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OB/GYN Chief Clinical Consultant's Corner

Volume 5, No. 9, October 2007

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

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

**Group Prenatal Care Improves Pregnancy Outcomes at No Additional
Cost**

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

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

#### Michael Berryhill {#michael-berryhill .Style-Heading-4-+-Arial-14-pt-Underline}

#### Interested in a subinternship / externship / observership {#interested-in-a-subinternship-externship-observership .Style-Heading-4-+-Arial-14-pt-Underline}

Scott Giberson

New items on IHS HIV website

**Amy Groom**

2007-2008 Influenza Vaccine

**Craig Vanderwagen**

Rebuilding Iraq one step at a time: You can be part of the solution

**Roberta Ward**

First trimester screening for Down Syndrome

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

#### Obstetrics page 9 {#obstetrics-page-9 .Style-Heading-4-+-Arial-14-pt-Underline}

## -Do Unsutured Second-Degree Perineal Lacerations Affect Postpartum Outcomes?

-Treating Gestational Diabetes May Reduce Childhood Obesity

-Increased still birth among obese mothers

-Neonatal sepsis increases linearly with membrane rupture up to 36 hours

-Extraabdominal uterine repair at cesarean: Increased patient
discomfort, nausea, vomiting

and more......

**Gynecology** **page 12**

-Cervical cancer differences disappear in rural women after controling
for poverty and race

-Improvements in outcome with subtotal hysterectomy not confirmed

-Cost effectiveness of home based population screening for Chlamydia
trachomatis

**Child Health** **page 12**

-How to improve psychosocial problems at well child care visits?

-Is Ibuprofen Appropriate for Pain Control in Children?

-School based intervention to lower incidence of disordered weight
control behavior

-Management of Type 2 Diabetes in Youth: An Update

-Are babies born to short, primiparous, or thin mothers \"normally\" or
\"abnormally\" small?

**Chronic Illness and Disease** **page 14**

## -Why Hasn\'t This Patient Been Screened for Colon Cancer? 

-Migraine With Aura Increases Risk for Ischemic Stroke

-US Dietary Guidelines Effectively Limit Insulin Resistance in Women

-The Choice of a Metabolic Syndrome Generation: Soft Drinks

-ACIP Recommends the Use of Tdap in Adults

and more......

#### Features **page 17** {#features-page-17 .Style-Heading-4-+-Arial-14-pt-Underline}

American College of Obstetricians and Gynecologists

-Pelvic Organ Prolapse

-Management of Delivery of a Newborn With Meconium-Stained Amniotic
Fluid

-ACOG Advises Against Cosmetic Vaginal Procedures: Safety and Efficacy
Data

-Research Involving Women

##### American Family Physician

Counseling Women About Mammography: Benefits vs. Harms

###### Guidelines on Screening for Fetal Chromosomal Abnormalities

**Agency for Healthcare Research and Quality**

-Maternal and fetal labor and delivery complications increase beyond 39
weeks

-Midwife practices vary greatly in compensation and employment
structures

-Pediatricians recognize most overweight or obese children without using
weight curves

-Gender of both the child and parent affect a child\'s participation
during visits to the doctor

-Pertussis vaccination in adults can be cost-effective depending on
incidence rates

**Ask a Librarian**

In Search of a Research Article?

**Breastfeeding**

A pacifier by any other name....\*

Medications: Information for Pregnant and Breastfeeding Women

Breastfeeding Trends and National Health Objectives for Exclusive
Breastfeeding

**CCC Corner Digest**

-Women\'s greater risk of dying after surgery: Transfusion-related
immunosuppression

-Ann Bullock is the new Chief Clinical Consultant for Family Medicine

-Low-dose aspirin has benefits when used for prevention of pre-eclampsia

-Human papillomavirus, vaccines and women\'s health: questions and
cautions

-Educate parents about new pre-adolescent vaccine recommendations

-Exposing the Great Bottled Water Scam

-Prevention of Deep Vein Thrombosis and Pulmonary Embolism  Practice
Bulletin

-Prevent Fetal Alcohol Spectrum Disorders: A Toolkit

-Various Implantable Contraceptives Equally Effective in Preventing
Pregnancy

-Moderate morning sickness only partially responding to doxylamine and
pyridoxine

-Don't use Google, use Blackle instead and save 750 mega watts/hour per
year

-Sex, Soap & Social Change - The Sabido Methodology

-Motor vehicle restraint use in American Indian children: Meaningful
interventions

-Nausea and Vomiting in Pregnancy

-Study Supports HRT Use for Short Term, but Little Benefit in Older
Women

-Group prenatal care reduces preterm births and increases breastfeeding
initiation: RCT

-Evaluation of the pregnant patient for non-obstetric surgery

-Nursing education scholarship opportunities

-Decision Rules Useful for Selecting Women for Bone Mineral Density
Testing

-Nausea and Vomiting of Pregnancy

-Chronic Renal Disease is Part of Primary Care

-Culture, context, and sexual risk among Northern Plains American Indian
Youth

-Within eight years, 75% of adults will be obese or overweight

-APN scope of practice: colonoscopy?

**Domestic Violence**

-Domestic Violence Awareness Month: October

-Health Cares About Domestic Violence Day: October 10, 2007

-Victim Advocates And Tribal Law Enforcement: October 17-18, 2007

-Location of shelters impacts the incidence of violence against homeless
women

**Elder Care News**

-Daily Back Pain May Have Adverse Health Effects in Elderly Women 

# -Estrogens May Modify Course of Parkinson\'s Disease in Women

**Family Planning**

Advance Provision for Emergency Oral Contraception

**Featured Website**

State trends on uninsured children

**Frequently asked questions**

What\'s the first course of action for this couple that\'s trying to
conceive?

**Indian Child Health Notes**

-Superhero related injuries in pediatrics

-Unpublicized nuclear releases in American Indian communities

-Removable brace versus casting in children with low-risk ankle
fractures.

-Influenza Vaccination for 2007-8

-The tail end of guinea worm -- global eradication without a drug or a
vaccine

**Information Technology**

-Changes in workflow and tasks with bar code medication administration
into nurses\' work

-Commonwealth Fund/Harvard University Fellowship in Minority Health
Policy

International Health

Prevention of Mother-to-Child HIV Transmission: An Innovative Program in
Cameroon

#### 

#### MCH Alert

-Infant Mortality Awareness Month Toolkit

-New Edition of Child Health USA Released

-MCH Library expands availability and access to historical documents

#### MCH Headlines

-AIAN researchers on perinatal depression requesting names of interested
individuals

-Protecting America's Future

-Alliance for a Healthier Generation Webinar

#### Medical Mystery Tour

#### Endometriosis: Where is the real truth? {#endometriosis-where-is-the-real-truth .Style-Heading-4-+-Arial-14-pt-Underline}

#### Medscape

#### -Hereditary Link to PMDD Identified {#hereditary-link-to-pmdd-identified .Style-Heading-4-+-Arial-14-pt-Underline}

#### -The Reproductive Phenotype in Polycystic Ovary Syndrome {#the-reproductive-phenotype-in-polycystic-ovary-syndrome .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Passive Smoking Increases Risk for Sleep Disturbance During Pregnancy {#passive-smoking-increases-risk-for-sleep-disturbance-during-pregnancy .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Management of Valvular Heart Disease in Pregnancy {#management-of-valvular-heart-disease-in-pregnancy .Style-Heading-4-+-Arial-14-pt-Underline}

**Menopause Management**

#### -Estrogen Protects Women's Brains Prior to Menopause {#estrogen-protects-womens-brains-prior-to-menopause .Style-Heading-4-+-Arial-14-pt-Underline}

-Atrophic Vaginitis and Estrogen Treatment - Medscape CME

\-[Cholesterol-Related Compound Can Block Estrogen To Prevent Heart
Disease](http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=47533)

**Midwives Corner**

-Nurse Midwife Week October 7-13, 2007

-Piercing the veil: the marginalization of midwives in the United States

-Impact of written information on women\'s use of postpartum services

**Navajo News**

Evaluation of the pregnant patient for non-obstetric surgery: Part Two

**Nurses Corner**

Memories, As a Public Health Nurse on the Navajo

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

-Common Questions about HPV and Cervical Cancer: For Women Who Have HPV

# -Prevalence of HPV Infection Among Sexually Active Females 

-Pre-Teen Vaccine Campaign

**Oklahoma Perspective**

Preconception Health of Women Delivering Live-Born Infants --- Oklahoma,
2000--2003

Osteoporosis

-Fracture Outcomes in Women Discontinuing Alendronate

-Childhood, Teen Restriction of Dairy Foods Lowers Spinal Bone Mineral
Content

-Pharmacologic Treatment of Osteopenia Not Usually Indicated

Patient Education

Type 2 Diabetes in Youth: What You Should Know

Perinatology Picks

-Procedure-related complications of amniocentesis and CVS are small

-Positive association between hyperemesis gravidarum and Helicobacter
pylori infection

-HgbA1C and GHb for risk of congenital anomaly in women with diabetes

-Crohn\'s disease: Preterm birth etc greater with azathioprine
/6-mercaptopurine

-Magnesium sulphate for women at risk of preterm birth for
neuroprotection of the fetus

and more......

Primary Care Discussion Forum

Chronic Kidney Disease: CKD is Part of Primary Care!

STD Corner

-Culture, context, and sexual risk among Northern Plains American Indian
Youth

-Sexual Assertiveness among Adolescent Girls: Initiation, Refusal, and
Protective Behaviors

-Sexually Transmitted Infections in Preadolescent Children

#### -Screening for Chlamydial Infection: USPSTF Recommendation Statements {#screening-for-chlamydial-infection-uspstf-recommendation-statements .Style-Heading-4-+-Arial-14-pt-Underline}

# -Home screening for sexually transmitted diseases in high-risk young women: RCT

...and more

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

-HAPO: Call for re-evaluation of gestational diabetes diagnosis and
treatment criteria

#### -Children whose mothers are overweight: Higher levels of body fat themselves at age nine {#children-whose-mothers-are-overweight-higher-levels-of-body-fat-themselves-at-age-nine .Style-Heading-4-+-Arial-14-pt-Underline}

-Women less likely than men to change habits that increase heart-disease
risk

#### -Maternal Diabetes Depletes Fetal Iron Stores {#maternal-diabetes-depletes-fetal-iron-stores .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Gestational diabetes mellitus may increase risk of developing pancreatic cancer {#gestational-diabetes-mellitus-may-increase-risk-of-developing-pancreatic-cancer .Style-Heading-4-+-Arial-14-pt-Underline}

**Women's Health Headlines**

Ovarian Cancer: Pinn Point on Women's Health

###### Save the Dates: Upcoming events of interest **page 44**

#### What's new on the ITU MCH web pages **page 45**

New Breastfeeding Headlines Box: The Latest in Breastfeeding Updates

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

#  {#section-2 .Style-Heading-1-+-Underline}

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

**Group Prenatal Care Improves Pregnancy Outcomes at No Additional
Cost**

OBJECTIVE: To determine whether group prenatal care improves pregnancy
outcomes, psychosocial function, and patient satisfaction and to examine
potential cost differences.

METHODS: A multisite randomized controlled trial was conducted at two
university-affiliated hospital prenatal clinics. Pregnant women aged
14-25 years (n=1,047) were randomly assigned to either standard or group
care. Women with medical conditions requiring individualized care were
excluded from randomization. Group participants received care in a group
setting with women having the same expected delivery month. Timing and
content of visits followed obstetric guidelines from week 18 through
delivery. Each 2-hour prenatal care session included physical
assessment, education and skills building, and support through
facilitated group discussion. Structured interviews were conducted at
study entry, during the third trimester, and postpartum.

RESULTS: Mean age of participants was 20.4 years; 80% were African
American. Using intent-to-treat analyses, women assigned to group care
were significantly less likely to have preterm births compared with
those in standard care: 9.8% compared with 13.8%, with no differences in
age, parity, education, or income between study conditions. This is
equivalent to a risk reduction of 33% (odds ratio 0.67, 95% confidence
interval 0.44-0.99, P=.045), or 40 per 1,000 births. Effects were
strengthened for African-American women: 10.0% compared with 15.8% (odds
ratio 0.59, 95% confidence interval 0.38-0.92, P=.02). Women in group
sessions were less likely to have suboptimal prenatal care (P\<.01), had
significantly better prenatal knowledge (P\<.001), felt more ready for
labor and delivery (P\<.001), and had greater satisfaction with care
(P\<.001). Breastfeeding initiation was higher in group care: 66.5%
compared with 54.6%, P\<.001. There were no differences in birth weight
nor in costs associated with prenatal care or delivery.

CONCLUSION: Group prenatal care resulted in equal or improved perinatal
outcomes at no added cost. LEVEL OF EVIDENCE: I

[Ickovics
JR](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Ickovics JR"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Group prenatal care and perinatal outcomes: a randomized
controlled trial. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007
Aug;110(2 Pt 1):330-9

<http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=17666608&dopt=AbstractPlus>

#### [National MCH Coordinator Editorial comment:]{.underline}

**CenteringPregnancy in the Indian Health system**

I want to acknowledge the 30 participants who attended the
CenteringPregnancy group prenatal care training held August 13 and 14th
in Albuquerque.  The training provided the fundamentals and the
experience of this new model of care. The August 15 to 17 Native
Women\'s Health and Maternity Care Conference, \"Improve the System,
Improve the Outcome\" provided a 1 hour workshop experience on
CenteringPregnancy lead by IHS facilities engaged in group prenatal
care.  Expect an article from the sites already involved in Centering
shortly in an upcoming CCC Corner.  

The web site is complete with information on research, trainings,
background materials and conferences on Centering.
<http://www.centeringpregnancy.org/>

A model of Centering Parenting is underway, encouraged by prenatal
clients and their families across the US. \
\
For site specific activities and training questions please contact me
<judith.thierry@ihs.gov> or Joel Rosen  <joel.rosen@ihs.gov>

You can subscribe to an IHS centering pregnancy list serve past this
link into your browser:
<http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=80&startrow=1> 

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

#### Michael Berryhill, HQE {#michael-berryhill-hqe .Style-Heading-4-+-Arial-14-pt-Underline}

#### Interested in a subinternship / externship / observership {#interested-in-a-subinternship-externship-observership-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### I am a graduate from Royal College of Surgeons in Ireland and would like to apply for a subinternship/elective in general gynaecology and obstetrics with Indian health organization.  I have completed my medical training in Ireland and have done one year of internship in medicine and surgery.I wish to be in the field of OBGYN,and would very much be greatful if you could allow be to be attached to one of your fellow OBGYNs for an observership or subinternship. {#i-am-a-graduate-from-royal-college-of-surgeons-in-ireland-and-would-like-to-apply-for-a-subinternshipelective-in-general-gynaecology-and-obstetrics-with-indian-health-organization.-i-have-completed-my-medical-training-in-ireland-and-have-done-one-year-of-internship-in-medicine-and-surgery.i-wish-to-be-in-the-field-of-obgynand-would-very-much-be-greatful-if-you-could-allow-be-to-be-attached-to-one-of-your-fellow-obgyns-for-an-observership-or-subinternship. .Style-Heading-4-+-Arial-14-pt-Underline}

#### Sincerely, {#sincerely .Style-Heading-4-+-Arial-14-pt-Underline}

#### Dorcus Ye CV available from [**Michael.Berryhill@ihs.gov**](mailto:Michael.Berryhill@ihs.gov) {#dorcus-ye-cv-available-from-michael.berryhillihs.gov .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Scott Giberson, HQE {#scott-giberson-hqe .Style-Heading-4-+-Arial-14-pt-Underline}

**New items on IHS HIV website**

As a reminder, please continue to check the IHS HIV/AIDS webpage as
there are continual updates to the site. Our 'web-hits' report shows a
trend of increasing website usage over the last 6 months, which is very
encouraging news. Currently, here are some of the items that can be
found on the site:

 

-   National Clinical Guidelines for the Treatment and Care of HIV/AIDS

-   Ryan White information, links and resources
    **[specific]{.underline}** to the AI/AN population

-   Marketing tools, posters, PowerPoints and tribal advocacy kit

-   Continuing medical education links specifically for free CME in
    HIV/AIDS

-   Published research dealing with HIV/AIDS specifically in the AI/AN
    population

-   Numerous links to interagency and native organization resources and
    websites

-   Announcements of trainings

-   "Antiretroviral Corner". Up-to-date art les on clinical topics with
    a focus on HIV/AIDS treatment. ic

[www.ihs.gov/medicalprograms/hivaids](http://www.ihs.gov/medicalprograms/hivaids)

**Amy Groom, IHS Immunization Program**

**2007-2008 Influenza Vaccine**

As we head into September, the IHS-NSSC is also heading into preparation
mode for the 2007-2008 Flu Season.  Last flu season (2006-2007) the
delivery and distribution of the influenza vaccine to the IHS was
delayed by the industry as a result of production issues associated with
the identified strains of the virus that make up the vaccine.  Delivery
of the vaccine came to the NSSC in multiple (4) allocations last year. 
Much of Indian Country did not receive the completion of their order
until December.  This created many problems for facilities and providers
in the field.

 

Each year the IHS-NSSC works with the Department of Veterans Affairs to
include influenza vaccine requirements in the VA National contract
solicitation.  This is done to ensure:

Increased chances to receive the vaccine in the event of production &
distribution issues & dilemmas.

The best price is available to the IHS & the Tribal community.

The product is shipped and received prior to the private sector.

 

In January of this year, after seeking, listening to, and evaluating
your concerns and frustrations from the 06-07 flu season, the IHS-NSSC
worked with the VA to inform the industry and worked to include language
in the solicitation for 2007-2008 flu vaccine to eliminate, or at least
reduce multiple allocations and provide guaranteed delivery dates.  In
April the VA awarded their 07-08 vaccine contract to Novartis (formerly
Chiron) for the adult multiple dose 10ml vial.  Glaxo-Smith-Kline was
awarded the 1 ml single dose syringe, and Sanofi-Pasteur was awarded the
pediatric single dose contract. 

This year, there is great news to report.  There appears to be no
anticipation of a shortage.  The FDA has approved this year's vaccines
and released LOT shipments from all 3 manufacturers to the United
States.  The NSSC received confirmation from the VA and Novartis that
our entire order has been shipped and will be received soon (shipped to
us this week).  For all facilities who pre-ordered the influenza vaccine
through the IHS-NSSC, your COMPLETE ORDER of adult multiple dose vials
of the vaccine will be shipped to you in the next two weeks.  There are
no anticipated allocations this year and we believe that all NSSC
customers will have their complete order by September 21, 2007.

Vaccine orders placed through the IHS NSSC increased by approximately
10,000 doses this year.  Unfortunately, the NSSC does not have extra
vaccine on order and will not be able to accommodate new or increased
orders from the field. 

While no changes are anticipated, it wise to have plan in place in the
event one of one or more of these occurrences

For the latest regarding the Influenza vaccine product information,
including safety, availability, and approval, please visit:
<http://www.fda.gov/cber/flu/flu.htm> 

For the latest on vaccination recommendations, please visit:
<http://www.cdc.gov/flu/>

For questions regarding IHS influenza vaccination recommendations and
the IHS Immunization program, please contact:

Amy V. Groom, MPH

IHS Immunization Program Manager/CDC Field Assignee

Phone: (505) 248 - 4374

Fax: (505) 248 - 4393

<Amy.Groom@ihs.gov>  

If you have questions regarding influenza vaccine orders for your
facility, please contact the NSSC at 888-948-1415.

Indian Health Services

National Supply Service Center

501 NE 122nd Street, Suite F

Oklahoma City, OK  73114

 Phone: (405) 951-6000

           (888) 948-1415

Fax:     (405) 951-6057

**Craig Vanderwagen, Assistant Secretary for Preparedness and Response**

**Rebuilding Iraq one step at a time: You can be part of the solution**

I have become a member of the editorial board for an English language
medical journal being published in Iraq through the Ministry of Health
called the New Iraqi Journal of Medicine. It is primarily managed by
faculty from the Baghdad College of Medicine. It is a listed referreed
journal (ISN 1817-5562) that follows the international conventions on
referreed journals. They are striving to achieve a high quality product.
I am most supportive because the medical community there has been
decimated and needs revitalization.

I am wondering if our colleagues in Indian Health would be interested in
submitting articles for this publication. As you can imagine primary
care in general and the care of women and children are critical needs
with infant mortality exceeding 125/1000 and maternal mortality
exceeding 200/100,000....we know this in Indian Health better than
anyone and I think that our experience would be most informative...over
half of deliveries are outside the hospital and our insights would be
useful.

