**Save the Dates: First International Meeting on Indigenous Women's
Health; Third International Meeting on Indigenous Child Health: Many
Voices into One Song**

**March 2009, Albuquerque, NM**

**Women's Health March 4-6, 2009**

**Children's Health March 6-8, 2009**

**(The 6^th^ is an overlap day with both groups participating!)**

![](media/image1.jpeg){width="5.992361111111111in" height="1.33125in"}

 

Chief Clinical Consultant's Corner

Volume 6, No. 11; November 2008

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

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

\- Effectiveness of maternal influenza immunization in mothers and
infants

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

#### Richard Church, IHS Headquarters {#richard-church-ihs-headquarters .Style-Heading-4-+-Arial-14-pt-Underline}

#### - CEO Brief -- Issue 7 {#ceo-brief-issue-7 .Style-Heading-4-+-Arial-14-pt-Underline}

**Joxel Garcia, U.S. Public Health Service**

\- Influenza Vaccination for Health Care Personnel

Scott Giberson, IHS Headquarters

\- Call for Abstracts -- Third Alaska Native Health Research Conference

**Paul Seligman, Food and Drug Administration**

## - FDA Creates Web Page with Drug Safety Information for Patients, Health Care Professionals 

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

##### Obstetrics

\- Alcohol Use Screening for FASD Prevention among a Cohort of American
Indian Women

\- Prevention of Diabetes in Women with a History of Gestational
Diabetes: Effects of Metformin and Lifestyle Interventions

\- Perinatal outcomes in low-risk term pregnancies: do they differ by
week of gestation?

\- Effect on birth outcomes of a formalised approach to care in hospital
labour assessment units: international, randomised controlled trial

\- Peripartum Clostridium difficile infection

**Gynecology**

\- Pregnancy outcome in women before and after cervical conisation

\- FDA Public Health Notification: Complications with Transvaginal
Placement of Surgical Mesh

\- The role of Lactobacillus in restoring the normal vaginal flora after
antibiotic treatment of bacterial vaginosis

\- Hormone therapy and the risk of breast cancer in BRCA1 mutation
carriers

**Child Health**

**-** [AAP Guidelines Recommend Doubling Children\'s Vitamin D
Intake](https://webmail.hhs.gov/exchange/Jean.Howe/reading 2/Vitamin D Guideline for Kids _x005F_xF8FF_ Stress Testing %26 PCI _x005F_xF8FF_ Episodic vs. Continuous Amiodarone.EML/#article1)

\- Interventions in primary care to promote breastfeeding

\- Use of a fan during sleep and the risk of sudden infant death
syndrome

**-** Support for Comprehensive Sexuality Education: Perspectives from
Parents of School-Age Youth **\
**- First-trimester maternal alcohol consumption and the risk of infant
oral clefts

**Chronic Illness and Disease**

\- Patients and Caregivers Benefit from End-of-Life Discussions

\- Comparative Effectiveness and Safety of Premixed Insulin Analogues in
Type 2 Diabetes

­- Smoking cessation interventions for hospitalized smokers

\- Patients with Coronary Heart Disease Benefit from Screening for
Depression

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

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

American College of Obstetricians and Gynecologists

\- Ultrasonography in Pregnancy

\- Use of Progesterone to Reduce Preterm Birth

\- Pregnant Women Reminded to Get Flu Vaccination

##### American Family Physician

\- Atypical Moles

\- Management of Mastitis

**Agency for Healthcare Research and Quality**

\- Behavioral Modification Programs Help Obese Children Manage Their
Weight

\- Task Force Finds Several Methods Equally Effective for Colorectal
Cancer Screening

**-** Behavioral Counseling to Prevent Sexually Transmitted Infections
** **

\- AHRQ's 2008 Guide to Clinical Preventive Services Now Available

**Ask a Librarian**

\- Medical Clinics of North America issue dedicated to Women's Health

**Behavioral Health Insights**

#### - Protecting urban American Indian young people from suicide {#protecting-urban-american-indian-young-people-from-suicide .Style-Heading-4-+-Arial-14-pt-Underline}

**Breastfeeding**

\- A Skinny Little Secret

**CCC Corner Digest**

**Domestic Violence**

#### - Health outcomes in women with physical and sexual intimate partner violence exposure {#health-outcomes-in-women-with-physical-and-sexual-intimate-partner-violence-exposure .Style-Heading-4-+-Arial-14-pt-Underline}

**Elder Care News**

\- Prescription drug misuse/abuse in the elderly

**Family Planning**

#### - Drospirenone for acne treatment {#drospirenone-for-acne-treatment .Style-Heading-4-+-Arial-14-pt-Underline}

**Featured Website**

-The Immunization Action Coalition; free resources about vaccination for
everyone!

**Frequently asked questions**

-Q. Should we treat asymptomatic trichomonas found on a Pap smear?

-Q. Should we withhold contraception from a woman who is not 'current'
on her pap?

**Indian Child Health Notes**

\- Alcohol-Attributable Deaths and Years of Potential Life Lost Among
American Indians and Alaska Natives

­- Effectiveness of Maternal Influenza Immunization in Mothers and
Infants

**Information Technology**

\- Alpha Testing to Start on the EHR Version of the Well Child Module

International Health

\- Disease risks of premastication as an infant feeding practice

#### MCH Alert

-MCH Library Releases New Edition of Domestic Violence Knowledge Path

-Article Assesses Smoking Patterns and Use of Cessation Interventions
During Pregnancy

#### MCH Headlines

\- Native American Action Plan: Addressing Tobacco Abuse among Pregnant
and Postpartum Women

\- Cough and Cold Medications Not Recommended for Children Under 4 Years
of Age

\- Breastfeeding Mini-Grant Opportunity

#### Medical Mystery Tour

#### - Test your knowledge on Polycystic Ovarian Syndrome (PCOS) {#test-your-knowledge-on-polycystic-ovarian-syndrome-pcos .Style-Heading-4-+-Arial-14-pt-Underline}

#### Medscape

**Menopause Management**

\- Hot flashes and subclinical cardiovascular disease

**Midwives Corner**

**-** Centering Pregnancy ListServe Revived

**Navajo News**

#### - Navajo Area Women's Health Provider Meeting {#navajo-area-womens-health-provider-meeting .Style-Heading-4-+-Arial-14-pt-Underline}

**Nurses Corner**

\- Strategies to prevent healthcare-associated infections in acute care
hospitals

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

\- What Works to Promote Cancer Screening

Osteoporosis

\- Serum 25-hydroxyvitamin D and functional outcomes in the elderly

Patient Education

#### - Free Flu Materials from the CDC {#free-flu-materials-from-the-cdc .Style-Heading-4-+-Arial-14-pt-Underline}

Perinatology Picks

\- Cesarean delivery for the second twin

\- Accuracy of ultrasonographic fetal weight estimation in twin
pregnancies

\- Nicotine gum for pregnant smokers: a randomized controlled trial

\- Risk of development of diabetes mellitus after diagnosis of
gestational diabetes

Primary Care Discussion Forum

\- Geriatric Medication Issues

STD Corner

\- Innovative uses of technology that are being used to prevent STDs/HIV

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

-Postpartum screening after GDM affected pregnancies---room for
improvement

\- The association between low birth weight and type 2 diabetes

**Women's Health Headlines**

\- A web-based resource for oral health providers on screening for
domestic violence

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

#### 

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

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

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

**Effectiveness of maternal influenza immunization in mothers and
infants**\
BACKGROUND: Young infants and pregnant women are at increased risk for
serious consequences of influenza infection. Inactivated influenza
vaccine is recommended for pregnant women but is not licensed for
infants younger than 6 months of age. We assessed the clinical
effectiveness of inactivated influenza vaccine administered during
pregnancy in Bangladesh. METHODS: In this randomized study, we assigned
340 mothers to receive either inactivated influenza vaccine
(influenza-vaccine group) or the 23-valent pneumococcal polysaccharide
vaccine (control group). Mothers were interviewed weekly to assess
illnesses until 24 weeks after birth. Subjects with febrile respiratory
illness were assessed clinically, and ill infants were tested for
influenza antigens. We estimated the incidence of illness, incidence
rate ratios, and vaccine effectiveness.

RESULTS: Mothers and infants were observed from August 2004 through
December 2005. Among infants of mothers who received influenza vaccine,
there were fewer cases of laboratory-confirmed influenza than among
infants in the control group (6 cases and 16 cases, respectively), with
a vaccine effectiveness of 63% (95% confidence interval \[CI\], 5 to
85). Respiratory illness with fever occurred in 110 infants in the
influenza-vaccine group and 153 infants in the control group, with a
vaccine effectiveness of 29% (95% CI, 7 to 46). Among the mothers, there
was a reduction in the rate of respiratory illness with fever of 36%
(95% CI, 4 to 57).

CONCLUSIONS: Inactivated influenza vaccine reduced proven influenza
illness by 63% in infants up to 6 months of age and averted
approximately a third of all febrile respiratory illnesses in mothers
and young infants. Maternal influenza immunization is a strategy with
substantial benefits for both mothers and infants.

Zaman K, Roy E, Arifeen SE, Rahman M, Raqib R, Wilson E, Omer SB, Shahid
NS, Breiman RE, Steinhoff MC. Effectiveness of maternal influenza
immunization in mothers and infants. N Engl J Med. 2008 Oct
9;359(15):1555-64. Epub 2008 Sep 17.

<http://www.ncbi.nlm.nih.gov/pubmed/18799552>

Free Full Text:

<http://content.nejm.org/cgi/content/full/359/15/1555>

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

This article is important because it demonstrates another way that flu
vaccine can be used to protect some of the most vulnerable amongst us.
In addition to conferring protection to the mothers in this study (who
experienced a 36% reduction in febrile respiratory illness), the infants
born to the mothers who received influenza vaccine had 63% fewer cases
of influenza than the infants born to the control group of mothers. The
infants also experienced 29% fewer febrile respiratory illnesses
overall. Influenza vaccine is not currently licensed for use in infants
younger than 6 months of age. Their best protections are for their
mothers to receive a flu shot in pregnancy and for the household
contacts of infants to be immunized as well.

In an article about the study published by Johns Hopkins, the authors of
the study observed:

"Even though there is no flu vaccine for these children, our study shows
that a newborn's risk of infection can be greatly reduced by vaccinating
mom during pregnancy. It's a two for one benefit," said Mark Steinhoff,
MD, the study's senior author and professor in the Bloomberg School's
Department of International Health. "Infants under six months have the
highest rates of hospitalization from influenza among children in the
U.S. These admission rates are higher than those for the elderly and
other high-risk adult groups."

AWHONN (the Association of Women's Health, Obstetric, and Neonatal
Nurses) is publicizing the results of a new national survey, conducted
on behalf of the national Women's Health Resource Center (NWHRC), which
demonstrated that only 20 percent of those currently pregnant planned to
get a flu shot this season. AWHONN has launched a campaign, *Flu-Free &
Mom To Be; Protect Yourself, Protect Your Baby---Get a Flu Shot!*, to
encourage influenza vaccination for pregnant women and new mothers.

Is your facility currently offering flu shots to pregnant women? Do you
have standing orders to make this a streamlined, efficient process? What
about vaccinating the rest of the household? Can partners, older
siblings, and grandparents easily receive a flu shot at your facility?
If not, then take time to develop strategies to meet this need right
away. It's still early enough in flu season for these interventions to
make a real difference.

You will find resources for flu season throughout this issue. The Indian
Child Health notes also address influenza vaccination, as do other items
in the "Features" section from *ACOG*, the *Featured Website* section
and the *Patient Education* section. And in the "From Your Colleagues"
section you'll find encouragement from Public Health Service leadership
for you to get your own flu shot if you haven't already.

Help someone get vaccinated today!

**AWHONN website**:

<http://www.awhonn.org/awhonn/content.do?name=02_PracticeResources/2B1_FluFreeMom2Be.htm>

**2008 CDC Influenza Vaccination Guidelines:**

The 2008 recommendations include:

**Vaccination of all children aged 6 months--18 years** should begin
before or during the 2008--09 influenza season if feasible, but no later
than during the 2009--10 influenza season. Vaccination of all children
aged 5--18 years is a new ACIP recommendation.

Children and adolescents at high risk for influenza complications should
continue to be a focus of vaccination efforts as providers and programs
transition to routinely vaccinating all children and adolescents.
Recommendations for these children have not changed. Children and
adolescents at higher risk for influenza complication are those:

-   aged 6 months--4 years;

-   who have chronic pulmonary (including asthma), cardiovascular
    (except hypertension), renal, hepatic, hematological or metabolic
    disorders (including diabetes mellitus);

-   who are immunosuppressed (including immunosuppression caused by
    medications or by human immunodeficiency virus);

-   who have any condition (e.g., cognitive dysfunction, spinal cord
    injuries, seizure disorders, or other neuromuscular disorders) that
    can compromise respiratory function or the handling of respiratory
    secretions or that can increase the risk for aspiration;

-   who are receiving long-term aspirin therapy who therefore might be
    at risk for experiencing Reye syndrome after influenza virus
    infection;

-   who are residents of chronic-care facilities; and,

-   who will be pregnant during the influenza season.

**Annual recommendations for adults have not changed.** Annual
vaccination against influenza is recommended for any adult who wants to
reduce the risk for becoming ill with influenza or of transmitting it to
others. Vaccination also is recommended for all adults in the following
groups, because these persons are either at high risk for influenza
complications, or are close contacts of persons at higher risk:

-   persons aged \>50 years;

-   women who will be pregnant during the influenza season;

-   persons who have chronic pulmonary (including asthma),
    cardiovascular (except hypertension), renal, hepatic, hematological
    or metabolic disorders (including diabetes mellitus);

-   persons who have immunosuppression (including immunosuppression
    caused by medications or by human immunodeficiency virus);

-   persons who have any condition (e.g., cognitive dysfunction, spinal
    cord injuries, seizure disorders, or other neuromuscular disorders)
    that can compromise respiratory function or the handling of
    respiratory secretions or that can increase the risk for aspiration;

-   residents of nursing homes and other chronic-care facilities;

-   health-care personnel;

-   household contacts and caregivers of children aged \<5 years and
    adults aged \>50 years, with particular emphasis on vaccinating
    contacts of children aged \<6 months; and,

-   household contacts and caregivers of persons with medical conditions
    that put them at high risk for severe complications from influenza.

Centers for Disease Control and Prevention. Prevention and Control of
Influenza; Recommendations of the Advisory Committee on Immunization
Practices (ACIP), 2008. MMWR 2008;57(No. RR-7).
<http://www.cdc.gov/mmwr/PDF/rr/rr5707.pdf>

**Immunization in Pregnancy Chart:**

<http://www.cdc.gov/vaccines/pubs/downloads/f_preg_chart.pdf>

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

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

#### Richard Church, IHS Headquarters {#richard-church-ihs-headquarters-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CEO Brief (An e-mail newsletter for IHS leaders) -- Issue 7 {#ceo-brief-an-e-mail-newsletter-for-ihs-leaders-issue-7 .Style-Heading-4-+-Arial-14-pt-Underline}

#### *The Office of Public Health Support presents the seventh IHS CEO Brief in this email series designed to help you address the challenge of retaining our professional and clinical staff.* {#the-office-of-public-health-support-presents-the-seventh-ihs-ceo-brief-in-this-email-series-designed-to-help-you-address-the-challenge-of-retaining-our-professional-and-clinical-staff. .Style-Heading-4-+-Arial-14-pt-Underline}

#### *In this issue, a clinical director initiates a program to improve retention and recruitment. He discovers that compensation is a change he can make with a measurable impact. This case stresses the best practices of leadership and shared management.* {#in-this-issue-a-clinical-director-initiates-a-program-to-improve-retention-and-recruitment.-he-discovers-that-compensation-is-a-change-he-can-make-with-a-measurable-impact.-this-case-stresses-the-best-practices-of-leadership-and-shared-management. .Style-Heading-4-+-Arial-14-pt-Underline}

C

Background: Recruitment and retention of staff members at the hospital
was a serious issue. Because of the remoteness of the hospital,
clinicians typically stayed for just two to three years before moving
on - and the facility lost about two staff members per year.\
 \
Challenge: The hospital\'s clinical director decided to initiate a
program specifically designed to reverse the hospital\'s recruitment and
retention trends. But when he looked at all of the factors involved, he
discovered that many of them were beyond his control. For instance, many
staff members were leaving their positions due to family concerns, such
as living too far from ailing parents or limited opportunities for a
spouse to find work. While compensation was not usually mentioned as a
reason for leaving, the clinical director knew that it was an area he
could positively affect, and one that was likely to have a measurable
impact on his hiring and retention processes.\
 \
Solution: The clinical director developed a Medical Staff Pay Committee
and invited his entire medical staff and administration to participate
in it. A number of people volunteered for the committee and met weekly
during their lunch hour. They performed a comprehensive review of
existing staff salaries, comparing them to data in the *Physician
Compensation and Production Survey* produced by the Medical Group
Management Association.\
 \
Based on the committee\'s analysis, they determined that salaries could
be increased by 50 percent of the pay gap. They used six specialties to
demonstrate their findings to the hospital\'s executive leadership.
Because hiring and retaining staff in these particular positions would
lessen the need for more costly contractors, it was projected that a pay
increase in these areas would not affect the hospital\'s budget. So the
hospital applied the salary increase to the six specialties, which
resulted in measurable success in the areas of recruitment and
retention. This proven success enabled the committee to propose another
new plan to the hospital\'s executive leadership - one that closed 50
percent of the pay gap for the entire medical staff.

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

Responsible leadership involves researching factors, such as
compensation levels, that might impact your retention efforts, and
finding innovative ways to appropriately address them.\
 \
When you implement the concept of shared management, employees feel they
are part of a fair and equitable decision making process, and they
become empowered by the organization\'s willingness to let them help
lead.

For questions about this newsletter, please contact Richard Church at
<Richard.Church@ihs.gov>.

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

**Joxel Garcia, U.S. Public Health Service**

**Influenza Vaccination for Health Care Personnel**

I am requesting your assistance in implementing the Departmental
initiative for the 2008-09 influenza vaccination season to improve
Health Care Personnel (HCP) influenza vaccination levels. The Office of
Public Health and Science (OPHS) has formed a task force of relevant
OPDIVs and STAFFDIVs, and discussed current activities promoting and/or
providing HCP influenza vaccination. The task force has developed the
attached toolkit for OPDIVs and STAFFDIVs for use in promoting HCP
influenza vaccination.

I urge you to use the toolkit and related strategies to improve
vaccination levels of health care personnel in your OPDIV or STAFFDIV.
The rationale for this initiative and strategies are fully discussed in
the recommendations for influenza vaccination of HCP of the Healthcare
Infection Control Practices Advisory Committee (HICPAC) and the Advisory
Committee on Immunization Practices (ACIP)
(<http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5502a1.htm>).

The Department is striving to achieve the Healthy People 2010 objective
of 60 percent vaccination coverage for HCP, both for employee HCP, and
those outside of the Department.

The toolkit, and other materials to assist you, are available at
[www.hhs.gov/ophs/](http://www.hhs.gov/ophs/). We will pay particular
attention to measuring activities promoting influenza vaccination, and
vaccination rates for HCP. For further information about this
initiative, please contact CAPT Raymond Strikas at 202-260-2652, or at
<Raymond.strikas@psc.hhs.gov>.

Thank you for your assistance in this important effort.

#### Scott Giberson, IHS Headquarters  {#scott-giberson-ihs-headquarters .Style-Heading-4-+-Arial-14-pt-Underline}

**Call for Abstracts -- Third Alaska Native Health Research Conference**

The planning taskforce for the Third Alaska Native Health Research
Conference to be held March 19-20, 2009 in Anchorage, AK is announcing a
call for abstracts. Please distribute this link to [all]{.underline}
researchers and students with interests in Alaska Native health research
who may wish to submit an abstract for oral or poster presentation.  The
link for abstract submission is: 
[http://events.SignUp4.net/ANHRC09Abstract](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://events.signup4.net/ANHRC09Abstract)
 . The link is also available by clicking on \"Alaska Native Tribal
Health Research Conference; March 19-20, 2009\" at
[www.alaskatribalhealth.org](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.alaskatribalhealth.org/)

**Paul Seligman, Food and Drug Administration**

## FDA Creates Web Page with Drug Safety Information for Patients, Health Care Professionals; *Consolidates information in one access point* 

Consumers and health care professionals can now go to a single page on
the U.S. Food and Drug Administration\'s Web site to find a wide variety
of safety information about prescription drugs. The Web page,
<http://www.fda.gov/cder/drugSafety.htm>, provides links to information
in these categories:

-   Drug labeling, including patient labeling, professional labeling,
    and patient package inserts;

-   Drugs that have a Risk Evaluation and Mitigation Strategy (REMS) to
    ensure that their benefits outweigh their risks;

-   A searchable database of postmarket studies that are required from,
    or agreed to by, drug companies to provide the FDA with additional
    information about a drug\'s safety, efficacy, or optimal use;

-   Clinicaltrials.gov, a searchable database of clinical trials,
    including information about each trial\'s purpose, who may
    participate, locations, and useful phone numbers;

-   Drug-specific safety information, including safety sheets with the
    latest information about the drug as well as related FDA press
    announcements, fact sheets, and drug safety podcasts;

-   Quarterly reports that list certain drugs that are being evaluated
    for potential safety issues, based on a review of information in the
    FDA\'s Adverse Event Reporting System (AERS);

-   Warning Letters, Import Alerts, Recalls, Market Withdrawals, and
    Safety Alerts;

-   Regulations and guidance documents;

-   Consumer information about using medications safely and disposing of
    unused medicines;

-   Instructions how to report problems to the FDA through its MedWatch
    program;

-   Consumer articles on drug safety; and

-   The FDA\'s response to the Institute of Medicine\'s 2006 report on
    the future of drug safety.

