**Final call: Last meeting of its kind till 2007**

**2004 American Native Women's Health and Maternity Care**

August 4-6, 2004, Albuquerque, New Mexico See 'Save the Dates' below

Great CEU /CME, plus networking for leaders of care of Native women /
MCH

Internationally known faculty, over 35 in all

[Theme:]{.underline} Prevention in Native Women, plus Tracks on DV and
Breastfeeding, and several Adolescent topics

[Target audience]{.underline}: leaders and opinion leaders - Primary
Care, Family Physicians, Nurses, Advance Practice Nurses, Midwives,
Physician Assistants, OB/GYNs, Pediatricians, and others

OB/GYN Chief Clinical Consultant's Corner

Volume 2, No. 7, July, 2004

**[Contents:]{.underline}**

**[Abstract of the Month]{.underline}: page 2**

Lidocaine Plus Naproxen for Endometrial Sampling Pain: POEM

[From your colleagues:]{.underline} page 3

From George Gilson: 80% of patients with gestational diabetes can be
treated effectively with glyburide.

**From Anne Girling**: Stomach upset instead of crushing substernal
chest pain: Women's cardiovascular Sx

**From Steve Holve:** IHS Child Health Notes -- June, July

**From Jennifer Retsinas:** Do you use e-mail with your patients? If so,
you may want a few style points for caution

**From Ros Singleton:** 17th Annual IHS Research Conference April 29-May
1, 2005

**[Hot Topics:]{.underline}**

**Obstetrics:** **page 4**

Aberdeen Area Infant Mortality Study (AAIMS) now available on the MCH
web page; Can mandatory second opinions lower cesarean section rates?
Metformin, Diet/Exercise Comparable at Cutting Diabetes Risk in Women
With GDM; Hypoglycemic events are common during treatment in gestational
diabetic pregnancies; AFI may cause more interventions by labeling twice
as many at-risk pregnancies as having oligohydramnios than with the
single deepest pocket technique; Racial/Ethnic Trends in Fetal Mortality
\-\-- United States, 1990---2000, CDC; Acyclovir Can Reduce Genital
Herpes Recurrence at Delivery; Vertical Incisions for Cesarean Delivery
in Obese Patients; Diminishing Racial Disparities in Neonatal Group B
Streptococcal Disease, 2003, CDC

**Gynecology**: **page 7**

Polycystic Ovary Syndrome More Prevalent in US Than Had Been Thought

**Child Health: page 8**

Emergency Contraception to Adolescents; Motivational Counseling improves
dental caries in children; Cigarette Use Among High School Students
\-\-- United States, 1991---2003, CDC

**Chronic Illness and Disease**: **page 8**

Continue Breast Cancer Screening After Age 65? **Liposuction:** Removing
20% of total body fat with liposuction does not improve the metabolic
abnormalities seen in obese women with and without impaired glucose
tolerance; Eliminating *H. pylori* doesn\'t reduce heartburn or reflux
symptoms; DVT and Pulmonary Embolism: Part I. Diagnosis; DVT and
Pulmonary Embolism: Part II. Treatment and Prevention;
Spondyloarthropathies; Metabolic Syndrome: Time for Action

[Features:]{.underline} page 9

**AFP: POEMS -** see #1 Abstract of the Month, #2 Osteoporosis**;**
Screening for Coronary Heart Disease: Recommendation Statement U.S.
PREVENTIVE SERVICES TASK FORCE

ACOG: Vaginal Birth After Previous Cesarean Delivery First-Trimester
Screening for Fetal Aneuploidy; Pain Relief During Labor

**AHRQ:** Less than half of older women who have suffered fractures due
to osteoporosis are treated properly to prevent further fractures;
Jaundice and feeding problems are not associated with short hospital
stay, as long as newborns are evaluated at 3 or 4 days of life; Studies
examine hospital mortality rates and long-term outcomes of very low
birth weight babies; Preventive Services Task Force issues 3 new
recommendations

**Breastfeeding:** The National Breastfeeding Campaign \-- Babies Were
Born to Be

**Domestic Violence:** New York City is largest American Indian Village:
Physical, sexual trauma, and HIV risk; Therapeutic Foster Care for the
Prevention of Violence

**Elder Care News:** Ten years\' experience with alendronate for
osteoporosis in postmenopausal women** **

**Frequently asked questions:** HIV - What are the latest screening and
treatment guidelines from the CDC ?

**Hormone Replacement Update**: Reducing Cardiovascular Risk Factors in
Postmenopausal Women through a Lifestyle Change Intervention

**Information Technology:** Behavioral health applications available:
All IHS-direct, tribal, and urban (I/T/U)

**International Health:** Adolescent related behaviors across five
countries

#### MCH Alert: Parents to help their daughters develop bone healthy habits

#### Medscape: Female Interstitial Cystitis: Chronic Pelvic Pain, Diagnosis and Misdiagnosis: CME

#### Office of Women's Health, CDC: Disparities in Maternal Health-Related Behaviors

Osteoporosis: Calcium Supplementation in Postmenopausal Women: Cochrane
Abstract; Strontium Reduces Risk of Vertebral Fracture: POEM

Patient Education: Metabolic Syndrome: What Is It and What Can I Do
About It?

Primary Care Discussion Forum: August 1, 2004 - **Adult Asthma;**
November 1, 2004: Violence against Native women

#### Barbara Stillwater, Alaska Diabetes Prevention and Control: Administration of Insulin Lispro Effective Alternative

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

#### Mammography Screening Among Low-Income Women

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

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

# [Abstract of the Month]{.underline}

**Lidocaine Plus Naproxen for Endometrial Sampling Pain: POEM**

**Clinical Question:** Do intrauterine lidocaine, oral naproxen, or
both, lead to better pain control for endometrial sampling?

**Setting:** Outpatient (primary care)

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

**Synopsis:** Oral analgesia is recommended frequently to decrease the
pain of endometrial sampling in the medical office. Intrauterine
anesthesia also is promising. In this study, 120 women undergoing
pipelle aspiration for endometrial sampling were randomized to one of
four groups: (1) local lidocaine plus oral naproxen; (2) lidocaine with
placebo oral analgesia; (3) placebo anesthesia (sterile saline) with
oral naproxen; or (4) both treatment placebos. Local lidocaine in a dose
of 5 mL of 2 percent solution was given via an 18-gauge angiocatheter
sheath. Syringe and sheath were left in place for three minutes and then
withdrawn. Naproxen sodium was given as a single 550-mg oral dose one
hour before the procedure.

Women rated their pain during the procedure on a 10-cm visual analog
scale. Mean pain scores were lower in the lidocaine plus naproxen group
than in the placebo group (4.6 versus 7.1, *P* \<.05), a clinically
relevant difference. Mean pain scores were intermediate and not
statistically different from placebo or combined treatment in the
lidocaine-only and naproxen-only groups (5.9 and 5.8, respectively).

**Bottom Line:** The combination of intrauterine lidocaine plus oral
naproxen sodium significantly decreases pain associated with endometrial
sampling in the medical office. (Level of Evidence: 1b)
<http://www.aafp.org/afp/20040615/tips/13.html>

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

Patients experience intense cramps / discomfort as the endometrial
device traverses the cervical canal. Any effort we can make to alleviate
that discomfort will serve our patients well, as this is can be one of
the more uncomfortable outpatient procedures we perform.

AI / AN facilities should explore ways to implement the above procedures
into their day to day practice guidelines. njm

## From your colleagues:

**[From George Gilson, Anchorage]{.underline}**

**80% of patients with gestational diabetes can be treated effectively
with glyburide.**\
OBJECTIVE: This study was undertaken to evaluate the effectiveness of
glyburide in patients with gestational diabetes who failed diet therapy.

