News flash

Good time to sign up (limited scholarships available)

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

-   September 17 -- 21, 2006

-   Denver, CO

Contact [**YMalloy@acog.org**](mailto:YMalloy@acog.org)

![](media/image1.png){width="5.990277777777778in"
height="1.3069444444444445in"}

 

OB/GYN Chief Clinical Consultant's Corner

Volume 4, No. 6, June 2006

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

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

**VariZIG replaces VZIG: Varicella Prophylaxis for high risk persons
(including pregnancy)**

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

Carolyn Aoyama

Management of Eating Disorders Webcast on July 18, 2006 - Save the Date

National Conference on women, addiction, and recovery

Burt Attico

Injectable Contraception and Skeletal Health: No fractures seen

Donald Clark

What is the rate of preterm birth in Native Americans?

Rich Dickson

#### Protein to Creatinine Ratio in Pre-eclampsia: Is the data preceding the U.S. benchmarks? {#protein-to-creatinine-ratio-in-pre-eclampsia-is-the-data-preceding-the-u.s.-benchmarks .Style-Heading-4-+-Arial-14-pt-Underline}

Steve Heath

#### Risk Management and Medical Liability, 2^nd^ Edition, Indian Health {#risk-management-and-medical-liability-2nd-edition-indian-health .Style-Heading-4-+-Arial-14-pt-Underline}

Sunnah Kim

#### Access to Mental Health Services {#access-to-mental-health-services .Style-Heading-4-+-Arial-14-pt-Underline}

Chris Lamer

#### Tobacco assessment algorithm, Cherokee {#tobacco-assessment-algorithm-cherokee .Style-Heading-4-+-Arial-14-pt-Underline}

Ron Pust

Prenatal setting: Missed opportunity to link tuberculin skin
test--positive and Tx

Ty Reidhead

Towards a better Patient Education webpage for Indian Health

Judy Thierry

-Achievements in Public Health: Reduction in Perinatal Transmission of
HIV Infection

-Safety belts: Single most effective means of preventing death and
serious injury in a crash

-MUST VIEW CHILD safety short video \"UNTIL THEY ARE 4\' 9\" 

-Connected Kids: Safe, Strong, Secure is a new set of resources
developed by VIPP

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

##### Obstetrics page 12

##### -Incontinence not correlated with vaginal delivery

-Serious maternal morbidity increases with increasing number of cesarean
deliveries

-Characteristics of glyburide failures in GDM: EGA at diagnosis, parity,
and fasting glucose

-Improve the systems against maternal mortality from hemorrhage

-High-risk centers have higher rates of cesarean delivery for their low
risk population

and more....

**Gynecology page 15**

-FDA Licenses New HPV Vaccine for Prevention of Cervical Cancer

-Overlap repair of obstetric anal sphincter injury: Decrease in fecal
incontinence

-Criteria should be developed for the use of intraoperative cystoscopy
to detect injuries

-Atypical glandular cell cytology confers a 38% risk of preinvasive
disease or carcinoma

-Cesarean scar ectopic pregnancies are becoming more frequent

and more....

**Child Health page 18**

-Maternal cholestasis is significantly associated with RDS in the
newborn

-Co-occurring maternal conditions and behavior problems in children

-Treatment of Chlamydia trachomatis in Adolescents

-Extremely Low-Birth-Weight Infants Become Normal Adults

-ACIP Updates Recommendations for Prevention of Hepatitis B Virus
Transmission

and more....

**Chronic Illness and Disease page 20**

-Group visits: Promising approach to chronic care management for the
motivated patient

-Depression Relapse in Pregnancy High When Medication Stopped

-Determining Eligibility for Gastric Bypass Surgery

-Metformin lowers cardiovascular risk factors in hyperinsulinemic women
with PCOS

-Nonpharmacologic Strategies for Managing Hypertension

and more....

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

##### American Family Physician

-Toremifene Is Effective Therapy for Mastalgia

-Low-Fat, High-Carbohydrate Diet Does Not Cause Obesity

-Duloxetine Is Effective for Fibromyalgia in Some Women

American College of Obstetricians and Gynecologists

-Use of Hormonal Contraception in Women With Coexisting Medical
Conditions

-Noncontraceptive Uses of the Levonorgestrel Intrauterine System

-Analgesia and Cesarean Delivery Rates

-Tamoxifen and Uterine Cancer

-Patient-Requested Cesarean Update: Cesareans should be performed for
medical reasons

and more....

**Agency for Healthcare Research and Quality**

-AHRQ study finds wrong-site surgery is rare and preventable

-Patient responses to medical errors: Timeliness and quality of the
communication

**Ask a Librarian**

MCH Library launches redesigned web site

**Breastfeeding**

-Early breastfeeding choice, GDM, and BMI

-Intervention to Increase Breastfeeding Rates

-Study hints at link between breastfeeding and intelligence

**CCC Corner Digest**

May 2006 Highlights include

\-[Maternal periodontal disease in early pregnancy:
Small-for-gestational-age
infant](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0506_AOM.cfm)

\-[Improve colorectal cancer screening: Contribute to this
survey](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0506_Coll.cfm)

\-[Counterpoint: Not Yet Time to Use the P:C Ratio for
pre-eclampsia](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0506_HT.cfm#ob)

\-[FDA: Vaccine to Prevent Cervical Cancer Is Safe,
Effective](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0506_HT.cfm#gyn)

\-[Relationship between team sport participation and adolescent
smoking](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0506_HT.cfm#child)

\-[Caring for Patients After Bariatric
Surgery](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0506_HT.cfm#chrIll)

\-[ACOG Recommends First Ob-Gyn Visit in Early
Teens](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0506_Feat.cfm#acog)

-ACOG: [Hepatitis B and Hepatitis C Virus Infections, Committee
Opinion](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0506_Feat.cfm#acog)

\-[31% of Sexually Active U.S. Teenage Girls Become
Pregnant](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0506_Feat.cfm#fp)

\-[Are there any cultural barriers/among Native Americans to becoming
cord blood
donors?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0506_Feat.cfm#faq)

\-[What was the common theme in these 2
cases?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0506_Feat.cfm#mmtour)

\-[Routine use of sweeping of membranes from 38 weeks of pregnancy
onwards](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0506_Feat.cfm#MidWives)

\-[Methamphetamine abuse among women on Navajo (Part 2 of
4)](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0506_Feat.cfm#navajo)

\-[Native American Scholarship Opportunities at the School of
Nursing](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0506_Feat.cfm#nurseCorner)

\-[Female Sexual
Dysfunction](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0506_Feat.cfm#okie)

\-[Factors Associated With Rise in Primary Cesarean Births in the United
States](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0506_Feat.cfm#periPicks)

\-[Adverse Childhood Events: Impact on chronic adult illness / Risk
taking](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0506_Feat.cfm#pcf)

\-[Prediction of Pelvic Inflammatory Disease Among Young, Single,
Sexually Active
Women](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0506_Feat.cfm#std)

\-[Long-term Dietary Intervention May Reduce Risk for Insulin Resistance
in
Children](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0506_Feat.cfm#stillW)

**Domestic Violence**

-Morbidity and Mortality of DV: 4x more common than breast cancer cannot
be ignored

-Physical Dating Violence Among High School Students -- United States,
2003

-50% with female cancers: History of violence correlates with advanced
stage at diagnosis

-Launch of Choose Respect Initiative!

**Elder Care News**

September 1, 2006: Palliative Medicine\'s Role in the Continuity of
Care**\
**

**Family Planning**

-Refusals by pharmacists to dispense emergency contraception: a critique

-Discussion needed: Reasons why women discontinue oral contraception

-Fertility, Contraception, and Fatherhood: 2002 National Survey of
Family

-Levonorgestrel-Releasing Intrauterine System (Mirena) for Contraception

**Featured Website**

GREAT site for Health Promotion Disease Prevention per Candace Jones

**Frequently asked questions**

The Indian Health MCH Frequently Asked Question (FAQ) site

**Indian Child Health Notes - June 2006 Highlights**

-Wrist Fractures in children - All those kids who sawed off their own
casts were right

-Developmental Dyslplasia of the Hip - USPSTF and AAP differ over value
of screening

-Watch out for mumps. It is spreading out of Iowa

-Doug Esposito weighs in on health disparities for urban Indians

**Information Technology**

RPMS Behavioral Health System Patch Release Announcement, June 1, 2006

International Health

-Nothing defines us better than providing service to colleagues less
fortunate than we

-Chlorhexidine: Potential to improve maternal /newborn outcomes -
Developing countries

-Report on Children and Families Displaced by Hurricanes Katrina and
Rita

#### MCH Alert

Association of poverty with overweight among adolescents, 1971 - 2004

#### Medical Mystery Tour

Copious post operative mucous secretions

#### Medscape

**Menopause Management**

Testosterone Treatments: Why, When, and How?

**Midwives Corner**

-Empowering women to find the power of birth is of great value

-Multiparous women with induced labor: Shorter active phase of labor
than spontaneous

-Pushing During Second-Stage Labor Is Matter of Preference

**Navajo News**

Methamphetamine abuse among women on Navajo (Part 3 of 4)

**Nurses Corner**

SANE/SAFE training and capacity

#### 

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

\-[Recommendations to Improve Preconception Health and Health Care -
United States](http://www.cdc.gov/nchs/data/ad/ad368.pdf)

-USPSTF: Recommendations on Screening / Supplementation for Iron
Deficiency Anemia

**Oklahoma Perspective**

Elective Cesarean Delivery

Osteoporosis

Calcium Plus Vitamin D for Fracture Prevention: POEM

Patient Education

#### -Testosterone Therapy: What You Should Know {#testosterone-therapy-what-you-should-know .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Microscopic Hematuria: What You Should Know {#microscopic-hematuria-what-you-should-know .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Is a Low-Carbohydrate Diet Right for Me? {#is-a-low-carbohydrate-diet-right-for-me .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### -Opioid Addiction: What You Should Know {#opioid-addiction-what-you-should-know .Style-Heading-4-+-Arial-14-pt-Underline}

and more....

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

Perinatology Picks

-Cesarean delivery rate: Continues to increase without improving
population outcomes

-Tocolysis after 32 weeks gestation does not reduce neonatal hospital
stay

-Vaginal delivery of singleton fetuses in breech presentation at term
remains a safe option

-Glyburide and insulin: Equally efficient for treatment of GDM in all
levels of severity

-Improve patient safety, prevent medical errors and resolve the
professional liability crisis

and more....

Primary Care Discussion Forum

September 1, 2006: Palliative Medicine\'s Role in the Continuity of Care

STD Corner

-HIV Testing and Additional Analysis of National Survey on HIV/AIDS

-Teenagers with chlamydial receive antibiotics, but few receive other
recommended care

-Social Networks Testing: Strategy for Identifying Persons with
Undiagnosed HIV Infection

-Diagnosis and Treatment of Neisseria gonorrhoeae Infections

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

Women Who Don\'t Snooze Enough Gain Weight

###### Save the Dates: Upcoming events of interest page 49

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

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

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

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

**Varicella Prophylaxis for high risk persons (including pregnancy):
VariZIG replaces VZIG**

On October 27, 2004, the Advisory Committee on Immunization Practices
(ACIP) was informed by the only U.S.-licensed manufacturer of varicella
zoster immune globulin (VZIG) (Massachusetts Public Health Biologic
Laboratories, Boston, Massachusetts) that the company had discontinued
production of VZIG. The supply of the licensed VZIG product is now
nearly depleted. In February 2006, an investigational (not licensed)
VZIG product, VariZIG™ (Cangene Corporation, Winnipeg, Canada) became
available under an investigational new drug application (IND) submitted
to the Food and Drug Administration (FDA).\* This product can be
requested from the sole authorized U.S. distributor, FFF Enterprises
(Temecula, California), for patients who have been exposed to varicella
and who are at increased risk for severe disease and complications.

The investigational VariZIG, similar to licensed VZIG, is a purified
human immune globulin preparation made from plasma containing high
levels of anti-varicella antibodies (immunoglobulin class G \[IgG\]).
Unlike the previous product, the investigational product is lyophilized.
When properly reconstituted, VariZIG is approximately a 5% solution of
IgG that can be administered intramuscularly. As with any product used

**Indications for Use of Investigational VariZIG**

Patients without evidence of immunity to varicella (i.e., without
history of disease or age-appropriate vaccination) who are at high risk
for severe disease and complications, who have been exposed to
varicella, and from whom informed consent has been obtained, are
eligible to receive the IND application product under an expanded access
protocol. The patient groups recommended by ACIP to receive VariZIG
include the following:

-Pregnant women.

-Immunocompromised patients.

-Neonates whose mothers have signs and symptoms of varicella around the
time of delivery (i.e., 5 days before to 2 days after).

-Premature infants born at \>28 weeks of gestation who are exposed
during the neonatal period and whose mothers do not have evidence of
immunity.

-Premature infants born at \<28 weeks of gestation or who weigh \<1,000
g at birth and were exposed during the neonatal period, regardless of
maternal history of varicella disease or vaccination.

Varicella vaccine was recommended in 1999 for postexposure prophylaxis
of other persons without evidence of varicella immunity and who have no
contraindications to vaccination
([2](http://www.cdc.gov/mmwr/preview/mmwrhtml/rr4806a1.htm)). The
vaccine should be administered preferably within 96 hours and possibly
up to 120 hours postexposure. If illness occurs, with or without
postexposure vaccination, antiviral treatment (e.g., acyclovir) can be
considered for adolescents and adults.

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

**Varicella Prophylaxis for high risk persons: VariZIG replaces VZIG**

Varicella Zoster Immune Globulin (VZIG) is no longer available. A
similar product, VariZIG™ (Cangene) is available under an
investigational new drug application (IND) with the FDA. VariZIG™ can be
used for patients without evidence of varicella immunity who have been
exposed to chicken pox and are at high risk for severe disease and
complications, including: immunocompromised patients, neonates whose
mothers have chicken pox around the time of deliver, certain premature
infants in the neonatal period, and pregnant women. These groups have
contraindications to Varicella vaccine.

VariZIG must be given within 96 hours of exposure. A protocol under the
IND has been approved by a Central IRB which allows use of VariZIG on a
case by case basis using the Central IRB approval as long as your
institution and local IRB allow that. Providers who identify a patient
can call FFF Enterprises 800-843-7477 for the necessary forms. FFF will
send VariZIG by next day air. This MMWR contains the full VariZIG
information:
<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm55e224a1.htm?s_cid=mm55e224_e>

Rosalyn Singleton MD

Immunization Consultant

Alaska Native Tribal Health Consortium

<ris2@cdc.gov>

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

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

**Management of Eating Disorders Webcast on July 18, 2006 - Save the
Date**

This national webcast will feature presentations based on the April 2006
"Management of Eating Disorders Evidence Report" funded by the Agency
for Healthcare, Research and Quality, National Institutes of Health,
Office of Research on Women's Health & the Health Resources and Services
Administration, in collaboration with Research Triangle Institute
(RTI)-UNC Evidence-Based Practice Center. The registration website
[[www.mchcom.com]{.underline}](../www.mchcom.com) can begin to take
registrants now

#### Abstract for the full report [[http://www.ahrq.gov/clinic/tp/eatdistp.htm]{.underline}](http://www.ahrq.gov/clinic/tp/eatdistp.htm) {#abstract-for-the-full-report-httpwww.ahrq.govclinictpeatdistp.htm .Style-Heading-4-+-Arial-14-pt-Underline}

**National Conference on women, addiction, and recovery**

July 12 -- 14, 2006

Anaheim, CA

News You Can Use brings together so many women's issues and perinatal
exposure issues; discussed inside of research, treatment services and
program evaluation including:

-   gender specific applications,

-   trauma informed systems,

-   eating disorders,

-   justice system issues,

-   tobacco,

-   underage drinking,

-   hiv/aids prevention and testing

-   family treatment models

-   strengthening the treatment continuum and improving continuity of
    care

-   Impact of parental AOD use on children and interventions for
    children.  

<http://conferences.jbs.biz/womensconference/>

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

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

**Injectable Contraception and Skeletal Health: No fractures seen**

[Question]{.underline}

Should it be standard clinical practice to perform baseline bone density
studies in young women starting Depo-Provera and to continue follow-up
studies periodically thereafter?

Maj Joyce Fiedler, MD

Injectable contraception (depot medroxyprogesterone acetate \[DMPA\],
Depo-Provera) is used by approximately 2 million women in the United
States, including 4 million adolescents, and has been associated with
declining rates of unintended pregnancy and abortion in teens.
Contraceptive doses of DMPA suppress ovarian production of estradiol
and, accordingly, lower bone mineral density (BMD) during use. Concern
that long-term use of DMPA might increase future risk of osteoporotic
fractures led the US Food and Drug Administration to add a black box
warning to the package labeling for DMPA in 2004. The warning states
that injectable contraception should be continued for more than 2 years
only if other birth control methods are inadequate and suggests that
dual x-ray absorptiometry (DXA) studies might be used to monitor BMD in
DMPA users.

No studies have found evidence of osteoporosis or fractures in DMPA
users. Cross-sectional studies have found no evidence of reduced BMD or
osteoporosis years after use of DMPA. Cohort studies conducted in the
United States in adolescent and adult women have shown complete recovery
of BMD after discontinuation of DMPA. Supplementation with menopausal
doses of estrogen (eg, conjugated equine estrogen 0.625 mg daily or
transdermal estrogen 0.05 mg patches) during DMPA use prevents any loss
of BMD during DMPA use.

Given the above observations, skeletal health concerns should not
restrict use of DMPA. In very long-term users who may continue use of
DMPA into menopause, supplemental estrogen as described in the previous
paragraph can be considered. I do not believe that routine DXA testing
in premenopausal women who use DMPA is appropriate because it is not
likely to provide clinical benefit.

Kaunitz AM. Depo-Provera\'s Black Box: time to reconsider?
Contraception. 2005;72:165-167

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16102548>

**Donald Clark, Albuquerque**

**What is the rate of preterm birth in Native Americans?**

Native Americans have the second highest rate of preterm birth, as per
Peristats from March of Dimes. During 2001-2003 (average) in the United
States, preterm birth rates were highest for black infants (17.7%),
followed by Native Americans (13.2%), Hispanics (11.6%), whites (11.0%)
and Asians (10.4%).

 

Here is a link to helpful graph from the March of Dimes Perinatal Stats
site

<http://www.marchofdimes.com/peristats/level1.aspx?reg=99&slev=1&top=3&stop=63&obj=1&lev=1&dv=cg>

(I just searched by race and the whole country)

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

The Peristats is a great resource provided the March of Dimes. You can
create your own search by various geographic or other demographic
parameters. Go to the link below create your own queries to see its many
dimensions. <http://www.marchofdimes.com/peristats/default.aspx>

In addition, as the AI/AN population has high rates of tobacco use, the
additional information on periodontal disease may let us to better
sculpt our effort to improve the AI/AN infant, neonatal, and
postneonatal deaths and mortality rates shown below. (Table A)

**Other resources on our MCH web site**

Preterm labor resources, multiple

<http://www.ihs.gov/medicalprograms/mch/M/Pr01.cfm#PretermLabor>

Preterm labor and Preterm Rupture of membranes: CEU/CME module -- or
just a great resource

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

Impact of oral disease on preterm birth

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/oralsystemicMCH7-04.ppt>

Infant Mortality Statistics from the 2003 Period Linked Birth/Infant
Death Data Set

T.J. Mathews, M.S. and Marian F. MacDorman, Ph.D., Division of Vital
Statistics
[[http://www.cdc.gov/nchs]{.underline}](http://www.cdc.gov/nchs)

Data from Guise JM, McDonagh M, Hashima J, et al. [[\
Vaginal birth after cesarean (VBAC). Evidence Report/Technological
Asessment No.
71]{.underline}](http://www.ahrq.gov/clinic/epcsums/vbacsum.htm).\
Rockville (MD): Agency for Healthcare Research and Quality; March 2003.
p. 31 Table 2.

+--------------+--------+--------+------+----------+-----------------+
| National     |        |        |      |          |                 |
| Vital        |        |        |      |          |                 |
| Statistics   |        |        |      |          |                 |
| Reports,     |        |        |      |          |                 |
| Vol. 54, No. |        |        |      |          |                 |
| 16, May 3,   |        |        |      |          |                 |
| 2006         |        |        |      |          |                 |
+--------------+--------+--------+------+----------+-----------------+
| Table A.     |        |        |      |          |                 |
| Infant,      |        |        |      |          |                 |
| neonatal,    |        |        |      |          |                 |
| and          |        |        |      |          |                 |
| postneonatal |        |        |      |          |                 |
| deaths and   |        |        |      |          |                 |
| mortality    |        |        |      |          |                 |
| rates by     |        |        |      |          |                 |
| race and     |        |        |      |          |                 |
| mother:      |        |        |      |          |                 |
| U.S., 2003   |        |        |      |          |                 |
| linked file  |        |        |      |          |                 |
+--------------+--------+--------+------+----------+-----------------+
| Race of      | All    | White  | B    | Am.      | Asian/Pacific   |
| mother       | races  |        | lack | Indian   | Islander        |
|              |        |        |      | \*       |                 |
+--------------+--------+--------+------+----------+-----------------+
| Live births  | 4,0    | 3,2    | 599  | 43,054   | 221,203         |
|              | 90,007 | 25,990 | ,860 |          |                 |
+--------------+--------+--------+------+----------+-----------------+
| **Number of  |        |        |      |          |                 |
| deaths**     |        |        |      |          |                 |
+--------------+--------+--------+------+----------+-----------------+
| Infant       | 27,995 | 18,458 | 8    | 376      | 1,068           |
|              |        |        | ,094 |          |                 |
+--------------+--------+--------+------+----------+-----------------+
| Neonatal     | 18,935 | 12,457 | 5    | 196      | 752             |
|              |        |        | ,530 |          |                 |
+--------------+--------+--------+------+----------+-----------------+
| Postneonatal | 9,060  | 6,000  | 2    | 180      | 316             |
|              |        |        | ,563 |          |                 |
+--------------+--------+--------+------+----------+-----------------+
| **Mortality  |        |        |      |          |                 |
| rate per     |        |        |      |          |                 |
| 1,000 live   |        |        |      |          |                 |
| births**     |        |        |      |          |                 |
+--------------+--------+--------+------+----------+-----------------+
| Infant       | 6.84   | 5.72   | 1    | 8.73     | 4.83            |
|              |        |        | 3.49 |          |                 |
+--------------+--------+--------+------+----------+-----------------+
| Neonatal     | 4.63   | 3.86   | 9.22 | 4.55     | 3.40            |
+--------------+--------+--------+------+----------+-----------------+
| Postneonatal | 2.22   | 1.86   | 4.27 | 4.18     | 1.43            |
+--------------+--------+--------+------+----------+-----------------+
| \* Includes  |        |        |      |          |                 |
| Aleuts and   |        |        |      |          |                 |
| Eskimos      |        |        |      |          |                 |
|              |        |        |      |          |                 |
| NOTES:       |        |        |      |          |                 |
| Infant       |        |        |      |          |                 |
| deaths are   |        |        |      |          |                 |
| weighted so  |        |        |      |          |                 |
| numbers may  |        |        |      |          |                 |
| not exactly  |        |        |      |          |                 |
| add to       |        |        |      |          |                 |
| totals due   |        |        |      |          |                 |
| to rounding. |        |        |      |          |                 |
| Neonatal is  |        |        |      |          |                 |
| less than 28 |        |        |      |          |                 |
| days and     |        |        |      |          |                 |
| postneonatal |        |        |      |          |                 |
| is 28 days   |        |        |      |          |                 |
| to under 1   |        |        |      |          |                 |
| year. Race   |        |        |      |          |                 |
| and Hispanic |        |        |      |          |                 |
| origin are   |        |        |      |          |                 |
| reported     |        |        |      |          |                 |
| separately   |        |        |      |          |                 |
| on birth     |        |        |      |          |                 |
| c            |        |        |      |          |                 |
| ertificates. |        |        |      |          |                 |
| Race         |        |        |      |          |                 |
| categories   |        |        |      |          |                 |
| are          |        |        |      |          |                 |
| consistent   |        |        |      |          |                 |
| with the     |        |        |      |          |                 |
| 1977 Office  |        |        |      |          |                 |
| of           |        |        |      |          |                 |
| Management   |        |        |      |          |                 |
| and Budget   |        |        |      |          |                 |
| standards.   |        |        |      |          |                 |
| In this      |        |        |      |          |                 |
| table all    |        |        |      |          |                 |
| women        |        |        |      |          |                 |
| (including   |        |        |      |          |                 |
| Hispanic     |        |        |      |          |                 |
| women) are   |        |        |      |          |                 |
| classified   |        |        |      |          |                 |
| only         |        |        |      |          |                 |
| according to |        |        |      |          |                 |
| their race.  |        |        |      |          |                 |
| See          |        |        |      |          |                 |
| reference 3. |        |        |      |          |                 |
+--------------+--------+--------+------+----------+-----------------+

#### Rich Dickson, MFM, Tucson {#rich-dickson-mfm-tucson .Style-Heading-4-+-Arial-14-pt-Underline}

#### Protein to Creatinine Ratio in Pre-eclampsia: Is the data preceding the U.S. benchmarks? {#protein-to-creatinine-ratio-in-pre-eclampsia-is-the-data-preceding-the-u.s.-benchmarks-1 .Style-Heading-4-+-Arial-14-pt-Underline}

Here is more follow-up on this topic (see prior postings below)

Some opinions:  We agree with the letter that your colleagues Gahn and
Manske wrote: we are not ready to recommend or work with the P:C ratio.

