News Flash

New Breast Feeding page just released

-   See Breastfeeding section below - Suzan Murphy

-   See Featured website section below -- David Gahn

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

 

OB/GYN Chief Clinical Consultant's Corner

Volume 4, No. 10, October 2006

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

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

CDC Advocates for Routine Voluntary Testing of HIV

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

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

Carolyn Aoyama

Grants for Nursing

Jim Galloway

Do you need nutrition services at your site?

Sunnah Kim, AAP (with comments by Elaine Locke, ACOG)

Forty years in partnership: the American Academy of Pediatrics and
Indian Health

Judy Thierry

-Smoking Cessation for Pregnancy and Beyond

-Northern Plains Tobacco Prevention Project - Smoke Free Families
Campaign

-Latest AI/AN birth and fertility data from NCHS, 2004

-Literature on feeding beliefs and attitudes in AIAN/indigenous
populations requested

-Release of IDEA 2004 Part B Regulations Links to forms and tool kits
for IEPS FSPs

**Myra Tucker, CDC**

Analyzing and Mapping Health Inequities to Impact Policies for
Eliminating Disparities

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

##### Obstetrics page 12

-Can a 29% Cesarean Delivery Rate Possibly Be Justified?

-Stricter VBAC Guideline Does Not Improve Mortality

-Dose-response pattern in the risk of previa, with increasing number of
cesarean deliveries

-12 and 24 hours of MgSO4: Similar course in postpartum mild
preeclampsia

-Oral misoprostol Can Reduce PPH When Given Prophylactically

and more.....

**Gynecology** page 15

-A new era in ovulation induction: Aromatase inhibitors

-Preventing Postoperative Nausea and Vomiting

-Flexible-dosing with anticholinergics: Simple and effective for
overactive bladder

-HPV and HPV Vaccine: Information for Healthcare and for the general
public

-MR imaging: Excellent at excluding appendicitis in pregnancy when not
visualized at US

**Child Health** page 16

# -Fetal injury at cesarean delivery: Related to the indication and type of uterine incision

-Youth Exposure to Alcohol Advertising on Radio

-YOUTH: 3 complementary resources: Needs based...asset
mapping...resiliency...

-TeenScreen Conference: Second Annual

# -Adolescent Death Rates by Race/Ethnicity and Sex

**Chronic Illness and Disease** page 18

-Aspirin to Prevent Heart Attack and Stroke: What's the Right Dose? 160
mg/day

-Benefits of Eating Fish Greatly Outweigh the Risks

-Daily Weighing and Quick Action Keeps Pounds Off, Study Shows

-F as in Fat and Failing: How Obesity Policies are Failing in America,
2006

-Regular exercise and keeping weight in check decreases breast-cancer
risk factors

and more.....

#### Features page 21 {#features-page-21 .Style-Heading-4-+-Arial-14-pt-Underline}

##### American Family Physician

-Postcoital Bleeding and Cervical Cancer Risk

-Metformin May Help Children Lose Weight

-Lubiprostone (Amitiza) for Chronic Idiopathic Constipation

American College of Obstetricians and Gynecologists

-Amnioinfusion Does Not Prevent Meconium Aspiration Syndrome

-Postpartum Hemorrhage (Technical Bulletin)

-Vulvodynia

**Agency for Healthcare Research and Quality**

-What processes are in place for same last name awareness?

-Do Not Resuscitate in the OR, but What About Afterwards?

-Prevalence, impact, and disclosure of domestic violence among women

-Premature infants born at 30 to 34 wks gestation suffer substantial
problems

-Bariatric obesity surgery complication rates are higher over time

and more.....

**Ask a Librarian**

Updated Cochrane Systematic Reviews....

-Aerobic Exercise and Pregnancy

-Calcium Supplementation Safe and Cheap

-Preclampsia Drugs: No Clear Choice

**Breastfeeding**

Do you have breastfeeding questions? The new Breast feeding site has the
answers

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

#### Lactation Support in the Indian Health Workplace: New Circular {#lactation-support-in-the-indian-health-workplace-new-circular .Style-Heading-4-+-Arial-14-pt-Underline}

**CCC Corner Digest**

#### September 2006 Highlights included: {#september-2006-highlights-included .Style-Heading-4-+-Arial-14-pt-Underline}

-FDA OTC Access for Plan B for 18 and Older: A 'Catch-22' for AI/AN
patients?

-USPSTF Best Practices - Breast and Cervical Cancer Screening, plus
Helpful Tips

-Cesarean delivery: Increased risks versus vaginal delivery - 4 articles

-See and treat: HPV positive, HSIL cytology, and a HG impression at 2nd
colposcopy

-Metformin Useful for Treating PCOS in Adolescents

-Varenicline was significantly more efficacious for smoking cessation

-Human Papillomavirus Vaccination: ACOG Committee Opinion

-Engorgement - It only feels like it is going to last forever

-Adolescent perception of sexual abstinence: A complete disconnect

-HIV Management System, v1.0 - National Release

-Health care and indigenous peoples: the other side of the planet

-First trimester screening: How would you counsel this patient?

-Postpartum Care: Still the neglected step child of perinatal services?

-Implanon- A single rod contraceptive implant...

-Harm Resulting from Inappropriate Telephone Triage in Primary Care

-How important is maternal intratpartum glucose to neonatal
hypoglycemia?

-Must Honor Advance Directives - Palliative Medicine\'s Role in the
Continuity of Care

-Sexual Education / HIV Education and youth

-Weight Loss Should be the Primary Intervention for Risk of Diabetes

**Domestic Violence**

A must WEB site for CHILD Abuse care and practice info

**Elder Care News**

-Palliative Care Training

-How is the Indian Health System providing palliative and end-of-life
care?

-The Last Hours of Living: Practical Advice for Clinicians

**Family Planning**

#### Ortho Evra Patch Linked to Risk for Venous Thromboembolism {#ortho-evra-patch-linked-to-risk-for-venous-thromboembolism .Style-Heading-4-+-Arial-14-pt-Underline}

**Featured Website**

New Breastfeeding Web Page for the Indian Health System

**Frequently asked questions**

-Is my first trimester patient always hyperthyroid if her labs are
abnormal?

**Indian Child Health Notes**

-Early prednisone therapy in Henoch-Schonlein purpura

-Physician documentation of neonatal risk assessment for perinatal
infections.\
-The Alaska Hib type b experience: lessons in controlling a
vaccine-preventable disease

**Information Technology**

New patient wellness handout

International Health

Maternal survival worldwide: consensus and controversies

and

An Entire Issue of Can J Public Health Dedicated to Health Policy

#### MCH Alert

-What is the contribution of preterm birth to infant mortality rates?

-Increased efforts are needed for states to achieve all eight HP 2010
objectives

-Portal to Maternal and Child History Materials

-Children's Opportunity Depends on Their Parent's Opportunity

#### Medical Mystery Tour

#### The words 'bizarre' and 'atypia' in the same pathology report sentence...hmmm.... {#the-words-bizarre-and-atypia-in-the-same-pathology-report-sentencehmmm. .Style-Heading-4-+-Arial-14-pt-Underline}

#### Medscape

**Menopause Management**

# -Associations between night sweats and other sleep disturbances

# -Combination Estrogen-Progestin Hormone Prescribed by Age Group

-Unopposed Estrogen Therapy Increases Breast Cancer Risk

**Midwives Corner**

-External Fetal Monitors - Can you kick the habit?

-EMTALA language changes addresses certification of false labor

**Navajo News**

-Great, low-cost, fun CME opportunity

**Nurses Corner**

-Improving Perinatal Outcomes: Reliably Using Elective Induction and
Labor Augmentation

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

-Preconception Care: Science, Practice, Challenges and Opportunities

-October is Breast Cancer Awareness Month

**Oklahoma Perspective**

-Asthma in Pregnancy

Osteoporosis

Fracture risk among First Nations people

Patient Education

Assessment of Adult Health Literacy

-Is patient education really working? GDM patients smoke more and eat
less vegetables

-HPV Vaccine: What You Need to Know

#### -Stress: How to Cope with Life\'s Challenges {#stress-how-to-cope-with-lifes-challenges .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Anxiety and Panic: Getting Control over Your Feelings {#anxiety-and-panic-getting-control-over-your-feelings .Style-Heading-4-+-Arial-14-pt-Underline}

and more.....

Perinatology Picks

-Fetal Lung Maturity Assessment

-Can a blood test predict pre-eclampsia? and will it help us?

-Fish oil for fetal brain development, hypertensive disorders, and
depression?

-Maternal oxygen administration for fetal distress

-A nuchal translucency measurement where there is no benefit from first
trimester screening

and more.....

Primary Care Discussion Forum

Causes of Type 2 Diabetes: Old and New Understandings

STD Corner

-Prevalence of HPV Infection among Men: A Systematic Review of the
Literature

-FDA Approves the First Once-a-Day Three-Drug Combination Tx of HIV-1\
-NIH launches new HIV Vaccine awareness campaign

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

### -No improvement in fetal outcome, plus increased maternal morbidity: Who pays for this? 

-Who Responds to Glyburide for Gestational Diabetes?

-Nearly one out of two women with gestational diabetes also have
periodontal disease

-Mothers Who Gain Weight Between Pregnancies Experience Pregnancy
Complications

-The growing trends in maternal obesity

and more.....

###### Save the Dates: Upcoming events of interest page 50

#### What's new on the ITU MCH web pages page 51

-Special Care Clinic -- Phoenix Indian Medical Center

-Heard about prenatal care and postpartum care? Here is something on
Internatal care

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

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

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

**CDC Advocates for Routine Voluntary Testing of HIV**

The U.S. Centers for Disease Control and Prevention (CDC) released
revised HIV Testing recommendations for adults, adolescents, and
pregnant women in health-care settings on September 22, 2006, which
marks the first time the recommendations have been revised since 2001.
After a thorough 2-plus year process of consultations, literature
review, and evidence-based research, the revisions were further refined
by a panel of multisectoral constituents into the final released
guidelines. The guidelines illuminate the need for voluntary HIV
screening as a routine part of medical care, which in turn should
increase the percentage of the population that is aware of their status
and form the foundation for an enhanced public health measure against
the pandemic. Here is a list of the major changes:

-   Routine, voluntary screening for all persons 13 to 64 years of age,
    regardless of risk profile;

-   Annual repeat of screening in persons with known risk;

-   Opt-out screening process with opportunity to ask questions and
    ability to decline (declination should be documented in health
    record). Include HIV consent within general consent for medical
    care. Specific and separate HIV consent not required. Oral or
    written pretest information should be provided and the patient
    should be well informed that they will be screened for HIV;

-   'Prevention counseling' in health-care settings is [not
    required]{.underline}. Patients are still to be linked with clinical
    care and support. High risk patients advised re-testing and offered
    or referred for prevention counseling. (Note: the CDC does NOT
    support removal of prevention counseling in appropriate settings or
    when it can be done. Rather, it gives the option to streamline the
    process to remove barriers and include broad screening in the
    general population or low risk groups);

-   For pregnant women: routine opt-out prenatal screening is
    recommended, repeat screening in third trimester is recommended in
    certain areas of elevated rates of HIV infection among pregnant
    women, and opt-out rapid testing in labor and delivery recommended
    for women with undocumented status;

-   General screening for HIV should be considered distinct from HIV
    counseling and testing conducted as prevention intervention for
    persons at perceived or known higher risk. There is still a need for
    community based prevention education, but it is a separate process.

Rationale for the changes included new research that awareness of
serostatus substantially reduces high-risk behaviors, data that support
screening is cost-effective, and evidence that late testing and
diagnosis is common.

The CDC remains committed to the process for minimizing barriers of
implementation and will work with state health departments as well as
individual agencies for successful implementation.

**[Editorial comment:]{.underline} Scott Giberson, IHS HIV Principal
Consultant\***

**A Call to Action for the Indian Health System**

Previous recommendations and efforts have not turned the tide of
transmission, nor reduced the number of new infections each year in our
population. From a public health perspective, release of these
guidelines truly represents a positive step forward in HIV/AIDS
mitigation efforts. The revisions have appropriately stimulated
discussion and revealed the challenges and barriers of implementation,
yet this gives us an opportunity to utilize them as a springboard for
action. In the spirit of the release and rationale, it is critical that
we do not create unnecessary barriers to screening within our system.

There may be concerns surrounding specific recommendations such as
'general consent' or the 'guidelines surrounding prevention counseling',
as well as the potential for stigma and discrimination and conflicting
state health regulations. Given these revisions, there have been
concerns raised surrounding the removal of specific informed consent,
the quality of care if prevention counseling is not required, the cost
to implement, and issue of stigma and discrimination.

The alternative - not taking advantage of these revisions - could keep
us locked into a pattern that will not improve or protect the health of
our people. These recommendations are for streamlining general
procedures and must be interpreted and applied with competence. The
American Indians / Alaskan Natives represent a specific population with
unique sub-populations of higher risk. This situation must be taken into
consideration with the science behind the revisions. There are
behavioral health, education, and health disparity components and issues
that will surface.

Programmatic Synergy

These guidelines are intended to improve *population* health by lowering
or preventing disease transmission (Read as: Health Promotion / Disease
Prevention, which is one of our Director's priorities).

Attempt to adopt the methods and be mindful of the individual, cultural,
and system barriers and perspectives with good communication and
collaboration as they arise. (Read as: Both a GPRA indicator and a
Healthy People 2010 goal)

At Headquarters, we are addressing the current HIV/AIDS testing policy
since the information is out-dated. In lieu of new IHS HIV/AIDS policy,
we suggest implementing the CDC guidelines and realize there is more
work to be done. Additional comments and progress on the revisions will
be forthcoming.

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

**HIV transmission is a sentinel event, signaling a missed opportunity
for prevention**

Important take home points are:

\- Awareness of serostatus substantially reduces high-risk behaviors,
plus screening is cost-effective.

-Hence, the revised recommendations call for routine HIV testing for ALL
individuals between the ages of 13 and 65 years in the United States.

-No separate written consent form is needed for screening, plus
high-risk patients should be tested for HIV annually

-The revised recommendations advocate for streamlining general
procedures and should be applied with competence

Two clinical pearls and some food for thought

**A teachable moment**

1.) There is also no central Indian Health system requirement for a
written consent.

'Having said that, you still need to provide 'pre-test' teaching, either
verbal or written. This is a very important teachable moment with your
patient that you should not let slip through your fingers.

'Pre-test' teaching is very different from 'Prevention' Counseling.
'Prevention' Counseling is relatively long and involved, while
'pre-test' counseling can be concise and to the point. In a way a
negative HIV screen result may be more important than a positive result,
because you still have the chance to prevent that patient with a
negative result from becoming a future HIV patient.

I suggest you coordinate with your patient educators and develop age
appropriate materials that you can give to all your patients. The CDC is
a great resource, plus the Indian Health system's Patient Education team
can help you adapt those materials to be more culturally specific. Our
goal is to decrease HIV transmission and all the barriers to that goal.

2.) The Indian Health system respects state laws, but be wary of
information from other staff that say your individual state 'requires' a
written consent.

In most cases your state does not actually 'require' a written consent.
Rather, the State Lab may require a written consent to perform free HIV
testing at their Lab. If you send your HIV tests out, perform them in
your own lab, or perform rapid testing at the bedside, then you would
not need a written consent.

When in doubt, check this out yourself. Don't depend on the
'conventional wisdom' without asking the right questions of the
appropriate state officials. I have included a great resource from
Charlton Wilson which answers that question on a state by state basis
below.