The latest version of the Journal is available (my e-mail address is
below) with Instructions to Authors. The Journal publishes articles on a
wide variety of topics. The Editorial Board have asked me to solicit
information from our experience in Indian Country and in other settings.
I will also be attempting to encourage folks from Indonesia to offer
some articles for instance and some of my Canadian colleagues as well.

Contributions from IHS would be most helpful both for nurturing the
science and best practices, but our experience in applying these
principles in a low cost and often challenging environment would be
instructive.

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

**Update on Dr. Vanderwagen**\
After serving in many helpful roles in the Indian Health system, RADM
W.C. Vanderwagen, M.D.. is currently the Assistant Secretary for
Preparedness and Response for HHS. He has the responsibility for
development of medical countermeasures (e.g. Pan flu vaccines, anthrax
anti-toxins, new lower cost ventilators) as well as the leadership for
all federal assets (including VA and DOD) in any medical or public
health emergency (natural or manmade). This role includes leadership in
international preparedness and response activities in partnership with
our international colleagues.\
\
His connection with the Iraqis goes back to 2003 and 2004 when he was
working in Iraq with them to try to stand up and strengthen the civilian
health system. It has been a very difficult transition for our medical
colleagues, just half a world away. Now some of the younger Iraqi
physicians are trying to get back in control and create a science
oriented culture to health services rather than a purely political
entity.in the Ministry of Health. Dr. Vanderwagen is asking for your
help in the transition to stability which will help our neighbors.\
\
A copy of the Journal, with Instructions to Authors, is available upon
request

<William.Vanderwagen@HHS.GOV>

**Roberta Ward, ANMC**

**First trimester screening for Down Syndrome**

WHAT IS THE COMBINED TEST?

The "combined test" is a combination of an ultrasound measurement of the
baby, plus a test for two chemicals that come from the baby and found in
your blood. This "combined test" is done at a very specific time\--11 to
13 weeks of pregnancy. The test looks for chromosome problems in the
baby, especially Down Syndrome. It is done earlier than other testing,
is more accurate, and has fewer false positive results.

WHAT IS DOWN SYNDROME?

Down Syndrome is a condition in children caused by an extra chromosome.
Chromosomes are found in all the baby's cells and are like "blue-prints"
that direct how the baby's whole body is formed. Babies with Down
Syndrome have an extra chromosome #21. As a result of this "extra
message," the baby may be born with several problems, including learning
disabilities, special facial features, heart defects, frequent
infections and other special needs.

WHO SHOULD HAVE THIS TEST FOR DOWN SYNDROME?

Women older than age 35 are more likely to have a baby with Down
Syndrome, however, women of any age can have such a child. At age 35, a
woman has a 1:300 chance of having a baby with Down Syndrome. A 40 year
old woman has a 1:100 chance, and a 45 year old woman has about a 1:10
chance. You need to decide if having this test is right for you.

HOW IS THE TEST DONE?

Between 11 and 13 weeks a special ultrasound measurement is made of the
back of the baby's neck. Babies with Down Syndrome will often have a
thickened area behind the neck. Blood will also be taken from your
finger and checked for the amount of the two chemicals that pass from
the baby to you. Babies with Down Syndrome usually have one of these
chemicals too high, or the other too low. The laboratory will combine
these three measurements to give you your risk of having a baby with
Down Syndrome.

IF THE TEST COMES OUT POSITIVE, DOES IT MEAN MY BABY HAS DOWN SYNDROME?

No, this is just a screening test. If your test results are positive,
further testing may be needed. Your prenatal care provider will explain
this to you if your test shows you may have an increased risk.

Questions: <rlward@scf.cc> ALASKA NATIVE MEDICAL CENTER

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

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

## Do Unsutured Second-Degree Perineal Lacerations Affect Postpartum Outcomes?

[Background:]{.underline} To compare the postpartum pelvic floor
function of women with sutured second-degree perineal lacerations,
unsutured second-degree perineal lacerations, and intact perineums.

[Methods:]{.underline} A prospective cohort of nurse-midwifery patients
consented to mapping of genital trauma at birth and an assessment of
postpartum pelvic floor outcomes. Women completed validated
questionnaires for perineal pain and urinary and anal incontinence at 12
weeks postpartum and underwent physical examination to assess pelvic
floor strength and anatomy at 6 weeks postpartum.

[Results:]{.underline} One hundred seventy-two of 212 (80%) eligible
women provided follow-up assessment data at 6 or 12 weeks postpartum.
Women with an intact perineum (n = 89) used fewer analgesics (P \< .002)
and had lower pain scores at the time of hospital discharge than women
with second-degree lacerations (sutured, n = 46; unsutured, n = 37;
intact, n = 89) (P ![](media/image2.png){width="7.152777777777777e-2in"
height="0.10486111111111111in"}.02). The sutured group was more likely
to use analgesics (52%) than the unsutured (35%) or intact (23%) groups
at time of hospital discharge (P \< .002), although pain scores were not
different between sutured and unsutured groups. Postpartum reports of
urinary or anal incontinence, sexual inactivity, or sexual function
scores did not vary between groups. Weak pelvic floor exercise strength
was more common among the women with second-degree lacerations compared
with women with an intact perineum (53% vs. 28%; P = .03) but did not
differ between sutured (58%) and unsutured (47%) groups (P = not
significant). Likewise, perineal body or genital hiatus measurements did
not vary between groups (P = not significant).

[Conclusions:]{.underline} Women with sutured lacerations report
increased analgesic use at the time of hospital discharge compared with
women with intact perineums or unsutured lacerations. At 12 weeks
postpartum, no differences were noted between groups regarding
complaints of urinary or anal incontinence, sexual inactivity, or sexual
function.

## Leeman LM et al Do Unsutured Second-Degree Perineal Lacerations Affect Postpartum Functional Outcomes? The Journal of the American Board of Family Medicine 20 (5): 451-457 (2007) <http://www.jabfm.org/cgi/content/abstract/20/5/451?etoc>

**Treating Gestational Diabetes May Reduce Childhood Obesity**

The risk of childhood obesity in offspring of mothers with GDM by NDDG
criteria (treated) was attenuated compared with the risks for the groups
with lesser degrees of hyperglycemia (untreated).

CONCLUSIONS: Our results in a multiethnic U.S. population suggest that
increasing hyperglycemia in pregnancy is associated with an increased
risk of childhood obesity. More research is needed to determine whether
treatment of GDM may be a modifiable risk factor for childhood obesity.

[**Hillier
TA**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Hillier TA"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Childhood obesity and metabolic imprinting: the ongoing effects of
maternal hyperglycemia. [Diabetes
Care.](javascript:AL_get(this, 'jour', 'Diabetes Care.');) 2007
Sep;30(9):2287-92.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17519427>

**Increased still birth among obese mothers**

We found a 40% increased likelihood for stillbirth among obese compared
with nonobese mothers. The authors found that

\* About 9.5% of the women had a BMI greater than 30 (12.8% among blacks
and 8.9% among whites).

\* The likelihood of stillbirth was 40% greater for obese women,
compared with normal-weight women. The likelihood of stillbirth for
extremely obese women was more than 90% higher than the likelihood for
normal-weight women.

\* Of the total number of stillbirths among obese women (N=1,149), 320
or 28% (stillbirth rate 11.4 per 1,000) occurred among black obese
women, while 829 or 72% (stillbirth rate 7.8 per 1,000) occurred among
white obese women.

\* In both racial groups, the risk for stillbirth increased
progressively with increase in BMI in a dose-effect pattern. However,
black-white disparity in obesity-related stillbirth remained persistent
to the disadvantage of blacks, regardless of the obesity subtype.

It is recommended that future research examines the linkage between
racial background and lethality of rising BMI on the fetus. Sstrategies
to reduce black-white disparities in birth outcomes should consider
targeting obese, black women.

Salihu HM, Dunlop A-L, Hedayatzadeh M, et al. 2007. Extreme obesity and
risk of stillbirth among black and white gravidas. Obstetrics and
Gynecology 110(3):552-557.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17766599>

**Neonatal sepsis increases linearly with membrane rupture up to 36
hours**

METHODS: A registry study included 113,568 singleton infants born at
term after a trial of labor (elective cesarean deliveries excluded). The
incidence of a diagnosis of sepsis during the neonatal period was
correlated to the interval between membrane rupture and delivery.
Multiple logistic regression analysis was done with adjustments for
maternal age, parity, infant gender, gestational age, birth weight, and
duration of labor. Receiver operating characteristics curves were
created to estimate the optimal cutoff of membrane rupture time
associated with an increased risk of neonatal septicemia.

CONCLUSION: The risk of neonatal sepsis increases with duration of
membrane rupture in a linear fashion during the first 36 hours,
independently of labor duration. LEVEL OF EVIDENCE: II.

[**Herbst
A**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Herbst A"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
[**Källén
K**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Källén K"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus).Time
between membrane rupture and delivery and septicemia in term neonates.
[Obstet Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');)
2007 Sep;110(3):612-8

<http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=17766608&dopt=AbstractPlus>

**Extraabdominal uterine repair at cesarean: Increased patient
discomfort, nausea, vomiting**

CONCLUSION: Exteriorization of the uterus for repair is associated with
an increased incidence of nausea and vomiting and tachycardia during
cesarean delivery under spinal anesthesia. Uterine repair should be done
in situ where possible. LEVEL OF EVIDENCE: I.

Siddiqui, M et al Complications of Exteriorized Compared With In Situ
Uterine Repair at Cesarean Delivery Under Spinal Anesthesia [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007
Sep;110(3):570-5.

<http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=17766602&dopt=AbstractPlus>

**Sonographic cervical length was not an effective predictor of
successful labor induction**

RESULTS: Cervical length predicted successful induction (likelihood
ratio of positive test, 1.66; 95% confidence interval \[CI\], 1.20-2.31)
and failed induction (likelihood ratio of negative test, 0.51; 95% CI,
0.39-0.67). Cervical length did not predict any specific outcome (eg,
mode of delivery). The assessment of cervical wedging proved to be a
useful diagnostic test, with a likelihood ratio of a positive test
result of 2.64 and a likelihood ratio of a negative result of 0.64.

CONCLUSION: Sonographic cervical length was not an effective predictor
of successful labor induction. Further evaluation of cervical wedging in
the prediction of labor induction appears warranted.

Hatfield AS et al Sonographic cervical assessment to predict the success
of labor induction: a systematic review with metaanalysis. [Am J Obstet
Gynecol.  2007;
197(2):186-92](http://www.medscape.com/medline/publicationbrowser/123?pmid=17689645)

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17689645>

**Daily intake of 100 mg of ascorbic acid played an important role in
the reduction of UTIs**

CONCLUSIONS: Daily intake of 100 mg of ascorbic acid played an important
role in the reduction of urinary infections, improving the health level
of the gestating women. We recommend additional vitamin C intake for
pregnant women in populations which have a high incidence of bacteriuria
and urinary infections.

Ochoa-Brust GJ et al Daily intake of 100 mg ascorbic acid as urinary
tract infection prophylactic agent during pregnancy. [Acta Obstet
Gynecol Scand.  2007;
86(7):783-7](http://www.medscape.com/medline/publicationbrowser/123?pmid=17611821) 

[http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowD**etailView&TermToSearch=17611821**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17611821)

**Concurrent oxytocin with dinoprostone reduced the requirement for
repeat dinoprostone**

RESULTS: Concurrent oxytocin infusion with dinoprostone pessary did not
significantly increase vaginal delivery rate within 24 hours (48.6
versus 35.9%; P = 0.07, relative risk \[RR\] 1.4 \[95% CI 1.0-1.9\]). It
reduced the requirement for repeat dinoprostone (37.1 versus 61.2%; P =
0.001, RR 0.61 \[95% CI 0.45-0.81\]) and improved maternal satisfaction
with the birth process (median score of 3 versus 5 on a 10-point visual
analogue scale, P = 0.007). Caesarean rates were not different (41.9
versus 44.7%, P = 0.52). CONCLUSIONS: Labour induction with concurrent
oxytocin infusion and vaginal dinoprostone could be considered for
nulliparas with an unfavourable cervix. Larger studies are needed.
Tan PC et al Concurrent oxytocin with dinoprostone pessary versus
dinoprostone pessary in labour induction of nulliparas with an
unfavourable cervix: a randomised placebo-controlled trial. [BJOG.
 2007;
114(7):824-32](http://www.medscape.com/medline/publicationbrowser/123?pmid=17506788) 

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17506788>

**Little evidence of an association between depression during pregnancy
and birth weight**

There is conflicting evidence regarding the effect of depression during
pregnancy on birth weight. We used data from the Avon Longitudinal Study
of Parents and Children to investigate whether depressive symptoms
during pregnancy in 10,967 women led to low birth weight at term in
their offspring. Those with a high depressive symptom score during
pregnancy were more likely to have babies of low birth weight (95% CI
1.16-2.40, P\<0.01), but this attenuated after adjustment for
confounders (OR=1.29,95% CI 0.87-1.91, P=0.210). Hence there is little
evidence of an independent association between depressive symptoms
during pregnancy and birth weight.

Evans J et al Depressive symptoms during pregnancy and low birth weight
at term: longitudinal study. [Br J Psychiatry.  2007;
191:84-5](http://www.medscape.com/medline/publicationbrowser/123?pmid=17602131)** **

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17602131>

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

**Cervical cancer** **differences** **disappear** **in rural** **women**
**after controling for poverty and race**

CONCLUSION: Rural women in the United States have higher cervical cancer
incidence rates. Among older women (aged 45-80 years) in whom half of
cervical cancers occur, geographic differences largely disappear after
controlling for poverty and race. LEVEL OF EVIDENCE: III.

[**Benard
VB**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Benard VB"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Cervical cancer incidence in the United States by area of
residence, 1998 2001. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007
Sep;110(3):681-6

<http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=17766618&dopt=AbstractPlus>

**Cochrane Update: Improvements in outcome with subtotal hysterectomy
not confirmed**

AUTHORS\' CONCLUSIONS: This review has not confirmed the perception that
subtotal hysterectomy offers improved outcomes for sexual, urinary, or
bowel function when compared with total abdominal hysterectomy. Surgery
is shorter and intraoperative blood loss and fever are reduced, but
women are more likely to experience ongoing cyclical bleeding up to a
year after surgery with subtotal hysterectomy compared with total
hysterectomy.

[**Neilson
JP**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Neilson JP"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus).
Total versus subtotal hysterectomy for benign gynaecological conditions
[Obstet Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');)
2007 Sep;110(3):705-6.

<http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=17766621&dopt=AbstractPlus>

**Cost effectiveness of home based population screening for Chlamydia
trachomatis**

CONCLUSIONS: Proactive register based screening for chlamydia is not
cost effective if the uptake of screening and incidence of complications
are based on contemporary empirical studies, which show lower rates than
commonly assumed. These data are relevant to discussions about the cost
effectiveness of the opportunistic model of chlamydia screening being
introduced in England

Roberts TE et al Cost effectiveness of home based population screening
for Chlamydia trachomatis in the UK: economic evaluation of chlamydia
screening studies (ClaSS) project. [BMJ.  2007;
335(7614):291](http://www.medscape.com/medline/publicationbrowser/123?pmid=17656504) 

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17656504>

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

**How to improve psychosocial problems at well child care visits?**

This study demonstrates the feasibility and effectiveness of addressing
multiple family psychosocial problems during WCC \[well child care\]
visits for low-income children.

The authors found that

\* The mean number of family psychosocial topics discussed at the WCC
visit was significantly higher for parents in the intervention group vs.

the control group (2.9 vs. 1.8).

\* Parents in the intervention group had fewer unmet desires to discuss
family psychosocial topics, compared with parents in the control group

(0.46 vs. 1.41).

\* Fifty-one percent of parents in the intervention group reported
receiving at least one referral from their child\'s provider, compared
with 11.6% in the control group. Parents in the intervention group had
significantly higher odds of receiving referrals for graduate degree
programs, job training, food resources, and smoking-cessation classes
than parents in the control group.

\* At 1 month, 20.0% of the parents in the intervention group reported
contacting a referred community resource, compared with 2.2% in the
control group.

\* Twenty-two (91.6%) of the 24 residents in the intervention group
completed the post-study questionnaire. Seventy-seven percent of the
residents who completed the post-study questionnaire reported that the
survey did not slow down the visit; 54.5% reported that the survey added
less than 2 minutes to the visit.

We believe that the WE CARE intervention can serve as a model for
addressing family psychosocial problems for medical homes that care for
low-income children. Additional research will be needed to assess the
long-term impact of family psychosocial screening interventions on
parental outcomes and child health, behavioral, and developmental
outcomes.

Garg A, Butz AM, Dworkin P, et al. 2007. Improving the management of
family psychosocial problems at low-income children\'s well-child care

visits: The WE CARE project. Pediatrics 120(3):547-588. Abstract
available at
[[http://pediatrics.aappublications.org/cgi/content/abstract/120/3/547]{.underline}](http://pediatrics.aappublications.org/cgi/content/abstract/120/3/547)

Is Ibuprofen Appropriate for Pain Control in Children?

**Conclusion:** Ibuprofen provided superior pain relief compared with
codeine and acetaminophen, especially in children with fracture-related
pain, but only 52 percent of the children received adequate pain relief.
Additional measures, such as ice or distraction, should be sought to
help alleviate acute musculoskeletal pain. When used alone, ibuprofen is
not an adequate analgesic in all children with musculoskeletal injuries.

Clark E, et al. A randomized, controlled trial of acetaminophen,
ibuprofen, and codeine for acute pain relief in children with
musculoskeletal trauma. Pediatrics March 2007;119:460-7.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17332198>

**School based intervention to lower incidence of** **disordered**
**weight control behavior**

The present study adds novel empirical evidence in support of the
viability of integrating obesity and eating disorders prevention
initiatives, The authors found that

\* After 2 school years, 3.6% of girls in control schools, compared with
1.2% of girls in intervention schools, reported new disordered
weight-control behaviors.

\* The odds of adopting a disordered weight-control behavior were
reduced by two-thirds in girls in intervention schools compared with
girls in control schools.

\* In models that also controlled for grade, race and ethnicity, and
overweight, the magnitude of the effect estimate associated with the
intervention for girls remained stable, changing less than 10%, but the
confidence interval widened to include the null value of 1.0.

\* No protective effects of the intervention were observed for boys.

New research efforts will need to identify protective strategies for
early adolescent boys also and to understand the mechanism of Planet
Health and other strategies in school settings that integrate obesity
and eating disorders prevention.

Austin SB, Kim J, Wiecha J, et al. 2007. School-based overweight
preventive intervention lowers incidence of disordered weight-control
behaviors in early adolescent girls. Archives of Pediatric and
Adolescent Medicine 161(9):865-869.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17768286>

**Management of Type 2 Diabetes in Youth: An Update (also see Patient
Education)**

Although type 1 diabetes historically has been more common in patients
eight to 19 years of age, type 2 diabetes is emerging as an important
disease in this group. Type 2 diabetes accounts for 8 to 45 percent of
new childhood diabetes. This article is an update from the National
Diabetes Education Program on the management of type 2 diabetes in
youth. High-risk youths older than 10 years have a body mass index
greater than the 85th percentile for age and sex plus two additional
risk factors (i.e., family history, high-risk ethnicity, acanthosis
nigricans, polycystic ovary syndrome, hypertension, or dyslipidemia).
Reducing overweight and impaired glucose tolerance with increased
physical activity and healthier eating habits may help prevent or delay
the development of type 2 diabetes in high-risk youths. The American
Academy of Pediatrics does not recommend population-based screening of
high-risk youths; however, physicians should closely monitor these
patients because early diagnosis may be beneficial. The American
Diabetes Association recommends screening high-risk youths every two
years with a fasting plasma glucose test. Patients diagnosed with
diabetes should receive self-management education, behavior
interventions to promote healthy eating and physical activity,
appropriate therapy for hyperglycemia (usually metformin and insulin),
and treatment of comorbidities. Am Fam Physician 2007;76:658-64, 665-6
<http://www.aafp.org/afp/20070901/658.html>

**Are babies born to short, primiparous, or thin mothers \"normally\" or
\"abnormally\" small?**

CONCLUSIONS: Slower fetal growth due to maternal short stature or low
prepregnancy body mass index appears to be physiologic, whereas the
slower growth of fetuses born to primiparous women is associated with
higher risks of perinatal death.