\"By placing Web links to these up-to-date resources on a single page,
we\'re helping consumers and health care professionals find drug safety
information faster and easier,\" said Paul Seligman, M.D., M.P.H.,
associate director of Safety Policy and Communication in the FDA\'s
Center for Drug Evaluation and Research. \"This type of communication is
aimed at helping consumers and health care professionals make
well-informed decisions about medication use.\"

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

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

**Alcohol Use Screening for FASD Prevention among a Cohort of American
Indian Women**

ABSTRACT:

INTRODUCTION: The purpose of the study was to compare three sequential
pregnancies of American Indian women who have children with FAS or
children with incomplete FAS with women who did not have children with
FAS.

METHODS: Two retrospective case-control studies were conducted of
Northern Plains American Indian children with fetal alcohol syndrome
(FAS) (Study 1) or incomplete FAS (Study 2) in 1981--1993. Three
successive pregnancies ending in live births of 43 case mothers who had
children with FAS, and 35 case mothers who had children with incomplete
FAS were compared to the pregnancies of 86 and 70 control mothers who
did not have children with FAS, respectively, in the two studies.
Prenatal records were abstracted for the index child (child with FAS or
incomplete FAS) and siblings born just before and just after the index
child, and comparable prenatal records for the controls.

RESULTS: Compared to the controls, significantly more case mothers used
alcohol before and after all three pregnancies and during pregnancy with
the before sibling and the index child. Mothers who had children with
FAS reduced their alcohol use during the pregnancy following the birth
of the index child. All Study 1 case mothers (100%) and 60% of Study 2
case mothers used alcohol during the pregnancy with the index child
compared to 20 and 9% of respective control mothers. More study 1 case
mothers experienced unintentional injuries (OR 9.50) and intentional
injuries during the index pregnancy (OR 9.33) than the control mothers.
Most case mothers began prenatal care in the second trimester.

CONCLUSIONS: Alcohol use was documented before, during and after each of
the three pregnancies. Women of child-bearing age should be screened for
alcohol use whenever they present for medical services. Mothers who had
a child with FAS decreased their alcohol consumption with the next
pregnancy, a finding that supports the importance of prenatal screening
throughout pregnancy. Women who receive medical care for injuries should
be screened for alcohol use and referred for appropriate treatment.
Protective custody, case management and treatment services need to be
readily available for women who use alcohol.

Kvigne VL, Leonardson GR, Borzelleca J, Brock E, Neff-Smith M, and Welty
TK. Alcohol Use, Injuries, and Prenatal Visits During Three Successive
Pregnancies Among American Indian Women on the Northern Plains Who have
Children with Fetal Alcohol Syndrome or Incomplete Fetal Alcohol
Syndrome. Maternal and Child Health Journal. Volume 12, Supplement 1 /
July, 2008. pp 37-45.
<http://www.springerlink.com/content/dj5203723n2l7l34/>

**Prevention of Diabetes in Women with a History of Gestational
Diabetes: Effects of Metformin and Lifestyle Interventions**

CONTEXT: A past history of gestational diabetes mellitus (GDM) confers a
very high risk of post-partum development of diabetes, particularly type
2 diabetes.

OBJECTIVE: The Diabetes Prevention Program (DPP) sought to identify
individuals with impaired glucose tolerance (IGT) and intervene in an
effort to prevent or delay their progression to diabetes. This analysis
examines the differences between women enrolled in DPP with and without
a reported history of GDM.

DESIGN: The DPP was a randomized, controlled clinical trial.

SETTING: The study was a multicenter, NIH-sponsored trial carried out at
27 centers including academic and Indian Health Services sites.

PATIENTS: 2190 women were randomized into the DPP and provided
information for past history of GDM. This analysis addresses the
differences between those 350 women providing a past history of GDM and
those 1416 women with a previous live birth, but no history of GDM.

INTERVENTIONS: Subjects were randomized to either standard lifestyle and
placebo or metformin therapy, or to an intensive lifestyle intervention.

MAIN OUTCOMES: The primary outcome was the time to development of
diabetes ascertained by semi-annual fasting plasma glucose and annual
oral glucose tolerance testing. Assessments of insulin secretion and
insulin sensitivity were also performed.

RESULTS: While entering the study with similar glucose levels, women
with a history of GDM randomized to placebo had a crude incidence rate
of diabetes 71% higher than that of women without such a history. Among
women reporting a history of GDM, both intensive lifestyle and metformin
therapy reduced the incidence of diabetes by approximately 50% compared
with the placebo group, whereas this reduction was 49% and 14%,
respectively in parous women without GDM. These data suggest that
metformin may be more effective in women with a GDM history as compared
to those without.

CONCLUSIONS: Progression to diabetes is more common in women with a
history of GDM compared to those without GDM history despite equivalent
degrees of IGT at baseline. Both intensive lifestyle and metformin are
highly effective in delaying or preventing diabetes in women with IGT
and a history of GDM.

Ratner RE, Christophi CA, Metzger BE, Dabelea D, Bennett PH, Pi-Sunyer
X, Fowler S, Kahn SE; The Diabetes Prevention Program Research Group.
Prevention of Diabetes in Women with a History of Gestational Diabetes:
Effects of Metformin and Lifestyle Interventions. J Clin Endocrinol
Metab. 2008 Sep 30. \[Epub ahead of print\]
<http://www.ncbi.nlm.nih.gov/pubmed/18826999>

**Perinatal outcomes in low-risk term pregnancies: do they differ by
week of gestation?**

OBJECTIVE: The objective of the study was to examine whether the risk of
perinatal complications increases with increasing gestational age among
term pregnancies.

STUDY DESIGN: This is a retrospective cohort study of low-risk women
with term, singleton births in 2003 in the United States. Gestational
age was subgrouped into 37, 38, 39, 40, and 41 completed weeks.
Statistical comparison was performed using chi(2) test and multivariable
logistic regression models, with 39 weeks\' gestation as the referent.

RESULTS: There were 2,527,766 women meeting study criteria. Compared
with 39 weeks, delivery at 37 or 38 weeks had lower risk of febrile
morbidity but slightly higher risk of cesarean delivery. Delivery at 40
or 41 weeks was also associated with higher overall maternal morbidity.
For neonates, delivery at 40 or 41 weeks had higher risk of birthweight
greater than 4500 g, neonatal injury (40 weeks: adjusted odds ratio
\[aOR\] 1.11 \[95% confidence interval (CI), 1.05-1.18\]; 41 weeks: aOR
1.27 \[95% CI, 1.17-1.37\]) and meconium aspiration (40 weeks: aOR 1.55
\[95% CI, 1.43-1.69\]; 41 weeks: aOR 2.12 \[95% CI, 1.91-2.35\]).
Delivery at 37 or 38 weeks had higher risk of hyaline membrane disease
(37 weeks: aOR 3.12 \[95% CI, 2.90-3.38\]); 38 weeks: aOR 1.30 \[95% CI,
1.19-1.43\]) but lower risk of meconium aspiration.

CONCLUSION: The risk of cesarean delivery and neonatal morbidity in
low-risk women increases at 40 weeks and beyond, whereas the odds of
serious neonatal pulmonary disease were highest at 37 weeks. Recognition
of such variation in term outcomes should lead providers to avoid
iatrogenic morbidity and consider interventions to prevent complications
of late-term pregnancy.

Cheng YW, Nicholson JM, Nakagawa S, Bruckner TA, Washington AE, Caughey
AB. Perinatal outcomes in low-risk term pregnancies: do they differ by
week of gestation? Am J Obstet Gynecol. 2008 Oct;199(4):370.e1-7.
<http://www.ncbi.nlm.nih.gov/pubmed/18928977>

**Effect on birth outcomes of a formalised approach to care in hospital
labour assessment units: international, randomised controlled trial**

OBJECTIVE: To determine if a complex nursing and midwifery intervention
in hospital labour assessment units would increase the likelihood of
spontaneous vaginal birth and improve other maternal and neonatal
outcomes.

DESIGN: Multicentre, randomised controlled trial with prognostic
stratification by hospital. SETTING: 20 North American and UK hospitals.

PARTICIPANTS: 5002 nulliparous women experiencing contractions but not
in active labour; 2501 were allocated to structured care and 2501 to
usual care.

INTERVENTIONS: Usual nursing or midwifery care or a minimum of one hour
of care by a nurse or midwife trained in structured care, consisting of
a formalised approach to assessment of and interventions for maternal
emotional state, pain, and fetal position.

MAIN OUTCOME MEASURES: Primary outcome was spontaneous vaginal birth.
Other outcomes included intrapartum interventions, women\'s views of
their care, and indicators of maternal and fetal health during hospital
stay and 6-8 weeks after discharge.

RESULTS: Outcome data were obtained for 4996 women. The rate of
spontaneous vaginal birth was 64.0% (n=1597) in the structured care
group and 61.3% (n=1533) in the usual care group (odds ratio 1.12, 95%
confidence interval 0.96 to 1.27). Fewer women allocated to structured
care (n=403, 19.5%) rated staff helpfulness as less than very helpful
than those allocated to usual care (n=544, 26.4%); odds ratio 0.67,
98.75% confidence interval 0.50 to 0.85. Fewer women allocated to
structured care (n=233, 11.3%) were disappointed with the amount of
attention received from staff than those allocated to usual care (n=407,
19.7%); odds ratio 0.51, 98.75% confidence interval 0.32 to 0.70. None
of the other results met prespecified levels of statistical
significance.

CONCLUSION: A structured approach to care in hospital labour assessment
units increased satisfaction with care and was suggestive of a modest
increase in the likelihood of spontaneous vaginal birth. Further study
to strengthen the intervention is warranted.

Hodnett ED, Stremler R, Willan AR, Weston JA, Lowe NK, Simpson KR,
Fraser WD, Gafni A; SELAN (Structured Early Labour Assessment and Care
by Nurses) Trial Group. Effect on birth outcomes of a formalised
approach to care in hospital labour assessment units: international,
randomised controlled trial. BMJ. 2008 Aug 28;337:a1021. doi:
10.1136/bmj.a1021. <http://www.ncbi.nlm.nih.gov/pubmed/18755762>

Free full text:

<http://www.bmj.com/cgi/content/full/337/aug28_1/a1021>

**Peripartum Clostridium difficile infection**

Clostridium difficile infection (CDI) in nonhospitalized patients has
been reported with increased frequency. An association between CDI and
pregnancy has not been stressed. This review will report 4 cases of
peripartum CDI with characterization of the infecting strain and a
literature review. A PubMed search identified 24 recorded cases of
peripartum CDI; information was available for 14 cases. Most patients
(91%) received prophylactic antibiotics during delivery or for treatment
of bacterial infections (50%). All patients reported diarrhea. Two of
our reported cases without known risk factors were found by polymerase
chain reaction analysis to be infected with an epidemic and
hypervirulent C difficile strain. These cases demonstrate the need for
clinicians to consider CDI in patients with severe diarrhea, even if
they do not have the traditional risk factors for CDI, such as
antibiotic use or concurrent hospitalizations. Further research into the
scope and risk factors for peripartum CDI is warranted.

Garey KW, Jiang ZD, Yadav Y, Mullins B, Wong K, Dupont HL. Peripartum
Clostridium difficile infection: case series and review of the
literature. Am J Obstet Gynecol. 2008 Oct;199(4):332-7. Epub 2008 Jul
17. <http://www.ncbi.nlm.nih.gov/pubmed/18639213>

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

**Pregnancy outcome in women before and after cervical conisation**

OBJECTIVES: To examine the consequences of cervical conisation in terms
of adverse outcome in subsequent pregnancies.

DESIGN: Population based cohort study.

DATA SOURCES: Data on cervical conisation derived from the Cancer
Registry of Norway and on pregnancy outcome from the Medical Birth
Registry of Norway, 1967-2003. 15 108 births occurred in women who had
previously undergone cervical conisation and 57 136 who subsequently
underwent cervical conisation. In the same period there were 2 164 006
births to women who had not undergone relevant treatment (control).

RESULTS: The proportion of preterm delivery was 17.2% in women who gave
birth after cervical conisation versus 6.7% in women who gave birth
before cervical conisation and 6.2% in women who had not undergone
cervical conisation. The relative risk of a late abortion (\<24 weeks\'
gestation) was 4.0 (95% confidence interval 3.3 to 4.8) in women who
gave birth after cervical conisation compared with no cervical
conisation. The relative risk of delivery was 4.4 (3.8 to 5.0) at 24-27
weeks, 3.4 (3.1 to 3.7) at 28-32 weeks, and 2.5 (2.4 to 2.6) at 33-36
weeks. The relative risk of preterm delivery declined during the study
period and especially of delivery before 28 weeks\' gestation.

CONCLUSION: Cervical conisation influences outcome in subsequent
pregnancies in terms of an increased risk of preterm delivery,
especially in the early gestational age groups in which the clinical
significance is highest. A careful clinical approach should be taken in
the selection of women for cervical conisation and in the clinical care
of pregnancies after a cervical conisation.

Albrechtsen S, Rasmussen S, Thoresen S, Irgens LM, Iversen OE. Pregnancy
outcome in women before and after cervical conisation: population based
cohort study. BMJ. 2008 Sep 18;337:a1343. doi: 10.1136/bmj.a1343.
<http://www.ncbi.nlm.nih.gov/pubmed/18801869>

Free Full Text: <http://www.bmj.com/cgi/content/full/337/sep18_1/a1343>

# 

# 

# FDA Public Health Notification: Serious Complications Associated with Transvaginal Placement of Surgical Mesh in Repair of Pelvic Organ Prolapse and Stress Urinary Incontinence

The FDA has informed healthcare professionals of serious complications
associated with transvaginal placement of surgical mesh in repair of
pelvic organ prolapse (POP) and stress urinary incontinence (SUI). Over
the past three years, FDA has received over 1,000 reports from nine
surgical mesh manufacturers of complications that were associated with
surgical mesh devices used to repair POP and SUI. The most frequent
complications included erosion through vaginal epithelium, infection,
pain, urinary problems, and recurrence of prolapse and/or incontinence.
There were also reports of bowel, bladder, and blood vessel perforation
during insertion. In some cases, vaginal scarring and mesh erosion led
to a significant decrease in patient quality of life due to discomfort
and pain, including dyspareunia. FDA provided recommended actions for
both physicians and patients to reduce the risks. 

Additional information is available at:

<http://www.fda.gov/cdrh/safety/102008-surgicalmesh.html>

**The role of Lactobacillus casei rhamnosus Lcr35 in restoring the
normal vaginal flora after antibiotic treatment of bacterial vaginosis**

OBJECTIVE: To evaluate the efficacy of additional topical Lactobacillus
casei rhamnosus (Lcr35) subsequent to antibiotic treatment of bacterial
vaginosis (BV) to restore the normal vaginal flora. STUDY DESIGN:
Single-centre, randomised, observer blinded study.

SETTING: Population-based study in Vienna over 1 year.

SAMPLE: 190 women were enrolled in the study.

METHODS: Women with Nugent scores between 7 and 10 on initial vaginal
swab were randomised to the one of two groups. All women were treated
with standard antibiotic therapy for 7 days. Only women in the
intervention group received vaginal capsules containing 10(9)
colony-forming units of live Lcr35 for 7 days after antibiotic
treatment. Final vaginal swabs for Nugent scoring were taken 4 weeks
after the last administration of the study medication.

MAIN OUTCOME MEASURES: The primary efficacy variable was a change in the
Nugent score between the baseline and the end of the study of at least 5
grades in each individual woman. RESULTS: Sixty-nine of the 83 women
(83%) in the intervention group and 31 of the 88 women (35%) in the
control group showed a reduction of the Nugent score by at least 5
grades. The difference in the number of women with improvement was
highly significant (P \< 0.001). The median difference in Nugent scores
between initial and final swabs was 6.61 in the intervention group and
4.13 in the control group (P \< 0.001).

CONCLUSION: Our data show that the restoration of the vaginal flora
after antibiotic treatment of BV can be significantly enhanced by
exogenously applied lactobacilli.

Petricevic L, Witt A. The role of Lactobacillus casei rhamnosus Lcr35 in
restoring the normal vaginal flora after antibiotic treatment of
bacterial vaginosis. BJOG. 2008 Oct;115(11):1369-74.
<http://www.ncbi.nlm.nih.gov/pubmed/18823487>

**Hormone therapy and the risk of breast cancer in BRCA1 mutation
carriers** BACKGROUND: Hormone therapy (HT) is commonly given to women
to alleviate the climacteric symptoms associated with menopause. There
is concern that this treatment may increase the risk of breast cancer.
The potential association of HT and breast cancer risk is of particular
interest to women who carry a mutation in BRCA1 because they face a high
lifetime risk of breast cancer and because many of these women take HT
after undergoing prophylactic surgical oophorectomy at a young age.
METHODS: We conducted a matched case-control study of 472 postmenopausal
women with a BRCA1 mutation to examine whether or not the use of HT is
associated with subsequent risk of breast cancer. Breast cancer case
patients and control subjects were matched with respect to age, age at
menopause, and type of menopause (surgical or natural). Odds ratios
(ORs) and 95% confidence intervals (CIs) were estimated with conditional
logistic regression. Statistical tests were two-sided. RESULTS: In this
group of BRCA1 mutation carriers, the adjusted OR for breast cancer
associated with ever use of HT compared with never use was 0.58 (95% CI
= 0.35 to 0.96; P = .03). In analyses by type of HT, an inverse
association with breast cancer risk was observed with use of estrogen
only (OR = 0.51, 95% CI = 0.27 to 0.98; P = .04); the association with
use of estrogen plus progesterone was not statistically significant (OR
= 0.66, 95% CI = 0.34 to 1.27; P = .21). CONCLUSION: Among
postmenopausal women with a BRCA1 mutation, HT use was not associated
with increased risk of breast cancer; indeed, in this population, it was
associated with a decreased risk.

Eisen A, Lubinski J, Gronwald J, Moller P, Lynch HT, Klijn J, et al.
Hormone therapy and the risk of breast cancer in BRCA1 mutation
carriers. J Natl Cancer Inst. 2008 Oct 1;100(19):1361-7. Epub 2008 Sep
23. <http://www.ncbi.nlm.nih.gov/pubmed/18812548>

Free Full Text:

<http://jnci.oxfordjournals.org/cgi/content/full/100/19/1361>

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

**Prevention of Rickets and Vitamin D Deficiency in Infants, Children,
and Adolescents**

ABSTRACT

Rickets in infants attributable to inadequate vitamin D intake and
decreased exposure to sunlight continues to be reported in the United
States. There are also concerns for vitamin D deficiency in older
children and adolescents. Because there are limited natural dietary
sources of vitamin D and adequate sunshine exposure for the cutaneous
synthesis of vitamin D is not easily determined for a given individual
and may increase the risk of skin cancer, the recommendations to ensure
adequate vitamin D status have been revised to include all infants,
including those who are exclusively breastfed and older children and
adolescents. It is now recommended that all infants and children,
including adolescents, have a minimum daily intake of 400 IU of vitamin
D beginning soon after birth. The current recommendation replaces the
previous recommendation of a minimum daily intake of 200 IU/day of
vitamin D supplementation beginning in the first 2 months after birth
and continuing through adolescence. These revised guidelines for vitamin
D intake for healthy infants, children, and adolescents are based on
evidence from new clinical trials and the historical precedence of
safely giving 400 IU of vitamin D per day in the pediatric and
adolescent population. New evidence supports a potential role for
vitamin D in maintaining innate immunity and preventing diseases such as
diabetes and cancer. The new data may eventually refine what constitutes
vitamin D sufficiency or deficiency.

Carol L. Wagner, MD, Frank R. Greer, MD, and the Section on
Breastfeeding and Committee on Nutrition. Prevention of Rickets and
Vitamin D Deficiency in Infants, Children, and Adolescents.

Pediatrics 2008;122:1142--1152.
<http://www.aap.org/new/VitaminDreport.pdf>

**Interventions in primary care to promote breastfeeding: an evidence
review for the U.S. Preventive Services Task Force**

BACKGROUND: Evidence suggests that breastfeeding decreases the risk for
many diseases in mothers and infants. It is therefore important to
evaluate the effectiveness of breastfeeding interventions.

PURPOSE: To systematically review evidence for the effectiveness of
primary care-initiated interventions to promote breastfeeding with
respect to breastfeeding and child and maternal health outcomes.

DATA SOURCES: Electronic searches of MEDLINE, the Cochrane Central
Register of Controlled Trials, and CINAHL from September 2001 to
February 2008 and references of selected articles, restricted to
English-language publications.

STUDY SELECTION: Randomized, controlled trials of primary care-initiated
interventions to promote breastfeeding, mainly in developed countries.

DATA EXTRACTION: Characteristics of interventions and comparators, study
setting, study design, population characteristics, the proportion of
infants continuing breastfeeding by different durations, and infant or
maternal health outcomes were recorded.

DATA SYNTHESIS: Thirty-eight randomized, controlled trials (36 in
developed countries) met eligibility criteria. In random-effects
meta-analyses, breastfeeding promotion interventions in developed
countries resulted in significantly increased rates of short- (1 to 3
months) and long-term (6 to 8 months) exclusive breastfeeding (rate
ratios, 1.28 \[95% CI, 1.11 to 1.48\] and 1.44 \[CI, 1.13 to 1.84\],
respectively). In subgroup analyses, combining pre- and postnatal
breastfeeding interventions had a larger effect on increasing
breastfeeding durations than either pre- or postnatal interventions
alone. Furthermore, breastfeeding interventions with a component of lay
support (such as peer support or peer counseling) were more effective
than usual care in increasing the short-term breastfeeding rate.

LIMITATIONS: Meta-analyses were limited by clinical and methodological
heterogeneity. Reliable estimates for the isolated effects of each
component of multicomponent interventions could not be obtained.

CONCLUSION: Evidence suggests that breastfeeding interventions are more
effective than usual care in increasing short- and long-term
breastfeeding rates. Combined pre- and postnatal interventions and
inclusion of lay support in a multicomponent intervention may be
beneficial.