**Food for thought about missed opportunity**

Every perinatal HIV transmission is a sentinel health event, signaling
either a missed opportunity for prevention or, more rarely, a failure of
interventions to prevent perinatal transmission. When these infections
occur, they underscore the need for improved strategies to ensure that
all pregnant women undergo HIV testing and, if found to be HIV positive,
receive proper interventions to reduce their transmission risk and
safeguard their health and the health of their infants. \#

Data confirm that testing rates are higher when HIV tests are included
in the standard panel of screening tests for all pregnant women. Women
also are much more likely to be tested if they perceive that their
health-care provider strongly recommends HIV testing. As universal
prenatal screening has become more widespread, an increasing proportion
of pregnant women who had undiagnosed HIV infection at the time of
delivery were found to have seroconverted during pregnancy. A second HIV
test during the third trimester for women in settings with elevated HIV
incidence (\>17 cases per 100,000 person-years) is cost-effective and
might result in substantial reductions in mother-to-child HIV
transmission.\*

For those outside the perinatal and neonatal arena, you now have an
opportunity to apply the success the perinatal and neonatal disciplines
have shown with reducing perinatal transmission..... but you can apply
to all persons from 13-64.

I would like to thank Scott Giberson very much for the important update,
above. Please contact Scott for other questions at
<Scott.Giberson@ihs.gov> (more on Scott's background below\*).

**From Charlton Wilson, PIMC**

Here is the link for a great resource for all the state laws as of
summer 2006. This resource is vast, so use the 'Find' function after you
have read the background material at the beginning, e. g., Arizona page
54, New Mexico page 689, North Dakota page 745, and South Dakota page
914.
[http://www.ucsf.edu/hivcntr/PDFs/WEB2006State%20Laws.pdf](http://www.ucsf.edu/hivcntr/PDFs/WEB2006State Laws.pdf)

**References**:

1.  Branson et. al. 2006. Revised Recommendations for HIV Testing of
    Adults, Adolescents, and Pregnant Women in Health-Care Settings.
    *MMWR Recommendations and Reports*. September 22. 55(RR14);1-17.
    <http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm>

2.  CDC Press Release. September 21, 2006.
    <http://www.cdc.gov/od/oc/media/pressrel/r060921.htm>

\# Many other references available upon request <nmurphy@scf.cc>

\*CDR Scott Giberson, the National IHS HIV/AIDS Principal Consultant,
has served 13 years (10 in the IHS) both domestically and abroad in
roles as Chief Pharmacist, Public Health Advisor, Medical Unit Lead (for
an international health program), and member of Family Practice medical
staffs.   In his previous position, he was responsible for operational
oversight on HIV/AIDS public health programs spanning multiple countries
in the Asia-Pacific region for the Department of Defense. He has
authored articles and spoken on HIV/AIDS topics at numerous venues
across the US and Asia Pacific.

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

**Carolyn Aoyama, HQE**

**Grants for Nursing**

The Indian Health Service (IHS), Office of Clinical and Preventive
Services, Division of Nursing Services announces competitive grant
applications for Public Health Nurse (PHN) Disease Prevention and Health
Promotion (DPHP).

The following grant opportunity posting was made on the Grants.gov Find
Opportunities service:\
Department of Health and Human Services\
Office of Clinical and Preventive Services; Division of Nursing
Services, Public Health Nursing Grant
<http://www.grants.gov/search/search.do?mode=VIEW&oppId=10779>

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

#### Out of the Shadows: Exploring the Barriers to Mental Health, Prevention and Treatment {#out-of-the-shadows-exploring-the-barriers-to-mental-health-prevention-and-treatment .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.apha.org/news/press/2006/0706_savethedate.htm**](http://www.apha.org/news/press/2006/0706_savethedate.htm) {#httpwww.apha.orgnewspress20060706_savethedate.htm .Style-Heading-4-+-Arial-14-pt-Underline}

**James M. Galloway, Tucson**

**Do you need nutrition services at your site?**

If your Service Unit, Hospital or Clinic is in need of nutrition
services or diabetes education services by a Registered
Dietitian/Certified Diabetes Educator, please consider an exciting and
innovative approach to providing these services through Telehealth.

If you currently have (or plan to soon have) teleconferencing
availability, the IHS Native American Cardiology Program would be
interested in potentially working in partnership with you to assist in
providing these services. If you are interested, please see the attached
documents.

For further information or questions, you may also directly contact our
program dietitian, Diane Phillips, RD, LD, CDE at
<diane.phillips@ihs.gov> or by phone at (928) 214-3920.

I appreciate your consideration of this possibility.

Warm regards,\
Jim

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

#### Sunnah Kim, American Academy of Pediatrics {#sunnah-kim-american-academy-of-pediatrics .Style-Heading-4-+-Arial-14-pt-Underline}

**Forty years in partnership: the American Academy of Pediatrics and
Indian Health**

Fifty years ago, American Indian and Alaska Native children faced an
overwhelming burden of disease, especially infectious diseases such as
pneumonia, meningitis, tuberculosis, hepatitis A and B, and
gastrointestinal disease. Death rates of American Indian/Alaska Native
infants between 1 month and 1 year were much higher than in the US
population as a whole, largely because of these infectious diseases. The
health care of American Indian/Alaska Native patients was transferred to
the Department of Health, Education, and Welfare in 1955 and placed
under the administration of an agency soon to be known as the Indian
Health Service. The few early pediatricians in the Indian Health Service
recognized the severity of the challenges facing American Indian/Alaska
Native children and asked for help.

The American Academy of Pediatrics responded by creating the Committee
on Indian Health in 1965. In 1986 the Committee on Native American Child
Health replaced the Committee on Indian Health. Through the involved
activity of these committees, the American Academy of Pediatrics
participated in and influenced Indian Health Service policies and
services and, combined with improved transportation, sanitation, and
access to vaccines and direct services, led to vast improvements in the
health of American Indian/Alaska Native children. In 1965, American
Indian/Alaska Native postneonatal mortality was more than 3 times that
of the general population of the United States. It is still more than
twice as high as in other races but has decreased 89% since 1965.
Infectious diseases, which caused almost one fourth of all American
Indian/Alaska Native child deaths in 1965, now cause \<1%. The Indian
Health Service and tribal health programs, authorized by the Indian
Self-Determination and Education Assistance Act of 1976 (Pub L. 93-638),
continue to seek American Academy of Pediatrics review and assistance
through the Committee on Native American Child Health to find and
implement interventions for emerging child health problems related to
pervasive poverty of many American Indian/Alaska Native communities.
Acute infectious diseases that once were responsible for excess
morbidity and mortality now are replaced by excess rates resulting from
harmful behaviors, substance use, obesity, and injuries (unintentional
and intentional). Through strong working partnerships such as that of
the American Academy of Pediatrics and the Indian Health Service,
progress hopefully will occur to address this \"new morbidity.\" In this
article we document the history of the Indian Health Service and the
American Academy of Pediatrics committees that have worked with it and
present certain statistics related to American Indian/Alaska Native
child health that show the severity of the health-status disparities
challenging American Indian/Alaska Native children and youth.

[Brenneman
G](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Brenneman+G"%5BAuthor%5D),
[Rhoades
E](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Rhoades+E"%5BAuthor%5D),
[Chilton
L](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Chilton+L"%5BAuthor%5D).
Forty years in partnership: the American Academy of Pediatrics and the
Indian Health Service
[Pediatrics.](javascript:AL_get(this, 'jour', 'Pediatrics.');) 2006
Oct;118(4):e1257-63

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17015514**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17015514) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgidbpubmedcmdretrievedoptabstractpluslist_uids17015514 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Editorial comment: Elaine Locke, ACOG]{.underline}

#### In the same era that the pediatricians were responding to the needs of AI/AN children, the obstetricians were responding in parallel. The American College of Obstetricians and Gynecologists \[ACOG\] established a Committee on American Indian Affairs on April 17, 1970 for the purpose of studying and developing expertise in the area of maternal and gynecologic health problems among Native American women. The following is a brief description of what ACOG currently offers as well as links to documents on the history of ACOG involvement as well as the Fellows in Service Program. {#in-the-same-era-that-the-pediatricians-were-responding-to-the-needs-of-aian-children-the-obstetricians-were-responding-in-parallel.-the-american-college-of-obstetricians-and-gynecologists-acog-established-a-committee-on-american-indian-affairs-on-april-17-1970-for-the-purpose-of-studying-and-developing-expertise-in-the-area-of-maternal-and-gynecologic-health-problems-among-native-american-women.-the-following-is-a-brief-description-of-what-acog-currently-offers-as-well-as-links-to-documents-on-the-history-of-acog-involvement-as-well-as-the-fellows-in-service-program. .Style-Heading-4-+-Arial-14-pt-Underline}

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

ACOG's Indian health activity began in 1970 and now includes programs
that:

-   Provide medical care when it is most needed to American Indian and
    Alaska Native women; obstetrician-gynecologists from the private
    sector fill short-term vacancies in Indian hospitals.

-   Offer an annual 4-day course on Obstetric, Neonatal, and Gynecologic
    Care for Indian Health Service and Tribal nurses and physicians who
    are not trained in the specialty. An optional Neonatal Resuscitation
    Program offers certificates of completion and additional education
    credits.

-   Produce a practical reference text for the use of nonspecialists in
    Indian Health Service and Tribal hospitals.

-   Conduct site visits to Indian Health Service and Tribal hospitals;
    reports can support improvements in equipment, staffing, management
    and clinical care.

ACOG continues to support the Committee on American Indian Affairs as an
expression of the College's concern for the health and well-being of
American Indian and Alaska Native women and their offspring. Please
Contact: Yvonne Malloy or Elaine Locke 202:863-2580

**Historical Background of ACOG AI/AN Involvement**

<http://www.ihs.gov/MedicalPrograms/MCH/F/documents/HistACOG101206.doc>

**History of the ACOG Fellows in Service Program**

<http://www.ihs.gov/MedicalPrograms/MCH/F/documents/ACOGFell101206.doc>

**Various ACOG Programs**

[http://www.ihs.gov/MedicalPrograms/MCH/F/documents/ACOG%20Prog101206.doc](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/ACOG Prog101206.doc)

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

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

**Smoking Cessation for Pregnancy and Beyond**

Interactive cases explore the broader psychosocial dimension of
cessation counseling.  The virtual classroom supplies strategies for
implementing optimal and efficient office systems to support smoking
cessation counseling and documentation. This program offers various
learning tools, including: (1) Interactive case simulations and
comprehensive discussions of the patient visits. (2) Mini-lectures on
relevant topics from leading experts, including former Surgeon General
Dr. C. Everett Koop and Dr. Neil Benowitz. And (3) Interviews with real
patients who have quit

<http://iml.dartmouth.edu/education/cme/Smoking/>

**Northern Plains Tobacco Prevention Project**

**Smoke Free Families Campaign**

Intergenerational activity addressing AIAN families in the AATCHB
catchment

<http://www.aatchb.org/nptpp/index.htm>

**Latest AI/AN birth and fertility data from NCHS, 2004**

Births 43,927 \[43,052 in 2003 and 29,389 in 1980\]

Birth rate 14.0 \[20.7 in 1980\]

Fertility rate 58.9 \[83.6 in 1982\]

Teen pregnancy rate 52.5 \[high of 84.2 in 1983 ages 15 - 19\]

![](media/image2.png){width="6.729166666666667in" height="4.125in"}

<http://www.cdc.gov/nchs>

**Literature on feeding beliefs and attitudes in AIAN/indigenous
populations requested**

Tam Lutz is requesting questionnaires or literature on feeding beliefs
and attitudes within Indian culture.  If you know of anyone or have
information please contact her directly.

Thanks so much. Judy

Tam Lutz, MPH, MHA - Project Director at the Northwest Portland Indian
Health Board

Tribal Epidemiology Center  527 SW Hall Suite 300    Portland, Oregon
97201

\(503\) 416-3271    FAX: 503-228-8182      <tlutz@npaihb.org>

**Release of IDEA 2004 Part B Regulations Links to forms and tool kits
for IEPS FSPs**

Individual with Disabilities Education Act 2004 reauthorization rolled
out part C regs (early childhood) and has NOW published Part B -- school
age children.   

-Tool Kit on Teaching and Assessing Students With Disabilities\
Extensive web site definitely for the educator.

[www.osepideasthatwork.org/toolkit/index.asp](http://www.osepideasthatwork.org/toolkit/index.asp)

-Raising the Achievement of Students with Disabilities: New Ideas for
IDEA:\
Chronologies of IDEA and No Child Left Behind...on the main page; many
other links.

[www.ed.gov/admins/lead/speced/ideafactsheet.html](http://www.ed.gov/admins/lead/speced/ideafactsheet.html)

-Model Forms for IEPs, Procedural Safeguards Notices and Prior Written
Notices on our Web site Available Forms

[www.ed.gov/IDEA](http://www.ed.gov/policy/speced/guid/idea/idea2004.html)

**Myra Tucker, CDC -- Reproductive Health**

**Analyzing and Mapping Health Inequities to Impact Policies for
Eliminating Disparities**

Eleventh Biennial CDC & ATSDR Symposium on Statistical Methods

April 17-18, 2007  Atlanta, GA.

Authors are encouraged to submit abstracts for contributed papers
related to one of the following session topics:

·         Racial and ethnic minorities

·         Statistical and cost methodologies, including systematic
reviews

·         At risk populations with characteristics related to age, low
income, sexual orientation,

language barriers, disability and geographic locations

·         Underrepresented or "invisible" populations: institutionalized
populations, the homeless,

immigrants, and others

·         Disparities in occupational employment

·         Environmental justice: cancer clusters, location of
brownfields, hazardous facilities and

socioeconomic class

·         Access to and quality of care

·         Emergency and program planning

·         Health behavior and promotion

Abstracts will be considered for either oral or poster presentation and
must be submitted no later than November 20, 2006.  Authors of accepted
presentation will be notified by January 5, 2007.  For more information,
please visit the Symposium website at

<http://www.cdc.gov/od/ads/sag/index.htm> or contact Mark Stevens at
(770) 488-5673.

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

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

**Can a 29% Cesarean Delivery Rate Possibly Be Justified?**

1.) Have there been measurable improvements in fetal outcome from the
use of EFM and its associated increase in the cesarean delivery rate?
There is a very high false-positive rate for \"nonreassuring\" heart
rate patterns used to predict a depressed newborn.

It did not achieve its promise because it was designed to prevent
intrapartum death, an event so rare that it was not possible to show a
significant difference, and to prevent cerebral palsy, which we now know
is attributable to birth asphyxia in term infants only about 6--17% of
the time. In fact, although most labors are followed with EFM, there has
been no reduction in the incidence of cerebral palsy over the last 3
decades.

2.) What about the maternal benefits of cesarean delivery? There is
little argument that vaginal delivery is associated with a higher
frequency of subsequent stress urinary incontinence and uterine and
vaginal prolapse. However, it is also clear that nulliparous women and
those who have had only cesarean delivery may also be symptomatic,
suggesting that the aging process, pregnancy per se, genetic factors,
and just walking upright for more than 50 years are significant
contributors to the problem.

3.) In contrast, the risks of the current cesarean delivery rate are not
difficult to discern. Getahun and co-workers (below) have reported a 50%
increase in the risk of placenta previa and a doubling of the risk of
abruptio placenta in the subsequent pregnancy after one previous
cesarean delivery. These risks increased with multiple prior cesareans.
Resnik R. Can a 29% Cesarean Delivery Rate Possibly Be Justified? Obstet
Gynecol 2006 107:752-4

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16582108>

Stricter VBAC Guideline Does Not Improve Mortality

The incidence of vaginal birth after cesarean delivery (VBAC) in the
United States has steadily declined after reaching a peak of 27.4
percent of all deliveries in 1997. The American College of Obstetricians
and Gynecologists (ACOG) revised its VBAC guidelines in 1999,
recommending for the first time that VBAC only be performed in
\"institutions equipped to respond to emergencies with physicians
immediately available to provide emergency care.\" Rural hospitals may
have been affected by this new guideline; however, it is uncertain if
adverse maternal and neonatal outcomes were reduced after the revision.
Zweifler and colleagues conducted a retrospective analysis of birth data
to determine if the ACOG guideline change affected neonatal and maternal
mortality.