Zhang X et al Are babies born to short, primiparous, or thin mothers
\"normally\" or \"abnormally\" small? [J Pediatr.  2007; 150(6):603-7,
607.e1-3](http://www.medscape.com/medline/publicationbrowser/123?pmid=17517243) 

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17517243>

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

## Why Hasn\'t This Patient Been Screened for Colon Cancer? 

[Results]{.underline}: Reasons patients were not up to date fell into 2
major categories: (1) no discussion by physician (50%) and (2) patient
refusal (43%). Reasons for no discussion included lack of opportunity,
assessment that cost would be prohibitive, distraction by other life
issues/health problems, physician forgetfulness, and expected patient
refusal. Patients declined because of cost, lack of interest, autonomy,
other life issues, fear of screening, and lack of symptoms. Patients who
were up to date received (1) diagnostic testing (for previous colon
pathology or symptoms; 56%) or (2) asymptomatic screening (44%).
Physicians who were more adamant about screening had higher screening
rates (P \< .05; Wilcoxon rank sum). Physicians framed their
recommendations differently (\"I recommend\" vs \"They recommend\"),
with lower screening rates among physicians who used \"they recommend\"
(P = .05; Wilcoxon rank sum).

[Conclusions:]{.underline} Reasons many patients remain unscreened for
CRC include (1) factors related to the health care system, patient, and
physician that impede or prevent discussion; (2) patient refusal; and
(3) the focus on diagnostic testing. Strategies to improve screening
might include patient and physician education about the rationale for
screening, universal coverage for health maintenance exams, and
development of effective tracking and reminder systems. The words
physicians choose to frame their recommendations are important and
should be explored further.

Levy BT et al Why Hasn\'t This Patient Been Screened for Colon Cancer?
An Iowa Research Network Study The Journal of the American Board of
Family Medicine 20 (5): 458-468 (2007)

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17823463>

**Migraine With Aura Increases Risk for Ischemic Stroke**

CONCLUSIONS: Probable migraine with visual aura (PMVA) was associated
with an increased risk of stroke, particularly among women without other
medical conditions associated with stroke. Behavioral risk factors,
specifically smoking and oral contraceptive use, markedly increased the
risk of PMVA, as did recent onset of PMVA.

[**MacClellan
LR**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="MacClellan LR"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Probable migraine with visual aura and risk of ischemic stroke:
the stroke prevention in young women study
[Stroke.](javascript:AL_get(this, 'jour', 'Stroke.');) 2007
Sep;38(9):2438-45

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17690308>

**US Dietary Guidelines Effectively Limit Insulin Resistance in Women**

CONCLUSIONS: Consumption of a diet consistent with the 2005 DGA may be
an effective means to limit insulin resistance in women.

[**Fogli-Cawley
JJ**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Fogli-Cawley JJ"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al The 2005 Dietary Guidelines for Americans and insulin resistance
in the Framingham Offspring Cohort. [Diabetes
Care.](javascript:AL_get(this, 'jour', 'Diabetes Care.');) 2007
Apr;30(4):817-22.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17259479>

**The Choice of a Metabolic Syndrome Generation: Soft Drink Consumption
Associated With Increased Metabolic Risk **

CONCLUSIONS: In middle-aged adults, soft drink consumption is associated
with a higher prevalence and incidence of multiple metabolic risk
factors.

[**Dhingra
R**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Dhingra R"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Soft drink consumption and risk of developing cardiometabolic risk
factors and the metabolic syndrome in middle-aged adults in the
community.
[Circulation.](javascript:AL_get(this, 'jour', 'Circulation.');) 2007
Jul 31;116(5):480-8.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17646581>

**ACIP Recommends the Use of Tdap in Adults**

In 2005, a tetanus toxoid, reduced diphtheria toxoid, and acellular
pertussis vaccine (Tdap; Adacel) was approved in the United States for
use in adults and adolescents. The Advisory Committee on Immunization
Practices (ACIP) now recommends the routine use of Tdap among adults 19
to 64 years of age who have not already received a dose of Tdap. The
ACIP recommendations are intended to decrease pertussis-related
morbidity among adults, to maintain the standard of care for tetanus and
diphtheria prevention, and to reduce transmission of pertussis to
infants and in health care settings.

Routine Vaccination

Patients 19 to 64 years of age who received their most recent dose of
tetanus and diphtheria toxoid (Td) at least 10 years earlier should be
given a single dose of Tdap for active booster vaccination against
tetanus, diphtheria, and pertussis. If less than 10 years has passed
since the previous dose of Td was administered, a single dose of Tdap is
appropriate to protect patients against pertussis. This is especially
true in patients at increased risk of pertussis or its complications;
the benefit of a single dose of Tdap at an interval of less than 10
years will likely outweigh the risk of adverse reactions to the vaccine.
In addition, an interval as short as two years between Td and Tdap is
considered safe.

In patients who have not previously received Tdap and who need a vaccine
containing tetanus toxoid as part of wound management care, Tdap is
preferred to Td.

Adults in contact with infants

Compared with adults, infants younger than 12 months are at a higher
risk of hospitalization from pertussis-related complications, and they
have a higher risk of death. Therefore, vaccinating adults who come into
contact with these infants may reduce the risk of transmitting pertussis

To protect against pertussis, adults who have not previously received
Tdap and who are in contact or anticipate contact with infants younger
than 12 months should receive a single dose of Tdap at an interval of
less than 10 years since their most recent Td vaccination. These adults
should receive the Tdap vaccine at least two weeks before coming into
contact with an infant. An interval as short as two years from the
previous dose of Td is recommended to reduce the risk of systemic and
local reactions after the vaccination, but shorter intervals may be
used, if appropriate.

Women who are pregnant or may become pregnant

Ideally, women should be vaccinated with Tdap before becoming pregnant.
If this is not possible, they should receive a single dose of Tdap in
the immediate postpartum period. It should be administered before the
patient is discharged from the hospital or birthing center.

Morbidity and Mortality Weekly Report, December 15, 2006

<http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5517a1.htm>

Comparison of Unsedated Colonoscopy and Flexible Sigmoidoscopy

[Background:]{.underline} Colonoscopy visualizes more of the colon than
flexible sigmoidoscopy. This study compares the outcomes of an unsedated
modified colon endoscopy (MCE) with flexible sigmoidoscopy (FS) in
family medicine practice.

[Results:]{.underline} No significant differences were found between MCE
and FS regarding completion rates (83.3% vs 75%, respectively). Expected
statistically significant differences were found between the 2
procedures in the anatomic site visualized (P \< .01) and depth reached
(P \< .01). Clinical pathologies were identified in 58% of MCE patients
and 37% of FS patients. Four adenocarcinomas were identified in the MCE
group in the proximal region of the colon that could not have been
detected by FS.

[Completion Rates]{.underline}\
The completion rate for MCE at the 3 practice sites was 83.3%, which is
not significantly different from the completion rate (75%) obtained for
FS. The main reason cited for failure to complete both procedures was
patient discomfort: 8.3% of MCE patients and 11.4% of FS patients did
not complete the procedure because of discomfort. In MCE, poor
preparation was also cited as a reason for noncompletion in 3 cases
(6.3%).

[Depth Reached and Site Visualized]{.underline}\
The cecum was visualized but not intubated in 72.9% of the MCE patients.
In 6.3% of MCE procedures there was a successful cecal intubation.
Because of the limited length of FS equipment, none of these sites could
be visualized. Thus, as expected, statistically significant differences
were found between the 2 procedures in anatomic site visualized (P \<
.01). Similarly, when analyzed by depth readings on the endoscopes, MCE
reached significantly further into the colon (mean, 130.1 cm; SD, 30.1
cm) than the FS (mean, 50.6 cm; SD, 10.0 cm); again showing an expected
and statistically significant difference (P \< .01). A summary of
findings is provided in

[Conclusions:]{.underline} Findings from this study suggest that MCE can
be an acceptable alternative to FS in office settings for colorectal
cancer screening.

## Knox L et al A Comparison of Unsedated Colonoscopy and Flexible Sigmoidoscopy in the Family Medicine Setting: An LA Net Study The Journal of the American Board of Family Medicine 20 (5): 444-450 (2007)

<http://www.jabfm.org/cgi/content/abstract/20/5/444?etoc>

**Preventing Patient Deaths from Fentanyl Patches**

A recent report from the Institute for Safe Medication Practices warns
about the dangers of misprescribing fentanyl transdermal patches, such
as Duragesic. ISMP reminds practitioners that these patches are intended
only for patients who are opioid-tolerant, and should not be used for
acute pain.\
\
ISMP also pointed out other prescribing errors. In some cases, deaths
occurred in patients who were prescribed multiple fentanyl patches,
resulting in overdose. In other cases the fentanyl was prescribed in
addition to other pain medications, such as oxycodone, or it was
prescribed for patients with pre-existing respiratory compromise. ISMP
points out that sometimes pharmacists have dispensed these prescriptions
without questioning them, and nurses have applied the patches without
recognizing the prescribing error.\
\
Here are some of ISMP\'s recommendations to help avoid these tragic and
preventable errors:\
• Prescribe fentanyl patches only for patients who are opioid tolerant,
and who have chronic pain that is not well-controlled with
shorter-acting analgesics. These patches should not be used for
postoperative pain, or for pain that\'s short-term or intermittent.
Pharmacists should ensure that the patient is opioid-tolerant and
suffering from chronic pain before dispensing the drug, and should
question the prescriber if this is not the case.\
• Set dosing limits. For example, pharmacy computer systems could be set
to flash an alert if more than 25 mcg per hour has been prescribed as a
first-time dose. Also, in evaluating whether the dose is appropriate,
take into account other opiates or analgesics that may have been
prescribed.\
• Educate practitioners and patients to know the signs of overdose,
which include respiratory distress, shallow breathing, fatigue,
sleepiness, confusion, dizziness and fainting.\
• Prescribing errors are not the only cause of deaths and injuries from
fentanyl patches. They also occur when patients mis-use the patches.
Sometimes patients and family members do not understand that heat can
increase absorption of the drug to dangerous levels. So patients should
be told to avoid heating pads, electric blankets or hot baths while the
patch is in place, and let their doctors know if they develop a
temperature above 102 degrees.\
• There have also been cases where children found used patches in the
trash and applied them to their own bodies, and died as a result. And so
patients should be warned to dispose of the patches by folding them in
half and flushing them down the toilet.

[Additional Information:]{.underline}

ISMP Medication Safety Alert! Ongoing, Preventable Fatal Events with
Fentanyl Transdermal Patches Are Alarming
[http://www.ismp.org/Newsletters/acutecare/articles/20070628.asp](http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/linkwarning/linkwarning.cfm?link=http%3A%2F%2Fwww.ismp.org%2FNewsletters%2Facutecare%2Farticles%2F20070628.asp)

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

#### ACOG, American College of Obstetricians and Gynecologists {#acog-american-college-of-obstetricians-and-gynecologists .Style-Heading-4-+-Arial-14-pt-Underline}

**Pelvic Organ Prolapse**

Summary of Recommendations and Conclusions

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

-   The only symptom specific to prolapse is the awareness of a vaginal
    bulge or protrusion. For all other pelvic symptoms, resolution with
    prolapse treatment cannot be assumed.

-   Pessaries can be fitted in most women with prolapse, regardless of
    prolapse stage or site of predominant prolapse.

-   Cadaveric fascia should not be used as graft material for abdominal
    sacral colpopexy because of a substantially higher risk of recurrent
    prolapse than with synthetic mesh.

-   Stress-continent women with positive stress test results (prolapse
    reduced) are at higher risk for developing postoperative stress
    incontinence after prolapse repair alone compared with women with
    negative stress test results (prolapse reduced).

-   For stress-continent women planning abdominal sacral colpopexy,
    regardless of the results of preoperative stress testing, the
    addition of the Burch procedure substantially reduces the likelihood
    of postoperative stress incontinence without increasing urgency
    symptoms or obstructed voiding.

-   For women with positive prolapse reduction stress test results who
    are planning vaginal prolapse repair, TVT midurethral sling (rather
    than suburethral fascial plication) appears to offer better
    prevention from postoperative stress incontinence.

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

-   Clinicians should discuss the option of pessary use with all women
    who have prolapse that warrants treatment based on symptoms. In
    particular, pessary use should be considered before surgical
    intervention in women with symptomatic prolapse.

-   Alternative operations for uterine preservation in women with
    prolapse include uterosacral or sacrospinous ligament fixation by
    the vaginal approach, or sacral hysteropexy by the abdominal
    approach.

-   Hysteropexy should not be performed by using the ventral abdominal
    wall for support because of the high risk for recurrent prolapse,
    particularly enter-ocele.

-   Round ligament suspension is not effective in treating uterine or
    vaginal prolapse.

-   Compared with vaginal sacrospinous ligament fixation, abdominal
    sacral colpopexy has less apical failure and less postoperative
    dyspareunia and stress incontinence, but is also associated with
    more complications.

-   Transvaginal posterior colporrhaphy is recommended over transanal
    repair for posterior vaginal prolapse.

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

-   Clinicians should discuss with women the potential risks and
    benefits in performing a prophylactic antiincontinence procedure at
    the time of prolapse repair.

-   Women with prolapse who are asymptomatic or mildly symptomatic can
    be observed at regular intervals, unless new bothersome symptoms
    develop.

-   For women who are at high risk for complications with reconstructive
    procedures and who no longer desire vaginal intercourse,
    colpocleisis can be offered.

-   Cystoscopy should be performed intraoperatively to assess for
    bladder or ureteral damage after all prolapse or incontinence
    procedures during which the bladder or ureters may be at risk of
    injury.

Pelvic Organ Prolapse. ACOG Practice Bulletin No. 85. American College
of Obstetricians and Gynecologists. Obstet Gynecol 2007; 110:717-29.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17766624>

**Management of Delivery of a Newborn With Meconium-Stained Amniotic
Fluid**

ABSTRACT: In accordance with the new guidelines from the American
Academy of Pediatrics and the American Heart Association, all infants
with meconium-stained amniotic fluid should no longer routinely receive
intrapartum suctioning. If meconium is present and the newborn is
depressed, the clinician should intubate the trachea and suction
meconium and other aspirated material from beneath the glottis.

Management of Delivery of a Newborn With Meconium-Stained Amniotic
Fluid. ACOG Committee Opinion No. 379. American College of Obstetricians
and Gynecologists. Obstet Gynecol 2007;110:73 <http://www.acog.org/>

**ACOG Advises Against Cosmetic Vaginal Procedures: Safety and Efficacy
Data**

ABSTRACT: So-called \"vaginal rejuvenation,\" \"designer vaginoplasty,\"
\"revirgination,\" and \"G-spot amplification\" are vaginal surgical
procedures being offered by some practitioners. These procedures are not
medically indicated, and the safety and effectiveness of these
procedures have not been documented. Clinicians who receive requests
from patients for such procedures should discuss with the patient the
reason for her request and perform an evaluation for any physical signs
or symptoms that may indicate the need for surgical intervention. Women
should be informed about the lack of data supporting the efficacy of
these procedures and their potential complications, including infection,
altered sensation, dyspareunia, adhesions, and scarring.

Vaginal \"Rejuvenation\" and Cosmetic Vaginal Procedures. ACOG Committee
Opinion No. 378. American College of Obstetricians and Gynecologists.
Obstet Gynecol 2007;110:737--8

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17766626>

**Research Involving Women**

ABSTRACT: All women should be presumed to be eligible for participation
in clinical studies. The potential for pregnancy should not
automatically exclude a woman from participating in a clinical study,
although the use of contraception may be required for participation.
Research objectives should not interfere with appropriate clinical
management. If a conflict arises between medically appropriate patient
care and research objectives, patient care should prevail. Consent of
the pregnant woman alone is sufficient for most research. Pregnant women
considering participation in a research study should determine the
extent to which the father is to be involved in the process of informed
consent and the decision.

Research Involving Women. ACOG Committee Opinion No. 377. American
College of Obstetricians and Gynecologists. Obstet Gynecol
2007;110:731--6.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17766625>

## AFP, American Family Physician {#afp-american-family-physician .Style-Heading-2-+-14-pt}

Counseling Women About Mammography: Benefits vs. Harms

[Clinical Scenario]{.underline}

A healthy 44-year-old woman with no family history of breast cancer has
never had a mammogram. Her best friend was recently diagnosed with
breast cancer.

[Clinical Question]{.underline}

How should physicians counsel women about mammography?

[Evidence-Based Answer]{.underline}

Studies of mammography show a 0.1 percent absolute reduction in breast
cancer mortality with mammography. This means that if 2,000 women are
offered mammography over 10 years, one woman would have her life
prolonged, 10 healthy women would be treated unnecessarily for breast
cancer, and about 200 women would undergo psychological distress and
additional testing because of false-positive results. Women should be
informed of the potential benefits and harms of mammography before
undergoing the screening test at any age.

[Authors\' Conclusions:]{.underline} Screening likely reduces breast
cancer mortality. Based on all trials, the reduction is 20 percent, but
because the effect is lower in the highest-quality trials, a more
reasonable estimate is a 15 percent relative risk reduction. Based on
the risk level of women in these trials, the absolute risk reduction was
0.05 percent. Screening also leads to overdiagnosis and overtreatment,
with an estimated 30 percent increase, or an absolute risk increase of
0.5 percent. This means that for every 2,000 women invited for screening
throughout 10 years, one will have her life prolonged. In addition, 10
healthy women, who would not have been diagnosed if not screened, will
be diagnosed with breast cancer and will be treated unnecessarily. Thus,
it is not clear whether screening does more good than harm. Women
invited to screening should be fully informed of benefits and harms.

Cochrane for Clinicians. Putting Evidence into Practice
<http://www.aafp.org/afp/20070901/cochrane.html>

Gøtzsche PC, Nielsen M. Screening for breast cancer with mammography.
Cochrane Database Syst Rev 2006;(4):CD001877.

###### 

###### Guidelines on Screening for Fetal Chromosomal Abnormalities

[Conclusion:]{.underline} Maternal age of 35 years should not be used as
a cutoff for offering diagnostic testing. The decision to offer
screening or invasive testing should not be based on age alone but
should take into account patient preferences. The goal is to offer
screening tests with high detection rates and low false-positive rates
that also provide patients with the diagnostic options they might want
to consider, with women being offered integrated or sequential screening
earlier in their pregnancies. Other screening options will depend on CVS
availability and physician expertise with nuchal translucency
measurement.

ACOG Practice Bulletin No. 77: screening for fetal chromosomal
abnormalities. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007
Jan;109(1):217-27

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17197615>

#### AHRQ, Agency for Healthcare Research and Quality  {#ahrq-agency-for-healthcare-research-and-quality .Style-Heading-4-+-Arial-14-pt-Underline}

**Risk of maternal and fetal labor and delivery complications increase
as pregnancy progresses beyond 39 weeks of gestation**

<http://www.ahrq.gov/research/aug07/0807RA8.htm>

**Midwife practices vary greatly in compensation and employment
structures**

<http://www.ahrq.gov/research/aug07/0807RA9.htm>

**Pediatricians recognize most overweight or obese children without
using proportional weight curves**

<http://www.ahrq.gov/research/aug07/0807RA4.htm>

**The gender of both the child and parent affect a child\'s
participation during visits to the doctor**

<http://www.ahrq.gov/research/aug07/0807RA5.htm>

**Pertussis vaccination in adults can be cost-effective depending on
incidence rates**

<http://www.ahrq.gov/research/aug07/0807RA21.htm>

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

**In Search of a Research Article?**

**The HSR Library- a branch of the NIH Library Provides Access to Many
Online Journals**

The HSR Library\'s online journal collection continues to expand. Select
from these options to access one of the titles now available:

-   Click on the ![](media/image3.png){width="1.0416666666666667in"
    height="0.2604166666666667in"} button that appears when searching
    *PubMed*®, *Scopus*™, *Web of Science*®, and other HSR Library
    databases.

> OR

-   Go to the [HSR Library](http://hsrl.nihlibrary.nih.gov/) website and
    select [Online
    Journals](http://hsrl.nihlibrary.nih.gov/ResearchTools/default.htm?srchType=OnlineJournals)
    under Quick Links.

-   OR

-   Search the HSR Library [Online
    Catalog](http://hsrl.nihlibrary.nih.gov/ResearchTools/Online+Catalog.htm)
    for a journal title.

If the Library does not subscribe to the journal you need, you may use
the [Order a
Document](http://hsrl.nihlibrary.nih.gov/LibraryServices/Order+a+Document.htm)
form to request electronic copies of articles.\
Links:

HSR Library <http://hsrl.nihlibrary.nih.gov/>

Online Journals
<http://hsrl.nihlibrary.nih.gov/ResearchTools/default.htm?srchType=OnlineJournals>

Online Catalog
<http://hsrl.nihlibrary.nih.gov/ResearchTools/Online+Catalog.htm>

Order a Document
<http://hsrl.nihlibrary.nih.gov/LibraryServices/Order+a+Document.htm>

For more information or help using your online library resources,
contact me at <cooperd@mail.nih.gov>

##### 

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

**A pacifier by any other name....\***

Pacifiers have been around for a long time. A painting by Dureer in 1506
shows a baby with a homemade pacifier. Historians describe "sugar
-teats" used in the 1800's as being pieces of cloth tied around about a
tablespoon of sugar or pieces of cloth soaked in honey. Today the
choices are many -- from utilitarian plastic to "orthodontic" to on-line
jeweled designer styles with coordinating clips for obvious bling.