Chung M, Raman G, Trikalinos T, Lau J, Ip S. Interventions in primary
care to promote breastfeeding: an evidence review for the U.S.
Preventive Services Task Force. Ann Intern Med. 2008 Oct
21;149(8):565-82. <http://www.ncbi.nlm.nih.gov/pubmed/18936504>

Full Text:
<http://www.ahrq.gov/clinic/uspstf08/breastfeeding/brfeedart.pdf>

**Use of a fan during sleep and the risk of sudden infant death
syndrome**

OBJECTIVE: To examine the relation between room ventilation during sleep
and risk of sudden infant death syndrome (SIDS).

DESIGN: Population-based case-control study.

SETTING: Eleven California counties.

PARTICIPANTS: Mothers of 185 infants with a confirmed SIDS diagnosis and
312 randomly selected infants matched on county of residence, maternal
race/ethnicity, and age.

INTERVENTION: Fan use and open window during sleep.

MAIN OUTCOME MEASURE: Risk of SIDS.

RESULTS: Fan use during sleep was associated with a 72% reduction in
SIDS risk (adjusted odds ratio \[AOR\], 0.28; 95% confidence interval
\[CI\], 0.10-0.77). The reduction in SIDS risk seemed more pronounced in
adverse sleep environments. For example, fan use in warmer room
temperatures was associated with a greater reduction in SIDS risk (AOR,
0.06; 95% CI, 0.01-0.52) compared with cooler room temperatures (0.77;
0.22-2.73). Similarly, the reduction associated with fan use was greater
in infants placed in the prone or side sleep position (AOR, 0.14; 95%
CI, 0.03-0.55) vs supine (0.84; 0.21-3.39). Fan use was associated with
a greater reduction in SIDS risk in infants who shared a bed with an
individual other than their parents (AOR, 0.15; 95% CI, 0.01-1.85) vs
with a parent (0.40; 0.03-4.68). Finally, fan use was associated with
reduced SIDS risk in infants not using pacifiers (AOR, 0.22; 95% CI,
0.07-0.69) but not in pacifier users (1.99; 0.16-24.4). Some differences
in the effect of fan use on SIDS risk did not reach statistical
significance.

CONCLUSION: Fan use may be an effective intervention for further
decreasing SIDS risk in infants in adverse sleep environments.

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

Coleman-Phox K, Odouli R, Li DK. Use of a fan during sleep and the risk
of sudden infant death syndrome. Arch Pediatr Adolesc Med. 2008
Oct;162(10):963-8. <http://www.ncbi.nlm.nih.gov/pubmed/18838649>

**Support for Comprehensive Sexuality Education:**

**Perspectives from Parents of School-Age Youth** \
PURPOSE: Controversy about school-based sexuality education in public
schools has continued over the past decade, despite mounting evidence
that comprehensive sexuality education effectively promotes sexual
health and that parents support these programs in public schools. The
present study replicates and expands upon previous findings regarding
public views on school-based sexuality education. METHODS: One thousand
six hundred five parents of school-age children in Minnesota responded
to telephone surveys in 2006-2007 (63% participation rate), including
items regarding general sexuality education, 12 specific topics, the
grade level at which each should be taught, and attitudes toward
sexuality education. RESULTS: The large majority of parents supported
teaching about both abstinence and contraception (comprehensive
sexuality education \[CSE\]; 89.3%), and support was high across all
demographic categories of parents. All specific sexuality education
topics received majority support (63.4%-98.6%), even those often viewed
as controversial. Parents believed most topics should first be taught
during the middle school years. Parents held slightly more favorable
views on the effectiveness of CSE compared to abstinence-only education,
and these views were strongly associated with support for CSE (odds
ratio \[OR\](CSE) = 14.3; OR(abstinence) = 0.11). CONCLUSIONS: This
study highlights a mismatch between parents\' expressed opinions and
preferences, and actual sexuality education content as currently taught
in the majority of public schools. In light of broad parental support
for education that emphasizes multiple strategies for prevention of
pregnancy and sexually transmitted infections (including abstinence),
parents should be encouraged to express their opinions on sexuality
education to teachers, administrators, and school boards regarding the
importance of including a variety of topics and beginning instruction
during middle school years or earlier.

Eisenberg ME, Bernat DH, Bearinger LH, Resnick MD. Support for
comprehensive sexuality education: perspectives from parents of
school-age youth. J Adolesc Health. 2008 Apr;42(4):352-9. Epub 2007 Dec
26. <http://www.ncbi.nlm.nih.gov/pubmed/18346660>

**First-trimester maternal alcohol consumption and the risk of infant
oral clefts**

Although alcohol is a recognized teratogen, evidence is limited on
alcohol intake and oral cleft risk. The authors examined the association
between maternal alcohol consumption and oral clefts in a national,
population-based case-control study of infants born in 1996-2001 in
Norway. Participants were 377 infants with cleft lip with or without
cleft palate, 196 with cleft palate only, and 763 controls. Mothers
reported first-trimester alcohol consumption in self-administered
questionnaires completed within a few months after delivery. Logistic
regression was used to calculate odds ratios and 95% confidence
intervals, adjusting for confounders. Compared with nondrinkers, women
who reported binge-level drinking (\>or=5 drinks per sitting) were more
likely to have an infant with cleft lip with or without cleft palate
(odds ratio = 2.2, 95% confidence interval: 1.1, 4.2) and cleft palate
only (odds ratio = 2.6, 95% confidence interval: 1.2, 5.6). Odds ratios
were higher among women who binged on three or more occasions: odds
ratio = 3.2 for cleft lip with or without cleft palate (95% confidence
interval: 1.0, 10.2) and odds ratio = 3.0 for cleft palate only (95%
confidence interval: 0.7, 13.0). Maternal binge-level drinking may
increase the risk of infant clefts.

DeRoo LA, Wilcox AJ, Drevon CA, Lie RT. First-trimester maternal alcohol
consumption and the risk of infant oral clefts in Norway: a
population-based case-control study. Am J Epidemiol. 2008 Sep
15;168(6):638-46. Epub 2008 Jul 30.
<http://www.ncbi.nlm.nih.gov/pubmed/18667525>

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

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

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

**Patients and Caregivers Benefit from End-of-Life Discussions**

CONTEXT: Talking about death can be difficult. Without evidence that
end-of-life discussions improve patient outcomes, physicians must
balance their desire to honor patient autonomy against a concern of
inflicting psychological harm.

OBJECTIVE: To determine whether end-of-life discussions with physicians
are associated with fewer aggressive interventions.

DESIGN, SETTING, AND PARTICIPANTS: A US multisite, prospective,
longitudinal cohort study of patients with advanced cancer and their
informal caregivers (n = 332 dyads), September 2002-February 2008.
Patients were followed up from enrollment to death, a median of 4.4
months later. Bereaved caregivers\' psychiatric illness and quality of
life was assessed a median of 6.5 months later.

MAIN OUTCOME MEASURES: Aggressive medical care (eg, ventilation,
resuscitation) and hospice in the final week of life. Secondary outcomes
included patients\' mental health and caregivers\' bereavement
adjustment.

RESULTS: One hundred twenty-three of 332 (37.0%) patients reported
having end-of-life discussions before baseline. Such discussions were
not associated with higher rates of major depressive disorder (8.3% vs
5.8%; adjusted odds ratio \[OR\], 1.33; 95% confidence interval \[CI\],
0.54-3.32), or more worry (mean McGill score, 6.5 vs 7.0; P = .19).
After propensity-score weighted adjustment, end-of-life discussions were
associated with lower rates of ventilation (1.6% vs 11.0%; adjusted OR,
0.26; 95% CI, 0.08-0.83), resuscitation (0.8% vs 6.7%; adjusted OR,
0.16; 95% CI, 0.03-0.80), ICU admission (4.1% vs 12.4%; adjusted OR,
0.35; 95% CI, 0.14-0.90), and earlier hospice enrollment (65.6% vs
44.5%; adjusted OR, 1.65;95% CI, 1.04-2.63). In adjusted analyses, more
aggressive medical care was associated with worse patient quality of
life (6.4 vs 4.6; F = 3.61, P = .01) and higher risk of major depressive
disorder in bereaved caregivers (adjusted OR, 3.37; 95% CI, 1.12-10.13),
whereas longer hospice stays were associated with better patient quality
of life (mean score, 5.6 vs 6.9; F = 3.70, P = .01). Better patient
quality of life was associated with better caregiver quality of life at
follow-up (beta = .20; P = .001). CONCLUSIONS: End-of-life discussions
are associated with less aggressive medical care near death and earlier
hospice referrals. Aggressive care is associated with worse patient
quality of life and worse bereavement adjustment.

Wright AA, Zhang B, Ray A, Mack JW, Trice E, Balboni T, Mitchell SL,
Jackson VA, Block SD, Maciejewski PK, Prigerson HG. Associations between
end-of-life discussions, patient mental health, medical care near death,
and caregiver bereavement adjustment. JAMA. 2008 Oct 8;300(14):1665-73.
[http://www.ncbi.nlm.nih.gov/pubmed/18840840](http://www.ncbi.nlm.nih.gov/pubmed/18840840  )

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

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

**Comparative Effectiveness and Safety of Premixed Insulin Analogues in
Type 2 Diabetes** BACKGROUND: Evidence comparing premixed insulin
analogues (a mixture of rapid-acting and intermediate-acting insulin
analogues) with other antidiabetic agents is urgently required to guide
appropriate therapy.

PURPOSE: To summarize the English-language literature on the
effectiveness and safety of premixed insulin analogues compared with
other antidiabetic agents in adults with type 2 diabetes.

DATA SOURCES: The authors searched MEDLINE, EMBASE, CINAHL, and the
Cochrane Central Register of Controlled Trials from inception to
February 2008 and sought unpublished data from the U.S. Food and Drug
Administration, European Medicines Agency, and industry. STUDY
SELECTION: Studies with control groups that compared premixed insulin
analogues with another antidiabetic medication in adults with type 2
diabetes.

DATA EXTRACTION: 2 reviewers using standardized protocols performed
serial abstraction. DATA SYNTHESIS: Evidence from clinical trials was
inconclusive for clinical outcomes, such as mortality. Therefore, the
review focused on intermediate outcomes. Premixed insulin analogues were
similar to premixed human insulin in decreasing fasting glucose levels,
hemoglobin A(1c) levels, and the incidence of hypoglycemia but were more
effective in decreasing postprandial glucose levels (mean difference,
-1.1 mmol/L; 95% CI, -1.4 to -0.7 mmol/L \[-19.2 mg/dL; 95% CI, -25.9 to
-12.5 mg/dL\]). Compared with long-acting insulin analogues, premixed
insulin analogues were superior in decreasing postprandial glucose
levels (mean difference, -1.5 mmol/L; CI, -1.9 to -1.2 mmol/L \[-27.9
mg/dL; CI, -34.3 to -21.5 mg/dL\]) and hemoglobin A(1c) levels (mean
difference, -0.39% \[CI, -0.50% to -0.28%\]) but were inferior in
decreasing fasting glucose levels (mean difference, 0.7 mmol/L; CI, 0.3
to 1.0 mmol/L \[12.0 mg/dL; CI, 6.0 to 18.1 mg/dL\]) and were associated
with a higher incidence of hypoglycemia. Compared with noninsulin
antidiabetic agents, premixed insulin analogues were more effective in
decreasing fasting glucose levels (mean difference, -1.1 mmol/L; CI,
-1.7 to -0.6 mmol/L \[-20.5 mg/dL; CI, -29.9 to -11.2 mg/dL\]),
postprandial glucose levels (mean difference, -2.1 mmol/L; CI, -3.4 to
-0.8 mmol/L \[-37.4 mg/dL; CI, -61.0 to -13.7 mg/dL\]), and hemoglobin
A(1c) levels (mean difference, -0.49% \[CI, -0.86% to -0.12%\]) but were
associated with a higher incidence of hypoglycemia. Limitations: The
literature search was restricted to studies published in English. Data
on clinical outcomes were limited. The small number of studies for each
comparison limited assessment of between-study heterogeneity.
CONCLUSION: Premixed insulin analogues provide glycemic control similar
to that of premixed human insulin and may provide tighter glycemic
control than long-acting insulin analogues and noninsulin antidiabetic
agents.

Qayyum R, Bolen S, Maruthur N, Feldman L, Wilson LM, Marinopoulos SS,
Ranasinghe P, Amer M, Bass EB. Systematic Review: Comparative
Effectiveness and Safety of Premixed Insulin Analogues in Type 2
Diabetes. Ann Intern Med. 2008 Sep 15. \[Epub ahead of print\]

<http://www.ncbi.nlm.nih.gov/pubmed/18794553>

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

Modified Insulin Most Effective for Controlling Post-Meal Blood Sugar
Levels*.* Press Release, September 15, 2008. Agency for Healthcare
Research and Quality, Rockville, MD.
<http://www.ahrq.gov/news/press/pr2008/modinspr.htm>

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

#### Smoking cessation interventions for hospitalized smokers: a systematic review {#smoking-cessation-interventions-for-hospitalized-smokers-a-systematic-review .Style-Heading-4-+-Arial-14-pt-Underline}

BACKGROUND: A hospital admission provides an opportunity to help people
stop smoking. Providing smoking cessation advice, counseling, or
medication is now a quality-of-care measure for US hospitals. We
assessed the effectiveness of smoking cessation interventions initiated
during a hospital stay.

METHODS: We searched the Cochrane Tobacco Addiction Review Group\'s
register for randomized and quasirandomized controlled trials of smoking
cessation interventions (behavioral counseling and/or pharmacotherapy)
that began during hospitalization and had a minimum of 6 months of
follow-up. Two authors independently extracted data from each article,
with disagreements resolved by consensus.

#### RESULTS: Thirty-three trials met inclusion criteria. Smoking counseling that began during hospitalization and included supportive contacts for more than 1 month after discharge increased smoking cessation rates at 6 to 12 months (pooled odds ratio \[OR\], 1.65; 95% confidence interval \[CI\], 1.44-1.90). No benefit was found for interventions with less postdischarge contact. Counseling was effective when offered to all hospitalized smokers and to the subset admitted for cardiovascular disease. Adding nicotine replacement therapy to counseling produced a trend toward efficacy over counseling alone (OR, 1.47; 95% CI, 0.92-2.35). One study added bupropion hydrochloride to counseling, which had a nonsignificant result (OR, 1.56; 95% CI, 0.79-3.06). CONCLUSIONS: Offering smoking cessation counseling to all hospitalized smokers is effective as long as supportive contacts continue for more than 1 month after discharge. Adding nicotine replacement therapy to counseling may further increase smoking cessation rates and should be offered when clinically indicated, especially to hospitalized smokers with nicotine withdrawal symptoms.  {#results-thirty-three-trials-met-inclusion-criteria.-smoking-counseling-that-began-during-hospitalization-and-included-supportive-contacts-for-more-than-1-month-after-discharge-increased-smoking-cessation-rates-at-6-to-12-months-pooled-odds-ratio-or-1.65-95-confidence-interval-ci-1.44-1.90.-no-benefit-was-found-for-interventions-with-less-postdischarge-contact.-counseling-was-effective-when-offered-to-all-hospitalized-smokers-and-to-the-subset-admitted-for-cardiovascular-disease.-adding-nicotine-replacement-therapy-to-counseling-produced-a-trend-toward-efficacy-over-counseling-alone-or-1.47-95-ci-0.92-2.35.-one-study-added-bupropion-hydrochloride-to-counseling-which-had-a-nonsignificant-result-or-1.56-95-ci-0.79-3.06.-conclusions-offering-smoking-cessation-counseling-to-all-hospitalized-smokers-is-effective-as-long-as-supportive-contacts-continue-for-more-than-1-month-after-discharge.-adding-nicotine-replacement-therapy-to-counseling-may-further-increase-smoking-cessation-rates-and-should-be-offered-when-clinically-indicated-especially-to-hospitalized-smokers-with-nicotine-withdrawal-symptoms. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Rigotti NA, Munafo MR, Stead LF. Smoking cessation interventions for hospitalized smokers: a systematic review. **Arch Intern Med. 2008 Oct 13;168(18):1950-60.** [**http://www.ncbi.nlm.nih.gov/pubmed/18852395**](http://www.ncbi.nlm.nih.gov/pubmed/18852395) {#rigotti-na-munafo-mr-stead-lf.-smoking-cessation-interventions-for-hospitalized-smokers-a-systematic-review.-arch-intern-med.-2008-oct-13168181950-60.-httpwww.ncbi.nlm.nih.govpubmed18852395 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Free Full Text: {#free-full-text .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://archinte.ama-assn.org/cgi/content/full/168/18/1950**](http://archinte.ama-assn.org/cgi/content/full/168/18/1950) {#httparchinte.ama-assn.orgcgicontentfull168181950 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Patients with Coronary Heart Disease Benefit from Screening for
Depression**

ABSTRACT

Depression is commonly present in patients with coronary heart disease
(CHD) and is independently associated with increased cardiovascular
morbidity and mortality. Screening tests for depressive symptoms should
be applied to identify patients who may require further assessment and
treatment. This multispecialty consensus document reviews the evidence
linking depression with CHD and provides recommendations for healthcare
providers for the assessment, referral, and treatment of depression.

Lichtman JH, Bigger JT Jr, Blumenthal JA, Frasure-Smith N, Kaufmann PG,
Lespérance F, Mark DB, Sheps DS, Taylor CB, Froelicher ES. Depression
and Coronary Heart Disease. Recommendations for Screening, Referral, and
Treatment. A Science Advisory From the American Heart Association
Prevention Committee of the Council on Cardiovascular Nursing, Council
on Clinical Cardiology, Council on Epidemiology and Prevention, and
Interdisciplinary Council on Quality of Care and Outcomes Research.
Circulation. 2008 Sep 29. \[Epub ahead of print\].
<http://www.ncbi.nlm.nih.gov/pubmed/18824640>

#### Free full text: {#free-full-text-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.108.190769v2**](http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.108.190769v2)  {#httpcirc.ahajournals.orgcgireprintcirculationaha.108.190769v2 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Resources for Depression Screening: {#resources-for-depression-screening .Style-Heading-4-+-Arial-14-pt-Underline}

#### The McArthur Initiative on Depression and Primary Care: {#the-mcarthur-initiative-on-depression-and-primary-care .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.depression-primarycare.org/clinicians/toolkits/**](http://www.depression-primarycare.org/clinicians/toolkits/)  {#httpwww.depression-primarycare.orgclinicianstoolkits .Style-Heading-4-+-Arial-14-pt-Underline}

#### Sample PHQ2: {#sample-phq2 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.commonwealthfund.org/usr_doc/PHQ2.pdf**](http://www.commonwealthfund.org/usr_doc/PHQ2.pdf) {#httpwww.commonwealthfund.orgusr_docphq2.pdf .Style-Heading-4-+-Arial-14-pt-Underline}

#### Sample PHQ9: {#sample-phq9 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.depression-primarycare.org/clinicians/toolkits/materials/forms/phq9/questionnaire_sample/**](http://www.depression-primarycare.org/clinicians/toolkits/materials/forms/phq9/questionnaire_sample/)  {#httpwww.depression-primarycare.orgclinicianstoolkitsmaterialsformsphq9questionnaire_sample .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

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

**ACOG Practice Bulletin #98 Ultrasonography in Pregnancy**

Most women have at least one ultrasound examination during pregnancy.
The purpose of this document is to present evidence regarding the
methodology of, indications for, benefits of, and risks associated with
obstetric ultrasonography in specific clinical situations. Portions of
this document were developed collaboratively with the American College
of Radiology and the American Institute of Ultrasound in Medicine. The
sections that address physician qualifications and responsibilities,
documentation, quality control, infection control, and patient safety
contain recommendations from the American College of Obstetricians and
Gynecologists.

**Summary of Recommendations and Conclusions**

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

-   Ultrasound examination is an accurate method of determining
    gestational age, fetal number, viability, and placental location.

-   Gestational age is most accurately determined in the first half of
    pregnancy.

-   Ultrasonography can be used in the diagnosis of many major fetal
    anomalies.

-   Ultrasonography is safe for the fetus when used appropriately.

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

-   Ultrasonography is helpful in detecting fetal growth disturbances.

-   Ultrasonography can detect abnormalities in amniotic fluid volume.

***The following conclusion and recommendation are based primarily on
consensus and expert opinion (Level C):***

-   The optimal timing for a single ultrasound examination in the
    absence of specific indications for a firsttrimester examination is
    at 18--20 weeks of gestation.

-   The benefits and limitations of ultrasonography should be discussed
    with all patients.

**Proposed Performance Measure**

Documentation of the discussion of the benefits and limitations of
ultrasonography

American College of Obstetricians and Gynecologists. ACOG Practice
Bulletin #98, October 2008. Ultrasonography in pregnancy. Obstet
Gynecol. 2008 Oct;112(4):951-61.
<http://www.ncbi.nlm.nih.gov/pubmed/18827142>

**ACOG Committee Opinion #419 Use of Progesterone to Reduce Preterm
Birth**

**ABSTRACT:** Preterm birth affects 12% of all births in the United
States. Recent studies support the hypothesis that progesterone
supplementation reduces preterm birth in a select group of women.
Despite the apparent benefits of progesterone, the ideal progesterone
formulation is unknown. The American College of Obstetricians and
Gynecologists' Committee on Obstetric Practice and the Society for
Maternal Fetal Medicine believe that further studies are needed to
evaluate the optimal preparation, dosage, route of administration, and
other indications for the use of progesterone for the prevention of
preterm delivery. Based on current knowledge, it is important to offer
progesterone for pregnancy prolongation to only women with a documented
history of a previous spontaneous birth at less than 37 weeks of
gestation.