The study population consisted of 386,232 women who previously had a
cesarean delivery for a singleton birth in a California hospital between
1996 and 2002. Data were collected from the California Department of
Health Services Birth Statistical Master Files. Data from before the
guideline revision (1996 to 1999) were compared with data from after the
revision (2000 to 2002). Neonatal deaths were defined as newborns living
fewer than 28 days, and maternal deaths were defined as deaths within 72
hours of delivery. The total number of attempted VBAC deliveries
(successful and unsuccessful) also was noted.

Although there was a significant decrease in attempted VBAC deliveries
after the ACOG guideline revision (24 percent of all deliveries before
the revision to 13.5 percent after), neonatal and maternal mortality
rates did not change. During both periods, neonatal mortality rates for
attempted VBAC deliveries were similar to those for repeat cesarean
deliveries, except for infants with a very low birth weight (i.e., less
than 1,500 g). Neonatal mortality rates for infants with a very low
birth weight were higher for attempted VBAC than for repeat cesarean
deliveries during both periods. Maternal death rates did not change
significantly after the guideline revision, regardless of delivery type.

The authors conclude that the ACOG guideline revision resulted in a
large decline in the percentage of women in California who attempted
VBAC, but that it did not improve neonatal or maternal mortality rates.
In addition, neonatal mortality in infants weighing more than 1,500 g
was not related to delivery type. The authors suggest that pregnant
women who have had a previous cesarean delivery be informed about these
encouraging findings in addition to the risks associated with VBAC.

Zweifler J, et al. Vaginal birth after cesarean in California: before
and after a change in guidelines. Ann Fam Med May/June 2006;4:228-34.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16735524>

**Dose-response pattern in the risk of previa, with increasing number of
cesarean deliveries**

CONCLUSION: A cesarean first birth is associated with increased risks of
previa and abruption in the second pregnancy. There is a dose-response
pattern in the risk of previa, with increasing number of prior cesarean
deliveries. A short interpregnancy interval is associated with increased
risks of previa and abruption. LEVEL OF EVIDENCE: II-2.

Getahun D et al Previous Cesarean Delivery and Risks of Placenta Previa
and Placental Abruption Obstet Gynecol 2006 107:771-8

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16582111>

**12 and 24 hours of MgSO4: Similar course in postpartum mild
preeclampsia**

CONCLUSION: Twelve hours of postpartum MgSO4 therapy for mild
preeclampsia is associated with infrequent disease progression and a
clinical course similar to that with 24-hour therapy. Patients with
chronic hypertension and insulin-requiring diabetes are at risk for
progression to severe disease postpartum. CLINICAL TRIAL REGISTRATION:
ClinicalTrials.gov, www.clinicaltrials.gov, NCT00344058 LEVEL OF
EVIDENCE: I.\
[Ehrenberg
HM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Ehrenberg+HM"%5BAuthor%5D),
[Mercer
BM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Mercer+BM"%5BAuthor%5D).
Abbreviated postpartum magnesium sulfate therapy for women with mild
preeclampsia: a randomized controlled trial. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Oct;108(4):833-8.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17012443&dopt=Abstract>

**Oral misoprostol Can Reduce PPH When Given Prophylactically**

A single oral dose of 600 μg of misoprostol (three 200 μg tablets) or
placebo (three tablets that were identical in appearance) was
administered after delivery of the baby and within 5 min of clamping and
cutting of the umbilical cord. After being given the drug, the women
were monitored by the midwife for a minimum of 2 h according to the
usual standard of care procedure to determine the need for transfer to a
higher level facility. Blood loss, uterine tone, changes in blood
pressure, pulse, and pallor, as well as possible maternal and neonatal
side effects from the misoprostol were documented in the data collection
form designed for the study

INTERPRETATION: Oral misoprostol was associated with significant
decreases in the rate of acute postpartum haemorrhage and mean blood
loss. The drug\'s low cost, ease of administration, stability, and a
positive safety profile make it a good option in resource-poor settings
[Derman
RJ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Derman+RJ"%5BAuthor%5D),
et al Oral misoprostol in preventing postpartum haemorrhage in
resource-poor communities: a randomised controlled trial.
[Lancet.](javascript:AL_get(this, 'jour', 'Lancet.');) 2006 Oct
7;368(9543):1248-53

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17027730>

**Obstetric outcomes in overweight and obese adolescents**

CONCLUSION: Overweight adolescent women are at increased risk for
adverse neonatal and perinatal outcomes. With rates of overweight
increasing overall, overweight in the gravid adolescent is a pressing
perinatal and public health concern.

[Sukalich
S](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Sukalich+S"%5BAuthor%5D),
et al Obstetric outcomes in overweight and obese adolescents. [Am J
Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Sep;195(3):851-5

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16949425>

**Operative vaginal delivery and midline episiotomy: A bad combination
for the perineum**

CONCLUSION: The use of operative vaginal delivery, particularly in
combination with midline episiotomy, was associated with a significant
increase in the risk of anal sphincter trauma in both primigravid and
multigravid women. Given the reported substantial long-term adverse
consequences for anal function, this combination of operative modalities
should be avoided if possible.

[Kudish
B](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Kudish+B"%5BAuthor%5D),
et al Operative vaginal delivery and midline episiotomy: A bad
combination for the perineum. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Sep;195(3):749-54

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16949408>

**OB/GYNs follow recommendations for obesity when patients are likely to
adhere**

CONCLUSION: A majority of obstetrician-gynecologists appear to use BMI
to screen for obesity and to counsel their patients about weight
control, diet, and physical activity. Many, however, do not prescribe
weight loss medications or refer patients to behavioral weight loss
therapy. Obstetrician-gynecologists who believe they can help patients
lose weight are more likely to follow recommendations for the treatment
of obesity. LEVEL OF EVIDENCE: III.

[Power
ML](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Power+ML"%5BAuthor%5D),
et al Obesity Prevention and Treatment Practices of U.S.
Obstetrician-Gynecologists. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Oct;108(4):961-968.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17012460&dopt=Abstract>

**All healthcare providers attending pregnancies must be prepared for
shoulder dystocia**

CONCLUSION: For many years, long-standing opinions based solely on
empiric reasoning have dictated our understanding of the detailed
aspects of shoulder dystocia prevention and management. Despite its
infrequent occurrence, all healthcare providers attending pregnancies
must be prepared to handle vaginal deliveries complicated by shoulder
dystocia.

[Gherman
RB](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Gherman+RB"%5BAuthor%5D),
et al Shoulder dystocia: the unpreventable obstetric emergency with
empiric management guidelines. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Sep;195(3):657-72.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16949396>

**Induction of labor may not increase a woman\'s risk of cesarean
delivery at 41 weeks**

CONCLUSION: Our findings suggest that IOL may not increase a woman\'s
risk of CD when compared to expectant management. While this question
has been addressed prospectively at 41 weeks gestation, it requires
further examination at earlier gestations and among various subgroups.

[Caughey
AB](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Caughey+AB"%5BAuthor%5D),
et al Induction of labor and cesarean delivery by gestational age. [Am J
Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Sep;195(3):700-5

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16949399>

**Risk factors for cervical insufficiency after term delivery**

CONCLUSION: Multiparous women who experience cervical insufficiency
after a term birth are more likely to have had a previous precipitous
delivery, a prolonged second stage of labor, or a previous curettage
compared with multiparous women who experience a repeat term birth with
no cervical insufficiency.

[Vyas
NA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Vyas+NA"%5BAuthor%5D),
et al Risk factors for cervical insufficiency after term delivery. [Am J
Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Sep;195(3):787-91

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16949413>

**Risk factors for the breakdown of perineal laceration repair after
vaginal delivery**

CONCLUSION: The most significant events were mediolateral episiotomy,
especially in conjunction with operative vaginal delivery, third- and
fourth-degree lacerations, and meconium.

[Williams
MK](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Williams+MK"%5BAuthor%5D),
[Chames
MC](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Chames+MC"%5BAuthor%5D).
Risk factors for the breakdown of perineal laceration repair after
vaginal delivery [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Sep;195(3):755-9

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16949409>

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

**A new era in ovulation induction: Aromatase inhibitors**

CONCLUSION(S): Aromatase inhibitors are as effective as or superior to
clomiphene citrate in ovulation induction and in superovulation. Unlike
CC, they do not carry an antiestrogenic effect on the endometrium. Given
the advantages of aromatase inhibitors, they can be used to replace CC
as ovulation-inducing drugs. Their role in IVF remains to be determined.

Holzer H et al A new era in ovulation induction. Fertility and Sterility
2006 85(2): 277-85

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16595197>

Preventing Postoperative Nausea and Vomiting

Up to 30 percent of patients vomit after surgery. As well as being
distressing for the patient and those nearby, postoperative nausea and
vomiting stresses sutures, drains, and intravenous lines; promotes
bleeding and venous hypertension; and increases the risk of pulmonary
aspiration. Layeeque and colleagues studied the ability of the
combination of dronabinol (Marinol; an anticannabinoid) and
prochlorperazine (Compazine; an anticholinergic) to prevent
postoperative nausea and vomiting in patients who had breast surgery.

The control cohort of 127 women had standard care that did not routinely
include antiemetic medications. The 115 women in the intervention cohort
received standard administration of prophylactic oral dronabinol (5 mg)
before anesthesia plus rectal prochlorperazine (25 mg) after anesthesia.
Cardiovascular and neurologic statuses were monitored in all patients,
and women in the intervention group were asked about possible medication
side effects. Episodes of postoperative nausea and vomiting and use of
antiemetic medications were measured for both groups.

Six patients in the intervention group did not receive prophylactic
therapy, and 20 patients in the control group received prophylactic
antiemetic treatment. Nevertheless, by intention-to-treat analysis, the
rate of postoperative nausea was significantly lower in the intervention
group (15 percent) than in the control group (59 percent). The rate of
postoperative vomiting also was significantly different: 3 percent in
the intervention group and 29 percent in the control group. Additional
antiemetic treatment was given to 60 percent of control patients but to
only 11 percent of the intervention group.

Postoperative nausea was significantly more prevalent in patients with
cancer (47 percent) than in women with a benign diagnosis (19 percent).
Similarly, rates of postoperative vomiting were significantly higher in
patients with cancer (22 percent compared with 5 percent in those
without cancer). The diagnosis of cancer had odds ratios of 3.88 for
likelihood of nausea after surgery and 7.49 for likelihood of vomiting;
but the most significant factor in multivariate analysis was being in
the intervention group, which had odds ratios of 7.79 for reduction in
nausea and 14.65 for reduction in vomiting. No significant side effects
were documented during the study.

The authors conclude that routine prophylaxis using drugs targeting two
stimulating mechanisms of the emetic center provided effective,
inexpensive, and easily administered antiemetic therapy during common
surgeries.

Layeeque R, et al. Prevention of nausea and vomiting following breast
surgery. Am J Surg June 2006;191:767-72.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16720146>

**Flexible-dosing with anticholinergics: Simple and effective for
overactive bladder**

Dose adjustment may improve the therapeutic outcome, facilitating a
balance between efficacy and anticholinergic side effects such as dry
mouth. Flexible-dosing studies indicate that dry mouth, the adverse
effect most frequently seen with the use of anticholinergic agents,
seldom leads to study withdrawal. Patient-initiated control of OAB
symptoms may be achieved in 1 month by following established protocols.

Staskin DR, MacDiarmid SA. Pharmacologic Management of Overactive
Bladder: Practical Options for the Primary Care Physician American
Journal of Medicine 2006 119(3A):245-285

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16483865>

**HPV and HPV Vaccine: Information for Healthcare and for the general
public**

This three page fact sheet provides information on provisional
recommendations, HPV vaccine safety, HPV vaccine efficacy, duration of
vaccine protection, HPV vaccine delivery, cost effectiveness, policies,
other vaccines in development, genital HPV infection, natural history of
HPV, HPV-associated disease, prevention of cervical cancer, and
additional sources of information. (Revised)
<http://www.cdc.gov/std/HPV/hpv-vacc-hcp-3-pages.pdf>

Other

CDC's HPV website: 2 items

The [Advisory Committee on Immunization
Practices](http://www.cdc.gov/nip/acip/) (ACIP) provisional
recommendations for the use of the quadrivalent HPV vaccine.

[www.cdc.gov/nip/recs/provisional_recs/hpv.pdf](http://www.cdc.gov/nip/recs/provisional_recs/hpv.pdf)

Q&A for the general public

[www.cdc.gov/std/hpv/STDFact-HPV-vaccine.htm](http://www.cdc.gov/std/hpv/STDFact-HPV-vaccine.htm)

**MR imaging: Excellent at excluding appendicitis in pregnancy when not
visualized at US**

CONCLUSION: MR imaging is an excellent modality for use in excluding
acute appendicitis in pregnant women who present with acute abdominal
pain and in whom a normal appendix is not visualized at US.

Pedrosa I et al MR Imaging Evaluation of Acute Appendicitis in Pregnancy
Radiology 2006 238(3):891-99

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16505393>

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

# Fetal injury at cesarean delivery: Related to the indication and type of uterine incision

RESULTS: A total of 37,110 cesarean deliveries were included in the
registry, and 418 (1.1%) had an identified fetal injury. The most common
injury was skin laceration (n=272, 0.7%). Other injuries included
cephalohematoma (n=88), clavicular fracture (n=11), brachial plexus
(n=9), skull fracture (n=6), and facial nerve palsy (n=11). Among
primary cesarean deliveries, deliveries with a failed forceps or vacuum
attempt had the highest rate of injuries (6.9%). In women with a prior
cesarean delivery, the highest rate of injury also occurred in the
unsuccessful trial of forceps or vacuum (1.7%), and the lowest rate
occurred in the elective repeat cesarean group (0.5%). The type of
uterine incision was associated with fetal injury, 3.4% \"T\" or \"J\"
incision, 1.4% for vertical incision, and 1.1% for a low transverse
(P=.003), as was a skin incision--to--delivery time of 3 minutes or
less. Fetal injury did not vary in frequency with the type of skin
incision, preterm delivery, maternal body mass index, or infant birth
weight greater than 4,000 g.

CONCLUSION: Fetal injuries complicate 1.1% of cesarean deliveries. The
frequency of fetal injury at cesarean delivery varies with the
indication for surgery as well as with the duration of the skin
incision--to--delivery interval and the type of uterine incision.