Pacifiers have helped many new families survive otherwise sleepless
nights and endless car rides. They have been praised, condemned,
associated with a variety of health issues, and most recently reduced
risk of SIDs. Among the thoughts about pacifiers and how they reduce
SIDs risk is that using a sleep/nap time pacifier may prevent a baby
from rolling from a safer back to sleep position to the riskier side or
tummy sleeping position. Another possibility is that intermittent sleep
time sucking may help keep baby in a less risky arousal zone of sleep.

But what impact do pacifiers have on breastfeeding? Numerous studies
have been done, most showing that regular use of pacifiers, especially
in the early weeks and months, is associated with reduced duration.
Speculations for how pacifiers disrupt lactation are that pacifiers:

-   Reinforce ineffective sucking habits that reduce milk intake and
    lead to sore nipples

-   Reduce of the baby's "practice time" needed to strengthen the
    facial/oral cavity muscles that are necessary for effective
    nutritive suckling,

```{=html}
<!-- -->
```
-   Encourage the loss of the stimulation/instinctual response by the
    baby to pull the maternal nipple into the mouth. (the
    pacifier/nipple rubs the roof of the mouth, stimulating the suck,
    rather than the baby instinctually responding or remembering the
    need to suck the nipple in)

But not every breastfeeding baby is affected negatively by pacifiers.
So, what can a provider tell a new family? Unfortunately there are no
absolute answers, although avoiding pacifier use in the first several
months is generally safer for supporting successful breastfeeding.
Consider these possible scenarios:

1\. At a 2 week newborn check, an exclusively breastfed baby is a few
ounces below birth weight. Mom states that when the baby nurses it
sometimes feels like "chomping at the breast" and the baby wants to
linger at nursing, taking 45 minutes or more every couple hours. The
baby has 5, maybe 6 diaper changes in 24 hours. They use a pacifier
routinely. It will help to:

-   Encourage the family to avoid using the pacifier for a while (4 or
    more weeks if possible). As the baby practices and gets better at
    nursing, the eating time will get shorter and the baby will go
    longer in between feeds. The baby will get more calories
    "practicing" too.

-   Watch the baby nurse -- apply firm, steady, finger-tip pressure to
    the bottom of the baby's chin through several suck cycles -- it will
    help to nudge the baby's jaw open for a deeper latch and assure that
    the baby's bottom lip is "popped" out and that the baby's tongue is
    now covering the gum line to more effectively milk the nipple. The
    baby will get more to eat without hurting mom. Everyone will be
    happier.

-   If short-term supplementation is needed, consider supplementing at
    the breast. This can be done by filling a syringe with formula or
    breast milk and attaching a 5 french feeding tube to the syringe.
    Then slip the end of the tube into the side of the baby's mouth, as
    the baby is latched and sucking. Gently tap the syringe plunger to
    keep the supplement seeping into the feeding. It may be easier to
    use a smaller syringe and supplement on each side rather than a
    large, cumbersome syringe on one side. Or - it might be more
    effective to offer the bulk of the supplement at the end of the
    feeding, on the 2nd side. Use what is most comfortable for mom.

-   It is ok to remind parents that talking to their baby and cuddling
    can be soothing, for everyone.

2.  A family comes in for the one month well baby check. The baby has
    gained 2 pounds above birth weight. Parents are beyond exhausted.
    They describe constant nursing (every hour), 14 or more diaper
    changes in 24 hours, etc. This baby may have an overly abundant need
    to suck. Careful use of a pacifier might help meet the baby's extra
    need to suck and give the parents a chance to sleep.

A little review about the "pacifier or not question" with full term,
healthy, breastfeeding newborns:

-   Avoid pacifiers until breastfeeding is well established.
    Establishing breastfeeding takes approximately 6-10 weeks.

-   If there are problems with breastfeeding such as poor weight gain,
    sore nipples, repeat thrush, fretful nursing -- pacifiers could be a
    key part of the problem.

-   If the baby is thriving and the family is becoming overwhelmed,
    occasional use of a clean, safe pacifier could be a reasonable
    thing.

-   If the family is eager to use a pacifier with their newborn,
    encourage them to watch and avoid pacifier use if there are problems
    with weight gain, fussy latch or nipple tenderness.

For more information, please consider:

American Academy of Pediatrics Policy Statement, The Changing Concept of
Sudden Infant Death Syndrome: Diagnostic Coding Shifts, Controversies
Regarding the Sleeping Environment, and New Variables to Consider in
Reducing Risk. Vol. 116 Nov 5 November 2005, pp. 1245-55.

Murray EK, et al. Hospital Practices that Increase Breastfeeding
Duration: Results from a Population-Based Study. Birth, 2007 Sep; 34(3):
202-11.

Scott JA, et al. Predictors of breastfeeding duration: evidence from a
cohort study. Pediatrics, 2006 Apr; 117(4): e646-55.

Hauck FR, et al. Do pacifiers reduce the risk of sudden infant death
syndrome? A meta-analysis. Pediatrics 2005 Nov; 116(5): e716-23, Epub
2005 Oct 10.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=16216900>

\* Dummy - British, New Zealand, Australian term

Binki/binky - US commercial term, 1935

Soother - Canadian, Irish term

**Other:**

**Medications: Information for Pregnant and Breastfeeding Women**

As additional research is published, it is increasingly important that
women talk with their doctor about the risks and benefits of taking
prescription and over-the-counter drugs, vitamins, and dietary or herbal
supplements before getting pregnant, during pregnancy, and while
breastfeeding. A survey in the U.S. in 1998--99 found that 46% of women
in their childbearing years took a prescription medicine during the
previous week. So, it is important that we know more about which
medications may be harmful during pregnancy and breastfeeding and which
are not. <http://www.cdc.gov/Features/MedicationUse/>

**Breastfeeding Trends and Updated National Health Objectives for
Exclusive Breastfeeding**

To monitor progress toward achieving HP2010 breastfeeding objectives,
CDC analyzed data from the National Immunization Survey. This report
describes the results of that analysis, which indicated that rates for
breastfeeding initiation and duration increased among infants born
during 2000-2004. Rates for exclusive breastfeeding through ages 3
months and 6 months among infants born in 2004 were 30.5% and 11.3%,
respectively, below targets set by HP2010. Rates of exclusive
breastfeeding were significantly lower among black infants (compared
with white infants) and infants born to unmarried mothers (compared with
married mothers). Additionally, older age, urban residence, higher
education, and higher income of mothers all were positively associated
with exclusive breastfeeding. Further research is needed to identify
successful programs and policies to support exclusive breastfeeding,
especially among subgroups with the lowest rates.
<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5630a2.htm>

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

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

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

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

-Women\'s greater risk of dying after surgery: Transfusion-related
immunosuppression

-Ann Bullock is the new Chief Clinical Consultant for Family Medicine

-Low-dose aspirin has benefits when used for prevention of pre-eclampsia

-Human papillomavirus, vaccines and women\'s health: questions and
cautions

-Educate parents about new pre-adolescent vaccine recommendations

-Exposing the Great Bottled Water Scam

-Prevention of Deep Vein Thrombosis and Pulmonary Embolism  Practice
Bulletin

-Prevent Fetal Alcohol Spectrum Disorders: A Toolkit

-Various Implantable Contraceptives Equally Effective in Preventing
Pregnancy

-Moderate morning sickness only partially responding to doxylamine and
pyridoxine

-Don't use Google, use Blackle instead and save 750 mega watts/hour per
year

-Sex, Soap & Social Change - The Sabido Methodology

-Motor vehicle restraint use in American Indian children: Meaningful
interventions

-Nausea and Vomiting in Pregnancy

-Study Supports HRT Use for Short Term, but Little Benefit in Older
Women

-Group prenatal care reduces preterm births and increases breastfeeding
initiation: RCT

-Evaluation of the pregnant patient for non-obstetric surgery

-Nursing education scholarship opportunities

-Decision Rules Useful for Selecting Women for Bone Mineral Density
Testing

-Nausea and Vomiting of Pregnancy

-Chronic Renal Disease is Part of Primary Care

-Culture, context, and sexual risk among Northern Plains American Indian
Youth

-Within eight years, 75% of adults will be obese or overweight

-APN scope of practice: colonoscopy?

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/CCCC_v5_08.pdf>

####  {#section-7 .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-8 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Domestic Violence Denise Grenier, Tucson / Rachel Locker, Warm Springs {#domestic-violence-denise-grenier-tucson-rachel-locker-warm-springs .Style-Heading-4-+-Arial-14-pt-Underline}

**Domestic Violence Awareness Month: October**

October is national Domestic Violence Awareness Month (DVAM). This is an
annual observance sponsored by the National Coalition Against Domestic
Violence. Every October across the country, domestic violence survivors
and advocates, health care providers, elected officials, law enforcement
and public safety personnel, business leaders, faith-based groups and
many others are organizing and participating in domestic violence
memorial activities, public education campaigns and community outreach
events. If you would like more information about how your facility can
participate in DVAM activities, visit
[www.ncadv.org](http://www.ncadv.org/)

**Health Cares About Domestic Violence Day: October 10, 2007**

Health Cares About Domestic Violence Day (HCADV Day) is a nationally
recognized awareness-raising day that takes place annually on the second
Wednesday of October. Sponsored by the Family Violence Prevention Fund,
HCADV Day aims to reach members of the healthcare community and educate
them about the critical importance of assessing for domestic violence,
as well as the long term health implications of domestic violence and
lifetime exposure to violence.

Medical studies link long term effects of domestic violence and abuse
with a myriad of health problems including smoking, diabetes, obesity,
eating disorders and substance abuse. However, while doctors and nurses
routinely screen for high blood pressure and high cholesterol, too few
screen for domestic violence. This year we hope to support you in your
efforts to prioritize routine assessment and intervention for domestic
violence as part of a preventative healthcare strategy.

There are many ways that you can provide leadership in your community on
HCADV Day and the Family Violence Prevention Fund is committed to
helping you craft activities that best meet your interests, resources
and time availability. Examples of past participation include hanging
posters in waiting rooms that advertise local resource numbers, writing
a newsletter article or an op-ed for a local paper, and inviting a
speaker to conduct a brown bag lunch on domestic violence for staff.

You can learn more about HCADV Day, and obtain an organizing packet by
visiting <http://www.endabuse.org/hcadvd/>

Health care providers are in a unique position to identify and assist
victims of domestic violence. If you would like more information about
how to improve the response of your facility to domestic violence visit
[www.endabuse.org/health](http://endabuse.org/health/)

Sample hospital and clinic domestic violence policies and procedures and
guidelines for providers can be found on the IHS Maternal and Child
Health Domestic Violence website at

<http://www.ihs.gov/MedicalPrograms/MCH/V/index.cfm>

If you are a victim of domestic violence, call the National Domestic
Violence Hotline at 1-800-799-SAFE (7233); 1-800-787-3224 (TTY).

**Victim Advocates And Tribal Law Enforcement**\
October 17-18, 2007\
Tucson, Arizona

Domestic Violence Expert Witness Institute\
This 2 day, tuition free course provides hands-on, experiential
 training on how to qualify as an expert witness on domestic violence
 in tribal, state, and federal courts. Learn from some of Indian
 Country\'s leading judges, attorneys, law enforcement officers, and
 victim advocates how to prepare for trial, qualify as an expert
 witness on domestic violence, and provide effective, persuasive
 testimony.\
Participants will have the opportunity to simulate taking the stand  and
providing domestic violence expert witness testimony in small,
 interactive breakout groups facilitated by legal, advocacy, and law
 enforcement experts.\
This is an advanced level professional course to assist experienced
 victim advocates and law enforcement officers in qualifying and\
providing effective testimony as expert witnesses on domestic  violence
against Native women. Registration is free. You can register  on-line at
[www.swclap.org](http://www.swclap.org/)  The deadline for registration
is very soon. Preference is given to OVW grantees working with Native
women.

**Location of shelters and other assistance programs impacts the
incidence of violence against homeless women**

<http://www.ahrq.gov/research/aug07/0807RA7.htm>

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

**Daily Back Pain May Have Adverse Health Effects in Elderly Women **

CONCLUSION: Daily back pain is associated with reduced quality of life,
mobility and longevity and increased risk of coronary heart events. The
adverse health effects of chronic back pain deserve greater recognition.

[**Zhu
K**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Zhu K"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Association of back pain frequency with mortality, coronary heart
events, mobility, and quality of life in elderly women.
[Spine.](javascript:AL_get(this, 'jour', 'Spine.');) 2007 Aug
15;32(18):2012-8

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17700450>

# **Estrogens May Modify Course of Parkinson\'s Disease in Women**

CONCLUSIONS: Our results suggest that, in women, the development of
symptomatic Parkinson\'s disease (PD). may be delayed by higher
physiological striatal dopamine levels, possibly due to the activity of
oestrogens. This could explain the epidemiological observations of a
lower incidence and higher age at onset in women. Women also presented
more often with tremor which, in turn, is associated with milder motor
deterioration and striatal degeneration. Taken together, these findings
suggest a more benign phenotype in women with PD.

[**Haaxma
CA**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Haaxma CA"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Gender differences in Parkinson\'s disease. J Neurol Neurosurg
Psychiatry. 2007 Aug;78(8):819-24.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17098842>

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

Advance Provision for Emergency Oral Contraception

[Clinical Question]{.underline}

Does providing women with emergency oral contraception in advance for
use as needed change pregnancy rates, frequency and timing of
contraceptive use, risk of sexually transmitted infections, or sexual
behavior?

[Evidence-Based Answer]{.underline}

Providing oral emergency contraceptives in advance to fertile women for
use after unprotected sexual intercourse (i.e., advance provision) does
not affect pregnancy rates, condom use, sexually transmitted infection
rates, or type of contraception used. Advance provision more than
doubles the odds that a woman will use emergency contraception once and
more than quadruples the odds that she will use it two or more times. It
also reduces the time from sexual intercourse to emergency contraceptive
use by about 15 hours.

[Practice Pointers]{.underline}

To increase the availability and use of emergency contraception, the
American College of Obstetricians and Gynecologists recommends one
1.5-mg dose of levonorgestrel (Plan B) or two 0.75-mg doses taken 12 to
24 hours apart for women who have had unprotected or inadequately
protected sexual intercourse.1 This practice guideline supports advance
provision. The American Academy of Pediatrics has a similar policy.2 The
American Academy of Family Physicians does not specifically address
advance provision.3 Although combined contraceptive pills and
mifepristone (Mifeprex) can be used for emergency contraception,
levonorgestrel is better tolerated, is more effective, and is approved
by the U.S. Food and Drug Administration for over-the-counter
distribution.

This Cochrane review included randomized controlled trials comparing
advance provision with standard access to emergency contraception. The
review included eight trials (6,389 total participants); five of the
trials were conducted in the United States. Two studies had the power to
show a difference in pregnancy rates. Control groups received general
contraceptive counseling, information about emergency contraceptives,
and/or access to emergency contraception on request. Most of the trials
provided one to three courses of levonorgestrel and followed patients
for three to 12 months.No study found a difference in pregnancy rates.
Women who had advanced access to emergency contraception were about 2.5
times more likely to use it once and over four times more likely to use
it two or more times. These women were also more likely to take the
contraception an average of about 15 hours sooner after sexual
intercourse than those in the control groups. The three studies that
measured rates of sexually transmitted infections did not find a
difference between groups. The five studies that reported on
contraception use did not find differences between groups in the type or
frequency of contraception use, including condom use. The six studies
that compared frequency of unprotected sexual intercourse did not find a
difference between groups. No adverse events were reported in any of the
studies.

Although most women took the first contraceptive pill as directed, in
one study, 17 percent of women who received advanced access took the
second pill incorrectly. Therefore, single-dose regimens may be
preferable. Providing women with advanced access to emergency
contraception appears to be safe but does not reduce pregnancy rates on
a population level. However, individual women might benefit because
advance provision increases the speed and frequency of contraceptive
use. Cochrane Briefs

Polis CB, Schaffer K, Blanchard K, Glasier A, Harper CC, Grimes DA.
Advance provision of emergency contraception for pregnancy prevention
(full review). Cochrane Database Syst Rev 2007;(2):CD005497

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17443596>

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

**Featured Website David Gahn, IHS MCH Portal Web Site Content
Coordinator**

**State trends on uninsured children**

Child health coverage publication with state level trends for SCHIP and
uninsured
[[http://covertheuninsured.org/pdf/americasfuture.pdf]{.underline}](http://covertheuninsured.org/pdf/americasfuture.pdf)

I would like you to particularly note these 3 key tables: SCHIP and the
uninsured child <Judith.Thierry@ihs.gov>

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

**What\'s the first course of action for this couple that\'s trying to
conceive?**

When assessing a couple who comes to the clinician complaining of
inability to conceive after 1 year, **which of the following statements
best describes the first course of action?**\
-The female partner should be administered an ovulation stimulator to
help promote conception

-A careful medical history of both partners should be taken to assess
fertility risk factors

-The male partner should undergo tests to evaluate ejaculatory function
and semen quality

-Both partners should provide blood samples to test for hormone levels

Go here to find out

<http://www.medscape.com/viewarticle/559055_7>

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

**October 2007 -- Highlights**

-Superhero related injuries in pediatrics

-Unpublicized nuclear releases in American Indian communities

-Removable brace versus casting in children with low-risk ankle
fractures.

-Influenza Vaccination for 2007-8

-The tail end of guinea worm -- global eradication without a drug or a
vaccine

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ICHN1007.doc>

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

**Changes in workflow and tasks need to be assessed when introducing bar
code medication administration into nurses\' work**

Bar code medication administration (BCMA) technology is being
implemented slowly in hospitals across the United States. The BCMA
technology consists of a medication network server and handheld devices
that connect to medication administration record data through a wireless
radio frequency link.

The software system enables users to document the administration of
medications at the bedside or other points of care in real time. When
hospitals introduce a new technology like BCMA, they should study how
the technology will change nurses\' workflow and tasks as well as the
safe administration of medications, according to a new study.

A human factors engineer and a pharmacist observed use of BCMA
technology during medication administrations to identify work system
factors that affected nurses\' use of and interaction with the
technology when they administered medications. Nurses varied in the
order in which they performed steps of the medication administration
process, with a total of 18 different sequences identified.

Some of these sequences were contrary to hospital policy and the
original design of the medication administration process. In addition,
they could be considered workarounds or potentially unsafe acts, notes
Pascale Carayon, Ph.D., of the University of Wisconsin-Madison.
Interruptions and patient factors typically were precursors to
medication errors and workarounds. For example, in 32 percent of
observations, nurses were interrupted by the needs of patients and their
families, nurses were interrupted by another provider or the nurse
initiated an exchange with another provider, or interruptions were
caused by equipment, technology, or medications.

Patient factors like unique patient populations (children, the disabled,
or the critically ill) or contact isolation requirements also affected
medication administration. These factors may not have been taken into
consideration during the development of BCMA technology, note the
researchers. Their study was supported by the Agency for Healthcare
Research and Quality (HS14253).

Evaluation of nurse interaction with bar code medication administration
technology in the work environment, by Dr. Carayon, Tosha B. Wetterneck,
M.D., Ann Schoofs Hundt, Ph.D., and others, in the March 2007 *Journal
of Patient Safety* 3(1), pp. 34-42.

<http://www.ahrq.gov/research/aug07/0807RA18.htm>

**The Commonwealth Fund/Harvard University Fellowship in Minority Health
Policy**

Supported by The Commonwealth Fund, administered by the Minority Faculty
Development Program at Harvard Medical School, this innovative
fellowship is designed to prepare physicians, particularly minority
physicians, for leadership roles in formulating and implementing public
health policy and practice on a national, state, or community level. 
Five one-year, degree-granting fellowships will be awarded per year. 
Fellows will complete academic work leading to a Master of Public Health
(MPH) degree at the Harvard School of Public Health, and, through
additional program activities, gain experience in and understanding of
major health issues facing minority, disadvantaged, and underserved
populations. CFHUF also offers a Master of Public Administration (MPA)
degree at John F. Kennedy School of Government to physicians possessing
an MPH. It is expected that CFHUF will support the development of a
cadre of leaders in minority health, well-trained academically and
professionally in public health, health policy, health management, and
clinical medicine, as well as actively committed to careers in public
service.