Some references, conclusions:

This might have all started with Rodriquez-Thompson\'s paper from
Harvard of all places (Use of random urine P:C ratio for diagnosis of
Significant proteinuria during pregnancy: AJOG, 2001,
Oct;185(4):808-811. They had a positive conclusion, used a cut-off of
.19 for high, .14 for \"negative\". This was confirmed by a study in
Thailand in \'03 by Yamasmit (J Med Assoc Thai, 2003 Jan;86(1):69-71.
They found a strong correlation with random urine P:C ratio and
quantification of 24-hr collect in Hospitalized pts.

However in our country: Durnwald found that P;C Ratio does not exclude
adequately the presence of significant proteinuria or predict severe
PIH, and \"should not be used as an alternative to 24-hr total protein
evaluation\". (AJOG, 2003 Sept;189(3):848-52.  Additionally, Hass found
that the Ratio does NOT predict total urine protein reliably in the 2nd
and 3rd trimester, but did in the 1st trimester and post partum period
(J Matern Fetal Neonat Med.2003 Oct;14(4):233-6.

This evidence, along with the fact that proteinuria itself is only one
marker, makes this a moot point to determine if a patient should be
transferred to a higher level of care or not.

So there you go\....

Warm Regards, Rich D

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

#### May CCC Corner - Abstract of the month {#may-ccc-corner---abstract-of-the-month .Style-Heading-4-+-Arial-14-pt-Underline}

#### Protein to Creatinine Ratio in Pre-eclampsia: Is the data preceding the U.S. benchmarks? {#protein-to-creatinine-ratio-in-pre-eclampsia-is-the-data-preceding-the-u.s.-benchmarks-2 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0406_AOM.cfm**](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0406_AOM.cfm) {#httpwww.ihs.govmedicalprogramsmchmobgyn0406_aom.cfm .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### June CCC Corner -- Obstetric Hot Topics {#june-ccc-corner-obstetric-hot-topics .Style-Heading-4-+-Arial-14-pt-Underline}

#### Counterpoint: Not Yet Time to Use the P:C Ratio (Gahn and Manske) {#counterpoint-not-yet-time-to-use-the-pc-ratio-gahn-and-manske .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0506_HT.cfm#ob**](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0506_HT.cfm#ob) {#httpwww.ihs.govmedicalprogramsmchmobgyn0506_ht.cfmob .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Steve Heath, Albuquerque {#steve-heath-albuquerque .Style-Heading-4-+-Arial-14-pt-Underline}

#### Risk Management and Medical Liability, 2^nd^ Edition, Indian Health {#risk-management-and-medical-liability-2nd-edition-indian-health-1 .Style-Heading-4-+-Arial-14-pt-Underline}

The Second Edition of the IHS publication, Risk Management and Medical
Liability, A Manual for Indian Health Service and Tribal Health Care
Professionals, by Stephen W. Heath, MD, MPH has been posted on the IHS
website at the National Council of Chief Clinical Consultants (NC4)
homepage. The button labeled "Credentials/Risk Management" will take you
to Manual site.

#### This current edition of the Manual describes the medical malpractice tort claim process changes that have taken place, updates data on tort claims, describes the IHS role in National Practitioner Data Bank reporting, and provides additional risk management guidance for local programs and health care professionals. It has been posted on the IHS website to allow access to as many individuals as possible. Users are encouraged to print the Manual for hard-copy use, if desired..[**http://www.ihs.gov/NonMedicalPrograms/nc4/Documents/RM2_a.pdf**](http://www.ihs.gov/NonMedicalPrograms/nc4/Documents/RM2_a.pdf) {#this-current-edition-of-the-manual-describes-the-medical-malpractice-tort-claim-process-changes-that-have-taken-place-updates-data-on-tort-claims-describes-the-ihs-role-in-national-practitioner-data-bank-reporting-and-provides-additional-risk-management-guidance-for-local-programs-and-health-care-professionals.-it-has-been-posted-on-the-ihs-website-to-allow-access-to-as-many-individuals-as-possible.-users-are-encouraged-to-print-the-manual-for-hard-copy-use-if-desired..httpwww.ihs.govnonmedicalprogramsnc4documentsrm2_a.pdf .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Sunnah Kim, IH-Special Interest Group, AAP {#sunnah-kim-ih-special-interest-group-aap .Style-Heading-4-+-Arial-14-pt-Underline}

#### Access to Mental Health Services {#access-to-mental-health-services-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Below is the link from the recent IH-SIG and Rural Health SIG listserv discussion on Access to Mental Health Services. In response to many of the comments and concerns, the summary lists a series of 9 possible strategies that could be adopted to address the identified systemic deficiencies regarding mental health services in rural and AI/AN communities. These strategies could be initiated locally, regionally, or nationally by various agencies and groups. {#below-is-the-link-from-the-recent-ih-sig-and-rural-health-sig-listserv-discussion-on-access-to-mental-health-services.-in-response-to-many-of-the-comments-and-concerns-the-summary-lists-a-series-of-9-possible-strategies-that-could-be-adopted-to-address-the-identified-systemic-deficiencies-regarding-mental-health-services-in-rural-and-aian-communities.-these-strategies-could-be-initiated-locally-regionally-or-nationally-by-various-agencies-and-groups. .Style-Heading-4-+-Arial-14-pt-Underline}

#### The discussion and summary were coordinated by Mick Storck, MD, AACAP Liaison to CONACH and Douglas H. Esposito, MD, MPH, FAAP [**http://www.aap.org/nach/AccesstoMentalHealthSummary.htm**](http://www.aap.org/nach/AccesstoMentalHealthSummary.htm) {#the-discussion-and-summary-were-coordinated-by-mick-storck-md-aacap-liaison-to-conach-and-douglas-h.-esposito-md-mph-faap-httpwww.aap.orgnachaccesstomentalhealthsummary.htm .Style-Heading-4-+-Arial-14-pt-Underline}

#### Chris Lamer, Cherokee {#chris-lamer-cherokee .Style-Heading-4-+-Arial-14-pt-Underline}

#### Three new additions to the Indian Health National Guidelines websites {#three-new-additions-to-the-indian-health-national-guidelines-websites .Style-Heading-4-+-Arial-14-pt-Underline}

#### Tobacco assessment algorithm, Cherokee {#tobacco-assessment-algorithm-cherokee-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/NonMedicalPrograms/NC4/Documents/Tobacco2-06.pdf**](http://www.ihs.gov/NonMedicalPrograms/NC4/Documents/Tobacco2-06.pdf) {#httpwww.ihs.govnonmedicalprogramsnc4documentstobacco2-06.pdf .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Tobacco cessation documentation and treatment, Cherokee {#tobacco-cessation-documentation-and-treatment-cherokee .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/NonMedicalPrograms/NC4/Documents/CIHTobaccoHandout.pdf**](http://www.ihs.gov/NonMedicalPrograms/NC4/Documents/CIHTobaccoHandout.pdf) {#httpwww.ihs.govnonmedicalprogramsnc4documentscihtobaccohandout.pdf .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Elder, Medication/ Beers Criteria, Cherokee {#elder-medication-beers-criteria-cherokee .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/NonMedicalPrograms/NC4/Documents/BeersTemplate.doc**](http://www.ihs.gov/NonMedicalPrograms/NC4/Documents/BeersTemplate.doc) {#httpwww.ihs.govnonmedicalprogramsnc4documentsbeerstemplate.doc .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Ron Pust, Tucson {#ron-pust-tucson .Style-Heading-4-+-Arial-14-pt-Underline}

**Prenatal setting: Missed opportunity to link tuberculin skin
test--positive and Tx**

RESULTS: Among 678 women with known tuberculin skin test (TST) status,
341 (50.3%) had a TST-positive result, including 200 who were newly
diagnosed. Of 291 TST-positive women with no previous LTBI treatment or
history of TB, 27 (9.3%) completed \> or =6 months of INH. In a subset
with detailed follow-up, the most important reasons for not completing
treatment were nonreferral for evaluation of a TST-positive result
(30.9%), not keeping the appointment (17.9%), and nonadherence with
prescribed treatment (34.6%). CONCLUSION: The prenatal setting
represents a missed opportunity to link TST-positive non-US-born women
with LTBI treatment and support for treatment completion.

[Sackoff
JE](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Sackoff+JE"%5BAuthor%5D),
Tuberculosis prevention for non-US-born pregnant women. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Feb;194(2):451-6.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16458645>

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

#### Ty Reidhead, Whiteriver {#ty-reidhead-whiteriver .Style-Heading-4-+-Arial-14-pt-Underline}

**Towards a better Patient Education webpage for Indian Health**

Ty Reidhead, the Internal Medicine Chief Clinical Consultant is helping
build our Indian Health Patient Education Resource page.
<http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-patEd.cfm>

Ty asks that you forward him any electronic educational materials that
you may have at your facility or know of from elsewhere

Please send them directly to Ty at <Charles.Reidhead@ihs.gov>

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

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

**Achievements in Public Health: Reduction in Perinatal Transmission of
HIV Infection**

Implementation of recommendations for universal prenatal HIV testing,
ARV prophylaxis, elective cesarean delivery, and avoidance of
breastfeeding has resulted in a 95% decrease in the number of perinatal
AIDS cases in the United States since 1992 and a decline in the risk for
perinatal HIV transmission from an HIV-infected mother to less than 2%.
However, barriers to the elimination of perinatal HIV infection remain,
as the number of HIV infections continues to rise among women, and
health-care services are not universally accessed by women in need of
these services. Finally, the success in reducing perinatal HIV
transmission observed in the United States contrasts with the situations
in poorer countries, particularly in sub-Saharan Africa, where perinatal
HIV transmission remains largely unabated. Continued success in the
United States and reduction of perinatal HIV transmission in areas where
such transmission remains common will require sustained commitment to
prevention of HIV infection among women and to treatment for women
affected by HIV/AIDS.

Achievements in Public Health: Reduction in Perinatal Transmission of
HIV Infection \-\-- United States, 1985---2005 MMWR June 2, 2006 /
55(21);592-597

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5521a3.htm?s_cid=mm5521a3_e>

#### [Editorial comment:]{.underline} George J. Gilson, MD

**Reduction in Perinatal Transmission of HIV Infection**

Since the first pediatric cases of HIV were reported in the early 80's,
significant progress has occurred in the prevention of vertical
transmission of the infection in the United States. Prior to the era of
anti-retroviral therapy (ARV), perinatal transmission was as high as
30%, but is currently under 2 per cent. Nevertheless, transmission
continues to occur, mostly to infants who are born to women who have had
no prenatal care (16%), or who have had prenatal care, but who have not
been tested (26%), or who had been recognized as infected, but who had
not been adequately treated (41% had not received zidovudine during
labor). These are the areas where we should be able to make improvements
in our care. Utilization of the "opt-out" approach to prenatal HIV
screening, testing with the rapid, point of care, "OraQuick" test in
labor for women with undocumented HIV status, and re-testing in the
third trimester of high-risk women (history of a sexually transmitted
infection or illicit drug use in the current pregnancy, or women from
high prevalence areas), are all areas where the primary provider can
play an important role in reducing transmission. Increased awareness
among women of the need for testing, and case management to insure
adequate prenatal care and adherence to ARV treatment for women
identified as infected, are also crucial in preventing new infant
infections. HIV infection in women is increasing rapidly, currently
accounting for over a quarter of the total cases in the United States,
and underscores the need for increased vigilance on the part of all of
us who care for pregnant clients.

**Safety belts: Single most effective means of preventing death and
serious injury in a crash**

....45% effective in preventing death in passenger cars and 60%
effective in preventing death in light trucks.

Child restraint Use: How do you add up compared to the NHTSA aggregate
data?                   

Infants ................    
98%                                                                                                            

Toddlers ..............   
83%                                                                                                       

4 -- 7 year old   73%

**MUST VIEW CHILD safety short video \"UNTIL THEY ARE 4\' 9\" **

Plus maps of states with booster seat requirements. List and maps of
states with booster seat requirements. Go to
[www.boosterseat.gov](http://www.boosterseat.gov/)  and Enter

-CHILD'S AGE,

-WEIGHT

-HEIGHT

Erica Streit-Kaplan, MPH, MSW <estreit-kaplan@edc.org>

**Connected Kids: Safe, Strong, Secure is a new set of resources
developed by VIPP**

The Violence Intervention and Prevention Program. Connected Kids
provides pediatricians with guidance and patient-oriented materials to
take an asset-based approach to violence prevention from birth through
21 years of age.  BUILD your query with age/ audience/ category/ key
words -- liking bullying or dating violence: <http://www.aap.org/vipp/>

Then a great list of links to sites and contact info and links to their
specific programs comes up

As part of this program, more than 20 Connected Kids handouts are
included. Some of the important topics covered are: Bullying,
Discipline, Interpersonal Skills, Parenting, Suicide, Television
Violence and more\... please contact <connectedkids@aap.org>

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

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

#### Incontinence not correlated with vaginal delivery {#incontinence-not-correlated-with-vaginal-delivery-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Incontinence is a common problem for postmenopausal women, but that no difference in prevalence or severity could be demonstrated between parous and nulliparous sisters. Conversely, familial factors appear to be highly significant predictors of urinary incontinence. The authors suggest that the current focus on delivery in the etiology of incontinence is inappropriate and that research and preventive efforts be directed toward understanding familial factors. {#incontinence-is-a-common-problem-for-postmenopausal-women-but-that-no-difference-in-prevalence-or-severity-could-be-demonstrated-between-parous-and-nulliparous-sisters.-conversely-familial-factors-appear-to-be-highly-significant-predictors-of-urinary-incontinence.-the-authors-suggest-that-the-current-focus-on-delivery-in-the-etiology-of-incontinence-is-inappropriate-and-that-research-and-preventive-efforts-be-directed-toward-understanding-familial-factors. .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

+-------------------------+----------+-------------------+------------+
| **Concordance of        |          |                   |            |
| Continence Status       |          |                   |            |
| Within Sister Pairs**   |          |                   |            |
+-------------------------+----------+-------------------+------------+
| *Incontinence in        | *None    | *Parous sister    | *Total     |
| nulliparous sister*     | (%)*     | present (%)*      | (%)*       |
+-------------------------+----------+-------------------+------------+
| None                    | 47       | 28 (19.58)        | 75 (52.45) |
|                         | (32.87)  |                   |            |
+-------------------------+----------+-------------------+------------+
| Present                 | 25       | 43 (30.07)        | 68 (47.55) |
|                         | (17.48)  |                   |            |
+-------------------------+----------+-------------------+------------+
| Total                   | 72       | 71 (49.65)        | 143        |
|                         | (50.35)  |                   | (100.00)   |
+-------------------------+----------+-------------------+------------+
| *note: Seven sister     |          |                   |            |
| pairs, in each of which |          |                   |            |
| one of the sisters had  |          |                   |            |
| incontinence unrelated  |          |                   |            |
| to stress or urge, were |          |                   |            |
| not included in this    |          |                   |            |
| table.*                 |          |                   |            |
|                         |          |                   |            |
| *Adapted with           |          |                   |            |
| permission from         |          |                   |            |
| Buchsbaum GM, Duecy EE, |          |                   |            |
| Kerr LA, Huang LS,      |          |                   |            |
| Guzick DS. Urinary      |          |                   |            |
| incontinence in         |          |                   |            |
| nulliparous women and   |          |                   |            |
| their parous sisters.   |          |                   |            |
| Obset Gynecol           |          |                   |            |
| 2005;106:1256.*         |          |                   |            |
+-------------------------+----------+-------------------+------------+

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

#### Buchsbaum GM, et al. Urinary incontinence in nulliparous women and their parous sisters. Obset Gynecol December 2005;106:1253-8. {#buchsbaum-gm-et-al.-urinary-incontinence-in-nulliparous-women-and-their-parous-sisters.-obset-gynecol-december-20051061253-8. .Style-Heading-4-+-Arial-14-pt-Underline}

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16319249>

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

#### Do we inject a bias toward cesarean delivery based on future incontinence? {#do-we-inject-a-bias-toward-cesarean-delivery-based-on-future-incontinence .Style-Heading-4-+-Arial-14-pt-Underline}

#### Hopefully this study will re-frame the discussion into the current situation in which cesarean delivery is being advocated (and demanded by some patients) to prevent urinary incontinence later in life. As Buchsbaum et al have raised serious questions about the argument that there is a direct correlation between vaginal delivery and future incontinence. {#hopefully-this-study-will-re-frame-the-discussion-into-the-current-situation-in-which-cesarean-delivery-is-being-advocated-and-demanded-by-some-patients-to-prevent-urinary-incontinence-later-in-life.-as-buchsbaum-et-al-have-raised-serious-questions-about-the-argument-that-there-is-a-direct-correlation-between-vaginal-delivery-and-future-incontinence. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### According to Wu et al, nearly two thirds of obstetricians support elective cesarean delivery for this reason. Combined with the current backlash against vaginal birth after cesarean delivery, the cesarean delivery rate seems set to spiral beyond the current 30 percent unless the debate can be refocused on scientific evidence of the net benefit for mothers. {#according-to-wu-et-al-nearly-two-thirds-of-obstetricians-support-elective-cesarean-delivery-for-this-reason.-combined-with-the-current-backlash-against-vaginal-birth-after-cesarean-delivery-the-cesarean-delivery-rate-seems-set-to-spiral-beyond-the-current-30-percent-unless-the-debate-can-be-refocused-on-scientific-evidence-of-the-net-benefit-for-mothers. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Please see the series of articles on outcome based data from cesarean delivery in Perinatology Picks below. {#please-see-the-series-of-articles-on-outcome-based-data-from-cesarean-delivery-in-perinatology-picks-below. .Style-Heading-4-+-Arial-14-pt-Underline}

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

Wu JM, Hundley AF, Visco AG. Elective primary cesarean delivery:
attitudes of urogynecology and maternal-fetal medicine specialists.
Obstet Gynecol 2005;105:301-6.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15684156>

**Serious maternal morbidity increases with increasing number of
cesarean deliveries**

CONCLUSION: Because serious maternal morbidity increases progressively
with increasing number of cesarean deliveries, the number of intended
pregnancies should be considered during counseling regarding elective
repeat cesarean operation versus a trial of labor and when debating the
merits of elective primary cesarean delivery. LEVEL OF EVIDENCE: II-2

Silver, RM et al Maternal Morbidity Associated With Multiple Repeat
Cesarean Deliveries

Obstetrics & Gynecology 2006;107:1226-1232

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16738145>

**Characteristics of glyburide failures in GDM: EGA at diagnosis,
parity, and fasting glucose**

CONCLUSION: Glyburide was more likely to fail in women diagnosed earlier
in pregnancy, of older age and multiparity, and with higher fasting
glucoses, suggesting that earlier glucose intolerance and a reduced
capacity to respond to an insulin secretagogue may distinguish this
group. The time for glyburide as an alternative treatment has come;
however, it should be prescribed after careful consideration of these
patient characteristics to minimize the likelihood of failure. LEVEL OF
EVIDENCE: II-2

Kahn BF et al Predictors of Glyburide Failure in the Treatment of
Gestational Diabetes Obstetrics & Gynecology 2006;107:1303-1309

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16738156>

**Improve the systems against maternal mortality from hemorrhage**

CONCLUSION: Despite a significant increase in major obstetric hemorrhage
cases, we found improved outcomes and fewer maternal deaths after
implementing systemic approaches to improve patient safety. Attention to
improving the hospital systems necessary for the care of women at risk
for major obstetric hemorrhage is important in the effort to decrease
maternal mortality from hemorrhage.

[Skupski
DW](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Skupski+DW"%5BAuthor%5D),
et al Improving hospital systems for the care of women with major
obstetric hemorrhage.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16648399&dopt=Abstract>

**High-risk centers have higher rates of cesarean delivery for their low
risk population**

CONCLUSION: Maternity units that frequently manage high-risk pregnancies
(levels 2b and 3) have higher rates of cesareans during labor for their
population of nulliparas at low risk than do facilities that deal mainly
with low-risk pregnancies. LEVEL OF EVIDENCE: II-2

Ray CL et al Level of Perinatal Care of the Maternity Unit and Rate of
Cesarean in Low-Risk Nulliparas. Obstetrics & Gynecology
2006;107:1269-1277

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16738151>

**Influence of rest during pregnancy on birth weight in working women**

CONCLUSION: The continuous increase in infants\' birth weight among
pregnant women in this study did not correlate with rest periods in the
form of leave supported by social benefit programs. The effects of
social benefit programs on pregnancy outcome may thus be overrated and
merits further research.