[Alexander
JM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Alexander+JM"%5BAuthor%5D),
et al Fetal injury associated with cesarean delivery. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Oct;108(4):885-90.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17012450&dopt=Abstract>

**Youth Exposure to Alcohol Advertising on Radio**

To determine the proportion of radio advertisements that occurred on
radio programs with audiences composed disproportionately of underage
youth and the proportion of total youth exposure to alcohol advertising
that occurs as a result of such advertising, researchers evaluated the
placement of individual radio advertisements for the most advertised
U.S. alcohol brands and the composition of audiences in the largest 104
markets in the United States. This report summarizes the results of that
study, which indicate that alcohol advertising is common on radio
programs which have disproportionately large youth audiences and that
this advertising accounts for a substantial proportion of all alcohol
radio advertising heard by underage youth. These results further
indicate that 1) the current voluntary standards limiting alcohol
marketing to youth should be enforced and ultimately strengthened, and
2) ongoing monitoring of youth exposure to alcohol advertising should
continue. Brand-specific exposure to radio advertising also varied by
the sex and racial/ethnic composition of the audience. Compared with
boys, underage girls had higher levels of exposure to 11 alcohol brands
and in 41 of the 104 markets and less exposure to 13 brands and in 63
markets

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5534a3.htm?s_cid=mm5534a3_e>

**YOUTH: 3 complementary resources: Needs based...asset
mapping...resiliency...**

1.) Resilience Project

The purpose of the IRP is to develop a better, more culturally sensitive
understanding of how youth around the world effectively cope with the
adversities that they face in life. The IRP uses a unique cross-cultural
approach that employs both quantitative and qualitative research methods
to examine individual, interpersonal, family, community and cultural
factors associated with building resilience in youth around the world.
The IRP is currently bringing to a close the first 3-year phase of the
research, in which the IRP piloted and integrated innovative
quantitative and qualitative research methods and collected data with
over 1500 children worldwide. 

<http://www.resilienceproject.org/cmp_text/>

<http://www.resilienceproject.org/documents/2006_reports/northerncanada.pdf>

2.) Resilience Net

ResilienceNet provides the single, most comprehensive world-wide source
of current, reviewed information about human resilience. The Web sites
with resilience resources that are cited in ResilienceNet have been
reviewed by a [panel of
experts](http://www.resilnet.uiuc.edu/revpanel.html) according to a [set
of criteria](http://www.resilnet.uiuc.edu/evalcrit.html) for assuring
the relevance and quality of the sites. If there is a Web site that you
would like to submit for review by the ResilienceNet review panel for
possible inclusion on ResilienceNet, please send a note with the name
and URL of the site to the [ResilienceNet
Webmaster](mailto:resnet@ceep-mailserver.crc.uiuc.edu). If you think
that any site listed on ResilienceNet is no longer appropriate or of
sufficient quality to be included, please inform the [ResilienceNet
Webmaster](mailto:resnet@ceep-mailserver.crc.uiuc.edu).Resilience is
defined as the \"human capacity and ability to face, overcome, be
strengthened by, and even be transformed by experiences of adversity.\"
ResilienceNet brings together information available through the Internet
and conventional published sources about the development and expression
of human resilience. Although we endeavor to cover all aspects of
resilience, ResilienceNet focuses on resilience in children, youth, and
families. Additional topics, especially as they impact on children,
youth, and families, are included as well, such as:

-   resilience of communities

-   resilience and life-long physical and mental health

-   resilience related to culture, ethnicity, and gender

-   children and adults at risk

<http://www.resilnet.uiuc.edu/>

3.) SEARCH Institute

There is an early childhood piece from SEARCH below:   While the focus
of the Institute began with school age youth this piece is on early
childhood.  

Search Institute\'s 40 Developmental Assets are concrete, common sense,
positive experiences and qualities essential to raising successful young
people. These assets have the power during critical adolescent years to
influence choices young people make and help them become caring,
responsible adults. <http://www.search-institute.org/> 

<http://www.searchinstitutestore.org/product.php?productid=16460>    

**TeenScreen Conference: Second Annual**

March 14 and 15, 2007

Washington D.C.

Bringing together TeenScreen champions for youth mental health from
across the country to explore...

✓ The latest research in youth mental health and suicide prevention

✓ Practical skills for your entire screening team

✓ Tools to expand your TeenScreen Program

✓ Increasing government and local support for mental health screening

Contact <TSConference@childpsych.columbia.edu>

# Adolescent Death Rates by Race/Ethnicity and Sex

During 2001\--2003, AI/AN and non-Hispanic black male adolescents had
higher average annual death rates than males in other racial/ethnic
populations. Among female adolescents, AI/ANs had a higher death rate
than any other population. In each racial/ethnic population, males had
higher adolescent death rates than females.

![](media/image3.png){width="5.792361111111111in"
height="3.1256944444444446in"}

\* Aged 15\--17 years.

† Average annual rate per 100,000 population.

§ Includes persons of Hispanic origin.

¶ Death rates are known to be underestimated.

\*\* Might be of any race.

National Vital Statistics System, 2001\--2003 mortality files; Health
Data for All Ages,
<http://www.cdc.gov/nchs/health_data_for_all_ages.htm>

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

**Aspirin to Prevent Heart Attack and Stroke: What's the Right Dose? 160
mg/day**

Despite hundreds of clinical trials, the appropriate dose of aspirin to
prevent myocardial infarction (MI) and stroke is uncertain. In the US,
the doses most frequently recommended are 80, 160, or 325 mg per day.
Because aspirin can cause major bleeding, the appropriate dose is the
lowest dose that is effective in preventing both MI and stroke because
these two diseases frequently co-exist. Five randomized clinical trials
have compared aspirin with placebo or no therapy for the prevention of
stroke and MI. These trials varied with regard to the dose of aspirin,
the duration of treatment, and, most important, the populations selected
for study varied in their baseline risk of stroke and MI. These studies
indicate that the most appropriate dose for the primary and secondary
prevention of stroke and MI is 160 mg/day.

Dalen J. Aspirin to Prevent Heart Attack and Stroke: What's the Right
Dose? American Journal of Medicine 2006 119: 198-202

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16490462>

**Benefits of Eating Fish Greatly Outweigh the Risks**

The benefits of eating one to two servings of fish a week greatly
outweigh the risks among adults and, except for a few species of fish,
women of child-bearing age. "It is striking how much greater both the
amount of the evidence and the size of the health effect are for health
benefits, compared with health risks. Seafood is likely the single most
important food one can consume for good health

[Conclusions ]{.underline} For major health outcomes among adults, based
on both the strength of the evidence and the potential magnitudes of
effect, the benefits of fish intake exceed the potential risks. For
women of childbearing age, benefits of modest fish intake, excepting a
few selected species, also outweigh risks.

Mozaffarian, D, Rimm, EB Fish Intake, Contaminants, and Human Health
Evaluating the Risks and the Benefits JAMA. 2006;296:1885-1899.

<http://jama.ama-assn.org/cgi/content/short/296/15/1885>

**Daily Weighing and Quick Action Keeps Pounds Off, Study Shows**

Most successful dieters regain the weight they lost. But new research
shows that a daily weigh-in -- and quick adjustments to diet and
exercise -- can significantly help dieters maintain weight loss. The
clinical trial, conducted by researchers at The Miriam Hospital and
Brown Medical School, reports results of the first program designed
specifically for weight loss maintenance.

Stepping on the scale every day, then cutting calories and boosting
exercise if the numbers run too high, can significantly help dieters
maintain weight loss, according to results of the first program designed
specifically for weight loss maintenance.

Self-regulation is the core of STOP Regain

Unlike other obesity studies, which focus on how to lose weight, the
"STOP Regain" trial tested a method that taught participants how to keep
those pounds from coming back -- regardless of the method they used to
lose the weight in the first place.

[Wing
RR](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Wing+RR"%5BAuthor%5D),
et al A self-regulation program for maintenance of weight loss [N Engl J
Med.](javascript:AL_get(this, 'jour', 'N Engl J Med.');) 2006 Oct
12;355(15):1563-71.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17035649>

**F as in Fat and Failing: How Obesity Policies are Failing in America,
2006**

Adult obesity rates increased in 31 states during the past year, leaving
an estimated two-thirds of Americans vulnerable to fatal diseases such
as diabetes, stroke and cancer.

This, despite federal and state government efforts to curb the
overweight epidemic, according to a new report from the Trust for
America\'s Health.

The report, titled F as in Fat: How Obesity Policies Are Failing
America, 2006 is the third in a series of annual reports by the trust
detailing state obesity rates as well as the effectiveness of government
policies to fight the problem.

According to official figures, the adult obesity rate rose from 15
percent in 1980 to 32 percent in 2004. Combine that with the number of
Americans who are overweight but not obese, and the figure stands at 64
percent. And the childhood obesity rate more than tripled between 1980
and 2004, from 5 percent to 17 percent.

Among the report\'s other findings:

-   The percentage of adults who are obese or overweight exceeds 60
    percent in 28 states.

-   West Virginia has the highest rate of type 2 diabetes among adults
    (10.4 percent) while Alaska has the lowest rate (4.5 percent).

-   Mississippi has the highest rate of adult hypertension (32.7
    percent) and Utah the lowest (19.8 percent).

-   Seven states now have body mass index screening requirements in
    schools.

-   All states except South Dakota have school physical education
    requirements, while 44 states plus Washington, D.C., have school
    health education requirements. There is little enforcement
    capability in either of these cases, however.

-   Seventeen states plus Washington, D.C., have passed taxes on junk
    food or sodas.

Efforts to combat the obesity epidemic have failed to meet their goals,
Nonas said. \"I don\'t think they\'re going far enough,\" she said.
\"The perfect example of this is the physical-education and
health-education requirements, where states have very little ability to
enforce it. It\'s good that people are doing this, but it\'s not
enough.\"

The report also offered a 20-step action plan to address the obesity
crisis. Recommendations include improved nutritional labeling on foods;
community-driven efforts to increase access to healthy foods in
low-income areas; improved nutritional content on foods and beverages
served and sold in schools; an improved physical environment with more
and better sidewalks, parks and bike paths; better physical fitness
curricula in schools; and employer-sponsored programs to increase
physical activity and provide better insurance coverage for preventive
services.

<http://healthyamericans.org/reports/obesity2006/>

**Regular exercise and keeping weight in check decreases breast-cancer
risk factors**

Postmenopausal women who want to significantly decrease their
breast-cancer risk would be wise to exercise regularly and keep their
weight within a normal range for their height, according to new findings
from the Women\'s Health Initiative.

Specifically, they found a significant decrease in the two most common,
biologically active forms of estrogen, estrone and estradiol, among the
most active, lean women studied. The researchers found that women with
high BMI and low physical-activity had mean estrogen concentrations that
were 50 percent to 100 percent higher than that of women with low BMI
and high activity levels.

[McTiernan
A](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="McTiernan+A"%5BAuthor%5D)
et al Relation of BMI and Physical Activity to Sex Hormones in
Postmenopausal Women. [Obesity (Silver
Spring).](javascript:AL_get(this, 'jour', 'Obesity (Silver Spring).');)
2006 Sep;14(9):1662-77

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17030978>

**Management of Common Opioid-Induced Adverse Effects**

Opioid analgesics are useful agents for treating pain of various
etiologies; however, adverse effects are potential limitations to their
use. Strategies to minimize adverse effects of opioids include dose
reduction, symptomatic management, opioid rotation, and changing the
route of administration. Nausea occurs in approximately 25 percent of
patients; prophylactic measures may not be required. Patients who do
develop nausea will require antiemetic treatment with an antipsychotic,
prokinetic agent, or serotonin antagonist. Understanding the mechanism
for opioid-induced nausea will aid in the selection of appropriate
agents. Constipation is considered an expected side effect with chronic
opioid use. Physicians should minimize the development of constipation
using prophylactic measures. Monotherapy with stool softeners often is
not effective; a stool softener combined with a stimulant laxative is
preferred. Sedation and cognitive changes occur with initiation of
therapy or dose escalation. Underlying disease states or other centrally
acting medications often will compound the opioid\'s adverse effects.
Minimizing unnecessary medications and judicious use of stimulants and
antipsychotics are used to manage the central nervous system side
effects. Pruritus may develop, but it is generally not considered an
allergic reaction. Antihistamines are the preferred management option
should pharmacotherapy treatment be required. Am Fam Physician
2006;74:1347-54.

<http://www.aafp.org/afp/20061015/1347.html>

**Preventing Cardiovascular Disease in Women (also see Patient
Education)**

Cardiovascular disease (CVD) has been the primary cause of death in
women for almost a century, and more women than men have died of CVD
every year since 1984. Although CVD incidence can be reduced by
adherence to a heart-healthy lifestyle and detection and treatment of
major risk factors, preventive recommendations have not been
consistently or optimally applied to women. The American Heart
Association guidelines for CVD prevention in women provide physicians
with a clear plan for assessment and treatment of CVD risk and
personalization of treatment recommendations. The emphasis of preventive
efforts has shifted away from treatment of individual CVD risk factors
in isolation toward assessment of a woman\'s overall or \"global\" CVD
risk. In addition to accounting for the presence or absence of
preexisting coronary heart disease or its equivalents (e.g., diabetes,
chronic kidney disease), cardiovascular risk can be further calculated
with the Framingham risk score, which is based on age, sex, smoking
history, and lipid and blood pressure levels. Intervention intensity and
treatment goals are tailored to overall risk, with those at highest risk
receiving the most intense risk-lowering interventions. Women at high
risk for CVD and without contraindications should receive aspirin, beta
blockers, and an angiotensin-converting enzyme inhibitor or angiotensin
receptor blocker in addition to pharmacologic therapy for
hyperlipidemia, hypertension, and diabetes. Women who already are at
optimal or low risk for CVD should be encouraged to maintain or further
improve their healthy lifestyle practices. Optimal application of these
preventive practices significantly reduces the burden of death and
disability caused by heart attack and stroke in women. Am Fam Physician
2006;74:1331-40, 1342. <http://www.aafp.org/afp/20061015/1331.html>

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

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

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

Postcoital Bleeding and Cervical Cancer Risk

**Clinical Question:** Does bleeding after intercourse indicate cervical
cancer?

**Study Design:** Systematic review

**Synopsis:** The authors systematically reviewed several databases for
English-language studies that reported or provided sufficient data to
estimate the incidence or prevalence of postcoital bleeding. The authors
do not report searching for unpublished data, independent and paired
application of inclusion criteria, or paired data abstraction.
Ultimately, they included 38 articles.

They found no studies that determined how often women presenting with
post-coital bleeding were subsequently found to have cervical cancer.
One mass screening study from Finland identified 2,648 women with
postcoital bleeding, of whom 12 (0.45 percent) had invasive cancer at
the time of presentation. Eight of the studies (including hundreds of
thousands of women) evaluated women in community settings. The overall
rate of complaints about postcoital bleeding is highly variable (0.7 to
9.0 percent); however, the large population-based studies report the
prevalence at approximately 1 percent. It is not known how many women
who experience postcoital bleeding seek medical care.

Sixteen studies reported the prevalence of postcoital bleeding in more
than 47,000 women with invasive cervical cancer. The range of prevalence
in these studies was 0.7 to 39.0 percent.

**Bottom Line**: In this systematic review, the rate of postcoital
bleeding is highly variable and of uncertain significance. The best
estimate is that approximately one out of 220 women with postcoital
bleeding has invasive cervical cancer.

**(Level of evidence: 3a-)**

###### Shapley M, et al. A systematic review of postcoital bleeding and risk of cervical cancer. Br J Gen Pract June 2006;56:453-60.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16762128>

Metformin May Help Children Lose Weight

Clinical Question: Does metformin (Glucophage) lead to weight loss for
obese children and adolescents?

Study Design: Crossover trial (randomized)

Synopsis: Participants were obese patients from nine to 18 years of age
(13 boys, 15 girls) who were treated in an endocrine clinic. All had
clinical evidence of insulin resistance but did not meet the criteria
for diabetes. Patients were randomized (double-blinded) to metformin 1 g
twice daily or placebo for six months. This was followed by a six-month
crossover period to the other treatment, with a two-week washout period
in between.