 As Director of CFHUF, I seek your assistance in informing potential
candidates of this opportunity to gain exposure to and understanding of
major health issues facing minority and disadvantaged populations.  For
application materials, information, and other training opportunities,
please contact the CFHUF Program Coordinator by telephone at (617)
432-2922; by fax at 617-432-3834; or by e-mail at
<mfdp_cfhuf@hms.harvard.edu>

 Sincerely,    

Joan Y. Reede, M.D., M.P.H., M.S.

Dean, Office for Diversity and Community Partnership, Harvard Medical
School

#### International Health Update Claire Wendland, Madison, WI {#international-health-update-claire-wendland-madison-wi .Style-Heading-4-+-Arial-14-pt-Underline}

**Prevention of Mother-to-Child HIV Transmission: An Innovative Program
in Cameroon**

For over twenty years, the Cameroon Baptist Convention Health Board
(CBCHB) has set up and maintained primary health centers in the more
isolated villages of rural Cameroon. Literate women selected by village
leaders are trained as birth attendants who provide basic antenatal
care, attend low-risk deliveries, and triage high-risk women to
facilities with more resources. (At least in theory -- many women don't
have adequate transportation to get to those facilities.) In a recent
article in the Journal of Midwifery and Women's Health, Benjamin Wanyu
and colleagues describe the initiation of a program in which those birth
attendants were also trained in services designed to reduce the
prevention of mother-to-child HIV transmission. Trained birth attendants
are now able to provide group pretest counseling, voluntary HIV testing
(using rapid oral tests \-- the only lab test of any kind currently
available in these health centers), individual posttest counseling and
single-dose nevirapine administration for mothers and newborns.

In the program\'s first three years, the birth attendants in twenty
village health centers tested over 2300 women. Of the 82 women (3.5%)
with positive tests, 42 were delivered by the birth attendants, and of
those 88% of mothers and 85% of newborns received single-dose nevirapine
prophylaxis.

The program encountered several problems. It has proved difficult to
maintain adequate supplies of HIV test kits, a problem made worse by the
short shelf-life of the oral kits. (In fact, program administrators are
shifting to a blood test, which is more stable for storage and also \--
because it is donated \-- is cheaper for the program.) Maintaining
regular stocks of nevirapine in these geographically isolated clinics
has also proved to be problematic, and the syrup is particularly
difficult as it too has a short shelf life. Because the oral tests have
a reasonably high false-positive rate, the program\'s protocol dictates
a second test to be done by a nurse supervisor who would visit monthly
for this purpose. Transportation for both nurse supervisors and patients
was an obstacle to this plan, especially during the rainy season when
the roads and trails are in terrible condition, and over a third of the
women with an initial positive test never had the second test done. The
most serious problem the program encountered was the stigma associated
with HIV/AIDS. This stigma is so great that 11 families moved out of
their communities after the first positive test, and program
coordinators also reported problems with domestic violence related to
positive test results. Despite these drawbacks, the program had many
significant successes. An astonishing 99% of women counseled accepted
the tests, which is much higher than rates seen elsewhere and may be
related to the respected position of these birth attendant counselors in
their communities. In addition, the treatment rates for both mothers and
infants are better than those seen in the larger hospitals running
similar programs. Best of all, only about 15% of infants had positive
HIV tests at 15 months of age, comparable to what has been seen with
nevirapine-based trials in urban settings.

Many of you will be pleased to know that there is an Indian Health
Service connection with this excellent program. The program's associate
directors, who were also instrumental in obtaining the grant that funded
it, are long-time I.H.S. veterans Drs. Tom and Edie Welty.

Wanyu B, Diom E, Mitchell P et al. 2007 Birth attendants Trained in
\"Prevention of Mother-to-Child HIV Transmission\" Provide Care in Rural
Cameroon, Africa. J Midwifery Womens Health 2007; 52(4):334-341.

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

Edie and Tom retired from IHS after 26 years (23 with IHS and 3 with
CDC) in 1997. They began to work as volunteers with the Cameroon Baptist
Convention Health Board in 1998 and go there about 6 weeks a year to
support their program. They wrote a grant to Elizabeth Glaser Pediatric
AIDS Foundation (EGPAF) in 2000, which was one of eight programs funded
and EGPAF has renewed it annually since then. The AIDS Program is quite
comprehensive (summary available upon request).

"It is very gratifying for us to see how much they have accomplished
with minimal resources. Everyone has been affected by HIV and is
motivated to do as much as possible to prevent and treat it." Tom and
Edie Welty

**Other**

**Visual inspection with acetic acid: Effective method to prevent
cervical cancer**

BACKGROUND: Cervical cancer is the most common cancer among women in
developing countries. We assessed the effect of screening using visual
inspection with 4% acetic acid (VIA) on cervical cancer incidence and
mortality in a cluster randomised controlled trial in India.

INTERPRETATION: VIA screening, in the presence of good training and
sustained quality assurance, is an effective method to prevent cervical
cancer in developing countries

Sankaranarayanan R et al Effect of visual screening on cervical cancer
incidence and mortality in Tamil Nadu, India: a cluster-randomised
trial. [Lancet.  2007;
370(9585):398-406](http://www.medscape.com/medline/publicationbrowser/123?pmid=17679017)

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17679017>

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

**Infant Mortality Awareness Month Toolkit**

The National Healthy Start Association\'s (NHSA\'s) Infant Mortality
Awareness Month Toolkit is designed to increase national awareness of
the factors that contribute to infant mortality in the United States and
to urge community leaders to get involved in efforts to reduce infant
mortality rates. The toolkit was produced by NHSA with support from the
Annie E. Casey Foundation following the introduction of a Congressional
resolution to observe September as Infant Mortality Awareness Month.

Contents include promotional materials, suggested fundraising and
advocacy activities, statistical resources, and public relations and
marketing tips. The toolkit is intended for use by Healthy Start
programs and others to help raise awareness of infant mortality
throughout the country and to gain community support for activities to
reduce infant mortality.
[[http://www.healthystartassoc.org/tkguide.html]{.underline}](http://www.healthystartassoc.org/tkguide.html)

**New Edition of Child Health USA Released**

Child Health USA 2006 reports on the health status and service needs for
the target population of Title V funding: infants, children,
adolescents, children with special health care needs, and women of
childbearing age. The book, published by the Health Resources and
Services Administration\'s Maternal and Child Health Bureau, comprises
secondary data for more than 50 health status and health care
indicators, provides both graphical and textual summaries of relevant
data, and addresses long-term trends where applicable and feasible. The
first section, Population Characteristics, presents statistics on
factors (including poverty, education, and child care) that influence
children\'s well-being. The second section, Health Status, contains
vital statistics and health behavior information for the maternal and
child health population. Health Services Financing and Utilization, the
third section, includes data on health care financing and newly
implemented health policies. The final sections, State Data and City
Data, contain information on selected indicators at state and city
levels.
[[http://www.mchb.hrsa.gov/chusa_06/pages/pdf/c06.pdf]{.underline}](http://www.mchb.hrsa.gov/chusa_06/pages/pdf/c06.pdf)

**MCH Library expands availability and access to historical documents**

The Maternal and Child Health (MCH) Library Web site now includes over
300 historical documents published by the U.S. Children\'s Bureau
between 1912 and 1969, the earliest years of the federal agency. The
documents have been made available electronically on the library\'s Web
site with support from the Health Resources and Services
Administration\'s Maternal and Child Health Bureau. Many of the
documents are being made available online for the first time and are
accessible only from the MCH Library.

Selected topics include child health, infant mortality, child labor, and
public health services for mothers and children, including children with
physical and cognitive disabilities.
[[http://www.mchlibrary.info/history/index.html]{.underline}](http://www.mchlibrary.info/history/index.html)

**MCH Headlines Judy Thierry HQE**

**AI** **/** **AN researchers on perinatal depression requesting names
of interested individuals**

Researchers that could knowledgeably present the American Indian/Alaska
Native perspective related to parental depression (maternal, paternal,
or both); as well as other issues that may place children at risk for
developing depression and/or behavioral disorders\--such as substance
abuse and intimate partner violence are being sought.

Institute of Medicine IOM is also interested in learning about any
promising community-based interventions that address these issues
for our populations. Institute of Medicine is interested in identifying
speakers for future committee meetings.

 

Submit names and contact info to me or have people contact me directly

Thanks so very much.

Judy

<Judith.Thierry@ihs.gov>

**Protecting America's Future**

The 4-page issue brief produced by the State Health Access Data
Assistance Center (SHADAC) at the University Of Minnesota School Of
Public Health presents the impact of reclassification of health
insurance coverage for Indian Health Service (IHS) in select states on
uninsured rates. The Current Population Survey (CPS) is a commonly used
data source for health insurance rate estimates.  In 1998 with
consultation between the BIA and the Census Bureau the definition
of insurance coverage for respondents who report IHS-only to that of
"uninsured" was made. The impact of this change in seven states with
five percent or more of the population self-reporting their
race/ethnicity as American Indian and Alaska Native (AIAN) either alone
or in combination with another race/ethnicity is discussed. The
methodology used two-year pooled averages before and after
the definition/reclassification change.   A statistically significant
increase (p\<0.01%) of uninsured was noted for all states except
Arizona.  Impact on position in state uninsured rankings worsened. 
Effect size nationally however showed no influence.  Of note: during
this period OMB standards for reporting racial categories changed from a
one of four categories to multiple race categories.  

The authors go on to point out that while the IHS is not defined as a
comprehensive health insurance it provides access to a level of
services, and services that vary across tribes.  In the seven state
analysis over one-half of the uninsured AIAN population reported IHS as
their sole source of health care.  

The 2005 SHADAC Issue Brief describes an important milestone in the
definitional change of AIAN coverage, that being the IHS-only uninsured
classification, and its measured impact on seven of the most AIAN
populous states. The change was statistically significant for six of the
seven states in this analysis.  These data impact administrative, fiscal
and patient care resources. Obvious and not so obvious costs of bearing
the load of care for sizeable uninsured populations (range of 24.2% to
43.2%) bear's further analysis.  Age-specific stratification within
states if described could provide understanding of actions to take for
coverage of potential eligible groups such as
children. <http://www.shadac.umn.edu/img/assets/18528/IssueBrief11.pdf>

**Alliance for a Healthier Generation Webinar**

### How to Register for a Webinar Session:

-   All webinar sessions are free, you simply need to have access to a
    phone and computer to participate

### Please email us at <webinars@HealthierGeneration.org> with the following information: 

### your name 

### email address 

### school/organization name 

### specify which session (including time) you would like to attend  

### We will confirm your participation via email, as well as provide you with directions on how to call-in and log-in for the training 

### Alliance for a Healthier Generation A Partnership between the William J. Clinton Foundation and the American Heart Association T: (646) 775-9155  55 W. 125th Street │ New York, NY 10027 www.HealthierGeneration.org8 [The Healthy Schools Program](http://www.healthiergeneration.org/schools): Making Schools Healthier Places to Learn, Work, Eat, and Play. 

Schedule at the following link:
<http://www.healthiergeneration.org/calendar-webinars.aspx>

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

#### Endometriosis: Where is the real truth? {#endometriosis-where-is-the-real-truth-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Here are some questions to ponder.  {#here-are-some-questions-to-ponder. .Style-Heading-4-+-Arial-14-pt-Underline}

#### 1.) Endometriosis virtually always progresses in severity without treatment {#endometriosis-virtually-always-progresses-in-severity-without-treatment .Style-Heading-4-+-Arial-14-pt-Underline}

#### True False {#true-false .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### 2.) Postoperative medical therapy has been shown to produce significant benefit in reducing pain in women who have treated for endometriosis laparscopically {#postoperative-medical-therapy-has-been-shown-to-produce-significant-benefit-in-reducing-pain-in-women-who-have-treated-for-endometriosis-laparscopically .Style-Heading-4-+-Arial-14-pt-Underline}

#### True False {#true-false-1 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### 3.) Appoximately 40% of women with endometriosis and pain will derive symptomatic benefit from treatment with placebo {#appoximately-40-of-women-with-endometriosis-and-pain-will-derive-symptomatic-benefit-from-treatment-with-placebo .Style-Heading-4-+-Arial-14-pt-Underline}

#### True False {#true-false-2 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### 4.) Surgical modalities, such as electrocautery, laser, or harmonic scalpel appear to be equally effective in treating endometriosis {#surgical-modalities-such-as-electrocautery-laser-or-harmonic-scalpel-appear-to-be-equally-effective-in-treating-endometriosis .Style-Heading-4-+-Arial-14-pt-Underline}

#### True False {#true-false-3 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### 5.) Surgical aspiration is the preferred treatment method for women with ovarian endometrioma {#surgical-aspiration-is-the-preferred-treatment-method-for-women-with-ovarian-endometrioma .Style-Heading-4-+-Arial-14-pt-Underline}

#### True False {#true-false-4 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### 6.) Treatment with a GnRH analog for 6 months is associated with an increased fracture risk in women with endometriosis {#treatment-with-a-gnrh-analog-for-6-months-is-associated-with-an-increased-fracture-risk-in-women-with-endometriosis .Style-Heading-4-+-Arial-14-pt-Underline}

#### True False {#true-false-5 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### 7.) Interstitial cystitis coexists with endometriosis in approximately 10 percent of cases {#interstitial-cystitis-coexists-with-endometriosis-in-approximately-10-percent-of-cases .Style-Heading-4-+-Arial-14-pt-Underline}

####  True False {#true-false-6 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### 8.) The extent of endometriosis does not parallel the extent of improvement after surgical therapy, e. g., minimal disease -- most benefit; greatest amount of disease -- least response {#the-extent-of-endometriosis-does-not-parallel-the-extent-of-improvement-after-surgical-therapy-e.-g.-minimal-disease-most-benefit-greatest-amount-of-disease-least-response .Style-Heading-4-+-Arial-14-pt-Underline}

#### True False {#true-false-7 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-17 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Extra credit {#extra-credit .Style-Heading-4-+-Arial-14-pt-Underline}

#### Promising therapies for endometriosis include: {#promising-therapies-for-endometriosis-include .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Aromatase inhibitors {#aromatase-inhibitors .Style-Heading-4-+-Arial-14-pt-Underline}

#### -RU-486 {#ru-486 .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Levonorgestrel containing IUDs {#levonorgestrel-containing-iuds .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Antiangiogenic cancer therapy {#antiangiogenic-cancer-therapy .Style-Heading-4-+-Arial-14-pt-Underline}

#### -None the above {#none-the-above .Style-Heading-4-+-Arial-14-pt-Underline}

#### -All of the above {#all-of-the-above .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### We'll thoroughly discuss the answers next month, but y {#well-thoroughly-discuss-the-answers-next-month-but-y .Style-Heading-4-+-Arial-14-pt-Underline}

#### ou can preview the answers on page 50 {#ou-can-preview-the-answers-on-page-50 .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

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

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

#### Hereditary Link to PMDD Identified {#hereditary-link-to-pmdd-identified-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### **http://www.medscape.com/resource/pmdd?src=rcupdate#1** {#httpwww.medscape.comresourcepmddsrcrcupdate1 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### The Reproductive Phenotype in Polycystic Ovary Syndrome {#the-reproductive-phenotype-in-polycystic-ovary-syndrome-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### <http://www.medscape.com/viewprogram/7768?src=nlcmealert> {#httpwww.medscape.comviewprogram7768srcnlcmealert .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Passive Smoking Increases Risk for Sleep Disturbance During Pregnancy {#passive-smoking-increases-risk-for-sleep-disturbance-during-pregnancy-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### <http://mp.medscape.com/cgi-bin1/DM/y/hBXc20Ou5N60Dzc0IvZY0Es> {#httpmp.medscape.comcgi-bin1dmyhbxc20ou5n60dzc0ivzy0es .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Management of Valvular Heart Disease in Pregnancy {#management-of-valvular-heart-disease-in-pregnancy-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### <http://www.medscape.com/viewarticle/561354?src=mp> {#httpwww.medscape.comviewarticle561354srcmp .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Ask the Experts topics in Women\'s Health and OB/GYN Index, by specialty, Medscape {#ask-the-experts-topics-in-womens-health-and-obgyn-index-by-specialty-medscape .Style-Heading-4-+-Arial-14-pt-Underline}

######### [**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**

#### Estrogen Protects Women's Brains Prior to Menopause {#estrogen-protects-womens-brains-prior-to-menopause-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSIONS: Both unilateral and bilateral oophorectomy preceding the onset of menopause are associated with an increased risk of cognitive impairment or dementia. The effect is age-dependent and suggests a critical age window for neuroprotection. {#conclusions-both-unilateral-and-bilateral-oophorectomy-preceding-the-onset-of-menopause-are-associated-with-an-increased-risk-of-cognitive-impairment-or-dementia.-the-effect-is-age-dependent-and-suggests-a-critical-age-window-for-neuroprotection. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Rocca WA](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Rocca WA"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus) et al Increased risk of cognitive impairment or dementia in women who underwent oophorectomy before menopause. [Neurology.](javascript:AL_get(this, 'jour', 'Neurology.');) 2007 Aug 29 {#rocca-wa-et-al-increased-risk-of-cognitive-impairment-or-dementia-in-women-who-underwent-oophorectomy-before-menopause.-neurology.-2007-aug-29 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17761551**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17761551) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch17761551 .Style-Heading-4-+-Arial-14-pt-Underline}

**Atrophic Vaginitis and Estrogen Treatment -** **Medscape CME**

<http://www.medscape.com/viewarticle/560167>

[**Cholesterol-Related Compound Can Block Estrogen From Helping To
Prevent Heart Disease in Some
Women**](http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=47533)

A molecule related to cholesterol can block the hormone estrogen from
performing functions in blood vessels that keep them healthy and
protected against heart disease

#### Umetani M et al 27-Hydroxycholesterol is an endogenous SERM that inhibits the cardiovascular effects of estrogen  {#umetani-m-et-al-27-hydroxycholesterol-is-an-endogenous-serm-that-inhibits-the-cardiovascular-effects-of-estrogen .Style-Heading-4-+-Arial-14-pt-Underline}

#### *Nature Medicine* Published online: 16 September 2007 {#nature-medicine-published-online-16-september-2007 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.nature.com/nm/journal/vaop/ncurrent/abs/nm1641.html**](http://www.nature.com/nm/journal/vaop/ncurrent/abs/nm1641.html) {#httpwww.nature.comnmjournalvaopncurrentabsnm1641.html .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Midwives Corner**, **Lisa Allee, CNM, Chinle**

**Nurse Midwife Week October 7-13, 2007**

National Midwifery Week, October 7-13, 2007, is a wonderful occasion
celebrating midwifery and midwives\' commitment to being \"With Women,
for a Lifetime.\" Whether you are a midwife, a new parent or
grandparent, or you\'re just seeking information about midwifery, this
week will be filled with educational opportunities. Please hug all the
midwives you see, after you help them work for equitable reimbursement,
that is. <http://www.midwife.org/index.cfm?id=312>

**Piercing the veil: the marginalization of midwives in the United
States**

This paper investigates the marginalization of certified nurse-midwives
(CNMs) in the US. This marginalization occurs despite ample evidence
demonstrating that a midwifery model delivers high-quality
cost-effective care. Currently midwives attend only 7% of births,
compared to 50-75% of births in other developed countries. Given the
escalating costs of health care and relatively poor maternal and child
health indicators in comparison with other developed countries, these
findings are disturbing. This paper investigates this paradox through a
qualitative case study of two prestigious but declining midwifery
services in a large US city. Fifty-two multi-sited in-depth interviews
were conducted along with an analysis of relevant archival sources. It
was found that institutions successfully altered maternity care and
diminished midwifery services without accountability for their actions.
These findings illuminate the larger political-economic forces that
shape the marginalization of midwifery in the US.

[Goodman
S](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Goodman S"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus).
Piercing the veil: the marginalization of midwives in the United States.
[Soc Sci Med.](javascript:AL_get(this, 'jour', 'Soc Sci Med.');) 2007
Aug;65(3):610-21.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17475381>

**Impact of written information on women\'s use of postpartum services**

RESULTS: Satisfaction with care during the postpartum period was 57.2%
in the intervention and 38.9% in the control arm (p\<0.001). Some 85% of
women in the intervention arm had a postpartum visit compared to 55% in
the control arm (p\<0.001). CONCLUSION: In the context of high female
literacy, the intervention is effective and requires few resources.

