments, we also don\'t know how long the immunization will
last. Currently at least one booster shot is recommended - and that will
probably be need before most young women begin to be sexually active.

The question of young women seeing the vaccine as permission to have sex
is a real issue among many of those speaking on behalf of various well
organized religious denominations. The fact that some see it as an issue
may decrease the acceptance of the vaccine among the parents of children
of the appropriate age for administration, around 9-11.

Dr. Stoler stressed the need for education, both to providers and
patients. Several groups including the American Society for Colposcopy
and Cervical Pathology (ASCCP) and the Digene corp., which markets the
HPV test, are developing \"Train the Trainers\" sessions to educate
health care providers about HPV and the vaccine. I suspect in the next
year, everyone reading this CCC will have the opportunity to attend an
HPV vaccine CME session.

I think the HPV vaccine will be a major contributor to reduction in
morbidity and mortality from cervical cancer, but most of the potential
for benefit will come in the developing world. The incidence and
mortality of cervical cancer in the U.S. is remarkably low thanks to the
last 50 years of Pap screening. 60 % of those getting cervical cancer in
the U.S. today have not availed themselves of regular Pap tests. It is
estimated that only about 5,000 new cases and 1600 deaths per year occur
among those who have had a Pap within the prior 5 years. This is a small
fraction of the more than 100 million women at risk. In many developing
countries, cervical cancer is the leading cause of cancer related death
in women. Pap tests are not feasible because of cost and logistics.
Other screening options are being looked at.

(See the editorial by Schiffman and Castle, plus the accompanying
article by Goldie et al NEJM, below).

In summary, if a vaccine could be made available cheaply enough it would
do wonders to decrease mortality from this disease.

Also see November CCC Corner

**Vaccine prevents cervical cancer, Gardasil: Preliminary results 100%
effective**

<http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_HT.cfm#gyn>

**Other**

**\*Human Papillomavirus Vaccine: A Newsmaker Interview With Mark H.
Stoler, MD**

[[http://www.medscape.com/viewarticle/514384?src=top10]{.underline}](http://www.medscape.com/viewarticle/514384?src=top10)

[Schiffman
M](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Schiffman+M"%5BAuthor%5D),
[Castle
PE](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Castle+PE"%5BAuthor%5D).
The promise of global cervical-cancer prevention. [N Engl J
Med.](javascript:AL_get(this, 'jour', 'N Engl J Med.');) 2005 Nov
17;353(20):2101-4.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16291978&query_hl=25>

[Goldie
SJ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Goldie+SJ"%5BAuthor%5D)
et al Cost-effectiveness of cervical-cancer screening in five developing
countries. [N Engl J
Med.](javascript:AL_get(this, 'jour', 'N Engl J Med.');) 2005 Nov
17;353(20):2158-68.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16291985&dopt=Abstract>

**Infectious Diseases Society of America, October 7, 2005**

[[http://www.idsociety.org/Template.cfm?Section=Abstracts2&Template=/TaggedPage/TaggedPageDisplay.cfm&TPLID=48&ContentID=11333]{.underline}](http://www.idsociety.org/Template.cfm?Section=Abstracts2&Template=/TaggedPage/TaggedPageDisplay.cfm&TPLID=48&ContentID=11333)

**Genital HPV Infection - CDC Fact Sheet**

[[http://www.cdc.gov/std/HPV/STDFact-HPV.htm]{.underline}](http://www.cdc.gov/std/HPV/STDFact-HPV.htm)

#### Judy Whitecrane, PIMC {#judy-whitecrane-pimc .Style-Heading-4-+-Arial-14-pt-Underline}

**Teen Birth Rate Continues to Decline, but Slowly**

In a preliminary look at national birth data for the year 2004, the
National Center for Health Statistics in the Centers for Disease Control
and Prevention said October 28 that teenage birth rates declined last
year, though at a slower pace than in any previous year since declines
began in 1991. The slightly encouraging news is that the birth rate for
females aged 15 to 19 reached a low of 41.2 births per thousand in 2004,
1 percent lower than in 2003 (when the rate was 41.6 per thousand) and
33 percent lower than in 1991. More than four of every five births to
teenagers were to unmarried young women. A trend toward childbearing by
unmarried women of all ages continued in 2004, with a record high of
almost 1.5 million such births. Overall, fertility was high in 2004;
more than 4 million babies were born, many of them to women over the age
of 40. \"Preliminary Births for 2004\" is available online at
[[www.cdc.gov/nchs]{.underline}](../www.cdc.gov/nchs).

The Child Trends report finds current trends \"positive\" but points out
that \"there are important reasons to be concerned about teen
childbearing in this country.\" On the basis of experience so far, 17
percent of current 15-year-old girls will give birth before age 20, and
one in five of those births will be repeat births. And within the United
States, the teen birth rate varies widely, from a low of 20 births per
1,000 15- to 19-year-old girls in New Hampshire to 65 births per 1,000
in Mississippi. The report also notes that more than half of the states
do not require that providers of health insurance include contraceptive
methods and services in their prescription drug coverage.

For state-by-state data on teen childbearing and the full text of the
statistical summary \"Facts at a Glance 2005,\"
[[http://www.childtrends.org/]{.underline}](http://www.childtrends.org/)
and
[[http://www.childtrendsdatabank.org/]{.underline}](http://www.childtrendsdatabank.org/)

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

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

**Paroxetine's pregnancy category changed from C to D**

FDA MedWatch

**Paroxetine HCl - Paxil and generic paroxetine**

The FDA has determined that exposure to paroxetine in the first
trimester of pregnancy may increase the risk for congenital
malformations, particularly cardiac malformations. At the FDA's request,
the manufacturer has changed paroxetine's pregnancy category from C to D
and added new data and recommendations to the WARNINGS section of
paroxetine's prescribing information. FDA is awaiting the final results
of the recent studies and accruing additional data related to the use of
paroxetine in pregnancy in order to better characterize the risk for
congenital malformations associated with paroxetine.\
\
Physicians who are caring for women receiving paroxetine should alert
them to the potential risk to the fetus if they plan to become pregnant
or are currently in their first trimester of pregnancy. Discontinuing
paroxetine therapy should be considered for these patients. Women who
are pregnant, or planning a pregnancy, and currently taking paroxetine
should consult with their physician about whether to continue taking it.
Women should not stop the drug without discussing the best way to do
that with their physician.

There are two main levels to approach this

1.) Patient notification phase

2.) Patient management phase (cognitive behavioral therapy, other
medications)

**Phase 1 Noftification**

In a way we have had this type of event happen before, e. g., Vioxx
earlier this year and hormone replacement therapy in 2000

This time we have the added element that some of the patients need to be
managed immediately, e.g., the first trimester patients should be
notified this week.

The non-first trimester patients and all other reproductive age women
need to be managed in a timely fashion, but don't have the same ramped
up element of immediacy.

The second added element is that one simply can't stop this drug
immediately, plus there can be significant negative downstream long term
effects to discontinuation.

We need to utilize a paroxetine drug tapering method to avoid withdrawal
syndrome

and

We need to be aware that some patients may develop worse depression
symptoms that may lead to hospitalization, drug abuse, pregnancy
termination, or suicide.

Here are some possible approaches to the Notification Phase:

-Notify all the health care providers who care for women of reproductive
age

E-mails (send it to all stakeholders)

Schedule urgent staff meetings

-Create a multi-disciplinary team to manage various aspects

Make sure all stakeholders are represented

Family Medicine, Pharmacy, Mental Health, Women's Health, Internal
Medicine, Emergency Room, Administration, Pediatrics, Urgent Care,
Social Service

Who did we miss?

If it is too big a group, it might be hard to manage

Who 'owns' this problem? Primary care staff? Mental Health staff?
Women's Health Staff? Pharmacy staff?

-Search RPMS for a list of patients on all forms of the product on your
formulary

1   PAXIL  PAROXETINE 30MG TAB       INITIAL RX FOR MAX 30 DAY SUPPLY 
\*D-A

SK LMP

     2   PAXIL  PAROXETINE 20MG TAB       INITIAL RX FOR MAX 30 DAY
SUPPLY     \*

D-ASK LMP

     3   PAXIL  PAROXETINE 40MG TAB       INITIAL RX FOR MAX 30 DAY
SUPPLY  \*D-A

SK LMP

     4   PAXIL  PAROXETINE 10MG TAB       INITIAL RX FOR MAX 30 DAY;
UNABLE TO G

ET, SAVE FOR 5MG DOSES \*D-ASK LMP

     5   PAXIL  PAROXETINE 10MG/5ML SUSP       \*D-ASK LMP

-Contact the patients on the above list

Create a spread sheet from the above list of patients...

Sort by EDC

Make sure it has all paroxetin patients, their contact info (phone and
address) and Rx and Issue/Fill date

Make sure it has the patient's Primary Care Provider (PCP) and PCP
clinic if applicable for case management work distribution

-Contact first trimester patients by phone

Many patients don't have phones

Who does this? Pharmacy staff? Primary Care case managers?

Should the provider call the patients?

-Contact all others by letter

Many of these letters get returned because of address changes

-Discuss paroxetine's effects with each patient as they come in for
their appointments

It is a bit of complicated physiology that may, or may not, ultimately
?effect all SSRIs

-Provide patient education handouts

Here is one, but it is it appropriate for your clients

FDA Patient Ed page

<http://www.fda.gov/cder/drug/InfoSheets/patient/paroxetinePT.htm>

-Document your discussion

Should you create an overlay PCC or PCC+ that has a checklist of the
above elements to streamline the documentation

**Phase 2**

**Management**

-Discuss treatment options and risk with the pregnancy-age or pregnant
patient,

-Encourage converting to alternative antidepressants or stopping
meds where indicated and

-Get consultation for the conversion or discontinuation as paroxetine
has a significant withdrawal syndrome associated with it (a possible
contributor to increased suicidal behavior).

Where available, cognitive behavioral therapy for mild to moderate
depressive symptoms is as effective as meds - unfortunately it requires
time and commitment on part of both patients and providers.

 

The question is how to get the info out . . .unfortunately the
antidepressants are not reliably interchangeable and for some patients
who have arrived at paroxetine after a trial of a number of other
antidepressants there may be few other effective options (though this
number will be small) . . . if that is the case referral/consultation
would definitely be in order.

Tapering paroxetine from 20 to 10 to 5, each for a week... although this
is still rapid for some patients) or going to fluoxetine first and then
tapering can be helpful in decreasing discontinuation effects which can
be wicked with paroxetine. It is also important to remember that
developmental effects of being raised by a very depressed mother can be
significant as well.

Try to avoid

....that some patients may get the message and stop the drug without
appropriate consultation with their physician and develop worse
depression symptoms that may lead to hospitalization, drug abuse,
pregnancy termination or suicide.  There is a danger in taking the
warning too literally.

**Background**

**Quick take: Reprotox**

Although experimental animal studies do not suggest an increased risk of
congenital anomalies, a preliminary case-control study and 2 other
independent studies presented in abstract or letter-form have suggested
a 2-fold increase in cardiovascular defects in children exposed
antenatally to paroxetine. Use of paroxetine late in pregnancy can be
associated with a mild transient neonatal syndrome of central nervous
system, motor, respiratory, and gastrointestinal signs.

<http://www.reprotox.org/Default.aspx>

**FDA Professional Ed page**

<http://www.fda.gov/cder/drug/InfoSheets/HCP/paroxetineHCP.htm>

**FDA Patient Education page**

<http://www.fda.gov/cder/drug/InfoSheets/patient/paroxetinePT.htm>

**Treatment of psychiatric disorders in pregnancy, UpToDate**

<http://www.uptodateonline.com/application/topic.asp?file=maternal/5976>

**Other paroxetine or depression related items in the literature this
month**

Exposure to selective serotonin reuptake inhibitors during pregnancy is
not independently associated with adverse perinatal outcomes other than
increased risk of needing treatment in special or neonatal intensive
care unit.

CONCLUSION: Use of SSRIs during pregnancy is not independently
associated with increased risk of adverse perinatal outcome other than
need for treatment in neonatal special or intensive care unit. LEVEL OF
EVIDENCE: II-2. [Malm
H](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Malm+H"%5BAuthor%5D),
et al Risks associated with selective serotonin reuptake inhibitors in
pregnancy. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2005
Dec;106(6):1289-96.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16319254&dopt=Abstract>

**Meta-analysis: Light therapy similar effect on non-seasonal depression
as medication**.

CONCLUSIONS: Many reports of the efficacy of light therapy are not based
on rigorous study designs. This analysis of randomized, controlled
trials suggests that bright light treatment and dawn simulation for
seasonal affective disorder and bright light for non-seasonal depression
are efficacious, with effect sizes equivalent to those in most
antidepressant pharmacotherapy trials. Adopting standard approaches to
light therapy\'s specific issues (e.g., defining parameters of active
versus placebo conditions) and incorporating rigorous designs (e.g.,
adequate group sizes, randomized assignment) are necessary to evaluate
light therapy for mood disorders.

[Golden
RN](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Golden+RN"%5BAuthor%5D),
et al The efficacy of light therapy in the treatment of mood disorders:
a review and meta-analysis of the evidence. [Am J
Psychiatry.](javascript:AL_get(this, 'jour', 'Am J Psychiatry.');) 2005
Apr;162(4):656-62.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15800134&query_hl=4>

**Other**

**Do you work with a low HIV prevalence population? Here is a strategy
to keep it that way**

CONCLUSION: In a low prevalence population, the universal use of
Oraquick rapid testing is cost-effective because of the low rate of
false-positive results, thus preventing the emotional and economic costs
of unnecessary treatment for human immunodeficiency virus to the new
mother and her family

[Doyle
NM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Doyle+NM"%5BAuthor%5D),
et al Rapid HIV versus enzyme-linked immunosorbent assay screening in a
low-risk Mexican American population presenting in labor: a
cost-effectiveness analysis. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2005
Sep;193(3 Pt 2):1280-5.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16157152&query_hl=1>

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

HIV screening is a routine test in pregnancy. It is initially performed
in an 'opt out' mode at the first prenatal visit. No additional written
consent is necessary, but it a critical 'teachable moment' during which
HIV patient education should be delivered. If the patient is unable to
obtain HIV screening at that time and presents in labor without
screening, then HIV screening should be routinely performed at that
time. In selected cases high risk individuals should be re-screened in
labor. Depending on the logistics of your facility rapid testing may be
the best choice.

Bulterys M et al Rapid HIV-1 testing during labor: a multicenter study.
JAMA 2004 Jul 14;292(2):219-23.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15249571&query_hl=3>

Kallenborn JC; Price TG; Carrico R; Davidson AB Emergency department
management of occupational exposures: cost analysis of rapid HIV test.
Infect Control Hosp Epidemiol 2001 May;22(5):289-93.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11428439&query_hl=1>

**Evidence-based surgery for cesarean delivery**

RESULTS: US Preventive Services Task Force recommendations favor blunt
uterine incision expansion, prophylactic antibiotics (either ampicillin
or first-generation cephalosporin for just 1 dose), spontaneous
placental removal, non-closure of both visceral and parietal peritoneum,
and suture closure or drain of the subcutaneous tissue when thickness is
\> or =2 cm. CONCLUSION: Cesarean delivery techniques that are supported
by good quality recommendations should be performed routinely. All
technical aspects that have recommendations with lower quality should be
researched with adequately powered and designed trials.

[Berghella
V](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Berghella+V"%5BAuthor%5D)
et al Evidence-based surgery for cesarean delivery. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2005
Nov;193(5):1607-17.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16260200&query_hl=14>

**Umbilical cord blood is a proven source of hematopoietic stem cells:
You can bank on it**

Until recently, blood that remained in the umbilical cord and placenta
after delivery was routinely discarded. Now that this blood is known to
contain both hematopoietic stem cells and pluripotent mesenchymal cells,
there has been a substantial increase in the clinical use and research
investigation of umbilical cord blood in hematopoietic transplantation
and regenerative medicine. Until now, standards for collection and
processing were not well established. The debate continues regarding the
private banking of autologous blood for \"biologic insurance\" versus
public banking for access by the general population. Obstetricians
should support the acquisition of cord units for public banking in their
geographic location where cord blood banks have established collection
procedures. Issues related to cost, quality control, and the need for
ethnic diversity in public banks preclude the universal collection of
units from all obstetric deliveries. Directed donation of cord blood
should be considered when there is a specific diagnosis of a disease
within a family known to be amenable to stem cell transplantation.

[Moise KJ
Jr](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Moise+KJ+Jr"%5BAuthor%5D).
Umbilical cord stem cells. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2005
Dec;106(6):1393-407.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16319269&dopt=Abstract>

**Other resources**

**Research News On Cord Blood Stem Cells**

<http://www.cord-blood-stem-cells.info/Site_Map.html>

**Cord Blood Guide: Links**

<http://www.cord-blood-stem-cells.info/links.html>

#### Women with a prior cesarean should be offered VBAC, and women with a prior cesarean and prior vaginal delivery should be encouraged to VBAC {#women-with-a-prior-cesarean-should-be-offered-vbac-and-women-with-a-prior-cesarean-and-prior-vaginal-delivery-should-be-encouraged-to-vbac .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: Women with a prior cesarean should be offered VBAC, and women with a prior cesarean and prior vaginal delivery should be encouraged to VBAC. Although other studies have suggested that prostaglandins should be avoided, we suggest that inductions requiring sequential agents be avoided {#conclusion-women-with-a-prior-cesarean-should-be-offered-vbac-and-women-with-a-prior-cesarean-and-prior-vaginal-delivery-should-be-encouraged-to-vbac.-although-other-studies-have-suggested-that-prostaglandins-should-be-avoided-we-suggest-that-inductions-requiring-sequential-agents-be-avoided .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**Macones GA**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Macones+GA"%5BAuthor%5D), et al Maternal complications with vaginal birth after cesarean delivery: a multicenter study. [**Am J Obstet Gynecol.**](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2005 Nov;193(5):1656-62. [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16260206&query_hl=9**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16260206&query_hl=9) {#macones-ga-et-al-maternal-complications-with-vaginal-birth-after-cesarean-delivery-a-multicenter-study.-am-j-obstet-gynecol.-2005-nov19351656-62.-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids16260206query_hl9 .Style-Heading-4-+-Arial-14-pt-Underline}

**Most women not screened for diabetes after a pregnancy with
gestational diabetes**

CONCLUSION: In the population studied, only 37% of women with a history
of GDM were screened for postpartum DM according to guidelines published
by the American Diabetes Association. Efforts to improve postpartum DM
screening in this high-risk group are warranted. LEVEL OF EVIDENCE:
II-2.\
[Smirnakis
KV](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Smirnakis+KV"%5BAuthor%5D),
et al Postpartum Diabetes Screening in Women With a History of
Gestational Diabetes. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2005
Dec;106(6):1297-1303\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16319255&dopt=Abstract>

**An Approach to the Postpartum Office Visit**

The postpartum period (typically the first six weeks after delivery) may
underscore physical and emotional health issues in new mothers. A
structured approach to the postpartum office visit ensures that relevant
conditions and concerns are discussed and appropriately addressed.
Common medical complications during this period include persistent
postpartum bleeding, endometritis, urinary incontinence, and thyroid
disorders. Breastfeeding education and behavioral counseling may
increase breastfeeding continuance. Postpartum depression can cause
significant morbidity for the mother and baby; a postnatal depression
screening tool may assist in diagnosing depression-related conditions.
Decreased libido can affect sexual functioning after a woman gives
birth. Physicians should also discuss contraception with postpartum
patients, even those who are breastfeeding. Progestin-only
contraceptives are recommended for breastfeeding women. The lactational
amenorrhea method may be a birth control option but requires strict
criteria for effectiveness. (Am Fam Physician 2005;72:2491-6, 2497-8.