[Sydsjo
A](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Sydsjo+A"%5BAuthor%5D),
et al Influence of rest during pregnancy on birth weight in working
women. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
May;107(5):991-6.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16648401&dopt=Abstract>

**Expand the use of oral analgesia in patients immediately after
cesarean delivery**

CONCLUSION: Oral analgesia with oxycodone-acetaminophen may offer
superior pain control after cesarean delivery with fewer side-effects as
compared with morphine patient-controlled analgesia. Consideration
should be given to expanding the use of oral analgesia in patients
immediately after cesarean delivery.

[Davis
KM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Davis+KM"%5BAuthor%5D),
et al Oral analgesia compared with intravenous patient-controlled
analgesia for pain after cesarean delivery: a randomized controlled
trial. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Apr;194(4):967-71.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16580284>

**Anal sphincter tears: Episiotomy, shoulder dystocia, forceps, and
previous sphincter tear**

CONCLUSION: The strongest clinical risk factors for anal sphincter tear
in multiparous women are episiotomy, shoulder dystocia, previous
sphincter tear, prolonged second stage of labor, and forceps delivery.
LEVEL OF EVIDENCE: II-2

DiPiazza D et al Risk Factors for Anal Sphincter Tear in Multiparas
Obstetrics & Gynecology 2006;107:1233-1237

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16738146>

**Improvements in asthma management to prevent severe exacerbations may
lead to a better outcome for both mother and baby**

Women with asthma experience an increased rate of exacerbations during
pregnancy and require substantial medical interventions. The rate of
severe exacerbations is highest in mothers with the most severe
prepregnancy asthma. Viral infections and nonadherence to medications
appear to be common causes. The study was too small to establish
significant relationships between exacerbations of asthma and poor
pregnancy outcomes, but it showed significantly reduced birth weight in
male infants. LEVEL OF EVIDENCE: II-2

Murphy VE, et al. Severe asthma exacerbations during pregnancy. Obstet
Gynecol November 2005;106:1046-54.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16260524>

**Prevention and Diagnosis of Fetal Alcohol Syndrome**

Alcohol use among women of childbearing age is prevalent in the United
States, with approximately 1 in 5 nonpregnant women reporting binge
drinking (5 or more drinks on any one occasion) and 1 in 25 pregnant
women reporting binge drinking. Alcohol use during pregnancy results in
a spectrum of adverse outcomes known as fetal alcohol spectrum
disorders. Fetal alcohol syndrome (FAS) is one of these disorders. Fetal
alcohol syndrome is characterized by specific facial abnormalities and
significant impairments in neurodevelopment and physical growth. Early
identification of children with FAS has been shown to enhance their
long-term outcomes. In an effort to improve clinical recognition of
children with this condition, Centers for Disease Control and Prevention
(CDC) was directed by Congress in 2002 to lead the development of
uniform diagnostic criteria for FAS and other prenatal alcohol-related
conditions. The purpose of this commentary is to provide clinicians a
summary of the report released by CDC describing the current diagnostic
criteria for FAS. In addition, advancements have been made in screening
and brief interventions for alcohol use disorders in women who have the
potential to make significant strides in the prevention of FAS spectrum
disorders. Knowledge of the diagnostic criteria for FAS can lead to
increased identification of the syndrome in infants and children and the
provision of appropriate medical and support services. Screening for and
intervening with women at risk for an alcohol-exposed pregnancy can
prevent FAS and other fetal alcohol spectrum disorders.

Floyd RL, et al. Recognition and prevention of fetal alcohol syndrome.
Obstet Gynecol November 2005;106:1059-64.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16260526>

**Calcium supplementation during pregnancy and lactation: Effects on
mother and the fetus**

Calcium consumption is essential for bone development and maintenance
throughout life, yet more than one half of the female population in the
United States does not consume the recommended amount of calcium.
Calcium intake is especially crucial during pregnancy and lactation
because of the potential adverse effect on maternal bone health if
maternal calcium stores are depleted. There is often a transient lowered
bone mineral density and increased rate of bone resorption, with the
greatest consequence during the third trimester and throughout
lactation. Studies indicate that calcium consumption should be
encouraged, especially during pregnancy and lactation, to replace
maternal skeletal calcium stores that are depleted during these periods.
Because the fetus in utero and the neonate through breast-feeding are
dependent on maternal sources for the total calcium load, adequate
maternal calcium intake also can affect fetal bone health positively.
Proper calcium consumption can be attained through the diet by the
consumption of dairy products or leafy greens (such as kale), the
consumption of fortified foods, or by supplementation with widely
available calcium-containing supplement products. Because many women
experience heartburn during pregnancy, calcium-based antacids are ideal
for providing heartburn relief, and they offer a calcium supplement to
ensure maternal and fetal bone health, without the danger of adverse
effects on the neonate.

[Thomas
M](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Thomas+M"%5BAuthor%5D),
[Weisman
SM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Weisman+SM"%5BAuthor%5D).
Calcium supplementation during pregnancy and lactation: effects on the
mother and the fetus. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Apr;194(4):937-45.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16580279>

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

**FDA Licenses New Vaccine for Prevention of Cervical Cancer and Other
Diseases in Females Caused by Human Papillomavirus**

The Food and Drug Administration (FDA) announced the approval of
Gardasil, the first vaccine developed to prevent cervical cancer,
precancerous genital lesions and genital warts due to human
papillomavirus (HPV) types 6, 11, 16 and 18. The vaccine is approved for
use in females 9-26 years of age. Gardasil was evaluated and approved in
six months under FDA\'s priority review process\--a process for products
with potential to provide significant health benefits.

\"Today is an important day for public health and for women\'s health,
and for our continued fight against serious life-threatening diseases
like cervical cancer,\" said Alex Azar, Deputy Secretary, U.S.
Department of Health and Human Services (HHS). \"HHS is committed to
advancing critical health measures such as the development of new and
promising vaccines to protect and advance the health of all Americans.\"

HPV is the most common sexually-transmitted infection in the United
States. The Centers for Disease Control and Prevention estimates that
about 6.2 million Americans become infected with genital HPV each year
and that over half of all sexually active men and women become infected
at some time in their lives.  On average, there are 9,710 new cases of
cervical cancer and 3,700 deaths attributed to it in the United States
each year. Worldwide, cervical cancer is the second most common cancer
in women; and is estimated to cause over 470,000 new cases and 233,000
deaths each year.

For most women, the body\'s own defense system will clear the virus and
infected women do not develop related health problems.  However, some
HPV types can cause abnormal cells on the lining of the cervix that
years later can turn into cancer.  Other HPV types can cause genital
warts.  The vaccine is effective against HPV types 16 and 18, which
cause approximately 70 percent of cervical cancers and against HPV types
6 and 11, which cause approximately 90 percent of genital warts. 

\"This vaccine is a significant advance in the protection of women\'s
health in that it strikes at the infections that are the root cause of
many cervical cancers,\" said Andrew C. von Eschenbach, MD, Acting
Commissioner of Food and Drugs.  \"The development of this vaccine is a
product of extraordinary work by scientists as well as by FDA\'s review
teams to help facilitate the development of very novel vaccines to
address unmet medical needs.  This work has resulted in the approval of
a number of new products recently, including Gardasil, which address
significant public health needs.\"

Gardasil is a recombinant vaccine (contains no live virus) that is given
as three injections over a six-month period.  Immunization with Gardasil
is expected to prevent most cases of cervical cancer due to HPV types
included in the vaccine.  However, females are not protected if they
have been infected with that HPV type(s) prior to vaccination,
indicating the importance of immunization before potential exposure to
the virus.  Also, Gardasil does not protect against less common HPV
types not included in the vaccine, thus routine and regular pap
screening remain critically important to detect precancerous changes in
the cervix to allow treatment before cervical cancer develops.

\"This is the first vaccine licensed specifically to prevent cervical
cancer. Its rapid approval underscores FDA\'s commitment to help make
safe and effective vaccines available as quickly as possible. Not only
have vaccines dramatically reduced the toll of diseases in infants and
children, like polio and measles, but they are playing an increasing
role protecting and improving the lives of adolescents and adults,\"
said Jesse Goodman, MD, MPH, Director of FDA\'s Center for Biologics
Evaluation and Research.

Four studies, one in the United States and three multinational, were
conducted in 21,000 women to show how well Gardasil worked in women
between the ages of 16 and 26 by giving them either the vaccine or
placebo.  The results showed that in women who had not already been
infected, Gardasil was nearly 100 percent effective in preventing
precancerous cervical lesions, precancerous vaginal and vulvar lesions,
and genital warts caused by infection with the HPV types against which
the vaccine is directed.  While the study period was not long enough for
cervical cancer to develop, the prevention of these cervical
precancerous lesions is believed highly likely to result in the
prevention of those cancers.

The studies also evaluated whether the vaccine can protect women already
infected with some HPV types included in the vaccine from developing
diseases related to those viruses.  The results show that the vaccine is
only effective when given prior to infection.

Two studies were also performed to measure the immune response to the
vaccine among younger females aged 9-15 years.  Their immune response
was as good as that found in 16-26 year olds, indicating that the
vaccine should have similar effectiveness when used in the 9-15 year age
group.

The safety of the vaccine was evaluated in approximately 11,000
individuals.  Most adverse experiences in study participants who
received Gardasil included mild or moderate local reactions, such as
pain or tenderness at the site of injection.

The manufacturer has agreed to conduct several studies following
licensure, including additional studies to further evaluate general
safety and long-term effectiveness.  The manufacturer will also monitor
the pregnancy outcomes of women who receive Gardasil while unknowingly
pregnant.   Also, the manufacturer has an ongoing study to evaluate the
safety and effectiveness of Gardasil in males. 

<http://www.fda.gov/cber/products/hpvmer060806.htm>
<http://www.fda.gov/womens/getthefacts/hpv.html>

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

**Rapid Approval Marks Major Advancement in Public Health**

This is the biggest news in Women's Health since the advent of the pap
smear. While FDA is very important, perhaps most important,
programmatically, is when and how the Merck vaccine gets approved for
roll out by the Advisory Committee on Immunization Practices (ACIP).

The ACIP meeting is due to occur in late June and it is really there
that more of the salient details will arise"

Will it be indicated universally?

or just for high risk groups?

-If universally, then it will qualify for the Vaccines For Children
(VFC) program approval and be essentially free to Natives through the
State Immunization program

-If for high risk groups only, then it will be difficult to get broad
acceptance, plus we would likely have to pay for it

As this would be the third new vaccine for adolescents in as many years
(Read as: Expensive -  approximately \$120 each times 3 doses), the HPV
vaccine will run into some stiff competition for limited State
Immunization funding with acellular DPTa and Menactra (meningitis).

Typically ACIP rolls out new vaccines the first of the calendar
year...hence January 2007 is the most likely roll out guess at this
point

Each Indian Health site needs to be mindful that this vaccine is limited
to only two of the major cancer causing subtypes, e. g., 16 and 18. In
Alaska Natives our rates of 16 and 18 are somewhat similar to the
national statistics, but we actually had a very high rate of multiple
infections, e.g., subtypes not covered by either the Merck or GSK
vaccines. It is for that reason one probably need to think along the
lines of long term immunogenicity studies in your population to monitor
its effect over time.

Similar studies and similar programmatic follow-up were very helpful
during the Hep B vaccine national roll out. In addition, the Merck
vaccine has not particularly well studied in minority patients to date.

This will be important because we need our patients with abnormal paps
to become the local champions for this vaccine in their conversations
with their adolescent daughters and sisters. Though we need to emphasize
this is a 'Cancer' vaccine, there still will be some questions about the
effect of a possible STI vaccine in a pre-pubescent girls.  This is
especially important to do asap because a possible ultimate rollout in
5- 6 months is really a short time line for something like this.

So......based on these and other issues, you may want to consider first
maximizing patient education to facilitate the roll out (based on local
focus group vetted materials), hopefully in the near term, e. g., the
cancer preventing nature of this vaccine should be emphasized vs this is
not primarily an STI preventing vaccine - with subsequent implications
on sexual behavior in pre-teen girls. See Fact Sheet below

**The FDA approved labeling for the new HPV vaccine.**

[[http://www.fda.gov/cber/label/hpvmer060806LB.pdf]{.underline}](http://www.fda.gov/cber/label/hpvmer060806LB.pdf)

**Human Papilloma Virus Vaccine Fact Sheet**

This fact sheet on Human Papilloma Virus (HPV) vaccines provides
questions and answers about HPV and HPV vaccines, which may be available
soon. <http://www.cdc.gov/std/hpv/STDFact-HPV-Vaccine.htm>

**Overlap repair of obstetric anal sphincter injury: Decrease in fecal
incontinence**

CONCLUSION: Primary overlap repair of the external anal sphincter is
associated with a significantly lower incidence of fecal incontinence,
urgency, and perineal pain. When symptoms do develop, they appear to
remain unchanged or deteriorate in the end-to-end group but improve in
the overlap group. LEVEL OF EVIDENCE: I

Fernando RJ et al Repair Techniques for Obstetric Anal Sphincter
Injuries

### A Randomized Controlled Trial. Obstetrics & Gynecology 2006;107:1261-1268

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16738150>

**Criteria should be developed for the use of intraoperative cystoscopy
to detect injuries**

CONCLUSION: The reasons for higher injury detection rates when routine
cystoscopy was performed are unclear. Further study is needed to
identify the scenarios where routine cystoscopy is warranted after major
gynecologic surgery.

Gilmour et al Rates of Urinary Tract Injury From Gynecologic Surgery and
the Role of Intraoperative Cystoscopy. Obstetrics & Gynecology
2006;107:1366-1372

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16738165>

**Atypical glandular cell cytology confers a 38% risk of preinvasive
disease or carcinoma**

CONCLUSION: Atypical glandular cell cytology confers a risk (38%) of
either preinvasive disease or carcinoma, with the risk of carcinoma
increasing significantly for women aged older than 40. Adherence to
recommended AGC management guidelines is crucial to identify underlying
malignancies. LEVEL OF EVIDENCE: II-2

DeSimone CP et al Rate of Pathology From Atypical Glandular Cell Pap
Tests Classified by the Bethesda 2001 Nomenclature. Obstetrics &
Gynecology 2006;107:1285-1291

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16738153>

**Cesarean scar ectopic pregnancies are becoming more frequent**

CONCLUSION: Surgical treatment or combined systemic and intragestational
methotrexate were both successful in the management of cesarean delivery
scar pregnancy. Because subsequent pregnancies may be complicated by
uterine rupture, the uterine scar should be evaluated before, as well as
during, these pregnancies.

Rotas MA et al Cesarean Scar Ectopic Pregnancies: Etiology, Diagnosis,
and Management. Obstetrics & Gynecology 2006;107:1373-1381

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16738166>

**Cervical cancer: An overview of the diagnosis, staging, and
treatment**

Worldwide, cervical cancer is the second most common malignancy in women
and a major cause of morbidity and mortality. Until recently, the
greatest strides in reducing cervical cancer mortality have occurred
with the advent and implementation of screening programs. Many important
advances have also taken place in the diagnosis and treatment of
cervical cancer. This review article will highlight diagnostic and
staging considerations with an emphasis on newer imaging modalities and
how they might augment approved FIGO clinical staging. Management
alternatives for patients with early-stage disease, locally advanced
(stage IIB-IVA) disease, and metastatic cervical cancer will be
discussed. Whenever possible, these discussions will unfold through an
overview of pertinent clinical trials and current controversies.

[Moore
DH](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Moore+DH"%5BAuthor%5D).
Cervical cancer. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
May;107(5):1152-61.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16648423&dopt=Abstract>

**Assessment of Microscopic Hematuria in Adults (see Patient
Education)**

Microscopic hematuria, a common finding on routine urinalysis of adults,
is clinically significant when three to five red blood cells per
high-power field are visible. Etiologies of microscopic hematuria range
from incidental causes to life-threatening urinary tract neoplasm. The
lack of evidence-based imaging guidelines can complicate the family
physician\'s decision about the best way to proceed. Patients with
proteinuria, red cell casts, and elevated serum creatinine levels should
be referred promptly to a nephrology subspecialist. Microscopic
hematuria with signs of urinary tract infection should resolve with
appropriate treatment of the underlying infection. Patients with
asymptomatic microscopic hematuria or with hematuria persisting after
treatment of urinary tract infection also need to be evaluated. Because
upper and lower urinary tract pathologies often coexist, patients should
be evaluated using cytology plus intravenous urography, computed
tomography, or ultrasonography. When urine cytology results are
abnormal, cystoscopy should be performed to complete the investigation.
Am Fam Physician 2006;73:1748-54, 1759.
<http://www.aafp.org/afp/20060515/1748.html>

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

**Maternal** **cholestasis** **is significantly associated with RDS in
the newborn**

RESULTS: The incidence of RDS in newborns from cholestatic pregnancies
was twice that the reference population (28.6% vs 14%). The multivariate
analysis showed that the risk of RDS in these newborns was approximately
2.5 times higher than in control infants. Within the ICP group, maternal
and neonatal bile acid levels of infants affected by RDS were not
significantly higher than those of healthy infants. The multivariate
analysis showed that a low gestational age was the most important risk
factor, but the probability of respiratory distress syndrome also
increased by 2 per thousand for every additional micromole of the
interaction term \"neonatal by maternal bile acids level.\" CONCLUSIONS:
Maternal ICP is significantly associated with the occurrence of RDS in
the newborn. We hypothesize that bile acids can produce surfactant
depletion in the alveoli reverting the reaction of phospholipase A2.
This hypothesis could potentially be confirmed by bronchoalveolar lavage
study.

[Zecca
E](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Zecca+E"%5BAuthor%5D)
et al Intrahepatic cholestasis of pregnancy and neonatal respiratory
distress syndrome.
[Pediatrics.](javascript:AL_get(this, 'jour', 'Pediatrics.');) 2006
May;117(5):1669-72.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16651322>

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

The incidence of intrahepatic cholestasis of pregnancy may also be
elevated in certain AI/AN women.

Our preliminary survey shows a high prevalence (3.9 %) of IHCP in
pregnant Alaska Native women.

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

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

<http://www.ihs.gov/medicalprograms/mch/m/documents/cholestas4206.doc>

**Co-occurring maternal conditions and behavior problems in children**

Our study suggests that, by 3 years of age, there is already evidence of
the effect of adverse childhood experiences, occurring in this study in
the form of parental mental health problems, substance use, and domestic
violence.

The authors found that

\* The risk of behavior problems in 3-year-olds increased with the
number of categories \-- mental health, substance use, and domestic
violence \-- in which the mother reported a condition in the year after
delivery.

\* The graded increase in risk was independent of sociodemographic and
prenatal factors, as well as measures of paternal mental health and
substance use in the year after delivery.

The authors conclude that \"to play their most useful role, health care
providers might wish to consider the health and well-being of the
family, the social unit involved in the transfer of health between
generations, rather than limiting their focus to the individual patient
or to a particular developmental period.\"

Whitaker RC, Orzol SM, Kahn RS. 2006. Maternal mental health, substance
use, and domestic violence in the year after delivery and subsequent
behavior problems in children at age 3 years. Archives of General
Psychiatry 63(5):551-560.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16651512>

**Treatment of Chlamydia trachomatis in Adolescents**

CONCLUSIONS: Most teenagers received appropriate antibiotics, but fewer
received other recommended care. The current study highlights important
\"missed-opportunity\" clinical encounters for counseling to address
high-risk behaviors, management of partners, detection of other sexually
transmitted infections, and retesting for reinfections. Systems to
address these gaps in care should be incorporated into the clinical
management of adolescents infected with C. trachomatis. Hwang LY, et al.
Examination of the treatment and follow-up care of adolescents who test
positive for *Chlamydia trachomatis* infection. Arch Pediatr Adolesc Med
December 2005;159:1162-6.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16330741>

Extremely Low-Birth-Weight Infants Become Normal Adults

**Clinical Question:** Do extremely low-birth-weight infants achieve
functional adulthood?

**Bottom Line:** Nearly all surviving extremely low-birth-weight
children and adolescents overcome early cognitive and social
difficulties and reach a functional level comparable with
normal-birth-weight peers. (Level of Evidence: 1b)

Saigal S, et al. Transition of extremely low-birth-weight infants from
adolescence to young adulthood: comparison with normal birth-weight
controls. JAMA February 8, 2006;295:667-75.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16467235>

ACIP Updates Recommendations for Prevention of Hepatitis B Virus
Transmission

The Advisory Committee on Immunization Practices (ACIP) of the Centers
for Disease Control and Prevention has updated its strategy to eliminate
hepatitis B virus (HBV) transmission in the United States. The report
provides new recommendations to improve prevention of perinatal and
early childhood HBV transmission, including implementation of universal
infant vaccination beginning at birth, and to increase vaccine coverage
among previously unvaccinated children and adolescents. December 23,
2005, *Morbidity and Mortality Weekly Report*
<http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5416a1.htm>

**Hypertension in Children and Adolescents**

The development of a national database on normative blood pressure
levels throughout childhood has contributed to the recognition of
elevated blood pressure in children and adolescents. The epidemic of
childhood obesity, the risk of developing left ventricular hypertrophy,
and evidence of the early development of atherosclerosis in children
would make the detection of and intervention in childhood hypertension
important to reduce long-term health risks; however, supporting data are
lacking. Secondary hypertension is more common in preadolescent
children, with most cases caused by renal disease. Primary or essential
hypertension is more common in adolescents and has multiple risk
factors, including obesity and a family history of hypertension.
Evaluation involves a thorough history and physical examination,
laboratory tests, and specialized studies. Management is multifaceted.
Nonpharmacologic treatments include weight reduction, exercise, and
dietary modifications. Recommendations for pharmacologic treatment are
based on symptomatic hypertension, evidence of end-organ damage, stage 2
hypertension, stage 1 hypertension unresponsive to lifestyle
modifications, and hypertension with diabetes mellitus. Am Fam Physician
2006;73:1158-68.

<http://www.aafp.org/afp/20060501/1558.html>

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

Group visits: Promising approach to chronic care management for the
motivated patient

RESULTS: Although the heterogeneity of the studies presented renders the
assessment of this care model problematic, there is sufficient data to
support the effectiveness of group visits in improving patient and
physician satisfaction, quality of care, quality of life, and in
decreasing emergency department and specialist visits.

CONCLUSION: Group visits are a promising approach to chronic care
management for the motivated patient. Future research may benefit,
however, from abandoning old nomenclatures and clearly defining the
structure, processes of care, content of visits, and appropriate outcome
measures.

[Jaber
R](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Jaber+R"%5BAuthor%5D)
et al Group visits: a qualitative review of current research. [J Am
Board Fam Med.](javascript:AL_get(this, 'jour', 'J Am Board Fam Med.');)
2006 May-Jun;19(3):276-90.\
[**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16672681&dopt=Abstract**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16672681&dopt=Abstract)

Depression Relapse in Pregnancy High When Medication Stopped

**Clinical Question:** What is the risk of relapse of major depression
in women who discontinue their antidepressant medication while pregnant?