Kabakian-Khasholian T; Campbell OM Impact of written information on
women\'s use of postpartum services: a randomised controlled trial.
[Acta Obstet Gynecol Scand.  2007;
86(7):793-8](http://www.medscape.com/medline/publicationbrowser/123?pmid=17611823).
<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17611823>

**Navajo News John Balintona, Shiprock**

**Evaluation of the pregnant patient for non-obstetric surgery: Part
Two**

**Editorial Note:**

This is Part Two of a two Part series on Evaluation of the Pregnant
Patient for Non-obstetric Surgery. Part One discussed the Epidemiology
and Maternal Adaptation in Pregnancy and is available here
<http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0907_Feat.cfm#navajo>

**Part Two**

# Laboratory Data and Imaging Studies

The maternal blood volume increases markedly throughout pregnancy with
levels 40 to 50 percent above nonpregnant levels when at term. This
increased volume is a result of both an increase in plasma, as well as,
erythrocytes with a slightly higher increase in plasma volume.
Therefore, despite the increased erythropoesis, normal pregnancies
result in a slight decrease in both hemoglobin concentration and
hematocrit. A hemoglobin concentration below 11.0 g/dl should be
considered abnormal in a term pregnancy resulting typically from iron
deficiency and not hypervolemia of pregnancy. The blood leukocyte count
can vary widely during pregnancy, quoted by experts as typically between
5, 000 -- 12, 000/ml with a normal range of 14, 000 to 16,000 shortly
after delivery. Many obstetric providers have observed the "leukocytosis
of pregnancy", but must take into account other signs and symptoms of
infection when interpreting this lab value. Gestational thrombocytopenia
of pregnancy is a known phenomenon. The platelet level is usually
greater than 70, 000, and after a thorough evaluation and dismissal of
other conditions and lack of signs of abnormal bleeding an obstetric
provider may elect to continue to observe these pregnant patients.
Although there is no firm recommendation for platelet transfusion in
relation to pending nonobstetric surgery, it may be reasonable to use a
threshold of greater than 50, 000 platelets for platelet transfusion.
The levels of several blood coagulation factors are increased during
pregnancy, e.g. fibrinogen, factor VII, VIII, IX, and X all of which are
important components in producing clot. The natural inhibitors of
coagulation including ATIII, protein C and S have been shown to be
unchanged quantitatively with protein S activity being shown to
decrease. The clotting time of pregnant patients when compared to their
nonpregnant counterparts shows no significant change. The overall effect
of these changes in coagulation factors predisposes toward a
hypercoagulable state and this can have implications for those who
undergo surgery. The prolonged immobilization coupled with the
aforementioned physiologic changes may predispose some patients to the
development of thrombosis and therefore proper prophylaxis should be
initiated.

Basic chemistry studies are included in the evaluation of any surgical
patient. Pregnancy is shown to confer a decrease in serum sodium and
potassium, but the literature does not give a firm range of normal
values during pregnancy. In the absence of signs and symptoms of
hyponatremia or hypokalemia, intervention is not indicated. Due to the
respiratory alkalosis of normal pregnancy the serum bicarbonate level
subsequently decreases from about 26 to 22 mmol/L, but this should not
be interpreted as acidosis in most cases. Due to the increase of
glomerular filtration rate during pregnancy, serum levels of creatinine
and urea normally decrease as a consequence. Some of the laboratory
tests that are commonly used to evaluate hepatic function are
appreciably different in pregnancy. Total alkaline phosphatase levels
almost double during pregnancy where serum albumin levels show a
decrease to an average of 3.0 g/L. Despite these changes, there is no
distinct change in liver morphology or function in normal pregnant
women.

A finding of glucosuria during pregnancy is not necessarily abnormal. An
increase in glomerular filtration may account for the majority of
glucosuria, but again this finding should be taken in context especially
when evaluating the patient for presumed gestational diabetes or related
diabetic condition. Proteinuria is normally not evident during
pregnancy, however some suggest that levels up to around 115 mg/day,
which translates to "trace" on a urine dipstick test, may be considered
normal. A pregnant patient who presents with hematuria, if not resulting
from contamination, is compatible with the diagnosis of urinary tract
disease, i.e. infection, urolithiasis, etc. Evidence of nitrites in the
urine is diagnostic for urinary tract infection in both pregnant and
nonpregnant individuals. The presence of leukocyte esterase,
representing white blood cells in the urine may be indicative of
infection but not in all cases.

Imaging techniques such as plain film, computerized tomography (CT),
magnetic resonance imaging, and ultrasound are utilized in the
evaluation of patients despite their pregnancy status. While the
majority of diagnostic procedures are associated with little or no known
significant fetal risks, obtaining certain imaging tests in a known
pregnant patient may be difficult due to the reluctance from the
nonobstetric provider. One must remember that certain conditions, e.g.
life-threatening emergencies and trauma, may necessitate imaging
modalities. Furthermore, according to the American College of Radiology
(ACR), no single diagnostic procedure results in a radiation dose
significant enough to threaten the well being of the developing embryo
and fetus. The obstetric provider, however, must be cognizant of the
accepted threshold for ionizing radiation (\< 5 rad) as well as the
estimated gestational age, organogenesis occurring between 8 and 15
weeks gestation, when recommending imaging studies. Abdominal shielding
is also a reasonable recommendation when it is indicated. The American
College of Obstetricians and Gynecologists (ACOG) has published
guidelines reviewing the effects of imaging during pregnancy and are
summarized as follows:

1.  Women should be counseled the x-ray exposure from a single
    diagnostic procedure does not result in harmful fetal effects.
    Specifically dose less than 5 rad.

2.  Concern about possible effects of high-dose ionizing radiation
    should not prevent medically indicated procedures from being
    performed. One should consider imaging procedure not associated with
    ionizing radiation.

3.  Ultrasonography and magnetic resonance imaging are not associated
    with known adverse effects. First trimester use of MRI is still
    considered controversial.

4.  Consultation with a radiologist may be helpful in calculating total
    fetal dose when multiple studies are indicated

5.  The use of radioactive isotopes of iodine is contraindicated for
    therapeutic use during pregnancy.

# Anesthetic and Operative Considerations

Most obstetric authorities would contend that the risk of an adverse
pregnancy outcome is not increased after undergoing most technically
uncomplicated or anesthetic procedures. The risk of spontaneous abortion
or premature labor may be increased, however, when the surgical
condition or procedure is associated with complications. The most
prudent recommendation that one can offer is that consideration for
nonobstetric surgical intervention in a pregnant patient should be
individualized.

The American Society of Anesthesiologists (ASA) has published guidelines
regarding the practice of obstetric anesthesia, but these are implicitly
stated to not apply to nonobstetric surgical intervention during
pregnancy. After a careful review of the ASA guidelines, one may be able
to extrapolate certain recommendations that are probably useful for the
pregnant woman. Each patient, pregnant or nonpregnant, deserves some
type of preanesthetic evaluation to include an appropriate history and
physical exam. Preoperative labs can be individualized. Solid food
intake should be avoided for at least 6 hours in patients undergoing
elective surgery and timely administration of aspiration prophylaxis
should be considered.

The administration of prophylactic antibiotics may be individualized and
ACOG practice bulletins #47 (Prophylactic Antibiotics in Labor and
Delivery) and #74 (Antibiotic Prophylaxis in Gynecologic Procedures)
provide guidelines for its use.

ACOG practice bulletin #9 (Antenatal Fetal Surveillance) does state that
all indications for antepartum testing must be considered somewhat
relative, but in general antepartum fetal surveillance has been employed
in pregnancies in which the risk of fetal demise is increased. There is
insufficient literature to demonstrate that perianesthetic recording of
fetal heart rate prevents fetal or neonatal complications. In spite of
its unproven value, antepartum fetal surveillance is widely integrated
into clinical practice in the developed world. The obstetric provider
should take into account several factors such as gestational age,
continuation of medical/surgical condition, etc when making
recommendations for perioperative antepartum fetal surveillance.

Obstetric providers have an enormous opportunity and responsibility for
ensuring the best possible maternal and fetal outcome for nonobstetric
surgical procedures. Knowledge of physiologic and laboratory changes, as
well as, advice on perioperative management should be well communicated
between the obstetric provider and other members of the health care
team. This review highlights some of the aspects of care that should be
conveyed and provides a general rational approach to management. In the
coming issues, more in depth review of specific conditions, such as
appendicitis, biliary gallstone disease, urolithiasis, adnexal masses in
pregnancy, and trauma in pregnancy will be presented...stay tuned!

**References:**

1.  Williams Obstetrics. 22nd Edition. 2005. Chapter 42. General
    Considerations and Maternal Evaluation

2.  American College of Obstetrics and Gynecologists. 2004. Committee
    Opinion \# 299. Guidelines for Diagnostic Imaging During Pregnancy

3.  American Society of Anesthesiologists. 2006. Practice Guidelines for
    Obstetric Anesthesia

Part One in this series is available here

<http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0907_Feat.cfm#navajo>

Questions? Contact John Balintona <John.Balintona@ihs.gov>

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

**Nurses Corner, Kendra Carter**

**Memories, As a Public Health Nurse on the Navajo**

Marie A. Swigert, RN MS is one of those nurses who have managed to be a
staff nurse in the hospital to becoming the Director of Community Health
Nursing for the State of Colorado. Along the way she stopped at Northern
Navajo Medical Center.

She graduated nursing in 1957 from the University of Connecticut; earn
her Master of Science in nursing in 1967 from University of Colorado in
Boulder. She became a nurse to earn her blue and red cape however what
she got was the white dress and white shoes and her cap. The year she
graduated they discontinued the cape. She still has the white dress and
she presented me with her cap during my graduation from nursing school
in 2002. She has been a source of inspiration for me as well as for
other along our way of becoming nursing.

Here are her stories about Maternal Child Health with in the Indian
Health Services.

I worked on the Navajo in the middle '70s. I was attached to the public
health section of the Shiprock Service Unit (IHS employee) as Nursing
Director/Supervisor. W had approximately 5-6 nurses, either RNs, LPNs
who were assigned as public health, school, and clinic nurses. Also
included were our driver-interpreters and CHNs (community health aides),
our office also worked closely with the environmental health team who
were located in same office, as well as the nutritionist and her
nutrition aides.

Our office was on the first floor of the apartment building adjacent to
the old hospital. All of the nursing staff and other health teams worked
closely together. One of my strongest memories is that of our off site
MCH clinics held in the small communities which constituted the Shiprock
Service Unit that covered the Four Corners area of Colorado, New Mexico,
Arizona, and Utah.

In the morning of the MCH clinics we would collect our supplies and
materials, our driver/interpreter telling us 'we're going to late'. Off
we head for Sanostee or one of the other small communities with our
crew, our nurses, nutritionist, nurse-midwives and whomever. Arriving,
we would open the clinic building, air it out and let our first families
in who would be waiting for us to open.

The Public Health nurses would do the child health portion of the
clinic, the nurse midwife the maternal portion, the nutritionist and her
staff the food aspect. All of us shared in the nutrition part as we
partook of the food prepared by them, they always made enough for the
mothers, children, staff, and whoever else was there.

The PHNs did the well baby checks, assessments of "sick kids" and
occasionally grandmas too.

Ear infections were the bane of our assessments. I remember one time,
having told one young mom that propping the baby's bottle was not
healthy and increased ear infections. I told her "you don't prop the
bottle when feeding you sheep, you can't do it with your baby." She
agreed, somewhat reluctantly. The next visit, there she was in the lobby
at Sanostee. As I approached her she yelled out, "I didn't prop the
bottle, I really didn't." Sure enough, the baby's ear infection was much
improved.

We had protocols which allowed us to treat ear infections so long as we
appointed them back to our clinic or the Shiprock clinic. Our protocols
included immunizations, treatment for impetigo and other minor
infections. Any infection treatment, we reviewed with the doctors prior
to the next local clinic. Our community clinics were held monthly,
located in communities such as Toadlene, Tees Nos Pos, Checkerboard and
others.

The families valued our clinics; I remember one instance when a
grandmother carried her grandson over to our clinic. It had rained the
night before the roads were muddy, the bottom of her shirt and shoes
were covered with mud. Her grandson had been vomiting and had diarrhea
all night, she said. He was a sick little fellow. So, we cleaned him up
as best we could, told Grandma that he needed to be seen in Shiprock:
"you take him' she asked, 'yes we take him'. Much to the displeasure of
the driver, I said I would sit in the front seat of the car, as I had
more room. The youngster's clothes were soiled and a bit smelly. Once in
Shiprock, the child was admitted and Grandma came in that evening to see
him. I think most everyone knew 'I was the PHN that brought the feverish
but smelly child in and I got smelly too as his clothes were wet.

The Navajo people and their land are fascinating; I don't practice
nursing anymore, but do return as a reading and math tutor at the public
schools in Mexican Hat and Monument Valley. As one Navaho, told me 'you
get our sand in your shoes, you return.' It's true\...

Submitted by Marie A Swigert and LTJG Kendra A. Carter RN BSN USPHS

#### [**Kendra.Carter@ihs.gov**](mailto:Kendra.Carter@ihs.gov) {#kendra.carterihs.gov .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-29 .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}

**Common Questions about HPV and Cervical Cancer: For Women Who Have
HPV**

This sheet answers 15 questions about HPV and cervical cancer, including
how to prevent infection, testing, talking to a partner about HPV, and
the HPV vaccine.

<http://www.cdc.gov/std/HPV/common-questions.htm>

# Prevalence of HPV\* Infection† Among Sexually Active Females 

# Aged 14\--59 Years, by Age Group \-\-- National Health and Nutrition Examination Survey, United States, 2003---2004, QuickStats

![](media/image4.png){width="4.9375in" height="3.104861111111111in"}

\* Human papillomavirus.

† Determined by DNA extraction from self-collected cervicovaginal swabs.

§ 95% confidence interval.

Among sexually active females (i.e., 57% of females aged 14\--19 years
and 97% of those aged 20\--59 years), the prevalence of HPV infection
was highest for those in the youngest age groups (i.e., approximately
40% in those aged 14\--19 years and 50% in those aged 20\--24 years).
Prevalence declined substantially after age 24 years.

SOURCES: National Health and Nutrition Examination Survey, 2003\--2004.
Available at
<http://www.cdc.gov/nchs/about/major/nhanes/nhanes2003-2004/nhanes03_04.htm>

Dunne EF, Unger ER, Sternberg M, et al. Prevalence of HPV infection
among females in the United States. JAMA 2007;297:813\--9.

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

**Pre-Teen Vaccine Campaign**

The Pre-teen Vaccine Campaign launched on August 1, 2007. Through
extensive audience research, CDC has created posters and flyers, in
English and Spanish to educate parents and providers about the three
pre-teen vaccines and the 11 and 12 year old medical check-up. Use the
links to visit the "flyers" and "posters" gallery pages to download
materials. You can also request a DVD if you plan to professionally
print any of these materials.

<http://www.cdc.gov/vaccines/spec-grps/preteens-adol/07gallery/default.htm>

####  {#section-31 .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}

**Preconception Health of Women Delivering Live-Born Infants ---
Oklahoma, 2000--2003**

The U.S. Public Health Service recommends that all women of childbearing
age consume \>400 µg of folic acid daily through either supplementation
or fortified foods. CDC recommends offering, as a component of maternity
care, one pre-pregnancy visit to a health care provider for women
planning pregnancy to enable women to receive risk assessment, health
education, and specific interventions to address identified risks before
conception. Analysis of data collected from women in Oklahoma during
2000--2003 from the Pregnancy Risk Assessment Monitoring System (PRAMS)
indicated that 21.5 percent of women with a recent live birth were not
aware of folic acid benefits before they became pregnant, 73.5 percent
did not consume multivitamins at least four times per week during the
month before pregnancy, and 84.8 percent did not receive preconception
counseling from a health-care provider. Although pre-pregnancy awareness
of the benefits of taking vitamins with folic acid in the prevention of
some birth defects was high among Oklahoma women with a recent live
birth, actual consumption of multivitamins during the month before
pregnancy was low. Promoting preconception health of women is a key
public health strategy in the United States to decrease morbidity and
mortality associated with negative maternal and infant outcomes.
Increased folic acid consumption before conception and during the first
trimester of pregnancy can reduce the incidence of neural tube defects
by 50--70 percent.

Surveillance of Preconception Health Indicators Among Women Delivering
Live-Born Infants \-\-- Oklahoma, 2000---2003 MMWR June 29, 2007 /
56(25);631-634

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5625a3.htm>

#### [Editorial comment:]{.underline} Greggory Woitte -- Hastings Indian Medical Center

**Preconception Counseling**

I am sure that most of your patients are similar to mine in that your
first visit with them is after they have become pregnant. They show up
at the clinic for a confirmatory pregnancy test, to schedule their first
prenatal visit and to get started on prenatal vitamins (or as I am
frequently seeing to start Flintstones vitamins). However, as I am sure
you are aware, by the time the patient reaches our doorstep, we have
missed a very important part of the pregnancy that we may have had some
dramatic affect upon.

Between 2000 and 2003, the state of Oklahoma developed and administered
a preconception survey. (See above) They found that 84.8% of women did
not have any preconception counseling by a provider. 21.5% of women did
not know about the benefits of preconception folic acid and equally
disturbing was that 73.5% did not take vitamins before trying to become
pregnant.

In accordance with the ACOG Committee Opinion No. 313, patients who are
in the reproductive ages should be questioned about the possibility of
becoming pregnant, especially if they are not on contraception. Women
should be encouraged to formulate a reproductive health plan. We, as
practitioners of Women's Health, should be encouraging women to take
steps to get as healthy as possible at every visit. This is especially
important in women of reproductive ages where we have the opportunity to
provide education regarding the benefits to the fetus, as well as to
identify patients at high risk for adverse pregnancy outcomes.

We also need to remind our colleagues from other disciplines of medicine
to ask their patients about potentially becoming pregnant and refer
those who may be in need of pre-conceptional counseling or those in need
of contraceptive counseling.

ACOG Committee Opinion Number 313. The importance of preconception care
in the continuum of women\'s health care. [American College of
Obstetricians and
Gynecologists](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="American College of Obstetricians and Gynecologists"%5BCorporate Author%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus).
[Obstet Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');)
2005 Sep;106(3):665-6.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=16135611>

Center for Chronic Disease Prevention and Health Promotion
<http://www.cdc.gov/nccdphp/>

Office of Communication (770) 488-5131

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

Fracture Outcomes in Women Discontinuing Alendronate

Conclusion: Women who continued alendronate treatment after the initial
five years had higher hip and spine BMD, lower bone remodeling, and a
lower rate of clinical vertebral fractures; there was no difference in
nonvertebral fractures. The authors conclude that, unless patients are
at high risk of clinical vertebral fracture, those who have taken
alendronate for five years can discontinue the drug for up to five years
without a significant increase in fracture risk.

Black DM, et al. Effects of continuing or stopping alendronate after 5
years of treatment. The Fracture Intervention Trial Long-term Extension
(FLEX): a randomized trial. JAMA December 27, 2006;296:2927-38.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17190893>

Childhood, Teen Restriction of Dairy Foods Lowers Spinal Bone Mineral
Content

CONCLUSIONS: These results suggest that, starting as early as 10 years
of age, self-imposed restriction of dairy foods because of perceived
milk intolerance is associated with lower spinal bone mineral content
values. The long-term influence of these behaviors may contribute to
later risk for osteoporosis.

[Matlik
L](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Matlik L"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Perceived milk intolerance is related to bone mineral content in
10- to 13-year-old female adolescents. Pediatrics. 2007
Sep;120(3):e669-77.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17766507>

Pharmacologic Treatment of Osteopenia Not Usually Indicated

**Background:** Osteoporosis is arbitrarily defined as a bone mineral
density (BMD) that is 2.5 standard deviations (SDs) or more below the
mean in younger women, as measured at the femoral neck. Osteopenia is
defined as a BMD that is 1 SD or more below the younger women's mean.
Using these cutoffs, it is estimated that 17 percent of U.S. women 50
years and older will be diagnosed with osteoporosis and 50 percent of
white U.S. women who are postmenopausal will be identified as having
osteopenia. Because there is only fair correlation in BMD measurements
at different sites, the convention is to use the lowest score from
measurements taken at the femoral neck, total hip, or lumbar spine.
However, this practice increases the number of women diagnosed with
osteopenia without providing additional predictive information about
fracture risk, and therefore is no more useful than the femoral neck
measurement alone.