METHODS: Patients who were beyond the first trimester and who failed to
achieve satisfactory glucose control with diet therapy were treated with
glyburide, at a starting dose of 2.5 mg daily. The dose was increased in
increments to a maximum of 20 mg/day. The main treatment outcome was
achievement of satisfactory glucose control, defined as a mean plasma
fasting glucose 90 mg % or less and mean 1-hour postprandial plasma
glucose determinations 135 mg % or less. Patients who failed to achieve
satisfactory control were treated with twice-daily doses of insulin.
RESULTS: During the period July 2001 through December 2002, we managed
197 patients with gestational diabetes. One-hundred twenty-four patients
responded to diet alone; 73 were treated with glyburide. Of the 73
patients, 59 (81%, 95% CI 76.4-85.6) achieved satisfactory glucose
control with glyburide; 44 women required 7.5 mg/day or less. Eleven of
the 59 women (19%) had macrosomic infants. Eight patients (11%)
experienced noticeable side effects related to glyburide; only 1 patient
discontinued treatment.

CONCLUSION: Approximately 80% of patients with gestational diabetes who
fail to respond to diet therapy can be treated effectively with
glyburide.

Kremer CJ, Duff P. Glyburide for the treatment of gestational diabetes.
Am J Obstet Gynecol. 2004 May;190(5):1438-9.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15167862>

**[From Anne Girling, Anchorage]{.underline}**

**Stomach upset instead of crushing substernal chest pain: Women's
cardiovascular Sx**

Here are some sites to offer to your patients that help explain some of
the different cardiovascular symptoms between females and males

<http://www.medem.com/MedLB/article_detaillb_for_printer.cfm?article_ID=ZZZ52GU3X9D&sub_cat=2008>

<http://www.4women.gov/pub/steps/Heart_Stroke.htm>

<http://www.bayeraspirin.com/press/releases/2000/womenssocietyrel.pdf>

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10682939&dopt=Abstract>

[http://www.skyaid.org/Skyaid%20Org/Medical/heart_disease_women.htm](http://www.skyaid.org/Skyaid Org/Medical/heart_disease_women.htm)

<http://www.framingham.com/heart/4stor_04.htm>

There is also a presentation on this topic by Dr. Beth Malasky form the
University of Arizona, Tucson, at the IHS Women's Health meeting in
Albuquerque, August 4-6, 2004

<http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#August2004>

**[From Steve Holve, Tuba City]{.underline}**

**IHS Child Health Notes**

**June**

<http://www.ihs.gov/MedicalPrograms/MCH/C/documents/ICHN604.doc>

**July**

<http://www.ihs.gov/MedicalPrograms/MCH/C/documents/ICHN704.doc>

**[From Jennifer Retsinas, Anchorage]{.underline}**

**Do you use e-mail with your patients? If so, you may want a few style
points for caution**

"Phones seem antagonistic these days, \[and\] I\'m not sure I can
process health stuff that quickly. With e-mail I can address issues when
I have the mental space. I have time to think and shape the question and
keep a file. And my doctor . . . helps me think things through. He has
really gotten to know me and my evolving circumstance.

--- A patient in our practice

Alexander Graham Bell invented the telephone in 1876, and within decades
it was impossible to imagine society without it. E-mail emerged in the
early 1970s, and today about 100 million Americans *. . ."*

Delbanco T, Sands DZ. Electrons in flight\--e-mail between doctors and
patients. N Engl J Med. 2004 Apr 22;350(17):1705-7.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15102994&dopt=Abstract>

or

NEJM Extract and Section Headings

<http://content.nejm.org/cgi/content/extract/350/17/1705>

Here is a second resource from MIEC, Liability Insurer

When using e-mail to communicate with patients: What physicians should
consider Request Special Report 24A, revised January 2004 for a Sample
agreement

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

**[From Ros Singleton, Anchorage]{.underline}**

**SAVE THE DATES 17th Annual IHS Research Conference April 29-May 1,
2005**

This is the [first time]{.underline} Annual IHS Research Conference was
held in Seattle... the [first time]{.underline} in connection with
another major Pediatric Conference and certainly must be [first
time]{.underline} for Peds - US and Canada and IHS to get
together....also [first time]{.underline} this Conference has been
scheduled this far in advance.
[[www.aap.org/nach]{.underline}](../www.aap.org/nach)

**[Hot Topics:]{.underline}**

**[Obstetrics]{.underline}**

**Aberdeen Area Infant Mortality Study (AAIMS) now available on the MCH
web page**

Leslie Randall, et al, present an [Audio and Powerpoint
Conference](http://www.uic.edu/sph/cade/mchepi/meetings/may2003/index.htm)
on infant mortality data from the Aberdeen Area
<http://www.ihs.gov/MedicalPrograms/MCH/M/Pr01.cfm#AAIMS>

**Can mandatory second opinions lower cesarean section rates?**

[INTERPRETATION:]{.underline} In hospitals applying this policy of
second opinion, 22 intrapartum caesarean sections could be prevented per
1000 deliveries, without affecting maternal or perinatal morbidity, and
without affecting mothers\' satisfaction with the care

Althabe F, et al Mandatory second opinion to reduce rates of unnecessary
caesarean sections in Latin America: a cluster randomised controlled
trial. Lancet. 2004 Jun 12;363(9425):1934-40.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15194252>

**Metformin, Diet/Exercise Comparable at Cutting Diabetes Risk in Women
With GDM**

Newly released data from the Diabetes Prevention Program (DPP) suggest
that either metformin or intensive lifestyle interventions are highly
effective in preventing the onset of type 2 diabetes mellitus (DM) in
women with a history of gestational diabetes mellitus (GDM). The
research was presented here at the 68th annual meeting of the American
Diabetes Association.

But in women who had children but no history of GDM, lifestyle
interventions were significantly more effective than metformin at
preventing or delaying type 2 DM, said Robert E. Ratner, MD, from the
MedStar Research Institute in Hyattsville, Maryland.

Knowler WC, et al Reduction in the incidence of type 2 diabetes with
lifestyle intervention or metformin. N Engl J Med. 2002 Feb
7;346(6):393-403.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11832527>

**Hypoglycemic events are common during treatment in gestational
diabetic pregnancies**

OBJECTIVE: The role of maternal hypoglycemia during pregnancy has not
yet been established. We sought to estimate the prevalence of
undiagnosed, asymptomatic hypoglycemic events that occur in diabetic
patients.

METHODS: All patients were evaluated using a continuous glucose
monitoring system for 72 consecutive hours. The continuous glucose
monitoring system measures in subcutaneous tissue interstitial glucose
levels within a range of 40-400 mg/dL every 5 minutes for a total of 288
measurements per day. All patients were instructed regarding diabetic
diet and assigned to pharmacological treatment as needed. Patients
documented the time of food intake, insulin or glyburide administration,
and all clinical hypoglycemic events. An asymptomatic hypoglycemic
episode was defined as more than 30 consecutive minutes of glucose value
below 50 mg/dL detected only by continuous glucose monitoring system
reading without patient awareness.

RESULTS: An evaluation of 82 patients with gestational diabetes was
performed; 30 were insulin-treated, 27 were managed by diet only, and 25
were patients treated with glyburide. For purposes of comparison, data
were obtained from 35 nondiabetic gravid women. Asymptomatic
hypoglycemic events were identified in 19 of 30 (63%) insulin-treated
patients and in 7 of 25 (28%) glyburide-treated patients. No
hypoglycemic events were identified in patients with gestational
diabetes mellitus treated by diet alone or in nondiabetic subjects. The
mean recorded hypoglycemic episodes per day was significantly higher in
insulin-treated patients (4.2 +/- 2.1) than in glyburide-treated
patients (2.1 +/- 1.1), P =.03. In insulin-treated patients, the
majority of the hypoglycemic events were nocturnal (84%), whereas in
glyburide-treated patients, episodes were identified equally by day and
night.