American College of Obstetricians and Gynecologists. ACOG Committee
Opinion #419, October 2008. Obstet Gynecol. 2008 Oct;112(4):963-5.
<http://www.ncbi.nlm.nih.gov/pubmed/18827143>

**ACOG NEWS RELEASE; October 1, 2008**

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**Pregnant Women Reminded to Get Flu Vaccination**

***Washington, DC*** \-- The American College of Obstetricians and
Gynecologists (ACOG) reminds women, including those who are pregnant, to
get their annual vaccination for the upcoming influenza (flu) season
which runs from October through mid-May in the US. According to ACOG,
flu vaccination should be a routine part of prenatal care, and the ideal
time to vaccinate pregnant women is October and November.

Roughly one-fifth of the US population is infected with the flu virus
each year, according to the Centers for Disease Control and Prevention
(CDC). Pregnant women have higher rates of illness and death from the
flu than other groups. The CDC estimates that each year 200,000 people
with the flu require hospitalization, and approximately 36,000 die from
flu-related illness. In 2005, flu/pneumonia was the eighth leading cause
of death overall in the US.

There are two types of flu vaccine: the injection and a nasal-spray
vaccine. The flu shot is an inactivated vaccine that contains killed
virus and is administered intramuscularly, usually in the arm. It is
approved for use in people older than six months, including healthy
people and those with chronic medical conditions. The nasal-spray
vaccine is made with live, weakened flu viruses and is approved for use
in people ages 2 to 49. It is **not** approved for pregnant women,
however. Women who are breastfeeding can choose either vaccine type.

The flu vaccination (injection) is both safe and effective for pregnant
women and offers some immunity to their infants as well. Some pregnant
women may be concerned about the safety of the flu vaccine because some
contain thimerosal, a mercury-containing antibacterial compound. ACOG
supports the recommendations and findings of the federal Advisory
Committee on Immunization Practices, which found that there is no
evidence showing that thimerosal is a danger to the health of the
pregnant woman or her fetus. Thimerosal-free flu vaccines are available,
but they tend to be more expensive.

In addition to pregnant women, other special high-risk populations
should make sure to be vaccinated every year. These include people older
than 50; people of any age who have diabetes, asthma, heart disease, a
weakened immune system, or other chronic illnesses, and their
caregivers; nursing home residents; health care workers; and household
contacts and caregivers of children younger than five and of adults age
50 and older.

Some people should not get the flu vaccine without first talking with
their physician including those: with a severe allergy to chicken eggs;
who have had a prior severe reaction to the flu vaccine; who previously
developed Guillain-Barre\' syndrome within six weeks of receiving the
flu vaccine; who are children less than six months old; and who
currently have a moderate-to-severe illness with a fever.

Both types of flu vaccine are effective at preventing the flu. Some
people who receive the flu shot may have minor side effects, usually
lasting only a day or two, such as soreness, redness, or swelling at the
injection site; low-grade fever; and/or aches. On rare occasions the flu
vaccine can cause a severe allergic reaction. The nasal-spray vaccine
may cause side effects such as runny nose, headache, sore throat, and
cough in adults and runny nose, wheezing, headache, vomiting, muscle
aches, and fever in children.

The American Lung Association has an online \"Flu Clinic Locator\" that
can help women find facilities that are administering flu shots. Go to:
[www.lungusa.org](http://www.acog.org/cgi-shl/leaving.pl?http://www.lungusa.org).

#### AFP American Family Physician {#afp-american-family-physician .Style-Heading-4-+-Arial-14-pt-Underline}

Atypical Moles

ABSTRACT: Atypical moles can be distinguished visually by clinical
features of size greater than 6 mm in diameter, color variegation,
indistinct borders, and textured surface. All patients who have atypical
moles should be counselled about sun avoidance, screening of family
members, and regular skin checks at least once per year. Total body
photography and dermoscopy can aid in regular skin monitoring for
changes in atypical moles and the emergence of new lesions. The presence
of multiple atypical moles increases the risk of melanoma. The greatest
risk of melanoma is in patients who have more than 50 atypical moles and
two or more family members with melanoma (familial atypical mole and
melanoma syndrome). Atypical moles should be removed when they have
features suggestive of malignant transformation. Elliptical excision is
the preferred removal technique. Removing all atypical moles is neither
necessary nor cost effective.

**Cyr, PR. Atypical Moles. Am Fam Physician. 2008 Sep 15;78(6):735-40.
<http://www.ncbi.nlm.nih.gov/pubmed/18819240>**

[**http://www.aafp.org/afp/20080915/735.html**](http://www.aafp.org/afp/20080915/735.html)

Patient Education Handout: Atypical Moles: What You Should Know

<http://www.aafp.org/afp/20080915/741ph.html>

**Management of mastitis in breastfeeding women**

ABSTRACT: Mastitis occurs in approximately 10 percent of U.S. mothers
who are breastfeeding, and it can lead to the cessation of
breastfeeding. The risk of mastitis can be reduced by frequent, complete
emptying of the breast and by optimizing breastfeeding technique. Sore
nipples can precipitate mastitis. The differential diagnosis of sore
nipples includes mechanical irritation from a poor latch or infant mouth
anomalies, such as cleft palate or bacterial or yeast infection. The
diagnosis of mastitis is usually clinical, with patients presenting with
focal tenderness in one breast accompanied by fever and malaise.
Treatment includes changing breastfeeding technique, often with the
assistance of a lactation consultant. When antibiotics are needed, those
effective against Staphylococcus aureus (e.g., dicloxacillin,
cephalexin) are preferred. As methicillin-resistant S. aureus becomes
more common, it is likely to be a more common cause of mastitis, and
antibiotics that are effective against this organism may become
preferred. Continued breastfeeding should be encouraged in the presence
of mastitis and generally does not pose a risk to the infant. Breast
abscess is the most common complication of mastitis. It can be prevented
by early treatment of mastitis and continued breastfeeding. Once an
abscess occurs, surgical drainage or needle aspiration is needed.
Breastfeeding can usually continue in the presence of a treated abscess.

Spencer JP. Management of mastitis in breastfeeding women. Am Fam
Physician. 2008 Sep 15;78(6):727-31.
<http://www.ncbi.nlm.nih.gov/pubmed/18819238>

<http://www.aafp.org/afp/20080915/727.html>

Patient Education Handout: Mastitis, What Should You Know?

<http://www.aafp.org/afp/20080915/732ph.html>

**AHRQ** **Agency for Healthcare Research and Quality**

**Behavioral Modification Programs Help Obese Children Manage Their
Weight**

AHRQ released a new report, *Effectiveness of Weight Management Programs
in Children and Adolescents*, that shows obese school-age kids and teens
can lose weight or prevent further weight gain if they participate in
medium- to high-intensity behavioral management programs.  Researchers
found that after completing weight management programs, obese children
would weigh between 3 pounds and 23 pounds less, on average, than obese
children not involved in such programs.  Among those enrolled, the
weight difference would be greatest among heavier children as well as in
those enrolled in more intensive programs.  Researchers also found that
weight improvements could be maintained for up to a year after the
program ended.  The report also showed that adding prescription drugs to
a behavioral weight management program helped extremely obese
adolescents lose weight.  However, no studies evaluated maintenance of
weight loss after drug treatment ended. 

<http://www.ahrq.gov/clinic/tp/chwghttp.htm>

Copies of the report may be ordered free of charge by calling the AHRQ
Publications Clearinghouse at 1-800-358-9295 or sending an E-mail to
<AHRQPubs@ahrq.hhs.gov>. For information on how children\'s and
teenagers weight is assessed and a BMI calculator to use for them, go to
<http://apps.nccd.cdc.gov/dnpabmi/Calculator.aspx>.

AHRQ also has a free DVD for families and children age 5 to 9 called
*Max\'s Magical Delivery: Fit for Kids*. The 30-minute DVD teaches
children and their parents about smart eating and physical activity.
Copies are available by calling 1-800-358-9295 or E-mailing
<AHRQPubs@ahrq.hhs.gov>.

**Task Force Finds Several Methods Equally Effective for Colorectal
Cancer Screening**

In a change from its previous recommendation, the U.S. Preventive
Services Task Force now recommends that adults age 50 to 75 be screened
for colorectal cancer using annual high-sensitivity fecal occult blood
testing, sigmoidoscopy every 5 years with fecal occult testing between
sigmoidoscopic exams, or colonoscopy every 10 years.  The Task Force
also recommended against routine colorectal cancer screening in adults
between the ages of 76 and 85 because the benefits of regular screening
were small compared with the risks.  Adults over the age of 85 should
not be screened at all because the harms of screening may be
significant, and other conditions may be more likely to affect their
health or well-being.

U.S. Preventive Services Task Force. Screening for Colorectal Cancer:
U.S. Preventive Services Task Force Recommendation Statement*.* AHRQ
Publication 08-05124-EF-3, October 2008. Agency for Healthcare Research
and Quality, Rockville, MD.

<http://www.ahrq.gov/clinic/uspstf08/colocancer/colors.htm>

A print copy of the summary and related material is available by sending
an e-mail to <ahrqpubs@ahrq.hhs.gov>.

**New Recommendations on Behavioral Counseling to Prevent Sexually
Transmitted Infections**  

The Task Force recommends high-intensity behavioral counseling to
prevent sexually transmitted infections (STIs) for all sexually active
adolescents and for adults at increased risk for STIs.  The Task
Force also concluded that evidence is insufficient to assess the balance
of benefits and harms of behavioral counseling to prevent STIs in
non-sexually active adolescents and in adults not at increased risk for
STIs.  Despite advances in screening, diagnosis, and treatment of STIs,
they remain an important cause of death in the U.S.  An estimated 19
million new STIs occur in the United States, almost half among people
from 15 to 24 years of age.  Common sexually transmitted infections
include chlamydia, hepatitis B, hepatitis C, herpes, HIV and syphilis
and direct medical costs are estimated at \$15 billion annually. 

U.S. Preventive Services Task Force. Behavioral Counseling to Prevent
Sexually Transmitted Infections: Clinical Summary of U.S. Preventive
Services Task Force Recommendation*.* AHRQ Publication No.
08-05123-EF-3, October 2008. Agency for Healthcare Research and Quality,
Rockville, MD. http://www.ahrq.gov/clinic/uspstf08/sti/stisum.htm

#### [**http://www.ahrq.gov/clinic/uspstf08/sti/stirs.htm**](http://www.ahrq.gov/clinic/uspstf08/sti/stirs.htm) {#httpwww.ahrq.govclinicuspstf08stistirs.htm .Style-Heading-4-+-Arial-14-pt-Underline}

A print copy of the summary and related material is available by sending
an e-mail to <ahrqpubs@ahrq.hhs.gov>.

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

**AHRQ's 2008 Guide to Clinical Preventive Services Now Available**

AHRQ has released the *Guide to Clinical Preventive Services 2008*,
which highlights recommendations from the U.S. Preventive Services Task
Force.  In addition to previous recommendations, this year's Guide
provides new Task Force recommendations released during 2007 on aspirin
or nonsteroidal anti-inflammatory drugs for the primary prevention of
colorectal cancer; screening for carotid artery stenosis; screening for
chronic obstructive pulmonary disease using spirometry; counseling about
proper use of motor vehicle occupant restraints and avoidance of alcohol
use while driving; screening for illicit drug use; screening for lipid
disorders in children; and, screening for sickle cell disease in
newborns.  The guide contains evidence-based recommendations that have
been adapted for a pocket-size book, making it easier for clinicians to
consult the recommendations in their daily practice.  Recommendations
are presented in an indexed, easy-to-use format, with at-a-glance
charts.  

<http://www.ahrq.gov/clinic/pocketgd.htm>

A print copy of the Guide is available by sending an e-mail to
<ahrqpubs@ahrq.hhs.gov>.

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

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

**An example of resources available on the HSRL/NIH website**

The current Chair of the ACOG Committee on Indian Affairs, Tony Ogburn,
has served as co-editor and author of a recent "**Medical Clinics of
North America**" issue dedicated to women's health. This volume includes
chapters by several authors well known to anyone who has attended an IHS
women's health conference in recent years. If you are interested in
reading any or all of this issue, you could view the entire issue (and
thousands of other journals) directly on the HSRL website from any IHS
computer. Prefer to read at home or on the road? Ms. Cooper (the IHS
librarian at the Health Services Research Library) can provide you with
a password for access to the HSRL website through a proxy server. Not an
IHS employee? Ms. Cooper can still help with access. Diane Cooper can be
reached at 301.594.2449 or at
[[cooperd@mail.nih.gov]{.underline}](mailto:cooperd@mail.nih.gov) or
[[Diane.Cooper2@ihs.gov]{.underline}](mailto:Diane.Cooper2@ihs.gov).

The Health Services Research Library (HSRL) website is:
[[http://hsrl.nihlibrary.nih.gov]{.underline}](http://hsrl.nihlibrary.nih.gov/)

Here is the list of chapters from the Medical Clinics of North America
issue:

**Preface\
**Ogburn T Voss C

<http://www.ncbi.nlm.nih.gov/pubmed/18721649>

**Barriers to Women\'s Health: Why Is It So Hard for Women to Stay
Healthy?\
**Ogburn T, Voss C, Espey E.

Women\'s health care has made great strides in the past two decades. The
recognition that women have different health care needs than men has
enabled changes to take place in clinical care, research, and education.
However, much remains to be done. Providing health care coverage to all
women must be a high priority. Research must address the differences
between men and women and how they respond to disease and treatment. The
physician workforce needs to be expanded; physicians should be well
trained to provide comprehensive health care to women. Strategies, such
as used in Comprehensive Centers of Women\'s Health and women\'s health
residencies, can improve education and increase the number of women in
academia.

<http://www.ncbi.nlm.nih.gov/pubmed/18721650>

**Preventive Health for Women: Screening and Immunizations\
**Zebrack JR, Brown KW.

Women\'s preventive health issues are frequently encountered in the
outpatient setting. Many general internists feel uncomfortable meeting
the needs of women due to a general lack of knowledge of women\'s health
and inadequate training in the evaluation of female-specific care. In
this article, the authors summarize evidence-based guidelines for
preventive health and immunizations for women.

<http://www.ncbi.nlm.nih.gov/pubmed/18721651>

**Contraception: What Every Internist Should Know\
**Espey E, Ogburn T, Fotieo D.

The human costs of unintended pregnancy-abortion and parenting under
difficult circumstances-are high. For this reason, all physicians who
treat female patients should be knowledgeable about the basics of
contraception-both its practical uses and its public health impact. This
knowledge will make physicians, including internists, better able to
counsel and provide contraceptives for individual patients and to
advocate for availability and access. This article discusses the problem
and determinants of unintended pregnancy and reviews contraceptive
methods.

<http://www.ncbi.nlm.nih.gov/pubmed/18721652>

**Preventing Cervical Cancer: The Pap Test and the HPV Vaccine**\
Waxman AG, Zsemlye MM.

Women look to their internists and other primary care physicians to
provide preventive health care. Periodic Pap tests are as much a part of
a woman\'s ongoing health care as periodic lipid assessments,
mammograms, screening for colon cancer, or any of the other recommended
screening assessments. This article provides primary care physicians
with the information needed to perform Pap tests at the appropriate
intervals, or if not set up to do Pap tests themselves, to make the
appropriate referrals. Also provided is the necessary information to
counsel women with abnormal Pap tests who may need colposcopy or other
follow-up evaluation. Finally, the role of the HPV vaccine in the
prevention of cervical cancer is summarized.

<http://www.ncbi.nlm.nih.gov/pubmed/18721653>

**Sexually Transmitted Infections and Pelvic Inflammatory Disease in
Women**\
Trigg BG, Kerndt PR, Aynalem G.

Sexually transmitted infections (STIs) are an important public health
challenge in the United States. Primary care clinicians can contribute
to decreasing these largely preventable causes of morbidity and
mortality by integrating routine screening, testing, counseling,
treatment, and partner management of STIs into their practice. Newer
tests for chlamydia and gonorrhea that can be performed on urine
specimens allow screening without a pelvic examination. The most recent
edition of the Centers for Disease Control and Prevention sexually
transmitted disease treatment guidelines provides an evidence-based,
reliable, and convenient set of recommendations for treating and caring
for patients who have STIs.

<http://www.ncbi.nlm.nih.gov/pubmed/18721654>

**Breast Disease: Benign and Malignant**\
Meisner AL, Fekrazad MH, Royce ME.

Breast diseases, both benign and malignant, are common. Typically, young
women present with more benign pathologies; however, breast malignancies
can occur in young women, especially in those harboring mutations in the
BRCA genes, other inherited genetic syndromes associated with increased
risk of breast cancer, or familial predisposition for breast cancer. In
all women aged 40 and over presenting with abnormalities of the breast,
a primary breast cancer should be ruled out because it is the leading
cancer among women in developed countries.

<http://www.ncbi.nlm.nih.gov/pubmed/18721655>

**Pelvic Masses**\
Barney SP, Muller CY, Bradshaw KD.

Pelvic masses develop commonly in women of all ages and states of
health. Despite the variety of masses that exist, general guidelines for
diagnosis and management allow most masses to be treated in a generalist
setting. This article is intended to guide non-obstetric and
non-gynecologic physicians through diagnosis and treatment of
nonmalignant pelvic masses. It includes information on physical
examination, appropriate imaging techniques, laboratory tests, and
variations in treatment for adolescents and pre- and postmenopausal
women. It also addresses referral guidelines for suspected malignant
masses.

<http://www.ncbi.nlm.nih.gov/pubmed/18721656>

**Basic Infertility Including Polycystic Ovary Syndrome\
**Brassard M, AinMelk Y, Baillargeon JP.

Infertility in women has many possible causes and must be approached
systematically. The most common cause of medically treatable infertility
is the polycystic ovary syndrome (PCOS). This syndrome is common in
young women and is the cause of anovulatory infertility in 70% of cases.
It is therefore an important condition to screen and manage in primary
care medical settings. In the past 10 years, insulin sensitization with
weight loss or metformin has been shown to be a safe and effective
treatment for PCOS infertility that eliminates the risk of multiple
pregnancy and may reduce the risk of early pregnancy loss as compared
with ovulation-inductor drugs. The authors believe metformin should be
considered as first-line therapy because it has the advantage to allow
for normal single ovulation, for reduced early pregnancy loss, and, most
importantly, lifestyle modifications and weight loss before pregnancy.
Losing weight not only improves fertility but also reduces adverse
pregnancy outcomes associated with obesity.

<http://www.ncbi.nlm.nih.gov/pubmed/18721657>

**Medical Issues from Preconception Through Delivery: A Roadmap for the
Internist\
**Carson MP, Ehrenthal D.

The age of the pregnant population and the number of pregnant women with
medical issues are increasing. It is widely recognized that internists
have the unique opportunity to identify potential pregnancy issues and
address them before a problem arises. Therefore, it\'s important that we
become aware of how to approach these issues. In addition to addressing
medical issues in a currently pregnant woman, doctors also have the
opportunity to identify issues that occurred during a prior pregnancy,
such as gestational diabetes, preeclampsia, or pregnancy loss, and to
decrease the risk of complications in future pregnancies. The goal of
this article is to provide a roadmap to practicing internists so they
will incorporate pregnancy planning into their everyday care plans. The
approach is similar to that used when performing a preoperative risk
assessment: We want to optimize our patients medically for pregnancy.

<http://www.ncbi.nlm.nih.gov/pubmed/18721658>

**Prescribing Medications Safely During Pregnancy**\
Rayburn WF, Amanze AC.

A large body of information about medications prescribed during
pregnancy is readily available to internists and patients either on-line
or through books and medical journals. Much of the evidence about many
prescribed drugs is either anecdotal or presented with sufficient
warnings about its use during pregnancy. This article discusses specific
medications to set the risks and benefits into a more proper
perspective, thereby alleviating certain fears and, when necessary,
improving compliance.

<http://www.ncbi.nlm.nih.gov/pubmed/18721659>

**Domestic Violence and Rape**\
Toohey JS

No compilation of women\'s health care is complete without confronting
domestic violence and sexual assault. Long recognized as a health care
and physician issue, intimate partner violence continues to be one of
the most frequent causes for injury and death to women in the United
States and worldwide. According to the Commonwealth Fund survey in 1998,
31% of women reported either physical or sexual abuse from a husband or
boyfriend. One in five American women also reported being raped during
their lifetime. Careful assessment and universal screening are important
tools for the primary care physician.

<http://www.ncbi.nlm.nih.gov/pubmed/18721660>

**Menopause and the Menopausal Transition**\
Lund KJ

Menopause and the menopausal transition present unique preventive health
and quality-of-life challenges for women. The number of patients in the
menopausal age group is increasing and represents a significant portion
of the population. Care of the menopausal patient can be challenging for
the caregiver. This chapter reviews the major health care challenges as
well as evaluation and treatment of common quality-of-life issues for
menopausal patients.

<http://www.ncbi.nlm.nih.gov/pubmed/18721661>

**Urinary Incontinence and Pelvic Organ Prolapse: Diagnosis and
Treatment for the Primary Care Physician**\
Abed H, Rogers RG.

This article outlines a simplified approach to diagnosis and treatment
of women with urinary incontinence or pelvic organ prolapse that can be
used by primary care physicians to identify patients with these
conditions and initiate treatment for basic problems.

<http://www.ncbi.nlm.nih.gov/pubmed/18721662>

##### 

##### Behavioral Health Insights Peter Stuart, IHS Psychiatry Consultant

#### Protecting urban American Indian young people from suicide {#protecting-urban-american-indian-young-people-from-suicide-1 .Style-Heading-4-+-Arial-14-pt-Underline}

OBJECTIVE: To examine the likelihood of a past suicide attempt for urban
American Indian boys and girls, given salient risk and protective
factors.

METHODS: Survey data from 569 urban American Indian, ages 9-15,
in-school youths. Logistic regression determined probabilities of past
suicide attempts.