Fracture risk increases with age and lower BMD; however, white race,
female sex, previous fractures, stroke, and deconditioning or weakness
also increase fracture risk. Alcohol consumption of one or two drinks
daily may decrease the risk, but consumption of greater amounts
increases it. Other modifiable risk factors include smoking and poor
visual acuity. Although low weight is associated with fracture risk, it
is not a meaningful risk factor when the BMD has been measured because
weight is merely a marker for BMD. Women with a history of fractures or
radiographically confirmed fractures have a fourfold risk of fracture,
and pharmacologic treatment in these women is indicated.

**Recommendations:** Weight-bearing exercise improves BMD and decreases
fall and fracture risk. The optimal types and durations of such exercise
are not known. Calcium and vitamin D supplementation are beneficial in
older women, but their benefit in younger women is unclear. One
recommendation for women in middle age is 800 IU vitamin D and 500 mg
calcium daily, to supplement the 700 IU calcium provided in the average
diet.

All medications improve BMD and reduce vertebral fracture risk in women
who are postmenopausal and have osteoporosis or low BMD, but not all
treatments reduce nonvertebral and hip fracture risk. Estrogen is the
only treatment that has been shown to reduce nonvertebral fracture risk
in women with osteopenia. Alendronate (Fosamax) reduces nonvertebral
fracture risk in women with osteoporosis but not in women with higher
BMDs (i.e., T-scores greater than -2.5). Decisions about pharmacologic
treatment for fracture prevention depend on fracture risk and patient
preference.

Other recommendations include starting BMD testing at age 65, or sooner
in patients with multiple risk factors. Because the difference in BMD
between two tests must be at least 4 to 5 percent to be a reliable
indication of change, women with osteopenia and no other risk factors
should wait five to 10 years before being retested. Factors influencing
the testing interval include the likelihood that the bone loss is rapid
(e.g., immediately after menopause) and whether the result would
influence management. Testing is warranted in patients of greater age if
their life expectancy is long enough for them to benefit from
treatment-usually two to three years.

Finally, it is likely that use of bisphosphonates is safe for at least
10 years. A conservative approach is for patients at lower risk to have
a five-year break from the drug after five years of use. In the future,
T-score definitions are likely to be replaced by fracture risk estimates
as a basis for treatment recommendations.

Cummings SR. A 55-year-old woman with osteopenia. JAMA December 6,
2006;296:2601-10.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17148725>

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

#### Type 2 Diabetes in Youth: What You Should Know {#type-2-diabetes-in-youth-what-you-should-know .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20070901/665ph.html**](http://www.aafp.org/afp/20070901/665ph.html) {#httpwww.aafp.orgafp20070901665ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-32 .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}

**Procedure-related complications of amniocentesis and CVS are small**

RESULTS: After genetic amniocentesis, pooled pregnancy loss within 14
days was 0.6% (95% confidence interval \[CI\] 0.5-0.7), rising to 0.9%
(95% CI 0.6-1.3) for pregnancy loss before 24 weeks and 1.9% (95% CI
1.4-2.5) for total pregnancy loss. Corresponding figures for CVS were
0.7%, 1.3%, and 2%. CONCLUSION: Although the risks of pregnancy loss are
relatively low, lack of adequate controls tends to underestimate the
true added risk of prenatal invasive procedures.

[**Mujezinovic
F**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Mujezinovic F"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
[**Alfirevic
Z**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Alfirevic Z"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus).
Procedure-related complications of amniocentesis and chorionic villous
sampling: a systematic review. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007
Sep;110(3):687-94

<http://www.greenjournal.org/cgi/external_ref?access_num=17766619&link_type=PUBMED>

**Positive association between hyperemesis gravidarum and Helicobacter
pylori infection**

CONCLUSION: An association between hyperemesis gravidarum and H pylori
infection is suggested by this systematic review. However, the
considerable heterogeneity among studies highlights study limitations.

[**Golberg
D**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Golberg D"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Hyperemesis gravidarum and Helicobacter pylori infection: a
systematic review. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007
Sep;110(3):695-703

[**http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=17766620&dopt=AbstractPlus**](http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=17766620&dopt=AbstractPlus)

**HgbA1C and GHb for risk of congenital anomaly in women with diabetes**

CONCLUSIONS: Using data from a limited number of published studies, a
practical aid was developed to optimize use of the GHb and A1C
concentrations for estimating the absolute risk of a congenital anomaly
in the offspring of women with prepregnancy diabetes.

Guerin A et al Use of maternal GHb concentration to estimate the risk of
congenital anomalies in the offspring of women with prepregnancy
diabetes.

[Diabetes Care.  2007;
30(7):1920-5](http://www.medscape.com/medline/publicationbrowser/123?pmid=17446531) 

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17446531>

**Crohn\'s disease:** **Preterm birth etc greater with azathioprine
/6-mercaptopurine**

CONCLUSIONS: The relative risk of adverse birth outcomes among Crohn\'s
disease women varied by type of drugs prescribed during pregnancy. The
risk of preterm birth and congenital abnormalities was greater when
(AZA)/6-mercaptopurine (6-MP) was prescribed, even after adjusting for
confounders. However, further information is needed to determine whether
the associations are causal

Nørgård B et alTherapeutic drug use in women with Crohn\'s disease and
birth outcomes: a Danish nationwide cohort study. [Am J Gastroenterol.
 2007;
102(7):1406-13](http://www.medscape.com/medline/publicationbrowser/123?pmid=17437503)

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17437503>

**Magnesium sulphate for women at risk of preterm birth for
neuroprotection of the fetus**

AUTHORS\' CONCLUSIONS: The role for antenatal magnesium sulphate therapy
as a neuroprotective agent for the preterm fetus is not yet established.
Given the possible beneficial effects of magnesium sulphate on gross
motor function in early childhood, outcomes later in childhood should be
evaluated to determine the presence or absence of later potentially
important neurologic effects, particularly on motor or cognitive
function. Further information will be available from one of the studies
where outcomes are being evaluated again at eight to nine years of age,
and from another trial currently in progress.

Doyle L et al Magnesium sulphate for women at risk of preterm birth for
neuroprotection of the fetus. [Cochrane Database Syst Rev.  2007;
(3):CD004661](http://www.medscape.com/medline/publicationbrowser/123?pmid=17636771)

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17636771>

**Lung-to-head ratio predicts survival in fetuses with left congenital
diaphragmatic hernia**

CONCLUSION: A significant positive linear relationship exists between
lung-to-head ratio (LHR) and gestational age (GA) at the time of
measurement, such that LHR reliably predicts postnatal survival in
fetuses with left congenital diaphragmatic hernia at 24-34 weeks of
gestation and less reliable at 20-24 weeks. However, given the
limitations of a retrospective, cross-sectional study, further
prospective longitudinal studies that will investigate the change of LHR
with GA and its association with fetal outcome are necessary.

Yang SH et al Reliability of the lung-to-head ratio as a predictor of
outcome in fetuses with isolated left congenital diaphragmatic hernia at
gestation outside 24-26 weeks. [Am J Obstet Gynecol.  2007;
197(1):30.e1-7](http://www.medscape.com/medline/publicationbrowser/123?pmid=17618746) 

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17618746>

#### Primary Care Discussion Forum Ann Bullock, Cherokee, NC {#primary-care-discussion-forum-ann-bullock-cherokee-nc .Style-Heading-4-+-Arial-14-pt-Underline}

**Chronic Kidney Disease: CKD is Part of Primary Care**!

Moderator: Andrew Narva, MD

Ongoing now

-   What is the burden of CKD in AI/AN?

-   How should CKD patients be identified and followed?

-   What should we be doing for CKD patients in the primary setting?

-   When should patients be referred?

### 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=26>

Unsubscribe from the Primary Care listserv

<http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=26>

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

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

**Culture, context, and sexual risk among Northern Plains American
Indian Youth**

American Indian adolescents have two to four times the rate of sexually
transmitted diseases (STDs) compared to whites nationally, they shoulder
twice the proportion of AIDS compared to their national counterparts,
and they have a 25% higher level of teen births. Yet little is known
about the contemporary expectations, pressures, and norms that influence
American Indian youth or how those might be shaped by today\'s lived
cultural experiences, which frustrates attempts to mitigate the apparent
disparity in sexual health. This paper used data from focus groups,
in-depth interviews, and surveys with American Indian adolescents and
young male and female adults from a Northern Plains tribe to
contextualize sexual risk (and avoidance). Placing the findings within
an adapted indigenist stress-coping framework, we found that youth faced
intense pressures for early sex, often associated with substance use.
Condoms were not associated with stigma, yet few seemed to value their
importance for disease prevention. Youth encountered few economic or
social recriminations for a teen birth. As such, cultural influences are
important to American Indian sexual health and could be a key part of
prevention strategies.

Kaufman CE et al Culture, context, and sexual risk among Northern Plains
American Indian Youth Social Science & Medicine. 64(10):2152-64, 2007
May

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17379373>

 

**Perceptions of Sexual Assertiveness among Adolescent Girls:
Initiation, Refusal, and Use of Protective Behaviors**

Conclusions:  Most of these girls perceived themselves as sexually
assertive. Given that sexual experience, not relationship factors, were
related to perceptions of sexual assertiveness, the design of counseling
messages should incorporate sexual experience. These messages should
find effective ways to help girls both to communicate their sexual
desires and to enhance their ability to protect themselves.

Auslander BA et al Perceptions of Sexual Assertiveness among Adolescent
Girls: Initiation, Refusal, and Use of Protective Behaviors Journal Of
Pediatric And Adolescent Gynecology, Volume 20, Issue 3, Pages 157-162
(June 2007)

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17561183>

**Sexually Transmitted Infections in Preadolescent Children**

Pediatric nurse practitioners may be called on to conduct an assessment
for sexual abuse of a young child. Depending on the type of sexual
contact, a decision may have to be made to obtain cultures for sexually
transmitted infections (STIs). Recognizing the symptoms of STIs in
preadolescent children, along with having knowledge of the modes of
transmission, diagnostics, and treatment, are part of the clinical
decision. The impact of STI in preadolescent children has physical and
emotional consequences for the child and family, along with legal
consequences for an accused perpetrator. Knowledge about types of sexual
contact that necessitate STI cultures, incubation periods, and
symptomatology is essential. Accurate techniques and appropriate
selection of culture materials are necessary. Proper positioning of the
child for obtaining cultures can decrease the potential for discomfort
during the examination. Gonorrhea, Chlamydia trachomatis, herpes simplex
virus, human papillomavirus virus, syphilis, Trichomonas vaginalis,
hepatitis B, and HIV are reviewed.  

Lewin LC. Sexually Transmitted Infections in Preadolescent Children
Journal of Pediatric Health Care, Volume 21, Issue 3, May-June 2007,
Pages 153-161

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17478304>

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

#### Screening for Chlamydial Infection: USPSTF Recommendation Statements {#screening-for-chlamydial-infection-uspstf-recommendation-statements-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### The USPSTF recommends screening for chlamydial infection for all sexually active nonpregnant young women age 24 years or younger and older nonpregnant women who are at increased risk. This is a grade A recommendation.  {#the-uspstf-recommends-screening-for-chlamydial-infection-for-all-sexually-active-nonpregnant-young-women-age-24-years-or-younger-and-older-nonpregnant-women-who-are-at-increased-risk.-this-is-a-grade-a-recommendation. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### The USPSTF recommends screening for chlamydial infection for all pregnant women age 24 years or younger and for older pregnant women who are at increased risk.  {#the-uspstf-recommends-screening-for-chlamydial-infection-for-all-pregnant-women-age-24-years-or-younger-and-for-older-pregnant-women-who-are-at-increased-risk. .Style-Heading-4-+-Arial-14-pt-Underline}

#### This is a grade B recommendation.  {#this-is-a-grade-b-recommendation. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### The USPSTF recommends against routinely screening for chlamydial infection for women age 25 years or older, regardless of whether they are pregnant, if they are not at increased risk. {#the-uspstf-recommends-against-routinely-screening-for-chlamydial-infection-for-women-age-25-years-or-older-regardless-of-whether-they-are-pregnant-if-they-are-not-at-increased-risk. .Style-Heading-4-+-Arial-14-pt-Underline}

#### This is a grade C recommendation.  {#this-is-a-grade-c-recommendation. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for chlamydial infection for men.  {#the-uspstf-concludes-that-the-current-evidence-is-insufficient-to-assess-the-balance-of-benefits-and-harms-of-screening-for-chlamydial-infection-for-men. .Style-Heading-4-+-Arial-14-pt-Underline}

#### This is an I statement. {#this-is-an-i-statement. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ahrq.gov/clinic/uspstf07/chlamydia/chlamydiars.pdf**](http://www.ahrq.gov/clinic/uspstf07/chlamydia/chlamydiars.pdf) {#httpwww.ahrq.govclinicuspstf07chlamydiachlamydiars.pdf .Style-Heading-4-+-Arial-14-pt-Underline}

# Home screening for sexually transmitted diseases in high-risk young women: RCT

Results: Of 197 women in the intervention group, 140 (71%) returned at
least one home test and 25 of 249 (10%) home tests were positive. Women
who received home screening tests completed significantly more STD tests
overall (1.94 vs 1.41 tests per woman-year, p\<0.001) and more STD tests
in the absence of symptoms (1.18 vs 0.75 tests per woman-year,
p\<0.001). More women in the intervention group completed at least one
test when asymptomatic (162 (82.2%) vs 117 (61.3%), p\<0.001). The
intervention was most effective among women recruited outside medical
clinics. There was no significant difference in the overall rate of STDs
detected.

Conclusions: Home screening significantly increased the utilisation of
chlamydia and gonorrhoea testing in this sample of high-risk young
women, and thus represents a feasible strategy to facilitate STD testing
in young women.

# Cook R et al Home screening for sexually transmitted diseases in high-risk young women: randomised controlled trial Sexually Transmitted Infections July  2007; Vol 83: p.  286-291. 

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17301105>

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

**Defining Virginity and Abstinence: Adolescents\' Interpretations of
Sexual Behaviors**\
The authors of the current study set out to examine adolescent
conceptualizations of virginity and abstinence. They further sought to
learn whether differences in youths\' definitions of these terms varied
by age, gender, ethnicity, and sexual experience.\
\
The researchers conducted a series of logistic regressions to study
whether gender, age, ethnicity, and sexual experience predicted whether
an individual was still a virgin after taking part in genital touching,
oral sex, anal sex or vaginal sex.\
\
The results indicated that youths\' concept of loss of virginity was
linked primarily with vaginal and anal intercourse, while a greater
proportion of respondents attributed a loss of abstinence to other
behaviors, such as genital touching and oral sex. Sexual experience was
the strongest predictor of how the adolescents defined virginity and
abstinence.\
\
The fact that significant differences in youths\' definitions of
abstinence and virginity existed \"suggests that additional attention is
needed to ensure a common understanding of these terms to achieve
successful sexual education and prevention programs,\" the authors
concluded.

Bersamin M et al Defining Virginity and Abstinence: Adolescents\'
Interpretations of Sexual Behaviors Journal of Adolescent Health Vol.
41; No. 2: P. 182-188    (08..07)

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17659223>

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

#### Barbara Stillwater Alaska State Diabetes Program  {#barbara-stillwater-alaska-state-diabetes-program .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### **Call for re-evaluation of gestational diabetes diagnosis and treatment criteria.** {#call-for-re-evaluation-of-gestational-diabetes-diagnosis-and-treatment-criteria. .Style-Heading-4-+-Arial-14-pt-Underline}

#### As heard at the 2007 Native Women's Health and MCH meeting..... {#as-heard-at-the-2007-native-womens-health-and-mch-meeting.. .Style-Heading-4-+-Arial-14-pt-Underline}

The following was discussed as part of Donald Coustan's comments on
diabetes in pregnancy....

More pregnant women and their infants may be at risk for adverse
outcomes associated with gestational diabetes than previously thought,
according to results from the Hyperglycemia and Adverse Pregnancy
Outcome, or HAPO, study presented at the American Diabetes Association
67th Annual Scientific Sessions.

"We found that the risk for having a large baby, a first-time cesarean
delivery, low blood glucose levels in the newborn requiring treatment
and high insulin levels in the baby that may signal problems ahead all
increased as blood glucose levels during pregnancy increased," Boyd E.
Metzger, MD, professor of medicine, division of endocrinology,
Northwestern University, Feinberg School of Medicine, Chicago, said in a
press release.

This relationship persisted across the entire range of blood glucose
levels examined in 23,325 pregnant women.\
The HAPO study was an international, prospective analysis that took
place at 15 centers in nine countries over seven years. At 28 weeks, the
researchers acquired three blood samples from each pregnant woman: a
morning fasting blood glucose, an oral glucose tolerance test with one
sample taken one hour after drinking 75 g of glucose and then another
sample taken one hour later.

At delivery, the researchers measured cord blood for serum C-peptide and
plasma glucose. One and two hours after birth; they measured neonatal
plasma glucose.

The study was blinded, except when values exceeded predefined cutoff
points and the pregnant women required treatment. In these cases, the
women were removed from the study and treated.

Results from the fasting blood glucose test ranged from 75 mg/dL to 105
mg/dL. The chance of the infant having macrosomia increased four to six
times the spread from the lowest to highest blood glucose results seen
in the study. Additionally, the chance of a high insulin level at
delivery increased by as much as 10 times the range of the mother's
levels. About 5% of women with the lowest fasting plasma glucose levels
(\<75 mg/dL) gave birth to infants with macrosomia. Similarly, 27% of
women who had the highest fasting levels (\>100 mg/dL) had children with
macrosomia (OR=6.6; 95% CI, 4.6-9.6).\
Increased blood glucose also signaled a greater likelihood that the
infant would be above the 90th percentile for total skinfolds (mothers
with lowest glucose levels, 5.4%, vs. highest, 28%; OR=1.52; 95% CI,
1.4-1.59).\
The researchers concluded that maternal glucose is strongly associated
with fetal adiposity. Infants of women with the highest glucose levels
were 10 times more likely to be born with high insulin levels. The same
infants were about five times more likely to have hypoglycemia.

"Low blood glucose levels in a newborn that require treatment are
thought to be a consequence of exposure to higher than normal blood
glucose levels in the mother, leading to a more difficult transition
from the womb to surviving independently --- a classical medical problem
in newborns of mothers with known diabetes," Metzger said.

Many problems that infants develop are a result of high insulin levels.
Hopefully, current and future research will determine which problems are
related to this condition, Metzger said. HAPO researchers cannot
independently determine exactly where along the range of blood glucose
the effects of higher levels are clinically important or which should be
considered abnormal values. Ultimately, the decision concerning
application of the study results requires the collective input from the
broader medical community, according to Metzger.

"It is probable that the level of maternal blood glucose at which a
diagnosis of gestational diabetes is made will soon be lowered based on
the findings of this study," he said.

There are no current guidelines for physicians to make a diagnosis of
gestational diabetes related to fetal outcomes. Metzger recommended a
consensus translation for diagnostic recommendations. A consensus group
is scheduled to meet in June 2008.

Metzger BE. Hyperglycemia and Adverse Pregnancy Outcome (HAPO)
highlights. Presented at: the American Diabetes Association 67th Annual
Scientific Sessions; June 22-26, 2007; Chicago.

American Diabetes Association Press Release

<http://www.diabetes.org/uedocuments/pr-fetus-risk-lower-glucose-062207.pdf>

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

#### Children whose mothers are overweight: Higher levels of body fat themselves at age nine {#children-whose-mothers-are-overweight-higher-levels-of-body-fat-themselves-at-age-nine-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Conclusions: Mothers with a higher pre-pregnant body mass index or a larger mid-upper arm circumference during pregnancy tend to have children with greater adiposity at age nine. The extent to which this is attributable to genetic factors, the influence of maternal lifestyle on that of her child, or maternal adiposity acting specifically during pregnancy on the child\'s fat mass cannot be determined in this study. {#conclusions-mothers-with-a-higher-pre-pregnant-body-mass-index-or-a-larger-mid-upper-arm-circumference-during-pregnancy-tend-to-have-children-with-greater-adiposity-at-age-nine.-the-extent-to-which-this-is-attributable-to-genetic-factors-the-influence-of-maternal-lifestyle-on-that-of-her-child-or-maternal-adiposity-acting-specifically-during-pregnancy-on-the-childs-fat-mass-cannot-be-determined-in-this-study. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Gale CR](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Gale CR"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus) et al Maternal Size in Pregnancy and Body Composition in Children. [J Clin Endocrinol Metab.](javascript:AL_get(this, 'jour', 'J Clin Endocrinol Metab.');) 2007 Aug 7 {#gale-cr-et-al-maternal-size-in-pregnancy-and-body-composition-in-children.-j-clin-endocrinol-metab.-2007-aug-7 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17684051**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17684051) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch17684051 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Women less likely than men to change habits that increase
heart-disease risk**

Smoking, eating fattening foods and not getting enough exercise are all
lifestyle habits that can lead to poor health and cardiovascular disease
-- more so if you have a family history. But researchers at UT
Southwestern Medical Center have found that women don't change these
habits as often as men, even when they have relatives with heart
disease.