<http://www.aafp.org/afp/20051215/2491.html> (Also see Patient
Education)

Stepwise oral misoprostol (50 microg then 100 microg) as effective as
vaginal

CONCLUSION: Stepwise oral misoprostol (50 microg followed by 100 microg)
appears to be as effective as vaginal misoprostol (25 microg) for
cervical ripening with a low incidence of hyperstimulation, no increase
in side effects, a high rate of patient satisfaction, and is associated
with a lower cesarean section rate.

Colón I, et al. Prospective randomized clinical trial of inpatient
cervical ripening with stepwise oral misoprostol vs vaginal misoprostol.
Am J Obstet Gynecol March 2005;192:747-52.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15746667&query_hl=12>

**Untreated Maternal Gingivitis Raises Risk of Preterm/low Birth
Weight**

Conclusions: Periodontal treatment significantly reduced the PT/LBW rate
in this population of women with pregnancy-associated gingivitis. Within
the limitions of this study, we conclude that gingivitis appears to be
an independent risk factor for PT/LBW for this population

[Lopez
NJ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Lopez+NJ"%5BAuthor%5D),
et al Periodontal Therapy Reduces the Rate of Preterm Low Birth Weight
in Women With Pregnancy-Associated Gingivitis. [J
Periodontol.](javascript:AL_get(this, 'jour', 'J Periodontol.');) 2005
Nov;76(11-s):2144-2153.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16277587&query_hl=10>

**Postpartum Physical Activity Levels Low in Women With Recent
Gestational Diabetes**

CONCLUSIONS: The prevalence of sufficient physical activity was found to
be low and strongly related to social support and self-efficacy. This is
an important group to whom diabetes prevention strategies can be
targeted.

[Smith
BJ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Smith+BJ"%5BAuthor%5D),
et al Postpartum physical activity and related psychosocial factors
among women with recent gestational diabetes mellitus. [Diabetes
Care.](javascript:AL_get(this, 'jour', 'Diabetes Care.');) 2005
Nov;28(11):2650-4.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16249534&query_hl=12>

**3 in 10 Gave Birth by Cesarean in 2004: Sharp, Rise Defies Evidence
and Best Practice**

The Maternity Center Association (MCA) has prepared three new Web pages
that contain information about cesarean section, including information
about recent changes in the U.S. cesarean section rate recently reported
by the National Center for Health Statistics. The Web pages are intended
for use by women, health professionals, the media, and others in their
efforts to promote evidence-based maternity care.

The first Web page summarizes factors associated with the increase,
discusses health costs and financial implications, and challenges
assumptions.
[[http://www.maternitywise.org/cesarean_response.html]{.underline}](http://www.maternitywise.org/cesarean_response.html)

The second page presents a brief overview of MCA\'s advice for pregnant
women about cesarean section, vaginal birth, and vaginal birth after
cesarean.
[[http://www.maternitywise.org/cesarean_advice.html]{.underline}](http://www.maternitywise.org/cesarean_advice.html)

The third page, which addresses myths about cesarean section, is
available at
[[http://www.maternitywise.org/cesarean_myth_vs_reality.html]{.underline}](http://www.maternitywise.org/cesarean_myth_vs_reality.html)

National Center for Health Statistics\' Preliminary Births for 2004:
Infant and Maternal Health,
i[[http://www.cdc.gov/nchs/products/pubs/pubd/hestats/prelimbirths04/prelimbirths04health.htm]{.underline}](http://www.cdc.gov/nchs/products/pubs/pubd/hestats/prelimbirths04/prelimbirths04health.htm)

**Complications Differ After Forceps- and Vacuum-Assisted Deliveries**

Infant shoulder dystocia rates are higher with vacuum-assisted
deliveries than with forceps deliveries, while women undergoing forceps
deliveries are more likely to suffer third- or fourth-degree
lacerations, according to a report in the November Obstetrics and
Gynecology.

CONCLUSION: Vacuum-assisted vaginal birth is more often associated with
shoulder dystocia and cephalohematoma. Forceps delivery is more often
associated with third- and fourth-degree perineal lacerations. These
differences in complications rates should be considered among other
factors when determining the optimal mode of delivery. LEVEL OF
EVIDENCE: II-2

[Caughey
AB](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Caughey+AB"%5BAuthor%5D),
et al Forceps compared with vacuum: rates of neonatal and maternal
morbidity. *Obstet Gynecol* 2005;106:908-912.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16260505&dopt=Abstract>

**40% of maternal deaths were preventable**

Using multiple methods to identify pregnancy-related deaths in North
Carolina in 1995-1999, we found that 40% of these deaths could
potentially have been prevented. Though the risk of dying from pregnancy
in the United States decreased dramatically during the 20th century,
evidence suggests that further reductions are possible. The authors
found that:

\* Of the 102 deaths deemed preventable, 41 (40%) were deemed
preventable through changes in at least one of the study areas.

\* Approximately 90% of deaths due to hemorrhage or to complications of
chronic diseases were deemed preventable, compared with none of the
deaths due to cerebrovascular accident, amniotic fluid emboli, or
microangiopathic hemolytic syndromes.

\* Improved medical care (quality of care) was most important in
preventing deaths due to hemorrhage and infection, whereas preconception
care could have prevented more than half of the deaths due to chronic
medical conditions.

\* Forty-six percent of the deaths among African American women were
deemed preventable, compared with 33% of the deaths among white women, a
difference that was statistically significant.

[Conclusion]{.underline} The process of in-depth review of
pregnancy-related deaths may provide guidance to help reduce the number
of these events.

Berg CJ, Harper MA, Atkinson MS, et al. 2005. Preventability of
pregnancy-related deaths: Results of a state-wide review. Obstetrics &
Gynecology 106(6):1228-1234.
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16319245&dopt=Abstract>

**Should all Indian Health facilities offer Level II US to
pre-gestational pregnant diabetics**

Or should the need for targeted ultrasounds just be done on those with
elevated HbA1c?

CONCLUSIONS: No cases of congenital heart disease were observed in
patients with a normal initial HbA1c value. Among patients with abnormal
HbA1c values, no critical level of glycohemoglobin was identified that
provided optimal predictive power for congenital heart disease
screening. We recommend detailed fetal echocardiographic imaging in all
patients with initial HbA1c levels above the upper limit of normal of
6.1%.\
[Shields
LE](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Shields+LE"%5BAuthor%5D)
et al The prognostic value of hemoglobin A1c in predicting fetal heart
disease in diabetic pregnancies. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 1993
Jun;81(6):954-7.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8497362&query_hl=23>

**Other thoughts**

**Ultrasound examination** --- Ultrasound examination at approximately
18 weeks of gestation is a routine procedure in pregnancies complicated
by pregestational diabetes because of the higher probability of
congenital anomalies and need to establish accurate dates to facilitate
the timing of induced labor, if required. This examination confirms or
is used to revise the estimated date of confinement and screens for
structural anomalies. Early fetal growth delay was thought to be
predictive of the development of congenital anomalies and low birth
weight[;]{.underline} however, this observation has been refuted by
subsequent analyses.

The ultrasound examination should include a fetal survey with a
four-chamber view of the heart and visualization of the outflow tracts.
Detailed fetal echocardiographic examination is important because
congenital heart disease occurs more frequently in the offspring of
diabetic women than in the general population. Conotruncal and
ventricular septal defects are the most common cardiac defects found in
these fetuses.

The utility of sonographic examination is illustrated by the following
large studies:

  ![](media/image2.wmf) In one series of 432 pregestational diabetic
gravidas evaluated at 12 to 23 weeks of gestation, the prevalence of
major congenital abnormalities at delivery was 7 percent . Sonographic
identification of major birth defects before 24 weeks had sensitivity,
specificity, and positive and negative predictive values of 56, 99.5,
90, and 97 percent, respectively. The lesions most commonly missed were
ventricular septal defect, an abnormal hand or foot, unilateral renal
abnormality, and cleft palate without cleft lip.\
\
  ![](media/image3.wmf) In another report, 289 gravid women with
pregestational diabetes underwent comprehensive prenatal diagnostic
testing including glycosylated hemoglobin, maternal serum AFP,
comprehensive fetal ultrasonography with a standard four-chamber cardiac
view at 18 weeks, and detailed multiimage echocardiography at 22 weeks
of gestation. Sensitivity, specificity, and positive and negative
predictive values for the diagnosis of major noncardiac fetal
abnormalities was 59, 100, 100, and 98 percent, respectively. The test
performance (sensitivity, specificity, and positive and negative
predictive values) of the standard four-chamber view was 33, 100, 100,
and 97 percent; the majority of missed cardiac defects were septal and
outflow tract lesions. The addition of echocardiography improved the
detection of cardiac defects.

See \"Prenatal sonographic diagnosis of fetal cardiac anomalies

<http://www.uptodateonline.com/application/topic.asp?file=pregcomp/15923&type=A&selectedTitle=20~62>

Can Ginger Relieve Nausea and Vomiting in Pregnancy?

Up to 85 percent of women who are pregnant experience nausea, and nearly
one half report vomiting. These symptoms (morning sickness) usually
resolve by the end of the third month, but symptoms persist in an
estimated 20 percent of pregnant women. Two percent report nausea and
vomiting throughout pregnancy, and the condition is severe (hyperemesis
gravidarum) in 0.3 to 3 percent of these women. Although many
medications are available to relieve morning sickness, interventions are
limited by concerns about adverse effects on the developing fetus. These
concerns have led to interest in alternative remedies. Borrelli and
colleagues reviewed the evidence regarding the safety and effectiveness
of ginger, one of the most commonly used alternative preparations for
morning sickness. The authors conclude that ginger may be a safe and
effective treatment for nausea and vomiting for morning sickness, but
more studies are needed. Borrelli F, et al. Effectiveness and safety of
ginger in the treatment of pregnancy-induced nausea and vomiting. Obstet
Gynecol April 2005;105:849-56

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15802416&query_hl=10>

**Night work is associated with preterm delivery. Standing, lifting, and
long hours are not**

CONCLUSION: Physically demanding work does not seem to be associated
with adverse pregnancy outcomes, whereas working at night during
pregnancy may increase the risk of preterm delivery. Studies to examine
the effect of shift work on uterine activity would help to clarify the
possibility of a causal effect on preterm birth. LEVEL OF EVIDENCE:
II-2.

[Pompeii
LA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Pompeii+LA"%5BAuthor%5D),
et al Physical Exertion at Work and the Risk of Preterm Delivery and
Small-for-Gestational- Age Birth [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2005
Dec;106(6):1279-88.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16319253&dopt=Abstract>

Second Trimester Cervical Changes and Preterm Delivery

Transvaginal ultrasonography of the cervix can assist physicians in
determining cervical length and funneling and also may help identify
women at high risk of preterm delivery. De Carvalho and colleagues
assessed the predictive performance of cervical changes and obstetric
history for preterm delivery. The authors conclude that the risk of
preterm delivery was 7 percent for women with a second trimester
cervical length of 20 mm. The risk increased to 34 percent in patients
who also had funneling, and the risk increased to 59 percent in women
who also had a history of preterm delivery. Mothers with a cervical
length of 20 mm and a history of prematurity had a risk of approximately
18 percent. The authors recommend that physicians consider second
trimester cervical length when identifying mothers at risk for preterm
delivery, especially in patients with a history of preterm birth. De
Carvalho MH, et al. Prediction of preterm delivery in the second
trimester. Obstet Gynecol March 2005;105:532-6.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15738020&query_hl=6>

**Use of dexamethasone for treatment of HELLP syndrome not supported**

STUDY DESIGN: A prospective, double-blind clinical trial CONCLUSION: The
results of this investigation do not support the use of dexamethasone
for treatment of HELLP syndrome.

[Fonseca
JE](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Fonseca+JE"%5BAuthor%5D),
et al Dexamethasone treatment does not improve the outcome of women with
HELLP syndrome: a double-blind, placebo-controlled, randomized clinical
trial. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2005
Nov;193(5):1591-8.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16260197&query_hl=18>

and

**Editorial**

Therefore, there is definite need for placebo-controlled trials with
adequate sample size to answer these questions. Until then, the use of
high-dose dexamethasone to improve maternal outcome in women with HELLP
syndrome beyond 34 weeks\' gestation and/or in the postpartum period
remains experimental.

[Sibai
BM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Sibai+BM"%5BAuthor%5D),
[Barton
JR](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Barton+JR"%5BAuthor%5D)
Dexamethasone to improve maternal outcome in women with hemolysis,
elevated liver enzymes, and low platelets syndrome. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2005
Nov; 193(5):1587-90.\
[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16260196&query_hl=23]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16260196&query_hl=23)

**Controversies Related to Gestational Diabetes**

Screening artificially increases the prevalence of gestational diabetes
but does not conclusively improve outcomes. The authors hope that the
HAPO study of 25,000 pregnancies will answer some of the questions about
gestational diabetes. In the meantime, making a diagnosis at 24 to 28
weeks of gestation appears to only modestly lower rates of macrosomia
but has little clear additional advantage Kelly L, et al. Controversies
around gestational diabetes. Practical information for family doctors.
Can Fam Physician May 2005;51:688-95.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15934273&query_hl=1>

**Both maternal and paternal ethnicity affect preeclampsia rates**

<http://www.ahrq.gov/research/oct05/1005RA14.htm>

**Women who smoke have nearly 2 X risk of Graves\' hyperthyroidism than
nonsmokers**

<http://www.ahrq.gov/research/oct05/1005RA21.htm>

**Elective primary cesarean delivery rates show a rising trend**

<http://www.ahrq.gov/research/oct05/1005RA22.htm>

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

#### Urinary incontinence: Familial association stronger than that of vaginal delivery {#urinary-incontinence-familial-association-stronger-than-that-of-vaginal-delivery-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: Vaginal birth does not seem to be associated with urinary incontinence in postmenopausal women. Considering the high concordance in continence status between sister pairs, and considering that the majority of parous women are continent, an underlying familial predisposition toward the development of urinary incontinence may be present. LEVEL OF EVIDENCE: II-2. {#conclusion-vaginal-birth-does-not-seem-to-be-associated-with-urinary-incontinence-in-postmenopausal-women.-considering-the-high-concordance-in-continence-status-between-sister-pairs-and-considering-that-the-majority-of-parous-women-are-continent-an-underlying-familial-predisposition-toward-the-development-of-urinary-incontinence-may-be-present.-level-of-evidence-ii-2. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**Buchsbaum GM**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Buchsbaum+GM"%5BAuthor%5D), et al Urinary incontinence in nulliparous women and their parous sisters. [**Obstet Gynecol.**](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2005 Dec;106(6):1253-8. [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16319249&dopt=Abstract**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16319249&dopt=Abstract) {#buchsbaum-gm-et-al-urinary-incontinence-in-nulliparous-women-and-their-parous-sisters.-obstet-gynecol.-2005-dec10661253-8.-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmedlist_uids16319249doptabstract .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Handle abnormal Pap smears differently in adolescents {#handle-abnormal-pap-smears-differently-in-adolescents .Style-Heading-4-+-Arial-14-pt-Underline}

#### Despite the high incidence of HPV infection in women less than 21 years of age, only a fraction of HPV positive adolescents develop cytologic abnormalities. Most infections are transient, e. g., 8 -- 18 months. Use ablative techniques sparingly in adolescents. Here are some helpful resources for ACOG and ASCCP.  {#despite-the-high-incidence-of-hpv-infection-in-women-less-than-21-years-of-age-only-a-fraction-of-hpv-positive-adolescents-develop-cytologic-abnormalities.-most-infections-are-transient-e.-g.-8-18-months.-use-ablative-techniques-sparingly-in-adolescents.-here-are-some-helpful-resources-for-acog-and-asccp. .Style-Heading-4-+-Arial-14-pt-Underline}

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

"Adolescents with ASC who are HPV positive or with LSIL results may be
monitored with repeat cytology tests at 6 and 12 months or a single HPV
test at 12 months, with colposcopy for a cytology result of ASC or
higher-grade abnormality or a positive HPV test result."

Other exceptions for adolescents

**When the results of cervical cytology are reported as atypical
squamous cells, how should the patient be treated?**

\"\....The exception to this recommendation for HPV follow-up is the
adolescent, for whom the risk of invasive cancer approaches zero and the
likelihood of HPV clearance is very high. As an alternative to immediate
colposcopy, adolescents with ASC HPV-positive test results may be
monitored with cytology tests at 6 and 12 months or with a single HPV
test at 12 months, with colposcopy for any abnormal cytology result or
positive HPV test result. The recommendation and the rationale are
similar for follow-up of LSIL in adolescents\....\"

**When the results of cervical cytology are reported as LSIL or atypical
squamous cells cannot exclude HSIL (ASC-H), how should the patient be
treated?**

\".. The risk of CIN 2/3+ at initial colposcopy following an LSIL result
is between 15% and 30% in most studies. This level of risk of CIN 2/3+
is similar to results of initial colposcopy associated with an ASC
HPV-positive cytology result in other studies (17.8% versus 17.9%) (4,
67). Therefore, colposcopy is recommended for evaluation of LSIL. For
adolescents with LSIL results, it may be reasonable to follow up without
immediate colposcopy. Low-grade squamous intraepithelial lesions are
very common in sexually active adolescents because of the recent onset
of sexual activity in this group, but clearance of HPV is high and
cancer rates are extremely low. Therefore, follow-up recommendations are
similar to those for adolescents with ASC HPV-positive results\....\"

**"When the initial evaluation of an HSIL cytology result is a diagnosis
of CIN 1 or less, how should the patient be treated?**

Interpretations of HSIL and CIN 2 or CIN 3 are poorly reproducible (6,
78, 89, 90). One study reported that less than half of HSIL results and
77% of CIN 2 or CIN 3 results were confirmed on quality control review.
As a consequence, experts have recommended review of the cytology and
histology results in cases with HSIL diagnoses and discrepancies in
colposcopic results, although this approach has not been tested in
clinical studies. If review is not undertaken or colposcopy results are
not satisfactory, excision is recommended. This approach is favored
because (as discussed previously) a single colposcopy can miss CIN 2 or
CIN 3, particularly small lesions, and because reports have documented
CIN 2/3+ when examining excision specimens in up to 35% of women with
HSIL cytology results and either negative or noncorrelating (CIN 1)
colposcopy results.

Adolescents are exceptions to this recommendation because interobserver
variability is most pronounced in younger women, the risk of invasive
cancer is extremely low, and the likelihood of spontaneous resolution of
CIN 1 or CIN 2 is high. Therefore, follow-up with colposcopy and
cytology tests at 4--6 months may be undertaken, as long as the
colposcopy results are adequate and the endocervical curettage is
negative...."