CONCLUSION: Our data suggest that asymptomatic hypoglycemic events are
common during pharmacological treatment in gestational diabetic
pregnancies. We speculate that this finding may be explained by
treatment modality rather than by the disease itself.

Yogev Y, Ben-Haroush A, Chen R, Rosenn B, Hod M, Langer O. Undiagnosed
asymptomatic hypoglycemia: diet, insulin, and glyburide for gestational
diabetic pregnancy. Obstet Gynecol. 2004 Jul;104(1):88-93.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15229005&dopt=Abstract>

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

Diabetes in pregnancy is one of the most common medical complications of
pregnancy in Native women. Conventional wisdom had suggested the
hypoglycemia was relatively uncommon in pregnancy due to extra adiposity
and the insulin resistant nature of the diabetes in pregnancy.

While that may be true for symptomatic hypoglycemia, Yogev et al
describe a remarkably high rate of asymptomatic hypoglycemic events
related to insulin therapy compared to glyburide and diet therapy alone.
While glyburide therapy has come into more common usage in pregnancy,
Indian Health system clinicians should still continue to counsel their
patients that glyburide is 'off label' for treatment in pregnancy. njm

**AFI may cause more interventions by labeling twice as many at-risk
pregnancies as having oligohydramnios than with the single deepest
pocket technique**

OBJECTIVE: To compare the amniotic fluid index (AFI) with the single
deepest pocket technique along with the other components of the
biophysical profile (BPP) in predicting an adverse pregnancy outcome.
METHODS: Prospective, randomized trial of amniotic fluid assessment by
AFI or single deepest pocket during a BPP. Cesarean delivery for fetal
distress was the primary outcome evaluated. RESULTS: The AFI was used in
273 pregnancies and the single deepest pocket in 264. The AFI
significantly increased the number of pregnancies labeled as
oligohydramnios, 102 women (38%) compared with 46 women (17%; P \<.001),
odds ratio (OR) = 2.84, 95% confidence interval 1.90-4.25 in the single
deepest pocket group. There was no difference in the number of women
with oligohydramnios in the AFI group, 16 of 102 (16%), undergoing a
cesarean delivery for fetal intolerance of labor compared with the
single deepest pocket group, 6 of 46 (13%; P =.676). More women with
normal fluid by the AFI method (AFI \> 5), 20 of 170 (12%), underwent a
cesarean delivery for fetal distress than the women with normal fluid by
the single deepest pocket technique (2 cm x 1 cm pocket present) group,
12 of 218 (6%; P =.037, OR = 2.22, 95% confidence interval 1.05-4.70).

CONCLUSION: The AFI offers no advantage in detecting adverse outcomes
compared with the single deepest pocket when performed with the BPP. The
AFI may cause more interventions by labeling twice as many at-risk
pregnancies as having oligohydramnios than with the single deepest
pocket technique.

Magann EF, Doherty DA, Field K, Chauhan SP, Muffley PE, Morrison JC.
Biophysical profile with amniotic fluid volume assessments. Obstet
Gynecol. 2004 Jul;104(1):5-10.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15228994&dopt=Abstract>

Editorial: Moore TR. Sonographic screening for oligohydramnios: does it
decrease or increase morbidity? Obstet Gynecol. 2004 Jul;104(1):3-4.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15228993&dopt=Abstract>

**Racial/Ethnic Trends in Fetal Mortality \-\-- United States,
1990---2000, CDC**

The findings in this report indicate substantial declines in late fetal
mortality for all populations (i.e., singleton and multiple deliveries
in all racial/ethnic populations) during 1990\--2000. The 23% decline
observed in late fetal mortality is similar to that reported for
neonatal mortality during the same period.

The findings also indicate that mortality among fetuses delivered at
20\--27 weeks\' gestation increased slightly during 1990\--2000. This
finding was consistent for all populations except multiples and AI/ANs.
To determine whether the lack of improvement in early fetal mortality
was restricted to earlier and less viable gestations, FMRs were
calculated separately for fetal deaths at 20\--23 and 24\--27 weeks. No
improvement in FMRs was reported for either group. In contrast, outcomes
among live-born infants delivered at 24\--27 weeks have improved.

Trends in the risk for early and late fetal death suggest that changes
in perinatal technologies (e.g., fetal imaging, prevention of perinatal
infections, effective treatment of maternal medical conditions such as
diabetes and chronic hypertension, and more aggressive management of
labor and delivery) might have had more of an impact on fetal survival
at later rather than earlier gestational ages. In addition, rates of
prenatal-care use increased substantially during the 1990s , and the
subsequent improved access to care also might have had more impact on
late rather than early fetal mortality (e.g., through the detection of
maternal, fetal, or placental abnormalities that might lead to a
live-born delivery). The lack of progress in reducing fetal mortality at
earlier gestational ages might be related to 1) poor understanding of
the factors associated with premature delivery and 2) limited
understanding of the causes of fetal death and the role of maternal,
fetal, and placental pathology.

Racial/ethnic disparities in fetal mortality persist. The risk for early
fetal mortality among non-Hispanic blacks was more than double that for
other racial/ethnic populations; the risk for late fetal mortality for
non-Hispanic blacks was approximately two thirds higher. Despite
substantial reductions in late fetal mortality among non-Hispanic blacks
during 1990\--2000, greater reductions must occur during the next decade
if the 2010 national health objective is to be achieved.

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5324a4.htm>

**Acyclovir Can Reduce Genital Herpes Recurrence at Delivery**

Prophylactic acyclovir therapy from the 36th week of pregnancy reduces
the risks of clinical HSV in the mother at delivery, cesarean delivery,
and asymptomatic viral shedding at delivery. Similar results were
noticed regardless of type of HSV disease and dosage of acyclovir.

Sheffield JS, et al. Acyclovir prophylaxis to prevent herpes simplex
virus recurrence at delivery: a systematic review. Obstet Gynecol
December 2003;102:1396-403.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14662233>

Vertical Incisions for Cesarean Delivery in Obese Patients

The rate of postoperative morbidity, including wound infections, is
highly increased among patients who are obese. Transverse incisions may
be more prone to infection when they are located in the moist folds of
the panniculus. However, these incisions may provide more secure wound
closure and reduce postoperative discomfort, resulting in earlier
mobility and fewer respiratory complications. Vertical incisions provide
improved surgical access and may be less prone to infection. Wall and
colleagues studied the rate of postoperative wound complications with
transverse and vertical incisions in obese women who were undergoing
their first cesarean delivery.

The authors used hospital records to identify and assess women with a
body mass index (BMI) of 35 or greater before pregnancy who were
undergoing a primary cesarean delivery. Skin incisions were classified
as transverse or vertical, and variables such as maternal age,
gestational age at delivery, smoking history, indications for cesarean
delivery, blood loss, operative time, and complications of pregnancy and
delivery were recorded. The outcome of interest was any wound
complication, further divided into infectious and noninfectious
etiologies.

Data were available for 239 mothers, about two thirds of whom were
white. The average age was 28 years. The women had high rates of
preeclampsia, diabetes, and hypertension. The groups were comparable
with regard to many characteristics, but those undergoing vertical
incisions were significantly heavier (BMI 44.1 ± 6 compared with 41.2 ±
4.8) and significantly more likely to have wound complications despite
greater use of subcutaneous sutures or drains.

The overall incidence of wound infection was 12.1 percent. Women with
wound infections had longer hospital stays and an increased rate of
endometritis. Wound complications were recorded in 20 of 213 (9.4
percent) transverse incisions and nine of 26 (34.6 percent) vertical
incisions. Infectious wound complications were recorded in 7 percent of
transverse incisions compared with 19 percent of vertical incisions; the
rates of noninfectious complications were 2 and 15 percent,
respectively. These differences were all highly significant
statistically.