#### CONCLUSIONS: Despite a stronger association with CVD risk factors and atherosclerosis prevalence with FHMI among young women compared with men, young women with FHMI demonstrated less CVD risk awareness and worse lifestyle choices. Family history of premature MI may be an especially useful risk assessment tool in young women, and greater efforts are needed to promote CVD risk awareness among young women with FHMI. {#conclusions-despite-a-stronger-association-with-cvd-risk-factors-and-atherosclerosis-prevalence-with-fhmi-among-young-women-compared-with-men-young-women-with-fhmi-demonstrated-less-cvd-risk-awareness-and-worse-lifestyle-choices.-family-history-of-premature-mi-may-be-an-especially-useful-risk-assessment-tool-in-young-women-and-greater-efforts-are-needed-to-promote-cvd-risk-awareness-among-young-women-with-fhmi. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Patel MJ](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Patel MJ"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus) et al Implications of family history of myocardial infarction in young women [Am Heart J.](javascript:AL_get(this, 'jour', 'Am Heart J.');) 2007 Sep;154(3):454-60 {#patel-mj-et-al-implications-of-family-history-of-myocardial-infarction-in-young-women-am-heart-j.-2007-sep1543454-60 .Style-Heading-4-+-Arial-14-pt-Underline}

#### <http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17719289> {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch17719289 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Maternal Diabetes Depletes Fetal Iron Stores {#maternal-diabetes-depletes-fetal-iron-stores-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Newborn infants of mothers with type 2 diabetes are prone to reduced iron levels secondary to increased erythropoiesis in utero {#newborn-infants-of-mothers-with-type-2-diabetes-are-prone-to-reduced-iron-levels-secondary-to-increased-erythropoiesis-in-utero .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSIONS: Maternal diabetes causes depletion of fetal iron stores and is associated with higher fetal iron demands as indicated by higher STfR level and TfR-F index in cord blood. {#conclusions-maternal-diabetes-causes-depletion-of-fetal-iron-stores-and-is-associated-with-higher-fetal-iron-demands-as-indicated-by-higher-stfr-level-and-tfr-f-index-in-cord-blood. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Maria Verner A](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Maria Verner A"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus) et al Influence of maternal diabetes mellitus on fetal iron status. [Arch Dis Child Fetal Neonatal Ed.](javascript:AL_get(this, 'jour', 'Arch Dis Child Fetal Neonatal Ed.');) 2007 Sep;92(5):F399-401 {#maria-verner-a-et-al-influence-of-maternal-diabetes-mellitus-on-fetal-iron-status.-arch-dis-child-fetal-neonatal-ed.-2007-sep925f399-401 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17095546**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17095546) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch17095546 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Gestational diabetes mellitus may increase risk of developing pancreatic cancer {#gestational-diabetes-mellitus-may-increase-risk-of-developing-pancreatic-cancer-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: We conclude that gestational diabetes is strongly related to the risk of cancer of the pancreas in women in this population and can precede its diagnosis by many years. {#conclusion-we-conclude-that-gestational-diabetes-is-strongly-related-to-the-risk-of-cancer-of-the-pancreas-in-women-in-this-population-and-can-precede-its-diagnosis-by-many-years. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Perrin MC](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Perrin MC"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus), et al Gestational diabetes as a risk factor for pancreatic cancer: A prospective cohort study [BMC Med.](javascript:AL_get(this, 'jour', 'BMC Med.');) 2007 Aug 16;5(1):25 {#perrin-mc-et-al-gestational-diabetes-as-a-risk-factor-for-pancreatic-cancer-a-prospective-cohort-study-bmc-med.-2007-aug-165125 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17705823**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17705823) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch17705823 .Style-Heading-4-+-Arial-14-pt-Underline}

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

####  {#section-45 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-46 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-47 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-48 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-49 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-50 .Style-Heading-4-+-Arial-14-pt-Underline .unnumbered}

#### Women's Health Headlines, Carolyn Aoyama, HQE {#womens-health-headlines-carolyn-aoyama-hqe .Style-Heading-4-+-Arial-14-pt-Underline}

Ovarian Cancer: Pinn Point on Women's Health

The Office of Research on Women's Health (ORWH) is broadcasting the
fifth in a series of podcasts, "Pinn Point on Women's Health," hosted by
Dr. Vivian W. Pinn, Associate Director for Research on Women's Health
and the Director of the Office of Research on Women's Health. The
monthly podcast discusses the latest news in women's health research and
includes conversations with guests on a variety of subjects. In this
episode, Dr. Pinn discusses ovarian cancer, the leading cause of
gynecological cancer death, with Dr. Edward L. Trimble, Head,
Gynecologic Cancer Therapeutics and Quality of Cancer Care Therapeutics,
Clinical Investigation Branch, Cancer Therapy Evaluation Program,
Division of Cancer Treatment and Diagnosis, National Cancer Institute.

"September is National Ovarian Cancer month and being aware of the
subtle symptoms of ovarian cancer is an important step towards early
diagnosis," emphasized Dr. Trimble. "Sharing information with your
physician about a family history of ovarian cancer, and getting a
physical exam and pelvic ultrasound and blood tests, if necessary, are
all important in recognizing ovarian cancer in its earliest and most
treatable stage."

"Podcasting" is a relatively new method of distributing audio and video
information via the Internet to iPods and other portable media players
on demand, so that it can be listened to at the user's convenience. The
main benefit of podcasting is that listeners can sync content to their
media player and take it with them to listen whenever they want to.
Because podcasts are typically saved in MP3 format, they can also be
listened to on nearly any computer.

To listen to Dr. Pinn's podcast, visit the ORWH homepage at
<http://orwh.od.nih.gov/> and click on Podcast 5: Ovarian Cancer
Symptoms. If you need further assistance on how to use podcasts, go to
<http://www.nih.gov/news/radio/nihpodcast.htm>

For questions, contact Marsha Love at the Office of Research on Women's
Health by calling (301) 496-9472 or e-mailing <lovem@od.nih.gov>.

# Save the dates {#save-the-dates .Style-Style-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5...1}

**Victim Advocates And Tribal Law Enforcement**

-   October 17-18, 2007

-   Tucson, Arizona

-   Domestic Violence Expert Witness Institute

-   [www.swclap.org](http://www.swclap.org/)  

**Second National Summit on Preconception Health and Health Care**

-   October 29-31 2007

-   Oakland, CA

-   CDC and March of Dimes

-   <http://www.marchofdimes.com/california/4947_24789.asp>

**2007 National HIV Prevention Conference**

-   December 2-5, 2007

-   Atlanta, Georgia

-   Center for Disease Control and Prevention

-   <http://www.2007nhpc.org/conferenceinfo.asp>

# What's new on the ITU MCH web pages? {#whats-new-on-the-itu-mch-web-pages .Style-Style-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5...1}

**New Breastfeeding Headlines Box: The** **Latest in Breastfeeding
Updates**

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

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-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5...1}

#### The September 2007 OB/GYN CCC Corner is available at: {#the-september-2007-obgyn-ccc-corner-is-available-at .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0907.cfm**](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0907.cfm) {#httpwww.ihs.govmedicalprogramsmchmobgyn0907.cfm .Style-Heading-4-+-Arial-14-pt-Underline}

####  Abstract of the Month page 6 {#abstract-of-the-month-page-6 .Style-Heading-4-+-Arial-14-pt-Underline}

## Women\'s greater risk of dying after surgery: Transfusion-related immunosuppression

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

Mike Engel

#### The spread of obesity in a large social network over 32 years {#the-spread-of-obesity-in-a-large-social-network-over-32-years .Style-Heading-4-+-Arial-14-pt-Underline}

Scott Giberson

2007 National HIV Prevention Conference

**Elaine Locke**

### 2008-09 Packer Fellowships: Deadline Extended

**Shannon Myers**

2008 APN/PA conference is already being planned. Any ideas?

**Chuck North**

Ann Bullock is the new Chief Clinical Consultant for Family Medicine

**Robert Pittman**

Questions about DEA or controlled substance policy

**Ros Singleton**

Immunization errors in Tdap and DTaP vaccine administration: ALERT
-VACCINE UPDATE

#### Hot Topics {#hot-topics-2 .Style-Heading-4-+-Arial-14-pt-Underline}

##### Obstetrics page 10

-Low-dose aspirin has benefits when used for prevention of pre-eclampsia

-Oral Antidiabetic Agents in Pregnancy and Lactation: A Paradigm Shift

-Preventive Approach to Cutting Cesarean Delivery Rates Appears Feasible

-No advantage to bulking agent after primary repair of obstetric anal
sphincter injury

-Prepregnancy obesity, overweight raise risk of birth defects

...and more

**Gynecology page 13**

-Human papillomavirus, vaccines and women\'s health: questions and
cautions

-HPV, Vaccines, and Gender: Policy Considerations

-Liquid prep no more accurate than conventional cytology, RCT

-Laparoscopically guided minilaparotomy reduces intraperitoneal spillage

-Quadrivalent HPV Recombinant Vaccine (Gardasil) for the Prevention of
Cervical Cancer

**Child Health page 14**

-Educate parents about new pre-adolescent vaccine recommendations

-Fact sheet focus on adolescent HPV vaccination issues and opportunities

-Tobacco Smoke Exposure During Pregnancy Increases Blood Pressure in
Infants 

-Body composition, physical activity and insulin sensitivity in
adolescents

-Updated AAP Guidelines on Newborn Screening and Tx for Congenital
Hypothyroidism

**Chronic Illness and Disease page 15**

-Exposing the Great Bottled Water Scam

# -Soda consumption linked with metabolic syndrome 

-Antiretroviral Prophylaxis for Occupational Exposure to HIV

-Does Consuming Red Meat Increase Risk of Breast Cancer?

-AHA Releases Statement on Physical Activity Interventions

...and more

#### Features page 19 {#features-page-19 .Style-Heading-4-+-Arial-14-pt-Underline}

American College of Obstetricians and Gynecologists

-Prevention of Deep Vein Thrombosis and Pulmonary Embolism

-Sexual Misconduct

-Nalbuphine Hydrochloride Use for Intrapartum Analgesia

-Expert Testimony

-Brand Versus Generic Oral Contraceptives

##### American Family Physician

-Screening and Treatment for Sexually Transmitted Infections in
Pregnancy

-Recommendations for Preconception Care

-Turner Syndrome: Diagnosis and Management

-Varenicline (Chantix) for Smoking Cessation

-CDC Publishes Statement on Cough and Cold Medications in Children

...and more

**Agency for Healthcare Research and Quality**

-Women: Stay Healthy at Any Age, Your Checklist for Health

-Today\'s teen smokers more likely to engage in risky behaviors than
teens in the 1990s

-Inadequate communication of mammogram results may prevent benefits from
screening

-Prophylactic antibiotics are more timely if given in the operating room

-Some diabetes drugs offer important advantages, though similar glucose
control

...and more

**Ask a Librarian**

### Prevent Fetal Alcohol Spectrum Disorders: A Toolkit

**Breastfeeding**

-Progress toward achieving Healthy People 2010 objective for
breastfeeding

-Cup feeding not be recommended over bottle feeding as a supplement to
breastfeeding

-Despite the benefits of early breastfeeding, many women find it
difficult and painful

-New IHS Breast feeding Family Support web page: Have pictures to share?

-What to do when Mom says, "My newborn likes the bottle better."

**CCC Corner Digest**

\-[Within the Hidden Epidemic: STDs and HIV/AIDS Among
AI/AN](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_AOM.cfm)

\-[American Indian / Alaska Native population has the shortest timeline
HIV to
AIDS](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Coll.cfm)

\-[VBAC: Smaller attributable risk than previously
reported](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_HT.cfm%23ob)

\-[LEEP doubles risk of preterm delivery: Patients need to be
informed](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_HT.cfm%23gyn)

\-[Physical Activity Alone May Not Reduce Obesity in
Children](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_HT.cfm%23child)

\-[Teratogenicity of SSRIs\--serious concern or much ado about
little?](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_HT.cfm%23chrIll)

\-[Management of Herpes in Pregnancy: Practice
Bulletin](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23acog)

\-[Scopus ™: A New
Database](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23AskLib)

\-[What to do when: Mom says, "My newborn likes the bottle
better."](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23breast)

\-[IHS-ACF DV Project: Conference CD: Patient Education, Safety
Planning,
etc....](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23dv)

\-[Waiting until the menses to start hormonal contraceptives: Needless
Obstacle](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23fp)

\-[Can oral or sublingual misoprostol be used for postpartum
hemorrhage?](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23faq)

\-[Integrated case management software application
release](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23it)

\-[Maternal survival redux: a view from Malawi - Failure of
justice](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23ih)

\-[Who needs liquor stores when parents will
do?](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23alert)

\-[Taking a harder line on blood
transfusions](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23headlines)

\-[Nausea and Vomiting in
Pregnancy](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23mmtour)

\-[Hormone Replacement Therapy Linked to Ovarian
Cancer ](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23menopause)

\-[Midwifery's approach to pre-labor SROM supported by professional
organization's
journal](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23MidWives)

\-[The evolution of management of Actinomyces on a Pap
report](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23navajo)

\-[Health Care Without Harm: Nurses Take
Action](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23nurseCorner)

\-[Preconception Health of Women Delivering Live-Born Infants ---
Oklahoma,
2000--2003](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23okie)

\-[Anemia in Pregnancy: The Common to the Unusual -- including IV
therapy](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23periPicks)

\-[Chronic Renal Disease: How is Primary Care
Effected?](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23pcf)

\-[Updated Screening for Chlamydial Infection Recommendations,
USPSTF](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23std)

\-[(How) can we prevent type 2
diabetes?](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23stillW)

\-[Why do Native American women have the poorest 5-year survival for
breast
cancer?](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm%23wheadlines)

**Domestic Violence**

Sexual assault among American Indian/Alaska Native women

**Elder Care News**

-\'What Older Women Want\' launches new website for doctors and
patients: New Website

-A fall management program improves care and reduces use of physical
restraints

-Certain resident and facility characteristics and medications increase
the risk of fractures

**Family Planning**

#### -Various Implantable Contraceptives Equally Effective in Preventing Pregnancy {#various-implantable-contraceptives-equally-effective-in-preventing-pregnancy .Style-Heading-4-+-Arial-14-pt-Underline}

-Oral Contraceptives Today: Changes, Challenges, Risks, and Benefits

**Featured Website**

# New Online Training Tool Available for Treatment of Adolescents with HIV

**Frequently asked questions**

Moderate morning sickness only partially responding to doxylamine and
pyridoxine

**Indian Child Health Notes**

-First prophylaxis for infective endocarditis has been written using
evidenced based guidelines. The difference is significant.

-RPMS Immunization Package: Version 8.2 coming this summer

-Substance abuse in Native American communities

**Information Technology**

-Save 750 mega watts/hour per year: It is easy

-iCare Training

International Health

Sex, Soap & Social Change - The Sabido Methodology

Arsenic exposure during pregnancy with fetal loss and infant death in
Bangladesh

#### MCH Alert

-Preconception brochure released

-School based programs decrease rates of violence among adolescents

#### MCH Headlines

-Motor vehicle restraint use in American Indian children: Meaningful
interventions

-Toolkit Supports Efforts in Native Communities to Prevent FAS Disorders

-Sister Study seeks more Native women 

-One size doesn\'t fit all: Helmet Safety Poster

-Get Your Head in the Game

...and more

#### Medical Mystery Tour

#### Nausea and Vomiting in Pregnancy {#nausea-and-vomiting-in-pregnancy .Style-Heading-4-+-Arial-14-pt-Underline}

#### Medscape

######### -HPV-16/18 Vaccination Should Not Be Used to Treat Prevalent Infections 

-Overactive Bladder in a Menopausal Woman With Complicating Conditions

######### -[Management of Depression and Premenstrual Dysphoria in a Woman Planning Pregnancy](http://mp.medscape.com/cgi-bin1/DM/y/hBVwo0Ou5N60Dzc0Imkv0Gq)

-Management of Premenstrual Dysphoric Disorder Throughout the Ages

\-[Premenstrual Syndrome/Premenstrual Dysphoric Disorder Treatment: Oral
Contraceptives](http://mp.medscape.com/cgi-bin1/DM/y/hBUaW0Ou5N60Dzc0Imkv0G4)

**Menopause Management**

-Study Supports HRT Use for Short Term, but Little Benefit in Older
Women

-Hormone Therapy Safer in Younger Women? A Best Evidence Review

-Caffeine Reduces Cognitive Decline in Women

-Treatment Options for Insomnia

-NAMS Position Statement on Estrogen and Progestogen in Postmenopausal
Women

...and more

**Midwives Corner**

-Group prenatal care reduces preterm births and increases breastfeeding
initiation: RCT

-Skin-to-skin care with the father after cesarean: Effect on crying and
prefeeding behavior

-Midwifery's approach to pre-labor SROM supported by professional
organization's journal

**Navajo News**

Evaluation of the pregnant patient for non-obstetric surgery

**Nurses Corner**

-Nursing education scholarship opportunities

#### -Behavioral and Social Sciences Research: National Assoc. of Clinical Nurse Specialists {#behavioral-and-social-sciences-research-national-assoc.-of-clinical-nurse-specialists .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Companion Animals and Human Health Risk: Animal Bites and Rabies {#companion-animals-and-human-health-risk-animal-bites-and-rabies .Style-Heading-4-+-Arial-14-pt-Underline}

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

-STD Treatment Guidelines - Personal Digital Assistant Version

-Perinatal Group B Streptococcal Disease After Universal Screening
Recommendations

**Oklahoma Perspective**

Preconception Health of Women Delivering Live-Born Infants --- Oklahoma,
2000--2003

Osteoporosis

-Lifestyle Intervention and BMD in Adolescent Girls

# -Decision Rules Useful for Selecting Women for Bone Mineral Density Testing

-SSRI Use in Older Women Linked to Accelerated Hip Bone Loss

-Effects of the phytoestrogen genistein on bone metabolism in
osteopenia: RCT

Patient Education

-Women\'s Health Booklets

#### -STIs in Pregnancy: Protecting Yourself and Your Baby {#stis-in-pregnancy-protecting-yourself-and-your-baby .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Monitoring Your Blood Pressure at Home {#monitoring-your-blood-pressure-at-home .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Monitoring Your Blood Sugar at Home {#monitoring-your-blood-sugar-at-home .Style-Heading-4-+-Arial-14-pt-Underline}

-Insomnia: What You Should Know

...and more

Perinatology Picks

-Nausea and Vomiting of Pregnancy

-Miscarriage risk from amniocentesis performed for abnormal maternal
serum screening

-Evidence base of predictive markers and therapies (eg, progesterone)
for preterm birth

-Noninherited risk factors and congenital cardiovascular defects: AHA /
AAP statement

-1^st^ trimester US of the nasal bone may improve Down syndrome
screening

...and more

Primary Care Discussion Forum

Chronic Kidney Disease: CKD is Part of Primary Care! Starts September 4,
2007

STD Corner

-Culture, context, and sexual risk among Northern Plains American Indian
Youth

-Sexual Assertiveness among Adolescent Girls: Initiation, Refusal, and
Protective Behaviors

-Sexually Transmitted Infections in Preadolescent Children

#### -Screening for Chlamydial Infection: USPSTF Recommendation Statements {#screening-for-chlamydial-infection-uspstf-recommendation-statements-2 .Style-Heading-4-+-Arial-14-pt-Underline}

# -Home screening for sexually transmitted diseases in high-risk young women: RCT

...and more

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

-Within eight years, 75% of adults will be obese or overweight

-Regular and Diet Soft Drinks Linked To Increase In Risk Factors For
Heart Disease

#### -Very Low Birth Weight Is Associated With Impaired Glucose {#very-low-birth-weight-is-associated-with-impaired-glucose .Style-Heading-4-+-Arial-14-pt-Underline}

**Women's Health Headlines**

-APN scope of practice: colonoscopy?

-Templates for Protocols and Procedures for Maternity Services 2nd
Edition

###### Save the Dates: Upcoming events of interest page 68

#### What's new on the ITU MCH web pages page 68

New Breastfeeding Family Support webpage, Indian Health

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/F/MCHdiscuss.cfm>

Medical Mystery Tour Answers

1.) F, 2.) F, 3.) T, 4.) T, 5.) F, 6.) F, 7.) F, 8.) F

Extra Credit:

All of the above

9/18/07