There were equal numbers of children at Tanner stages 1 and 2 and at
Tanner stages 3 to 5 at study entry. Mean body mass index (BMI) was 35
kg per m2. Standardized information on exercise and healthy eating was
given to all patients. Four patients dropped out during the study, but
not because of medication side effects. At the end of the active
treatment period, significant benefits were observed for weight, BMI,
abdominal circumference, and fasting insulin levels. The mean treatment
effects after six months of active therapy compared with placebo were
weight loss of 9.6 lb (4.4 kg), BMI decrease of 1.3 kg per m2, waist
circumference decrease of 1.1 inches (2.8 cm), and fasting insulin
decrease of 2 mIU per L (14 pmol per L). Data to calculate a number
needed to treat were not presented.

Bottom Line: For obese patients nine to 18 years of age, six months of
metformin (1 g twice daily) treatment resulted in a mean weight loss of
approximately 10 lb (4.5 kg). Larger and longer studies are needed to
support the effectiveness and safety of this regimen.

**(Level of evidence: 1b-)**

Srinivasan S, et al. Randomized, controlled trial of metformin for
obesity and insulin resistance in children and adolescents: improvement
in body composition and fasting insulin. J Clin Endocrinol Metab June
2006;91:2074-80.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16595599>

Lubiprostone (Amitiza) for Chronic Idiopathic Constipation (STEPS)

Lubiprostone (Amitiza) is a prostaglandin derivative that reduces
constipation and improves stool consistency by activating specific
chloride channels (ClC-2) in the small intestine to increase intestinal
fluid secretion and accelerate small intestine and colonic transit
time.1-3 It is labeled for the treatment of chronic idiopathic
constipation lasting at least 12 weeks.4 Lubiprostone also is being
studied for use in constipation-predominant irritable bowel syndrome and
postoperative ileus.

Bottom Line

Although bulk or osmotic laxatives are less expensive first options for
treating patients with chronic idiopathic constipation, lubiprostone is
an alternative for those who do not tolerate or respond to these agents,
or in patients older than 65 years in whom tegaserod use is not
recommended.

<http://www.aafp.org/afp/20061015/steps.html>

STEPS drug updates cover Safety, Tolerability, Effectiveness, Price, and
Simplicity. Each update provides an independent review of a new
medication by authors who have no financial association with the drug
manufacturer.

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

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

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

**Amnioinfusion Does Not Prevent Meconium Aspiration Syndrome**

ABSTRACT: Amnioinfusion has been advocated as a technique to reduce the
incidence of meconium aspiration and to improve neonatal outcome.
However, a large proportion of women with meconium-stained amniotic
fluid have infants who have taken in meconium within the trachea or
bronchioles before meconium passage has been noted and before
amnioinfusion can be performed by the obstetrician; meconium passage may
predate labor. Based on current literature, routine prophylactic
amnioinfusion for the dilution of meconium-stained amniotic fluid is not
recommended. Prophylactic use of amnioinfusion for meconium-stained
amniotic fluid should be done only in the setting of additional clinical
trials. However, amnioinfusion remains a reasonable approach in the
treatment of repetitive variable decelerations, regardless of amniotic
fluid meconium status.

Amnioinfusion does not prevent meconium aspiration syndrome. ACOG
Committee Opinion No. 346. American College of Obstetricians and
Gynecologists. Obstet Gynecol 2006;108:1053--5.

<http://www.acog.org/publications/committee_opinions/co346.cfm>

**Postpartum Hemorrhage**

ACOG Practice Bulletin No. 76

Summary of Recommendations and Conclusions

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

-   Uterotonic agents should be the first-line treatment for postpartum
    hemorrhage due to uterine atony.

-   Management may vary greatly among patients, depending on etiology
    and available treatment options, and often a multidisciplinary
    approach is required.

-   When uterotonics fail following vaginal delivery, exploratory
    laparotomy is the next step.

-   In the presence of conditions known to be associated with placenta
    accreta, the obstetric care provider must have a high clinical
    suspicion and take appropriate precautions.

-   

Postpartum hemorrhage. ACOG Practice Bulletin No. 76. American College
of Obstetricians and Gynecologists. Obstet Gynecol 2006;108:1039--47.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17012482>

**Vulvodynia**

ABSTRACT: Vulvodynia is a complex disorder that can be difficult to
treat. It is described by most patients as burning, stinging,
irritation, or rawness. Many treatment options have been used, including
vulvar care measures, medication, biofeedback training, physical
therapy, dietary modifications, sexual counseling, and surgery. A cotton
swab test is used to distinguish generalized disease from localized
disease. No one treatment is effective for all patients. A number of
measures can be taken to prevent irritation, and several medications can
be used to treat the condition.

Vulvodynia. ACOG Committee Opinion No. 345. American College of
Obstetricians and Gynecologists. Obstet Gynecol 2006;108:1049--52.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17012483>

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

**What processes are in place for same last name awareness?**

This article reports on a case of mistaken identity that resulted in
erroneous surgery, despite a \"time out\" before beginning the
operation. <http://psnet.ahrq.gov/resource.aspx?resourceID=4211>

**Here is an interesting DNR case from this month's AHRQ Web M + M**

An elderly woman who had a DNR in place took a fall that required her to
have surgery. Discussion with the patient\'s health care proxy led to
the DNR order being suspended during surgery, with the understanding
that it would be reinstated postoperatively. Several days later, a nurse
noticed that patient remained \'full code\' because the DNR had not been
restored. See the link below for the rest of the story

**DNR in the OR and Afterwards**

<http://www.webmm.ahrq.gov/case.aspx?caseID=135>

**Prevalence, impact, and disclosure of domestic violence among women**

<http://www.ahrq.gov/research/aug06/0806RA4.htm>

**Moderately premature infants born at 30 to 34 weeks gestation tend to
suffer substantial health problems**

<http://www.ahrq.gov/research/aug06/0806RA11.htm>

**Bariatric obesity surgery complication rates are higher over time**

<http://www.ahrq.gov/research/aug06/0806RA1.htm>

**Elderly women are more likely than men to die after coronary bypass
surgery**

<http://www.ahrq.gov/research/aug06/0806RA5.htm>

**Minority women are nearly twice as likely as white women to not
receive needed postoperative treatments for early-stage breast cancer**

<http://www.ahrq.gov/research/aug06/0806RA3.htm>

**Complications from chemotherapy in women with breast cancer are
greater than previously estimated**

<http://www.ahrq.gov/research/aug06/0806RA2.htm>

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

**From your Library: Updated Cochrane Systematic Reviews**

**Aerobic Exercise and Pregnancy**

A review of 11 trials involving 472 pregnant women suggested that
pregnant women who engage in vigorous exercise at least two to three
times per week improve or maintain their physical fitness, and there is
some evidence that these women have pregnancies of the same length as
those who maintain their usual activities. There is too little evidence
to show whether there are other effects on the woman and her baby. The
trials reviewed included non-contact exercise such as swimming, static
cycling and general floor exercise programs. Most of the trials were
small and of insufficient methodologic quality, and larger, better
trials are needed before confident recommendations can be made about the
benefits and risk of aerobic exercise in pregnancy. Aerobic exercise is
physical activity that stimulates a person\'s breathing and blood
circulation.

Kramer MS, McDonald SW. Aerobic exercise for women during pregnancy.
Cochrane Database of Systematic Reviews 2006, Issue 3.

**Calcium Supplementation Safe and Cheap**

Calcium supplementation during pregnancy is a safe and relatively cheap
means of reducing the risk of pre-eclampsia in women at increased risk,
and women from communities with low dietary calcium, according to a
recent review.. Preterm birth (birth before 37 weeks) is often caused by
high blood pressure and is the leading cause of newborn deaths,
particularly in low-income countries. No adverse effects have been found
from calcium supplementation, but further research is needed into the
ideal dosage.

Hofmeyr GJ, Atallah AN, Duley L. Calcium supplementation during
pregnancy for preventing hypertensive disorders and related problems.
Cochrane Database of Systematic Reviews 2006, Issue 3.

**Preclampsia Drugs: No Clear Choice**

A review of 24 trials including 2949 women found that while
antihypertensive drugs lower blood pressure, there is not enough
evidence to show which drug is the most effective when taken by pregnant
women with hypertension. There is some evidence that diazoxide may
result in the woman\'s blood pressure falling too quickly, and that
ketanserin may not be as effective as hydralazine. Further research into
the effects of antihypertensive drugs is needed.

Duley L, Henderson-Smart DJ, Meher S. Drugs for treatment of very high
blood pressure during pregnancy. Cochrane Database of Systematic Reviews
2006, Issue 3.

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

**[Cochrane Library](http://hsrl.nihlibrary.nih.gov/): Evidence based
reviews of an array of clinical topics**\
Thanks to Diane Cooper at the NIH library, the link below will take you
from our Indian Health website to the NIH Health Services Research
Library. The Cochrane Library is the definitive evidence based medicine
resource. It reviews only randomized controlled trials.

Paste the link below into your browser. Click on the Cochrane Library
link. This will take you to the NIH Library site. Scroll across the top
menu to RESEARCH TOOLS. In the drop down box select DATABASES, and
scroll down the list to COCHRANE.

<http://www.ihs.gov/MedicalPrograms/CIR/index.cfm?module=cir_answering_clinical_questions>

##### 

Contact Diane Cooper for questions: <cooperd@ors.od.nih.gov>

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

**Do you have breastfeeding questions? The new Breast feeding site has
the answers**

The I.H.S MCH Breastfeeding webpage has been updated. To see the new
look, go to [www.ihs.gov](http://www.ihs.gov/), click on Medical
Programs, then Maternal Child Health and then Breastfeeding.

Once on the Breastfeeding home page, you will find quick access to
helpful resources like the Easy Guide to Breastfeeding for AI/AN
Families, the new Lactation Support Policy in the Workplace, and list of
topics designed to make breastfeeding support a reality.

**Curious about breastfeeding reducing risk of diabetes and obesity?**
-- Look in the Breastfeeding, diabetes and obesity section for
information and references.

**Want to know what to tell a mom about commonly asked concerns** --
like sore nipples and how-do-I-know-that-my-baby-is-getting-enough-milk?
Click on FAQs and scroll to the topic.

**How about breastfeeding benefits?** The Breastfeeding Benefits section
has a quick list of benefits, plus a link to the American Academy of
Pediatrics' (AAP) most recent position paper on breastfeeding. The paper
includes numerous, landmark studies about breastfeeding benefits with
links to Pubmed for abstracts.

**Need ideas for breastfeeding moms who work or go school**? -- Take a
look at the Going back to Work or School section. Also, look at the Home
Page link to the NEW I.H.S Circular for Lactation Support Policy in the
Workplace (July 2006). The new circular has the latest, most current
information about supporting breastfeeding employees in the I.H.S. work
environment.

**Want to know about medications and breast milk?** The section on
Medications is the spot for you. Jim Bresette and his amazing I.H.S.
Pharmacists have collaborated to create this section -- there is even a
link to the NIH Lactnet page where a medication can be typed in and the
studies, issues, AAP reviews, possible alternative drugs, etc are listed
-- quickly and easily read.

**What about the nitty, gritty stuff** - the things that staff need to
make the real work of patient care come together? Like patient education
materials/videos/posters, ways to easily keep track of feeding choice
rates, PCC templates, job descriptions, policy/procedure ideas, what
other agencies/coalitions are doing, etc? Don't recreate the wheel, go
directly to Staff Resources, use what fits, edit what you need and send
suggestions.

**Weary of limiting breastfeeding karma to just mom and baby?** Be in
awe of the beautiful dad and child picture on the Dads and Family Page
-- and email us your pictures!

**Want to know about what other groups are doing or what other resources
are available for lactation support?** Try out the Links & Contact info
page.

**Got a bone to pick or question to ask about lactation support?** Put
your thoughts on line with the ListServ/Discussion Forum. Lactation is
an evolving science, practice and research change the fact of what we
do, no one knows all the answers, together we are better.

**What is next for the web page?** Possible additions include updates,
more links, conference announcements, and CEUs.

Please send pictures, ideas, suggestions, and thoughts to
<suzan.murphy@ihs.gov>

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

#### A New Look for Lactation Support -- The New Breastfeeding web page {#a-new-look-for-lactation-support-the-new-breastfeeding-web-page .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

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

#### Lactation Support in the Indian Health Workplace: New Circular {#lactation-support-in-the-indian-health-workplace-new-circular-1 .Style-Heading-4-+-Arial-14-pt-Underline}

We are pleased to announce - the Issuance of Circular 2006-05 --
Lactation Support Program. 

Signed by the Director on July 7, 2006 the circular establishes policy
to allow women who are returning to work who choose to breastfeed their
infant, to express breast milk during their tour of duty, provided they
have obtained prior approval.  The draft circular went out for review
and comment in early winter 2006 and now in its final form will be sent
to all Area Offices. 
<http://www.ihs.gov/PublicInfo/Publications/IHSManual/Circulars/Circ06/Circ06_05/circ06_05/circ06_05.htm>** **

Please note the circular includes 'exhibits' on FAQ's for employees,
supervisor and for management allowing for ease of implementation.  An
implementation tool kit is being planned and we will be seeking your
input. <Judith.Thierry@ihs.gov>

Thank you!  Judy

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

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

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

#### September 2006 Highlights included: {#september-2006-highlights-included-1 .Style-Heading-4-+-Arial-14-pt-Underline}

-FDA OTC Access for Plan B for 18 and Older: A 'Catch-22' for AI/AN
patients?

-USPSTF Best Practices - Breast and Cervical Cancer Screening, plus
Helpful Tips

-Cesarean delivery: Increased risks versus vaginal delivery - 4 articles

-See and treat: HPV positive, HSIL cytology, and a HG impression at 2nd
colposcopy

-Metformin Useful for Treating PCOS in Adolescents

-Varenicline was significantly more efficacious for smoking cessation

-Human Papillomavirus Vaccination: ACOG Committee Opinion

-Engorgement - It only feels like it is going to last forever

-Adolescent perception of sexual abstinence: A complete disconnect

-HIV Management System, v1.0 - National Release

-Health care and indigenous peoples: the other side of the planet

-First trimester screening: How would you counsel this patient?

-Postpartum Care: Still the neglected step child of perinatal services?

-Implanon- A single rod contraceptive implant...

-Harm Resulting from Inappropriate Telephone Triage in Primary Care

-How important is maternal intratpartum glucose to neonatal
hypoglycemia?

-Must Honor Advance Directives - Palliative Medicine\'s Role in the
Continuity of Care

-Sexual Education / HIV Education and youth

-Weight Loss Should be the Primary Intervention for Risk of Diabetes

**Entire September 2006 hard copy newsletter here**

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/documents/06SepOL.pdf**](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/06SepOL.pdf)  {#httpwww.ihs.govmedicalprogramsmchmdocuments06sepol.pdf .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

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

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

**A must WEB site for CHILD Abuse care and practice info**

Ann S. Botash, MD at Upstate New York and colleagues has developed an
extraordinary and comprehensive web site, cross referenced, appended,
and updated\-\--this could be your go-to reference for everything
related to child maltreatment and child sexual abuse. Site is extremely
intuitive and reflective of everyday practice needs.

The CPT code tells the insurer \"what\" was done (i.e. type of visit),
and the ICD-9 tells \"why\" or the diagnosis.
<http://www.childabusemd.com/documentation/coding-billing.shtml#cpt>

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

**Palliative Care Training**

We have the opportunity for training in palliative and end-of-life care
made possible through a partnership with the National Cancer Institute
Office of Education and Special Initiatives (NCI/OESI). 

 

January 23 -- 25, 2007 (with January 22 and 26 as possible travel days)
in Window Rock, Arizona.