On statistical analysis, the only factors independently associated with
wound complications were vertical skin incision and postpartum
endometritis. A high preoperative hematocrit level was protective
against wound complications. Other factors, including smoking status,
use of subcutaneous drains or sutures, operative time, or use of
regional anesthesia, were not independently associated with wound
complications.

The authors conclude that primary cesarean delivery in severely obese
patients is frequently complicated by wound infections. However,
contrary to expectations, infections in vertical incisions appear to be
associated with higher rates of wound complications than infections in
transverse incisions

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14672469>

**Diminishing Racial Disparities in Neonatal Group B Streptococcal
Disease, 2003, CDC**

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5323a2.htm>

**[Gynecology]{.underline}**

**Polycystic Ovary Syndrome More Prevalent in US Than Had Been Thought**

The prevalence rates of PCOS for Black and White women were 8.0 and
4.8%, respectively, not significantly different. These data from a large
representative unselected population support the concept that PCOS is
the most common endocrine abnormality of reproductive-aged women in the
United States. Azziz R, et al The prevalence and features of the
polycystic ovary syndrome in an unselected population. J Clin Endocrinol
Metab. 2004 Jun;89(6):2745-9.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15181052>

**[Child Health]{.underline}**

**Emergency Contraception to Adolescents**

A position paper published by the Society for Adolescent Medicine in the
July 2004 issue of the Journal of Adolescent Health. In this paper,
\"emergency contraception\" refers to the use of estrogen- and
progestin-containing pills (combination emergency contraceptive pills,
or ECPs) or levonorgestrel-only pills (progestin-only ECPs) that are
taken after unprotected or underprotected intercourse to prevent
pregnancy. The paper presents background information on ECPs and
adolescents and discusses ECP provision, accessibility, and advocacy.

Gold M, Sucato GS, Conard LE, et al. 2004. Provision of emergency
contraception to adolescents. Position Paper of the Society for
Adolescent Medicine. American Journal of Adolescent Health 35(1):66-70.
[[http://www.adolescenthealth.org/html/publications.html]{.underline}](http://www.adolescenthealth.org/html/publications.html)

**Motivational Counseling improves dental caries in children**

\"Motivational interviewing, a brief form of counseling, presents
promise in working with parents of young children to prevent caries in
those children, especially children at high risk for developing the
disease,\"

The MI approach used for this study focused on establishing rapport and
need, discussing options, and using strategies that structure and
reinforce change.

\* After 1 year, children in the experimental group had .71 carious
surfaces while those in the control group had 1.91 carious surfaces.

The authors conclude that \"results of the study, at this time the only
clinical dental study using MI counseling, suggest that MI counseling
has an effect on children\'s health that is greater than the effect of
traditional health education.\"

Weinstein P, Harrison R, Benton T. 2004. Motivating parents to prevent
caries in their young children: One-year findings. Journal of the
American Dental Association 156(6):731-738.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15270155>

**Cigarette Use Among High School Students \-\-- United States,
1991---2003, CDC**

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5323a1.htm>

**[Chronic disease and Illness]{.underline}**

Continue Breast Cancer Screening After Age 65?

Breast cancer is most commonly found in women 65 years or older. The
increasing number of women in this age group means an absolute increase
in new breast cancer cases. Because studies looking at the efficacy of
mammography as a screening test for breast cancer have for the most part
included younger women, recommendations for screening mammography in
women at or older than age 65 are unclear. The nature of breast cancer
in this population and the morbidity associated with treatment influence
the potential value of screening. Analyzing cost-effectiveness and
considering expected benefits, harms, and costs reduced the value of
screening women under age 65, but the analysis of older women has been
less clear. The U.S. Preventive Services Task Force (USPSTF)
systematically reviewed published cost-analyses that evaluate breast
cancer screening in women.

Life-years gained and costs per person were determined for different age
groups. Screening for breast cancer after age 65 was compared with
cessation of screening at that age. Ten studies were available that
included data about older women. The results of the studies were fairly
consistent, demonstrating that biennial screening after age 65 resulted
in incremental costs of about \$34,000 to \$88,000 per life-year saved
compared with stopping screening at age 65. It also was found to be
cost-effective to screen women after age 65 if they previously had not
been screened on a regular basis. The studies that looked specifically
at comorbid conditions found that screening reduces breast cancer
mortality in all but the sickest women.

This USPSTF review suggests that it is cost-effective to screen women 65
years and older for breast cancer every two years. However, screening is
more costly among sicker women, who are likely to have a life expectancy
similar to that of an 85-year-old woman (about five years).

Further analysis of women\'s preferences, clarification of the natural
history of tumors in older women, the value of diagnosing ductal
carcinomas, potential needless distress from false-positive
examinations, and the development of new adjuvant therapies need to be
considered before concluding that the benefits of screening outweigh the
harms.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14623621>

**Liposuction:** **Removing 20% of total body fat with liposuction does
not improve the** metabolic abnormalities seen in obese women with and
without impaired glucose tolerance.

[CONCLUSIONS]{.underline}: Abdominal liposuction does not significantly
improve obesity-associated metabolic abnormalities. Decreasing adipose
tissue mass alone will not achieve the metabolic benefits of weight loss
Klein S, et al Absence of an effect of liposuction on insulin action and
risk factors for coronary heart disease. N Engl J Med. 2004 Jun
17;350(25):2549-57\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15201411>

**Eliminating *H. pylori* doesn\'t reduce heartburn or reflux symptoms**

CONCLUSIONS: H pylori infection is associated with a slightly increased
prevalence of heartburn but not reflux. Treatment to eradicate H pylori
has no net benefit in patients with heartburn or gastro-oesophageal
reflux. Harvey RF, et al Randomised controlled trial of effects of
Helicobacter pylori infection and its eradication on heartburn and
gastro-oesophageal reflux: Bristol helicobacter project. BMJ. 2004 Jun
12;328(7453):1417.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15126313>

**DVT and Pulmonary Embolism: Part I. Diagnosis**

<http://www.aafp.org/afp/20040615/2829.html>

**DVT and Pulmonary Embolism: Part II. Treatment and Prevention**

<http://www.aafp.org/afp/20040615/2841.html>

**Spondyloarthropathies**

<http://www.aafp.org/afp/20040615/2853.html>

**Metabolic Syndrome: Time for Action**

<http://www.aafp.org/afp/20040615/2875.html>

##### Features

## American Family Physician\*\*

###### 

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

###### See 

###### #1 Abstract of the Month

###### #2 Osteoporosis

Screening for Coronary Heart Disease: Recommendation Statement

U.S. PREVENTIVE SERVICES TASK FORCE

Summary of Recommendations

• The USPSTF recommends against routine screening with resting
electrocardiography (ECG), exercise treadmill test (ETT), or
electron-beam computerized tomography (EBCT) scanning for coronary
calcium for either the presence of severe coronary artery stenosis (CAS)
or the prediction of coronary heart disease (CHD) events in adults at
low risk for CHD events. **D recommendation.**

The USPSTF found at least fair evidence that ECG or ETT can detect some
asymptomatic adults at increased risk for CHD events independent of
conventional CHD risk factors (see Clinical Considerations), and that
ETT can detect severe CAS in a small number of asymptomatic adults.
Similar evidence for EBCT is limited. In the absence of evidence that
such detection by ECG, ETT, or EBCT among adults at low risk for CHD
events ultimately results in improved health outcomes, and because
false-positive tests are likely to cause harm, including unnecessary
invasive procedures, overtreatment, and labeling, the USPSTF concluded
that the potential harms of routine screening for CHD in this population
exceed the potential benefits.