RESULTS: For girls, suicidal histories were associated with substance
use (risk) and positive mood (protective); probabilities ranged from
6.0% to 57.0%. For boys, probabilities for models with violence
perpetration (risk), parent prosocial behavior norms (protective), and
positive mood (protective) ranged from 1.0% to 38.0%.

CONCLUSIONS: Highlights the value of assessing both risk and protective
factors for suicidal vulnerability and prioritizing prevention
strategies.

Pettingell SL, Bearinger LH, Skay CL, Resnick MD, Potthoff SJ, Eichhorn
J. Protecting urban American Indian young people from suicide. [Am J
Health Behav.](javascript:AL_get(this, 'jour', 'Am J Health Behav.');)
2008 Sep-Oct;32(5):465-76.

<http://www.ncbi.nlm.nih.gov/pubmed/18241131>

#### The following is a discussion of the above article from "MCH ALERT": \"These findings for urban American Indian youth support the strategy of boosting protective factors while addressing key risk factors that impede the healthy development of young people,\" state the authors of an article published in the September-October 2008 issue of the American Journal of Health Behavior. Although there has been a general decline in youth suicides since 1992 across all racial and ethnic groups, increased suicide among those ages 10-19 underscores the need for prevention efforts. Suicide is the second leading cause of death for American Indian-Alaska Native youth. The article presents findings from a study to identify the strongest risk and protective factors relative to a past suicide attempt among males and females and examines these factors in combination to predict the likelihood of a history of a suicide attempt in a sample of urban American Indian youth.  Data for the study were drawn from surveys conducted between 1995 and 1998 as part of the Indian Youth Resiliency Impact Study. Study participants (youth ages 9-15; N=569) completed a self-report survey comprising items focused on a host of factors affecting health and well-being. The resilience paradigm guided the selection of items used to develop nine scales measuring risk and protective factors in the current study. The seven protective scales in the current analysis included (1) connectedness to others, (2) family caring, (3) parental prosocial behavior norms, (4) peer prosocial behavior norms, (5) perceived self-image, (6) positive mood, and (7) school connectedness. The two risk scales were (1) substance use and (2) violence perpetration. All analyses were conducted separately by gender. The researchers first examined bivariate relationships between the outcome, past suicide attempt, and risk and protective factors. Then, separate models were created for protective factors only and risk factors only.  From these two models, the strongest risk and protective factors associated with a past suicide attempt were entered, and probability profiles were created.  The authors found that  \* For girls, positive mood was the only protective factor achieving statistical significance; positive mood and parental prosocial behavior norms were significant protective factors for boys.  \* For girls, the only significant risk factor was substance use; involvement in violence perpetration was the sole significant risk factor for boys.  \* For girls, with the significant risk factor of substance use in the model, the likelihood of a past suicide attempt decreased from 57% to 24% in the presence of one protective factor (positive mood); for boys, the change was from 38% to 6% in the presence of violence perpetration (one risk factor) and two significant protective factors (positive mood and parent prosocial behavior norms).  \"Our study points to the necessity of responding to indications of vulnerability to suicidal involvement for those in elementary as well as secondary schools,\" state the authors, concluding that \"the identification of salient risk and protective factors for suicide . . .creates a road map for comprehensive assessment and effective intervention.\"  Readers: More information is available from the following MCH Library resources:  - Emotional, Behavioral, and Mental Health Challenges in Children and Adolescents: Knowledge Path at [**http://www.mchlibrary.info/KnowledgePaths/kp_Mental_Conditions.html**](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.mchlibrary.info/KnowledgePaths/kp_Mental_Conditions.html)  - Racial and Ethnic Disparities in Health: Knowledge Path at [**http://www.mchlibrary.info/KnowledgePaths/kp_race.html**](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.mchlibrary.info/KnowledgePaths/kp_race.html) {#the-following-is-a-discussion-of-the-above-article-from-mch-alert-these-findings-for-urban-american-indian-youth-support-the-strategy-of-boosting-protective-factors-while-addressing-key-risk-factors-that-impede-the-healthy-development-of-young-people-state-the-authors-of-an-article-published-in-the-september-october-2008-issue-of-the-american-journal-of-health-behavior.-although-there-has-been-a-general-decline-in-youth-suicides-since-1992-across-all-racial-and-ethnic-groups-increased-suicide-among-those-ages-10-19-underscores-the-need-for-prevention-efforts.-suicide-is-the-second-leading-cause-of-death-for-american-indian-alaska-native-youth.-the-article-presents-findings-from-a-study-to-identify-the-strongest-risk-and-protective-factors-relative-to-a-past-suicide-attempt-among-males-and-females-and-examines-these-factors-in-combination-to-predict-the-likelihood-of-a-history-of-a-suicide-attempt-in-a-sample-of-urban-american-indian-youth.-data-for-the-study-were-drawn-from-surveys-conducted-between-1995-and-1998-as-part-of-the-indian-youth-resiliency-impact-study.-study-participants-youth-ages-9-15-n569-completed-a-self-report-survey-comprising-items-focused-on-a-host-of-factors-affecting-health-and-well-being.-the-resilience-paradigm-guided-the-selection-of-items-used-to-develop-nine-scales-measuring-risk-and-protective-factors-in-the-current-study.-the-seven-protective-scales-in-the-current-analysis-included-1-connectedness-to-others-2-family-caring-3-parental-prosocial-behavior-norms-4-peer-prosocial-behavior-norms-5-perceived-self-image-6-positive-mood-and-7-school-connectedness.-the-two-risk-scales-were-1-substance-use-and-2-violence-perpetration.-all-analyses-were-conducted-separately-by-gender.-the-researchers-first-examined-bivariate-relationships-between-the-outcome-past-suicide-attempt-and-risk-and-protective-factors.-then-separate-models-were-created-for-protective-factors-only-and-risk-factors-only.-from-these-two-models-the-strongest-risk-and-protective-factors-associated-with-a-past-suicide-attempt-were-entered-and-probability-profiles-were-created.-the-authors-found-that-for-girls-positive-mood-was-the-only-protective-factor-achieving-statistical-significance-positive-mood-and-parental-prosocial-behavior-norms-were-significant-protective-factors-for-boys.-for-girls-the-only-significant-risk-factor-was-substance-use-involvement-in-violence-perpetration-was-the-sole-significant-risk-factor-for-boys.-for-girls-with-the-significant-risk-factor-of-substance-use-in-the-model-the-likelihood-of-a-past-suicide-attempt-decreased-from-57-to-24-in-the-presence-of-one-protective-factor-positive-mood-for-boys-the-change-was-from-38-to-6-in-the-presence-of-violence-perpetration-one-risk-factor-and-two-significant-protective-factors-positive-mood-and-parent-prosocial-behavior-norms.-our-study-points-to-the-necessity-of-responding-to-indications-of-vulnerability-to-suicidal-involvement-for-those-in-elementary-as-well-as-secondary-schools-state-the-authors-concluding-that-the-identification-of-salient-risk-and-protective-factors-for-suicide-.-.-.creates-a-road-map-for-comprehensive-assessment-and-effective-intervention.-readers-more-information-is-available-from-the-following-mch-library-resources---emotional-behavioral-and-mental-health-challenges-in-children-and-adolescents-knowledge-path-at-httpwww.mchlibrary.infoknowledgepathskp_mental_conditions.html---racial-and-ethnic-disparities-in-health-knowledge-path-at-httpwww.mchlibrary.infoknowledgepathskp_race.html .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

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

**A Skinny Little Secret**

Sometimes it takes a celebrity to make an old idea work. Now, thanks to
Angelina Jolie, the secret is out about breastfeeding's sleek down
potential. While other superstars like singer Christina Aguilera,
Gwyneth Paltrow (Shakespeare in Love), and Kate Winlset (Titanic) have
publicly commented about how breastfeeding sped their maternal weight
loss, one picture of Ms. Jolie in a "great dress" at 11 weeks post
partum from twins, told the story.

While the resources available to superstars -- like personal trainers,
money-is-no-object menus, chefs, exotic entrees, spa pampering, etc -
help post partum weight loss, they are not likely public health obesity
risk interventions. But breastfeeding could be.

In the last 15 years, several clinical studies have looked at the impact
of lactation on maternal weight retention. Studies of US subjects found
that lactation reduced weight retention to varying degrees. Variables
associated with greater weight retention included single marital status,
older maternal age, not breastfeeding, mixed feeding, and/or early
weaning to formula. In 1993, Dewey et al found that exclusive
breastfeeding significantly enhanced weight loss if continued for at
least 6 months, when compared to weight loss patterns of mothers who
formula fed. In 1997, Janney C et al found that maternal weight loss was
slowed when moms increased formula use or stopped breastfeeding.

A recent study by Hatsu IE et al (2008) found that exclusive
breastfeeding resulted in greater maternal weight loss in the first 12
weeks when compared to mixed feeding mothers. The exclusive
breastfeeding mothers consumed more calories (1980 +/- 618 kcals, vs
1541 +/-196 kcal p = 0.08). Despite less weight loss, the mixed feeding
mothers reported a higher physical activity level. A limitation of the
study was small size, 24 participants.

There are several factors that could contribute to breastfeeding women
losing more weight than those formula or mixed feeding. The maternal
levels of prolactin, oxytocin, and estrogen are different in lactating
compared to non-lactating postpartum women. Many breastfeeding women do
not resume menses until a year or longer post partum. Also, the caloric
cost of milk production is significant. By the second month of
lactation, daily breast milk production is roughly 600-900 ml, resulting
in approximately 400-600 kcals of milk for the baby. There are also
maternal energy costs needed to fuel lactogensis. Although the kcal cost
of the mechanics of breast milk production are not yet well understood,
it is likely that the process of making breast milk adds to the drain of
maternal energy stores.

The same myriad of variables that complicate childhood and adult weight
patterns impact maternal weight retention. Food choices/availability,
stress, meal preparation methods, socio-economics, activity patterns,
life style issues, co-existing diseases/handicaps, genetics, and
medication can exert subtle but potentially significant sway over weight
change. Controlling for these variables and others will require on-going
study.

For more information about your clinic's early feeding choice and
maternal weight retention patterns, please consider data available on
RPMS/EHR. The infant feeding tool will define how babies are fed and can
include the mothers' names. Specific information about the infant
feeding tool is available at
[www.ihs.gov/MedicalPrograms/MCH/M/bf.cfm](http://www.ihs.gov/MedicalPrograms/MCH/M/bf.cfm),
under the Breastfeeding Headlines section: *Frequently asked questions
about capturing infant feeding choice on RPMS and E.H.R.* or call
1-877-868-9473.

#### 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}

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

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

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

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

**Women sexually abused by partners have worse health than never abused
women, even years after the abuse has stopped**

**(Funded and reviewed below by ARHQ)**

Thirty-four percent of women surveyed in a large health plan had
suffered from physical and/or sexual intimate partner violence (IPV)
during their adult lifetime. Sexual IPV took an enormous toll on
women\'s health, whether or not they also suffered from physical
IPV---their depression and physical symptoms persisted for many years
after the abuse had stopped, according to a new study.

The researchers analyzed the surveys of 3,429 insured women about
whether they had ever suffered from physical or sexual IPV, as well as
their mental, social, and physical health. Although 34 percent of the
women had suffered from sexual and/or physical IPV, only 5 percent said
they suffered the abuse within the past year. For the others, it had
been a median of 19 years since the last episode of abuse. Compared with
never abused women, women with a history of sexual IPV had the worst
overall health.

Women with a history of sexual IPV only had scores on the mental and
social health components of the Short Form-36 survey that were 4.28 to
6.22 points lower than nonabused women, and women with a history of both
physical and sexual IPV had scores that were 4.95 to 5.81 points lower.
Women who suffered from physical IPV only had scores that were 2.41 to
2.87 points lower than never abused women.

Depression was also more prevalent among sexually abused women than
other women.

Compared with never abused women, women with a history of sexual IPV
only had 2.4 to 3 times greater prevalence of depressive and severe
depressive symptoms.

Women with a history of both physical and sexual IPV had 2.3 to 2.9
times greater prevalence, and women who had been physically abused only
had 1.6 to 1.9 times greater prevalence of these symptoms than never
abused women.

Finally, compared with never abused women, women who were both
physically and sexually abused were nearly twice as likely to report
fair or poor health, had more overall symptoms, more limited involvement
in voluntary groups, and less trust of individuals in their community.

**AHRQ Link:** <http://www.ahrq.gov/research/sep08/0908RA5.htm>

**Citation and PubMed Abstract:**

Bonomi AE, Anderson ML, Rivara FP, Thompson RS. Health outcomes in women
with physical and sexual intimate partner violence exposure. J Womens
Health (Larchmt). 2007 Sep;16(7):987-97.
<http://www.ncbi.nlm.nih.gov/pubmed/17903075>

#### Elder Care News Bruce Finke, Elder Care Initiative {#elder-care-news-bruce-finke-elder-care-initiative .Style-Heading-4-+-Arial-14-pt-Underline}

**Prescription drug misuse/abuse in the elderly**

One quarter of the prescription drugs sold in the United States are used
by the elderly, often for problems such as chronic pain, insomnia, and
anxiety. The prevalence of abuse may be as high as 11 percent with
female gender, social isolation, depression, and history of substance
abuse increasing risk. Screening instruments for prescription drug abuse
have not been validated in the geriatric population. Benzodiazepines,
opiate analgesics, and some skeletal muscle relaxants may result in
physical dependence; however, tolerance, withdrawal syndrome, and dose
escalation may be less common in the older patient. Lower doses may
decrease the risk of abuse and dependence; however, fear of abuse often
results in a failure to adequately treat symptoms such as anxiety, pain,
and insomnia.

Culberson JW, Ziska M. Prescription drug misuse/abuse in the elderly.
Geriatrics. 2008 Sep 1;63(9):22-31.
<http://www.ncbi.nlm.nih.gov/pubmed/18763848>

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

#### Drospirenone for acne treatment {#drospirenone-for-acne-treatment-1 .Style-Heading-4-+-Arial-14-pt-Underline}

OBJECTIVE: To assess the efficacy of the combined oral contraceptive
containing 3-mg drospirenone/20-microgram ethinyl estradiol (3-mg
drospirenone/20-microgram ethinyl estradiol) administered as 24
consecutive days of active treatment after a 4-day hormone-free interval
(24/4 regimen) compared with placebo for the treatment of moderate acne
vulgaris.

METHODS: Healthy females aged 14-45 years with moderate acne were
randomized in this double-blind study to 3-mg drospirenone/20-microgram
ethinyl estradiol (n=270) or placebo (n=268) for six cycles of 28 days.
The primary outcome measures of acne lesion counts and Investigator
Static Global Assessment scale ratings were assessed at baseline and
during cycles 1, 3, and 6.

RESULTS: The percentage reduction from baseline to endpoint for total
lesions is 46.3% for 3-mg drospirenone/20-microgram ethinyl estradiol
24/4 combination oral contraceptive group and 30.6% for placebo group
(P\<.001). The likelihood of participants in the 3-mg
drospirenone/20-microgram ethinyl estradiol 24/4 regimen group having
\"clear\" or \"almost clear\" skin as rated by the investigators at
endpoint was about threefold (odds ratio 3.13, 95% confidence interval
1.69-5.81; P=.001) greater than in the placebo group. The 3-mg
drospirenone/20-microgram ethinyl estradiol 24/4 regimen was well
tolerated.

CONCLUSION: The low-dose combined oral contraceptive containing 3-mg
drospirenone/20-microgram ethinyl estradiol administered in a 24/4
regimen significantly reduced acne lesion counts more effectively than
placebo and demonstrated greater improvement in the Investigator Static
Global Assessment rating of acne. The safety profile was consistent with
low-dose combined oral contraceptive use.

Maloney JM, Dietze P Jr, Watson D, Niknian M, Lee-Rugh S,
Sampson-Landers C, Korner P. Treatment of acne using a 3-milligram
drospirenone/20-microgram ethinyl estradiol oral contraceptive
administered in a 24/4 regimen: a randomized controlled trial. Obstet
Gynecol. 2008 Oct;112(4):773-81.
<http://www.ncbi.nlm.nih.gov/pubmed/18827119>

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

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

**Featured Website**

**The Immunization Action Coalition**

The Immunization Action Coalition, a 501(c)3 nonprofit organization,
works to increase immunization rates and prevent disease by creating and
distributing educational materials for health professionals and the
public that enhance the delivery of safe and effective immunization
services. The Coalition also facilitates communication about the safety,
efficacy, and use of vaccines within the broad immunization community of
patients, parents, health care organizations, and government health
agencies.

IAC publishes three periodicals\-\--*Needle Tips*, *Vaccinate Adults*,
and *Vaccinate Women* with a combined circulation of nearly 300,000.
[*Needle Tips*](http://www.immunize.org/nt), a 24-page publication full
of information about immunization across the age span, is mailed to
health professionals twice each year. [*Vaccinate
Adults*](http://www.immunize.org/va), a 12-page publication that
promotes adult immunization recommendations, is sent to adult medicine
specialists twice each year. [*Vaccinate
Women,*](http://www.immunize.org/vw) an 8- to 12-page publication, is
mailed to obstetrician/gynecologists and other women\'s health
specialists once each year.

Due to our close collaboration with the Centers for Disease Control and
Prevention (CDC) and the funding they provide, contributions from our
members, educational grants provided by several foundations and
companies, and the world-class expertise of our [Advisory
Board](http://www.immunize.org/aboutus/advisoryboard.asp), we have been
able to create, find, and distribute the most complete, up-to-date, and
accurate supply and listing of immunization and hepatitis B resources
available anywhere.

We would be delighted to have you
[join](http://www.immunize.org/support) the thousands of people who
support the Coalition. Your contribution is tax-deductible to the
fullest extent of the law.

Help yourself to the unique resource materials we offer. All of our
print materials are camera-ready, copyright-free, and reviewed by CDC
for technical accuracy with the exception of opinion pieces written by
non-CDC authors. Our materials are ready for you to make copies and
distribute to your patients and staff. Be our guest!

<http://www.immunize.org/>

The Immunization Action Coalition has an excellent on-line resource page
to assist providers in addressing parents\' and patients' concerns about
immunization.

 

<http://www.immunize.org/concerns/> 

 

#### Frequently asked questions Neil Murphy, ANMC, SouthCentral Foundation {#frequently-asked-questions-neil-murphy-anmc-southcentral-foundation .Style-Heading-4-+-Arial-14-pt-Underline}

**Q. Should we treat asymptomatic trichomonas found on a Pap smear?**

A. It depends what type of Pap smear you are using. See details below

**Answer**

If is it was a conventional Pap, then please bring the non-pregnant
patient in for a confirmatory test. If it was a liquid based Pap, then
you can treat the patient without further evaluation.

Treating asymptomatic trichomoniasis is [not]{.underline} recommended in
[pregnant]{.underline} women given the potentially increased risk of
preterm birth associated with antibiotic therapy, but treatment of
symptomatic [non-pregnant]{.underline} women [is]{.underline}
recommended.

**Background**

Treatment is indicated in all nonpregnant women\* diagnosed with
trichomonas vaginitis, even if asymptomatic. The rationale for treatment
of asymptomatic women is that if left untreated, up to one-third become
symptomatic within six months and they continue to transmit the
infection to sexual partners while untreated.

The most sensitive method of detecting trichomonas vaginitis is culture.
Unfortunately trichomonas culture is not available at most sites, plus
one would also need a special medium to even send it to most outside
laboratories.  Microscopy and pH is only 50 to 70 percent sensitive and
is time sensitive secondary to motility. DNA probes are sensitive and
specific, but not readily available. Conventional cytology has a
sensitivity of only 60 to 70 percent and false positive results are
common (at least 8 percent). Thus, conventional Pap smear should not be
used to diagnose trichomoniasis. Asymptomatic women with trichomonads
identified on conventional Pap smear should be evaluated by wet mount,
or culture if the wet mount is negative and should not be treated until
the diagnosis is confirmed.

By comparison, the reliability of liquid-based cervical cytology appears
to be higher. Although the sensitivity of liquid-based smears for
trichomonas infection is low (61 percent), specificity is high (99
percent) compared to conventional Pap smear, resulting in a false
positive rate of only 1 percent. Therefore, although liquid-based
cervical cytology is not a sensitive test for diagnosis of
trichomoniasis, we feel treatment of asymptomatic women with
trichomonads noted on liquid-based cervical cytology is a reasonable
approach.

In summary, patients with trichomonas on a conventional Pap need to come
in confirmation before treatment. If you utilize a liquid based prep,
then it is recommended that you treat based on that alone.

\*Treating asymptomatic trichomoniasis is not recommended in pregnant
women given the potentially increased risk of preterm birth associated
with antibiotic therapy, but treatment of symptomatic pregnant women is
recommended.

**Addendum: Diagnostic tools**

**Diagnosis** --- As with other types of vaginitis, none of the clinical
features of trichomonas vaginitis is sufficiently sensitive or specific
to allow a diagnosis based upon signs and symptoms alone.

Microscopy and pH --- The presence of motile trichomonads on wet mount
is diagnostic of infection, but this occurs in only 50 to 70 percent of
culture-confirmed cases. The organisms remain motile for 10 to 20
minutes after collection of the sample. Other findings that are almost
invariably present with trichomonas infection, but nondiagnostic,
include an elevated vaginal pH (\>4.5) and an increase in
polymorphonuclear leukocytes on saline microscopy.

Culture --- Culture on Diamond\'s medium has a high sensitivity (95
percent) and specificity (\>95 percent) and should be considered in
patients with elevated vaginal pH, increased numbers of
polymorphonuclear leukocytes and an absence of motile trichomonads and
clue cells on wet mount; or when microscopy is unavailable or yields
unreliable results. Alternatively, a commercial "In Pouch\" T vaginalis
culture system can be used and is readily available (BioMed Diagnostics,

White City, Oregon).