 

This training is structured around the EPEC-O curriculum.  The EPEC-O
curriculum was produced by The EPEC Project™ with major funding provided
by National Cancer Institute, with supplemental funding provided by the
Lance Armstrong Foundation.  It is a modular curriculum, well suited to
a Train the Trainer model.

 

Our intent with this first training is to develop a national cohort of
clinicians who are familiar with the curriculum and comfortable with the
content.  They would not only use the content in local program
development and education, but be available for Area or regional
training using the curriculum.

 

NCI/OESI views this as an ongoing relationship and hopes to continue to
partner with us in the development of Area or regional trainings
starting later in FY07.  This would bring dollars to the Areas to
continue this training.

 

We have asked the Area Chief Medical Officers to nominate individuals
from each Area for training.  An important consideration is that we
expect the folks attending this training to be able to be available to
serve as trainers for regional or Area trainings.  We have funding to
support travel and per diem for two trainers from each Area but we have
additional capacity for Area or Service Unit sponsored trainers.  We
would recommend the nomination of one physician and either a nurse,
pharmacist, or behavioral health professional from each Area.  We need
to identify attendees by October 31.

 

Attached you will find a draft curriculum outline for the training.  We
have IHS faculty as well as faculty from NCI and the Mayo Clinic.

 

Dr. Tim Domer at Fort Defiance Indian Hospital is leading this
training.  Please contact him with questions regarding the specifics of
the training:  <Tim.Domer@ihs.gov>**     928-729-8021.**

 

Feel free to contact me as well with any questions, comments,
suggestions.  Your feedback helps us stay on track.

 

Let your Area CMO know of your interest sending folks to attend the
meeting.

**How is the Indian Health System providing palliative and end-of-life
care?**

We need your help. We are trying to get a handle on where we are in the
Indian Health System (IHS, Tribal, and Urban programs) when it comes to
providing palliative and end-of-life care.

-We have designed a brief (5 minutes) survey to get the perspective of
physicians, nurses, pharmacists, and administrators working in the
health system, tasked with providing the care.

-This survey is being sent out through various list serves. If you have
already completed the survey, we apologize for the duplication;
disregard this message.

-Please feel free to share the link with others. We hope to reach as
many facilities as possible and recognize that there may be different
perspectives in a single facility.

The survey is available by clicking on this link:

[Palliative Care Services and Access
Survey](http://www.surveymonkey.com/s.asp?u=231271843431)

or by clicking on, or cutting and pasting this URL:

[http://www.surveymonkey.com/s.asp?u=231271843431](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.surveymonkey.com/s.asp?u=231271843431) 

If you have questions, feel free to call me at 413-584-0790 or
615-417-4915.

Thank you!

Bruce Finke, MD

IHS Elder Care Initiative

**The Last Hours of Living: Practical Advice for Clinicians**\
A free CME module with very helpful ideas and resources including:\
Preparing for the Last Hours of Life\
Physiologic Changes and Symptom Management\
Two Roads to Death\
When Death Occurs\
Notifying Others of the Death\
Pronouncing Death\
Summary of Take-Home Lessons\
References\
Related Resources

[http://www.medscape.com/viewprogram/5808?sssdmh=dm1.217567&src=top10#](http://www.medscape.com/viewprogram/5808?sssdmh=dm1.217567&src=top10)

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

#### Ortho Evra Patch Linked to Risk for Venous Thromboembolism {#ortho-evra-patch-linked-to-risk-for-venous-thromboembolism-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### On September 21, 2006 the US Food and Drug Administration (FDA) and Ortho-McNeil Pharmaceutical (a Johnson & Johnson company) notified healthcare professionals regarding changes to the safety labeling for a weekly norelgestromin/ethinyl estradiol transdermal system (Ortho Evra).  The label has been updated to reflect new data from 2 US epidemiologic studies that evaluated the relative risk for developing nonfatal venous thromboembolism (VTE) in women using the contraceptive patch vs oral contraceptives containing 35 µg of ethinyl estradiol, according to an alert sent yesterday from MedWatch, the FDA\'s safety information and adverse event reporting program. Both studies were conducted using electronic healthcare claims data, and the second study also included patient chart reviews.  Although findings from the first study revealed no significant difference in VTE risk for patch users compared with those taking oral contraceptives containing 35 µg of ethinyl estradiol (odds ratio \[OR\] = 0.9; 95% confidence interval \[CI\], 0.5 - 1.6), the second study linked the patch to more than double the risk for the event (OR = 2.4; 95% CI, 1.1 - 5.5).  The FDA notes that the latter finding supports the agency\'s concerns regarding the risk for VTE in women using the contraceptive patch.  Healthcare professionals are advised to balance the higher estrogen exposure and the possible increased risk of VTE against the chance of pregnancy if the patch is not used; contraceptive options other than the patch should be considered for women with risk factors for thromboembolic disease.  Adverse events related to use of the norelgestromin/ethinyl estradiol contraceptive patch should be reported to the FDA\'s MedWatch reporting program by phone at 1-800-FDA-1088, by fax at 1-800-FDA-0178, online at [**http://www.fda.gov/medwatch**](http://www.fda.gov/medwatch), or by mail to 5600 Fishers Lane, Rockville, MD 20852-9787.[**http://www.medscape.com/viewarticle/544925?sssdmh=dm1.217567&src=top10**](http://www.medscape.com/viewarticle/544925?sssdmh=dm1.217567&src=top10) {#on-september-21-2006-the-us-food-and-drug-administration-fda-and-ortho-mcneil-pharmaceutical-a-johnson-johnson-company-notified-healthcare-professionals-regarding-changes-to-the-safety-labeling-for-a-weekly-norelgestrominethinyl-estradiol-transdermal-system-ortho-evra.-the-label-has-been-updated-to-reflect-new-data-from-2-us-epidemiologic-studies-that-evaluated-the-relative-risk-for-developing-nonfatal-venous-thromboembolism-vte-in-women-using-the-contraceptive-patch-vs-oral-contraceptives-containing-35-µg-of-ethinyl-estradiol-according-to-an-alert-sent-yesterday-from-medwatch-the-fdas-safety-information-and-adverse-event-reporting-program.-both-studies-were-conducted-using-electronic-healthcare-claims-data-and-the-second-study-also-included-patient-chart-reviews.-although-findings-from-the-first-study-revealed-no-significant-difference-in-vte-risk-for-patch-users-compared-with-those-taking-oral-contraceptives-containing-35-µg-of-ethinyl-estradiol-odds-ratio-or-0.9-95-confidence-interval-ci-0.5---1.6-the-second-study-linked-the-patch-to-more-than-double-the-risk-for-the-event-or-2.4-95-ci-1.1---5.5.-the-fda-notes-that-the-latter-finding-supports-the-agencys-concerns-regarding-the-risk-for-vte-in-women-using-the-contraceptive-patch.-healthcare-professionals-are-advised-to-balance-the-higher-estrogen-exposure-and-the-possible-increased-risk-of-vte-against-the-chance-of-pregnancy-if-the-patch-is-not-used-contraceptive-options-other-than-the-patch-should-be-considered-for-women-with-risk-factors-for-thromboembolic-disease.-adverse-events-related-to-use-of-the-norelgestrominethinyl-estradiol-contraceptive-patch-should-be-reported-to-the-fdas-medwatch-reporting-program-by-phone-at-1-800-fda-1088-by-fax-at-1-800-fda-0178-online-at-httpwww.fda.govmedwatch-or-by-mail-to-5600-fishers-lane-rockville-md-20852-9787.httpwww.medscape.comviewarticle544925sssdmhdm1.217567srctop10 .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

**New Breastfeeding Web Page for the Indian Health System**

The Maternal Child Health Website now boasts a new breastfeeding website
developed by Suzan Murphy in Phoenix. The site is located at
<http://www.ihs.gov/MedicalPrograms/MCH/M/bf.cfm>.

The page contains many useful links for providers such as the Health and
Human Services National Women's Health Information Center which contains
a wealth of accurate and pertinent information. Also available through
the web page is access to the IHS Breastfeeding Guide with online
ordering (up to 100 copies for free). You can also find the IHS Circular
on the Lactation Support Policy in the Workplace which details the
official policy on how we are to support our employees who are
lactating.

PS: Don't forget to regularly visit the MCH Home Page at
<http://www.ihs.gov/MedicalPrograms/MCH/index.cfm>.

There you will easily find links to new postings on the entire MCH site
such as new USPSTF guidelines on breast and cervical cancer screening
and the new CDC guidelines for the treatment of STD's.

As always, comments and contributions on the website are welcome and
encouraged.

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

**Q. Is my first trimester patient always hyperthyroid if her labs are
abnormal?**

A. No, not necessarily. If she is clinically stable, then wait till
18-20 weeks to decide. See details

**More about the question**

A patient presents in the first trimester with hyperemesis. One of your
colleagues obtains a complete thyroid function panel. The thyroid
stimulating hormone (TSH) is significantly decreased. The patient
follows up with you and wants to know how soon she should start her
hyperthyroid medication.

**Quick answer**

If clinically stable, then wait till 18-20 weeks to decide if the
patient is truly hyperthyroid

Now, let's explore this issue a little more closely.

The rest of the answer is here

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/Hyperthy4706.doc>

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

**October 2006 -- Highlights**

-Early prednisone therapy in Henoch-Schonlein purpura

-Physician documentation of neonatal risk assessment for perinatal
infections.\
-The Alaska Haemophilus influenzae type b experience: lessons in
controlling a vaccine-preventable disease

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ICHN1006.doc>

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

**New patient wellness handout**

OIT is pleased to announce the release of the new patient wellness
handout. Please see the attached instructions for more details on this
handout. This functionality is part of the new health summary patch
(Patch APCH\*2\*15). OIT would like to thank Chris Lamer, Mary Wachacha
and others for their ongoing work with OIT in patient education and
wellness.

The Health Summary patch adds a new option to generate an Adult Patient
Wellness Handout. The Adult Patient Wellness Handout is a new addition
to the IHS Health Summary.  The goal of the Wellness Handout is to
empower patients to increase their role in their own health care. The
Wellness Handout provides access to key patient clinical information to
enhance patient education and knowledge. This should help improve
clinical outcomes and health status. 

The Health Summary patch also fixes/modifies the following functionality
on the health summary:\
1) Changes the term \"prescribed at\" to \"dispensed at\" in the
medication components.\
2) Changes the domestic violence exam terminology to \"DOMESTIC VIOLENCE
SCREENING\" in the exam section and adds the result of the Domestic
Violence Screening to the exam section.\
 3) Adds a new Depression Screening Health maintenance reminder this
reminder. Check with your computer operations or IT department if you
would like this item added to a health summary that you use.\
 4) Adds a new supplement which allows you to display only medications
that have been documented as being \"chronic\" through the pharmacy
package or electronic health record (EHR).

Please ask you site manager for further details.

Theresa Cullen <Theresa.Cullen@ihs.gov>

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

**Maternal survival worldwide: consensus and controversies**

In the year 2000, 189 countries and many major international agencies
signed a "Millennium Declaration" that was to provide a blueprint for
improving conditions around the world -- in particular, the conditions
of the poor. The blueprint was divided into eight goals. Millennium
Development Goal #5 committed signatory countries to improve maternal
health; since improving health is difficult to measure, the agreement
was to try to reduce maternal mortality by two thirds by 2015.

Anyone interested in maternal and child health will want to take a look
at the Lancet's new series on maternal survival, hot off the presses
last week. In a series of five review articles and several associated
commentaries, major figures in maternal health review what we know about
maternal mortality (and to a lesser extent morbidity) and what to do
about it. The upshot? Six years into the millennium, progress on
maternal mortality does not look good. Statistics are unreliable, but it
appears that maternal deaths have stabilized at about 400 per 100,000
live births (far from the MDG target of 141per 100,000 by 2015).
Improvements in some countries, like Bangladesh, have been offset by
worsening in others, such as Afghanistan and much of sub-Saharan Africa.
Inequality is worse for obstetric risk than for any other health
indicator: a woman in Sweden has a 1in 30,000 lifetime risk of death in
childbirth, while for a woman in Sierra Leone that risk is 1 in 6.

Readers will find both consensus and controversy here. All contributors
agree that political commitment and financial investment fall short of
what they should be. All contributors seem to agree that funding
competition between maternal health programs and child health programs,
and between community-based and clinic-based programs, has been a waste
of opportunity and time. (To use the memorable Cameroonian proverb
quoted in one editorial, "When the elephant and the rhino fight, it is
the grass that suffers.") And all contributors agree that women have a
right to birth in a safe facility attended by a skilled health worker --
preferably a midwife. Major areas of controversy remain, however: chief
among them are the role of home birth with skilled attendants in the
developing world; the contribution of iatrogenic illness, especially
infection, to maternal death; and the importance of providing safe
abortion.

Review articles 1 (by C Ronsmans and WJ Graham), 2 (OMR Campbell and WJ
Graham), and 5 (V Filippi et. ­al) are especially helpful overviews of
global research on maternal health and survival. The authors provide
evidence debunking some myths many of us will find hard to let go (for
instance, that risk screening during antenatal care will improve
maternal mortality). They also provide heartening evidence that many
different strategies can improve maternal health, from improving control
of infectious diseases to ensuring access to hospital care to providing
midwifery in the community.

You can access all five articles and several related commentaries at
[www.thelancet.com](http://www.thelancet.com/)

(requires free registration). Look for the Maternal Survival Series,
September 30, 2006.

**Other**

**An Entire Issue of Can J Public Health Dedicated to Health Policy**

Here is just one example. There are many more

Martens PJ et al. (eds), Health Services Use of Manitoba First Nations
People: Is It Related to Underlying Need? [Can J Public
Health.](javascript:AL_get(this, 'jour', 'Can J Public Health.');) 2005
Jan-Feb;96 Suppl 1:S39-44.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=15686152>

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

**What is the contribution of preterm birth to infant mortality rates?**

\"We found that more infants died because they were born preterm than as
a result of any other cause of death,\" state the authors of an article
published in the October 2006 issue of Pediatrics. The Healthy People
2010 objectives have identified reduction of the U.S. infant mortality
rate as a national priority; however, there has been minimal progress in
recent years.

The data used in the analyses were taken from the death certificates for
all infants (less than 365 days of age) who died during 2002 and from
the birth certificates of those infants, regardless of whether they were
born in 2001 or 2002. For the 2002 linked file, 99% of infant death
records were linked to the corresponding birth certificates. All
analyses were weighted to account for the small fraction of unlinked
records. The authors identified the top 20 leading causes of death in
the linked file. The role of preterm birth for each cause was assessed
by determining the proportion of infants who were born preterm for each
cause of death and by considering the connection between preterm birth
and the specific cause of death.

The authors found that

\* There were 27,970 infant deaths in 2002, and the leading causes of
death accounted for 22,273 of those deaths.

\* According to traditional NCHS ranking rules, congenital malformations
accounted for 5,630 (20%) of all infant deaths; short gestation/low
birthweight was the second leading cause of death, accounting for 4,636

(17%) of all infant deaths.

\* Overall, 93% of the 10,372 infants with causes of death the authors
considered attributable to preterm birth were born at less than 37 weeks
of gestation; these 9,596 infant deaths were designated as attributable
to preterm birth. The vast majority (95%) of these 9,595 infants were
born at less than 32 weeks of gestation and weighed less than 1,500 g at
birth.

\* The 9,596 deaths classified as attributable to preterm birth
represented 34% of all infant deaths and 43% of all deaths among the 20
leading causes.

\* With the strictest requirements for gestational age at birth (less
than 32 weeks) and birthweight (less than 1,500 g), deaths classified as
attributable to preterm birth represented 33% of all infant deaths and
41% of all deaths among the 20 leading causes of death.