**Setting:** Outpatient (specialty)

**Bottom Line:** Nearly 50 percent of women currently receiving
antidepressant medication will experience a relapse of major depression
during pregnancy. The risk is highest for those discontinuing their
medication. It is likely that this study sample consists of patients
with a higher severity of illness than those found in a routine
community practice, so the findings may not generalize to other
settings. (Level of Evidence: 1b)

Cohen LS, et al. Relapse of major depression during pregnancy in women
who maintain or discontinue antidepressant treatment. JAMA February 1,
2006;295:499-507.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16449615>

Determining Eligibility for Gastric Bypass Surgery

Case Scenario: I have a 65-year-old patient with a body mass index (BMI)
close to 50 kg per m2. Her weight dramatically affects her quality of
life. She uses a wheelchair and has difficulty getting around. Her
weight also has affected her health: she has congestive heart failure,
sleep apnea, and pulmonary hypertension. A thallium stress test has
shown that she has minimal coronary artery disease. The patient has been
unable to lose weight with diet and exercise. I thought she was an
acceptable candidate for gastric bypass surgery, and I referred her to a
surgeon to discuss this option. But soon afterward, my patient returned
to my office devastated. The surgeon had informed her that she was not a
candidate for gastric bypass surgery because of her age.

Should this patient be allowed to have the surgery? Should I try to find
another surgeon who is willing to perform the risky procedure? What are
the ethical implications of allocating an expensive resource such as
gastric bypass surgery?

See discussion <http://www.aafp.org/afp/20060501/curbside.html>

**Metformin lowers cardiovascular risk factors in hyperinsulinemic women
with PCOS**

RESULTS: The hyperinsulinemic group had significantly lower high-density
lipoprotein (HDL) (by 11%), higher total cholesterol to HDL ratio (by
23%), and greater triglycerides (by 57%) than the normoinsulinemic
group. Six-month metformin therapy in hyperinsulinemic women was
associated with a significant decrease of insulin level (by 35%), total
cholesterol (by 11%), low-density lipoprotein (LDL) (by 12%), and
triglycerides (by 33%). Levels of lipids in hyperinsulinemic women after
metformin therapy were comparable to levels observed in normoinsulinemic
subjects. CONCLUSION: The present study supports the notion that
metformin may be considered as a prophylactic therapy lowering
cardiovascular risk factors in hyperinsulinemic women with polycystic
ovary syndrome.

[Banaszewska
B](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Banaszewska+B"%5BAuthor%5D),
et al Lipids in polycystic ovary syndrome: role of hyperinsulinemia and
effects of metformin. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
May;194(5):1266-72\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16647909>

Nonpharmacologic Strategies for Managing Hypertension (also see Patient
Education)

The Seventh Report of the Joint National Committee on Prevention,
Detection, Evaluation, and Treatment of High Blood Pressure recommends
lifestyle modification for all patients with hypertension or
prehypertension. Modifications include reducing dietary sodium to less
than 2.4 g per day; increasing exercise to at least 30 minutes per day,
four days per week; limiting alcohol consumption to two drinks or less
per day for men and one drink or less per day for women; following the
Dietary Approaches to Stop Hypertension eating plan (high in fruits,
vegetables, potassium, calcium, and magnesium; low in fat and salt); and
achieving a weight loss goal of 10 lb (4.5 kg) or more. Alternative
treatments such as vitamin C, coenzyme Q10, magnesium, and omega-3 fatty
acids have been suggested for managing hypertension, but evidence for
their effectiveness is lacking. Am Fam Physician 2006;73:1953-6, 1957-8.

[**http://www.aafp.org/afp/20060601/1953.html**](http://www.aafp.org/afp/20060601/1953.html)

Screening for Depression - Cochrane for Clinicians

Clinical Question

Are screening tools for depression effective in primary care practice?

Evidence-Based Answer

Sensitive and specific screening tools and effective treatments are
available for depression. However, screening for depression has not been
shown to increase the number of patients who receive treatment or to
improve patient outcomes. This may be because the positive predictive
values of screening tests for depression are lower in primary care, or
because physicians already are adept at identifying those patients most
likely to benefit from treatment (i.e., those who have the most severe
symptoms and the greatest functional limitations).

<http://www.aafp.org/afp/20060501/cochrane.html>

**Carbamazepine for Acute and Chronic Pain - Cochrane for Clinicians**

Clinical Scenario

A 52-year-old man with diabetic neuropathic pain has read on the
Internet that some seizure medicines are helpful, and he asks for your
recommendation.

Clinical Question

How effective is carbamazepine (Tegretol) in controlling pain?

Evidence-Based Answer

Two small trials have shown carbamazepine to be beneficial in the
treatment of diabetic neuropathic pain. Carbamazepine shows similar
clinical effect to gabapentin (Neurontin) and phenytoin (Dilantin), but
there have been no head-to-head trials directly comparing these drugs.
Carbamazepine is effective in the treatment of trigeminal neuralgia and
may be effective for other types of neuropathic pain, but the data are
limited. Carbamazepine is not beneficial for the treatment of acute
pain.

<http://www.aafp.org/afp/20060501/cochrane.html>

Dietary Advice to Lower Cardiovascular Risk - Cochrane for Clinicians

Clinical Question

Does dietary advice to patients achieve sustained dietary change or
improvements in cardiovascular risk profile?

Evidence-Based Answer

Dietary advice to lower fat and salt intake and increase intake of
fruits, vegetables, and fiber produces modest improvements in
cardiovascular risk factors. More intensive counseling yields greater
effects. <http://www.aafp.org/afp/20060501/cochrane.html>

**Thyroiditis**

Thyroiditis is an inflammation of the thyroid gland that may be painful
and tender when caused by infection, radiation, or trauma, or painless
when caused by autoimmune conditions, medications, or an idiopathic
fibrotic process. The most common forms are Hashimoto\'s disease,
subacute granulomatous thyroiditis, postpartum thyroiditis, subacute
lymphocytic thyroiditis, and drug-induced thyroiditis (caused by
amiodarone, interferon-alfa, interleukin-2, or lithium). Patients may
have euthyroidism, hyperthyroidism, or hypothyroidism, or may evolve
from one condition to another over time. Diagnosis is by clinical
context and findings, including the presence or absence of pain,
tenderness, and autoantibodies. In addition, the degree of radioactive
iodine uptake by the gland is reduced in most patients with viral,
radiation-induced, traumatic, autoimmune, or drug-induced inflammation
of the thyroid. Treatment primarily is directed at symptomatic relief of
thyroid pain and tenderness, if present, and restoration of
euthyroidism. Am Fam Physician 2006;73:1769-76
<http://www.aafp.org/afp/20060515/1769.html>

**Managing Opioid Addiction with Buprenorphine (see Patient Education)**

Legislation has enabled physicians to treat opioid-dependent patients
with an office-based maintenance program using buprenorphine, a partial
mu-opioid receptor agonist. Clinical studies indicate buprenorphine
effectively manages opioid addiction. Buprenorphine is more effective
than placebo for managing opioid addiction but may not be superior to
methadone if high doses are needed. It is comparable to lower doses of
methadone, however. Treatment phases include induction, stabilization,
and maintenance. Buprenorphine therapy should be initiated at the onset
of withdrawal symptoms and adjusted to address withdrawal symptoms and
cravings. Advantages of buprenorphine include low abuse potential and
high availability for office use. Disadvantages include high cost and
possible lack of effectiveness in patients who require high methadone
doses. Most family physicians are required to complete eight hours of
training before they can prescribe buprenorphine for opioid addiction.
Am Fam Physician 2006;73:1573-8, 1580.

<http://www.aafp.org/afp/20060501/1573.html>

Low-Carbohydrate Diets (also see Patient Education)

Americans spend \$33 billion annually on weight loss products and
services, and a large portion of this money is spent on low-carbohydrate
diets. Because of their higher protein and fat content and lower fiber
and carbohydrate content, concerns have been raised about the potential
health consequences of low-carbohydrate diets. Published long-term data
are lacking. Short-term studies comparing traditional low-fat diets with
low-carbohydrate diets found lower triglyceride levels, higher
high-density lipoprotein cholesterol levels, similar low-density
lipoprotein cholesterol levels, and lower A1C levels in persons on
low-carbohydrate diets. These diets induce greater weight loss at three
and six months than traditional low-fat diets; however, by one year
there is no significant difference in maintained weight loss. Weight
loss is directly related to calorie content and the ability to maintain
caloric restriction; the proportions of nutrients in the diet are
irrelevant. Low-carbohydrate diets had lower dropout rates than low-fat
diets in several studies, possibly because of the high protein content
and low glycemic index, which can be appetite suppressing. Data indicate
that low-carbohydrate diets are a safe, reasonable alternative to
low-fat diets for weight loss. Additional studies are needed to
investigate the long-term safety and effectiveness of these and other
approaches to weight loss. Am Fam Physician 2006;73:1942-8, 1951.

<http://www.aafp.org/afp/20060601/1942.html>

Depressive Disorders

Clinical Evidence Concise A Publication of BMJ Publishing Group

What are the effects of treatments in mild to moderate or severe
depression?

Beneficial

**Prescription Antidepressant Drugs (Tricyclic Antidepressants
\[Including Low Doses\], Selective Serotonin Reuptake Inhibitors
\[SSRIs\], Monoamine Oxidase Inhibitors \[MAOIs\], Reboxetine, or
Venlafaxine) Improved Symptoms Compared with Placebo in Mild to Moderate
and Severe Depression).** Systematic reviews and subsequent randomized
controlled trials (RCTs) including persons 18 years or older in primary
and secondary care showed that prescription antidepressant drugs were
effective treatments for all grades of depressive disorders compared
with placebo. However, the most robust available evidence on the
effectiveness of antidepressant drug treatment is in the pharmacologic
management of moderate and severe depression.

One systematic review and two subsequent RCTs including persons 55 years
or older with all grades of depressive disorders showed that tricyclic
antidepressants, SSRIs, or MAOIs reduced the proportion of persons who
did not recover over 26 to 49 days compared with placebo. The reviews
included little information on severe adverse effects of antidepressant
drugs compared with placebo. There is evidence of publication bias in
trials of SSRIs. Current evidence indicates no clear relationship
between SSRIs and increased risk of suicide in adults, but SSRIs and
tricyclic antidepressants may induce or worsen suicidal ideation and
behavior during the early phases of treatment. This may be because of
increased agitation and activation. SSRIs generally increase adverse
events in children and adolescents compared with placebo, and regulatory
authorities in several countries are reviewing the safety of these
drugs.

**Tricyclic Antidepressants vs. Other Prescription Antidepressant
Drugs.** Three systematic reviews showed no significant difference in
outcomes with different kinds of antidepressant drugs. One systematic
review and one subsequent RCT showed no significant difference between
tricyclic antidepressants and venlafaxine in the proportion of persons
who responded over one to 12 months. Another systematic review suggested
that tricyclic antidepressants were more effective than MAOIs in persons
with severe depressive disorders, but that it may be less effective in
atypical depressive disorders with biologic features (e.g., increased
sleep and appetite). A third systematic review showed that tricyclic
antidepressants were associated with higher rates of adverse effects
than SSRIs, but the difference was small. One systematic review and two
case-control studies showed no significant difference in risk of suicide
between SSRIs and tricyclic antidepressants.

Two RCTs, primarily including persons with severe depression, showed no
significant difference in symptoms between desipramine or imipramine and
reboxetine at four weeks, but results were sensitive to outcome scales
used. One systematic review showed no significant difference between
milnacipran and imipramine in persons with major depressive disorder,
although it showed that imipramine had an overall higher incidence of
adverse events. One systematic review showed no significant difference
between low-dose and standard-dose tricyclic antidepressants in the
proportion of responders at six to eight weeks. One systematic review
showed that combined antidepressants (primarily tricyclic
antidepressants) with benzodiazepines increased response rates within
one week compared with antidepressants alone, although this difference
was not significant at six weeks.

**SSRIs and Related Drugs vs. Other Prescription Antidepressant Drugs.**
Three systematic reviews showed no significant difference in outcomes
with different kinds of antidepressant drugs, although one systematic
review showed that SSRIs were less effective than venlafaxine in
increasing the proportion of persons who responded. RCTs including
persons with major depression showed similar response rates for
fluoxetine and reboxetine at six weeks, but they showed that reboxetine
may be slightly more effective in improving social functioning. One RCT
showed that mirtazapine was significantly more effective than sertraline
during the first two weeks of treatment, although this benefit did not
last longer than two weeks. Another RCT showed no significant difference
between paroxetine and mirtazapine after 24 weeks.

One systematic review showed that SSRIs were associated with fewer
adverse effects than tricyclic antidepressants, but the difference was
small. Two systematic reviews, one retrospective cohort study, and two
case-control studies showed contradictory evidence about the risk of
suicide in adults treated with SSRIs. One of the systematic reviews and
the case-control studies reported no significant difference in risk of
suicide between SSRIs and tricyclic antidepressants. One RCT and
observational data suggested that abrupt withdrawal of SSRIs was
associated with adverse symptoms (e.g., dizziness, rhinitis) and that
these symptoms were more likely to occur with drugs with a short
half-life (e.g., paroxetine). There is evidence of publication bias in
trials of SSRIs.

Current evidence indicates no clear relationship between SSRIs and
increased suicide in adults; however, SSRIs and tricyclic
antidepressants may induce or worsen suicidal ideation and behavior
during the early phases of treatment. This may be because of increased
agitation and activation. SSRIs generally increase adverse events in
children and adolescents compared with placebo, and regulatory
authorities in several countries are reviewing the safety of these
drugs.

**MAOIs vs. Other Prescription Antidepressant Drugs.** Three systematic
reviews showed no significant difference in outcomes with different
kinds of antidepressant drugs. One systematic review showed that MAOIs
were less effective than tricyclic antidepressants in persons with
severe depressive disorders. However, the review showed that MAOIs may
be more effective for atypical depressive disorders with biologic
features (e.g., increased sleep and appetite).

**Venlafaxine vs. Other Prescription Antidepressant Drugs.** One
systematic review and one RCT showed no significant difference between
venlafaxine and tricyclic antidepressants in the proportion of persons
who responded to treatment over one to 12 months. The review showed that
venlafaxine increased the proportion of persons who responded compared
with SSRIs, although one subsequent RCT showed no significant difference
between extended-release venlafaxine and escitalopram. One RCT showed no
significant difference between venlafaxine and mirtazapine in the
proportion of persons who responded, but both treatments improved
baseline depressive symptoms.

**Electroconvulsive Therapy (in Severe Depression).** One systematic
review including persons, mostly inpatients, with moderate to severe
depressive disorder showed that electroconvulsive therapy improved
symptoms over one to six weeks compared with simulated electroconvulsive
therapy or antidepressant drugs. The review showed that bilateral
electroconvulsive therapy improved symptoms compared with unilateral
therapy and that high-dose electroconvulsive therapy was more effective
than low-dose therapy. The degree of reported short-term cognitive
impairment seemed to be inversely related to treatment effectiveness.

Another systematic review provided insufficient evidence to assess
electroconvulsive therapy in older adults. Electroconvulsive therapy is
a short-term treatment and may be inappropriate for some patients;
therefore, the consensus is that the therapy normally should be reserved
for persons who cannot tolerate or have not responded to
antidepressants. Electroconvulsive therapy may be useful when a rapid
response is required.

**Cognitive Therapy (in Mild to Moderate Depression).** One systematic
review including younger and older adults showed that cognitive therapy
improved symptoms compared with no treatment. Three systematic reviews
including younger and older adults with mild to moderate depression
showed that psychological therapies (mainly interpersonal psychotherapy
and cognitive therapy) increased the proportion of persons whose
depression was in remission over 10 to 34 weeks compared with control
(i.e., usual care, usual care plus a placebo pill, or supportive
therapy). These reviews did not report results for cognitive therapy
alone compared with control.

One systematic review showed no significant difference between cognitive
therapy and interpersonal therapy, although it showed that cognitive
therapy was more successful than combined interpersonal therapy, brief
psychodynamic therapy, or supportive therapy. One systematic review
showed no significant difference between short-term psychodynamic
psychotherapy and cognitive therapy in remission rates or improvement of
depressive symptoms. One systematic review of poor-quality RCTs
including persons 55 years or older with mild to moderate depression
showed no significant difference in symptom improvement between
psychological treatments (e.g., cognitive therapy, cognitive behavior
therapy) and no treatment.

**Interpersonal Psychotherapy (in Mild to Moderate Depression).** Two
systematic reviews including adults with mild to moderate depression
showed that psychological therapies increased the proportion of persons
whose depression was in remission over 10 to 34 weeks compared with
control. These reviews did not report results for interpersonal therapy
alone compared with control. One RCT identified by a third review showed
that interpersonal therapy increased response rates compared with usual
care, although the review showed no difference between cognitive therapy
and interpersonal therapy. One RCT showed that group interpersonal
psychotherapy improved depressive symptoms in adults in Uganda compared
with no treatment. One systematic review including older adults showed
no significant difference among interpersonal therapy, psychodynamic
psychotherapy, and no treatment.

Likely to be beneficial

**Reboxetine vs. Other Antidepressant Drugs (in Mild to Moderate or
Severe Depression).** Two RCTs that primarily included persons with
severe depression showed no significant difference in symptoms at four
weeks among reboxetine, desipramine, and imipramine, but results were
sensitive to the outcome scales used. RCTs including persons with major
depression showed similar response rates at six weeks between reboxetine
and fluoxetine, although reboxetine may have slightly improved social
functioning.

**St. John\'s Wort (More Effective Than Placebo, as Effective as Other
Antidepressants in Mild to Moderate Depression).** One systematic review
showed that St. John\'s wort (*Hypericum perforatum*) improved
depressive symptoms over four to 12 weeks compared with placebo. The
review showed no significant difference between St. John\'s wort and
tricyclic antidepressants or SSRIs. The results of the RCTs should be
interpreted cautiously, because many patients did not use standardized
preparations of St. John\'s wort and dosages of antidepressants varied.
Questions have been raised regarding the methodologic quality of
available studies, which have examined heterogenous patient populations
and have used standardized symptom rating instruments inconsistently.
St. John\'s wort likely interacts with many more drugs than previously
reported.

**Nondirective Counseling (in Mild to Moderate Depression).** One
systematic review including persons 18 years or older with recent-onset
psychological problems, including depression, showed that brief,
nondirective counseling in the primary care setting reduced short-term
(less than six months) symptom scores in persons with mild to moderate
depression compared with usual care. However, the review showed no
significant difference in long-term (more than six months) scores. One
RCT showed that eight counseling sessions significantly improved anxiety
and depression symptoms compared with no treatment.

**Combining Prescription Antidepressant Drugs and Psychological
Treatments (in Mild to Moderate and Severe Depression).** Two systematic
reviews showed that a combination of pharmacotherapy and psychotherapy
improved depressive symptoms compared with either treatment alone. One
subsequent poor-quality RCT showed no significant difference in response
rate between a combination of interpersonal therapy and sertraline and
either therapy alone. A subsequent RCT showed no significant difference
between short-term psychodynamic psychotherapy plus antidepressants and
antidepressants alone, although subgroup analysis showed that
combination therapy was more effective in persons with depression and a
personality disorder.

Unknown effectiveness

**Problem-Solving Therapy (in Mild to Moderate Depression).** One
systematic review including younger and older adults presenting to
primary care physicians with mild to moderate depression showed that
psychological therapies (including problem-solving therapy) improved
outcomes compared with usual care. The review did not report results of
problem-solving therapy alone in persons with moderate depression. It
showed no significant difference between problem-solving therapy and
usual care in symptoms at six to 11 weeks in persons with mild
depression or dysthymia. One large subsequent RCT showed that
problem-solving therapy increased the proportion of persons who were not
depressed at six months compared with usual care. However, it showed no
significant difference at one year. A smaller RCT showed no significant
difference between problem-solving therapy and usual care in symptoms at
eight or 26 weeks in persons, most of whom were depressed, presenting to
primary care physicians with emotional disorders. RCTs showed
insufficient evidence to assess the relative effectiveness of drug and
nondrug treatments of severe depression.

**Befriending (in Mild to Moderate Depression).** One small RCT provided
insufficient evidence to assess befriending in persons with mild to
moderate depression.

**Exercise (in Mild to Moderate Depression).** One systematic review
including adults showed limited evidence from poor-quality RCTs that
exercise may improve symptoms compared with no treatment, and that it
may be as effective as cognitive therapy. One poor-quality RCT including
older adults identified by the review showed limited evidence that
exercise may be as effective as antidepressant drugs in improving
symptoms and may reduce relapse over 10 months.

**Lithium Augmentation.** RCTs provided insufficient evidence to assess
augmentation of prescription antidepressants with lithium in younger and
older adults with treatment-resistant depression.

**Pindolol Augmentation.** RCTs provided insufficient evidence to assess
augmentation of prescription antidepressants with pindolol in younger
and older adults with treatment-resistant depression.

Which interventions reduce relapse rates?

Beneficial

**Continuing Prescription Antidepressant Drugs (Reduced Risk of Relapse
After Recovery in Persons with Mild to Moderate Depression).** One
systematic review showed that continuing prescription antidepressant
drug treatment after recovery reduced the proportion of persons who
experienced a relapse over one to three years compared with placebo. The
effect of continuing antidepressant therapy was independent of the
underlying risk of relapse, the duration of treatment before
randomization, or the duration of previous antidepressant treatment.

Five subsequent RCTs also showed that continuing antidepressant
treatment reduced absolute risk of recurrence by up to one half compared
with treatment discontinuation. Two RCTs including persons 60 years or
older showed that continued treatment after recovery with dosulepin
(dothiepin) or citalopram reduced the risk of relapse over one to two
years compared with placebo, but it may increase the risk of ischemic
heart disease. One RCT showed no benefit from continuing treatment with
sertraline for another two years compared with placebo.

Unknown effectiveness

**Cognitive Therapy (Weak Evidence That May Reduce Relapse Over One to
Two Years After Stopping Treatment in Persons with Mild to Moderate
Depression Compared with Antidepressant Drugs).** One systematic review,
including younger and older adults with mild to moderate depression,
that combined relapse rates across RCTs showed limited evidence that
cognitive therapy reduced the risk of relapse over one to two years
after stopping treatment compared with antidepressant drugs. Four
subsequent RCTs showed limited evidence that cognitive therapy reduced
relapse rates up to one year after remission. We found no systematic
review or RCT that specifically included older adults.

**Relapse Prevention Program (Improved Symptoms Over One Year After
Recovery in Persons with Mild to Moderate Depression but No Significant
Difference in Relapse Rates).** One RCT identified by a systematic
review showed that a relapse prevention program improved depressive
symptoms over one year compared with usual care in persons who had
recovered after eight weeks of antidepressant treatment. However, there
were no significant differences in relapse rates.