• The USPSTF found insufficient evidence to recommend for or against
routine screening with ECG, ETT, or EBCT scanning for coronary calcium
for either the presence of severe CAS or the prediction of CHD events in
adults at increased risk for CHD events. **I recommendation.**

The USPSTF found inadequate evidence to determine the extent to which
the added detection offered by ECG, ETT, or EBCT (beyond that obtained
by ascertainment of conventional CHD risk factors; see Clinical
Considerations) would result in interventions that lead to improved
CHD-related health outcomes among adults at increased risk for CHD
events. Although there is limited evidence to determine the magnitude of
harms from screening this population, harms from false-positive tests
(i.e., unnecessary invasive procedures, overtreatment, and labeling) are
likely to occur. As a result, the USPSTF could not determine the balance
between benefits and harms of screening this population for CHD.

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

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

##### ACOG

**Vaginal Birth After Previous Cesarean Delivery**

Practice Bulletin, NUMBER 54, JULY 2004

**Summary of Recommendations**

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

-   Most women with one previous cesarean delivery with a low-transverse
    incision are candidates for VBAC and should be counseled about VBAC
    and offered a trial of labor.

-   Epidural anesthesia may be used for VBAC.

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

-   Women with a vertical incision within the lower uterine segment that
    does not extend into the fundus are candidates for VBAC.

-   The use of prostaglandins for cervical ripening or induction of
    labor in most women with a previous cesarean delivery should be
    discouraged.

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

-   Because uterine rupture may be catastrophic, VBAC should be
    attempted in institutions equipped to respond to emergencies with
    physicians immediately available to provide emergency care.

-   After thorough counseling that weighs the individual benefits and
    risks of VBAC, the ultimate decision to attempt this procedure or
    undergo a repeat cesarean delivery should be made by the patient and
    her physician. This discussion should be documented in the medical
    record.

-   Vaginal birth after a previous cesarean delivery is contraindicated
    in women with a previous classical uterine incision or extensive
    transfundal uterine surgery.

**First-Trimester Screening for Fetal Aneuploidy**

**Committee Opinion Number 296, July 2004**

ABSTRACT: First-trimester screening for chromosomal abnormalities offers
potential advantages over second-trimester screening. Studies in the
1990s demonstrated an association between chromosomal abnormalities and
the ultrasonographic finding of abnormally increased nuchal translucency
(an echo-free area at the back of the fetal neck) between 10 and 14
weeks of gestation. First-trimester screening using nuchal translucency,
free ß-hCG, and pregnancy-associated plasma protein-A has comparable
detection rates and positive screening rates for Down syndrome as
second-trimester screening using 4 serum markers (alpha-fetoprotein,
ß-hCG, unconjugated estriol, and inhibin-A). Although first-trimester
screening for Down syndrome and trisomy 18 is an option, it should be
offered only if certain criteria can be met.

Non-ACOG members

<https://www.acog.com/from_home/publications/press_releases/nr06-30-04.cfm>

ACOG members

<http://www.acog.org/publications/committee_opinions/co296.cfm>

**Pain Relief During Labor: Committee Opinion, Number 295, July 2004**

ABSTRACT: Pain management should be provided whenever medically
indicated. The American Society of Anesthesiologists (ASA) and the
American College of Obstetricians and Gynecologists (ACOG) believe that
women requesting epidural analgesia during labor should not be deprived
of this service based on their insurance or inadequate nursing
participation in the management of regional analgesic modalities.
Furthermore, in an effort to allow the maximum number of patients to
benefit from neuraxial analgesia, ASA and ACOG believe that labor nurses
should not be restricted from participating in the management of pain
relief during labor.

ACOG members

<http://www.acog.org/publications/committee_opinions/co295.cfm>

##### AHRQ

**Less than half of older women who have suffered fractures due to
osteoporosis are treated properly to prevent further fractures**

<http://www.ahrq.gov/research/may04/0504RA2.htm#head1>

**Jaundice and feeding problems are not associated with short hospital
stay, as long as newborns are evaluated at 3 or 4 days of life**

<http://www.ahrq.gov/research/may04/0504RA8.htm#head1>

**Studies examine hospital mortality rates and long-term outcomes of
very low birth weight babies**

<http://www.ahrq.gov/research/may04/0504RA10.htm#head3>

**Preventive Services Task Force issues 3 new recommendations:**

[Screening for hepatitis C virus
infection](http://www.ahrq.gov/clinic/uspstf/uspshepc.htm)

[Family and intimate partner
violence](http://www.ahrq.gov/clinic/uspstf/uspsfamv.htm).

[Fluoride supplements to prevent cavities in preschool
children](http://www.ahrq.gov/clinic/uspstf/uspsdnch.htm)

<http://www.ahrq.gov/research/may04/0504RA34.htm#head1>

##### Breastfeeding

**The National Breastfeeding Campaign \-- Babies Were Born to Be
Breastfed**

aims to promote breastfeeding among first-time parents (mothers and
fathers) who would not typically breastfeed their infants. The overall
goal is to increase the proportion of mothers who breastfeed their
babies in the early postpartum period to 75% and during the 6-month
period following delivery to 50% by the year 2010. More information:
[[http://www.4woman.gov/breastfeeding]{.underline}](http://www.4woman.gov/breastfeeding)

**[Domestic Violence]{.underline}**

**New York City is largest American Indian Village: Physical, sexual
trauma, and HIV risk**

A study focusing on American Indians in the New York City area found
that urban American Indian women endure extremely high rates of physical
and sexual trauma and may engage in risky behaviors that place them at
high risk for HIV. Overall, 52 percent of 155 women surveyed reported
physical or sexual abuse, or both. In addition, 91 percent of the women,
all living in

New York or New Jersey, had engaged in at least one lifetime risky
sexual behavior and 7 percent said they had injected illegal drugs,
according to lead authors Jane Simoni and Karina

Walters of the University of Washington.

The study was funded by the New York City Department of Health and was
part of a comprehensive assessment of HIV risk behaviors and prevention
needs among American Indians in the metropolitan New York area. Data on
American Indian men are being analyzed. New York City has the largest
urban Indian population in the United States, surpassing Tulsa and Los
Angeles in the past decade.

Simoni JM, Sehgal S, Walters KL. Triangle of risk: urban American Indian
women\'s sexual trauma, injection drug use, and HIV sexual risk
behaviors. AIDS Behav. 2004 Mar;8(1):33-45.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15146132>

**Therapeutic Foster Care for the Prevention of Violence**

To assess the effectiveness of therapeutic foster care programs in
preventing violent behavior among youths who are unable to live at home,
the Task Force on Community Preventive Services reviewed the scientific
literature concerning two interventions:

(1)Therapeutic foster care for reduction of violence by children with
severe emotional disturbance. This intervention involved programs in
which clusters of foster-parent families cooperated in the care of such
children. The Task Force found insufficient evidence to determine the
effectiveness of this intervention.\
(2) Therapeutic foster care for the reduction of violence by chronically
delinquent adolescents. This intervention involved short-term programs
in which program personnel collaborated closely\
and daily with foster families caring for such adolescents. The Task
Force recommends this intervention as effective. The report briefly
describes how the reviews were conducted,\
provides additional information about the findings, and provides
information that might help communities in applying the intervention
locally

<http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5310a1.htm>

**[Elder Care News]{.underline}**

**Ten years\' experience with alendronate for osteoporosis in
postmenopausal women **

This study reports on the ten year follow-up of 247 postmenopausal women
with osteoporosis treated with the bisphosphonate agent alendronate
(Fosamax).  They were initially part of a larger cohort in a placebo
controlled treatment trial reported at 3 years.  This group of women has
been followed to evaluate for continued response to alendronate and
adverse effects.  Women were divided into three branches, those who had
5 years of treatment and discontinued, those treated with 5mg a day for
10 years, and those treated for 10mg a day for 10 years.