***"How should CIN 2 and CIN 3 be managed?***

In contrast to CIN 1, CIN 2 and CIN 3 are recognized potential cancer
precursors, although CIN 2 is associated with significant spontaneous
regression. Evidence from ALTS suggests that approximately 40% of CIN 2
cases regressed over 2 years, whereas regression of CIN 3, if present,
was too rare to measure accurately during the study. Reports of
significant regression of CIN 3 generally are based on cytology and not
histology or are associated with multiple follow-up biopsies, which
influence the natural history of the disease. Even when histology is
assessed, only 77% of CIN 2 and CIN 3 diagnoses were verified on quality
control review in ALTS, making assertions about regression more
difficult to interpret in studies without rigorous pathology review (6).
In addition, histologic differentiation between CIN 2 and CIN 3 is not
sufficiently reliable to permit clear stratification of risk. As a
consequence, immediate treatment of CIN 2 and CIN 3 with excision or
ablation in the nonpregnant patient is recommended. The only exception
to this recommendation is that follow-up similar to CIN 1 may be
considered in the adolescent with CIN 2, whose likelihood of spontaneous
clearance is substantial and whose risk of cancer approaches zero.
Therefore, care of the adolescent with CIN 2 may be individualized..."

Management of abnormal cervical cytology and histology. ACOG Practice
Bulletin No. 66. American College of Obstetricians and Gynecologists.
Obstet Gynecol 2005;106:645--64.

**Another good resource**

ASCCP Consensus Guidelines
<http://www.asccp.org/pdfs/consensus/algorithms.pdf>

Simplifying the Diagnosis of Bacterial Vaginosis

The Gram stain is a common method for diagnosing bacterial vaginosis.
However, Gram stain results are not routinely available right away, and
treatment cannot be initiated at the time of the office visit. The
Amstel criteria are used to quickly diagnose bacterial vaginosis. These
criteria require at least three findings (thin homogenous vaginal
discharge, a vaginal pH greater than 4.5, a positive \"whiff\" test, or
a saline wet preparation that microscopically shows clue cells). Gutman
and colleagues examined whether further simplifying the diagnosis by
using fewer criteria would be as effective as using three criteria. The
authors conclude that using any two of the four clinical findings is
equivalent to the current recommendation of using at least three. They
recommend that physicians initially perform a pH test, followed by any
of the other tests. If the pH is 4.5 or greater and one other test is
positive, the patient can be diagnosed with bacterial vaginosis and
treated accordingly. Gutman RE, et al. Evaluation of clinical methods
for diagnosing bacterial vaginosis. Obstet Gynecol March 2005;105:551-6.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15738023&query_hl=8>

**Certain factors predict chronic pelvic pain after pelvic inflammatory
disease**

<http://www.ahrq.gov/research/sep05/0905RA22.htm>

#### Uterine artery embolization: Low complication rate, reduced length stay {#uterine-artery-embolization-low-complication-rate-reduced-length-stay-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: UAE is a procedure similar to hysterectomy with a low major complication rate and with a reduced length of hospital stay. Higher readmission rates after UAE stress the need for careful postprocedural follow-up. {#conclusion-uae-is-a-procedure-similar-to-hysterectomy-with-a-low-major-complication-rate-and-with-a-reduced-length-of-hospital-stay.-higher-readmission-rates-after-uae-stress-the-need-for-careful-postprocedural-follow-up. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**Hehenkamp WJ**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Hehenkamp+WJ"%5BAuthor%5D), et al Uterine artery embolization versus hysterectomy in the treatment of symptomatic uterine fibroids (EMMY trial): peri- and postprocedural results from a randomized controlled trial. [**Am J Obstet Gynecol.**](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2005 Nov;193(5):1618-29. [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16260201&query_hl=12**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16260201&query_hl=12) {#hehenkamp-wj-et-al-uterine-artery-embolization-versus-hysterectomy-in-the-treatment-of-symptomatic-uterine-fibroids-emmy-trial-peri--and-postprocedural-results-from-a-randomized-controlled-trial.-am-j-obstet-gynecol.-2005-nov19351618-29.-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids16260201query_hl12 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Two RCTs show promising results with hypothermia for neonatal
encephalopathy**

Hypoxic ischemic encephalopathy is a rare condition associated with high
neonatal mortality and morbidity. Two randomized clinical trials have
recently been published showing potentially promising results with
hypothermia for neonatal encephalopathy. Additional clinical trials are
underway to test cooling as a therapeutic modality for hypoxic ischemic
encephalopathy. Outcome information about infants treated with
hypothermia is available for children up to approximately 2 years of
age. Longer-term outcome (ie, school age information) is currently
lacking with respect to benefit and risk. Therapeutic hypothermia offers
a potentially promising therapy for hypoxic ischemic encephalopathy.
Hypothermia for encephalopathy should be considered an evolving therapy
because of lack of long-term safety and efficacy data.

[Higgins
RD](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Higgins+RD"%5BAuthor%5D)
Hypoxic ischemic encephalopathy and hypothermia: a critical look.
[Obstet Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');)
2005 Dec;106(6):1385-7.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16319267&dopt=Abstract>

**Guidelines for Identifying and Referring Persons with Fetal Alcohol
Syndrome**

This report summarizes the diagnostic guidelines drafted by the
scientific working group, provides recommendations for when and how to
refer a person suspected of having problems related to prenatal alcohol
exposure, and assesses existing practices for creating supportive
environments that might prevent long-term adverse consequences
associated with FAS. The guidelines were created on the basis of a
review of scientific evidence, clinical expertise, and the experiences
of families affected by FAS regarding the physical and neuropsychologic
features of FAS and the medical, educational, and social services needed
by persons with FAS and their families. The guidelines are intended to
facilitate early identification of persons affected by prenatal exposure
to alcohol so they and their families can receive services that enable
them to achieve healthy lives and reach their full potential. This
report also includes recommendations to enhance identification of and
intervention for women at risk for alcohol-exposed pregnancies.

<http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5411a1.htm>

CNS Abnormalities Associated with FAS
<http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5411a2.htm>

**National Conference on Juvenile Issues**

January 9--13, 2006 (see pre-conference below\*)

Washington, DC

Coordinating Council on Juvenile Justice and Delinquency Prevention

Office of Juvenile Justice and Delinquency Prevention

<http://www.juvenilecouncil.gov/2006NationalConference/index.html>

**\*One day Pre-Conference**

Monday, January 9, 2006 9 a.m. - 5 p.m.  Preconference Training

-Addressing Disproportionate Minority Contact (DMC) and Confinement

-Community Assessment and Planning for Juvenile Justice Programs

-Leadership for Truancy Reduction: Practices, Partnerships, and Policies

-Addressing the Needs of Juvenile Female Offenders

**AAP Report on Assessment of Sexual Abuse in Children**

The American Academy of Pediatrics (AAP) has released recommendations
for the recognition of possible sexual abuse in children, the need for
diagnostic testing for sexually transmitted diseases (STDs) in these
children, and determination of the need to inform child protective
services. <http://www.pediatrics.org/cgi/content/full/116/2/506>

**Heads Up: Concussion in High School Sports**

On behalf of the Centers for Disease Control and Prevention (CDC), it is
my pleasure to announce the availability of the final version of the
*Heads Up: Concussion in High School Sports* tool kit.  We are grateful
for your valuable assistance in the development of these materials and
we hope that we can count on you to help us promote the tool kit to
athletic staff (coaches, athletic directors and trainers) across the
country. You should be receiving a copy of the tool kit in the mail
soon.

We encourage your help in promoting the tool kit to your members by:

·Announcing the tool kit\'s availability through letters, e-mails, your
list serve, newsletter, or website announcements;

·Linking your website announcement to CDC\'s tool kit site;
<http://www.cdc.gov/ncipc/tbi/Coaches_Tool_Kit.htm>\
·Announcing the kit\'s availability at appropriate meetings and
conferences; and/or\
·Making presentations at meetings.

To facilitate your promotion efforts, we are attaching a package of
sample promotional materials, including; a CDC national news release,
fact sheet, a newsletter or website article and a flyer that can be
tailored to fit your organization\'s needs.

The *Heads Up* tool kit can be ordered or downloaded free-of-charge at:
<http://www.cdc.gov/ncipc/tbi/Coaches_Tool_Kit.htm>

We would like to thank you again for your efforts and contributions to
this project and we would appreciate your informing us about any
promotional activities you undertake in support of our efforts. If you
have any questions or comments, please feel free to contact me at
<janemitchko@cdc.gov>

**Minority-serving hospitals may be providing lower quality of care to
VLBW infants**

\* The infant mortality rate among all white and black infants (before
risk adjustment) was 11%.

\* Fifty-seven percent of black infants (vs. 18% of white infants) were
treated at minority-serving hospitals.

\* For both black and white infants, neonatal mortality was higher at
minority-serving hospitals than at other hospitals.

\* Black and white infants were at similarly higher odds of mortality at
minority-serving hospitals than at other hospitals. Interaction between
race, other hospital characteristics, and process-of-care measures was
not statistically significant.

This study suggests that minority-serving hospitals may be providing
lower quality of care to VLBW \[very low birth weight\] infants than
other hospitals. The study described in the article investigated whether
the proportion of minority infants treated by hospitals is associated
with neonatal mortality and, if it is, whether the differences are
explained by hospital characteristics.

This study points to the importance of hospital characteristics in
understanding racial disparities in infant mortality.

They conclude that \"interventions to improve quality of care and reduce
neonatal mortality at minority-serving hospitals may result in reduced
racial disparities in infant mortality in the United States.

Morales LS, Staiger D, Horbar JD, et al. 2005. Mortality among very
low-birthweight infants in hospitals serving minority populations.
American Journal of Public Health 95(12):2206-2212
[[http://www.ajph.org/cgi/content/abstract/95/12/2206]{.underline}](http://www.ajph.org/cgi/content/abstract/95/12/2206)

**Improving the safety of Older Child Passengers**

New report assessing the nation\'s progress in improving the safety of
older child passengers

has just been posted. Poster available
<http://www.nhtsa.dot.gov/people/injury/childps/BoosterSeatProgress/index.htm>

![](media/image4.jpeg){width="3.21875in" height="4.166666666666667in"}

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

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

**AAP Releases Policy on Tetanus, Diphtheria, Acellular Pertussis (Tdap)
Vaccine**

To protect adolescents against pertussis and reduce the reservoir of
pertussis within the population at large, the American Academy of
Pediatrics (AAP) is releasing a new policy recommending adolescents,
11-18 years of age (preferably at the 11-to12-year visit) receive the
newly licensed tetanus toxoid, diphtheria toxoid, and acellular
pertussis (Tdap) vaccine. This policy also contains extensive
information on special circumstances surrounding the use of the Tdap
vaccine.

The Academy has prepared a number of resources to help pediatricians
implement the new recommendations. The resources can be found on the AAP
Member Center and include:

-   AAP policy on Tdap

-   AAP News article on the topic

-   Tdap Vaccine Implementation Information for 2005

-   Vaccine Reminder Recall Systems: A Practical Guide for Pediatric
    Practices

The AAP posts continually updated information on the licensure and
recommendation status for new vaccines on Red Book Online at
<http://aapredbook.aappublications.org/news/vaccstatus.shtml>

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

**Youth Suicide: Two factors predict risk in youth emergency psychiatric
hospitalization**

<http://www.ahrq.gov/research/oct05/1005RA19.htm>

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

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

**Quick Assessment of Literacy in Primary Care: The Newest Vital Sign**

RESULTS The Newest Vital Sign (NVS), is a nutrition label that is
accompanied by 6 questions and requires 3 minutes for administration. It
is reliable (Cronbach
![](media/image5.png){width="8.333333333333333e-2in"
height="6.25e-2in"}\>0.76 in English and 0.69 in Spanish) and correlates
with the TOFHLA. Area under the ROC curve is 0.88 for English and 0.72
for Spanish versions. Patients with more than 4 correct responses are
unlikely to have low literacy, whereas fewer than 4 correct answers
indicate the possibility of limited literacy.

CONCLUSION The Quick Assessment of Literacy in Primary Care, the newest
vital sign, is suitable for use as a quick screening test for limited
literacy in primary health care settings.

## **Barry D. Weiss, et al** Quick Assessment of Literacy in Primary Care: The Newest Vital Sign **Annals of Family Medicine** 3:514-522 (2005)

<http://www.annfammed.org/cgi/content/full/3/6/514>

**Stroke preventive treatments are well understood and widely available:
Why isn't it used?**

Cerebrovascular disease is the third leading cause of mortality and the
leading cause of long-term neurological disability in the United States.
Most strokes are of ischemic origin and, other than cardioembolic or
small vessel strokes, are caused by the development of platelet-fibrin
thrombi on an atherosclerotic plaque. This underlying disease mechanism
shares important features with coronary artery disease and peripheral
artery disease, highlighting the systemic nature of atherothrombosis and
the elevated cross risk in stroke patients for ischemic events in other
vascular beds. It has been estimated that up to 80% of ischemic strokes
could be prevented with application of currently available treatments
for blood pressure, cholesterol, and antithrombotic therapies. Stroke is
not, like cancer, waiting for a scientific breakthrough; stroke
preventive treatments are well understood and widely available. It is
only the application of these treatments to patients, many of whom do
not visit physicians, that is lacking. Clearly, better education of the
public and active participation of primary care physicians is essential
to get the message out to all those at risk. [Kirshner
HS](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Kirshner+HS"%5BAuthor%5D),
et al Long-term therapy to prevent stroke. [J Am Board Fam
Pract.](javascript:AL_get(this, 'jour', 'J Am Board Fam Pract.');) 2005
Nov-Dec;18(6):528-40.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16322415&dopt=Abstract>

USPHS Releases Updated Guidelines for Management of Occupational
Exposure to HIV

The U.S. Public Health Service (USPHS) has issued updated guidelines for
prophylaxis of health care professionals with occupational exposure to
blood and other body fluids that might contain human immunodeficiency
virus (HIV). The recommendations, \"Updated U.S. Public Health Service
Guidelines for the Management of Occupational Exposures to HIV and
Recommendations for Postexposure Prophylaxis,\" were published in the
Sept. 30, 2005, issue of *Morbidity and Mortality Weekly Report
Recommendations and Reports* and are available online at
<http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5409a1.htm>

Moderate Exercise Improves Breast Cancer Outcomes

Physical activity appears to be associated with a lower risk of
developing breast cancer and an improved quality of life after breast
cancer diagnosis. The mechanism may be hormonal, with lower levels of
circulating ovarian hormones present in women who exercise. Holmes and
colleagues examined the relationship between physical activity and
recurrence and mortality outcomes after breast cancer diagnosis.

The authors conclude that women have improved survival by any measured
outcome if they exercise more than 3.0 MET hours per week. Because the
finding applied particularly to women with receptor-positive tumors in
this study, the authors speculate that hormonal alterations are
responsible for this benefit. Walking at an average pace for three to
five hours per week is associated with the maximal benefit. Holmes MD,
et al. Physical activity and survival after breast cancer diagnosis.
JAMA May 25, 2005;293:2479-86.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15914748&query_hl=4>

**Management of Active Tuberculosis**

Although the overall incidence of tuberculosis has been declining in the
United States, it remains an important public health concern,
particularly among immigrants, homeless persons, and persons infected
with human immunodeficiency virus. Patients who present with symptoms of
active tuberculosis (e.g., cough, weight loss, or malaise with known
exposure to the disease) should be evaluated. Three induced sputum
samples for acid-fast bacillus smear and culture should be obtained from
patients with findings of tuberculosis or suspicion for active disease.
If the patient has manifestations of extrapulmonary tuberculosis, smears
and cultures should be obtained from these sites. Most patients with
active tuberculosis should be treated initially with isoniazid,
rifampin, pyrazinamide, and ethambutol for eight weeks, followed by 18
weeks of treatment with isoniazid and rifampin if needed. Repeat
cultures should be performed after the initial eight-week treatment. Am
Fam Physician 2005;72:2225-32, 2235.

<http://www.aafp.org/afp/20051201/2225.html>

**Acetaminophen-related liver failure rising sharply in US**

In conclusion, acetaminophen hepatotoxicity far exceeds other causes of
acute liver failure in the United States. Susceptible patients have
concomitant depression, chronic pain, alcohol or narcotic use, and/or
take several preparations simultaneously. Education of patients,
physicians, and pharmacies to limit high-risk use settings is
recommended.

[Larson
AM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Larson+AM"%5BAuthor%5D),
et al Acetaminophen-induced acute liver failure: results of a United
States multicenter, prospective study.
[Hepatology.](javascript:AL_get(this, 'jour', 'Hepatology.');) 2005
Dec;42(6):1364-72.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16317692&query_hl=6>

St. John\'s Wort

St. John\'s wort has been used to treat a variety of conditions. Several
brands are standardized for content of hypericin and hyperforin, which
are among the most researched active components of St. John\'s wort. St.
John\'s wort has been found to be superior to placebo and equivalent to
standard antidepressants for the treatment of mild to moderate
depression. Studies of St. John\'s wort for the treatment of major
depression have had conflicting results. St. John\'s wort is generally
well tolerated, although it may potentially reduce the effectiveness of
several pharmaceutical drugs. Am Fam Physician 2005;72:2249-54.

<http://www.aafp.org/afp/20051201/2249.html>

**Management of *Staphylococcus aureus* Infections**

Because of high incidence, morbidity, and antimicrobial resistance,
*Staphylococcus aureus* infections are a growing concern for family
physicians. Strains of *S. aureus* that are resistant to vancomycin are
now recognized. Increasing incidence of unrecognized community-acquired
methicillin-resistant *S. aureus* infections pose a high risk for
morbidity and mortality. Although the incidence of complex *S. aureus*
infections is rising, new antimicrobial agents, including daptomycin and
linezolid, are available as treatment. *S. aureus* is a common pathogen
in skin, soft-tissue, catheter-related, bone, joint, pulmonary, and
central nervous system infections. *S. aureus* bacteremias are
particularly problematic because of the high incidence of associated
complicated infections, including infective endocarditis. Adherence to
precautions recommended by the Centers for Disease Control and
Prevention, especially handwashing, is suboptimal. (Am Fam Physician
2005;72:2474-81. <http://www.aafp.org/afp/20051215/2474.html>

**Treatment of Irritable Bowel Syndrome**

Irritable bowel syndrome affects 10 to 15 percent of the U.S. population
to some degree. This condition is defined as abdominal pain and
discomfort with altered bowel habits in the absence of any other
mechanical, inflammatory, or biochemical explanation for these symptoms.
Irritable bowel syndrome is more likely to affect women than men and is
most common in patients 30 to 50 years of age. Symptoms are improved
equally by diets supplemented with fiber or hydrolyzed guar gum, but
more patients prefer hydrolyzed guar gum. Antispasmodic agents may be
used as needed, but anticholinergic and other side effects limit their
use in some patients. Loperamide is an option for treatment of
moderately severe diarrhea. Antidepressants have been shown to relieve
pain and may be effective in low doses. Trials using alosetron showed a
clinically significant, although modest, gain over placebo, but it is
indicated only for women with severe diarrhea-predominant symptoms or
for those in whom conventional treatment has failed. Tegaserod has an
advantage over placebo in constipation-predominant irritable bowel
syndrome; it is indicated for up to 12 weeks of treatment in women.
However, postmarketing reports of severe diarrhea and ischemic colitis
further limit its use. Herbal therapies such as peppermint oil also may
be effective in the treatment of irritable bowel syndrome. Therapies
should focus on specific gastrointestinal dysfunctions (e.g.,
constipation, diarrhea, pain), and medications only should be used when
nonprescription remedies do not work or when symptoms are severe. (Am
Fam Physician 2005;72:2501-6.
<http://www.aafp.org/afp/20051215/2501.html>

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

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

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

Duration of Therapy for Women with Uncomplicated UTI: Cochrane Briefs

Clinical Question

What is the most appropriate duration of therapy for uncomplicated
urinary tract infections (UTIs) in women?