What are the effects of interventions to improve delivery of treatments?

Likely to be beneficial

**Care Pathways (in Mild to Moderate Depression).** Two systematic
reviews and eight subsequent RCTs showed that care pathways improved the
effectiveness of treatment for depression (i.e., antidepressant drugs or
cognitive behavior therapy) compared with usual care in persons older
than 18 years with mild to moderate depression. These pathways included
collaboration between primary care physicians and psychiatrists,
intensive patient education, case management, and telephone support. The
RCTs also showed that clinical practice guidelines and educational
strategies without other organizational processes did not improve
detection or outcome of depression compared with usual care. It was not
possible to determine from the results which components of care pathways
were most effective.

One RCT including older persons with depression showed that initial care
by a community mental health team did not improve depressive symptoms
compared with usual care from a primary physician. Another RCT showed
that management of depression in older persons by a community nurse
improved symptoms and increased recovery after three months compared
with usual primary care. One RCT including persons older than 60 years
with major depression, dysthymic depression, or both who were treated in
a variety of primary care clinics showed that collaborative care was
more effective than usual care in reducing depressive symptoms. One RCT
showed that treatment recommendations had no significant effect on
depressive symptoms in older persons compared with usual primary care.
However, diagnosis of depression and antidepressant prescribing were
more prevalent in the intervention group.

<http://www.aafp.org/afp/20060601/bmj.html>

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

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

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

Toremifene Is Effective Therapy for Mastalgia

**Clinical Question:** Is toremifene (Fareston) an effective treatment
for mastalgia?

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

**Synopsis:** Mastalgia (i.e., painful symptoms of the breast) is the
most common clinical complaint in women with benign breast disease.
Toremifene is a new selective estrogen receptor modulator that is
equally as effective as, but less toxic than, tamoxifen (Nolvadex) in
the treatment of breast cancer. To evaluate the benefit of toremifene
for the treatment of mastalgia, the investigators performed a
randomized, double-blind (concealed allocation assignment) trial of 195
women with persistent (i.e., lasting longer than six months) mastalgia.
They assigned patients to toremifene 30 mg daily or matched placebo for
three menstrual cycles. Patients were recruited from a breast disease
pain clinic, and from this group the authors included only the most
severe cases. Thus, generalizability to routine practice is suspect.

Participants were blinded to treatment group assignment and
self-reported the severity of breast pain using a visual analog scale
from 0 (no pain) to 10 (worst pain). A 50 percent reduction in total
pain score for the three months met criteria for a clinically
significant treatment response. Follow-up occurred for all subjects at
three months. Using intention-to-treat analysis, women receiving
toremifene reported a significant reduction in total breast pain
compared with those receiving placebo (69.2 versus 31.9 percent,
respectively; number needed to treat = 3; 95% confidence interval, 2 to
4). Women with cyclical mastalgia had a higher response rate to
toremifene than those with noncyclical pain. Adverse events in both
groups included menses disturbance, dizziness, vaginal discharge, and
nausea. Overall, the incidences of adverse events were the same in both
groups.

**Bottom Line:** Toremifene effectively relieves moderate to severe
mastalgia. Women with cyclical mastalgia received the greatest treatment
benefit. (Level of Evidence: 1b)

[**http://www.aafp.org/afp/20060515/tips/14.html**](http://www.aafp.org/afp/20060515/tips/14.html)

Low-Fat, High-Carbohydrate Diet Does Not Cause Obesity

**Clinical Question:** Do low-fat, high-carbohydrate diets increase the
risk of obesity among postmenopausal women?

**Bottom Line:** Following long-term recommendations to reduce dietary
fat and increase consumption of fruits, vegetables, and whole grains
does not cause weight gain among postmenopausal women. (Level of
Evidence: 2b)

###### Howard BV, et al. Low-fat dietary pattern and weight change over 7 years: the Women\'s Health Initiative Dietary Modification Trial. JAMA January 4, 2006;295:39-49.

<http://www.aafp.org/afp/20060501/tips/8.html>

Duloxetine Is Effective for Fibromyalgia in Some Women

**Clinical Question:** Is duloxetine (Cymbalta) effective in controlling
symptoms in women with fibromyalgia?

**Bottom Line:** Duloxetine is effective in some women with
fibromyalgia, whether or not they are depressed. (Level of Evidence:
1b-)

Arnold LM, et al. A randomized, double-blind, placebo-controlled trial
of duloxetine in the treatment of women with fibromyalgia with or
without major depressive disorder. Pain December 15, 2005;119:5-15

[[http://www.aafp.org/afp/20060601/tips/18.html]{.underline}](http://www.aafp.org/afp/20060601/tips/18.html)

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

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

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

**Use of Hormonal Contraception in Women With Coexisting Medical
Conditions**

**Practice Bulletin, No, 73**

Summary of Recommendations and Conclusions

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

-   A history of benign breast disease or a positive family history of
    breast cancer should not be regarded as contraindications to oral
    contraceptive use.

-   Combination oral contraceptives are safe for women with mild lupus
    who do not have antiphospholipid antibodies.

-   Combination contraceptives are not recommended for women with a
    documented history of unexplained venous thromboembolism or venous
    thromboembolism associated with pregnancy or exogenous estrogen use,
    unless they are taking anticoagulants.

-   Combination oral contraceptives should be prescribed with caution,
    if ever, to women who are older than 35 years and are smokers.

-   Use of the levonorgestrel intrauterine system is appropriate for
    women with diabetes without retinopathy, nephropathy, or other
    vascular complications.

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

-   Healthy, nonsmoking women doing well on a combination contraceptive
    can continue their method until the ages of 50--55 years, after
    weighing the risks and benefits.

-   Progestin-only oral contraceptives and DMPA can be initiated safely
    at 6 weeks postpartum in lactating women and immediately postpartum
    in nonbreastfeeding women.

-   Combination contraceptives are not recommended as the first choice
    for breastfeeding women because of the possible negative impact of
    contraceptive doses of estrogen on lactation. However, use of
    combination contraceptives by well-nourished breastfeeding women
    does not appear to result in infant development problems; therefore,
    their use can be considered once milk flow is well established.

-   Women with well-controlled and monitored hypertension who are aged
    35 years or younger are appropriate candidates for a trial of
    combination contraceptives, provided they are otherwise healthy,
    show no evidence of end-organ vascular disease, and do not smoke.

-   The use of combination contraceptives by women with diabetes should
    be limited to such women who do not smoke, are younger than 35
    years, and are otherwise healthy with no evidence of hypertension,
    nephropathy, retinopathy, or other vascular disease.

-   The use of combination contraceptives may be considered for women
    with migraine headaches if they do not have focal neurologic signs,
    do not smoke, are otherwise healthy, and are younger than 35 years.
    Although cerebrovascular events rarely occur among women with
    migraines who use combination oral contraceptives, the impact of a
    stroke is so devastating that clinicians should consider the use of
    progestin-only, intrauterine, or barrier contraceptives in this
    setting.

-   Because of the increased risk of venous thrombotic embolism,
    combination contraceptives should be used with caution in women
    older than 35 years who are obese.

-   In women with depressive disorders, symptoms do not appear to worsen
    with use of hormonal methods of contraception.

-   If oral contraceptives are continued before major surgery, heparin
    prophylaxis should be considered.

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

-   Most women with controlled dyslipidemia can use combination oral
    contraceptives formulated with 35 mcg or less of estrogen. In women
    with uncontrolled LDL cholesterol greater than 160 mg/dL, a
    triglyceride level greater than 250 mg/dL, or multiple additional
    risk factors for coronary artery disease, alternative contraceptives
    should be considered.

-   Depot medroxyprogesterone acetate has noncontraceptive benefits and
    is appropriate for women with sickle cell disease.

-   Progestin-only contraceptives may be appropriate for women with
    coronary artery disease, congestive heart failure, or
    cerebrovascular disease. However, combination contraceptives are
    contraindicated in these women.

-   Short- or long-term use of DMPA in healthy women should not be
    considered an indication for DXA or other tests that assess bone
    mineral density. In adolescents, the advantages of DMPA likely
    outweigh the theoretical safety concerns regarding bone mineral
    density and fractures. However, in the absence of long-term data in
    this population, consideration of long-term use should be
    individualized.

Use of hormonal contraception in women with coexisting medical
conditions. ACOG Practice Bulletin No. 73. American College of
Obstetricians and Gynecologists. Obstet Gynecol 2006:107:1453--72.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16738183>

**Noncontraceptive Uses of the Levonorgestrel Intrauterine System,
Committee Opinion**

ABSTRACT: The levonorgestrel intrauterine system, approved for
contraceptive use for up to 5 years, also has noncontraceptive uses. It
appears to reduce menstrual bleeding significantly in women with
idiopathic menorrhagia. Current studies suggest that menopausal hormone
therapy regimens combining the levonorgestrel intrauterine system with
estradiol are effective in reducing climacteric symptoms and in inducing
amenorrhea in most women after 1 year. Further studies are required
before this device can be recommended as a treatment for
endometriosis-associated pelvic pain, hyperplasia, or endometrial
adenocarcinoma, or as adjuvant therapy with tamoxifen.

Noncontraceptive uses of the levonorgestrel intrauterine system. ACOG
Committee Opinion No. 337. American College of Obstetricians and
Gynecologists. Obstet Gynecol 2006;107:1479--82.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16738186>

**Analgesia and Cesarean Delivery Rates**

ABSTRACT: Neuraxial analgesia techniques are the most effective and
least depressant treatments for labor pain. The American College of
Obstetricians and Gynecologists previously recommended that
practitioners delay initiating epidural analgesia in nulliparous women
until the cervical dilatation reached 4--5 cm. However, more recent
studies have shown that epidural analgesia does not increase the risks
of cesarean delivery. The choice of analgesic technique, agent, and
dosage is based on many factors, including patient preference, medical
status, and contraindications. The fear of unnecessary cesarean delivery
should not influence the method of pain relief that women can choose
during labor.

Analgesia and cesarean delivery rates. ACOG Committee Opinion No. 339.
American College of Obstetricians and Gynecologists. Obstet Gynecol
2006;107:1487--8.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16738188>

**Tamoxifen and Uterine Cancer**

ABSTRACT: Tamoxifen may be associated with endometrial proliferation,
hyperplasia, polyp formation, invasive carcinoma, and uterine sarcoma.
Any symptoms of endometrial hyperplasia or cancer reported by a
postmeno-pausal woman taking tamoxifen should be evaluated.
Premenopausal women treated with tamoxifen have no known increased risk
of uterine cancer and as such require no additional monitoring beyond
routine gynecologic care. If atypical endometrial hyperplasia develops,
appropriate gynecologic management should be instituted, and the use of
tamoxifen should be reassessed.

Tamoxifen and uterine cancer. ACOG Committee Opinion No. 336. American
College of Obstetricians and Gynecologists. Obstet Gynecol
2006;107:1475--8.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16738185>

**Patient-Requested Cesarean Update: Cesareans should be performed for
medical reasons**

Experts addressed the growing controversy of \"patient-choice\"
cesarean, recently dubbed \"cesarean delivery on maternal request
(CDMR),\" at a news briefing during The American College of
Obstetricians and Gynecologists\' (ACOG) 54th Annual Clinical Meeting in
Washington, DC. The increasing number and rate of cesarean deliveries in
the US over the past three decades has been of interest to ACOG,
governmental agencies, and other health care entities. The issue of
whether cesarean delivery should be allowed purely on the basis of
maternal request in the absence of any medical indication has added yet
another element of intense debate.

The total cesarean delivery rates increased rapidly in the 1970s and the
1980s, although the rates declined in the late 1980s through the
mid-1990s. In 2004, 29.1% of all live births were delivered by cesarean,
according to the National Center for Health Statistics (NCHS). One of
the major drivers of the overall increase in cesarean delivery has been
that, after a cesarean delivery, the likelihood of cesarean delivery
increases in subsequent pregnancies. The increase in primary cesarean
delivery parallels the total cesarean delivery rate, which cannot,
therefore, be explained by the decreasing use of vaginal birth after
cesarean (VBAC). \"Some indications for cesarean delivery, whether
planned or emergency, include breech presentation, poor fetal heart
rate, uterine rupture, prolapsed umbilical cord, abruption placental,
and placenta previa,\" says Stanley Zinberg, MD, MS, ACOG deputy
executive vice president, and vice president of ACOG\'s Practice
Activities division.

Mary E. D\'Alton, MD, director of obstetrics and gynecology services at
Columbia University Medical Center, College of Physicians and Surgeons
in New York City, was the conference chair of the recent National
Institutes of Health State-of-the-Science Conference on Cesarean
Delivery on Maternal Request. \"One of the key points that came out of
the conference is that more research is needed. There just isn\'t
sufficient evidence at this time to fully evaluate the benefits and
risks of cesarean delivery based on maternal request compared to normal
vaginal delivery.\" There was consensus, says Dr. D\'Alton, that CDMR is
not recommended for women who are planning on having several children
since the risks of placenta previa and placenta accrete increase with
each cesarean delivery. \"While some data show an association between
both vaginal and cesarean delivery with pelvic floor problems and
incontinence later, the data are not definitive,\" according to Dr.
D\'Alton.

\"Patient-requested cesarean is but one of the many factors that have
converged over the years to produce the current cesarean rate,\" says
Fredric D. Frigoletto Jr, MD, associate chief of staff and vice chair at
Massachusetts General Hospital in Boston, and an ACOG past president.
\"At this time, the best delivery mode for any woman is best decided by
her and her physician, considering her individual circumstances. A woman
must be thoroughly and accurately informed about the risks and benefits
of each option for her as she participates in the decision,\" Dr.
Frigoletto added.

\"ACOG continues to review all of the issues surrounding
maternal-request cesarean, but at this time our position is that
cesareans should be performed for medical reasons,\" says Dr. Zinberg.
While the increase in cesarean deliveries over the years has been
significant, it\'s important to understand that there has been a
noticeable shift in the demographic of women at high risk for cesarean,
Dr. Zinberg noted. Some of these high-risk groups include women carrying
multiple fetuses conceived through fertility treatments, older women
becoming pregnant, and overweight and obese women.

Both Dr. Zinberg and Dr. D\'Alton stress that women who request cesarean
delivery in the absence of any medical indication should be counseled on
the risks associated with cesarean, including a higher risk of
infection, adhesions (painful scar tissue under the skin), pulmonary
embolisms (blood clots), complications from the use of anesthesia, and
the potential need for future cesareans, which entail additional risk.
They also pointed out that the decision to perform a CDMR should be
carefully individualized and consistent with ethical principles. \"There
is also a growing concern of the increased risk of babies born before 39
weeks of gestation; therefore, CDMR should not be performed prior to 39
weeks of gestation or without verification of lung maturity,\" says Dr.
Zinberg.

<http://www.acog.org/from_home/publications/press_releases/nr05-09-06-1.cfm>

**Screening for Fragile X Syndrome**

ABSTRACT: Fragile X syndrome is the most common inherited form of mental
retardation, affecting approximately 1 in 4,000 males and 1 in 8,000
females. DNA-based molecular analysis is the preferred method of
diagnosis for fragile X syndrome and its premutations. Prenatal testing
for fragile X syndrome should be offered to known carriers of the
premutation or mutation. Testing for fragile X syndrome should be
considered for any child with developmental delay of uncertain etiology,
autism, or autistic behavior or for any individual with mental
retardation of uncertain etiology. Women with ovarian failure or an
elevated follicle-stimulating hormone level before 40 years of age
without a known cause should be screened to determine whether they have
the fragile X premutation.

Screening for fragile X syndrome. ACOG Committee Opinion No. 338.
American College of Obstetricians and Gynecologists. Obstet Gynecol
2006;107:1483--5.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16738187>

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

**AHRQ study finds wrong-site surgery is rare and preventable**

<http://www.ahrq.gov/research/apr06/0406RA1.htm>

**Patient responses to medical errors depend on the timeliness and
quality of the physician\'s communication about the event**

<http://www.ahrq.gov/research/apr06/0406RA3.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}

**MCH Library launches redesigned web site**

The MCH Library has launched a redesigned Web site that provides
accurate, reliable, and timely information and resources for the
maternal and child health (MCH) community. The Web site contains the MCH
Alert weekly e-newsletter, resource guides, full text publications,
databases, and links to quality MCH Web sites.

A search box, an A-Z topic index, and frequently asked questions are
featured on the Web site home page. The home page also includes links to
the MCH thesaurus, final reports produced by Maternal and Child Health
Bureau grantees, an index to non-English-language materials and
resources, and resources for families. The Healthy People 2010 Web page
provides information related to MCH goals and objectives and library
products related to leading health indicators. The Web site, intended
for use by health professionals, policymakers, family advocates,
community service professionals, MCH/public health faculty and students,
and families:
[[http://www.mchlibrary.info]{.underline}](http://www.mchlibrary.info/)

##### 

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

**Early breastfeeding choice, GDM, and BMI**

When a mother has diabetes during pregnancy, she has more to worry
about. Among other diabetes related concerns, her baby has a greater
risk for being large for gestational age, developing type 2 diabetes at
an early age. Also, studies indicate that if are babies born large for
gestational age, they are likely to stay over weight or obese as they
grow.

But there is hope that more children born to mothers with gestational
diabetes mellitus (GDM) can avoid early childhood obesity and its risk
of later adult obesity, and so possibly diabetes. A study by
Schaefer-Graf et al in Germany found that early feeding choice could
change risk of overweight for children from mothers with GDM.

During 1995-2000, 2000 women with GDM were cared for at the Vivantes
Medical Center in Berlin, Germany. Later, many returned for follow-up,
including 354 children (54% males, 46% females) who were included in
this study. The mean age was 5.4 + 1.6 years, 28.4% were overweight.
Overweight prevalence by feeding choice was:

> Children not breastfed 37.3%.
>
> Children breastfed up to 3 months 32.5%
>
> Children breastfed more than 3 months 22.0%

The impact of breastfeeding as a preventive measure was maintained after
adjusting for confounding factors such as parental obesity and high
birth weight. The authors concluded that "the risk of childhood
overweight may be reduced by 40-50% when breastfeeding is \>3 months."

For more information about this study, please see the complete article
by Schaefer-Graf UM et al, Association of Breast-feeding and Early
Childhood Overweight in Children From Mothers With Gestational Diabetes
Mellitus, Diabetes Care, Vol:29, Number 5, May 2006, pp 1105-1007.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16644645>

**Other**

**Intervention to Increase Breastfeeding Rates**

Overall, the patients in the control group had a 90 percent greater risk
of low breastfeeding rates at three months and a 150 percent greater
risk at 12 months. Women in the intervention group maintained a 50
percent rate of breastfeeding at six months compared with 33 percent in
the control group. Women born in the United States had much lower
breastfeeding intensity than foreign-born women. The authors suggest
that prenatal visits and postpartum home visits were important
contributors to the intervention\'s success. They acknowledge, however,
that the intervention was labor intensive.

CONCLUSIONS: This \"best-practices\" intervention was effective in
increasing breastfeeding duration and intensity. Breastfeeding promotion
should focus on US-born women and exclusive breastfeeding

Bonuck KA, et al. Randomized, controlled trial of a prenatal and
postnatal lactation consultant intervention on duration and intensity of
breastfeeding up to 12 months. Pediatrics December 2005;116:1413-26.

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16322166**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16322166) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids16322166 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Study hints at link between breastfeeding and intelligence**

<http://www.ahrq.gov/research/apr06/0406RA12.htm>

####  {#section-20 .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}

May 2006 Highlights include

\-[Maternal periodontal disease in early pregnancy:
Small-for-gestational-age
infant](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0506_AOM.cfm)

\-[Improve colorectal cancer screening: Contribute to this
survey](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0506_Coll.cfm)

\-[Counterpoint: Not Yet Time to Use the P:C Ratio for
pre-eclampsia](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0506_HT.cfm#ob)

\-[FDA: Vaccine to Prevent Cervical Cancer Is Safe,
Effective](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0506_HT.cfm#gyn)

\-[Relationship between team sport participation and adolescent
smoking](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0506_HT.cfm#child)

\-[Caring for Patients After Bariatric
Surgery](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0506_HT.cfm#chrIll)

\-[ACOG Recommends First Ob-Gyn Visit in Early
Teens](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0506_Feat.cfm#acog)

-ACOG: [Hepatitis B and Hepatitis C Virus Infections, Committee
Opinion](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0506_Feat.cfm#acog)

\-[31% of Sexually Active U.S. Teenage Girls Become
Pregnant](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0506_Feat.cfm#fp)

\-[Are there any cultural barriers/among Native Americans to becoming
cord blood
donors?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0506_Feat.cfm#faq)

\-[What was the common theme in these 2
cases?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0506_Feat.cfm#mmtour)

\-[Routine use of sweeping of membranes from 38 weeks of pregnancy
onwards](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0506_Feat.cfm#MidWives)

\-[Methamphetamine abuse among women on Navajo (Part 2 of
4)](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0506_Feat.cfm#navajo)

\-[Native American Scholarship Opportunities at the School of
Nursing](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0506_Feat.cfm#nurseCorner)

\-[Female Sexual
Dysfunction](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0506_Feat.cfm#okie)

\-[Factors Associated With Rise in Primary Cesarean Births in the United
States](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0506_Feat.cfm#periPicks)

\-[Adverse Childhood Events: Impact on chronic adult illness / Risk
taking](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0506_Feat.cfm#pcf)

\-[Prediction of Pelvic Inflammatory Disease Among Young, Single,
Sexually Active
Women](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0506_Feat.cfm#std)

\-[Long-term Dietary Intervention May Reduce Risk for Insulin Resistance
in
Children](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0506_Feat.cfm#stillW)

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0506.cfm**](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0506.cfm) {#httpwww.ihs.govmedicalprogramsmchmobgyn0506.cfm .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-21 .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-22 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**DV: A cause of major morbidity and mortality, 4x more common than
breast cancer, cannot be ignored**

The present investigation focusing on intimate partner violence \[IPV\]
prevalence in a cohort of insured, employed, educated, English-speaking
U.S. women provides new knowledge on the high prevalence, several
dimensions of chronicity, severity, and interrelatedness of IPV types.

The authors found that

\* Over 14% of the women reported IPV of any type in the past 5 years,
and 7.9% in the past year.

\* Many women reported more than one IPV type. For example, among the

138 women with physical abuse (not sexual) in the past 5 years, 28

(20.3%) experienced physical abuse only, while 79.7% also experienced
other types of IPV. Of the 138 women reporting physical abuse, 84

(60.9%) experienced a total of two to three types of IPV, and 26

(18.8%) experience four to five types.

\* Between 10% and 21% (depending on IPV type) of the women who reported
IPV reported abuse by two or more partners.

\* The proportion of women with IPV rating it as moderately to extremely
violent was 61% for physical violence, 45% for sexual intercourse, 36%
for forced sexual contact, 63% for fear due to a partner\'s threats or
anger, and 31% for controlling behavior.