 

-   Bone mineral density (BMD) increased in a dose-dependent fashion
    throughout the treatment period for those treated for 10 years,
    remaining within the normal range.

-   Those women treated for 5 years and discontinued preserved some of
    their BMD gains after discontinuation but did not further increase. 

-   No insufficiency fractures or fracture malunions were reported,
    indicating that the bone developed in the presence of  the
    bisphosphonate was functioning normally.

-   Adverse effects attributable to the medication were minimal and did
    not differ between the three groups.

 

We already know from a number of studies that bisphosphonate treatment
for women with low BMD (T-score of less than 2.5 or two standard
deviations below the mean for healthy young women) is effective in
preventing fracture.   This descriptive study suggests that long term
treatment with alendronate is safe and effective and that we can carry
treatment out at least ten years without concern.

[Bone HG et al.  Ten years\' experience with alendronate for
osteoporosis in postmenopausal women. N Engl J Med 2004 Mar 18,
350:1189-99.](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15028823)

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15028823>

**[Frequently asked questions]{.underline}**

Q. What are the latest screening and treatment guidelines from the CDC ?

A. The HHS AIDS info site has the [updated HIV
information.](http://www.aidsinfo.nih.gov/)

<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHfaq.asp#HIVscreen>

**[Hormone Replacement Update]{.underline}**

**Reducing Cardiovascular Risk Factors in Postmenopausal Women through a
Lifestyle Change Intervention**

CONCLUSIONS: Lifestyle change interventions may be an effective means
for reducing cardiovascular risk in obese, sedentary, postmenopausal
women. However, greater attention should be devoted to the maintenance
of these positive lifestyle changes.

Carels RA, Darby LA, Cacciapaglia HM, Douglass OM. Reducing
cardiovascular risk factors in postmenopausal women through a lifestyle
change intervention. J Womens Health (Larchmt). 2004 May;13(4):412-26.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15186658>

# [Information Technology]{.underline}

**Behavioral health applications available: All IHS-direct, tribal, and
urban (I/T/U)**

-Patch two of the Behavioral Health System (BHS v3.0)

-Patch one of the behavioral health GUI (Patient Chart v1.41)

 

The behavioral health applications are available for use by all
IHS-direct, tribal, and urban (I/T/U) behavioral health programs.  They
were developed with input by I/T/U behavioral health providers and are
intended to enhance continuity of care and case management, support
practice management, and assist in meeting reporting requirements and
standards of care.   The BH GUI resides within the IHS Patient Chart
framework and provides a "point and click" Windows-like front-end to the
very robust existing RPMS behavioral health application, Behavioral
Health System, v3.0.  

Patches to applications are released periodically to address minor
problems and requests for enhancements as identified by the users. 
Patch release notices are sent to all RPMS site managers who are advised
to notify users that a patch has been installed.  All of the
modifications included in the patches are contained within the attached
official release notices.  Some of the changes that will have the
greatest impact for users are the addition of new security features to
increase the privacy and security of clinical information, the new RPMS
IPV/DV Screening Exam, and several changes in data entry, labeling and
navigation designed to enhance usability.  

<http://www.ihs.gov/Cio/BH/index.asp> or contact
<Denise.Grenier@na.ihs.gov>

#### [International Health]{.underline}

ADOLESCENT-VIOLENCE-RELATED BEHAVIORS ACROSS FIVE COUNTRIES

\"In this cross-national comparison of violence-related behaviors in
adolescents, our results show that youth in 5 different countries
behaved remarkably similarly with respect to violent behaviors,\" state
the authors of an article published in the June 2004 issue of Archives
of Pediatric and Adolescent Medicine. The authors state that violent
behavior among adolescents is a significant problem worldwide and that
three developed countries, Israel, France, and Norway, now join the
United States as nations in which firearms are the second leading
mechanism of death among

15- to 24-year-olds. However, the literature on violent behavior among
adolescents outside the United States is relatively limited. The study
described in this article used information from the World Health
Organization-coordinated cross-national Study of Health Behavior in
School-Aged Children to derive country-specific distributions of certain
violent behaviors and to assess country-specific explanatory factors,
which then provided a basis for comparing violence-related behaviors in
five developed countries (Ireland, Israel, Portugal, Sweden, and the
United States).

The analysis is based on cross-national, school-based surveys conducted
during the 1997-1998 school year of students at mean ages of 11.5, 13.5,
and 15.5 years. The numbers of participating students, as well as the
response rate, for each country are as follows: Ireland: 4,398 (response

rate: 74%), Israel: 5,054 (response rate: 75.0%), Portugal: 3,721
(response rate: 94.0%), Sweden: 3,802 (response rate: 91.7%), and United

States: 5,168 (response rate: 87.0%). The main outcome measures were
frequency of physical fighting, bullying, weapon carrying, and fighting
injuries in relation to other risk behaviors and characteristics in home
and school settings.

The authors found that

\* The frequencies of any fighting, frequent fighting, weapon carrying,
and fighting injuries were remarkably similar across countries.

\* The frequency of bullying ranged from 14.8% in Sweden to 42.9% in
Israel for students who bullied once or more per school term.

\* Violence-related behaviors often occurred together in adolescents
cross-nationally.

\* Fighting was associated with smoking, alcohol use, feeling irritable
or bad tempered, having been bullied, and not living with the father.

The authors concluded that \"These findings are particularly important
to today\'s climate, in which violent behavior in youth has increased to
epidemic proportions and high-publicity school shootings in the United
States and recently in Germany have raised public concern about teenage
violence even further.\"

Smith-Khuri E, Iachan R, Scheldt PC. 2004. A cross-national study of
violence-related behavior in adolescents. Archives of Pediatric and
Adolescent Medicine 158(6):539-344.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15184216>

#### 

#### [MCH Alert]{.underline}

**PARENTS TO HELP THEIR DAUGHTERS DEVELOP BONE-HEALTHY HABITS**

The Powerful Bones, Powerful Girls campaign promotes optimal bone health
in girls ages 9 to 12 in an effort to reduce their risk of developing
osteoporosis later in life. The campaign Web site for parents, which is
part of the National Bone Health Campaign, offers suggestions on ways
parents can integrate healthy behaviors into their daughter\'s social
lifestyles. The Web site provides information on calcium and physical
activity, and also includes the Powerful Bones Toolbox. The toolbox
contains recipes and shopping lists, explanations of nutritional
requirements, examples of weight-bearing physical activities, and
question-and-answer sections providing parents with an array of
resources.

The Web site is available at

[[http://www.cdc.gov/powerfulbones/parents/index.html]{.underline}](http://www.cdc.gov/powerfulbones/parents/index.html).

#### [Medscape\*]{.underline}

######### Female Interstitial Cystitis: Chronic Pelvic Pain, Diagnosis and Misdiagnosis: CME

<http://www.medscape.com/viewprogram/3070?src=mp>

######### 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.

**[Office of Women's Health, CDC]{.underline}**

**Disparities in Maternal Health-Related Behaviors**

Selected States, Pregnancy Risk Assessment Monitoring System (PRAMS),
2000---2001 on four behaviors (smoking during pregnancy, alcohol use
during pregnancy, breastfeeding initiation, and use of the infant back
sleep position) for which such disparities have been identified
previously.

Overall, the prevalence of smoking during pregnancy ranged from 9.0% to
17.4%, prevalence of alcohol use during pregnancy ranged from 3.4% to
9.9%, prevalence of breastfeeding initiation ranged from 54.8% to 89.6%,
and use of the back sleep position for infants ranged from 49.7% to
74.8%.