Evidence-Based Answer

Three days of antibiotic therapy is as effective as longer courses for
treatment of uncomplicated UTIs in women.

Practice Pointers

Uncomplicated UTIs in women are one of the most common indications for
antibiotics. To prevent resistance, antibiotics should be used
judiciously; thus, it is important to determine the minimum duration of
antibiotic therapy required for treatment to be effective.

Milo and colleagues reviewed 32 randomized controlled trials (with a
total of 9,605 patients) comparing three days of oral antibiotic therapy
with longer courses for women 18 to 65 years of age. Pregnant women and
women with symptoms that suggest upper UTI (e.g., fever, flank pain,
vomiting, positive blood cultures) were excluded.

For short- and long-term resolution of symptoms, the reviewers found no
difference between a three-day antibiotic course and a course lasting
five to 10 days. Longer courses were more effective at clearing the
bacteria on follow-up culture but also caused more adverse effects, and
it is not clear that bacterial clearance results in improved
patient-oriented outcomes. Although data were limited, organisms
cultured were not more likely to be resistant to antibiotics after
treatment in either group. For most women, a three-day course of
antibiotics is sufficient to treat symptoms.

The Institute for Clinical Systems Improvement (ICSI) guideline
recommends treatment with double-strength trimethoprim/sulfamethoxazole
(Bactrim DS, Septra DS), one tablet twice per day for three days; or
trimethoprim (Proloprim) at a dosage of 100 mg twice per day for three
days. For women who are allergic to these first-line medications, the
ICSI guideline^1^ recommends ciprofloxacin (Cipro) at a dosage of 250 mg
twice per day for three days, or nitrofurantoin (Macrobid) at a dosage
of 100 mg twice per day for seven days. Telephone screening and
prescription of treatment is appropriate if there are no complicating
factors. In the office, urinalysis is adequate for evaluating symptoms.

Institute for Clinical Systems Improvement. Uncomplicated urinary tract
infection in women.

Bloomington, Minn.: Institute for Clinical Systems Improvement, 2004.

Milo G, et al. Duration of antibacterial treatment for uncomplicated
urinary tract infection in women. Cochrane Database Syst Rev
2005;(2):CD004682

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

Metformin Increases Fertility in Patients with PCOS

**Clinical Question:** Is metformin (Glucophage) more effective than
clomiphene (Clomid) for improving fertility in nonobese women with
polycystic ovary syndrome (PCOS)?

**Bottom Line:** In nonobese women with PCOS, metformin is more
effective than clomiphene for improving the rate of conception.

(Level of Evidence: 1b)

Palomba S, et al. Prospective parallel randomized, double-blind,
double-dummy controlled clinical trial comparing clomiphene citrate and
metformin as the first-line treatment for ovulation induction in
nonobese anovulatory women with polycystic ovary syndrome. J Clin
Endocrinol Metab July 2005;90:4068-74.
<http://www.aafp.org/afp/20051215/tips/7.html>

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

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

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

**Intrapartum fetal heart rate monitoring. ACOG Practice Bulletin**

Summary of Recommendations and Conclusions

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

-   The false-positive rate of EFM for predicting adverse outcomes is
    high.

-   The use of EFM is associated with an increase in the rate of
    operative interventions (vacuum, forceps, and cesarean delivery).

-   The use of EFM does not result in a reduction of cerebral palsy
    rates.

-   With persistent variable decelerations, amnioinfusion reduces the
    need to proceed with emergent cesarean delivery and should be
    considered.

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

-   The labor of parturients with high-risk conditions should be
    monitored continuously.

-   Reinterpretation of the FHR tracing, especially knowing the neonatal
    outcome, is not reliable.

-   The use of fetal pulse oximetry in clinical practice cannot be
    supported at this time

Intrapartum fetal heart rate monitoring. ACOG Practice Bulletin No. 70.
American College of Obstetricians and Gynecologists. Obstet Gynecol
2005;106:1453--61.

**ACOG Members**

<http://www.acog.org/publications/educational_bulletins/pb070.cfm>

**Non-members**

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16319279&query_hl=11>

**Inappropriate use of the terms fetal distress and birth asphyxia**

ABSTRACT: The Committee on Obstetric Practice is concerned about the
continued use of the term \"fetal distress\" as an antepartum or
intrapartum diagnosis and the term "birth asphyxia" as a neonatal
diagnosis. The Committee reaffirms that the term fetal distress is
imprecise and nonspecific. The communication between clinicians caring
for the woman and those caring for her neonate is best served by
replacing the term fetal distress with \"nonreassuring fetal status,\"
followed by a further description of findings (eg, repetitive variable
decelerations, fetal tachycardia or bradycardia, late decelerations, or
low biophysical profile). Also, the term birth asphyxia is a nonspecific
diagnosis and should not be used.

Inappropriate use of the terms fetal distress and birth asphyxia. ACOG
Committee Opinion No. 326. American College of Obstetricians and
Gynecol-ogists. Obstet Gynecol 2005;106:1469--70.

**ACOG Members**

<http://www.acog.org/publications/committee_opinions/co326.cfm>

**Non-members**

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16319282&query_hl=15>

**Vaginal Birth Not Associated With Incontinence Later in Life**

<http://www.acog.org/from_home/publications/press_releases/nr11-30-05-1.cfm>

**Update on Carrier Screening for Cystic Fibrosis: Committee Opinion**

ABSTRACT: In 2001, the American College of Obstetricians and
Gynecologists and the American College of Medical Genetics introduced
guidelines for prenatal and preconception carrier screening for cystic
fibrosis. The American College of Obstetricians and Gynecologists has
updated current guidelines for cystic fibrosis screening practices among
obstetrician--gynecologists.

Update on carrier screening for cystic fibrosis. ACOG Committee Opinion
No. 325. American College of Obstetricians and Gynecologists. Obstet
Gynecol 2005;106:1465--8.

**ACOG Members**

<http://www.acog.org/publications/committee_opinions/co325.cfm>

**Non-members**

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16319281&query_hl=13>

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

**Two American Indian tribes with different rates of smoking, but
similarly high life traumas**

<http://www.ahrq.gov/research/sep05/0905RA7.htm>

**Survey reveals shortage of radiologists and certified mammography
technologists at U.S. community mammography facilities**

<http://www.ahrq.gov/research/sep05/0905RA21.htm>

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

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

**Obesity Before Pregnancy Linked to Childhood Weight Problems**

A new study shows that a child\'s weight may be influenced by the mother
even before the child is actually born. A child is more likely to be
overweight at a very young age - at 2 or 3 years old - if the mother was
overweight or obese before she became pregnant. The data also indicate
that other prenatal characteristics, particularly race, ethnicity, and
maternal smoking during pregnancy, place a child at greater risk of
becoming overweight.

##### Specifically, a child is at greater risk of becoming overweight if born to a black or Hispanic mother, or to a mother who smoked during her pregnancy. The study, conducted by researchers from Ohio State University (OSU) College of Nursing and School of Public Health was supported by the National Institute of Nursing Research (NINR), one of the National Institutes of Health (NIH). [**Salsberry PJ**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Salsberry+PJ"%5BAuthor%5D), [**Reagan PB**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Reagan+PB"%5BAuthor%5D).. Dynamics of early childhood overweight. Pediatrics 2005 Dec; 116(6): 1329-38

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16322155&query_hl=3>

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

**New studies shows a 15% reduction for the risk of diabetes for every
year of lactation**

The risk for developing diabetes is reduced with longer duration of
breastfeeding, according to the results of two large cohort studies
published in the Nov. 23/30 issue of JAMA.

\"Lactation is associated with improved glucose and insulin homeostasis,
independent of weight change,\" write Alison M. Stuebe, MD, from Brigham
and Women\'s Hospital in Boston, Massachusetts, and colleagues.
\"Although several studies have examined the effects of lactation on
glucose metabolism, no study, to our knowledge, has examined the
association between maternal lactation and type 2 diabetes \[DM\]
risk.\"

The investigators analyzed data from a prospective observational cohort
of 83,585 parous women in the Nurses\' Health Study (NHS) and from a
retrospective observational cohort of 73,418 parous women in the
Nurses\' Health Study II (NHS II). The primary outcome was incident
cases of type 2 DM.

In the NHS, 5,145 cases of type 2 DM were diagnosed between 1986 and
2002 during 1,239,709 person-years of follow-up. In the NHS II, 1,132
cases were diagnosed during 778,876 person-years of follow-up between
1989 and 2001.

Increasing duration of lactation was associated with a reduced risk for
type 2 DM. In the NHS, for each additional year of lactation, women with
a birth in the prior 15 years had a decrease in diabetes risk of 15%,
after adjustment for current body mass index (BMI) and other relevant
risk factors for type 2 DM. In the NHS II, the corresponding decrease in
risk was 14%.

Our data on exclusive breastfeeding and duration stratified by parity
suggest that the length and intensity of breastfeeding with each
pregnancy affect the association with diabetes risk,\" Dr. Michels and
colleagues wrote.

\"We found that each year of exclusive breastfeeding was associated with
a greater risk reduction than total breastfeeding,\" they continued.
\"This may reflect the greater metabolic burden imposed by exclusive
breastfeeding.\"

They also found that longer duration of breastfeeding per pregnancy was
associated with a greater benefit. For example: women who breastfed one
child for a total of one year had a 44% reduction in age-adjusted risk
for diabetes, whereas one-year total breastfeeding duration divided
between two children was associated with only a 24% reduction in risk.

\"Together with clinical evidence of improved glucose homeostasis in
lactating women, these data suggest that lactation may reduce the risk
of type 2 diabetes in young and middle-aged women,\" the investigators
concluded.

Duration of Lactation and Incidence of Type 2 Diabetes

Stuebe AM et al. Duration of Lactation and Incidence of Type 2 Diabetes
JAMA. 2005;294:2601-2610
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16304074&query_hl=1>

**Infant feeding choice collection tool**

We are moving to infant feeding choices that will clarify and
distinguish initiation, duration, feeding practices. The following has
been tested at PIMC since August in the Pediatrics practice.

+----------------+-------------------+--------------+------+----------+
| **Feeding      |                   |              |      |          |
| Choice (today) |                   |              |      |          |
| X**            |                   |              |      |          |
+----------------+-------------------+--------------+------+----------+
| Breastfeeding  |                   |              |      |          |
| only           |                   |              |      |          |
+----------------+-------------------+--------------+------+----------+
| Mostly         |                   |              |      |          |
| Breastfeeding  |                   |              |      |          |
+----------------+-------------------+--------------+------+----------+
| ½              |                   |              |      |          |
| Breastfeeding  |                   |              |      |          |
|                |                   |              |      |          |
| ½ Formula      |                   |              |      |          |
| feeding        |                   |              |      |          |
+----------------+-------------------+--------------+------+----------+
| Mostly Formula |                   |              |      |          |
| feeding        |                   |              |      |          |
+----------------+-------------------+--------------+------+----------+
| Formula        |                   |              |      |          |
| feeding only   |                   |              |      |          |
+----------------+-------------------+--------------+------+----------+
| **One time     |                   |              |      |          |
| data fields**  |                   |              |      |          |
+----------------+-------------------+--------------+------+----------+
| Mom's name     |                   |              |      |          |
|                |                   |              |      |          |
| Or chart#      |                   |              |      |          |
+----------------+-------------------+--------------+------+----------+
| birth order    |                   | Birth wt.    |      |          |
+----------------+-------------------+--------------+------+----------+
| started        |                   | \            |      |          |
| formula        |                   | _\_\_wks/mth |      |          |
+----------------+-------------------+--------------+------+----------+
| stopped        |                   | \            |      |          |
| breastfeeding  |                   | _\_\_wks/mth |      |          |
+----------------+-------------------+--------------+------+----------+
| started solids |                   | \            |      |          |
|                |                   | _\_\_wks/mth |      |          |
+----------------+-------------------+--------------+------+----------+

Questions? <Judith.Thierry@ihs.gov>

**Women in the US Need More Breastfeeding Support**

CONCLUSIONS: Our findings indicate a need to provide extensive
breastfeeding support after delivery, particularly to women who may
experience difficulties in breastfeeding.

[Ahluwalia
IB](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Ahluwalia+IB"%5BAuthor%5D),
et al Why do women stop breastfeeding? Findings from the Pregnancy Risk
Assessment and Monitoring System.
[Pediatrics.](javascript:AL_get(this, 'jour', 'Pediatrics.');) 2005
Dec;116(6):1408-12.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16322165&query_hl=8>

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

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

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

\-[Evidence does not justify routine use: Magnesium sulfate
prophylaxis - mild
pre-eclampsia](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_AOM.cfm)

\-[Medical Staff Credentialing and Privileging Guide, 3rd Edition: Now
available](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Coll.cfm)

\-[Two handy 'Best Practice' checklists now available: DM or HTN in
pregnancy](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_HT.cfm#ob)

\-[Have you ever had problems with a stenotic cervix? Here's an easy
solution](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_HT.cfm#gyn)

\-[Advanced skills practitioner not needed at uncomplicated elective
cesarean
delivery](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_HT.cfm#child)

\-[Beyond Red Lake - The persistent crisis in American Indian Health
Care](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_HT.cfm#chrIll)

\-[Low Testosterone Not Linked with Female Sexual
Dysfunction](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Feat.cfm#afp)

\-[USPSTF Releases Updated Guide to Clinical Preventive
Services](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Feat.cfm#ahrq)

\-[Exciting news: All clinicians involved with Indian Health are now
invited: Tribal, urban,
etc..](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Feat.cfm#AskLib)

\-[We need your expertise: Breast Feeding Best Practices in Indian
Country](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Feat.cfm#breast)

\-[FDA Updates Labeling for Ortho Evra Contraceptive
Patch](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Feat.cfm#fp)

\-[DMPA bone mass loss is
reversible](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Feat.cfm#fp)

\-[The HCG curve has been redefined. How about
ultrasound?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Feat.cfm#mmtour)

\-[Bioidentical Hormones: No scientific evidence to support claims of
increased
efficacy](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Feat.cfm#mscape)

\-[Trends in umbilical cord care: Scientific Evidence for
Practice](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Feat.cfm#MidWives)

\-[Once a day gentamicin dosing intrapartum may provide better coverage
for the
fetus ](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Feat.cfm#navajo)

\-[Stressful workplaces and unfair bosses can raise cardiac
risks](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Feat.cfm#nurseCorner)

\-[Shoulder
dystocia](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Feat.cfm#okie)

\-[Many new additions to the Indian Health Guidelines / Patient
Education web
page](http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-guidesA-Z.cfm)

\-[Estrogen supplementation may be protective of BMD in adolescents who
use
DMPA](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Feat.cfm#oste)

\-[Medical Management of Early Pregnancy Failure -- Use
Misoprostol](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Feat.cfm#periPicks)

\-[Daily suppressive therapy is recommended for HSV-2 seropositive
individuals](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Feat.cfm#std)

\-[Just an additional 3200 steps a day, not 10,000 shows fitness
gains](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105_Feat.cfm#stillW)

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/documents/05NovOL.pdf**](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/05NovOL.pdf) {#httpwww.ihs.govmedicalprogramsmchmdocuments05novol.pdf .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

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

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

**"Dating & Violence Should Never Be a Couple" Preventing Teen Dating
Violence**

WEBCAST Tuesday, February 7, 2006 2:00 -- 4:00 p.m. EST

Room 18-05, Parklawn Building

For more information please contact Larissa J. Estes at
<LEstes@hrsa.gov> or 301-443-1527

**Funding for Legal Services to Victims of DV, Sexual Assault, Stalking
& Dating Violence**\
The Office on Violence Against Women, U.S. Department of Justice will be
accepting applications from tribal governments, tribal consortia, and
non-profit corporations (such as shelters, victim advocacy
organizations, and legal services programs)  under the Fiscal Year 2006
Legal Assistance for Victims Grant Program (LAV).  Grants of \$450,000
to \$850,000 can be used to provide direct civil legal services to
victims of domestic violence, dating violence, sexual assault, and
stalking during a 24 month period.  Examples of civil legal services
include representation in divorces, child custody and support cases,
protection orders, landlord-tenant or housing authority disputes, public
benefits, and other civil legal matters related to the violence.

[Why Apply?]{.underline}\
Many Native victims of domestic violence, sexual assault, stalking, and
dating violence do not have access to basic legal services critical to
ensuring their safety and autonomy. This federal grant can provide the
funding to start a legal services program or to hire\
additional personnel for an existing program. Letter of Intent Deadline:
December 27, 2005\
<http://www.fedgrants.gov/Applicants/DOJ/HQ/OJP/OVW-2006-1204/listing.html>

**Project about Adult Native American and Alaska Native Women and Sexual
Assault**

Request for Testimony

Amnesty is now researching the prevalence of sexual assault against
adult Native American and Alaska Native women as well as what is being
done to address these crimes. We are being assisted in this project by
the Tribal Law and Policy Institute, a Native American owned and
operated non-profit corporation organized to design and deliver
education and research which promote the enhancement of justice in
Indian country and the health, well-being, and culture of Native
peoples.

The goal of the project is to make real changes. At the end of the
project, Amnesty will be publishing a report that will describe violence
against adult Native American and Alaska Native women across the
country. The report will talk about specific examples, and will let the
public know how tribal, state and federal justice systems respond to
sexual assault against adult Native American and Alaska Native women.
The report will include recommendations based on our conversations with
adult Native American and Alaska Native survivors and service providers.
In collaboration, Amnesty International will be campaigning based on the
report\'s recommendations to try and effect changes that need to be
made.

In order to do our research, it is very important that we hear about the
experiences of Native American survivors and their families. Any
testimony you feel comfortable sharing with us will help us document the
prevalence of sexual assault against adult Native American and Alaska
Native women, and will help us identify patterns and problems. Complete
confidentiality is guaranteed to people who come forward to tell their
stories. We will not include names or identifying information in any
public documents unless you tell us that it is OK to do so.

If you are interested in participating in our research or have any
questions about it, please contact Bonnie Clairmont of the Tribal Law
and Policy Institute or Carol Pollack of Amnesty International USA.
Bonnie can be reached at: <bonnie@tribal-institute.org> or call Bonnie
toll free at: 1-888-644-1125. Carol can be reached at:
<cpollack@aiusa.org> or call Carol toll free at: 1-866-634-6519.