\* IPV risk was higher among younger women, women with lower incomes,
women with less education, women who were single mothers, and women who
had been exposed to any form of abuse as a child or who had witnessed
IPV as a child.

From the present work, a picture emerges of both physical and
non-physical IPV as very common, chronic, intergenerational, and present
in highly overlapping forms. A cause of major morbidity and mortality,
which is fourfold more common than breast cancer, cannot be ignored.

Thompson RS, Bonomi AE, Anderson M, et al. 2006. Intimate partner
violence: Prevalence, types, and chronicity in adult women. American
Journal of Preventive Medicine 30(6):447-457.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16704937>

Readers: More information about domestic violence is available from the
MCH Library\'s knowledge path at
[[http://www.mchlibrary.info/KnowledgePaths/kp_domviolence.html]{.underline}](http://www.mchlibrary.info/KnowledgePaths/kp_domviolence.html)

**Physical Dating Violence Among High School Students -- United States,
2003**

CDC analyzed the prevalence of physical dating violence (PDV)
victimization among high school students. The results indicated that
8.9% of students (8.9% of males and 8.8% of females) reported PDV
victimization during the 12 months preceding the survey and that
students reporting PDV victimization were more likely to engage in four
of five risk behaviors.

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5519a3.htm>

**50% with female cancers: History of violence correlates with advanced
stage at diagnosis**

CONCLUSION: A history of violence in breast, ovarian, endometrial, and
ovarian cancer patients was extremely common and correlated with
advanced stage at diagnosis.

LEVEL OF EVIDENCE: II-2

Modesitt et al Adverse Impact of a History of Violence for Women With
Breast, Cervical, Endometrial, or Ovarian Cancer. Obstetrics &
Gynecology 2006;107:1330-1336

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16738160>

**Launch of Choose Respect Initiative!**

Choose Respect is an initiative to help adolescents form healthy
relationships to prevent dating abuse before it starts. Learn about this
new initiative and what you can do to promote healthy relationships in
your community. <http://www.cdc.gov/ncipc/dvp/DatingViolence.htm>

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

#### September 1, 2006: Palliative Medicine\'s Role in the Continuity of Care Moderator: Tim Domer, M.D.

-   Management of acute vs chronic pain

-   Quality of Life in chronic illness

-   The meaning of \"Code Status\"

-   Preparing for a \"Good Death\"

-   End-of-Life Care as part of Continuity of Care and Prevention

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

[http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForum.cfm#](http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForum.cfm#disc)

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

**Refusals by pharmacists to dispense emergency contraception: a
critique**

Over the past several months, numerous instances have been reported in
the United States media of pharmacists refusing to fill prescriptions
written for emergency postcoital contraceptives. These pharmacists have
asserted a \"professional right of conscience\" not to participate in
what they interpret as an immoral act. In this commentary, we examine
this assertion and conclude that it is not justifiable, for the
following reasons: 1) postcoital contraception does not interfere with
an implanted pregnancy and, therefore, does not cause an abortion; 2)
because pharmacists do not control the therapeutic decision to prescribe
medication but only exercise supervisory control over its dispensation,
they do not possess the \"professional right\" to refuse to fill a
legitimate prescription; 3) even if one were to grant pharmacists the
\"professional right\" not to dispense prescriptions based on their own
personal values and opinions, pharmacists \"at the counter\" lack the
fundamental prerequisites necessary for making clinically sound ethical
decisions, that is, they do not have access to the patient\'s complete
medical background or the patient\'s own ethical preferences, have not
discussed relevant quality-of-life issues with the patient, and do not
understand the context in which the patient\'s clinical problem is
occurring. We conclude that a policy that allows pharmacists to dispense
or not dispense medications to patients on the basis of their personal
values and opinions is inimical to the public welfare and should not be
permitted.

[Wall
LL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Wall+LL"%5BAuthor%5D),
[Brown
D](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Brown+D"%5BAuthor%5D).
Refusals by pharmacists to dispense emergency contraception: a critique.
[Obstet Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');)
2006 May;107(5):1148-51.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16648422&dopt=Abstract>

**Discussion needed: Reasons why women discontinue oral contraception**

RESULTS: Most women who reported having discontinued OCs did so because
of medical side effects, and most had switched to less effective
methods. Among OC users, 26.4% had sexual intercourse on days they
missed pills just before or after their placebo week. Nonadherence did
not differ by socioeconomic factors or obesity. CONCLUSION: Clinicians
may need to encourage their patients to discuss their reasons for
wanting to discontinue the use of an effective contraceptive method and
assist them with their concerns or to switch to other effective methods
to protect themselves from unintended pregnancy.

[Huber
LR](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Huber+LR"%5BAuthor%5D),
et al Contraceptive use and discontinuation: findings from the
contraceptive history, initiation, and choice study. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
May;194(5):1290-5\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16647912>

# Fertility, Contraception, and Fatherhood: 2002 National Survey of Family Growth        

The Centers for Disease Control and Prevention has issued a
comprehensive report on fertility, contraception, and fatherhood
indicators among men 15-44 years of age in the United States. The data
are from the National Survey of Family Growth conducted in 2002. It's
the latest survey of this type, and\--for the first time\--this
large-scale, nationwide survey includes men. Whenever appropriate, the
findings for men and women are contrasted. Men's and women's
reproductive experiences vary significantly, and often sharply, by
characteristics such as education, income, and Hispanic origin and race.

-Teen fathers - Among non-Hispanic black fathers, 25 percent fathered
their first child before they were 20 years old; 19 percent of Hispanic
fathers also became fathers as teenagers, and 11 percent of non-Hispanic
white men became fathers while they were teens.

-Nonmarital childbearing -- About one-half of the men without a high
school education have fathered a child outside of marriage compared with
about 6 percent among college graduates.

-Child support -- About three-quarters of the 28 million men who have
children (under age 19) live with those children. Among fathers who live
apart from their children, 85 percent of fathers with higher incomes
contributed to their children's support on a regular basis, compared
with 64 percent of fathers with income below the poverty level.

-Marriage and divorce - A third of men marry by age 25; almost
two-thirds marry by age 30. Among women, one-half are married by the
time they are 25 and three-quarters by age 30. Overall, men marry later
in life than women. The average woman marries a man 2 years older than
she. One-half of the men who married as teenagers were divorced or
separated within 10 years, compared with 17 percent of men who married
at 26 years or over.

-Sexual activity - Men who did not live with both parents at age 14 were
more likely to have had sexual intercourse during the teenage years (19
or younger) compared with those who lived with both parents at age 14.

Fertility, Contraception, and Fatherhood: Data from the 2002 National
Survey of Family Growth Martinez, GM, Chandra A, Abma J, Jones, J,
Mosher W. <http://www.cdc.gov/nchs>

Levonorgestrel-Releasing Intrauterine System (Mirena) for Contraception

The levonorgestrel-releasing intrauterine system (Mirena) is a T-shaped
intrauterine device (IUD), 1.3 inches (32 mm) in length and width, that
releases levonorgestrel. It is labeled for use as a contraceptive agent
for up to five years.

[Bottom Line]{.underline}

The levonorgestrel-releasing intrauterine system is a reliable,
reversible, low-maintenance method of long-term contraception. Rates of
failure are similar to those of female sterilization, and the risk of
expulsion is minimal for most users.
<http://www.aafp.org/afp/20060515/steps.html>

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

#### From Candace Jones, HQE and Terry Cullen, Tucson {#from-candace-jones-hqe-and-terry-cullen-tucson .Style-Heading-4-+-Arial-14-pt-Underline}

#### This is a GREAT site for Health Promotion Disease Prevention Utah Department of Health [**http://www.ibis.health.utah.gov/**](http://www.ibis.health.utah.gov/) {#this-is-a-great-site-for-health-promotion-disease-prevention-utah-department-of-health-httpwww.ibis.health.utah.gov .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

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

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

Go here to explore the frequently asked question page

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

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

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

**June 2006 Highlights**

\- Wrist Fractures in children - All those kids who sawed off their own
casts were right

\- Developmental Dyslplasia of the Hip - US Preventive Task Force and
AAP differ over value of screening

\- Watch out for mumps. It is spreading out of Iowa

\- Doug Esposito weighs in on health disparities for urban Indians

[[http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ICHN606.doc]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ICHN606.doc)

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

**RPMS Behavioral Health System Patch Release Announcement, June 1,
2006**

The Indian Health Service Office of Information Technology and the
Division of Behavioral Health announce the following application patch
releases:

Significant changes in the current patches include:

-   New 2006 ICD codes

-   Updated DSM-ICD code mapping as appropriate for 2006 ICD codes

-   Addition of new RPMS Alcohol and Depression Screening Exam Codes

-   Addition of Goal and Goal Status to Patient Education

-   Most Recently Used functionality is now patient-specific not
    user-specific where applicable

-   Sensitive Patient Tracking functionality

-   Minimize capability

-   Name of Group displays on all printed encounters

-   All printed forms include date and time of printing

-   Technical modifications to accommodate the future release of the
    Patient Chart behavioral health component in the RPMS Electronic
    Health Record

Further information including application documentation and training
opportunities can be found at the IHS RPMS website: 
<http://www.ihs.gov/Cio/RPMS/index.cfm>

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

**Nothing defines us better than providing service to colleagues less
fortunate than we**

As citizens of the United States, we have the opportunity and means to
volunteer our time and skills to assist our colleagues in less-developed
areas of the world to achieve higher quality of care for their patients.
As obstetricians and gynecologists, we have a special interest in such
humanitarian efforts. Whether it be offering emergency aid or bringing
care and expertise to clinics and hospitals in the developing world,
there are many opportunities for physicians to make a difference in the
global community.

Americans have a tradition of being generous with their time, money, and
services. Witness the recent response of the American people to the
victims of the 2004 tsunami and 2005 hurricanes. Our philanthropic
outpouring was enormous, with over \$3 billion raised by private
nonprofits for hurricane Katrina relief alone. But that should not be
surprising, because for many decades the United States has been quietly
and effectively combating disease and suffering throughout the world. We
have assisted in bringing education, medicine, and infrastructure to
developing countries worldwide.

The United States Agency for International Development (USAID) has
programs in approximately 100 countries. This agency strives to provide
education to eliminate illiteracy, agriculture to help eliminate hunger,
and know-how to produce economic growth and has made major efforts
toward improving global health. The USAID budgetary resources exceeded
\$13 billion for fiscal year 2005; these funds allow USAID to promote a
broad-based sustainable effort and provide humanitarian assistance in
the developing world.

The United States is also the major contributor to the World Health
Organization, which provides critical health measures globally. The
World Health Organization plays an extremely important role in fighting
the acquired immunodeficiency syndrome (AIDS) scourge, detecting
outbreaks of epidemics, and combating many other diseases worldwide.

There are myriad nongovernmental organizations through which Americans
participate with donations and services. Nongovernmental organizations
work predominantly in the developing world as well as anywhere a
disaster occurs. Many foundations are directed toward bringing medicine
and public health to people in need. Most notably, the Bill & Melinda
Gates Foundation has made major strides in worldwide immunizations, AIDS
prevention, and recently, prevention of prematurity. Rotary Clubs
worldwide have helped to wipe out poliomyelitis by ensuring
immunizations even in the remotest parts of the globe. They are now
considering their role in alleviating the avian influenza threat.

In all of these efforts, physicians have played a vital role. From the
American College of Obstetricians and Gynecologists (ACOG) Fellows
volunteering their surgical skills to repair fistulae (ACOG Today, April
2005) to Dr. Brown\'s 2-year volunteer effort combating the human
immunodeficiency virus (HIV)/AIDS epidemic in western Kenya (ACOG Today,
January 2006), many are giving the benefit of their skills worldwide.
Through organizations such as Doctors Without Borders/Médecins Sans
Frontières, for instance, physicians are able to aid people in
underserved areas of the globe, many of whom are affected by wars or
natural disasters.

The American College of Obstetricians and Gynecologists played a major
role in helping our neighbors in Central America decrease maternal
mortality in the Save the Mothers Initiative of FIGO. The College paired
up with 4 Central American countries: Honduras, Nicaragua, El Salvador
and Guatemala. As an outgrowth of this collaboration, the 7 Central
American countries have become a Central American Section of ACOG.

Certainly, it is not possible for everyone to pick up and travel to
remote areas to volunteer, but Fellows should develop interests in
certain projects, local or international or both, and offer support.
Moreover, Fellows are encouraged to become familiar with the local,
regional, or national organizations that are responsible for
implementing the kinds of programs in which a Fellow develops an
interest. Even letting your local congressional representative know of
your interests can aid in the establishment of worthwhile programs.
While monetary contributions are always welcome, when the propitious
time arrives, the Fellow can volunteer. What we do defines who we are in
this global community, and nothing defines us better than providing
service or support to colleagues less fortunate than we are.

[Queenan
JT](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Queenan+JT"%5BAuthor%5D).
Worldwide involvement. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
May;107(5):974-5.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16648397&dopt=Abstract>

The College maintains a list of religious and secular organizations that
sponsor volunteers in developing countries

Religious organizations:
[[http://www.acog.org/from_home/departments/international/religiousorganizations.pdf]{.underline}](http://www.acog.org/from_home/departments/international/religiousorganizations.pdf)

Secular organizations:
[[http://www.acog.org/from_home/departments/international/organizationdatabase.pdf]{.underline}](http://www.acog.org/from_home/departments/international/organizationdatabase.pdf)

**Chlorhexidine: Potential to improve maternal /newborn outcomes -
Developing countries**

TABULATION, INTEGRATION AND RESULTS: Chlorhexidine is a highly effective
killer of most bacteria, has an excellent safety profile, rarely is
associated with bacterial resistance, is easy to administer, and costs a
few cents per application. When used as a vaginal or newborn
disinfectant, it clearly reduces bacterial load, including transmission
of Group B Streptococcus from the mother to the fetus. Nevertheless, in
developed countries, chlorhexidine generally has not been shown to
significantly reduce life-threatening maternal or neonatal infections.
However, 2 large but not randomized studies, one in Malawi and the other
in Egypt, suggest that important reductions in maternal and neonatal
sepsis and neonatal mortality may be achievable with vaginal or neonatal
chlorhexidine treatment.

CONCLUSION: With 4 million neonates and about 700,000 pregnant or
recently pregnant women--mostly in developing countries--dying each
year, many from infections originating in the vagina, further study of
this highly promising treatment is indicated.

[Goldenberg
RL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Goldenberg+RL"%5BAuthor%5D)
et al Use of vaginally administered chlorhexidine during labor to
improve pregnancy outcomes. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
May;107(5):1139-46.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16648420&dopt=Abstract>

**Report on Children and Families Displaced by Hurricanes Katrina and
Rita**

The findings from the first comprehensive face-to-face field survey of
residents living in FEMA-subsidized shelters following Hurricanes
Katrina and Rita reveal a host of under-or untreated medical and mental
health conditions affecting adults and children. The study was part of
an ongoing needs assessment by Operation Assist, a collaborative effort
of the Children's Health Fund and The National Center for Disaster
Preparedness at the Columbia University Mailman School of Public Health.
The purpose of the study was to gather information that could inform
local, state, and Federal policymakers about the health and social
service needs of displaced populations living in transitional
community-based settings, such as trailer parks and hotels with
FEMA-subsidized housing units. Key findings include poor access to care,
high rates of chronic illness, mental health issues, and gaps in
children/family welfare (decreases in stability, income and security).
[[www.hrsa.gov/womenshealth]{.underline}](../www.hrsa.gov/womenshealth)

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

**Association of poverty with overweight among adolescents, 1971 -
2004**

A widening disparity in overweight that disadvantages adolescents in
poor families has emerged in the 15- to 17-year-old age group in recent
years. The prevalence of overweight among adolescents in the United
States has more than doubled during the past three decades. Whether this
increasing prevalence is characterized by larger, smaller, or unchanged
disparities in overweight status across socioeconomic strata is not
known but is important for evaluating the success of recent efforts by
the Department of Health and Human Services to reduce health
disparities.

The authors found that

\* In general, at no year of the surveys did the prevalence of
overweight status differ significantly across poor and nonpoor families
among all adolescents ages 12-14, or within any of the racial and ethnic
subsamples. An exception was found, however, among Hispanic black
adolescents ages 12-14, for whom a disparity in adolescent overweight
reversed over time so that the prevalence of overweight was higher among
nonpoor families compared with poor families by the last years of the
surveys.

\* Differences in the prevalence of adolescent overweight were most
evident among respondents ages 15-17 in the last two surveys. In
general, the prevalence of overweight increased over the period of the
surveys at a faster rate among these adolescents from poor families
compared with their counterparts in nonpoor families.

\* A disparity in physical inactivity by family poverty was more
pronounced for older compared with younger adolescents in the
cross-sectional NHANES 1999-2004.

\* A disparity across poverty status in percentage of calories from
sweetened beverages was more pronounced for older vs. younger
adolescents in the cross-sectional NHANES 1999-2002.

These results suggest that efforts to reduce health disparities in the
United States require monitoring of population health, so that emergent
disparities and their underlying causes can be detected and addressed at
early stages of their development.

Miech RA, Kumanyika SK, Stettler NS. 2006. Trends in the association of
poverty with overweight among US adolescents, 1971-2004. JAMA, The
Journal of the American Medical Association 295(20):2385-2395.
[[http://jama.ama-assn.org/cgi/content/abstract/295/20/2385?etoc]{.underline}](http://jama.ama-assn.org/cgi/content/abstract/295/20/2385?etoc)

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

Copious post operative mucous secretions

A 60 year old female presented to her primary care provider with lower
abdominal discomfort. The patient did not complain of increasing weight
or abdominal girth, and noted no change in her appetite. The patient was
s/p vaginal hysterectomy for a history of irregular bleeding with normal
pap smears. Imaging studies revealed a complex cystic pelvic mass with
no evidence of ascites. Other medical issues included hypertension
controlled on oral medication, a one pack a day history of tobacco
smoking with no current respiratory symptoms. The patient was well
nourished had no previous history of abdominal surgery.

The patient underwent a staging laparotomy that revealed bilateral
hydrosalpinges, and was otherwise without complications. On post op day
one, the patient was afebrile and tolerated an advancing diet, but had
coarse breath sounds. On the second day post-op the patient developed
increased mucous production and had periods of desaturation. Examination
revealed rhonchi and continued coarse breath sounds. Chest X-ray
revealed complete opacification of the left hemithorax. The patient was
transferred to the Intensive Care Unit and received an urgent
bronchoscopy and was found to have tenacious mucous plugging. Her left
lung was easily reinflated. The patient rapidly improved and was
returned to the medical surgical ward the following day. The patient
continued to produce copious mucous secretions and she received vigorous
pulmonary toilet with bronchodilators and incentive spirometry.

On the day the following the bronchoscopy the patient was noted to have
several small fatty spots between her midline staples, but she was
otherwise tolerating an advancing diet, voiding, and had bowel
movements. It was felt the prolapsed subcutaneous fat was a result of
the patient's coughing due to the copious secretions. On the fourth
postoperative day, there was no wound discharge. In fact the
subcutaneous fat was becoming dehydrated so moist gauze was placed on
the wound to facilitate replacement of the slightly prolapsed
subcutaneous fat the next day. The patient was prepared for discharge on
the fifth post-operative day and it was elected to remove the staples,
replace the slightly prolapsed subcutaneous fat and then place
steristrips over the otherwise clean and dry incision. In anticipation
of discharge the patient was encouraged to stop smoking and the nature
of chronic obstructive pulmonary was discussed with the patient.

Can you think of any further discharge or wound care instructions you
would give this patient?

Stay tuned to next month's CCCC Newsletter for the rest of the story

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

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

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

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

######### 

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

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

**Clinical Discussion Board Index, Medscape**

Hundreds of ongoing clinical discussions available

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

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

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

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

**Menopause Management**

#### Testosterone Treatments: Why, When, and How? (see also Patient Education) {#testosterone-treatments-why-when-and-how-see-also-patient-education .Style-Heading-4-+-Arial-14-pt-Underline}

#### Testosterone treatment is controversial for men and even more so for women. Although long-term outcome data are not available, prescriptions for testosterone are becoming more common. Testosterone is used primarily to treat symptoms of sexual dysfunction in men and women and hot flashes in women. Potential benefits include improved libido, increased bone mass, and increased sense of well-being. In individuals with human immunodeficiency virus infection or other chronic diseases, testosterone has been shown to improve mood and energy levels, even in patients with normal testosterone levels. Testosterone can be administered by injection, patch, topical gel, pill, or implant. Side effects in men include polycythemia and acne. Side effects in women include acne, hepatotoxicity, and virilization and usually only occur when testosterone is used in supraphysiologic doses. Long-term studies of the effects of testosterone on prostate cancer, breast cancer, and heart disease have not been completed. Mammograms and monitoring of prostate-specific antigen, hematocrit, and lipid levels are recommended for patients taking testosterone. Am Fam Physician 2006;73:1591-8, 1603. {#testosterone-treatment-is-controversial-for-men-and-even-more-so-for-women.-although-long-term-outcome-data-are-not-available-prescriptions-for-testosterone-are-becoming-more-common.-testosterone-is-used-primarily-to-treat-symptoms-of-sexual-dysfunction-in-men-and-women-and-hot-flashes-in-women.-potential-benefits-include-improved-libido-increased-bone-mass-and-increased-sense-of-well-being.-in-individuals-with-human-immunodeficiency-virus-infection-or-other-chronic-diseases-testosterone-has-been-shown-to-improve-mood-and-energy-levels-even-in-patients-with-normal-testosterone-levels.-testosterone-can-be-administered-by-injection-patch-topical-gel-pill-or-implant.-side-effects-in-men-include-polycythemia-and-acne.-side-effects-in-women-include-acne-hepatotoxicity-and-virilization-and-usually-only-occur-when-testosterone-is-used-in-supraphysiologic-doses.-long-term-studies-of-the-effects-of-testosterone-on-prostate-cancer-breast-cancer-and-heart-disease-have-not-been-completed.-mammograms-and-monitoring-of-prostate-specific-antigen-hematocrit-and-lipid-levels-are-recommended-for-patients-taking-testosterone.-am-fam-physician-2006731591-8-1603. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20060501/1591.html**](http://www.aafp.org/afp/20060501/1591.html) {#httpwww.aafp.orgafp200605011591.html .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Midwives Corner Lisa Allee, CNM {#midwives-corner-lisa-allee-cnm .Style-Heading-4-+-Arial-14-pt-Underline}

**Empowering women to find the power of birth is of great value**

The effect of labor pain relief medication on neonatal suckling and
breastfeeding duration.