States can use PRAMS data to identify populations at greatest risk for
maternal behaviors that have negative consequences for maternal and
infant health and to develop policies and plan programs that target
populations at high risk. The results from this report can aid state and
national agencies in creating more effective public health policies and
programs. The data described in this report should serve as a baseline
that states can use to measure the impact of policies and programs on
eliminating these health disparities

<http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5304a1.htm>

**[Osteoporosis]{.underline}**

**Calcium Supplementation in Postmenopausal Women: Cochrane Abstract**

Calcium supplementation has a beneficial effect on bone density and may
reduce vertebral fractures. It has no clear effect on nonvertebral
fractures, although the number of patients studied may be too small to
predict this outcome.

<http://www.aafp.org/afp/20040615/cochrane.html>

**Strontium Reduces Risk of Vertebral Fracture: POEM**

**Clinical Question:** Does strontium ranelate improve clinical outcomes
in patients with postmenopausal osteoporosis and at least one previous
vertebral fracture?

**Bottom Line:** The use of strontium ranelate prevents one symptomatic
vertebral fracture for every 17 postmenopausal women with a history of
vertebral fracture who take it for three years. (Level of Evidence: 1b)

<http://www.aafp.org/afp/20040615/tips/12.html>

**[Patient Information]{.underline}**

**Metabolic Syndrome: What Is It and What Can I Do About It? AFP**

<http://www.aafp.org/afp/20040615/2887ph.html>

**[Primary Care Discussion Forum]{.underline}**

## August 1, 2004        Adult Asthma 

On August 1, 2004, thanks to Charles (Ty) Reidhead, Whiteriver, we will
start an Adult Asthma Discussion.   This topic is a special request from
the Council of Clinical Directors.

Ty is the IHS Internal Medicine Chief Clinical Consultant and will
moderate a discussion that uses evidence based practice to improve
patient outcomes in Indian Country for this common problem.

 

Also see the [summary of the AAP, Indian Health - Special Interest Group
Discussion of Childhood
Asthma.](http://www.aap.org/nach/asthmasummary.htm)
<http://www.ihs.gov/MedicalPrograms/MCH/M/PCdiscForum.asp#aaped>

Contact Steve Holve for questions about the AAP Indian Health Special
Interest Group, <steve.holve@tcimc.ihs.gov> or 928 283 2679

**November 1, 2004: Violence against Native women**

Moderator: Terry Cullen

This discussion will include the scope of violence against Native women,
tools for patient evaluation, best practice policies and procedures,
plus ideas about available resources.

NB: To subscribe to the **Primary Care Discussion Forum**, please go the
site below and click the word 'subscribe' in the first paragraph,
[[www.ihs.gov/MedicalPrograms/MCH/M/MCHdiscuss.asp]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdiscuss.asp)

or contact me, <nmurphy@anmc.org>

**[Barbara Stillwater, Alaska Diabetes Prevention and
Control]{.underline}**

**Administration of Insulin Lispro Effective Alternative**\
No significant difference in glycemic excursion with respect to the time
of lispro dose.\
\
Postprandial administration of insulin lispro (IL), a fast-acting human
insulin analogue, in pregnant women with diabetes produces a similar
glycemic excursion profile to preprandial injections. According to a
recent British study, this finding suggests that postprandial
administration may serve as an effective alternative for diabetic women
who experience nausea or vomiting during pregnancy.

At least 50% of European women are estimated to experience nausea and
vomiting during the first 12 to 16 weeks of pregnancy, and the problem
can persist throughout later stages of pregnancy for a subset of women.
This creates an important concern for diabetic women who take insulin
before meals, as they may be at risk for hypoglycemia if vomiting occurs
soon after the meal.

Take Lispro after a meal so that if nausea or vomiting occurs,
hypoglycemia avoided

Nine pregnant diabetic women regularly treated with IL were asked to
bring their usual lunch to an antenatal day unit on 4 separate visits.
The participants were assigned to receive IL 5 minutes before eating on
2 random visits and immediately after finishing the meal on the other 2
occasions. Maternal glycemia was monitored before starting the meal and
at 15-minute intervals for 3 hours following the meal. Glucose
excursions were calculated by subtracting the preprandial glucose level
from the values at each time point.

A total of 27 meals were completed during the study. No significant
difference was detected between the mean fasting blood glucose
associated with preprandial and postprandial IL administration (5.8 vs.
5.7 mmol/L, t=.03). Furthermore, no significant differences in glucose
excursion levels were detected between preprandial and postprandial
administration at any of the time points analysed. None of the women
experienced hypoglycemic attacks during the study, and no evidence of
fetal compromise was detected.

Although the study did not include women with nausea and vomiting, the
researchers suggest that the findings can be extrapolated to the
clinical management of women who do experience the problem. \"Our data
presented demonstrates that there is no significant difference in
glycemic excursion with respect to the time of IL dose and therefore we
recommend the postprandial administration of IL as an option in the
management of pregnant women with diabetes,\" they conclude. J Obstet
Gynaecol 2004;24:4:382-386

Carr KJ, Idama TO, Masson EA, Ellis K, Lindow SW A randomised controlled
trial of insulin lispro given before or after meals in pregnant women
with type 1 diabetes\--the effect on glycaemic excursion. J Obstet
Gynaecol. 2004 Jun;24(4):382-6\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15203576>

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

**Mammography Screening Among Low-Income Women**

<http://www.ihs.gov/MedicalPrograms/MCH/W/WHcancer.asp#Mammo>

There are several upcoming **Conferences**

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

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

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

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

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

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

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

### **[Save the dates]{.underline}**

**2004 Native Maternity Care and Women's Health meeting: Prevention in
Women's Health**

August 4-6, 2004

Albuquerque, New Mexico

Great CEU /CME, plus good networking for leaders of Women's Health / MCH

Contact Neil Murphy for questions <nmurphy@anmc.org>

<http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#August2004>

**Indian Health Service Health Summit**

**"Healthier Indian Communities through Partnership and Prevention"**

September 22-24, 2004

Washington, D.C.

Sponsor: Health Promotion/Disease Prevention (HP/DP)

<http://www.ihs.gov/HPDP/Documents/IHS_Indian_Health_Summit.doc>

**20th Annual Midwinter Conference**

-   For providers caring for Native women and children

-   February 25 - 27, 2005 **Final dates**

-   Telluride, CO
    <http://www.ihs.gov/MedicalPrograms/MCH/M/ConfDnlds/Tellurideagenda10-2004.doc>

-   Contact Alan Waxman <awaxman@salud.unm.edu>

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

The **June 2004 OB/GYN CCC Corner** is available at:

<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/4C61404.doc>

**[Contents:]{.underline}**

**[Abstract(s) of the Month]{.underline}: page 3**

1.) Improving competency in the management of shoulder dystocia with
simulation training

2.) Middle-aged women, regardless of ovarian function, experienced
greater sleep disturbance than do younger controls

[From your colleagues:]{.underline} page 4

From Frank Anderson: Sudden death was the presenting scenario in 75% of
ectopic deaths

**From Donna Brown:** Tobacco use: 1 / 10 deaths worldwide and 5 million
deaths / yr

From Tom Burke: Practical abnormal pap smear and colposcopy guidelines
for both the non-colposcopist and colposcopist

**From Sandra Cook:** Is membrane stripping associated with abruption
placenta?

**From Terry Cullen:** Intimate Partner Violence: Funding available to
Indian Health sites

**From Barbara Fine:** Let me know about your PHN program or individual
PHNs success(s) or achievements; Hearts N' Parks Program: Helps all ages
adopt heart health behaviors

**From Sandra Haldane:** NANAINA Summit 2004; CHILD Profile Statewide
Conference(s)

**From Yolanda Meza:** Centering or group prenatal visits: Exciting
prenatal management program

**From Chuck North:** Making Evidence-base Medicine Doable in Everyday
Practice; Understanding the Risks of Medical Interventions;
Evidence-based Obstetrics & Gynecology  

**From Richard Olson**: American Indian & Alaska Native Health Care
Needs: Papers sought\
**From Judy Thierry:** Helping Pregnant Women Quit Smoking: Progress and
Directions; Interested in SIDS / IMR? Consider attending this....
Prenatal classes : What are you doing?