Please contact us by January 31, 2006

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

**Women with DM had about 25% higher prevalence of incontinence**

This prospective, observational study in 81,845 women of the Nurses
Health Study cohort asked about prevalence and severity of incontinence
in 1996 and 2000 and evaluated the relationship to prevalence and
duration of diabetes mellitus (DM).  The average age in 1996 was about
62 for women with DM, about 64 for women without.

 Women with DM had about 25% higher prevalence of incontinence. However
women with DM had a much higher risk of severe incontinence (up to 80%
higher) of the sort likely to affect daily activities (leakage through
clothing).  Incidence (new onset) severe incontinence was roughly double
for those women with DM.  Duration of DM increased the risk of new
incontinence, so that women with DM of 10 years or longer duration were
half again as likely as women without DM (RR=1.47) to develop any
incontinence and at 150% greater risk (RR 2.62) of severe incontinence. 
Women with microvascular complications of DM had over double risk of
developing any kind of incontinence. 

 Although obesity is a well recognized risk factor for incontinence and
the BMI for the women with DM were, on average, higher than for those
without, the relationship between DM and incontinence persisted when
only non-obese women with and without DM were compared.

#### 

#### [Elder Care Initiative Director Editorial comment: Bruce Finke]{.underline}

The high rates of diabetes in Indian Country make this study even more
relevant in the Indian health system.  Incontinence often goes
unreported and severe incontinence can contribute to social isolation,
depression, and functional impairment.  How many of us would be eager to
exercise in a social setting if we were worried about leaking through
our clothing?  And how many of us would raise this as an issue with our
physician, PA, or NP if were not asked?  Asking about incontinence
should be a routine part of care for older women (see Preventive Care
Guidelines for the Elderly in the IHS Primary Care Provider, [May 2003
Issue](http://www.ihs.gov/PublicInfo/Publications/HealthProvider/issues/PROV0503.pdf))
and a routine part of our care for all women with diabetes. 

[Lifford KL, Curhan GC, Hu FB, Barbieri RL, Grodstein
F.](http://www.ncbi.nlm.nih.gov.libproxy.unm.edu/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16274364&query_hl=1) 
Type 2 diabetes mellitus and risk of developing urinary incontinence.  J
Am Geriatr Soc. 2005 Nov;53(11):1851-7.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16274364&query_hl=12>

Treatment of Constipation in Older Adults

Constipation is a common complaint in older adults. Although
constipation is not a physiologic consequence of normal aging, decreased
mobility and other comorbid medical conditions may contribute to its
increased prevalence in older adults. Functional constipation is
diagnosed when no secondary causes can be identified, such as a medical
condition or a medicine with a side effect profile that includes
constipation. Empiric treatment may be tried initially for patients with
functional constipation. Management of chronic constipation includes
keeping a stool diary to record the nature of the bowel movements,
counseling on bowel training, increasing fluid and dietary fiber intake,
and increasing physical activity. There are a variety of
over-the-counter and prescription laxatives available for the treatment
of constipation. Fiber and laxatives increase stool frequency and
improve symptoms of constipation. If constipation is refractory to
medical treatment, further diagnostic evaluation may be warranted to
assess for colonic transit time and anorectal dysfunction. Alternative
treatment methods such as biofeedback and surgery may be considered for
these patients. Am Fam Physician 2005;72:2277-84, 2285.

<http://www.aafp.org/afp/20051201/2277.html>

**Older Patients with Caregivers and Assistance for Activities of Daily
Living: 1998 and 2000**

This analysis uses data from the 1998 and 2000 National Home and Hospice
Care Surveys to examine activities of daily living (ADL) assistance
received by home health patients ages 65 years and over and the extent
to which receipt of services is related to sex. More males than females
lived with their primary caregiver, 90 percent versus 68 percent, most
likely due to men being cared for by their spouses who outlived them.
Significant differences were found between the sexes in the receipt of
ADL assistance. Specifically, more women than men received assistance
with any activity of daily living overall, 53 percent compared to 42
percent, respectively. Almost half of the female patients (45 percent)
received assistance from a home health agency to bathe or shower
compared to more than one-third of male patients (35 percent). Eating
assistance was almost twice as likely among female patients as male. In
addition, 25 percent of females received assistance from the agency in
using the toilet room compared to 16 percent of males.

<http://www.cdc.gov/nchs/products/pubs/pubd/hestats/homhltpatients.htm>

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

**Women who attend a postpartum visit 3x more likely to use postpartum
contraception**

Our results are consistent with previous findings that use of a reliable
method of contraception is associated with postpartum visits. The study
sample included 4,096 women (1,970 Hispanic, 502 Native American, and
1,352 non-Hispanic white).

\* Women who had a postpartum visit were three times more likely to use
postpartum contraception than women who did not

\* In 44% of the women, the index pregnancy was mis-timed or undesired.

\* Hispanics were more likely than Native Americans to use postpartum
contraception.

Our experience shows that it is especially important to provide
\[contraception counseling for family planning\] in the postpartum
setting. [CONCLUSION]{.underline}: Focused contraception counseling,
especially in the postpartum setting, is important to help ensure the
well-being of women and children

DePineres T, Blumenthal PD, Diener-West M. 2005. Postpartum
contraception:

The New Mexico Pregnancy Risk Assessment Monitoring System.
Contraception 72(6):422-425

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16307963&query_hl=10>

**Ortho Evra Contraceptive Patch Linked to Increased Estrogen Exposure**

The U.S. Food and Drug Administration (FDA) approved new labeling
regarding the increased level of estrogen exposure associated with use
of an ethinyl estradiol/norelgestromin transdermal system (Ortho Evra,
made by Ortho McNeil Pharmaceuticals, Inc.) compared with most oral
contraceptives.\
The warning was based on the results of pharmacokinetic studies showing
that steady-state levels of ethinyl estradiol were increased by 60% in
patch users compared with those taking once-daily oral contraceptives
containing 35 µg of estrogen. However, use of the transdermal patch also
yielded a 25% decrease in maximal exposure.\
Although use of the weekly patch may reduce the risk of pregnancy in
women who are noncompliant with a daily oral contraceptive regimen, the
FDA advises that the potential risks of increased estrogen exposure (eg,
thrombotic adverse events) be considered prior to use of the product.\
The FDA notes that it remains unclear whether women using the patch are
at higher risk for serious adverse events compared with those taking
oral contraceptives.\
Further information regarding the ethinyl estradiol/norelgestromin
transdermal contraceptive system may be obtained by contacting the FDA
Division of Drug Information at 1-888-INFO-FDA (1-888-463-6332), or by
sending an email to <druginfo@cder.fda.gov>.\
Adverse events related to the use of the contraceptive patch devices
should be reported to the FDA\'s MedWatch program by phone at
1-800-FDA-1088, by fax at 1-800-FDA-0178, online at
<http://www.fda.gov/medwatch>, or by mail to 5600 Fishers Lane,
Rockville, MD 20852-9787.

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

**The Indian Health Women's Health pages are getting a facelift and
needs input**

This site provides resources on access to care, maturity issues,
violence against Native women, just to name a few items. Please take a
look at this site as we are currently performing a re-design and
facelift to let us know what other resources would be helpful and / or
how to make this site more user friendly for Indian Health staff.
<http://www.ihs.gov/MedicalPrograms/MCH/Wh.asp>

Contact David Gahn <David.Gahn@ihs.gov>

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

**Q. Should we perform a routine urine screen at each prenatal visit?**

<http://www.ihs.gov/MedicalPrograms/MCH/M/UVfaqs.cfm#urineScreen>

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

**December 2005 Highlights**

\- Antibiotics: Everyone says there overused in America. Here is one
study that supports that with regards to strep throat infections and a
second one that suggests under treatment of otitis media may lead to
more mastoiditis

-Dr Singelton weighs in on whether the success of the current Prevnar
vaccine may lead to an increase of non vaccine serotypes of Strep
pneumoniae

\- Dr.Esposito weighs in on many matters including motor vehicle
accident rates in Native Americans and a new increased risk of
retinopathy of prematurity in Asians and Native Americans

<http://www.ihs.gov/MedicalPrograms/MCH/C/documents/ICHN1205.doc>

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

**National Release Notice - Clinical Reporting System, Version 6.0**

The new Clinical Reporting System (CRS ) has been released today. Please
ask your site managers about technical issues. Special thanks to
Stephanie Klepacki, Lori Butcher and Mark Williams for their development
assistance.

We are pleased to announce the release of BGP Clinical Reporting System,
Version 6.0.  The package was beta tested at Shoalwater Bay Tribal
Health, Portland Area Office, Choctaw Nation Health, Cherokee Indian
Hospital, Warm Springs Health and Wellness Center, Red Lake Indian
Hospital and Indian Health Council, Inc.  The routines and documentation
adhere to the 2005 RPMS Programming Standards and Conventions.
Available: <http://www.ihs.gov/Cio/RPMS/appselect.cfm>

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

Cross-Cultural Medicine

Cultural competency is an essential skill for family physicians because
of increasing ethnic diversity among patient populations. Culture, the
shared beliefs and attitudes of a group, shapes ideas of what
constitutes illness and acceptable treatment. A cross-cultural interview
should elicit the patient\'s perception of the illness and any
alternative therapies he or she is undergoing as well as facilitate a
mutually acceptable treatment plan. Patients should understand
instructions from their physicians and be able to repeat them in their
own words. To protect the patient\'s confidentiality, it is best to
avoid using the patient\'s family and friends as interpreters. Potential
cultural conflicts between a physician and patient include differing
attitudes towards time, personal space, eye contact, body language, and
even what is important in life. Latino, Asian, and black healing
traditions are rich and culturally meaningful but can affect management
of chronic medical and psychiatric conditions. Efforts directed toward
instituting more culturally relevant health care enrich the
physician-patient relationship and improve patient rapport, adherence,
and outcomes. Am Fam Physician 2005;72:2267-74.

<http://www.aafp.org/afp/20051201/2267.html>

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

**New cigarettes with flavors that appeal to youth**

The researchers reviewed internal tobacco industry documents via a
Web-based search of collections made publicly available through the 1998
Master Settlement Agreement between the state attorneys general and
major U.S. tobacco manufacturers

\* Internally, the appeal of flavored cigarettes has long been
associated with specific consumer populations, particularly young
smokers and novice smokers.

\* The concept of flavored cigarettes as a strategy for expanding the
cigarette market has been revisited periodically over many years.

\* Product concepts targeting smokers ages 18-24 include aftertaste,
tobacco satisfaction, and menthol aftertaste and aroma. The product
technologies proposed to address these areas include non-conventional
methods.

\* Past research on flavor technology is directly linked to the
development of today\'s flavored cigarettes.

\* A physical examination of the filter confirmed the placement of a
flavor-delivering pellet not visible to the consumer in certain Camel
Exotic Blend cigarettes.

\* The review identified few internal evaluations of the new product
technologies used in today\'s flavored cigarettes.

\"The potential influence of flavored cigarettes initiation might go
unrecognized without efforts to increase awareness,\" state the authors.

They conclude that \"coordinated public education and community action
are needed to inform youth . . . and confront the tobacco industry,
especially in the absence of governmental regulation.\" Carpenter CM,
Wayne GF, Pauly JL, et al. 2005. New cigarette brands with flavors that
appeal to youth: Tobacco marketing strategies. Health Affairs
24(6):1601-1610.
[[http://content.healthaffairs.org/cgi/content/full/24/6/1601]{.underline}](http://content.healthaffairs.org/cgi/content/full/24/6/1601)

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

#### CC: I feel really cold and my side hurts, plus I am shaking all over {#cc-i-feel-really-cold-and-my-side-hurts-plus-i-am-shaking-all-over .Style-Heading-4-+-Arial-14-pt-Underline}

#### The patient was a 21 year old G2 P1001 who presented to her Community Health Aide (CHA) in a rural Alaskan village complaining of nausea, vomiting, shaking chills, and contractions every 2 minutes.  {#the-patient-was-a-21-year-old-g2-p1001-who-presented-to-her-community-health-aide-cha-in-a-rural-alaskan-village-complaining-of-nausea-vomiting-shaking-chills-and-contractions-every-2-minutes. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### The patient was 37 3/7 weeks EGA by a 32 week ultrasound. Her prenatal history was significant for 3 total prenatal visits, anemia with hemoglobin 10.2 g/dL, and a previous 10 lb. 2 oz term NSVD. The patient had a glucose challenge test result of 129 mg/dL. {#the-patient-was-37-37-weeks-ega-by-a-32-week-ultrasound.-her-prenatal-history-was-significant-for-3-total-prenatal-visits-anemia-with-hemoglobin-10.2-gdl-and-a-previous-10-lb.-2-oz-term-nsvd.-the-patient-had-a-glucose-challenge-test-result-of-129-mgdl. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### The entry level CHA recorded the temperature to be 99.2 F which was 100.8 F on repeat. The patient was tender in her right flank and abdomen. The fetal heart rate was in the 140s and the patient noted to have a negative urine dipstick, except a trace of protein. The CHA determined the patient had a viral syndrome and preterm contractions. The CHA consulted a provider at a regional hospital by phone. The patient was then treated with prochlorperazine intramuscularly, terbutatline subcutaneously, Tylenol by mouth, and intravenous fluids. A transport was arranged on the next regularly scheduled mail plane.  {#the-entry-level-cha-recorded-the-temperature-to-be-99.2-f-which-was-100.8-f-on-repeat.-the-patient-was-tender-in-her-right-flank-and-abdomen.-the-fetal-heart-rate-was-in-the-140s-and-the-patient-noted-to-have-a-negative-urine-dipstick-except-a-trace-of-protein.-the-cha-determined-the-patient-had-a-viral-syndrome-and-preterm-contractions.-the-cha-consulted-a-provider-at-a-regional-hospital-by-phone.-the-patient-was-then-treated-with-prochlorperazine-intramuscularly-terbutatline-subcutaneously-tylenol-by-mouth-and-intravenous-fluids.-a-transport-was-arranged-on-the-next-regularly-scheduled-mail-plane. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Upon arrival at the Emergency Department, the patient noted fever and chills, abdominal pain (R \> L). The patient's temperature was recorded as 103.6 F, pulse 122-136 bpm, and the FHR was in the 160 -- 210 bpm. Examination revealed right middle quadrant tenderness, suprapubic tenderness, and mid-epigastric tenderness. There was guarding, but no rebound tenderness. The cervix was 1 cm dilated, thick, and -- 3 station. The hemoglobin was 6.1 g/dL, and white blood cell count 4, 000 /microL. {#upon-arrival-at-the-emergency-department-the-patient-noted-fever-and-chills-abdominal-pain-r-l.-the-patients-temperature-was-recorded-as-103.6-f-pulse-122-136-bpm-and-the-fhr-was-in-the-160-210-bpm.-examination-revealed-right-middle-quadrant-tenderness-suprapubic-tenderness-and-mid-epigastric-tenderness.-there-was-guarding-but-no-rebound-tenderness.-the-cervix-was-1-cm-dilated-thick-and-3-station.-the-hemoglobin-was-6.1-gdl-and-white-blood-cell-count-4-000-microl. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Urinalysis showed specific gravity 1.025, WBC 10-30 hpf, positive leukocyte esterase, bacteria 1+, 3 + ketones, epithethial cells 1-5 hpf, trace protein, nitrite negative, and negative casts. {#urinalysis-showed-specific-gravity-1.025-wbc-10-30-hpf-positive-leukocyte-esterase-bacteria-1-3-ketones-epithethial-cells-1-5-hpf-trace-protein-nitrite-negative-and-negative-casts. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### The patient was admitted with a diagnosis of pyelonephritis and treated with Ceftriaxone 1 gm intravenously.  {#the-patient-was-admitted-with-a-diagnosis-of-pyelonephritis-and-treated-with-ceftriaxone-1-gm-intravenously. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### The next morning the patient noted dysuria, feeling cold with shaking chills, shortness of breath, chest pain, and right sided abdominal pain. Her temperature was 104.0 F, pulse 150 bpm, BP 138/58, and pulse oximetry 99%. The physical examination was otherwise essentially unchanged.  {#the-next-morning-the-patient-noted-dysuria-feeling-cold-with-shaking-chills-shortness-of-breath-chest-pain-and-right-sided-abdominal-pain.-her-temperature-was-104.0-f-pulse-150-bpm-bp-13858-and-pulse-oximetry-99.-the-physical-examination-was-otherwise-essentially-unchanged. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### The hemoglobin was 8.6 g/dL, white blood cell count 3, 000 cells /microL, and platelet count 267, 000 /microL. The electrocardiogram revealed a trigeminal rhythm at 138 bpm and LVH by voltage. Arterial blood gases on two liters by nasal prongs revealed pH 7.43, P02 130, PCO2 17.8, HCO3 11.9 meq/L, and base excess -12.  {#the-hemoglobin-was-8.6-gdl-white-blood-cell-count-3-000-cells-microl-and-platelet-count-267-000-microl.-the-electrocardiogram-revealed-a-trigeminal-rhythm-at-138-bpm-and-lvh-by-voltage.-arterial-blood-gases-on-two-liters-by-nasal-prongs-revealed-ph-7.43-p02-130-pco2-17.8-hco3-11.9-meql-and-base-excess--12. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Later that day the laboratory reported a preliminary blood culture result with gram positive cocci in clusters. Gentamicin 140 mg IV and vancomycin 500 mg IV were added to the antibiotic regime.  {#later-that-day-the-laboratory-reported-a-preliminary-blood-culture-result-with-gram-positive-cocci-in-clusters.-gentamicin-140-mg-iv-and-vancomycin-500-mg-iv-were-added-to-the-antibiotic-regime. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### The patient was subsequently transferred to a tertiary care facility approximately 500 miles away by air ambulance. Upon arrival the patient was afebrile, but had shaking chills. The patient had developed exquisite right flank pain. The physical examination was otherwise essentially unchanged. The cervix was 1 cm dilated, thick, and -- 3 station {#the-patient-was-subsequently-transferred-to-a-tertiary-care-facility-approximately-500-miles-away-by-air-ambulance.-upon-arrival-the-patient-was-afebrile-but-had-shaking-chills.-the-patient-had-developed-exquisite-right-flank-pain.-the-physical-examination-was-otherwise-essentially-unchanged.-the-cervix-was-1-cm-dilated-thick-and-3-station .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### The referring facility subsequently reported the preliminary positive blood culture as gram negative rods. The patient's gentamicin was changed to 100 mg q 8 hours IV and the vancomycin was stopped. The pyelonephritis patient was suspected of urosepsis. The admission plan included an order for a renal ultrasound in the morning to rule out perinephric abscess. {#the-referring-facility-subsequently-reported-the-preliminary-positive-blood-culture-as-gram-negative-rods.-the-patients-gentamicin-was-changed-to-100-mg-q-8-hours-iv-and-the-vancomycin-was-stopped.-the-pyelonephritis-patient-was-suspected-of-urosepsis.-the-admission-plan-included-an-order-for-a-renal-ultrasound-in-the-morning-to-rule-out-perinephric-abscess. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Five hours after admission the patient's white blood cell count increased to 26,100 cells /microL and the patient continued to have right flank and right lower quadrant pain. The right flank pain now required intermittent intravenous morphine. The General Surgery Service was consulted. {#five-hours-after-admission-the-patients-white-blood-cell-count-increased-to-26100-cells-microl-and-the-patient-continued-to-have-right-flank-and-right-lower-quadrant-pain.-the-right-flank-pain-now-required-intermittent-intravenous-morphine.-the-general-surgery-service-was-consulted. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### The General Surgery team concurred that the patient had pyelonephritis with a suspected perinephric abscess. They suggested adding vancomycin back to the regimen because of the preliminary positive blood culture at the referring facility had suggested gram positive cocci in clusters and was still unidentified. There was a significant prevalence of methicillin resistant Staphylococcus aureus infection in the patient's home region. The General Surgery Service agreed with obtaining a renal ultrasound in the morning. {#the-general-surgery-team-concurred-that-the-patient-had-pyelonephritis-with-a-suspected-perinephric-abscess.-they-suggested-adding-vancomycin-back-to-the-regimen-because-of-the-preliminary-positive-blood-culture-at-the-referring-facility-had-suggested-gram-positive-cocci-in-clusters-and-was-still-unidentified.-there-was-a-significant-prevalence-of-methicillin-resistant-staphylococcus-aureus-infection-in-the-patients-home-region.-the-general-surgery-service-agreed-with-obtaining-a-renal-ultrasound-in-the-morning. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Is there anything else would you like to do now for this patient diagnosed with urosepsis at 37 weeks EGA? {#is-there-anything-else-would-you-like-to-do-now-for-this-patient-diagnosed-with-urosepsis-at-37-weeks-ega .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### More on this story in the January CCC Corner {#more-on-this-story-in-the-january-ccc-corner .Style-Heading-4-+-Arial-14-pt-Underline}

#### Questions [**nmurphy@scf.cc**](mailto:nmurphy@scf.cc) {#questions-nmurphyscf.cc .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

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

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

######### 

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

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

**Clinical Discussion Board Index, Medscape**

Hundreds of ongoing clinical discussions available

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

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

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

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

**Menopause Management**

**WHI clinical trial revisit: imprecise methodology disqualifies the
study\'s outcomes**

We analyzed The Women\'s Health Initiative (WHI) Study because it had a
significant impact on clinical practice, both nationally and
internationally. However, despite the widespread public and professional
awareness of the results, an independent, nonbiased analysis of the
quality of the methodology of the study has not been available. We find
the study design and its execution question the validity of the results,
making it difficult to apply the WHI results to healthy postmenopausal
women, different ethnic groups, or as general postmenopausal prevention.