This study by Jan Riordan and colleagues is unique in that they had a
true control group of women who delivered without any pain medication.
Previous studies had compared groups of women with different types of
medications. They also used a tool to assess breastfeeding specifically,
whereas other studies used tools that assessed general neonatal
behaviors. The study was prospective, multisite, and involved 129
mother-baby dyads with vaginal births at term, 29% of which occurred
after unmedicated labors and 71% had some form of pain medication. The
results showed significant differences in breastfeeding ability between
the non-medicated group and those receiving pain medications. The babies
who were not exposed to any pain medication had significantly higher
scores, meaning more vigorous and effective suckling, than the other
three groups. The IV-analgesia-only group and the epidural-only group
had similar scores, significantly lower than the non-med group, and the
IV and epidural group had the lowest scores. The results did not show a
difference in duration of breastfeeding, but the dyads with low scores
weaned earlier than those with medium or high scores.

The authors conclude that pain medication during labor, including
epidurals (and I think we can easily extrapolate to intrathecals)
clearly hinder breastfeeding. They make the following points for
consideration in clinical care:

-   Nonpharmacological comfort measures are effective and do not
    compromise early neonatal suckling and breastfeeding.

-   Informed consent includes telling women that their infant's ability
    to breastfeed is diminished with IV analgesics and epidurals
    (intrathecals.)

-   If epidurals (intrathecals) are used, it appears the best choice is
    medication that does not include a narcotic.

-   Breastfeeding mothers who have had pain medication during labor may
    become discouraged and babies with poor breastfeeding behaviors are
    at greater risk for dehydration, jaundice, and poor weight gain.

Riordan J, Gross A, Angeron J, Krumwiede B, Melin J. 2000. The Effect of
Labor Pain Relief Medication on Neonatal Suckling and Breastfeeding
Duration. Journal of Human Lactation 16(1): 7-12
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11138228>

Full article is available at:
<http://jhl.sagepub.com/cgi/reprint/16/1/7>

#### [Midwives Corner Editorial comment:]{.underline} Lisa Allee, CNM

I find this article to be yet another affirmation that empowering women
to find the power of birth is of great value. When we teach, support,
encourage, cajole, advocate, and do whatever else is necessary to assist
women through the intense, life-altering experience of labor and birth
without using narcotics, there are profound benefits for the woman, the
baby, and, with this article, society when you consider the far-reaching
effects of breastfeeding success. This article also points out that when
women do use narcotics during labor that we must be very attentive to
breastfeeding support initially and ongoing.

**Other topics**

**Multiparous women with induced labor: Shorter active phase of labor
than spontaneous**

CONCLUSION: The pattern of labor progression differs for women with an
electively induced labor without cervical ripening compared with those
who present with spontaneous onset of labor.

[Hoffman
MK](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Hoffman+MK"%5BAuthor%5D),
et al Comparison of labor progression between induced and noninduced
multiparous women. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
May;107(5):1029-34.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16648407&dopt=Abstract>

Pushing During Second-Stage Labor Is Matter of Preference

**Clinical Question:** During the second stage of labor, is coaching to
push more beneficial than not coaching to push?

**Study Design:** Randomized controlled trial (nonblinded)

**Allocation:** Concealed

**Synopsis:** The benefit of the routine practice of coaching to push
during the second stage of labor is debated. In this study, 325 women
with uncomplicated term pregnancies in spontaneous active labor for the
first time were randomized to coached pushing or uncoached pushing
during the second stage of labor. Women were excluded if the estimated
fetal weight was more than 8.2 lb (4,000 g), if they had a diagnosis of
chorioamnionitis, or if oxytocin (Pitocin) or epidural analgesia was
used.

Coaching consisted of asking women to bear down with a closed glottis
and legs pulled back for 10-second intervals during contractions. Women
who were not coached to push were told to \"do what comes naturally.\"
All women were asked to assume a recumbent or lateral position and were
attended by certified nurse-midwives. The midwives were trained to be
compliant with the instructions for the corresponding arm of the study.
Forceps delivery was considered only if there was a prolonged second
stage (more than two hours) or a fetal heart rate abnormality.

Mean duration of second-stage labor was 46 minutes in the coached group
and 59 in the uncoached group (*P* = .014). There were no differences in
mode of delivery, perineal trauma, or episiotomy use. There were no
differences in neonatal Apgar scores, need for resuscitation, sepsis
work-up, or neonatal intensive care unit admission. There were more
infants with meconium-stained fluid in the coached group, but in most
cases, it was noted before the second stage of labor. It also appears
unlikely that a larger study would have detected clinically important
differences.

**Bottom Line:** Pushing time is reduced by an average of 13 minutes
when women are coached to push during the expulsive phase of labor.
Other than that, coached pushing demonstrated neither benefit nor harm.
The choice is a matter of preference. This study included only women who
were not receiving epidural analgesia or oxytocin. (Level of Evidence:
1b)

<http://www.aafp.org/afp/20060515/tips/13.html>

**Navajo News Kathleen Harner,** **Chinle**

METHAMPHETAMINE ABUSE AMONG WOMEN ON NAVAJO (Part 3 of 4)

Phoenix Indian Medical Center (PIMC) has developed a program designed
specifically for the special needs of substance abusers and women with
mental health disorders. Their goal was to: protect the unborn from
toxic drug exposure, assist the mother in successfully abstaining from
drugs and alcohol, and to prevent repeat pregnancies with drug affected
newborns. Beginning in October of 2003, the midwives at PIMC staff a
"Special Care Clinic" devoted to pregnant drug users, victims of
domestic violence and women with mental health disorders. The clinic
meets one afternoon a week and has longer appointments than the normal
prenatal care visits. Social workers and substance abuse counselors are
in the clinic and available for same time appointments. At the first
prenatal care visit problems are identified, a routine prenatal workup
and sexually transmitted disease (STD) testing is performed. If
substance abuse is identified it is discussed thoroughly and a drug
contract is created and the patient is asked to sign it. A urine drug
screen (UDS) is obtained if the patient agrees.

PIMC has created a wide network of referrals for the women in their
"Special Care Clinic". These include Mental Health, Public Health
Nursing, Home Health, Case Management and some Community Support Groups
(e.g. Twelve Step Programs). Social services and substance abuse
counseling are as accessible as possible because they are in the clinic
with the midwives. The patient sees the same counselor and midwife at
each visit whenever practical. The patient need never explain the
purpose of her visit to the admitting clerk, which avoids embarrassment.
A UDS is obtained at each visit if the patient has agreed and the drug
contract is signed at each visit as well. Patients are seen weekly if
needed and otherwise are on a routine prenatal care schedule.

Patients receive gifts and incentives for participating in the "Special
Care Clinic". At each visit the pregnant woman is given a gift for
herself and her baby. These gifts include make-up, hair care products,
inexpensive jewelry and lotions for the mother. Baby gifts are blankets,
clothing, pacifiers, and baby picture frames. Patients seem to
particularly like the "Fetus Models" of a 12-week fetus. When a patient
has had three negative UDS in a row she is rewarded with a \$15.00 gift
certificate for Wal-Mart, Target or Food City. If she tests positive for
drugs there is no punitive action but she is usually seen more
frequently.

If a patient is abusing MA heavily, residential treatment is offered. If
she is positive for drugs, in addition to her weekly visit with the
midwife and mental health counselor she also sees the social worker two
or more times a week. Once several drug screens have been negative, she
may be seen on a weekly schedule.

As of January 15, 2005 the program had been operating for 15 months.
Over ninety women participated with a total of 275 midwife visits. Their
diagnosis included substance abuse, anxiety/depressive disorders,
bipolar disease, homelessness, severe congenital anomalies incompatible
with life and domestic violence. Some patients are still lost to follow
up. Many are drug free or have only occasional lapses. The midwives and
patients are happy with the program. At PIMC every success is
celebrated.

The PIMC program uses contingency management very effectively in their
program. Contingency management (CM) treatments are based on a simple
behavioral principle, if a behavior is reinforced or rewarded it is more
likely to occur in the future. Reinforcement of good behaviors such as
negative urine screens and attending prenatal or therapy appointments
encourage women to stay abstinent. Rewards need not be large to be
effective.

Cognitive behavioral therapy (CBT) has been widely used for treating
cocaine abusers. CBT attempts to help patients recognize, avoid and cope
with problematic behaviors associated with substance abuse. It has many
advantages over other more traditional therapies such as twelve step
programs and traditional psychotherapy. It is a short-term therapy that
creates skills the patient can use after therapy is over. It has been
studied extensively in clinical trials and has been proven very
effective. It is flexible and can be individualized and it is compatible
with other treatments.

MA abuse among women of childbearing age is a complicated problem. Using
a multifaceted and multidisciplinary approach to helping pregnant women
stop abusing MA provides the best opportunity for success.

**Next Month: The 'drop in' meth abusing gravida**

**References:**

Hunter, F What we did about Prenatal Substance Abuse Special Care
clinic. A Power Point presentation 2005.

Check out these sites for messaging for children and adolescents created
in Montana.

**Montana Meth ads**

<http://www.montanameth.org/ads_television.aspx>

**Meth, not even once**

[www.notevenonce.com](http://www.notevenonce.com/)

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

**Nurses Corner Sandra Haldane, HQE**

**SANE/SAFE training and capacity**

Dear nursing colleagues:

I am gathering information on IHS and tribal capacity to conduct sexual
assault examinations for adults and children. Specifically, I need to
know which IHS and tribal facilities currently have a trained forensic
nurse examiner on staff.

Please send me the following information:

\- For each area, which hospitals and health centers have one or more
nurses or APNs trained to perform a forensic examination and which do
not?

\- Please let me know if SANE or SAFE training has been offered in the
past year, and where

#### Thank you very much for your help in getting me this information! {#thank-you-very-much-for-your-help-in-getting-me-this-information .Style-Heading-4-+-Arial-14-pt-Underline}

#### Carolyn Aoyama [**Carolyn.Aoyama@ihs.gov**](mailto:Carolyn.Aoyama@ihs.gov) {#carolyn-aoyama-carolyn.aoyamaihs.gov .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-27 .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}

[**Recommendations to Improve Preconception Health and Health Care -
United States**](http://www.cdc.gov/nchs/data/ad/ad368.pdf)

[This report provides recommendations to improve both preconception
health and care. The goal of these recommendations is to improve the
health of women and couples, before conception of a first or subsequent
pregnancy. The recommendations focus on changes in consumer knowledge,
clinical practice, public health programs, health-care financing, and
data and research activities. Each recommendation is accompanied by a
series of specific action steps and, when implemented, can yield results
within 2-5 years. Based on implementation of the recommendations,
improvements in access to care, continuity of care, risk screening,
appropriate delivery of interventions, and changes in health behaviors
of men and women of childbearing age are expected to
occur.](http://www.cdc.gov/nchs/data/ad/ad368.pdf)
<http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5506a1.htm?s_cid=rr5506a1_e>

**Preconception Care website**

<http://www.cdc.gov/ncbddd/preconception/default.htm>

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

**USPSTF: Recommendations on Screening / Supplementation for Iron
Deficiency Anemia**

The U.S. Preventive Services Task Force issued new recommendations on
routine screening for iron deficiency anemia and iron supplementation in
pregnant women and children.

The Task Force recommends routine screening for iron deficiency anemia
in asymptomatic pregnant women **(B recommendation**).

The Task Force recommends routine iron supplementation for asymptomatic
children ages 6 to 12 months who are at increased risk for iron
deficiency anemia **(B recommendation).**

The Task Force concludes that evidence is insufficient to recommend for
or against routine iron supplementation for non-anemic pregnant women
**(I recommendation).**

The Task Force concludes that evidence is insufficient to recommend for
or against routine iron supplementation for asymptomatic children ages 6
to 12 months who are at average risk for iron deficiency anemia **(I
recommendation).**

#### [**http://www.ahrq.gov/clinic/uspstf/uspsiron.htm#top#top**](http://www.ahrq.gov/clinic/uspstf/uspsiron.htm#top%23top) {#httpwww.ahrq.govclinicuspstfuspsiron.htmtoptop .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-29 .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}

**Elective Cesarean Delivery**

When asked the question in your office about an elective primary
cesarean delivery, how do you respond? Do you defer to the patient's
right to determine her birthing method or do you respond that you don't
perform one without an indication? As the media popularizes elective
cesareans for the famous, where do we stand as a profession? The NIH
convened a consensus conference March 27-29 to review the available
evidence.

**Here is a summary of their conclusions:**

Cesarean deliveries without medical or obstetrical indications are on
the rise and a component of this is due to elective maternal request.

[Insufficient evidence to fully evaluate]{.underline}

There is insufficient evidence to evaluate fully the benefits and risks
of cesarean delivery on maternal request as compared to planned vaginal
delivery, and more research is needed.

Until quality evidence becomes available, any decision to perform a
cesarean delivery on maternal request should be carefully individualized
and consistent with ethical principles.

Given that the risks of placenta previa and accreta rise with each
cesarean delivery, cesarean delivery on maternal request is not
recommended for women desiring several children.

Cesarean delivery on maternal request should not be performed prior to
39 weeks of gestation or without verification of lung maturity, because
of the significant danger of neonatal respiratory complications.

Maternal request for cesarean delivery should not be motivated by
unavailability of effective pain management. Efforts must be made to
assure availability of pain management services for all women.

NIH or another appropriate Federal agency should establish and maintain
a Web site to provide up-to-date information on the benefits and risks
of all modes of delivery.

<http://consensus.nih.gov/2006/2006CesareanSOS027html.htm>

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

Calcium Plus Vitamin D for Fracture Prevention: POEM

**Clinical Question:** Does supplementation with 1,000 mg of calcium and
400 IU of vitamin D reduce the risk of fracture in healthy women?

**Bottom Line:** The ability of a small dose of calcium and vitamin D to
prevent fractures in healthy community-dwelling women is modest at best.
This study used a relatively low dose of vitamin D (less than the 700 to
800 IU found most beneficial in previous studies), and the patients were
generally at low risk of fracture. Perhaps that explains the discordance
of these findings with the bulk of the literature on this topic. (Level
of Evidence: 1b)

Jackson RD, et al., for the Women\'s Health Initiative Investigators.
Calcium plus vitamin D supplementation and the risk of fractures
\[Published correction appears in N Engl J Med 2006;354:1102\]. N Engl J
Med February 16, 2006;354:669-83.

<http://www.aafp.org/afp/20060601/tips/19.html>

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

#### Testosterone Therapy: What You Should Know {#testosterone-therapy-what-you-should-know-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20060501/1591.html**](http://www.aafp.org/afp/20060501/1591.html) {#httpwww.aafp.orgafp200605011591.html-1 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Microscopic Hematuria: What You Should Know {#microscopic-hematuria-what-you-should-know-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20060515/1759ph.html**](http://www.aafp.org/afp/20060515/1759ph.html) {#httpwww.aafp.orgafp200605151759ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Is a Low-Carbohydrate Diet Right for Me? {#is-a-low-carbohydrate-diet-right-for-me-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20060601/1951ph.html**](http://www.aafp.org/afp/20060601/1951ph.html) {#httpwww.aafp.orgafp200606011951ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

#### [**http://www.aafp.org/afp/20060515/1786ph.html**](http://www.aafp.org/afp/20060515/1786ph.html) {#httpwww.aafp.orgafp200605151786ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Opioid Addiction: What You Should Know {#opioid-addiction-what-you-should-know-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20060501/1580ph.html**](http://www.aafp.org/afp/20060501/1580ph.html) {#httpwww.aafp.orgafp200605011580ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### High Blood Pressure: What You Should Know {#high-blood-pressure-what-you-should-know .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20060601/1957ph.html**](http://www.aafp.org/afp/20060601/1957ph.html) {#httpwww.aafp.orgafp200606011957ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-35 .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}

**Cesarean delivery rate: Continues to increase without improving
population outcomes**

Attempts to define, or enforce, an \"ideal\" cesarean delivery rate are
futile, and should be abandoned. The cesarean rate is a consequence of
individual value-laden clinical decisions, and is not amenable to the
methods of evidence-based medicine. The influence of academic authority
figures on the cesarean rate in the US is placed in historic context.
Like other population health indices, the cesarean deliver rate is an
indirect result of American public policy during the last century.
Without major changes in the way health and maternity care are delivered
in the US, the rate will continue to increase without improving
population outcomes.

An RCT requires a hypothesis that is testable in the real world: it
should be simple, specific, and stated in advance. On those grounds,
there is no direct way to test the hypothesis that there is an ideal
cesarean delivery rate. Because the cesarean rate is calculated
post-hoc, it is also impossible to design a prospective trial comparing
specific cesarean rates. Conceptually, one might set up a large RCT with
multiple arms, each having a different proportion of women by intended
method of delivery, e. g., 100% elective cesarean versus 0% planned
vaginal birth, 80/20, 50/50, etc. For specified outcome variables, an
ideal cesarean rate could then be estimated retrospectively. It is clear
that the ideal rate will depend on which women are studied, and how much
weight is given to maternal versus fetal morbidity---all subjective
criteria.

[Cyr
RM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Cyr+RM"%5BAuthor%5D).
Myth of the ideal cesarean section rate: commentary and historic
perspective. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Apr;194(4):932-6.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16580278>

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

**Patient-choice vaginal delivery? (See also the Oklahoma Perspective)**

As Dr. Gilson points out the rapidly increasing cesarean rate does not
improve commonly measured patient outcomes. Zweifler et al confirm that
trend in this 1996 through 2002 California study of the Birth
Statistical Master Files were used to identify 386,232 California
residents who previously gave birth by cesarean delivery and had a
singleton birth planned in a California hospital. (Results below)

Here is an excerpt from a Reflection by Dr. Larry Leeman and Dr. Lauren
Plante from the May/June Annals of Family Medicine:

Patient-choice cesarean delivery is increasing in the United States. The
American College of Obstetricians and Gynecologists supports this
option, citing ethical premises of autonomy and informed consent,
despite a lack of evidence for its safety. This increase in
patient-choice cesarean delivery occurs during a time when women with a
breech-presenting fetus or a previous cesarean deliver have fewer
choices as to vaginal birth. Patient-choice cesarean delivery may become
widely disseminated before the potential risks to women and their
children have been well analyzed. The growing pressure for cesarean
delivery in the absence of a medical indication may ultimately result in
a decrease of women's childbirth options. Advocacy of patient-choice
requires preserving vaginal birth options as well as cesarean delivery.

[Leeman
LM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Leeman+LM"%5BAuthor%5D),
[Plante
LA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Plante+LA"%5BAuthor%5D).
Patient-choice vaginal delivery? [Ann Fam
Med.](javascript:AL_get(this, 'jour', 'Ann Fam Med.');) 2006
May-Jun;4(3):265-8.
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16735530>

CONCLUSIONS: Neonatal and maternal mortality rates did not improve
despite increasing rates of repeat cesarean delivery during the years
after the ACOG 1999 VBAC guideline revision. Women with infants weighing
\> or =1,500 g encountered similar neonatal and maternal mortality rates
with VBAC or repeat cesarean delivery.

[Zweifler
J](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Zweifler+J"%5BAuthor%5D),
et al Vaginal birth after cesarean in California: before and after a
change in guidelines. [Ann Fam
Med.](javascript:AL_get(this, 'jour', 'Ann Fam Med.');) 2006
May-Jun;4(3):228-34.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16735524>

**Shifts in primary cesarean rates were not related to shifts in
maternal risk profiles**\
Results: More than half (53%) of the recent increase in overall cesarean
rates resulted from rising primary cesarean rates. There was a steady
decrease in the primary cesarean rate from 1991 to 1996, followed by a
rapid increase from 1996 to 2002. In 2002, more than one fourth of
first-time mothers delivered their infants via cesarean. Changing
primary cesarean rates were not related to general shifts in mothers'
medical risk profiles. However, rates for virtually every condition
listed on birth certificates shifted in the same pattern as with the
overall rates.\
Conclusions: Our results showed that shifts in primary cesarean rates
during the study period were not related to shifts in maternal risk
profiles.\
Declercq E, Menacker F, MacDorman M Factors Associated With the Rise in
Primary Cesarean Births in the United States, 1991-2002 Am. J Public
Health. 2006; 96(5):867-872

<http://www.medscape.com/viewarticle/530788>

**Tocolysis after 32 weeks gestation does not reduce neonatal hospital
stay**

RESULTS: The 2 groups had similar mean cervical dilation and gestational
age at enrollment. There were no statistically significant differences
in total neonatal hospital stay (5.8 +/- 7.2 days; median of 3 days in
the no tocolysis vs. 7.5 +/- 8.6 days; median of 3 days in the tocolysis
group), rate of preterm delivery (57% vs. 75%) or need for oxygen
supplementation (7% vs. 21%, p \< 0.23). The neonatal complications were
similar in each group. CONCLUSION: Tocolysis after 32 weeks gestation
does not reduce neonatal hospital stay.

[How
HY](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="How+HY"%5BAuthor%5D),
et al Tocolysis in women with preterm labor between 32 0/7 and 34 6/7
weeks of gestation: a randomized controlled pilot study. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Apr;194(4):976-81.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16580286>

**Vaginal delivery of singleton fetuses in breech presentation at term
remains a safe** **option**

RESULTS: Cesarean delivery was planned for 5579 women (68.8%) and
vaginal delivery for 2526 (31.2%). Of the women with planned vaginal
deliveries, 1796 delivered vaginally (71.0%). The rate of the combined
neonatal outcome measure was low in the overall population (1.59%; 95%
CI \[1.33-1.89\]) and in the planned vaginal delivery group (1.60%; 95%
CI \[1.14-2.17\]). It did not differ significantly between the planned
vaginal and cesarean delivery groups (unadjusted odds ratio = 1.10, 95%
CI \[0.75-1.61\]), even after controlling for confounding variables
(adjusted odds ratio = 1.40, 95% CI \[0.89-2.23\]).

CONCLUSION: In places where planned vaginal delivery is a common
practice and when strict criteria are met before and during labor,
planned vaginal delivery of singleton fetuses in breech presentation at
term remains a safe option that can be offered to women.

[Goffinet
F](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Goffinet+F"%5BAuthor%5D),
et al Is planned vaginal delivery for breech presentation at term still
an option? Results of an observational prospective survey in France and
Belgium. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Apr;194(4):1002-11.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16580289>

**Glyburide and insulin: Equally efficient for treatment of GDM in all
levels of severity**

STUDY DESIGN: In a secondary analysis of our previous randomized study,
404 women were analyzed. The association among glyburide dose, severity
of GDM, and selected maternal and neonatal factors was evaluated.
Severity levels of GDM were stratified by fasting plasma glucose (FPG)
from the oral glucose tolerance test (OGTT). Infants with birth weight
at or above the 90th percentile were considered large-for-gestational
age (LGA). Macrosomia was defined as birth weight \> or =4000 g.
Well-controlled was defined as mean blood glucose \< or =95 mg/dL. The
association between glyburide- and insulin-treated patients by severity
of GDM and neonatal outcome was evaluated.