DNA probes --- No FDA-approved PCR test for T. vaginalis is available in
the United States, but several rapid diagnostic kits using DNA probes
and monoclonal antibodies have been developed commercially, with a
sensitivity of 90 percent and a specificity of 99.8 percent. These can
be useful in areas of high prevalence where microscopy or culture is not
available (i.e. high prevalence refers to STD clinics and inner city
clinics serving the uninsured). A point-of-care test for trichomonas
antigens, the OSOM Trichomonas Rapid Test has a sensitivity of 88.3
percent and specificity of 98.8 percent. Physicians and staff can read
results in 10 minutes. The Affirm VP III Microbial Identification System
(Becton Dickinson) test uses a nucleic acid probe and is read in 45
minutes.

Cervical cytology --- Trichomonads are sometimes reported as an
incidental finding on conventional Papanicolaou (Pap) smears.
Conventional Pap smears are inadequate for diagnosis of trichomoniasis
because this technique has a sensitivity of only 60 to 70 percent and
false positive results are common (at least 8 percent). Thus, Pap smear
should not be used to diagnose trichomoniasis. Asymptomatic women with
trichomonads identified on conventional Pap smear should be evaluated by
wet mount, or culture if the wet mount is negative and should not be
treated until the diagnosis is confirmed.

By comparison, the reliability of liquid-based cervical cytology appears
to be higher. One study involved both liquid-based cervical cytology and
culture for T. vaginalis on 203 consecutive women. Forty-four women had
a positive culture and 28 women had a positive liquid-based smear for
trichomonads. Although the sensitivity of liquid-based smears for
trichomonas infection was low (61 percent), specificity was high (99
percent) compared to conventional Pap smear, resulting in a false
positive rate of only 1 percent. Therefore, although liquid-based
cervical cytology is not a sensitive test for diagnosis of
trichomoniasis, we feel treatment of asymptomatic women with
trichomonads noted on liquid-based cervical cytology is a reasonable
approach.

**Resources**

**Trichomonas vaginitis , UpToDate**

<http://www.uptodateonline.com/utd/content/topic.do?topicKey=gen_gyne/28379>

**Diagnosis of trichomoniasis. Comparison of conventional wet-mount
examination with cytologic studies, cultures, and monoclonal antibody
staining of direct specimens.**

ABSTRACT:\
The accuracy of (1) conventional wet-mount examination, (2)
Papanicolaou-stained gynecologic smears, (3) a direct slide test using
fluorescein-conjugated monoclonal antibodies against Trichomonas
vaginalis, and (4) two different culture media for the diagnosis of
trichomoniasis in a high-risk population of 600 women was compared. Use
of Feinberg-Whittington or Diamond\'s culture medium resulted in a
diagnosis of 82 and 78 cases, respectively, and the combination of two
cultures identified 88 infected women. In comparison, wet-mount
examination detected only 53 (60%) of the cases. Cytologic smears were
interpreted as positive for T vaginalis in 49 (56%) of the 88 cases but
also resulted in seven false-positive smears, and specimens from 18
women with negative cultures were interpreted as \"suspicious\" for
trichomoniasis. Monoclonal antibody staining detected 76 (86%) of the 88
positive specimens, including 27 (77%) of the 35 cases missed by
wet-mount examination. In summary, wet-mount and cytologic studies were
insensitive, and cytology study was the least specific method for
diagnosis of trichomoniasis. Direct immunofluorescence with monoclonal
antibodies holds promise as a sensitive and specific alternative to
cultures for rapid detection of T vaginalis in clinical specimens.

Krieger JN; Tam MR; Stevens CE; Nielsen IO; Hale J; Kiviat NB; Holmes KK
Diagnosis of trichomoniasis. Comparison of conventional wet-mount
examination with cytologic studies, cultures, and monoclonal antibody
staining of direct specimens. JAMA 1988 Feb 26;259(8):1223-7.
<http://www.ncbi.nlm.nih.gov/pubmed/2448502>

**Accuracy of detection of trichomonas vaginalis organisms on a
liquid-based Papanicolaou smear**

OBJECTIVE: The study was undertaken to determine the accuracy of the
liquid-based Papanicolaou (Pap) smear in the detection of Trichomonas
vaginalis organisms in women. STUDY DESIGN: Two hundred three
consecutive patients who had the liquid-based Pap smear also underwent a
culture for T vaginalis. A wet mount was performed if symptomatic.
Results were analyzed for sensitivity, specificity, and positive and
negative predictive values. RESULTS: Forty-four patients (21.6%) had a
positive culture. On the liquid-based Pap smear, 28 patients (13.8%)
were positive for T vaginalis, showing a sensitivity of 61.4%, a
specificity of 99.4%, a positive predictive value of 96.4%, and a
negative predictive value of 90.8%. When wet mount and culture were
compared, a sensitivity of 50%, a specificity of 93%, a positive
predictive value of 77%, and a negative predictive value of 80% were
obtained. CONCLUSION: The presence of T vaginalis organisms, as stated
by the liquid-based Pap smear pathology report, is accurate and warrants
treatment without further testing.

Lara-Torre E; Pinkerton JS Accuracy of detection of trichomonas
vaginalis organisms on a liquid-based Papanicolaou smear. Am J Obstet
Gynecol 2003 Feb;188(2):354-6.

<http://www.ncbi.nlm.nih.gov/pubmed/12592239>

**Bonus FAQ:**

**Q. Should I withhold contraception from a woman who is not 'current'
on her pap?**

**A.** No, there should be no barriers to the use of FDA approved
contraception.

(Detailed answer to follow next month.)

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

November 2008

# Quote of the month

*"Our capability to prevent and treat disease seems to exceed our
willingness to apply our interventions."*

C Everett Koop, MD

Former Surgeon general

**Article of Interest**

Effectiveness of Maternal Influenza Immunization in Mothers and Infants.

N Engl J Med. 2008 Sep 17. (See "Abstract of the Month" for the abstract
of this article.)

The current influenza vaccine is not licensed for use in infants \< 6
months age. Unfortunately; this age group is at highest risk for
morbidity and mortality from influenza infections. Researchers looked at
immunizing mothers in the third trimester of pregnancy as a way to
transfer immunity to infants at birth.

340 women participated in a randomized controlled trial and were
followed for 24 weeks after birth. Women who were vaccinated for
influenza had 36% less febrile respiratory illnesses themselves. Their
infants had 29% less febrile respiratory illnesses than unvaccinated
mothers. More striking was the 63% reduction of laboratory confirmed
influenza in infants born to mothers that had been vaccinated. These
numbers suggest that for each 100 mothers vaccinated 7 maternal febrile
illnesses and 14 newborn illnesses will be prevented.

**Pediatrics CCC Editorial Comment**

Few interventions in medicine are this cheap and effective. Even though
vaccination of pregnant women has been a recommendation of the CDC for
several years the number of pregnant women vaccinated has been low. The
quote from Dr. Koop above highlights the fact that we often fail to use
treatments of known benefit.

Our challenge is to make sure that this intervention is available to as
many patients as possible. Prenatal clinics should consider standing
orders for administration of flu vaccine. Obstetric wards should also
consider the use of standard orders for flu shots at discharge from
mothers who were not vaccinated during pregnancy. This strategy will not
result in transplacental protection of the infant but can decrease
mother-child transmission.

**Recent literature on American Indian/Alaskan Native Health**

**Michael L. Bartholomew, MD**

Naimi TS, Cobb N, Boyd D, Jarman DW, Brewer R, Nelson DE, Holt J, Espey
D, Snesrud P, Chavez P. Alcohol-Attributable Deaths and Years of
Potential Life Lost Among American Indians and Alaska Natives\-\--United
States, 2001-2005. *MMWR Morb Mortal Wkly Rep*. 2008 Aug
29;57(34);938-941. <http://www.ncbi.nlm.nih.gov/pubmed/18756193>

Excessive alcohol consumption is both a pervasive problem and the
leading cause of preventable death in both the general U.S. population
and the American Indian and Alaska Native (AI/AN) population. This study
is the first to estimate the average annual number of
alcohol-attributable deaths and years of potential life lost among
AI/ANs. By using death certificate data and the CDC Alcohol-Related
Disease Impact (ARDI) software, estimates of alcohol-attributable deaths
and years of life lost were generated by analyzing multiple data sources
including the Behavioral Risk Factor Surveillance System from 2001-2005.

Among AI/ANs, 1,514 alcohol-attributable deaths occurred annually from
2001-2005, accounting for 11.7% of all AI/AN deaths. For the general
U.S. population, alcohol-attributable deaths accounted for 3.3% of total
deaths. Acute causes, such as motor vehicle crashes, accounted for
nearly 51% of these deaths, while 49% were attributed to chronic causes
(alcoholic liver disease). Similarly, 60% of years of potential life
lost were attributed to acute causes and nearly 40% were related to
chronic conditions. Men accounted for more alcohol-attributable deaths
in all age groups and nearly 7% of these deaths were in persons aged
\<20 years. Within the Indian Health Service (IHS) regions, the Northern
Plains had the greatest number of alcohol-attributable deaths followed
by the Southwest, and the Pacific Coast. Additionally, the age adjusted
alcohol-attributable death rates were highest in the Northern Plains,
Alaska, and the Southwest.

AI/AN age adjusted alcohol-attributed death rates were higher than the
general U.S. population (55 per 100,000 for AI/AN versus nearly 27 per
100,000 for general U.S. population). The average number of years of
life lost per alcohol-attributable death was 36.3 years for AI/ANs and
29.9 years for the general U.S. population.

Estimating the years of life lost and the alcohol attributed mortality
rate in AI/ANs demonstrates the effect of excessive alcohol consumption
within our population The authors conclude that effective population
based interventions to reduce excessive alcohol consumption should be
implemented and regional differences in alcohol-attributable deaths be
explored.

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

**Alpha Testing to Start on the EHR Version of the Well Child Module**

Good news! We are on the verge of alpha testing the EHR version of the
Well Child Module. The electronic versions of both the Well Child and
Prenatal modules will be available in EHR or as "free-standing"
components for sites that have yet to migrate to the IHS EHR.

 

Cherokee Indian Hospital has volunteered to alpha test the EHR version
of the WCM. The other iteration of the electronic version of the WCM
(for sites not yet on EHR) will also be alpha tested soon.

 

The EHR version of the Prenatal Module is also very close to alpha
testing and should be ready for testing late this fall.

 

For further information, contact: <clarence.smiley@ihs.gov>*.*

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

**Disease risks of premastication as an infant feeding practice**

Before the era of blenders, and beyond the reach of the purveyors of
canned baby food, parents have long chewed up solid foods and fed the
resulting mash to their weaning infants. This practice, called
premastication, is old and widespread. It makes physiological sense: the
chewing not only makes food manageable for little ones without teeth,
but also mixes it with salivary enzymes to begin the digestive process.
Unfortunately, premastication also seems to have some health risks that
may not have been adequately considered.

Although the anthropological literature on premastication is not
extensive (primarily because the anthropological record does not have
much to say about infant feeding in general), we have evidence that it
is practiced in every major region of the world. Using the Human
Relations Area Files, a fascinating compendium of ethnographic records
collected over the course of sixty years, I was able to identify good
evidence of premastication of infant food in fifteen cultural groups
from Asia, South America, North America, Oceania, and Africa. (Two
others premasticate food for animals: one Amazonian group occasionally
chews up taro for their prized dogs, and a South Seas people masticates
yam for the boars that have grown such long spiral tusks -- valuable
among the South Seas islanders for ceremonial purposes -- that they can
no longer open their mouths enough to chew.) Anecdotal reports from the
Indian Health Service indicate that premastication for infants is at
least occasionally practiced among many Native peoples in North America
as well, particularly among Navajo, northern Plains, and Alaska Native
groups. Just how prevalent the practice is, however, is unknown.

So why does it matter? There have been suggestions that premastication
can introduce the infant to pathogens carried by the adults who pre-chew
their weaning food. A Canadian First Nations study (Sinha et al. 2004)
implicates maternal saliva -- potentially transferred to the infant
through premastication and possibly also on pacifiers -- in the
oral-oral transmission of *Helicobacter pylori*, etiologic factor in
both peptic ulcer and gastric cancer later in life. A Thai study (Imong
et al. 1995) documents bacterial contamination of premasticated infant
food and raises concerns over diarrheal diseases. Finally, a study from
China (Huang 1990) raises concerns over the transmission of blood-borne
pathogens in some cases: the author reports a two-fold rise in relative
risk of hepatitis B among kindergartners whose mothers premasticated
food for them in infancy, even when controlled for other routes of
transmission. If further research confirms that blood-borne pathogens
like HBV and HIV can be transmitted by premastication, even if such
transmission is a relatively minor route, the implications for global
health are obvious.

There are reasons for caution, however. First, the research available is
preliminary; it is not at all clear whether premasticated infant food
really is an important route of disease transmission. Second, the
alternatives must be carefully thought through, especially for families
who cannot afford commercial baby food. (Clinicians and public health
professionals should be chastened by remembering the catastrophic impact
of pushing bottle-feeding to mothers in the Third World.) Imong and
colleagues' Thai study of infant feeding cited above showed bacterial
contamination of *both* premasticated and mashed foods. Anthropologists
provide another cautionary tale. Public health officials convinced the
Orokaiva people of Papua New Guinea that premasticating babies' food was
unhygienic and uncivilized. But their instructions to mash taro instead
were ignored: mashing was a grievous offense to the taro spirit. Babies
fed solid taro could not digest it; Orokaiva babies suffered critical
weaning-period malnutrition because of this well-intentioned public
health intervention, and the anthropologists' suggestion that going back
to premastication would help was taken as a distasteful joke. It is not
yet time to rush out and start a new public health campaign against
premastication, but it probably is time to start considering -- and
researching -- the risks of this and alternative weaning approaches
among those who practice them.

Sinha SK et al. The incidence of Helicobacter pylori acquisition in
children of a Canadian First Nations community and the potential for
parent-to-child transmission. Helicobacter 9(1):59-68, 2004.
<http://www.ncbi.nlm.nih.gov/pubmed/15156905>

Huang MJ. \[An epidemiological study on prevalence and risk factors of
hepatitis B virus (HBV) infection in preschool children.\] Zhongua Liu
Xing Bing Xue Za Zhi 11(3):129-32, 1990. *Note: article is in Chinese
and only the abstract is available in English*.
<http://www.ncbi.nlm.nih.gov/pubmed/2390775>

Imong SM et al. Maternal behaviour and socio-economic influences on the
bacterial content of infant weaning foods in rural northern Thailand. J
Trop Pediatr 41(4):234-40,1995.
<http://www.ncbi.nlm.nih.gov/pubmed/7563277>

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

**MCH Library Releases New Edition of Domestic Violence Knowledge
Path**\
Domestic Violence: Knowledge Path is an electronic guide to recent
resources about identifying and responding to domestic violence within
the home and the community. The knowledge path, produced by the MCH
Library, contains information on Web sites, publications, databases,
and\
newsletters and online discussion lists. Separate sections identify
resources for families and resources about children exposed to domestic
violence; dating violence among adolescents; and violence between gay,
lesbian, bisexual, and transgender partners. The knowledge path is\
available at
[http://www.mchlibrary.info/KnowledgePaths/kp_domviolence.html](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.mchlibrary.info/KnowledgePaths/kp_domviolence.html).\
\
MCH Library knowledge paths on other maternal and child health topics
are available at
[http://www.mchlibrary.info/KnowledgePaths/index.html](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.mchlibrary.info/KnowledgePaths/index.html).

**Article Assesses Smoking Patterns and Use of Cessation Interventions
During Pregnancy\
**\"If women enter prenatal care while smoking, there is an opportunity
for clinicians to assess smoking status, counsel them to quit smoking,
and provide referrals for cessation services,\" state the authors of an
article published in the October 2008 issue of the American Journal of\
Preventive Medicine. Maternal smoking has been causally associated with
fetal growth restriction, premature rupture of the membranes, placenta
previa, placental abruption, preterm delivery, and low birthweight. In
addition, in utero exposure to cigarette smoke can have long-term
negative effects on the growth, development, and behaviors of offspring.
Further, women who quit smoking during pregnancy have better health
outcomes than those who continue to smoke. However, more than 10% of
women who delivered a live infant in 2004 reported smoking during
pregnancy \-- far above the Healthy People goal of 1%. This study
analyzed population-based surveillance data to describe women\'s smoking
patterns and the use of cessation services during pregnancy. Smoking
status during pregnancy as well as before and after entry into prenatal
care was examined. Health professional assistance, the use of
interventions, and barriers to quitting were also described.\
\
Data were analyzed from 4,473 women who responded to a questionnaire
from the New Jersey PRAMS (Pregnancy Risk Assessment and Monitoring
System) during 2004-2005. PRAMS, a population-based survey of women
whose pregnancies resulted in a live birth, is conducted in partnership
with the Centers for Disease Control and Prevention and the New Jersey
Department of Health and Senior Services. New Jersey was selected
because it is the only PRAMS state that includes detailed supplemental
questions on patterns of smoking and the use of cessation services.\
\
The authors found that:\
- Among New Jersey women who delivered a live infant, an estimated 16.2%
smoked in the 3 months before pregnancy, and 7.3% smoked during the last
3 months of pregnancy. Of the 16.2% who smoked before pregnancy, half
(49.8%) quit before entering prenatal care, and 5.2% quit afterwards.\
\
-Of women who smoked before pregnancy, 92.7% reported that they were
asked by their prenatal care health professionals about their smoking
status. Of women who were smoking when they entered prenatal care, 56.7%
reported that a health professional spent time discussing how to quit,
and 31.1% reported that a health professional set a specific date to
quit.\
\
-Among women who smoked during the last 3 months of pregnancy, 52.4%
tried to quit or cut back on their own, 10.2% tried to quit or cut back
but did not report using a cessation method, 25.9% did not try to quit
or cut back, and 11.5% used a cessation method when trying to quit or\
cut back.\
\
-The most frequent barriers to quitting were cravings for a cigarette,
loss of a way to handle stress, and having other people around who
smoke.\
\
The authors conclude that \"increasing the knowledge, promotion, and
referral of effective smoking-cessation interventions is necessary to
reduce the harmful impact of smoking on the health of women and their
newborns.\"\
\
Tong V, Englad LJ, Dietz PM, et al. 2008. Smoking patterns and use of
cessation interventions during pregnancy. American Journal of Preventive
Medicine 35(4):327-333. Abstract available at\
[http://www.ajpm-online.net/article/S0749-3797(08)00602-8/abstract](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.ajpm-online.net/article/S0749-3797(08)00602-8/abstract).\
\
Readers: More information is available from the following MCH Library
resources:\
\
- Smoking During Pregnancy: Bibliography at\
[http://www.mchlibrary.info/action.lasso?-database=Biblio&-layout=Web&-response=/databases/BibLists/bib_smokingpreg.html&-MaxRecords=all&-DoScript=auto_search_smokingpreg&-search](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.mchlibrary.info/action.lasso?-database=Biblio%26-layout=Web%26-response=/databases/BibLists/bib_smokingpreg.html%26-MaxRecords=all%26-DoScript=auto_search_smokingpreg%26-search)\
\
- Smoking/Tobacco Use Prevention: Bibliography at\
[http://www.mchlibrary.info/action.lasso?-database=Biblio&-layout=Web&-response=/databases/BibLists/bib_smokingprev.html&-MaxRecords=all&-DoScript=auto_search_smokingprev&-search](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.mchlibrary.info/action.lasso?-database=Biblio%26-layout=Web%26-response=/databases/BibLists/bib_smokingprev.html%26-MaxRecords=all%26-DoScript=auto_search_smokingprev%26-search)

**MCH Headlines Judy Thierry HQE**

**Native American Action Plan: Addressing Tobacco Abuse among Pregnant
and Postpartum Women**

The 32 page: \"Native American Action Plan: Addressing Tobacco Abuse
among Pregnant and Postpartum Women,\" developed by The National
Partnership to Help Pregnant Smokers Quit with contractual technical
assistance from LaDonna BlueEye is being released in PDF and hard copy
November 1st.

Meant for Tribal Leaders, Healthcare providers, Program planners and
policy makers, and Funding agencies the TOC with cases, lessons learned
and action steps in each section as follows:

I. The National Partnership to Help Pregnant Smokers Quit

> II\. Introducing the Issues; The Problem; The Challenge; The Current
> Intervention;
>
> The Opportunity

III\. Action to Reduce Smoking among Pregnant Native Americans: The 5
C's

> -Collaborate with other organizations; Traditional Ties

  -Cultivate cultural competency; SEMA Tobacco Project

> -Coach providers on working with Native American populations; Southern
>
> Ute Health Clinic
>
> -Care for patients using evidence-based practices; Alaska Nicotine
> Research
>
> and Control Program
>
> -Communicate cessation messages through multiple media; Aberdeen
>
> Healthy Start  

 

An online version including the appendices will be available soon at:

[www.tobacco-cessation.org/pregnantsmokers.htm](http://www.tobacco-cessation.org/pregnantsmokers.htm).

Limited hard copies are available by contacting LaDonna BlueEye at
<lblueeye@indiana.edu>**.**

**Cough and Cold Medications Not Recommended for Children Under 4 Years
of Age**

FDA notified healthcare professionals and consumers that the Consumer
Healthcare Products Association (CHPA) is voluntarily modifying the
product labels for consumers of over the counter (OTC) cough and cold
medicines to state \"do not use\" in children under 4 years of age. FDA
supports CHPA members to help prevent and reduce misuse and to better
inform consumers about the safe and effective use of these products for
children. FDA continues to assess the safety and efficacy of these
products and to revise its OTC list of approved ingredients and amounts
for these medicines. Parents and care givers should adhere to the dosage
instructions and warnings on the label that accompanies OTC cough and
cold medications before giving the product to children, and should
consult their healthcare professionals if they have any questions or
concerns.