The authors conclude that \"there is an urgent need for an expanded
comprehensive agenda to understand the complex social and biological
factors that determine susceptibility to preterm birth, to detect women
at risk early in pregnancy, and to develop and to evaluate new methods
for preventing this important cause of death.\"

Callaghan WM, et al. 2006. The contribution of preterm birth to infant
mortality rates in the United States. Pediatrics 118(4):1566-1573
[[http://pediatrics.aappublications.org/cgi/content/abstract/118/4/1566?rss=1]{.underline}](http://pediatrics.aappublications.org/cgi/content/abstract/118/4/1566?rss=1)

**Increased efforts are needed for states to achieve all eight HP 2010
objectives**

The report provides a snapshot of state progress toward achieving HP
2010 objectives with a focus on perinatal indicators associated with the
following eight objectives: (1) pregnancy intention, (2) multivitamin
use, (3) physical abuse, (4) cigarette smoking during pregnancy, (5)
cigarette smoking cessation, (6) drinking alcohol during pregnancy, (7)
breastfeeding initiation, and (8) infant sleep position.

Data for the analysis were drawn from the Pregnancy Risk Assessment
Monitoring System (PRAMS), an ongoing, state- and population-based
surveillance designed to monitor selected self-reported maternal
behaviors and experiences that occur before, during, and after pregnancy
among women who deliver live-born infants. Results from 19 states that
collected data during 2000-2003 and achieved weighted response rates of
greater than or equal to 70% in 1 year were included in the analysis.

The authors found that

\* Preconception period \-- No state achieved the HP 2010 objectives for
intended pregnancy, multivitamin use during the month before pregnancy,
and physical abuse during the 12 months before pregnancy.

\* Prenatal period \-- No state achieved the objective for abstinence
from smoking during pregnancy. However, all states achieved the
objective for smoking cessation during pregnancy, and more than
three-fourths achieved or exceeded the objective for abstinence from
alcohol during pregnancy.

\* Postpartum period \-- Nearly half of the states achieved the
objective for breastfeeding, and slightly more than one-third achieved
the objective for infant sleep position.

\"More progress has been made in the health indicators related to
maternal behaviors during pregnancy . . . and after pregnancy . . .

than for those related to behaviors before pregnancy,\" state the
authors. They conclude that \"continued use of PRAMS data to monitor
these maternal behaviors is important for implementing, evaluating, and
setting priorities for future initiatives at the state level.\"

Suellentrop K, Morrow B, Williams L, et al. 2006. Monitoring progress
toward achieving maternal and infant Healthy People 2010 objectives
\--19 states, Pregnancy Risk Assessment Monitoring System (PRAMS),
2000-2003. MMWR Surveillance Summaries 55(SS09):1-11

[[http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5509a1.htm?s_cid=ss5509a1_e]{.underline}](http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5509a1.htm?s_cid=ss5509a1_e)

**Portal to Maternal and Child History Materials**

The MCH Library recently launched a new portal on its Web site. The
portal, titled Maternal and Child Health History, includes a collection
of historical documents and reports related to maternal and child health
(MCH) and health services for children and families in the United
States. The portal focuses particularly on federal programs, including
activities of the Children\'s Bureau and MCH services under Title V of
the Social Security Act. Contents include an overview, materials in the
MCH Library, special collections, legislation and program data, and
links. Plans are under way to digitize materials not currently
accessible in electronic format. The portal is available at
[[http://mchlibrary.info/history/index.html]{.underline}](http://mchlibrary.info/history/index.html)

**Children's Opportunity Depends on Their Parent's Opportunity**

The Fall 2006 issue of The Future of Children, titled Opportunity in
America, examines the dominant set of beliefs about America as a land of
opportunity and reviews evidence on how close the nation has come to
this ideal and what might be done to improve opportunity. The e-journal,
published by Princeton University\'s Woodrow Wilson School of Public and
International Affairs and the Brookings Institution, contains a
collection of articles that examine how opportunity has changed over
time and how it varies by race, gender, and national origin. The authors
also explore how education, health, and culture affect social mobility
for children born in different circumstances and what the government
might do in each of these domains to make opportunity in the United
States more equal.
[[http://www.futureofchildren.org/pubs-info2825/pubs-info_show.htm?doc_id=388485]{.underline}](http://www.futureofchildren.org/pubs-info2825/pubs-info_show.htm?doc_id=388485)

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

#### The words 'bizarre' and 'atypia' in the same pathology report sentence...hmmm.... {#the-words-bizarre-and-atypia-in-the-same-pathology-report-sentencehmmm.-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### A 53 yo G6 P5015 presented to a field facility with ongoing menometrorrhagia despite conservative therapy with medroxyprogesterone 10 mg for 10 days a month for 3 months. Initial ultrasound revealed a 2.7 x 2.4 cm endometrial structure felt to be consistent with an endometrial polyp or a leiomyoma.  {#a-53-yo-g6-p5015-presented-to-a-field-facility-with-ongoing-menometrorrhagia-despite-conservative-therapy-with-medroxyprogesterone-10-mg-for-10-days-a-month-for-3-months.-initial-ultrasound-revealed-a-2.7-x-2.4-cm-endometrial-structure-felt-to-be-consistent-with-an-endometrial-polyp-or-a-leiomyoma. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### A follow-up ultrasound 2 months later at the field facility revealed 2 complex masses involving the endometrium with the appearance of some myometrial extension. The first was located in the mid-uterus and endometrium and was larger than the second which was located in the lower uterine segment. {#a-follow-up-ultrasound-2-months-later-at-the-field-facility-revealed-2-complex-masses-involving-the-endometrium-with-the-appearance-of-some-myometrial-extension.-the-first-was-located-in-the-mid-uterus-and-endometrium-and-was-larger-than-the-second-which-was-located-in-the-lower-uterine-segment. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### An endometrial biopsy was obtained at the initial visit and was consistent with benign proliferative phase endometrium. {#an-endometrial-biopsy-was-obtained-at-the-initial-visit-and-was-consistent-with-benign-proliferative-phase-endometrium. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Examination revealed an eight week size uterus and no adnexal masses. There was urethral hypermobility, but no visible incontinence with Valsalva maneuver. The examination was otherwise unremarkable. {#examination-revealed-an-eight-week-size-uterus-and-no-adnexal-masses.-there-was-urethral-hypermobility-but-no-visible-incontinence-with-valsalva-maneuver.-the-examination-was-otherwise-unremarkable. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### A discussion with the patient ensued and it was felt that further imaging modalities were indicated. In addition, the patient was offered a hysteroscopy, further endometrial sampling, and possible hysteroscopic resection. As both the above management options required transportation to a distant referral facility, the patient stated she would prefer a definitive operative intervention, if she needed to make such a trip. {#a-discussion-with-the-patient-ensued-and-it-was-felt-that-further-imaging-modalities-were-indicated.-in-addition-the-patient-was-offered-a-hysteroscopy-further-endometrial-sampling-and-possible-hysteroscopic-resection.-as-both-the-above-management-options-required-transportation-to-a-distant-referral-facility-the-patient-stated-she-would-prefer-a-definitive-operative-intervention-if-she-needed-to-make-such-a-trip. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### The patient subsequently received an uncomplicated total vaginal hysterectomy with a left salpingo-oophorectomy. The patient was discharged on the second post operative day. {#the-patient-subsequently-received-an-uncomplicated-total-vaginal-hysterectomy-with-a-left-salpingo-oophorectomy.-the-patient-was-discharged-on-the-second-post-operative-day. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Pathologic evaluation revealed cytologic atypia present throughout the neoplasm that was of a degenerative and bizarre type. Occasional mitotic figures were identified. No tumor type necrosis was seen. The increased cellularity was felt to be somewhat increased over what one normally sees in a highly cellular leiomyoma. The pathologic material was sent to a second site for pathologic evaluation and the above impression was confirmed. {#pathologic-evaluation-revealed-cytologic-atypia-present-throughout-the-neoplasm-that-was-of-a-degenerative-and-bizarre-type.-occasional-mitotic-figures-were-identified.-no-tumor-type-necrosis-was-seen.-the-increased-cellularity-was-felt-to-be-somewhat-increased-over-what-one-normally-sees-in-a-highly-cellular-leiomyoma.-the-pathologic-material-was-sent-to-a-second-site-for-pathologic-evaluation-and-the-above-impression-was-confirmed. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### What do you think this patient's diagnosis is?  {#what-do-you-think-this-patients-diagnosis-is .Style-Heading-4-+-Arial-14-pt-Underline}

#### What is the risk of recurrence? {#what-is-the-risk-of-recurrence .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Stay tuned to next month's Medical Mystery Tour for the rest of the story {#stay-tuned-to-next-months-medical-mystery-tour-for-the-rest-of-the-story .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

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

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

######### 

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

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

**Clinical Discussion Board Index, Medscape**

Hundreds of ongoing clinical discussions available

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

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

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

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

**Menopause Management**

# Associations between night sweats and other sleep disturbances

# RESULTS: Thirty-four percent of the 363 patients interviewed reported night sweats, one half of whom reported saturating their bedclothes. In the multivariate model, night sweats were associated with daytime tiredness (OR = 1.99; 95% CI, 1.12-3.53), waking up with a bitter taste in the mouth (OR = 1.94; 95% CI, 1.19-3.18), legs jerking during sleep (OR = 1.78; 95% CI, 1.05-3.00), and awakening with pain in the night (OR = 1.87; 95% CI, 1.16-2.99). CONCLUSIONS: Night sweats are associated with several sleep symptoms. Both night sweats and sleep disturbances are commonly experienced by adult primary care patients. When their patients report night sweats, clinicians should consider asking about sleep quality and sleep-related symptoms.

# [Mold JW](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Mold+JW"%5BAuthor%5D), [Woolley JH](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Woolley+JH"%5BAuthor%5D), [Nagykaldi Z](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Nagykaldi+Z"%5BAuthor%5D). Associations between night sweats and other sleep disturbances: An OKPRN study. [Ann Fam Med.](javascript:AL_get(this, 'jour', 'Ann Fam Med.');) 2006 Sep-Oct;4(5):423-6. 

# Combination Estrogen-Progestin Hormone Prescribed by Age Group

# Annual Rate of Visits\* to Office-Based Physicians and Hospital Outpatient Departments During Which Combination Estrogen-Progestin Hormone Therapy Was Prescribed for Women Aged \>40 years, by Age Group \-\-- United States, 2001\--2003

![](media/image4.png){width="5.156944444444444in"
height="3.071527777777778in"}

\* Per 100 women in age group.

From 2001 to 2003, the overall rate of visits to physicians during which
combination estrogen-progestin hormone therapy was prescribed decreased
by 44%. The decline was greatest among women aged \>50 years. In July
2002, the National Institutes of Health terminated a clinical trial of
combined hormone therapy (a component of the Women\'s Health Initiative)
after investigators determined that the associated health risks
outweighed the benefits.

Hing E, Brett K. Changes in U.S. prescribing patterns of menopausal
hormone replacement therapy, 2001\--2003. Obstet Gynecol
2006;108:33\--40.

#### [**http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5538a6.htm?s_cid=mm5538a6_e**](http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5538a6.htm?s_cid=mm5538a6_e) {#httpwww.cdc.govmmwrpreviewmmwrhtmlmm5538a6.htms_cidmm5538a6_e .Style-Heading-4-+-Arial-14-pt-Underline}

**Unopposed Estrogen Therapy Increases Breast Cancer Risk**

Postmenopausal hormone therapy increases the risk of breast cancer, but
many studies attribute this risk to the combination of estrogen and
progestin treatments. In a study by the Women\'s Health Initiative,
unopposed estrogen was found to have a hazard ratio of 0.77 (adjusted
confidence interval, 0.59 to 1.01) for developing breast cancer after
seven years of follow-up. Chen and colleagues evaluated whether
long-term use of unopposed estrogen increased the risk of invasive
breast cancer in postmenopausal women.

The study analyzed data from participants in the Nurses\' Health Study
from 1980 to 2002, which included baseline questionnaires with
information about cancer and cardiovascular risks and follow-up
questionnaires that were mailed every two years. Women who were
postmenopausal, had a hysterectomy, and were considered current users of
unopposed conjugated estrogens (Premarin) participated in the study.
Estrogen use was established through the self-reported information on
the questionnaire. As the study progressed, women who became
postmenopausal and had a hysterectomy were added to the analysis. The
status of estrogen and progesterone receptors for breast cancer was
recorded, and the main outcome measure was invasive breast cancer.

At the end of the study, 28,835 women were enrolled. Of the 934 women
who had invasive breast cancer, 226 had never used estrogen therapy (see
accompanying table). The researchers also found that women who had
positive estrogen or progesterone receptors had the highest risk for
breast cancer. Additionally, the risk of positive estrogen or
progesterone receptor breast cancer was significantly higher in women
who had been on unopposed estrogen for more than 15 years.

+------------------------------+---------+----------------------------+
| **Invasive Breast Cancer     |         |                            |
| Risk in Postmenopausal Women |         |                            |
| with Hysterectomy Who Use    |         |                            |
| Unopposed Estrogen**         |         |                            |
+------------------------------+---------+----------------------------+
| *Duration of estrogen        | *Cases* | *Risk (95% confidence      |
| therapy (years)*             |         | interval)\**               |
+------------------------------+---------+----------------------------+
| Never                        | 226     | 1.00                       |
+------------------------------+---------+----------------------------+
| Less than 5                  | 99      | 0.96 (0.75 to 1.22)        |
+------------------------------+---------+----------------------------+
| 5 to 9.9                     | 145     | 0.90 (0.73 to 1.12)        |
+------------------------------+---------+----------------------------+
| 10 to 14.9                   | 190     | 1.06 (0.87 to 1.30)        |
+------------------------------+---------+----------------------------+
| 15 to 19.9                   | 129     | 1.18 (0.95 to 1.48)        |
+------------------------------+---------+----------------------------+
| 20 and more                  | 145     | 1.42 (1.13 to 1.77)        |
+------------------------------+---------+----------------------------+
| *P* for trend for current    |         | \< .001                    |
| use                          |         |                            |
+------------------------------+---------+----------------------------+
| *\*-Multivariate relative    |         |                            |
| risk controlled for age, age |         |                            |
| at menopause, age at         |         |                            |
| menarche, body mass index,   |         |                            |
| history of benign breast     |         |                            |
| disease, family history of   |         |                            |
| breast cancer, average       |         |                            |
| alcohol consumption, and     |         |                            |
| parity and age at first      |         |                            |
| birth.*                      |         |                            |
|                              |         |                            |
| *Adapted with permission     |         |                            |
| from Chen WY, Manson JE,     |         |                            |
| Hankinson SE, Rosner B,      |         |                            |
| Holmes MD, Willett WC, et    |         |                            |
| al. Unopposed estrogen       |         |                            |
| therapy and the risk of      |         |                            |
| invasive breast cancer. Arch |         |                            |
| Intern Med 2006;166:1029.*   |         |                            |
+------------------------------+---------+----------------------------+

The authors conclude that long-term use of unopposed estrogen therapy
increases the risk of breast cancer, but using estrogen for less than 10
years is not associated with an increased risk. They also note that
using estrogen to prevent or treat osteoporosis usually requires
long-term therapy; therefore, other options should be considered.

Chen WY, et al. Unopposed estrogen therapy and the risk of invasive
breast cancer. Arch Intern Med May 8, 2006;166:1027-32.