**[Hot Topics:]{.underline}**

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

New Perinatology Corner Module available: Syphilis in Pregnancy; Glucose
challenge thresholds \> than 180 mg/dL are NOT DIAGNOSTIC for GDM:
Predictive value for GDM only 50%; Noninvasive Prenatal Testing Cuts
Amniocentesis Use; Vitamin C Reduces Risk of Gestational Diabetes; Oral
Misoprostol an Inexpensive Alternative for Induction of Labor; Physician
characteristics are a major determinant of cesarean delivery; Closure of
subcutaneous fat during cesarean delivery decreases wound disruption;
Fetal Alcohol Syndrome \-\-- Alaska, Arizona, and Colorado; Cervical
cerclage shown not to reduce preterm delivery; Genetic variation linked
to gestational diabetes; 12 suggestions for practice for all personnel
in an obstetric--neonatal unit

**Gynecology:** **page 11**

Test your women\'s health IQ\...; Does Hysterectomy Have an Impact on
Sexuality? Self testing for HPV DNA may be sufficiently sensitive for
the detection of high-risk HPV; Evidence for the management of
mastalgia; Mifepristone for the Treatment of Uterine Leiomyomata:
Systematic Review; USPSTF recommends against routine screening for
ovarian cancer: D recommendation; Study finds that symptoms precede
diagnosis of ovarian cancer; Need some data on the health of women? Quiz
Answers from above

**Child Health:** **page 13**

Adolescent Risk Taking Behavior: Primary Forum Discussion Summary --
Donna Perry; Four causes of death account for 70 percent of deaths among
persons aged 10-24 years; Ways to measure the quality of health services
for children and adolescents; Bicycle Helmet Use by National Safe Kids;
Flu vaccine: New recommendations for children aged 6-23 mo health
workers

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

Disparities in Tobacco Use -- Alaska Natives; Aspirin and other NSAID
effective chemopreventive agents for breast cancer; Increased body
weight was associated with increased cancer death rates; Cigarette
Smoking Among Adults: Related to socioeconomic status; Influencing
Attitudes Toward Mammography Screening; Suicide and Attempted Suicide:
Entire MMWR dedicated to topic; Surgeon General Updates Report on Health
Effects of Smoking

[Features:]{.underline} page 15

**AFP:** POEMS: Breast Augmentation Unlikely to Affect Cancer
Identification; Labor in Water Is Effective Treatment for Slow Labor;
Use Single Course of Corticosteroids for PPROM; Ethinyl Estradiol /
Drospirenone (Yasmin): A Newer Oral Contraceptive; Over-the-Counter
Medications in Pregnancy; Diethylstilbestrol Exposure; Depression in
Later Life: A Diagnostic and Therapeutic Challenge; Prevention and
Treatment of Overweight in Children and Adolescents

**ACOG:** Diagnosis and Treatment of Gestational Trophoblastic Disease;
At-Risk Drinking and Illicit Drug Use: Ethical Issues in Obstetric and
Gynecologic Practice; Pregnancy, Airline Travel and Radiation Exposure

**AHRQ:** Hysterectomy results in better outcomes than medicine with
abnormal uterine bleeding; Cervical cancer screening every 3 yrs after
three or more normal Pap tests is a safe option; USPSTF: Primary care
clinicians should screen / counsel adults to prevent ETOH misuse;
Telecolposcopy reduces barriers to diagnosis of cervical cancer among
rural women; Mammography increases likelihood of breast-conserving
surgery among older women; Findings discount link between estrogen
deficiency and cognitive decline in older women

**Breastfeeding:** Breastfeeding may reduce heart disease risk later in
life; Diabetes prevention and breastfeeding

**Domestic Violence:** Pregnancy-associated assault hospitalizations;
Health care and contraception among adolescents reporting unwanted
sexual intercourse; Patterns of intimate partner violence among
adolescent mothers in the postpartum period; Domestic violence screening
behaviors among pediatricians and family physicians; Domestic violence:
an education program for hospital staff; Violence-inflicted injuries:
reporting laws in the fifty states; Measuring the quality of
hospital-based domestic violence programs;

**Elder Care News:** Ultrasound bone assessment is a reliable predictor
of fracture risk

**Frequently asked questions:** Should Active Management of the Third
Stage of Labor Be Routine? How can my department tell if we providing
effective urinary incontinence procedures? Is membrane stripping
associated with abruption placenta? Is percutaneous drainage of
tubo-ovarian abscess standard of care?

**Hormone Replacement Update**: Regular soy intake may protect against
endometrial cancer

**Information Technology:** Q Man, Collecting Data for the CMS
Initiatives

**International Health** Eating Dirt

**MCH Alert** Blood pressure has increased substantially among children
and adolescents

**Medscape** Understanding Sleep Problems - The Basics

**Office of Women's Health, CDC** Spina Bifida and Anencephaly decreased
by 25% After Folic Acid Mandate; Few Women Regret Sterilization
Procedures

**Osteoporosis** Childbearing reduces hip fracture risk by means that
may be independent of hip BMD; Depot Medroxyprogesterone Acetate Use
Associated With Bone Mineral Density Loss

**Patient Education** Consumer Health Journal

**Primary Care Discussion Forum** Next topic: Adult Asthma, on August 1,
2004, thanks to Charles (Ty) Reidhead, Whiteriver; then on November 1,
2004: Violence against Native women

Moderator: Terry Cullen; Adolescent Risk Taking Behavior Summary - Donna
Perry, now online

**Barbara Stillwater, Alaska Diabetes Prevention and Control** Pediatric
Obesity and Type 2 Diabetes, Cardiovascular Disease Teleconference --
June 23, 2004; DID YOU KNOW -- only 10 miles per week or about 3500
steps per day, can decrease coronary heart disease by 1/3? Dark
Chocolate Improves Endothelial Function in Healthy Adults; Two New RCTs:
Low Carb Diet More Beneficial Than Low Fat Diet; Acarbose Curbs
Atherosclerosis in Pre-Diabetes; 41 MILLION ADULTS NOW REPORTED TO HAVE
PRE-DIABETES: 40% of US Adults; Walking \... A Step in the Right
Direction; How many children are likely to get type 2 diabetes and why
it develops? What are the best ways to treat type 2 diabetes in children
and teens? Fat Distribution In Women Tied To Heart Disease Risks;
Physical Activity Does More Than Burn Calories & Improve Diabetes
Control

**What's new on the ITU MCH web pages:** **page 26**

New Perinatology Corner Module available: Syphilis in Pregnancy; FDA
Estrogen and Estrogen with Progestin Therapies: Good patient handouts;

Women\'s Health Information - National Institutes of Health

**The past CCC Corners are archived at:**

<http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN01.cfm#top>

The CCC Corner is good way to inform ITU providers about recent updates,
while decreasing the number of e-mail messages.

Let me know if you want to add something to next month's CCC Corner at
<nmurphy@anmc.org>

or 907 729 3154 (with voicemail)

\*The opinions expressed in the OB/GYN CCC Corner are strictly those of
the authors, and not necessarily those of the Indian Health System, or
the author of this newsletter. If you have any comments, please share
them by joining the Primary Care Discussion Forum where this topic was
recently discussed. To join the Primary Care Listserv, contact Jason
Crim at: [jason.crim@mail.ihs.gov](mailto:jason.crim@mail.his.gov)
8/2/04njm