 

Read the entire 2008 MedWatch Safety Summaries, including a link to the
FDA Press Release regarding the above issue at:
[http://www.fda.gov/medwatch/safety/2008/safety08.htm#CoughCold](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.fda.gov/medwatch/safety/2008/safety08.htm%23CoughCold)

**United States Breastfeeding Committee Coalition Mini-Grants
Application Now Open**

The United States Breastfeeding Committee is launching the **Coalition
Mini-Grants Program** this fall with funding from the Centers for
Disease Control and Prevention, to support state/territory/tribal
breastfeeding coalitions. This program will award several \$500 to
\$3,000 grants, totaling \$18,000 in funding for state, territory, and
tribal breastfeeding coalitions.

The purpose of this program is to enhance the capacity of
state/territory/tribal breastfeeding coalitions while ensuring that
coalitions are not duplicating efforts. The mini-grants will promote
enhanced focus on developing innovative strategies; refining, tailoring,
and replicating previously successful strategies; and sharing results
widely; thereby building on the work of others to enhance protection,
promotion, and support of breastfeeding across the United States.

Key Dates and Deadlines:

Application Deadline: 5:00 p.m. (ET), Friday, January 9, 2009

Notification of Funded Proposals: February 6, 2009

Checks to Funded Coalitions: by February 28, 2009

Presentations at 2010 Conference: January 23-25, 2010

Final Mini-Grant Reports Due: March 31, 2010

We look forward to launching this exciting new program!

**United States Breastfeeding Committee**\
2025 M Street, NW, Suite 800\
Washington, DC 20036\
Phone: (202) 367-1132\
Fax: (202) 367-2132\
E-mail: [office@usbreastfeeding.org[\
]{.underline}](mailto:office@usbreastfeeding.org)Web:
[www.usbreastfeeding.org](http://org2.democracyinaction.org/dia/track.jsp?v=2&c=U1BNcLN1WQHsToxrM8%2FZlI1AwXQsjlW%2F)

#### Medical Mystery Tour Neil Murphy, ANMC, SouthCentral Foundation {#medical-mystery-tour-neil-murphy-anmc-southcentral-foundation .Style-Heading-4-+-Arial-14-pt-Underline}

#### Test your knowledge on Polycystic Ovarian Syndrome (PCOS) {#test-your-knowledge-on-polycystic-ovarian-syndrome-pcos-1 .Style-Heading-4-+-Arial-14-pt-Underline}

1\. Menstrual cycles become more irregular in women with polycystic
ovarian syndrome (PCOS) as they approach menopause

True

False

2\. Medical management of adolescents with PCOS are *most* appropriately
directed towards

-Maximizing fertility

-Preventing excessive weight gain

-Arresting the progression of hirsutism

-Decreasing insulin levels

3\. Intrauterine growth retardation is associated with an increased risk
of PCOS in offspring

True

False

4\. Brothers of women with PCOS are at greater risk for which of the
following conditions?

-Decrease sperm counts

-Type 2 diabetes

-Hirsutism

-Increased pregnancy wastage

5\. The most appropriate first line modality for ovulation induction in
women with PCOS is

-Ovarian drilling

-Clomiphene citrate

-Metformin

-Exogenous gonadotropin

**Answers to follow in the December CCC Corner...**

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

#### [A sampling of the CME offerings available on Medscape]{.underline}: {#a-sampling-of-the-cme-offerings-available-on-medscape .Style-Heading-4-+-Arial-14-pt-Underline}

#### Vitamin D and Musculoskeletal Health {#vitamin-d-and-musculoskeletal-health .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.medscape.com/viewprogram/17495**](http://www.medscape.com/viewprogram/17495) {#httpwww.medscape.comviewprogram17495 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### [The Expanding Benefits of HPV Vaccination: Update on Clinical Data and Expert Panel Discussion](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://mp.medscape.com/cgi-bin1/DM/y/hBwdX0S6WkC0Jdl0JjoD0E2%26uac=84779ST) {#the-expanding-benefits-of-hpv-vaccination-update-on-clinical-data-and-expert-panel-discussion .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.medscape.com/viewprogram/17055**](http://www.medscape.com/viewprogram/17055) {#httpwww.medscape.comviewprogram17055 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Communicating Drug Risks to Patients {#communicating-drug-risks-to-patients .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.medscape.com/viewprogram/17379**](http://www.medscape.com/viewprogram/17379) {#httpwww.medscape.comviewprogram17379 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Adhesive Disease Associated With Gynecologic Surgery {#adhesive-disease-associated-with-gynecologic-surgery .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.medscape.com/viewprogram/17370**](http://www.medscape.com/viewprogram/17370) {#httpwww.medscape.comviewprogram17370 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Selecting Menopausal Estrogen Therapy: Oral or Transdermal? {#selecting-menopausal-estrogen-therapy-oral-or-transdermal .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.medscape.com/viewprogram/17277**](http://www.medscape.com/viewprogram/17277) {#httpwww.medscape.comviewprogram17277 .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

#### [General Medscape Links]{.underline}: {#general-medscape-links .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**

**Hot flashes and subclinical cardiovascular disease: findings from the
Study of Women\'s Health Across the Nation Heart Study**

BACKGROUND: Although evidence suggests adverse vascular changes among
women with hot flashes, it is unknown whether hot flashes are associated
with subclinical cardiovascular disease. The aim of this study was to
examine relations between menopausal hot flashes and indices of
subclinical cardiovascular disease. We hypothesized that women with hot
flashes would show reduced flow-mediated dilation and greater coronary
artery and aortic calcification compared with women without hot flashes.

METHODS AND RESULTS: The Study of Women\'s Health Across the Nation
Heart Study (2001 to 2003) is an ancillary study to the Study of
Women\'s Health Across the Nation, a community-based cohort study.
Participants were 492 women (35% black, 65% white) 45 to 58 years of age
who were free of clinical cardiovascular disease and had a uterus and at
least 1 ovary. Measures included a brachial artery ultrasound to assess
flow-mediated dilation, electron beam tomography to assess coronary
artery and aortic calcification, reported hot flashes (any/none,
previous 2 weeks), and a blood sample for measurement of estradiol
concentrations. Cross-sectional associations were evaluated with linear
regression and partial proportional odds models. Hot flashes were
associated with significantly lower flow-mediated dilation (beta=-1.01;
SE, 0.41; P=0.01) and greater coronary artery (odds ratio, 1.48; 95%
confidence interval, 1.04 to 2.12) and aortic (odds ratio, 1.55; 95%
confidence interval, 1.10 to 2.19) calcification in age- and
race-adjusted models. Significant associations between hot flashes and
flow-mediated dilation (beta=-0.97; SE, 0.44; P=0.03) and aortic
calcification (odds ratio, 1.63; 95% confidence interval, 1.07 to 2.49)
remained in models adjusted for cardiovascular disease risk factors and
estradiol.

CONCLUSIONS: Women with hot flashes had reduced flow-mediated dilation
and greater aortic calcification. Hot flashes may mark adverse
underlying vascular changes among midlife women.

Thurston RC, Sutton-Tyrrell K, Everson-Rose SA, Hess R, Matthews KA. Hot
flashes and subclinical cardiovascular disease: findings from the Study
of Women\'s Health Across the Nation Heart Study. Circulation. 2008 Sep
16;118(12):1234-40. Epub 2008 Sep 2.
<http://www.ncbi.nlm.nih.gov/pubmed/18765392>

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

**Midwives Corner** **Lisa Allee, CNM, 4 Corners Regional Health Center,
Red Mesa, AZ**

**Centering Pregnancy ListServe Revived**

Hello All!  The Centering Pregnancy ListServe is being revived!!

This list serve is for anyone who is doing Centering, is about to start
Centering, is interested in doing Centering soon or sometime in the
future, or anyone who is just downright curious about Centering.  It is
our forum to discuss ideas, frustrations, successes, stories, trainings,
etc!! Please feel free to send in anything about Centering and forward
this to anyone who you think might be interested!

Here are two questions currently being discussed on the ListServe:

Who is currently doing Centering??---where are you, how many groups are
you running; average group size; and how many providers and
co-facilitators are involved?

Who would be interested in an Advanced Centering Pregnancy and Parenting
Training? There is some funding available to put one on if we have the
numbers to support it!

To join the ListServe, please contact Lisa Allee at
<lisa.allee@ihs.gov>.

**Navajo News John Balintona, Northern Navajo Medical Center**

#### Navajo Area Women's Health Provider Meeting {#navajo-area-womens-health-provider-meeting-1 .Style-Heading-4-+-Arial-14-pt-Underline}

The following is a continuation of the excerpts from the Navajo Area
Women's Health Provider Meeting held in Chinle, Arizona on September 12,
2008.

# MATERNITY CARE ISSUES

**GPRA HIV Screening**

a.  Navajo Area target goal (74%) was met with a screening of 81.2% of
    eligible patients screened.

b.  Attendees discussed ideas for maintaining and increasing screening
    rate, ideas included establishing scheduled audits of RPMS and
    implementation of rapid HIV screening tests.

**Navajo Area Birth Statistics**

a.  Total of 3136 deliveries in NAIHS for 2007 which is similar to 2006

b.  Overall cesarean delivery rate: 14.1%

c.  Overall VBAC success rate: 92.6%

d.  Attendees confirmed the dedication for providing VBAC services for
    our area.

**OB Survey**

a.  Attendees discussed the results and implementation of recent NAIHS
    OB provider survey circulated in Summer 2008.

b.  Results published in recent CCC Clinical Corner.

**Fetal Monitoring Nomenclature**

a.  Dr. Paul Drinen, Chinle, presented a review of recent NICHD changes
    for fetal monitoring language.

b.  Attendees agreed that adoption of the new NICHD guidelines should be
    implemented area-wide for uniformity and ease of communication.

**OB Drills**

a.  Discussed specific OB Drills to include; emergency cesarean,
    shoulder dystocia, postpartum hemorrhage, and neonatal
    resuscitation.

b.  Surveyed the group as to the use of OB Drills and to the frequency
    of performing the drills. Most sites performed some type of drill
    exercise, but the frequency varied from monthly to quarterly.

c.  Dr. Howe can be contacted for literature regarding implementation of
    OB Drills.

**Area-wide Nursing Shortage and Kayenta Maternity Care Update**

a.  Attendees discussed the nursing shortage in the NAIHS pertaining to
    L&D, Ward, and Nursery nurses.

b.  All sites except Fort Defiance reported a shortage of available
    nurses.

c.  Attendees noted a high utilization of contract and locums nurses as
    opposed to permanent staff.

d.  Discussed future availability of maternity care at Kayenta Medical
    Center.

**Prenatal Genetic Screening**

a.  Discussed the challenge in obtaining some of the genetic screening,
    i.e. universal first trimester screening, nuchal thickness
    measurements, etc.

b.  Reviewed the cost of a variety of screening regimens.

# UPCOMING EVENTS

**Telluride Conference on Maternal and Child Health**

**Telluride, Colorado; January 30^th^ -- February 1^st^, 2009**

**Navajo Area ALSO Course**

**Chinle, Arizona; April 18-19, 2009 (tentative)**

For additional information about this column, please contact
<John.Balintona@ihs.gov>.

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**Nurses Corner Sandra Haldane, HQE**

**Strategies to prevent healthcare-associated infections in acute care
hospitals**\
Preventable healthcare-associated infections (HAIs) occur in US
hospitals. Preventing these infections is a national priority, with
initiatives led by healthcare organizations, professional associations,
government and accrediting agencies, legislators, regulators, payers,
and consumer advocacy groups. To assist acute care hospitals in focusing
and prioritizing efforts to implement evidence-based practices for
prevention of HAIs, the Society for Healthcare Epidemiology of America
and the Infectious Diseases Society of America Standards and Practice
Guidelines Committee appointed a task force to create a concise
compendium of recommendations for the prevention of common HAIs. This
compendium is implementation focused and differs from most previously
published guidelines in that it highlights a set of basic HAI prevention
strategies plus special approaches for use in locations and/or
populations within the hospital when infections are not controlled by
use of basic practices, recommends that accountability for implementing
infection prevention practices be assigned to specific groups and
individuals, and includes proposed performance measures for internal
quality improvement efforts.

Yokoe DS, Mermel LA, Anderson DJ, Arias KM, Burstin H, Calfee DP, et al.
A compendium of strategies to prevent healthcare-associated infections
in acute care hospitals. Infect Control Hosp Epidemiol. 2008 Oct;29
Suppl 1:S12-21. <http://www.ncbi.nlm.nih.gov/pubmed/18840084>

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

#### Free full text: {#free-full-text-2 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.journals.uchicago.edu/doi/abs/10.1086/591060**](http://www.journals.uchicago.edu/doi/abs/10.1086/591060) {#httpwww.journals.uchicago.edudoiabs10.1086591060 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### New York Times article covering this issue: {#new-york-times-article-covering-this-issue .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.nytimes.com/2008/10/09/us/09infection.html**](http://www.nytimes.com/2008/10/09/us/09infection.html) {#httpwww.nytimes.com20081009us09infection.html .Style-Heading-4-+-Arial-14-pt-Underline}

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

####  {#section-41 .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}

**What Works to Promote Cancer Screening**

The Community Guide has conducted systematic reviews of interventions
designed to improve early detection and control of cancer by increasing
screenings for breast, cervical, and colorectal cancer. The list
identifies all current Task Force on Community Preventive Services
findings for increasing breast, cervical, and colorectal screening. The
Task Force considered client-based interventions separately for the
three types of cancer sites (breast, cervical, and colorectal) because
the clients for each of these screening tests can be very different.
They considered provider-oriented interventions across all three sites
because providers might be influenced by similar factors when deciding
whether to recommend screening for their various clients.

<http://www.thecommunityguide.org/cancer/screening/>

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

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

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

**Serum 25-hydroxyvitamin D and functional outcomes in the elderly** The
objective of this article was to consider key evidence that treatment of
vitamin D insufficiency has measurable clinical benefits for the
musculoskeletal system in the elderly. The functional outcomes
considered were increased bone mass, decreased rates of bone loss,
improved muscle performance, reduced risk of falls, and reduced fracture
incidence. Available evidence suggests that the elderly need a mean
serum concentration of \>/=65 nmol/L of vitamin D to improve muscle
performance and reduce the risk of falling and \>/=75 nmol/L to reduce
the risk of fracture. Many elderly persons in the United States and
elsewhere have serum 25-hydroxyvitamin D concentrations below these
levels. For this reason, supplementation is likely to provide
significant benefit to this segment of the population.

Dawson-Hughes B. Serum 25-hydroxyvitamin D and functional outcomes in
the elderly. Am J Clin Nutr. 2008 Aug;88(2):537S-540S.
<http://www.ncbi.nlm.nih.gov/pubmed/18689397>

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

#### Free Flu Materials from the CDC {#free-flu-materials-from-the-cdc-1 .Style-Heading-4-+-Arial-14-pt-Underline}

**December 8-14, 2008** is **National Influenza Vaccination Week**. Make
sure that your community is ready with patient educational materials and
posters from the CDC. This year's seasonal flu materials are free for
download---no printed versions are available. They may be printed on a
standard office printer, or you may use a commercial printer.

Emphasis remains on outreach to high-risk groups, as well as parents of
all children, health care workers, and people in the workplace.

#### [**http://www.cdc.gov/flu/professionals/flugallery/index.htm**](http://www.cdc.gov/flu/professionals/flugallery/index.htm)  {#httpwww.cdc.govfluprofessionalsflugalleryindex.htm .Style-Heading-4-+-Arial-14-pt-Underline}

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#### Perinatology Picks  {#perinatology-picks .Style-Heading-4-+-Arial-14-pt-Underline}

**Cesarean delivery for the second twin**

OBJECTIVE: To examine maternal and infant outcomes after a vaginal
delivery of twin A and a cesarean delivery of twin B, and to identify
whether the second twin experienced increased short-term morbidity as
part of a combined route of delivery.

METHODS: Between January 1, 1999, and December 31, 2000, a prospective
cohort study of all cesarean deliveries was conducted at 13 university
centers. This secondary analysis was limited to women with twin
gestations who experienced labor and underwent cesarean delivery. We
compared outcomes of the second twin in women who had vaginal delivery
of the first twin and a cesarean delivery of the second twin to those
who had cesarean delivery of both twins.

RESULTS: One thousand twenty-eight twin pregnancies experienced labor
and underwent cesarean delivery; 179 (17%) had a combined
vaginal/cesarean delivery. Gestational age at delivery was 34.6 weeks in
both groups (P=.97). The rupture of membranes to delivery interval was
longer in the combined group (3.2 compared with 2.3 hours, P\<.001).
Endometritis and culture-proven sepsis in the second twin were more
common in the combined group, respectively (n=24, odds ratio 1.6, 95%
confidence interval, 1.0-2.7; n=15, odds ratio 1.8, 95% confidence
interval, 1.0-3.4). These differences were not significant after
logistic regression analysis. There were no statistically significant
differences in an arterial cord pH of less than 7.0, Apgar score less
than or equal to 3 at 5 minutes, seizures, grade III or IV
intraventricular hemorrhage, hypoxic ischemic encephalopathy, or
neonatal death.

CONCLUSION: Combined twin delivery may be associated with endometritis
and neonatal sepsis when compared with a twin delivery where both are
delivered by cesarean in twin pregnancies experiencing labor. More
serious neonatal sequelae, including hypoxic ischemic encephalopathy and
death, were not affected by the route of delivery of the second twin.

Alexander JM, Leveno KJ, Rouse D, Landon MB, Gilbert SA, Spong CY, et
al. Cesarean delivery for the second twin. Obstet Gynecol. 2008
Oct;112(4):748-52. <http://www.ncbi.nlm.nih.gov/pubmed/18827115>

**Accuracy of ultrasonographic fetal weight estimation in twin
pregnancies**\
OBJECTIVE: To compare the accuracy of fetal weight estimations between
normal and growth-restricted twin and singleton pregnancies in a single
tertiary center.

METHODS: The computerized ultrasound database of a tertiary center was
searched for all fetal weight estimations made in twin pregnancies from
2001 to 2006, which were performed up to 3 days before delivery.
Accuracy was compared with a control group of singleton pregnancies at a
3:1 ratio. Estimated fetal weight was calculated by the Hadlock formula.
Analyses were performed for the whole group and for pregnancies
associated with fetal growth restriction and discordancy. RESULTS: The
study groups included 278 twins and 834 singleton pregnancies. The twins
group was characterized by a higher mean absolute percentage error
compared with the singleton group (8.9% compared with 6.8%). Accuracy
was lower for the second twins than for the first twins. When comparing
the subgroup of fetal growth restriction, differences in sensitivity and
specificity were small for singleton compared with overall twins (47.5%
compared with 48.9% and 97.7% compared with 95.7%, respectively).
Overall accuracy was better in the singleton group (95% compared with
88%), mainly due to relatively low accuracy in the second twin (86%).
For detection of discordancy, estimated fetal weight had a sensitivity
of 52%, specificity of 88%, and overall accuracy of 81%.

CONCLUSION: The accuracy of the ultrasonographic estimated fetal weight
seems to be lower for twin gestations than for singleton gestations,
especially for second twins. These data should be considered by
clinicians when making decisions based on ultrasonographic
characteristics.

Danon D, Melamed N, Bardin R, Meizner I. Accuracy of ultrasonographic
fetal weight estimation in twin pregnancies. Obstet Gynecol. 2008
Oct;112(4):759-64. <http://www.ncbi.nlm.nih.gov/pubmed/18827117>

**Nicotine gum for pregnant smokers: a randomized controlled trial**

OBJECTIVE: To estimate the safety and efficacy of treatment with 2-mg
nicotine gum for smoking cessation during pregnancy.

METHODS: Pregnant women who smoked daily received individualized
behavioral counseling and random assignment to a 6-week treatment with
2-mg nicotine gum or placebo followed by a 6-week taper period. Women
who did not quit smoking were instructed to reduce the number of
cigarettes smoked by substituting with gum. Measures of tobacco exposure
were obtained throughout the study.

RESULTS: Participants in the nicotine (n = 100) and placebo (n = 94)
groups were comparable in age, race/ethnicity, and smoking history.
Biochemically validated smoking-cessation rates were not significantly
higher with nicotine gum compared with placebo (after 6 weeks of
treatment: 13% compared with 9.6%, P=.45; at 32-34 weeks of gestation:
18% compared with 14.9%, P=.56). Using a completer analysis, nicotine
gum significantly reduced the number of cigarettes smoked per day
(nicotine gum: -5.7 \[standard deviation (SD)=6.0\]; placebo: -3.5
\[SD=5.7\], P=.035), and cotinine concentration (nicotine gum: -249
ng/mL \[SD=397\]; placebo: -112 ng/mL \[SD=333\]; P=.04). Birth weights
were significantly greater with nicotine gum compared with placebo
(3,287 g \[SD=566\] and 2,950 g \[SD=653\], respectively, P\<.001).
Gestational age was also greater with nicotine-replacement therapy than
with placebo (38.9 weeks \[SD=1.7\] and 38.0 weeks \[SD=3.3\],
respectively; P=.014).

CONCLUSION: Although nicotine gum did not increase quit rates, use of
nicotine gum increased birth weight and gestational age, two key
parameters in predicting neonatal wellbeing.

Oncken C, Dornelas E, Greene J, Sankey H, Glasmann A, Feinn R, Kranzler
HR. Nicotine gum for pregnant smokers: a randomized controlled trial.
Obstet Gynecol. 2008 Oct;112(4):859-67.
<http://www.ncbi.nlm.nih.gov/pubmed/18827129>

**Risk of development of diabetes mellitus after diagnosis of
gestational diabetes**

BACKGROUND: It is generally appreciated that gestational diabetes is a
risk factor for type 2 diabetes. However, the precise relation between
these 2 conditions remains unknown.

We sought to determine the incidence of diabetes mellitus after
diagnosis of gestational diabetes.