#### [**Ostrzenski A**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Ostrzenski+A"%5BAuthor%5D), [**Ostrzenska KM**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Ostrzenska+KM"%5BAuthor%5D) WHI clinical trial revisit: imprecise scientific methodology disqualifies the study\'s outcomes. [**Am J Obstet Gynecol.**](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2005 Nov;193(5):1599-604; discussion 1605-6. [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16260198&query_hl=6**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16260198&query_hl=6) {#ostrzenski-a-ostrzenska-km-whi-clinical-trial-revisit-imprecise-scientific-methodology-disqualifies-the-studys-outcomes.-am-j-obstet-gynecol.-2005-nov19351599-604-discussion-1605-6.-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids16260198query_hl6 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### WHI response to Ostrzenski and Ostrzenska {#whi-response-to-ostrzenski-and-ostrzenska-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Contrary to Ostrzenski\'s and Ostrzenska\'s[**1**](http://www.ajog.org/article/PIIS0002937805012184/fulltext#bib1%23bib1) premise, the Women\'s Health Initiative (WHI) Estrogen plus Progestin (E+P) Trial has generated considerable scientific scrutiny, from a *JAMA* editorial describing the results as "strong evidence," to the American College of Obstetricians and Gynecologists characterizing the trial as "...the largest, most statistically valid, and well-analyzed research to evaluate the use of HRT in healthy postmenopausal women," and the American Society for Reproductive Medicine writing "The data emerging from this methodologically sound randomized controlled trial appear incontrovertible." Sackett, whose principles of evidence-based medicine Ostrzenski and Ostrzenska endorse, described the trial as a "rigorous" randomized clinical trial, designed and executed to answer the study question. {#contrary-to-ostrzenskis-and-ostrzenskas1-premise-the-womens-health-initiative-whi-estrogen-plus-progestin-ep-trial-has-generated-considerable-scientific-scrutiny-from-a-jama-editorial-describing-the-results-as-strong-evidence-to-the-american-college-of-obstetricians-and-gynecologists-characterizing-the-trial-as-the-largest-most-statistically-valid-and-well-analyzed-research-to-evaluate-the-use-of-hrt-in-healthy-postmenopausal-women-and-the-american-society-for-reproductive-medicine-writing-the-data-emerging-from-this-methodologically-sound-randomized-controlled-trial-appear-incontrovertible.-sackett-whose-principles-of-evidence-based-medicine-ostrzenski-and-ostrzenska-endorse-described-the-trial-as-a-rigorous-randomized-clinical-trial-designed-and-executed-to-answer-the-study-question. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**Cochrane BB**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Cochrane+BB"%5BAuthor%5D), et al WHI response to Ostrzenski and Ostrzenska. [**Am J Obstet Gynecol.**](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2005 Nov;193(5):1605-1606. [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16260199&query_hl=8**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16260199&query_hl=8) {#cochrane-bb-et-al-whi-response-to-ostrzenski-and-ostrzenska.-am-j-obstet-gynecol.-2005-nov19351605-1606.-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids16260199query_hl8 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Mechanisms of Premature Menopause {#mechanisms-of-premature-menopause-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Although this article focuses on potential mechanisms for premature menopause, it seems appropriate to end with a few comments about diagnosis and treatment. It is important to identify those causes that have important health consequences for the patient or any children. Once hypergonadotropic amenorrhea is identified, it is important to communicate this information to the patient with sensitivity. Young women are unprepared emotionally for the diagnosis of premature menopause. Moreover, as has been noted, the ovarian failure is not always permanent, and it is not always possible to identify those who will ovulate or conceive in the future.  {#although-this-article-focuses-on-potential-mechanisms-for-premature-menopause-it-seems-appropriate-to-end-with-a-few-comments-about-diagnosis-and-treatment.-it-is-important-to-identify-those-causes-that-have-important-health-consequences-for-the-patient-or-any-children.-once-hypergonadotropic-amenorrhea-is-identified-it-is-important-to-communicate-this-information-to-the-patient-with-sensitivity.-young-women-are-unprepared-emotionally-for-the-diagnosis-of-premature-menopause.-moreover-as-has-been-noted-the-ovarian-failure-is-not-always-permanent-and-it-is-not-always-possible-to-identify-those-who-will-ovulate-or-conceive-in-the-future. .Style-Heading-4-+-Arial-14-pt-Underline}

#### Professional counseling may be necessary, as may referral to an organization such as the Premature Ovarian Failure Support Group (available at [**http://pofsupport.org**](http://pofsupport.org/)[).]{.underline} Because young women with premature menopause have pathologically low levels of serum estradiol at least some of the time, and commonly suffer from signs and symptoms of estrogen deficiency, it seems rational to replace ovarian steroid hormones even in the absence of randomized controlled trials proving safety. There are no controlled trials regarding the ideal hormone replacement strategy for women with premature menopause, however. Typically, young women require twice as much estrogen as women going through normal menopause for relief of menopausal symptoms. This makes sense given that circulating levels of estradiol through the menstrual cycle average about 100 pg. Combination oral contraceptives are not recommended as hormone replacement in women with premature menopause, because such preparations contain much more steroid hormone (two to four times) than is required for physiologic replacement. Moreover, for unknown reasons neither oral contraceptives nor hormone replacement prevent ovulation or pregnancy in women with premature menopause [**\[4\]**](http://home.mdconsult.com/das/article/body/53222726-2/jorg=journal&source=&sp=15892020&sid=0/N/506320/1.html#r05000836004%23r05000836004). For women with this disorder who wish to have children, use of donor oocytes and adoptions are the most viable options. {#professional-counseling-may-be-necessary-as-may-referral-to-an-organization-such-as-the-premature-ovarian-failure-support-group-available-at-httppofsupport.org.-because-young-women-with-premature-menopause-have-pathologically-low-levels-of-serum-estradiol-at-least-some-of-the-time-and-commonly-suffer-from-signs-and-symptoms-of-estrogen-deficiency-it-seems-rational-to-replace-ovarian-steroid-hormones-even-in-the-absence-of-randomized-controlled-trials-proving-safety.-there-are-no-controlled-trials-regarding-the-ideal-hormone-replacement-strategy-for-women-with-premature-menopause-however.-typically-young-women-require-twice-as-much-estrogen-as-women-going-through-normal-menopause-for-relief-of-menopausal-symptoms.-this-makes-sense-given-that-circulating-levels-of-estradiol-through-the-menstrual-cycle-average-about-100-pg.-combination-oral-contraceptives-are-not-recommended-as-hormone-replacement-in-women-with-premature-menopause-because-such-preparations-contain-much-more-steroid-hormone-two-to-four-times-than-is-required-for-physiologic-replacement.-moreover-for-unknown-reasons-neither-oral-contraceptives-nor-hormone-replacement-prevent-ovulation-or-pregnancy-in-women-with-premature-menopause-4.-for-women-with-this-disorder-who-wish-to-have-children-use-of-donor-oocytes-and-adoptions-are-the-most-viable-options. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**Rebar RW**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Rebar+RW"%5BAuthor%5D). Mechanisms of premature menopause. [**Endocrinol Metab Clin North Am.**](javascript:AL_get(this, 'jour', 'Endocrinol Metab Clin North Am.');) 2005 Dec;34(4):923-33. [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16310631&query_hl=3**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16310631&query_hl=3) {#rebar-rw.-mechanisms-of-premature-menopause.-endocrinol-metab-clin-north-am.-2005-dec344923-33.-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids16310631query_hl3 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Midwives Corner: Marsha Tahquechi, GIMC {#midwives-corner-marsha-tahquechi-gimc .Style-Heading-4-+-Arial-14-pt-Underline}

**Liability in Triage: Management of EMTALA Regulations and Common
Obstetric Risks**

The Emergency Medical Treatment and Active Labor Act (EMTALA) affects
all clinicians who provide triage care for pregnant women. EMTALA has
specific regulations for hospitals relative to women in active labor.
Violations can carry stiff penalties. It is critical for clinicians
performing obstetric triage to understand the duties and obligations of
this law. This article discusses EMTALA and reviews common liability
risks in obstetric triage as well as strategies to modify those risks.

[Angelini
DJ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Angelini+DJ"%5BAuthor%5D),
[Mahlmeister
LR](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Mahlmeister+LR"%5BAuthor%5D).
Liability in triage: management of EMTALA regulations and common
obstetric risks. [J Midwifery Womens
Health.](javascript:AL_get(this, 'jour', 'J Midwifery Womens Health.');)
2005 Nov-Dec;50(6):472-8.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16260361&query_hl=16>

**Post Partum Hemorrhage is the most common cause of maternal mortality
worldwide**

This month\'s midwife corner presents two reviews from the Cochrane data
base.  One focus is on the use of prophylactic oxytocin for the third
stage of labor and the other reviews active vs. expectant management of
the third stage of labor.  The literature reviewed found that the active
management of labor is superior to expectant management.  There is
included a joint position statement from the International Confederation
of Midwives(ICM) and the International Federation of Gynecologists and
Obstetricians (FIGO) on active management of the third stage of labor. 
Another article from the Journal of Midwifery and Women\'s Health
approaches PPH from a global perspective and reviews prevention
strategies in low risk settings. 

Last but not least, a Cochrane review on placental drainage as part of
the management of the third stage of labor shows that there is
potentially some benefit to using this technique.

By the way, what does 'controlled cord traction' mean?

The controlled cord traction used is relatively constant and firm, but
not aggressive. It is not necessarily timed to the increasing infrequent
post partum contractions, but it often can be applied on q 2-3 minutes
basis just to give the patient a break (because many times we ask the
patient to give a little push while we are doing it).

\*Controlled cord traction technique from Khan et al

Patients allocated to the controlled cord traction group had the third
stage of labor managed actively. Oxytocin (10 units) was administered
intramuscularly during delivery of the anterior shoulder of the baby. In
the case of breech vaginal delivery this was given soon after delivery
of the baby. The umbilical cord was clamped and cut immediately after
delivery of the baby. As soon as the baby was separated and palpation of
the uterus through a sterile abdominal towel confirmed that it was
contracting firmly, controlled cord traction was commenced
(Brandt-Andrews technique). The lower segment of the uterus was grasped
between the thumb and index finger, and steady pressure was exerted in
an upward and backward direction. At the same time the other hand,
holding the clamp on the cord, at the level of the introitus started
steady traction on the cord in a backward and downward direction,
exactly countered by the upward pressure of the hand on the uterus, so
that the position of the uterus remained unchanged. The traction was
gentle at first and then was slowly increased, the placenta usually
being delivered quite easily. Controlled cord traction was repeated
every 2 to 3 minutes, if the first attempt was unsuccessful. No fundal
pressure was applied to the abdomen even if the placenta failed to
deliver by the controlled cord traction method.

Khan GQ, et al Controlled cord traction versus minimal intervention
techniques in delivery of the placenta: a randomized controlled trial.
Am J Obstet Gynecol. 1997 Oct;177(4):770-4.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9369817&query_hl=1>

Prophylactic oxytocin for the third stage of labor\*

<http://www.medscape.com/viewarticle/485839_print>

Active vs expectant management of the third stage of labor\*

<http://www.medscape.com/viewarticle/484958_print>

 

Joint Statement by the ICS and ICOBGYN on Management of third stage of
labor

[http://www.internationalmidwives.org/modules/ContentExpress/img_repository/final%20joint%20statement%20active%20manangement-eng%20with%20logo.pdf](http://www.internationalmidwives.org/modules/ContentExpress/img_repository/final joint statement active manangement-eng with logo.pdf)

Highlights of the American College of Nurse Midwives 49th Annual
Meeting\*

<http://www.medscape.com/viewarticle/482164_print>

Placental cord drainage after spontaneous vaginal delivery as part of
the management of the third stage of labor\*

 <http://www.medscape.com/viewarticle/514982_print>

#### \*See Medscape for access questions. It is free, but needs a password. Sorry {#see-medscape-for-access-questions.-it-is-free-but-needs-a-password.-sorry .Style-Heading-4-+-Arial-14-pt-Underline}

**Jenny Glifort, ANMC**

**Motherhood a \"rite of passage\" for some teens**

This longitudinal, interpretive study explored how teen mothers
experienced the self and future during a 12-year period. Sixteen
families were first interviewed intensively in 1988-1989 once the
teen\'s infant reached age 8 to 10 months; they were re-interviewed in
1993, 1997, and 2001 (Time 4). Twenty-seven family members were
re=interviewed at Time 4. The metaphor of a narrative spine is used to
describe how the mothers\' lives unfolded during the 12-year period. The
narrative spines of some mothers were large and supported
well-developed, coherent \"chapters\" on mothering, adult love, and
work. For others, mothering provided a \"backbone\" for a meaningful
life; however, chapters on adult love and work were less fully
developed. The lives of a third group of mothers lacked a coherent
narrative structure. Each pattern is presented with a paradigm case.
[Smithbattle
L](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Smithbattle+L"%5BAuthor%5D)
Teenage mothers at age 30. [West J Nurs
Res.](javascript:AL_get(this, 'jour', 'West J Nurs Res.');) 2005
Nov;27(7):831-50.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16275703&query_hl=8>

**Other**

**A trial should focus on women at low risk for failed trial or uterine
rupture and should not be limited to a restrictive evaluation of
short-term complications**

A trial of labor may be associated with a higher rate of uterine rupture
and a higher rate of neonatal death related to uterine rupture. However,
it remains unclear to what degree this is related to selection or
exclusion of certain subgroups and what the impact would be with a
policy of planned elective repeat cesarean births for all. Moreover, it
is likely that a policy of systematic elective repeat cesarean births
would increase the rate of maternal mortality when all complications are
included. Mothers are more likely to be concerned about the overall rate
of death rather than the death rates from only a certain subset of
complications. Ultimately, observations from retrospective analyses
remain affected by how the women were selected for each delivery method
and by how they were excluded from the analysis. Given the greater
understanding of the natural history of uterine rupture and better
methods to select and manage women undergoing a trial of labor as well
as elective repeat birth, a contemporary randomized controlled trial is
desirable to elucidate current risk or benefit. Such a trial should
focus on carefully selected women at low risk for failed trial or
uterine rupture and should not be limited to a restrictive evaluation of
short-term complications.\
[Bujold
E](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Bujold+E"%5BAuthor%5D),
[Gauthier
RJ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Gauthier+RJ"%5BAuthor%5D),
[Hamilton
E](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Hamilton+E"%5BAuthor%5D).
Maternal and perinatal outcomes associated with a trial of labor after
prior cesarean delivery. [J Midwifery Womens
Health.](javascript:AL_get(this, 'jour', 'J Midwifery Womens Health.');)
2005 Sep-Oct;50(5):363-4.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16154061&query_hl=19>

**Midwifery Measures in Stage Two: Reduction of Genital Tract Trauma at
Birth**

Genital tract trauma after spontaneous vaginal childbirth is common, and
evidence-based prevention measures have not been identified beyond
minimizing the use of episiotomy. This study randomized 1211 healthy
women in midwifery care at the University of New Mexico teaching
hospital to 1 of 3 care measures late in the second stage of labor: 1)
warm compresses to the perineal area, 2) massage with lubricant, or 3)
no touching of the perineum until crowning of the infant\'s head. The
purpose was to assess whether any of these measures was associated with
lower levels of obstetric trauma. After each birth, the clinical midwife
recorded demographic, clinical care, and outcome data, including the
location and extent of any genital tract trauma. The frequency
distribution of genital tract trauma was equal in all three groups.
Individual women and their clinicians should decide whether to use these
techniques on the basis of maternal comfort and other considerations

[Albers
LL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Albers+LL"%5BAuthor%5D),
et al Midwifery care measures in the second stage of labor and reduction
of genital tract trauma at birth: a randomized trial. [J Midwifery
Womens
Health.](javascript:AL_get(this, 'jour', 'J Midwifery Womens Health.');)
2005 Sep-Oct;50(5):365-72.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16154062&query_hl=21>

**Navajo News Jean Howe, Chinle**

**MRSA presents new challenges in treating skin and soft-tissue
infections, including in pregnancy...**

MRSA (Methicillin-Resistant *Staphylococcus aureus*) spread in
healthcare settings has been a grave concern for several years and is
evidence of our dwindling antibiotic armamentarium. More recently,
community-acquired MRSA infections have also become relatively common
and may require consideration of alternative antibiotic regimens in some
situations. Over the past three months our rural health care facility
has noted a series of cases of MRSA soft tissue infections in pregnant
and postpartum patients, most of which were more likely to have been
community acquired than nosocomial.