CONCLUSION: Glyburide and insulin are equally efficient for treatment of
GDM in all levels of disease severity. Achieving the established level
of glycemic control, not the mode of pharmacologic therapy, is the key
to improving the outcome in GDM

[Langer
O](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Langer+O"%5BAuthor%5D)
et al Insulin and glyburide therapy: dosage, severity level of
gestational diabetes, and pregnancy outcome. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2005
Jan;192(1):134-9.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15672015>

**Improve patient safety, prevent medical errors and resolve the
professional liability crisis**

The current professional liability crisis is the third in the last 30
years. Similarities of the 3 crises are the rising cost of professional
liability insurance and a diminishing number of sources available to
purchase coverage. Proposed tort reform with caps on noneconomic damages
and attorney contingency fees is a back end approach and will do little
to solve this crisis or prevent future ones. The current situation can
only be solved by placing an increased emphasis on improving patient
safety and elimination of all preventable medical errors. A national
electronic medical record must be developed and rapid response teams
need to be available in most hospitals. The protective devices of
privileged communication and peer review are counterproductive and must
be eliminated. Full and prompt disclosure of any medical error or injury
needs to be made. Physicians must be taught proper communication skills
and the importance of teamwork. Providers with frequent patient, nursing
or medical staff complaints must be critically reviewed. The present
system of risk management needs to move from a reactive position to a
role of being proactive for both patient and physician. Claims
management should offer the patient early compensation when appropriate
and pursue a vigorous defense when medical care is adequate. Experts
should be identified who will render fair, unbiased reviews of medical
care with all of their findings being disclosed. Similar experts need to
devise clear, concise, evidenced based standards of care for common
medical conditions.

[Weinstein
L](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Weinstein+L"%5BAuthor%5D).
A multifacited approach to improve patient safety, prevent medical
errors and resolve the professional liability crisis. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Apr;194(4):1160-5; discussion 1165-7.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16580322>

**Progestational agents in second trimester may reduce preterm birth in
women at risk**

RESULTS: Three trials were eligible for inclusion. There was a
significant reduction in risk of delivery less than 37 weeks with
progestational agents (relative risk \[95% CI\] = 0.57 \[0.36-0.90\]).
There was no significant effect on perinatal mortality or serious
neonatal morbidity.

CONCLUSION: Progestational agents, initiated in the second trimester of
pregnancy, may reduce the risk of delivery less than 37 weeks\'
gestation, among women at increased risk of spontaneous preterm birth,
but the effect on neonatal outcome is uncertain. Larger randomized
controlled trials are required to determine whether this treatment
reduces perinatal mortality or serious neonatal morbidity.

[Mackenzie
R](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Mackenzie+R"%5BAuthor%5D),
et al Progesterone for the prevention of preterm birth among women at
increased risk: a systematic review and meta-analysis of randomized
controlled trials. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
May;194(5):1234-42\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16647905>

**SSRIs in pregnancy increase low birth weight, preterm birth, fetal
death, and seizures**

RESULTS: The risks of low birth weight (adjusted odds ratio, 1.58; 95%
CI, 1.19, 2.11), preterm birth (adjusted odds ratio, 1.57; 95% CI, 1.28,
1.92), fetal death (adjusted odds ratio, 2.23; 95% CI, 1.01, 4.93), and
seizures (adjusted odds ratio, 3.87; 95% CI, 1.00, 14.99) were increased
in infants who were born to mothers who had received selective serotonin
reuptake inhibitor therapy.

CONCLUSION: The use of selective serotonin reuptake inhibitors in
pregnancy may increase the risks of low birth weight, preterm birth,
fetal death, and seizures.

[Wen
SW](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Wen+SW"%5BAuthor%5D)
et al Selective serotonin reuptake inhibitors and adverse pregnancy
outcomes. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Apr;194(4):961-6.,

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16580283>

#### Primary Care Discussion Forum {#primary-care-discussion-forum-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### September 1, 2006: Palliative Medicine\'s Role in the Continuity of Care Moderator: Tim Domer, M.D.

-   Management of acute vs chronic pain

-   Quality of Life in chronic illness

-   The meaning of \"Code Status\"

-   Preparing for a \"Good Death\"

-   End-of-Life Care as part of Continuity of Care and Prevention

[http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForum.cfm#](http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForum.cfm#disc)

Thanks very much to Andy Hsi for his hard work and thoughtful approach
to the Adverse Events of Childhood discussion. The captured discussion
and summary are here:

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

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

Subscribe to the Primary Care listserv

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

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

**HIV Testing and Additional Analysis of National Survey on HIV/AIDS**\
The Centers for Disease Control and Prevention (CDC)'s reported plans
to\
recommend routine HIV testing for patients in health care settings will
mark\
a major change in the way HIV testing is conducted in the United States\
and is intended to increase testing nationwide.  Given that an estimated
one\
in four of the more than one million people living with HIV/AIDS in the
U.S.\
do not know they are infected, increased testing could help more people
learn\
they are HIV positive, linking them to necessary care and services and\
leading to reduced risk behaviors.  In order to help inform discussions
about\
expanded testing, the Kaiser Family Foundation is releasing additional
data\
from its \"2006 Survey of Americans on HIV/AIDS\"\
<http://www.kff.org/kaiserpolls/pomr050806pkg.cfm>

\"HIV Testing: 2006 Kaiser Family Foundation Survey of Americans on
HIV/AIDS\"\
\-- New public opinion data finds that two-thirds of the public (65%)
say HIV\
testing should be treated just like routine screening for other
diseases,\
while about one-quarter (27%) say it should require special procedures,
such\
as written permission from the patient.  The survey also found that
most\
people (65%) think rapid home HIV-testing is a good idea, but when
asked\
their personal preference, most (62%) would still prefer to get tested
in a\
doctor's office rather than use a home test. 
<http://www.kff.org/kaiserpolls/7521.cfm>\
\
\"Opinions and Experiences of 18-25 Year Olds: 2006 Kaiser Family
Foundation\
Survey of Americans on HIV/AIDS\" \-- New analysis of public opinion
data finds\
that large shares of 18-25 year olds would like to have more
information\
about the different kinds of HIV tests available (60%); where to go to
get\
tested (54%); how to protect their privacy when getting an HIV test
(51%);\
and how to bring up the topic of getting tested with a partner (43%). 
This\
report also examines young peoples\' views on a wide variety of issues
related\
to HIV in addition to
testing. <http://www.kff.org/kaiserpolls/7522.cfm>\
\
\"HIV Testing in the U.S.\" \-- An updated fact sheet that provides key
testing\
statistics and outlines testing recommendations and requirements,
state-by-\
state policies, and different testing techniques. 

The fact sheet is available at <http://www.kff.org/hivaids/6094.cfm>

State-by-state data on HIV testing
[www.statehealthfacts.org/r/hivtesting.cfm](http://www.statehealthfacts.org/r/hivtesting.cfm)

These two new reports are based on subsets of the full survey. 
<http://www.kff.org/kaiserpolls/pomr050806pkg.cfm>

**Most teenagers with chlamydial infections receive appropriate
antibiotics, but fewer receive other recommended care**

<http://www.ahrq.gov/research/apr06/0406RA14.htm>

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

**Social Networks Testing: Strategy for Identifying Persons with
Undiagnosed HIV Infection**

One strategy for reaching and providing HIV CTR to persons with
undiagnosed HIV infection is the use of social networks. Enlisting
HIV-positive or high-risk HIV-negative persons (i.e., recruiters) to
encourage people in their network (i.e., network associates) to be
tested for HIV may provide an efficient and effective route to accessing
individuals who are infected, or at very high risk for becoming
infected, with HIV and linking them to services. The social network
approach has proven to be a viable recruitment strategy for reaching
people beyond current partners.
<http://www.cdc.gov/hiv/resources/guidelines/snt/index.htm>

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

#### Diagnosis and Treatment of Neisseria gonorrhoeae Infections (see Patient Education) {#diagnosis-and-treatment-of-neisseria-gonorrhoeae-infections-see-patient-education .Style-Heading-4-+-Arial-14-pt-Underline}

#### The most common site of *Neisseria gonorrhoeae* infection is the urogenital tract. Men with this infection may experience dysuria with penile discharge, and women may have mild vaginal mucopurulent discharge, severe pelvic pain, or no symptoms. Other *N. gonorrhoeae* infections include anorectal, conjunctival, pharyngeal, and ovarian/uterine. Infections that occur in the neonatal period may cause ophthalmia neonatorum. If left untreated, *N. gonorrhoeae* infections can disseminate to other areas of the body, which commonly causes synovium and skin infections. Disseminated gonococcal infection presents as a few skin lesions that are limited to the extremities. These legions start as papules and progress into bullae, petechiae, and necrotic lesions. The most commonly infected joints include wrists, ankles, and the joints of the hands and feet. Urogenital *N. gonorrhoeae* infections can be diagnosed using culture or nonculture (e.g., the nucleic acid amplification test) techniques. When multiple sites are potentially infected, culture is the only approved diagnostic test. Treatments for uncomplicated urogenital, anorectal, or pharyngeal gonococcal infections include cephalosporins and fluoroquinolones. Fluoroquinolones should not be used in patients who live in or may have contracted gonorrhea in Asia, the Pacific islands, or California, or in men who have sex with men. Gonorrhea infection should prompt physicians to test for other sexually transmitted diseases, including human immunodeficiency virus. Am Fam Physician 2006;73:1779-84, 1786. {#the-most-common-site-of-neisseria-gonorrhoeae-infection-is-the-urogenital-tract.-men-with-this-infection-may-experience-dysuria-with-penile-discharge-and-women-may-have-mild-vaginal-mucopurulent-discharge-severe-pelvic-pain-or-no-symptoms.-other-n.-gonorrhoeae-infections-include-anorectal-conjunctival-pharyngeal-and-ovarianuterine.-infections-that-occur-in-the-neonatal-period-may-cause-ophthalmia-neonatorum.-if-left-untreated-n.-gonorrhoeae-infections-can-disseminate-to-other-areas-of-the-body-which-commonly-causes-synovium-and-skin-infections.-disseminated-gonococcal-infection-presents-as-a-few-skin-lesions-that-are-limited-to-the-extremities.-these-legions-start-as-papules-and-progress-into-bullae-petechiae-and-necrotic-lesions.-the-most-commonly-infected-joints-include-wrists-ankles-and-the-joints-of-the-hands-and-feet.-urogenital-n.-gonorrhoeae-infections-can-be-diagnosed-using-culture-or-nonculture-e.g.-the-nucleic-acid-amplification-test-techniques.-when-multiple-sites-are-potentially-infected-culture-is-the-only-approved-diagnostic-test.-treatments-for-uncomplicated-urogenital-anorectal-or-pharyngeal-gonococcal-infections-include-cephalosporins-and-fluoroquinolones.-fluoroquinolones-should-not-be-used-in-patients-who-live-in-or-may-have-contracted-gonorrhea-in-asia-the-pacific-islands-or-california-or-in-men-who-have-sex-with-men.-gonorrhea-infection-should-prompt-physicians-to-test-for-other-sexually-transmitted-diseases-including-human-immunodeficiency-virus.-am-fam-physician-2006731779-84-1786. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20060515/1779.html**](http://www.aafp.org/afp/20060515/1779.html) {#httpwww.aafp.orgafp200605151779.html .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#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}

**Women Who Don\'t Snooze Enough Gain Weight**\
Not enough sleep for women may lead to extra pounds over the years,
researchers reported.

Women who slept five hours or less per night gained 1.14 kg (2.5 lb)
more than women who got in at least seven hours each night. The
investigators found that weight gain appeared to have something of a
dose-dependent effect. Women who slept six hours gained 0.71 1 kg (1.6
lbs) compared with women who slept for seven hours or more. The average
weight gain in the women who slept the least may not sound like much,
but it is an average amount. Some women gained much more than that, and
even a small difference in weight can increase a person\'s risk of
health problems such as diabetes and hypertension. Less sleep may also
affect the basal metabolism rate to lower energy expenditures in those
who get less rest. NB: This study was published as an abstract and
presented orally at a conference. These data and conclusions should be
considered to be preliminary as they have not yet been reviewed and
published in a peer-reviewed publication.\
Practice Pearl:

-   Those who slept only five hours per night gained significantly more
    weight, and gained weight at a more rapid pace over 16 years, than
    women who slept seven or more hours per night.

2006 American Thoracic Society Annual Meeting: Patel SR et al. \"Short
Sleep is a Risk Factor for Weight Gain\" Presented May 23, 2006
<http://www.thoracic.org/>

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

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

-   September 17 -- 21, 2006

-   Denver, CO

-   Contact <YMalloy@acog.org> or call Yvonne Malloy at 202-863-2580

-   Neonatal Resuscitation Program available

-   Brochure

> <http://www.ihs.gov/MedicalPrograms/MCH/F/documents/ACOG_06brochR1_1.pdf>

**2007 Indian Health MCH and Women's Health National Conference**

-   August 15 -17, 2007

-   Albuquerque, NM

-   THE place to be for anyone involved in care of women, children

-   Internationally recognized speakers

-   Save the dates. Details to follow

-   14 months away and counting

-   Want a topic discussed? Contact <nmurphy@scf.cc>

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

**Is a fetal ultrasound survey indicated for all patients routinely?**

**Impromptu Discussion -- Primary Care Forum**

<http://www.ihs.gov/MedicalPrograms/MCH/F/documents/USsurvey42406.doc>

There are several upcoming **Conferences**

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

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

<http://www.ihs.gov/MedicalPrograms/MCH/M/CN13.cfm>

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

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

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

<http://www.ihs.gov/MedicalPrograms/MCH/W/WN00.asp#top>

# Did you miss something in the last OB/GYN Chief Clinical Consultant Corner? {#did-you-miss-something-in-the-last-obgyn-chief-clinical-consultant-corner .Style-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5%)}

#### The May 2006 OB/GYN CCC Corner is available at: {#the-may-2006-obgyn-ccc-corner-is-available-at .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0506.cfm**](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0506.cfm) {#httpwww.ihs.govmedicalprogramsmchmobgyn0506.cfm-1 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Abstract of the Month:  {#abstract-of-the-month-1 .Style-Heading-4-+-Arial-14-pt-Underline}

Maternal periodontal disease in early pregnancy:
Small-for-gestational-age infant

#### From your colleagues: {#from-your-colleagues-1 .Style-Heading-4-+-Arial-14-pt-Underline}

Carolyn Aoyama

-Women's Health Assessment Toolkit (WHAT)

-The Management of Eating Disorders: New Report, AHRQ

**Donald Haverkamp**

Take the provider survey on colorectal cancer screening!

Chuck North

#### The new medical \"missionaries\"\--grooming the next generation of global health workers {#the-new-medical-missionaries--grooming-the-next-generation-of-global-health-workers .Style-Heading-4-+-Arial-14-pt-Underline}

Ty Reidhead

New funding opportunity under the IHS Chronic Disease Initiative

Christine Rinki

Infant Mortality Statistics from the 2003 Period Linked Birth/Infant
Death Data Set

Judy Thierry

Gestational Diabetes best practices CALL for examples

Congratulations to Yolanda Adams, Charlotte Briggs and all!

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

##### Obstetrics:

-Counterpoint: Not Yet Time to Use the P:C Ratio by David Gahn and Eric
Manske

-New campaign materials released to help GDM patients prevent or delay
Type 2 Diabetes

-Prenatal Weight Gain Recommendations - Obesity in Pregnancy

-Preconception Care: Recommendations to Improve Health of Babies and
Moms, CDC

-Early Glucose Challenge Testing Identifies Diabetes Versus Gestational
Diabetes\
-Strategies and outcome of Infant Mortality Reviews in the Aberdeen Area
of the IHS

and more....

**Gynecology:**

-FDA: Vaccine to Prevent Cervical Cancer Is Safe, Effective

-Amenorrhea: Evaluation and Treatment

**Child Health:**

-Relationship between team sport participation and adolescent smoking

-Prevalence of diabetes and impaired fasting glucose levels among U.S.
adolescents

-Sudden, Unexplained Infant Death Initiative

#### -Tool Kit on Teaching and Assessment children with Special needs {#tool-kit-on-teaching-and-assessment-children-with-special-needs .Style-Heading-4-+-Arial-14-pt-Underline}

-SIDS/Infant Death Resource Center is looking for materials\
and more....

**Chronic Illness and Disease:**

Caring for Patients After Bariatric Surgery

#### Features: {#features-1 .Style-Heading-4-+-Arial-14-pt-Underline}

##### American Family Physician

Immersion Exercise Reduces Leg Edema in Pregnancy

American College of Obstetricians and Gynecologists

-ACOG Recommends First Ob-Gyn Visit in Early Teens

-Vaginitis, Practice Bulletin

-Hepatitis B and Hepatitis C Virus Infections in Obstetrics--Gynecology,
Committee Opinion

-The Apgar Score, Committee Opinion

-Role of the ON/GYN in the Screening and Diagnosis of Breast Masses,
Committee Opinion

-The Initial Reproductive Health Visit, Committee Opinion

**Agency for Healthcare Research and Quality**

-Do-not-resuscitate orders for terminally ill children may not be
honored by public schools

-Ectopic pregnancy rates are declining, but the decline is slower among
black women

-Close-call reporting systems may be underutilized in identifying
potential medical errors

-Doctors still prescribe antibiotics for over half of children with sore
throats

**Ask a Librarian**

MCH Library launches redesigned web site

**Breastfeeding**

Database provides information about drugs in breastfeeding mothers

**CCC Corner Digest**

\-[Protein to Creatinine Ratio in Pre-eclampsia: Is the data preceding
the U.S.
benchmarks?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0406_AOM.cfm)

\-[RCTs: Do they have external validity for patients with multiple
co-morbidities
?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0406_Coll.cfm)

\-[Gestational Diabetes Mellitus Tracking Sheets and Case Management
PPT](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0406_Coll.cfm)

\-[Glyburide is at least as effective as insulin therapy in treating
gestational
diabetes](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0406_HT.cfm#ob)

\-[Urinary incontinence: Substantial economic costs and decrement in
quality of
life](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0406_HT.cfm#gyn)

\-[Infant Mortality Reviews in the Aberdeen Area: Strategies and
Outcomes](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0406_HT.cfm#child)

\-[Breast cancer study from
PIMC](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0406_HT.cfm#chrIll)

\-[Less Invasive Management of Cervical Cytology Abnormalities in
Adolescents](http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN0406_Feat.cfm#acog)

\-[ACOG: New Guidelines Call for Restricted Use of
Episiotomies](http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN0406_Feat.cfm#acog)

\-[Early feeding choice and
obesity](http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN0406_Feat.cfm#breast)

\-[MCH Frequently Asked Question (FAQ)
site](http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN0406_Feat.cfm#webSite)

\-[What is the common
theme?](http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN0406_Feat.cfm#mmtour)

\-[Hands off\" versus \"hands on\" for decreasing perineal lacerations:
No
difference](http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN0406_Feat.cfm#MidWives)

\-[Methamphetamine abuse among women on Navajo, Part
1](http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN0406_Feat.cfm#navajo)

\-[Journey to
Magnet](http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN0406_Feat.cfm#nurseCorner)

\-[Peripartum
Cardiomyopathy](http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN0406_Feat.cfm#okie)

\-[Vaginal breech \< 3, 500 g - No increase risk in neurodevelopment at
2 years of
age](http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN0406_Feat.cfm#periPicks)

\-[Adverse Childhood Events: Impact on chronic adult illness / Risk
taking](http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN0406_Feat.cfm#pcf)

\-[Announcing New Program Manager for the IHS National STD
Program](http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN0406_Feat.cfm#std)

\-["Clinical inertia\" - Providers not intensifying diabetes therapy
when
indicated](http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN0406_Feat.cfm#stillW)

**Domestic Violence**

Grants Alert: Domestic Violence, Cultural Competence

**Elder Care News**

Maintenance treatment of major depression in old age

**Family Planning**

-31% of Sexually Active U.S. Teenage Girls Become Pregnant

-Postpartum contraception: New Mexico Pregnancy Risk Assessment
Monitoring System

**Featured Website**

The MCH Frequently Asked Question (FAQ) site

**Frequently asked questions**

-Are there any cultural barriers among Native Americans to becoming cord
blood donors?

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

**Indian Child Health Notes**

Remember when they told you in medical school that half of what they
were teaching you was wrong, they must didn\'t know which half. Now we
do\...

\- Humidification doesn\'t benefit croup

\- Fluoroquinolones can be used in children \< 12 years

However our editors Drs. Singleton and Esposito do know some things and
will share them\...

\- Which Haemophilus influenzae type b vaccine is the best for AI/AN
infants?

\- Helicobacter pylori and anemia in AI/AN children

\- Lessons from New Zealand - access to care for indigenous Maori

**Information Technology**

Annual IHS Technology Conference

International Health

Special Journal Issue Features Articles on Women, Gender, and Health
Care Disparities

MCH Alert

Dieting behavior among overweight and non-overweight adolescents

#### Medical Mystery Tour

#### What was the common theme in these 2 cases? {#what-was-the-common-theme-in-these-2-cases .Style-Heading-4-+-Arial-14-pt-Underline}

#### Medscape

**Menopause Management**

#### Effects of Conjugated Equine Estrogen on Quality of Life {#effects-of-conjugated-equine-estrogen-on-quality-of-life .Style-Heading-4-+-Arial-14-pt-Underline}

**Midwives Corner**

#### Routine use of sweeping of membranes from 38 weeks of pregnancy onwards {#routine-use-of-sweeping-of-membranes-from-38-weeks-of-pregnancy-onwards .Style-Heading-4-+-Arial-14-pt-Underline}

**Navajo News**

Methamphetamine abuse among women on Navajo (PART 2 of 4)

**Nurses Corner**

-Native American Scholarship Opportunities at the School of Nursing

-Success stories of American Indian people throughout the US needed

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

April was National Child Abuse Prevention Month. This year's theme was
Safe Children and Healthy Families are a Shared Responsibility --MMWR
article

**Oklahoma Perspective**

Female Sexual Dysfunction

Osteoporosis

Women need information about alternatives, risks, and benefits of
hormone therapy for osteoporosis to make an informed decision

Patient Education

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

Perinatology Picks

-Factors Associated With Rise in Primary Cesarean Births in the United
States, 1991-2002\
-Recurrence of hypertensive disorder in second pregnancy

-Despite \"inadequate placentation\" hypothesis, preeclampsia and IUGR
do not seem to be related as different aspects of the same disorder

Primary Care Discussion Forum

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

STD Corner

-Prediction of Pelvic Inflammatory Disease Among Young, Single, Sexually
Active Women

#### -Diagnosis and Treatment of Chlamydia trachomatis Infection {#diagnosis-and-treatment-of-chlamydia-trachomatis-infection .Style-Heading-4-+-Arial-14-pt-Underline}

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

-Long-term Dietary Intervention May Reduce Risk for Insulin Resistance
in Children

-Insulin Sensitivity Measures Predict Preeclampsia

The past CCC Corners are archived at:

<http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN01.cfm#top>

The CCC Corner is good way to inform ITU providers about recent updates,
while decreasing the number of e-mail messages.

Let me know if you want to add something to next month's CCC Corner at
<nmurphy@scf.cc>

or 907 729 3154 (with voicemail)

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

6/13/06njm