METHODS: We used a population-based database to identify all deliveries
in the province of Ontario over the 7-year period from Apr. 1, 1995, to
Mar. 31, 2002. We linked these births to mothers who had been given a
diagnosis of gestational diabetes through another administrative
database that records people with diabetes on the basis of either
physician service claims or hospital admission records. We examined
database records for these women from the time of delivery until Mar.
31, 2004, a total of 9 years. We determined the presence of diabetes
mellitus according to a validated administrative database definition for
this condition.

RESULTS: We identified 659 164 pregnant women who had no pre-existing
diabetes. Of these, 21 823 women (3.3%) had a diagnosis of gestational
diabetes. The incidence of gestational diabetes rose significantly over
the 9-year study period, from 3.2% in 1995 to 3.6% in 2001 (*p* \<
0.001).The probability of diabetes developing after gestational diabetes
was 3.7% at 9 months after delivery and 18.9% at 9 years after delivery.
After adjustment for age, urban or rural residence, neighbourhood income
quintile, whether the woman had a previous pregnancy, whether the woman
had hypertension after the index delivery, and primary care level before
the index delivery, the most significant risk factor for diabetes was
having had gestational diabetes during the index pregnancy (hazard ratio
37.28, 95% confidence interval 34.99--40.88; *p* \< 0.001). Age, urban
residence and lower income were also important factors. When analyzed by
year of delivery, the rate of development of diabetes was higher among
the latest subcohort of women with gestational diabetes (delivery during
1999--2001) than among the earliest subcohort (delivery during 1995 or
1996) (16% by 4.7 years after delivery v. 16% by 9.0 years).

INTERPRETATION: In this large population-based study, the rate of
development of diabetes after gestational diabetes increased over time
and was almost 20% by 9 years. This estimate should be used by
clinicians to assist in their counselling of pregnant women and by
policy-makers to target these women for screening and prevention.

Feig DS, Zinman B, Wang X, Hux JE. Risk of development of diabetes
mellitus after diagnosis of gestational diabetes *CMAJ*
2008;179(3):229-34. <http://www.ncbi.nlm.nih.gov/pubmed/18663202>

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

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

**Ongoing discussion of Geriatric Medication Issues**

This discussion is being led by Bruce Finke, MD and Chris Lamer,
PharmD.  The case study which will serve as the springboard for our
discussion is below.  This is certainly a topic that affects all of us
in I/T/U settings\-\--how do we offer the benefits of preventive and
therapeutic medications to elders without causing more harm than good? 
We hope you will participate with your thoughts and experiences as the
discussion progresses over the next couple weeks.  Welcome to Drs Finke
and Lamer, the IHS Elder Care Consultant and IHS Clinical Informaticist
for Health Education, respectively. See the instructions on enrollment
after the following case description.

**Case:**

 An 80 year old woman comes to see you for a routine follow-up.  You
have seen her episodically in walk-in but her primary care was provided
by a physician who recently left.  She is accompanied by her daughter
who teaches 1^st^ grade at the elementary school.  

 

You greet her and ask her how she is doing.  She complains about pain in
her knees and thumbs and that her left wrist and hand are still not back
to normal after her recent fracture.  You are reminded that you saw her
in walk-in after that fall (she had tripped on a step when she was
pulling weeds from the flowerbed in her front yard)

 

You take a moment to review her medical problem list and medications. 
You see that she has diagnoses of diabetes, hypertension,
hyperlipidemia, arthritis.  You see atrial fibrillation on her problem
list but notice that in her most recent visits she was in sinus rhythm.
 It appears that she had several episodes of atrial fibrillation with a
controlled rate in the past two years but is mostly in sinus rhythm.

Current medications:

Aspirin EC 81mg daily

Lisinopril 10mg daily

Diltiazem 180mg daily

Atenolol 25mg daily

Alprazolam 0.5mg prn started by the surgeon after the fall

Digoxin 0.25mg daily

Glyburide 10mg BID

Metformin XR 1000mg BID

Tylenol #3, 2 tablets Q4-6h prn pain

Ibuprofen 600mg Q6h prn pain

Tylenol PM 2 tabs HS prn sleep

Lansoprazole 30mg daily

Glucosamine 600mg TID

Simvistatin 5mg daily

Vitals:

T: 94.4      P: 65     R: 18      BP: 150/72      Pain: 5 / 10

Labs at the last visit:

AIC: 8.2%, goes to 9.0% with change in meds.

LDL: 125

TSH: normal

B12: 330

CBC: 13.2 / 42.2

Chemistries:  Na+: 142    K+: 3.8     Cl: 108    HCO3: 28   Cr: 1.1
   Bun: 28   glucose: 165 random

Albumin: 3.8

eGFR:  47.05

 

**What do you think about this elderly woman's medication management?**

**Are there medications prescribed that she perhaps should not be
taking?  Are there medications that she is taking that she should
perhaps not be prescribed?  What further information do you need or
want?**

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

Subscribe to the Primary Care listserv

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

Unsubscribe from the Primary Care listserv

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

Questions on how to subscribe, contact <ANNBULL@nc-cherokee.com>
directly.

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

This month I wanted to draw attention to draw attention to some
innovative uses of technology that are being used to prevent STDs/HIV
and to promote safe sex.

**Project Red Talon Launches MySpace Page**

Project Red Talon, the STD/HIV prevention program at the Northwest
Portland Area Indian Health Board, has launched a MySpace page to reach
Native youth and young adults with age-appropriate STD/HIV prevention
information. Encourage Native youth in your community to check it out
and send Project Red Talon their comments and feedback. The website link
is: <http://www.myspace.com/projectredtalon>. Project Red Talon's
website is: <http://www.npaihb.org/epicenter/project/project_red_talon>.

Some other innovative uses of technology to address STDs include:

**Confidential web-based chlamydia testing**---At "I Want the Kit"
people living in participating areas can confidentially order a
home-based chlamydia test that gets returned to the project's lab in an
unmarked envelope. Results are provided, linkages to local public health
agencies for partner services are made, and treatment is provided. The
Alaska native Tribal Health Consortium, the State of Alaska STD Program,
and the IHS National STD Program are having discussions about
implementing a variation of I Want the Kit in Alaska in the near future.
To learn more, visit [www.iwantthekit.org](http://www.iwantthekit.org/).

**Anonymous web-based partner notification**---InSpot is a web-based
service that allows you to anonymously tell sex partners they have been
exposed to an STD. InSpot's website is
[www.inspot.org](http://www.inspot.org/).

**Cellular ringtones with a STD message**---BBC World Trust has produced
a cellular phone ringtone in India that says \"condom, condom\" to
promote safer sex and curb the spread of HIV in the country. It features
a popular professional singer who sings the word \"condom\" more than 50
times---a \"playful approach\" that some advocates hope will \"spark
discussion and make condoms more socially acceptable". To hear the ring
tone, visit:
[http://www.condomcondom.org](http://www.condomcondom.org/).

**Safe sex messages via text messaging**---SexText is a project
developed by the San Francisco Department of Health where youth can text
a number that allows to receive targeted STD prevention messages
tailored for their geographic location. Some rural areas---such as
Wyoming---have considered using this service. To learn more, visit
[www.sextextsf.org](http://www.sextextsf.org/).

**Internet dating for people with STDs/HIV**---There are many websites
that link people who know they have STDs or HIV. People who use these
sites say it takes the stigma of having to disclose having an STD or HIV
to a new partner away, since both people know up front that they both
have something. To learn more, visit: Meet People with Herpes
([www.MPwH.net](http://www.MPwH.net/)), Positive Personals
([www.positivepersonals.com](http://www.positivepersonals.com/)),
Positive Singles
([www.positivesingles.com](http://www.positivesingles.com/)), A Greater
Date ([www.agreaterdate.com](http://www.agreaterdate.com/)).

**Advertising on social networking sites**---The Queensland Government
in Australia is launching a \"Safe Sex. No Regrets\" campaign through
advertisements on internet sites such as MySpace, Facebook and Google.

The IHS National STD Program would be interested in hearing about other
uses of technology to prevent STDs/HIV, especially those that are being
used in Indian Country. Also, do you think any of these mentioned uses
of technology would work in your community? Why or why not? Let us hear
from you! <lori.deravello@ihs.gov>

 

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

**Postpartum screening for diabetes after a gestational diabetes
mellitus-affected pregnancy**\
OBJECTIVE: To estimate trends in postpartum glucose testing in a cohort
of women with gestational diabetes mellitus (GDM).

METHODS: A validated computerized algorithm using Kaiser Permanente
Northwest automated data systems identified 36,251 live births or
stillbirths from 1999 through 2006. The annual percentage of pregnancies
complicated by gestational diabetes with clinician orders for and
completion of a fasting plasma glucose (FPG) test within 3 months of
delivery was calculated. Logistic regression with generalized estimating
equations was used to test for statistically significant trends.

RESULTS: The percentages of pregnancies affected by GDM increased from
2.9% in 1999 to 3.6% in 2006 (P\<.01). Clinician orders for postpartum
tests increased from 15.9% in 1999 to 79.3% in 2004 (P\<.01), and then
remained stable through 2006. Completed FPG tests increased from 9.0% in
1999 to 57.8% in 2004 (P\<.01), and then remained stable through 2006.
No oral glucose tolerance tests were ordered. From 2004 to 2006, the
practice site where women received care was the factor most strongly
associated with the clinician order, but it was not predictive of test
completion. Among women with clinician orders, those who were Asian or
Hispanic or who attended the 6-week postpartum examination were more
likely to complete the test than their counterparts.

CONCLUSION: Postpartum glucose testing in women with GDM-affected
pregnancies increased over time. However, even in recent years, 42% of
women with GDM-affected pregnancies failed to have a postpartum FPG
test, and no test was ordered for 21% of GDM-affected pregnancies.

Dietz PM, Vesco KK, Callaghan WM, Bachman DJ, Bruce FC, Berg CJ, England
LJ, Hornbrook MC. Postpartum screening for diabetes after a gestational
diabetes mellitus-affected pregnancy.\
Obstet Gynecol. 2008 Oct;112(4):868-74.
<http://www.ncbi.nlm.nih.gov/pubmed/18827130>

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

**The association between low birth weight and type 2 diabetes:
contribution of genetic factors**

BACKGROUND: Low birth weight has been associated with an increased risk
of type 2 diabetes in adulthood. Poor fetal nutrition has been suggested
to explain this association. Our objective was to determine whether
genetic factors contribute to the association between low birth weight
and subsequent risk of type 2 diabetes.

METHODS: We retrieved information from original birth records on
same-sex Swedish twins with known zygosity, born from 1926 to 1958. We
used regression models to investigate whether birth weight was
associated with risk of type 2 diabetes in the cohort of twins overall,
and in case-control analyses within disease-discordant dizygotic and
monozygotic twin pairs.

RESULTS: Of 18,230 twins, 592 (3.2%) had type 2 diabetes. The rate of
type 2 diabetes consistently increased with decreasing birth weight,
from 2.4% among twins with birth weights of 3500 g or more to 5.3% among
those with birth weights less than 2000 g. In the cohort analysis, in
which twins are analyzed as independent individuals, the adjusted odds
ratio (95% confidence interval) of type 2 diabetes per 500-g decrease in
birth weight was 1.44 (1.28-1.63). When we compared the diseased twin
with the healthy cotwin, the corresponding odds ratios were 1.38
(1.02-1.85), among dizygotic twins, and 1.02 (0.63-1.64), among
monozygotic twins. CONCLUSIONS: Low birth weight is associated with type
2 diabetes in adulthood. The difference in this association between
monozygotic and dizygotic twin pairs suggests that genetic mechanisms
play an important role in this association.

Johansson S, Iliadou A, Bergvall N, dé Fairé U, Kramer MS, Pawitan Y, et
al. The association between low birth weight and type 2 diabetes:
contribution of genetic factors. Epidemiology. 2008 Sep;19(5):659-65.
<http://www.ncbi.nlm.nih.gov/pubmed/18714437>

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

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

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

**A web-based resource for oral health providers on screening for
domestic violence**

Oral health providers are in a pivotal position for identifying head,
face and neck injuries typical of domestic violence or child abuse. As
primary care providers, we hope to engage them in domestic violence
screening so they can also begin to connect women with community
advocates as well as the medical, behavioral health and social services
that their patients may wish to access.

I am excited to announce that through collaboration with among IHS
Division of Oral Health, IHS Women\'s Health, HRSA\'s Maternal and Child
Health Bureau, and the National Maternal and Child Oral Health Resource
Center, a web-based \"portal\" to materials on domestic violence and
oral health is now available at <http://www.mchoralhealth.org/AZ.html>.

The link takes you to a page on the National MCH Oral Health Resource
Center\'s web site that has a list of references arranged in
alphabetical order. Under \"D\" you will see \"Domestic violence and
oral health.\"

Click on the \'library\' that appears to the right of \"Domestic
Violence and oral health\" and you\'ll see 11 items featured - the first
three focus on domestic violence, the other eight focus on child abuse.

####  {#section-51 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-52 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**2008 Indian Health Information Management Conference, "Managing Health
Information Technology to Improve Performance and Outcomes"**

-   December 15 -- 19, 2008 ; Phoenix, Arizona

-   Information at: <http://www.ihs.gov/cio/ihimc/>

**Telluride Midwinter Conference on Maternal and Child Health**

-   January 30^th^ -- February 1^st^, 2009

-   Fun and inexpensive CME

-   Telluride, Colorado

-   [http://www.ihs.gov/MedicalPrograms/MCH/F/CN01.cfm?module=09&option=1#top](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/F/CN01.cfm?module=09%26option=1%23top)

> (scroll down to date)

**First International Meeting on Indigenous Women's Health/Third
International Meeting on Indigenous Child Health Conference; Many Voices
into One Song**

-   Women's Health March 4-6, 2009

-   Child Health March 6-8, 2009

-   Albuquerque , NM

-   Joint conference of Women's Health and Children's Health Providers
    from Canada and the United States

-   <http://www.ihs.gov/MedicalPrograms/MCH/F/CN01.cfm?module=09&option=3#top>

 **Advances in Indian Health Conference**

-   April 21-24, 2009 in Albuquerque, NM 

-   Indian Health\'s conference for primary care providers and nurses

-   28 hours of CME/CE credit

-   Optional Diabetes track

-   Contact the Course Director, Dr. Ann Bullock, at
    <annbull@nc-cherokee.com> for more information.

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

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/index.cfm>

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

The **October 2008 CCC Corner** is available at:

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

#### [Abstract of the Month]{.underline} {#abstract-of-the-month-2 .Style-Heading-4-+-Arial-14-pt-Underline}

\- Diabetes mellitus and birth defects

#### [From your colleagues]{.underline} {#from-your-colleagues-2 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Jean Howe, CCC -- Ob/Gyn {#jean-howe-ccc-obgyn .Style-Heading-4-+-Arial-14-pt-Underline}

#### - First International Conference for Indigenous Women's Health/Third International Conference for Indigenous Child Health; Albuquerque, March 4-8, 2009 {#first-international-conference-for-indigenous-womens-healththird-international-conference-for-indigenous-child-health-albuquerque-march-4-8-2009 .Style-Heading-4-+-Arial-14-pt-Underline}

**Robert McSwain, IHS Director**

-Susan V. Karol, MD, named IHS Chief Medical Officer

**Sheila Warren, Headquarters**

-Joint Commission Resources is Challenging YOUR HOSPITAL to Increase
Health Care Worker Vaccination against the Flu

####  {#section-53 .Style-Heading-4-+-Arial-14-pt-Underline}

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

##### Obstetrics

\- Electronic Fetal Monitoring: Update on Definitions and Interpretation

# - Bariatric surgery linked to improved perinatal outcomes 

\- A randomized, controlled trial of magnesium sulfate for the
prevention of cerebral palsy

\- Gestational weight gain and risk of overweight in the offspring at
age 7 y in a multicenter, multiethnic cohort study

**Gynecology**

\- Methicillin-resistant Staphylococcus aureus as a common cause of
vulvar abscesses\
- Hysterectomy Complication Rates Decline Significantly

\- Prevalence of symptomatic pelvic floor disorders in U.S. women

\- Behavioral therapy to enable women with urge incontinence to
discontinue drug treatment: a randomized trial

\- Success rates \<1% following fresh assisted reproduction treatment in
women aged 45 years and older

**Child Health**

\- Randomized controlled trial of a pictogram-based intervention to
reduce liquid medication dosing errors and improve adherence among
caregivers of young children

\- Ibuprofen more effective than acetaminophen for treating fever in
children

\- Identifying postpartum depression: are 3 questions as good as 10?

**Chronic Illness and Disease**

## - Incidence and Risk Factors for Stroke in American Indians; The Strong Heart Study

\- Expanded Recommendations for Hepatitis B Screening

\- Association of Urinary Bisphenol A Concentration with Medical
Disorders and Laboratory Abnormalities in Adults

# - Alcohol-Attributable Deaths and Years of Potential Life Lost Among American Indians and Alaska Natives \-\-- United States, 2001\--2005

-Should the window for thrombolytic use be extended for stroke?

#### [Features]{.underline} {#features-2 .Style-Heading-4-+-Arial-14-pt-Underline}

American College of Obstetricians and Gynecologists

-Fetal Lung Maturity

-Depot Medroxyprogesterone Acetate and Bone Effects

-The Uninsured

-Addressing Health Risks of Noncoital Sexual Activity

-Prenatal and Perinatal Human Immunodeficiency Virus Testing: Expanded
Recommendations

##### American Family Physician

\- Health maintenance for postmenopausal women

**Agency for Healthcare Research and Quality**

# - US Surgeon General Issues \"Call to Action\" on DVT and PE

**Ask a Librarian**

-BMJ Clinical Evidence Adds Medical Conditions

**Behavioral Health Insights**

\- Antipsychotics -- The Old versus the New - What Should I Use?

### - SAMHSA Awards More Than \$16 Million to Tribes/Tribal Organizations for Youth Suicide Prevention and Early Intervention Programs

**Breastfeeding**

### - Mastitis and Plugged Ducts 

**CCC Corner Digest**

**Domestic Violence**

\- Break the Silence: Stop the Violence; new video addresses teen dating
violence

**Elder Care News**

\- Less Sleep May Equal Greater Risk of Falling in Elderly Women 

**Family Planning**

\- ACOG Press Release: Bone Mineral Density Concerns Should Not
Discourage Use of Contraceptive Shot

\- Management of Breakthrough Bleeding with Continuous Use of the
Transvaginal Contraceptive Ring\
**Featured Website**

# - Welcome to WIN, The Weight-control Information Network

**Frequently asked questions**

\- Can a patient receive *outpatient* cervical ripening?

**Indian Child Health Notes**

\- Universal screening for hearing loss in newborns: US Preventive
Services Task Force

\- Pediatric Practice-based Versus an Agency-Based Model of Care
Coordination for Children and Youth with Special Health Care Needs

**Information Technology**

\- RPMS iCare Population Management Immunization Patch Released

International Health

\- Preventing and treating HIV/AIDS in Thai prisons

#### MCH Alert

\- Social, Emotional, and Physical Health and Workplace Challenges of
Women in the Postpartum Period

\- Opportunities to Improve Adolescent Health and Prevent Cardiovascular
Disease

\- Special Notice: New Name Signals an Expanded Focus for The National
Sudden Infant Death Syndrome and Other Infant Death (SIDS/ID)
Cooperative Agreement Program\
- Partners Engage in Focused Effort to Improve the Oral Health of
Pregnant Women

#### MCH Headlines

\- New American Academy of Pediatrics (AAP) Resources for Vaccination

\- Preventing Alcohol, Tobacco, and Other Substance-exposed Pregnancies:
A Community Affair

#### Medical Mystery Tour

\- Fetal Heart Monitoring: The answers applied

#### Medscape

**Menopause Management**

## - Cochrane Update: Oestrogens for Preventing Recurrent Urinary Tract Infection in Postmenopausal Women

**Midwives Corner**

\- The conflict and compromises between how we want to practice
midwifery and how we do practice midwifery in the hospital setting

**Navajo News**

\- Navajo Area Women's Health Provider Meeting

**Nurses Corner**

\- Nursing Leadership; An Excerpt from the IHS CEO Brief

\- MEDCOM has added Obstetrical Series to the Course Catalog

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

\- Emergency Planning Tips If You\'re Pregnant or Have Young Children

\- Electronic Media and Youth Violence: A CDC Issue Brief for Educators
and Caregivers

\- Increasing Prevalence of Gestational Diabetes and Pregnancy-Related
Hypertension in Los Angeles County, California, 1991--2003

Osteoporosis

\- Pharmacologic treatment of low bone density or osteoporosis to
prevent fractures: a clinical practice guideline from the American
College of Physicians

Patient Education

\- The Eagle Book Animation Series

Perinatology Picks

\- Correlation of catheterized and clean catch urine protein/creatinine
ratios in preeclampsia evaluation

\- A randomised controlled trial of early versus delayed oxytocin
augmentation to treat primary dysfunctional labour in nulliparous women

\- Do Mechanical Methods of Cervical Ripening Increase Infectious
Morbidity? A Systematic Review

# - QuickStats: Rates\* of Cesarean Deliveries \-\-- Selected Countries,^†^ 2005

Primary Care Discussion Forum

STD Corner

# - Trends in HIV- and STD-Related Risk Behaviors Among High School Students \-\-- United States, 1991\--2007

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

\- Small Steps, Big Rewards for Families with a History of Gestational
Diabetes

\- Healthcare Cost and Utilization Project

**Women's Health Headlines**

\- Differentiation among Types of Intimate Partner Violence: Research
Update and Implications for Interventions

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

The past CCC Corners are archived at:

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

The CCC Corner is good way to inform ITU providers about recent updates,
while decreasing the number of e-mail messages. Let me know if you want
to add something to next month's CCC Corner at <jean.howe@ihs.gov> or
928-674-7422 (with voicemail).

\*The opinions expressed in the CCC Corner are strictly those of the
authors, and not necessarily those of the Indian Health System, or the
author of this newsletter.