The article by Laibl, et al in the September Obstetrics and Gynecology
suggests that this experience may soon be rather commonplace. The
authors conducted a chart review of pregnant patients diagnosed with
MRSA between 1/1/00 and 7/30/04 at Parkland Hospital in Dallas, Texas.
They noted 2 cases in 2000, 4 in '01, 11 in '02, 23 in '03, and 17
through 7/04. 96% of cases were skin and soft tissue infections with 44%
involving extremities, 25% buttocks, and 23% breast/mastitis. Multiple
sites were often involved. 18% of cases were diagnosed in the postpartum
period. All isolates were sensitive to trimethoprim-sulfamethoxazole,
vancomycin, and rifampin. 98% gentamicin sensitivity and 84%
levofloxacin sensitivity were also noted. They conclude that recurrent
skin abscesses in pregnancy should prompt an investigation for MRSA.

Another article in the March Annals of Emergency Medicine described a
prospective observational study of a high-risk (non-pregnant) population
presenting to an urban E.R. While their findings that 51% of skin
abscesses were MRSA-colonized may not be generalizable to other
populations, it again raises interesting questions about antibiotic
choices. They found MRSA sensitivities to trimethoprim-sulfamethoxazole
(100%), clindamycin (94%), tetracycline (86%), and levofloxacin (57%).
This article and the accompanying editorial suggest that a
trimethoprim-sulfamethoxazole-based regimen may be appropriate for skin
abscesses in some populations but also raise concern that *Streptococcus
pyogenes* not be overlooked as another potential virulent pathogen and
recommend that cellulitis without abscess treatment include cephalexin
or another antibiotic known to be effective against *S pyogenes*.
Treatment of abscesses with I&D alone may be sufficient regardless of
pathogen but they also suggest a role for culture, both to guide further
treatment if required and to monitor shifts prevalence of MRSA in the
community.

Laibl VR, Sheffield JS, Roberts, S, et al. Clinical Presentation of
Community-Acquired Methicillin-Resistant *Staphylococcus aureus* in
Pregnancy. Obstetrics & Gynecoloogy;106:461-465.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16135574&query_hl=2>

Frazee BW, Lynn J, Charlebois ED, et al. High Prevalence of
Methicillin-Resistant Staphylococcus aureus in Emergency Department Skin
and Soft Tissue Infections. Annals of Emergency Medicine.
2005;45:311-320.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15726056&query_hl=9>

Moran GJ and Talan DA. Community-Associated Methicillin-Resistant
Staphylococcus aureus: Is it in Your Community and Should it Change
Practice? Annals of Emergency Medicine. 2005;45:321-322.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15726057>

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

**Nurses Corner**

#### Seeking Executive Nurse Leaders  {#seeking-executive-nurse-leaders-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### The Robert Wood Johnson Executive Nurse Fellows Program is seeking applicants for an advanced leadership program for nurses in senior executive roles in health services, public health and nursing education who aspire to help lead and shape the U.S. health care system. Up to 20 three-year fellowships will be awarded in 2006.Apply [[http://www.enfp-info.org/]{.underline}](http://www.enfp-info.org/) until Feb. 1, 2006 {#the-robert-wood-johnson-executive-nurse-fellows-program-is-seeking-applicants-for-an-advanced-leadership-program-for-nurses-in-senior-executive-roles-in-health-services-public-health-and-nursing-education-who-aspire-to-help-lead-and-shape-the-u.s.-health-care-system.-up-to-20-three-year-fellowships-will-be-awarded-in-2006.apply-httpwww.enfp-info.org-until-feb.-1-2006 .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

**Cigarette Smoking in the United States, 2004**

To assess progress toward this objective, CDC analyzed self-reported
data from the 2004 National Health Interview Survey (NHIS) sample adult
core questionnaire. This report describes the results of that analysis,
which indicated that, in 2004, approximately 20.9% of U.S. adults were
current smokers. This prevalence is lower than the 21.6% prevalence
among U.S. adults in 2003 and is significantly lower than the 22.5%
prevalence among adults in 2002. Current smoking was higher among men
(23.4%) than women (18.5%). Hispanic (10.9%) and Asian (4.8%) women,
women with less than an 8th-grade education (10.5%), women with
undergraduate (10.1%) or graduate (8.1%) degrees, men with graduate
degrees (7.9%), men aged [\>]{.underline}65 years (9.8%), and women aged
[\>]{.underline}65 years (8.1%) all had smoking prevalence rates below
the national health objective of [\<]{.underline}12%.
<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5444a2.htm>

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

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

**Who do you contact in Oklahoma for MCH issues?**

Two contacts are Dr. George Chiarchiaro in the Area Office and Greggory
Woitte at Tahlequah.

-Dr. George Chiarchiaro is the MCH Coordinator and has a helpful website
with many resources

[[http://www.ihs.gov/MedicalPrograms/MCH/M/MCHC07.cfm#top]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/M/MCHC07.cfm#top)

-Greggory Woitte at Tahlequah is available at
[[Greggory.Woitte@mail.ihs.gov]{.underline}](mailto:Greggory.Woitte@mail.ihs.gov)

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

**Screening and treatment for osteoporosis low among patients taking
glucocorticoids**

<http://www.ahrq.gov/research/oct05/1005RA11.htm>

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

**FDA Patient Education page- paroxetine changed for Class C to Class
D**

<http://www.fda.gov/cder/drug/InfoSheets/patient/paroxetinePT.htm>

**The Eagle's Nest: Safe (online) place for youth to learn more about
living healthy with DM**

The Eagle's Nest is a safe (online) place to visit where kids can learn
more about living healthy and diabetes. It is for those who may have
diabetes or have a friend or relative with diabetes. For most American
Indians and Alaska Natives, the eagle represents balance, courage,
healing, strength, and wisdom, and is seen as a messenger or a teacher.
In the Eagle book series, the wise bird teaches children how to use
these values to prevent diabetes and grow safe and strong.

<http://www.cdc.gov/diabetes/eagle/index.html>

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

#### Constipation: What You Should Know {#constipation-what-you-should-know-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20051201/2285ph.html**](http://www.aafp.org/afp/20051201/2285ph.html) {#httpwww.aafp.orgafp200512012285ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-41 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Taking Care of Yourself After Having a Baby {#taking-care-of-yourself-after-having-a-baby-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20051215/2497ph.html**](http://www.aafp.org/afp/20051215/2497ph.html) {#httpwww.aafp.orgafp200512152497ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-42 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Tuberculosis: What You Should Know {#tuberculosis-what-you-should-know-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20051201/2235ph.html**](http://www.aafp.org/afp/20051201/2235ph.html) {#httpwww.aafp.orgafp200512012235ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-43 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Perinatology Picks George Gilson, MFM, ANMC {#perinatology-picks-george-gilson-mfm-anmc .Style-Heading-4-+-Arial-14-pt-Underline}

**Meconium Happens**

BACKGROUND: It is uncertain whether amnioinfusion (infusion of saline
into the amniotic cavity) in women who have thick meconium staining of
the amniotic fluid reduces the risk of perinatal death, moderate or
severe meconium aspiration syndrome, or both.

METHODS: We performed a multicenter trial in which 1998 pregnant women
in labor at 36 or more weeks of gestation who had thick meconium
staining of the amniotic fluid were stratified according to the presence
or absence of variable decelerations in fetal heart rate and then
randomly assigned to amnioinfusion or to standard care. The composite
primary outcome measure was perinatal death, moderate or severe meconium
aspiration syndrome, or both. RESULTS: Perinatal death, moderate or
severe meconium aspiration syndrome, or both occurred in 44 infants (4.5
percent) of women in the amnioinfusion group and 35 infants (3.5
percent) of women in the control group (relative risk, 1.26; 95 percent
confidence interval, 0.82 to 1.95). Five perinatal deaths occurred in
the amnioinfusion group and five in the control group. The rate of
cesarean delivery was 31.8 percent in the amnioinfusion group and 29.0
percent in the control group (relative risk, 1.10; 95 percent confidence
interval, 0.96 to 1.25).

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

Fraser WD, et al, Amnioinfusion for the prevention of the meconium
aspiration syndrome. NEJM 2005; 353:909-17.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16135835&query_hl=1>

**Comment: George Gilson, MFM**

Meconium happens in about 12% of all births, and in over 30% of post
term births. The meconium aspiration syndrome (MAS) occurs in 1/2000
births, and in up to 8% of post term births. Meconium is found below the
cords in almost half of births through meconium stained fluid, but only
a small proportion of infants with "mec" below the cords will develop
MAS. Pharyngeal suctioning and endotracheal intubation and suctioning
have not been shown to reduce the risk of MAS. A 2002 Cochrane Review
found that amnioinfusion was associated with an overall reduction in the
incidence of MAS (RR = 0.44, CI 0.25-0.78), but the current study
challenges this.

Fraser et al carried out a multicenter randomized controlled trial of
1,998 women at term with thick meconium into treatment with
amnioinfusion, or standard labor care without amnioinfusion. The study
groups were further stratified into cases with and without recurrent
severe variable decelerations of the fetal heart rate. Women in the
amnioinfusion arm had a rate of MAS of 4.4%, a neonatal death rate of
0.5%, and a cesarean delivery rate of 32%. Women in the control group
had corresponding rates of 3.1%, 0.5%, and 29%, none of which were
significantly different. There was likewise no significant effect of
amnioinfusion in the subgroup with variable decelerations, however the
study was underpowered for this occurrence. Modalities used for neonatal
suctioning and resuscitation were likewise not significantly different
between the groups.

This large RCT most likely trumps the previous meta-analyses. There are
probably several reasons why amnioinfusion did not effect the
anticipated result. MAS is not correlated with FHR decelerations, low
pH, 5 minute Apgar score, or other markers of acute hypoxia. It is
correlated with oligohydramnios, elevated cord blood erythropoietin, and
muscularization of the pulmonary arteries at autopsy, all markers of
*chronic* hypoxia. Most infants in whom the syndrome develops have
meconium in the tracheobronchial tree before labor. As their chronic
hypoxia worsens and their pCO2 rises, they probably involuntarily
defecate and then gasp, aspirating meconium deep into their lower
respiratory tract before any intervention could have been helpful. Since
most MAS occurs in post term infants, preventing the occurrence of
postmaturity by inducing labor at 41 weeks is the intervention most
likely to be of benefit in preventing deaths secondary to meconium
aspiration.

We'll have to wait to see how our professional organizations respond to
this important paper before we abandon amnioinfusion altogether, and
hopefully we'll see some confirmatory studies as well, so please stay
tuned....

**Resources**

The Cochrane Database of Systematic Reviews
<http://www.update-software.com/cochrane/abstract.htm>

Hofmeyr GJ. Amnioinfusion for meconium-stained liquor in labour. *The
Cochrane Database of Systematic Reviews* 2002, Issue 1. Art. No.:
CD000014. DOI: 10.1002/14651858.CD000014.

Hofmeyr GJ. Amnioinfusion for potential or suspected umbilical cord
compression in labour. *The Cochrane Database of Systematic Reviews*
1998, Issue 1. Art. No.: CD000013. DOI: 10.1002/14651858.CD000013

Hofmeyr GJ. Amnioinfusion for preterm rupture of membranes. *The
Cochrane Database of Systematic Reviews* 1998, Issue 1. Art. No.:
CD000942. DOI: 10.1002/14651858.CD000942.

Hofmeyr GJ. Prophylactic versus therapeutic amnioinfusion for
oligohydramnios in labour. *The Cochrane Database of Systematic Reviews*
1996, Issue 1. Art. No.: CD000176. DOI: 10.1002/14651858.CD000176.

**Other**

#### Since the amnio is immature today, should we re-tap in a week or just deliver then? {#since-the-amnio-is-immature-today-should-we-re-tap-in-a-week-or-just-deliver-then-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: The mean weekly increment of TDx-FLM II is 14.4 +/- 9.9 mg/g and is constant during the latter part of pregnancy. This information, combined with the gestational age, should be useful in treating women with an initial immature test. {#conclusion-the-mean-weekly-increment-of-tdx-flm-ii-is-14.4---9.9-mgg-and-is-constant-during-the-latter-part-of-pregnancy.-this-information-combined-with-the-gestational-age-should-be-useful-in-treating-women-with-an-initial-immature-test. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**Bildirici I**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Bildirici+I"%5BAuthor%5D), et al The mean weekly increment of amniotic fluid TDx-FLM II ratio is constant during the latter part of pregnancy. [**Am J Obstet Gynecol.**](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2005 Nov;193(5):1685-90. [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16260211&query_hl=7**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16260211&query_hl=7) {#bildirici-i-et-al-the-mean-weekly-increment-of-amniotic-fluid-tdx-flm-ii-ratio-is-constant-during-the-latter-part-of-pregnancy.-am-j-obstet-gynecol.-2005-nov19351685-90.-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids16260211query_hl7 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Cardiology Topics for Primary Care Providers -- February 15, 2006**

Moderator: Jim Galloway, MD

Director, Native American Cardiology Program

**Here are some of the topics to be discussed**

-Role of CRP in cardiac evaluation

-Should we all take statins? or get out of our chairs, work out, lose
weight, diet and get fitness religion?

-Lipid screening guidelines in non-smoking non-diabetic Native Americans

-Newer cardiac imaging techniques (MRI, CT angio) over traditional
catheterization procedures.  

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

Subscribe to the Primary Care listserv

<http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=51>

Unsubscribe from the Primary Care listserv

<http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=51>

Questions on how to subscribe, contact <nmurphy@scf.cc> directly

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

## High-Risk HPV Associated with Chlamydia trachomatis with Female Adolescents 

Human papillomavirus (HPV) infection is a necessary but not sufficient
cause of cervical cancer. While chlamydia infection has been associated
with cervical cancer, the meaning of this association remains unclear.
The authors\' objective was to investigate this association by
evaluating whether concurrent genital tract infections are associated
with HPV persistence, a precursor to cervical cancer. Interview data and
biologic samples for HPV, Chlamydia trachomatis, Neisseria gonorrhoeae,
Trichomonas vaginalis, and bacterial vaginosis testing were collected
from female adolescents in an Atlanta, Georgia, longitudinal cohort
study at 6-month visits (1999-2003). Associations with persistence
(detection of the same HPV type at two sequential visits (visit pair))
were assessed among subjects with 2-5 visits and \> or =6 months of
follow-up. Associations were evaluated by logistic regression using
methods for correlated data. Type-specific persistence of high-risk HPV
types was detected in 77 of 181 (43%) analyzed visit pairs. Concurrent
infection with C. trachomatis was independently associated with
persistence of high-risk HPV types (adjusted odds ratio = 2.1, 95%
confidence interval: 1.0, 4.1). Infection with more than one HPV type at
the initial visit was also associated with high-risk persistence
(adjusted odds ratio = 2.8, 95% confidence interval: 1.6, 4.9). The
association between chlamydia infection and cervical cancer may be due
to an effect of chlamydia infection on persistence of high-risk HPV
[Samoff
E](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Samoff+E"%5BAuthor%5D)
et al Association of Chlamydia trachomatis with persistence of high-risk
types of human papillomavirus in a cohort of female adolescents. [Am J
Epidemiol.](javascript:AL_get(this, 'jour', 'Am J Epidemiol.');) 2005
Oct 1;162(7):668-75
[http://aje.oxfordjournals.org/cgi/content/abstract/162/7/668](blocked::http://aje.oxfordjournals.org/cgi/content/abstract/162/7/668)

####  {#section-44 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Financial support for I/T/U staff to attend STD/HIV training in FY2006 {#financial-support-for-itu-staff-to-attend-stdhiv-training-in-fy2006-1 .Style-Heading-4-+-Arial-14-pt-Underline}

The IHS National STD Program announces the availability of financial
support for up to 10 IHS, tribal health, or urban Indian health (I/T/U)
staff to attend STD/HIV training in FY2006. The training will be
provided by the CDC-funded STD/HIV Prevention Training Centers (PTCs).
The PTCs provide STD training in three areas: clinical care, behavioral
and social interventions, and partner services/program support. For more
information on the courses, locations, and dates of PTC training, visit
<http://depts.washington.edu/nnptc/>

I/T/U staff are encouraged to apply if they 1) diagnose, treat, and
manage patients with STDs; 2) deliver STD interventions directly to
clients, supervisors of those providers, and persons who plan STD/HIV
intervention programs in a community- or clinic-based setting; and 3)
work in STD/HIV prevention programs.

**Completed applications are due January 31, 2006**. A team with
representatives from the Centers for Disease Control and Prevention
(CDC), PTCs, and IHS will review completed applications; successful
applicants will be informed by February 28, 2006. The selection will be
based on an expressed training need, the availability of other STD
training resources, and future plans in the area of STD/HIV prevention
and care. If you have additional questions, e-mail or call Lori de
Ravello at the IHS National STD Program 505-248-4202,
<lori.deravello@ihs.gov>

 

**Other**

Screening for HIV: Recommendation Statement U. S. Preventive Services
Task Force

Summary of Recommendations

The USPSTF strongly recommends that physicians screen for HIV infection
in all adolescents and adults at increased risk of HIV infection (see
Clinical Considerations for discussion of risk factors). **A
recommendation**

The USPSTF found good evidence that both standard and U.S. Food and Drug
Administration (FDA)-approved rapid screening tests accurately detect
HIV infection. The USPSTF also found good evidence that appropriately
timed interventions, particularly highly active antiretroviral therapy
(HAART), lead to improved health outcomes for many of those screened,
including reduced risk of clinical progression and reduced mortality
rates. Because false-positive test results are rare, harms associated
with HIV screening are minimal. Potential harms of true-positive test
results include increased anxiety, labeling, and effects on close
relationships. Most adverse events associated with HAART, including
metabolic disturbances associated with an increased risk of
cardiovascular events, may be ameliorated by changes in regimen or
appropriate treatment. The USPSTF concluded that the benefits of
screening persons at increased risk substantially outweigh potential
harms.

The USPSTF makes no recommendation for or against routinely screening
for HIV infection in adolescents and adults who are not at increased
risk of HIV infection (see Clinical Considerations for discussion of
risk factors). **C recommendation**

The USPSTF found fair evidence that screening adolescents and adults not
known to be at increased risk of HIV infection can detect additional
persons with HIV infection, and good evidence that appropriately timed
interventions, especially HAART, lead to improved health outcomes for
some of these persons. However, the yield of screening persons without
risk factors would be low, and potential harms associated with screening
have been noted (see above). The USPSTF concluded that the benefit of
screening adolescents and adults without risk factors for HIV infection
is too small relative to potential harms to justify a general
recommendation.

The USPSTF recommends that physicians screen all pregnant women for HIV
infection. **A recommendation**

The USPSTF found good evidence that both standard and FDA-approved rapid
screening tests accurately detect HIV infection in pregnant women and
fair evidence that introduction of universal prenatal counseling and
voluntary testing increases the proportion of HIV-infected women who are
diagnosed and are treated before delivery. There is good evidence that
recommended regimens of HAART are acceptable to pregnant women and lead
to significantly reduced rates of mother-to-child transmission. Early
detection of maternal HIV infection also allows for discussion of
elective cesarean section and avoidance of breastfeeding, both of which
are associated with lower HIV transmission rates. There is no evidence
of an increase in fetal anomalies or other fetal harm associated with
currently recommended antiretroviral regimens (with the exception of
efavirenz; see below). Serious or fatal maternal events are rare using
currently recommended combination therapies. The USPSTF concluded that
the benefits of screening all pregnant women substantially outweigh
potential harms. <http://www.ahrq.gov/clinic/uspstf/uspshivi.htm>

**HIV-Prevention Research in Minority Communities Program Accepting
Applications**

The UCSF Center for AIDS Prevention Studies invites applications for its
Collaborative HIV-Prevention Research in Minority Communities Program.

This program helps Scientists/Researchers improve their research
programs and obtain additional funding.
[[http://www.caps.ucsf.edu/capsweb/projects/minorityindex.html]{.underline}](http://www.caps.ucsf.edu/capsweb/projects/minorityindex.html)

Participants spend six weeks in San Francisco for three consecutive
summers. They receive mentoring from UCSF investigators, \$25,000 to
conduct preliminary research, a monthly stipend, and roundtrip airfare
each summer.

Applicants should be scientists/researchers in tenure track positions
and investigators in research institutes who have not yet obtained
funding. Application deadline: January 13, 2006

Contact: M. Margaret Dolcini, Ph.D. Program Director, Center for AIDS
Prevention Studies, UCSF <pdolcini@psg.ucsf.edu>

#### Barbara Stillwater Alaska State Diabetes Program  {#barbara-stillwater-alaska-state-diabetes-program .Style-Heading-4-+-Arial-14-pt-Underline}

**Type 2 diabetes mortality in women: Same as a \"coronary heart disease
equivalent\"**

Similar Mortality Risks in Diabetes as Those with Heart Disease

CONCLUSIONS: Diabetes without prior myocardial infarction and prior
myocardial infarction without diabetes indicate similar risk for CHD
death in men and women. However, diabetes without any prior evidence of
CHD (myocardial infarction or angina pectoris or ischemic ECG changes)
indicates a higher risk than prior evidence of CHD in nondiabetic
subjects, especially in women.

[Juutilainen
A](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Juutilainen+A"%5BAuthor%5D),
et al Type 2 diabetes as a \"coronary heart disease equivalent\": an
18-year prospective population-based study in Finnish subjects.
[Diabetes Care.](javascript:AL_get(this, 'jour', 'Diabetes Care.');)
2005 Dec;28(12):2901-7.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16306552&dopt=Abstract>

**Homocysteine: Risk factor for the development of diabetes in women
with previous GDM**

[Cho
NH](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Cho+NH"%5BAuthor%5D),
et al Elevated homocysteine as a risk factor for the development of
diabetes in women with a previous history of gestational diabetes
mellitus: a 4-year prospective study. [Diabetes
Care.](javascript:AL_get(this, 'jour', 'Diabetes Care.');) 2005
Nov;28(11):2750-5.\
CONCLUSIONS: This prospective study identified homocysteine level as a
significant risk factor for development of diabetes in women with
previous GDM.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16249551&query_hl=6>

**Protein and Unsaturated Fats Lowers BP, Improves Lipids, and May
Reduce CVD**

CONCLUSION: In the setting of a healthful diet, partial substitution of
carbohydrate with either protein or monounsaturated fat can further
lower blood pressure, improve lipid levels, and reduce estimated
cardiovascular risk

[Appel
LJ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Appel+LJ"%5BAuthor%5D),
et al Effects of protein, monounsaturated fat, and carbohydrate intake
on blood pressure and serum lipids: results of the OmniHeart randomized
trial. [JAMA.](javascript:AL_get(this, 'jour', 'JAMA.');) 2005 Nov
16;294(19):2455-64.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16287956&query_hl=3>

**Glycemic Index online**

Here is a good resource for you or your patients
<http://www.glycemicindex.com/>

# Save the dates {#save-the-dates .Style-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5%)}

**National Conference on Juvenile Issues**

-   January 9--13, 2006

-   Washington, DC

-   Coordinating Council on Juvenile Justice and Delinquency Prevention

-   Office of Juvenile Justice and Delinquency Prevention

<http://www.juvenilecouncil.gov/2006NationalConference/index.html>

**21st Annual Midwinter Indian Health OB / PEDS Conference**

-   For providers caring for Native women and children

-   January 27-29, 2006

-   Telluride, CO

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

**Sudden Infant Death Syndrome (SIDS), Sudden Unexplained Death in
Childhood (SUDC)**

-   February 23-26, 2006

-   Philadelphia, Pennsylvania

-   [[http://www.cjsids.com/]{.underline}](http://www.cjsids.com/)

**Advances in Indian Health, 6^th^ Annual**

-   May 2-6, 2006

-   Albuquerque, NM

-   Save the dates brochure

<http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#May06>

**Native Peoples of North America HIV/AIDS Conference**

-   May 3--6, 2006

-   Anchorage, Alaska

-   Embracing Our Traditions, Values, and Teachings
    [www.embracingourtraditions.org](http://www.embracingourtraditions.org/)

-   [National Institutes of Health (NIH),
    DHHS](http://www.embracingourtraditions.org/conf_info.htm)
    <http://www.ou.edu/rec/pdf/Native_Fact_Sheet.pdf>

**ACOG 2006 Annual Clinical Meeting (ACM)**

-   May 6-10, 2006

-   Washington, DC

-   Save the dates brochure
    [http://www.acog.org/abstract%2Dsubmission/](http://www.acog.org/abstract-submission/)

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

-   September 17 -- 21, 2006

-   Denver, CO

-   Contact <YMalloy@acog.org> or call Yvonne Malloy at 202-863-2580

```{=html}
<!-- -->
```
-   Last year's brochure link below (2005 Brochure) (PDF 145k)

-   <http://www.ihs.gov/MedicalPrograms/MCH/M/Documents/FinalACOGBrochure.pdf>

-   NEONATAL RESUSCITATION PROGRAM available

# What's new on the ITU MCH web pages? {#whats-new-on-the-itu-mch-web-pages .Style-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5%)}

**Rectal bleeding in 40 year old AI/ AN female - Web M + M**

<http://www.ihs.gov/MedicalPrograms/MCH/M/PCdiscForumMod.asp#rectalBleed>

**Northern Plains Indians: Risk factors for sudden infant death
syndrome**

<http://www.ihs.gov/MedicalPrograms/MCH/M/Pr01.cfm#piRisks>

There are several upcoming **Conferences**

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

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

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

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

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

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

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

# Did you miss something in the last OB/GYN Chief Clinical Consultant Corner? {#did-you-miss-something-in-the-last-obgyn-chief-clinical-consultant-corner .Style-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5%)}

#### The November 2005 OB/GYN CCC Corner is available at: {#the-november-2005-obgyn-ccc-corner-is-available-at .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105.cfm**](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1105.cfm) {#httpwww.ihs.govmedicalprogramsmchmobgyn1105.cfm .Style-Heading-4-+-Arial-14-pt-Underline}

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

Evidence does not justify routine use of magnesium sulfate in mild
pre-eclampsia

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

Carolyn Aoyama:

#### Excess Cervical Cancer Mortality: Marker for Low Access to Health Care in Poor  {#excess-cervical-cancer-mortality-marker-for-low-access-to-health-care-in-poor .Style-Heading-4-+-Arial-14-pt-Underline}

Steve Holve:

Is there an IHS RSV policy? 

Richard Olson:

Medical Staff Credentialing and Privileging Guide, 3^rd^ Edition: Now
available

Phil Smith:

#### Guidelines for Identifying and Referring Persons with Fetal Alcohol Syndrome {#guidelines-for-identifying-and-referring-persons-with-fetal-alcohol-syndrome .Style-Heading-4-+-Arial-14-pt-Underline}

Judy Thierry:

-We would like to hear from people -- Diabetes in pregnancy

-AAP Revises SIDS Prevention Recommendations

-Prenatal tobacco - Canadian Best practices - Expecting to Quit

-Teen pregnancy: Protective and risk factors and those that can be
altered

-National Conference on Juvenile Issues January 9--13, 2006

and more....

**Seh Welch:**

Embracing Our Traditions, Values, and Teachings: Native Peoples of North
America HIV/AIDS

Conference May 2-6, 2006

#### Hot Topics:  {#hot-topics-2 .Style-Heading-4-+-Arial-14-pt-Underline}

##### Obstetrics: page 11

-Two handy 'Best Practice' checklists now available: DM or HTN in
pregnancy

-1^st^ trimester combined screening better than 2^nd^ trimester
quadruple screening: NEJM

-A Call to End Routine Episiotomy, No Maternal Benefit

-Dexamethasone treatment does not improve the outcome of women with
HELLP syndrome

-Guidelines on Trial of Labor After Cesarean Delivery

and more....

**Gynecology: page 16**

-Have you ever had problems with a stenotic cervix?

-Vaccine prevents cervical cancer, Gardasil: Preliminary results 100%
effective

-Tubo-ovarian abscess - Ultrasound-guided aspiration with antibiotics:
First-line procedure

-Bladder perforation for TVT are higher for inexperienced / appears to
be a learning curve

#### -Cigarette Smoking and Effects on Hormone Function in Premenopausal Women {#cigarette-smoking-and-effects-on-hormone-function-in-premenopausal-women .Style-Heading-4-+-Arial-14-pt-Underline}

and more....

**Child Health: page 19**

-Advanced skills practitioner not needed at uncomplicated elective
cesarean delivery

-Do Pacifiers Reduce the Risk of Sudden Infant Death Syndrome? A
Meta-Analysis

-Complications of Body Piercing

-Skin-to-Skin Care Cuts Stress for NICU Infants and Mothers

### -AAP Revises Recommendations on Reducing the Risk of SIDS - Pearls for Practice

and more....

**Chronic Illness and Disease: page 22**

-Beyond Red Lake - The persistent crisis in American Indian Health Care

-Paving the way\--providing opportunities for Native American students

-Provider education in depression recognition and treatment reduces
suicide rates

-New Studies Document the Health Benefits of Seafood Consumption

-Options for Breast Cancer Screening

and more....

#### Features: page 24 {#features-page-24 .Style-Heading-4-+-Arial-14-pt-Underline}

##### American Family Physician

-Low Testosterone Not Linked with Female Sexual Dysfunction

-Should Women with Dysuria and Negative Dipstick Test Be Treated?

-Antiviral Agents for Pregnant Women with Genital Herpes

American College of Obstetricians and Gynecologists

-Antiphospholipid syndrome. ACOG Practice Bulletin

-Compounded Bioidentical Hormones

-Elective Coincidental Appendectomy

-Partnering With Patients to Improve Safety

-Maternal Decision Making, Ethics, and the Law

and more....

**Agency for Healthcare Research and Quality**

-AHRQ Releases Updated Guide to Clinical Preventive Services

-Women who smoke have nearly twice the risk of developing Graves\'
hyperthyroidism

-Certain factors predict chronic pelvic pain after pelvic inflammatory
disease

-Two factors predict risk for suicide attempts in youths

-Events surrounding injury affect likelihood an adolescent will suffer
post traumatic stress disorder

and more....

**Ask a Librarian**

Exciting news: ***All*** clinicians involved with Indian Health are now
invited -- Tribal, Urban, IHS

**Breastfeeding**

-We need your expertise: Breast Feeding Best Practices in Indian Country

-The breastfeeding mother is physiologically different

-More sleep was obtained when breastfeeding mothers slept with the
newborn

-New Released Patch includes breast feeding and waist circumference

**CCC Corner Digest**

\-[Judy Thierry, HQE - Maternal Morbidity in Indian
Country](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1005_Coll.cfm)

\-[First Validated Model Predicts Risk of Failed Vaginal Birth After
Cesarean](http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN1005_HT.cfm#ob)

\-[Paroxetine Curbs Premenstrual Dysphoric
Disorder](http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN1005_HT.cfm#gyn)

[#1 cause of pediatric
deaths!!!](http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN1005_HT.cfm#child)

\-[Native Americans with highest rates of major depressive
disorder](http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN1005_HT.cfm#chrIll)

\-[ACOG:Racial and Ethnic Disparities in Women\'s Health, ACOG Committee
Opinion No.
317](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1005_Feat.cfm#acog)

\-[Help Us Establish a Free Electronic Patient Education Resource
Center](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1005_Feat.cfm#AskLib)

\-[October was Domestic Violence Awareness
Month](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1005_Feat.cfm#dv)

\-[Cancer screening in elderly patients: a framework for individualized
decision
making](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1005_Feat.cfm#elder)

\-[ParaGard ® T 380A Approved for Nulliparous Women in Stable
Relationships from Age
16](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1005_Feat.cfm#fp)

\-[Newly Released Perinatology Corner Module:  Shoulder Dystocia  (free
CME/CEUs)](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1005_Feat.cfm#faq)

\-[R/O Ectopic - HCG curves
redefined](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1005_Feat.cfm#mmtour)

\-[Paxil Use in Early Pregnancy May Cause Birth
Defects](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1005_Feat.cfm#MidWives)

\-[Syphilis Treatment Issues---Azithromycin Use Not Encouraged for
Syphilis
Treatment](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1005_Feat.cfm#navajo)

\-[Prenatal visits: Less quantity and higher quality: Outcome based
analysis](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1005_Feat.cfm#okie)

-Patient Education - Mary Lynn Eaglestaff, Aberdeen Area Women's Health
Program

\-[Preterm Labor: Signs and Symptoms - Patient Education
Brochure](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1005_Feat.cfm#pi)

\-[Thyroid-stimulating hormone decreases significantly during the first
trimester](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1005_Feat.cfm#periPicks)

-STD Corner - Welcome Lori de Ravello

\-[Which Comes First in Adolescence---Sex and Drugs or
Depression?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1005_Feat.cfm#std)

**Domestic Violence**

-GPRA Domestic Violence clinical performance indicators

-Legal Assistance for Victims Grants November 29^th^ at 2:00 CST

-Study Documents High Costs and Impact of Intimate Partner Violence

-National Center on Domestic Violence and Sexual Violence web site

-Pre-Pregnancy Physical Abuse in Alaska

**Elder Care News**

Estrogen plus progestin increases risk of urge and stress incontinence
within 4 months

**Family Planning**

## -FDA Updates Labeling for Ortho Evra Contraceptive Patch

#### -DMPA bone mass loss is reversible {#dmpa-bone-mass-loss-is-reversible .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Increased Risk of Oral Contraceptive Failure in Obese Women {#increased-risk-of-oral-contraceptive-failure-in-obese-women .Style-Heading-4-+-Arial-14-pt-Underline}

#### -No evidence supports practice of switching oral contraceptives to treat headache {#no-evidence-supports-practice-of-switching-oral-contraceptives-to-treat-headache .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Dietary Calcium Prevents Bone Loss in Oral Contraceptive Users {#dietary-calcium-prevents-bone-loss-in-oral-contraceptive-users .Style-Heading-4-+-Arial-14-pt-Underline}

and more....

**Featured Website**

USDA\'s main page on Avian Influenza

**Frequently asked questions**

-How do we treat tuberculosis in pregnancy?

-Do adult women experience different symptoms of ADHD from men**?**

**Indian Child Health Notes**

-Phoning It In - Telepsychiatry Services for American Indians

-Hepatitis B - Is it Time for a Boost?

-A is as bad as B - Monitoring invasive Haemophilus A disease in Native
American Children

**Information Technology**

-Want to learn more about the RPMS Women's Health Package? Ongoing
training available

-UpToDate Version 13.3 is now available

-RPMS Suicide Reporting Form now available

International Health

-Pregnancy, Travel and Malaria: A Precautionary Tale

-Return of children to areas impacted by flooding / hurricanes:
Recommendations

-KNOW, PLAN, PACK: Disaster or Emergency Preparedness Plan for Women

-Tracking Health in Underserved Communities: Factline

#### MCH Alert

-Protecting Children in Foster Care

-Maternal cigarette consumption is a strong predictor of newborn birth
weight percentile

#### Medical Mystery Tour

#### -The HCG curve has been redefined R/O ectopic. How else can you follow HCG ? {#the-hcg-curve-has-been-redefined-ro-ectopic.-how-else-can-you-follow-hcg .Style-Heading-4-+-Arial-14-pt-Underline}

#### -What it accuracy of ultrasound in R/O ectopic?  {#what-it-accuracy-of-ultrasound-in-ro-ectopic .Style-Heading-4-+-Arial-14-pt-Underline}

#### What type of ultrasound characteristics should we find? {#what-type-of-ultrasound-characteristics-should-we-find .Style-Heading-4-+-Arial-14-pt-Underline}

#### Medscape

**Menopause Management**

-Bioidentical Hormones: No scientific evidence to support claims of
increased efficacy

#### -Estrogen Therapy and the Risk of Cognitive Decline {#estrogen-therapy-and-the-risk-of-cognitive-decline .Style-Heading-4-+-Arial-14-pt-Underline}

**Midwives Corner**

-Which Cord strikes a sour note?

-A Simple Method for Evaluating the Clinical Literature

-Eating Fish During Pregnancy Boosts Baby\'s Brainpower

-Low risk home births using CNMs: Similar intrapartum and neonatal
mortality

-Elevated Uric Acid in Blood Linked To Preterm Births

**Navajo News**

Once a day gentamicin dosing intrapartum may provide better coverage for
the fetus 

**Nurses Corner**

-Stressful workplaces and unfair bosses can raise cardiac risks

## -Average age of nurses increases: **By 2010, the average nurse will be over 45 years old**

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

-Diabetes and Pregnancy: Frequently Asked Questions

-General Information and National Estimates on Diabetes in the United
States, 2005

-Influenza Vaccination in Pregnancy: Practices Among
Obstetrician-Gynecologists

**Oklahoma Perspective**

Shoulder dystocia

Osteoporosis

Estrogen supplementation may be protective of BMD in adolescents who use
DMPA

Patient Education

-Body Piercing: What You Should Know

-Respiratory Infections During Pregnancy

-Genital Herpes: What You Should Know

-Prenatal Diagnosis: Amniocentesis and CVS

-Ectopic Pregnancy: What You Should Know

and more....

Perinatology Picks

-Medical Management of Early Pregnancy Failure

-Papers of interest from the 25^th^ Annual Meeting of the Society for
Maternal Fetal Medicine

Primary Care Discussion Forum

Rectal bleeding: Is it hemorrhoids? Morbidity and Mortality Rounds - Web
Based

STD Corner

-Daily suppressive therapy is recommended for HSV-2 seropositive
individuals

-HIV - Grade A recommendation: Screen high risk adolescents / adults,
plus all pregnant

-Need to reassess screening young men to complement screening among
young women

#### -Genital Herpes Screening: Recommendation Statement USPSTF  {#genital-herpes-screening-recommendation-statement-uspstf .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Gonorrhea Screening: Recommendation Statement USPSTF {#gonorrhea-screening-recommendation-statement-uspstf .Style-Heading-4-+-Arial-14-pt-Underline}

and more....

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

-Big Babies at Risk of Obesity Later in Life

-Pedometers may help couch potatoes get sorely needed exercise

-Rate of BMI Increase in Childhood Predicts Risk of Adult Heart Disease

-Just an additional 3200 steps a day, not 10,000 shows fitness gains

-Apple Shape Predicts Heart Attack Risk Better than BMI

and more....

###### Save the Dates: Upcoming events of interest page 49

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

The past CCC Corners are archived at:

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

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

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

12/17/05