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16682578**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16682578) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgidbpubmedcmdretrievedoptabstractpluslist_uids16682578 .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

**External Fetal Monitors - Can you kick the habit?**

Hindley, et al, undertook a three year research project due to the
indiscriminate use of electronic fetal monitoring (EFM) in the United
Kingdom despite evidence that states it should be used sparingly. They
point out that extensive research in the last 30 years has shown limited
benefit of EFM in low risk women and an increase in cesarean section
rates when women are monitored continuously during labor. The evidence
instead states that the most appropriate method of fetal monitoring for
women of low obstetric risk is intermittent auscultation (IA).

Hindley, et al, present their qualitative research interviewing midwives
about EFM and IA. They interviewed 58 midwives practicing in northern
England with an average of 15 years of experience. For IA they found
three main categories: freedom/liberating effects for the woman;
closeness/proximity of the midwife; and quicker progress in labor. For
EFM the categories included: oppressive/restrictive; midwife by proxy;
and increased requirements for pain medications. For both monitoring
methods the interviews also revealed paradoxes. For IA there was a
paradox that the midwives' positive comments were tempered by fears that
they would miss some pathological event between auscultations. The
paradox for EFM was that the midwives' negative comments and their
insights that EFM is causing midwives to attend less to women and more
to machines and to loose sight of what is normal are contradicted by
their practice realities of continuing to work with EFM, even for low
risk women. In their discussion, Hindley, et al, illuminate what occurs
for many midwives---a belief in the normal process of birth and a desire
to work with women to support and enhance that process, but then the
realities of where they work including the reliance on EFM resulting in
a devaluation and decreased use of the traditional, watchful, hands-on
approach of the midwife and an increased likelihood of the cascade
effect leading to increasing numbers of interventions in the process of
birth. They point out a persistent paradox in our practices---the
evidence shows overwhelmingly that the use of EFM is not beneficial and
may be harmful to patients and to midwifery practice, but we keep on
using it.

Hindley, et al, bring to the forefront the quandary we are in---we know
that evidence- based care would mean not using EFM, especially with low
risk women, as it has not been shown to improve outcomes and has been
shown to increase interventions, yet we continue to use it with
virtually all laboring women. The authors discuss the many influences
that make this so, including: lack of institutional support for IA;
staffing issues causing EFM to be used as a midwife proxy---"a
substitute for the presence of the midwife who would otherwise use the
clinical skills of perception, auscultation, palpation, and
communication"; trust in machines; that it's easier to busy oneself with
the monitor than to engage deeply with a laboring woman; medical
policies and the persistent belief by many obstetricians that birth is
inherently dangerous and should be risk managed. They also make
suggestions for finding our way out of the quandary: where guidelines
exist for appropriate use of EFM, audit compliance with the guidelines;
provide resources for one-to-one midwifery care in labor to stop the use
of EFM as a proxy; continued debate and discussion about routine use of
oxytocin and epidurals that often necessitate EFM use and about precise
clinical risk indicators for the use of EFM. They also offer a first
step in the process of change:

> Simple strategies such as removing fetal monitors from rooms might
> also help the midwife to consciously question the need for EFM rather
> than applying it routinely, merely because it is proximal."

English midwives\' views and experiences of intrapartum fetal heart rate
monitoring in women at low obstetric risk: conflicts and compromises. J
Midwifery Womens Health. 2006 Sep-Oct;51(5):354-60.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16945783>

**[Editorial Comment]{.underline}: Lisa Allee, CNM**

First, I have got to say that I love qualitative research because the
results sound like actual humans and not just numbers. For example, the
quotes the authors put in this article will likely ring true with many
of us:

*"I think it (IA) gives the woman more freedom. She can mobilise. I
think the labour tends to get quicker because she is not pinned to the
bed in one position. She can move around, it's more natural, it's more
normal."*

*"I think a lot of the women feel really restricted by monitoring. It
also means that as a midwife, your time is taken up with analysing and
looking at the machine a lot of the time when you could be giving other
support to the woman."*

*"I think, especially with the monitors, they are waiting for the next
pain. The focus is on the pain. Certainly, there are more epidurals as
opposed to the woman who is labouring in the bath or moving about."*

*"I think IA brings you closer to them, and it's just more natural and
normal, so it's less technology that I am in favour of."*

Second, when I got to the end of this article I let out a whoop and did
a little happy dance---someone finally said in print "TAKE THE MONITOR
OUT OF THE ROOM"!!!! Wow, what a concept. There are some many reasons to
do this, but most of all it would mean that everyone would have to
really think about using EFM, it's appropriateness and it's
implications, because to use it you would have to drag the thing into
the room. This change would also make it ok to not use EFM, as
appropriate, using doptones instead and, thus, make the focus of our
care the laboring woman, the baby, and the family instead of the
machine. Those of us who have practiced in home birth, birth centers,
and internationally know that this really is ok, safe, and so satisfying
for all involved. I would love to hear from any site that makes this
change or has already done so!

E-mail me at
[[lisa.allee@ihs.gov]{.underline}](mailto:lisa.allee@ihs.gov) and I will
include the information in a future column.

**One Last Thing:** It is time to update the midwifery page on the IHS
website. A few ideas I have are patient education section, midwifery
conferences, an ask the midwife column, why you are lucky to have
midwifery care, and profiles of the different midwifery services in IHS.
PLEASE send me your comments on these ideas and your suggestions for
other items. Also, please send me pictures that could be used on the
page! Thanks for your help!!!

**Other**

**EMTALA language changes addresses certification of false labor**

<http://www.midwife.org/legislative.cfm?id=957>

**Navajo News Jean Howe, Chinle**

**Great, low-cost, fun CME opportunity**

The Telluride Conference, to be held on January 26-28, 2007

This is a great, low-cost, fun CME opportunity attended by many current
IHS providers and IHS alumni. Please share this announcement with anyone
who might be interested at your facilities.

Hope to see you there! <Jean.Howe@ihs.gov>

#### [**http://www.ihs.gov/MedicalPrograms/MCH/F/CN01.cfm#Jan07**](http://www.ihs.gov/MedicalPrograms/MCH/F/CN01.cfm#Jan07) {#httpwww.ihs.govmedicalprogramsmchfcn01.cfmjan07 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Nurses Corner, Sandra Haldane, HQE**

**Improving Perinatal Outcomes: Reliably Using Elective Induction and
Labor Augmentation**\
Begins October 25

The quality of care provided during labor and delivery can become safer
and more reliable through the use of \"bundles\" - a group of
evidence-based interventions related to a disease or care process that,
when executed together, result in better outcomes than when implemented
individually. Elective labor induction and augmentation bundles provide
reliable processes that can be used to evaluate and manage labor and
delivery. Through implementing these bundles, teams improve
communication and deliver those elements of care that decrease the
chances that an adverse event will occur.

Upon completion of this Web&ACTION series participants will be able to:

-   Implement elective induction and augmentation bundles to increase
    their organization\'s current level of performance during labor and
    delivery

-   Engage all members of the team using effective communication and
    documentation techniques

-   Address the barriers in their organizations during implementation of
    the bundles

<http://www.ihi.org/IHI/Programs/ConferencesAndTraining/PerinatalWebandACTION.htm>

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

The Institute for Healthcare Improvement is interested in helping the
Indian Health system related to the cost of the above program.  Please
email Carolyn Aoyama for details at <Carolyn.Aoyama@ihs.gov>

####  {#section-25 .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}

**Preconception Care: Science, Practice, Challenges and Opportunities**

This special supplement of the Maternal and Child Health Journal
includes over 25 original papers on preconception care. The issue
includes papers on the history of preconception care, preconception
health activities in the United States, promising practices,
international settings, what ob/gyns think, provider practice regarding
folic acid, what women know and believe, social marketing, public
finance policy, and more.  Maternal and Child Health Journal -
<http://springerlink.com/content/k33g85g4242v/?p=5e9442a6c00a40888ebe95936ebca50a&pi=4>

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

**October is Breast Cancer Awareness Month**

To increase awareness of Breast Cancer, October is Breast Cancer
Awareness Month

For more information on breast cancer see the site below:

[http://www.cdc.gov/cancer/breast/basic_info/facts.htm#](http://www.cdc.gov/cancer/breast/basic_info/facts.htm)

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

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

**Asthma in Pregnancy**

Your next patient is a new OB physical. After scanning her history, you
note that she reports having a medical history significant for Asthma in
the past. Given the high prevalence of asthma in the general population,
it is one of the more common complications of pregnancy. Pregnancies
complicated with asthma are more likely to also be complicated by
Preterm birth, hyperemesis gravidarium, pre-eclampsia, IUGR and neonatal
mortality. The goals that should be met in taking care of this patient
include:

1.  objectively evaluating the maternal fetal clinical condition

```{=html}
<!-- -->
```
1.  control of asthma symptoms and prevention of acute attacks by
    avoidance/control of triggers

2.  Maximize lung function with drug while minimizing side effects

3.  patient education

Placing a patient into a category, mild-intermittent, mild-persistent,
moderate or severe, based on her pre-pregnancy condition will assist in
your treatment of the patient during pregnancy. However, the foundation
of management of these patients is the Peak Expiratory Flow Rate (PEFR).
Use of this peak flow meter can assist in management, recognition and
prevention of exacerbations. Here are the National Asthma Education and
Prevention Program recommendations.

Asthma and pregnancy report. NAEPP report of the Working Group on Asthma
and Pregnancy: management of asthma during pregnancy

<http://www.nhlbi.nih.gov/health/prof/lung/asthma/astpreg.txt>

NAEPP expert panel report 2: guidelines for the diagnosis and treatment
of asthma

<http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm>

NAEPP expert panel report: guidelines for the diagnosis and treatment of
asthma---update on selected topics 2002

<http://www.nhlbi.nih.gov/guidelines/asthma/asthupdt.htm>

Managing Asthma During Pregnancy: Recommendations for Pharmacologic
Treatment\--Update 2004

<http://www.nhlbi.nih.gov/health/prof/lung/asthma/astpreg/astpreg_qr.pdf>

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

**Fracture risk among First Nations people**

CONCLUSION: First Nations people are at high risk for fracture but the
causal factors contributing to this are unclear. Further research is
needed to evaluate the importance of other potential explanatory
variables.

[Leslie
WD](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Leslie+WD"%5BAuthor%5D),
et al Demographic risk factors for fracture in First Nations people.
[Can J Public
Health.](javascript:AL_get(this, 'jour', 'Can J Public Health.');) 2005
Jan-Feb;96 Suppl 1:S45-50.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=15686153>

and

**The prior report**

RESULTS: First Nations people had significantly higher rates of any
fracture (age- and sex-adjusted SIR 2.23, 95% CI 2.18-2.29). Hip
fractures (SIR 1.88, 95% CI 1.61-2.14), wrist fractures (SIR 3.01, 95%
CI 2.63-3.42) and spine fractures (SIR 1.93, 95% CI 1.79-2.20) occurred
predominantly in older people and women. In contrast, craniofacial
fractures (SIR 5.07, 95% CI 4.74-5.42) were predominant in men and
younger adults. INTERPRETATION: First Nations people are a previously
unidentified group at high risk for fracture.

[Leslie
WD](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Leslie+WD"%5BAuthor%5D),
et al Fracture risk among First Nations people: a retrospective matched
cohort study. [CMAJ.](javascript:AL_get(this, 'jour', 'CMAJ.');) 2004
Oct 12;171(8):869-73

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=15477625>

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

**Assessment of Adult Health Literacy**

The Health Literacy of America\'s Adults: Results from the 2003 National
Assessment of Adult Literacy describes how health literacy varies across
the population and where adults with different levels of health literacy
obtain information about health issues. The report, produced by the
National Center for Education Statistics, contains analyses that examine
differences related to health literacy that are based on self-reported
background characteristics among groups in 2003. Topics include health
literacy levels, demographic characteristics and health literacy,
overall health, health insurance coverage, and sources of information
about health issues. The appendices contain sample
health-literacy-assessment question, definitions of all subpopulation
and background variables reported, technical notes, standard errors for
tables and figures, and additional analyses. References are also
included. The full report, executive summary, and appendices are
available at
[[http://nces.ed.gov/pubsearch/pubsinfo.asp?pubid=2006483]{.underline}](http://nces.ed.gov/pubsearch/pubsinfo.asp?pubid=2006483)

**Is patient education really working? GDM patients smoke more and eat
less vegetables**

CONCLUSIONS: Despite their elevated risk for future diabetes, women with
history of GDM who lived with children were less likely to meet fruit
and vegetable consumption guidelines and more likely to smoke than women
with children who did not have history of GDM.

[Kieffer
EC](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Kieffer+EC"%5BAuthor%5D)
et al Health Behaviors Among Women of Reproductive Age With and Without
a History of Gestational Diabetes Mellitus [Diabetes
Care.](javascript:AL_get(this, 'jour', 'Diabetes Care.');) 2006
Aug;29(8):1788-93

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16873781>

**HPV Vaccine: What You Need to Know (Interim Vaccine Information
Statement)**

This two page fact sheet answers the following questions: what is HPV,
why get vaccinated, who should get HPV vaccine and when, who should not
get vaccinated (or should wait), what are the risks from HPV vaccine,
what if there is a severe reaction, and how can I learn more.

<http://www.cdc.gov/nip/publications/VIS/vis-hpv.pdf>

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

#### Stress: How to Cope with Life\'s Challenges {#stress-how-to-cope-with-lifes-challenges-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20061015/1385ph.html**](http://www.aafp.org/afp/20061015/1385ph.html) {#httpwww.aafp.orgafp200610151385ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Anxiety and Panic: Getting Control over Your Feelings {#anxiety-and-panic-getting-control-over-your-feelings-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20061015/1393ph.html**](http://www.aafp.org/afp/20061015/1393ph.html) {#httpwww.aafp.orgafp200610151393ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

#### [**http://www.aafp.org/afp/20061015/1395ph.html**](http://www.aafp.org/afp/20061015/1395ph.html) {#httpwww.aafp.orgafp200610151395ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Emotional Health: What You Should Know {#emotional-health-what-you-should-know .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20061015/1388ph.html**](http://www.aafp.org/afp/20061015/1388ph.html) {#httpwww.aafp.orgafp200610151388ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Shingles Vaccine: What You Need to Know**

This two page fact sheet discusses the following issues: what is
shingles, shingles vaccine information, who should not get the shingles
vaccine (or should wait), risks, reactions, and more.

<http://www.cdc.gov/nip/publications/VIS/vis-shingles.pdf>

#### Cardiovascular Disease: What You Should Know {#cardiovascular-disease-what-you-should-know .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20061015/1342ph.html**](http://www.aafp.org/afp/20061015/1342ph.html) {#httpwww.aafp.orgafp200610151342ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

**#1 Fetal Lung Maturity Assessment**

The evaluation of fetal lung maturity by use of lipid chromatography
analysis of amniotic fluid surfactant with the lecithin-sphingomyelin
ratio and per cent phosphatidyl glycerol ("L/S and PG") has been
standard obstetric practice for over 40 years. Over the last 20 years
however, this test has been largely supplanted by the fluorescence
polarization assay, which, in its current iteration, is known as the
"TDx-FLM II" test (Abbott Laboratories). There is an extensive
literature (see below for partial list of references) evaluating its
accuracy, both evaluating its correlation with L/S and PG, as well as
investigating its clinical efficacy in predicting infants diagnosed with
respiratory distress syndrome (IRDS).

The accuracy of the TDx-FLM is now considered excellent, and, in the
latest studies, demonstrates that it is probably superior to L/S and PG
determinations. Our consultants at the University of Washington and our
reference lab have now largely abandoned the L/S and PG in favor of the
TDx-FLM II. I would therefore like to propose that we also exclusively
use this simpler and less costly test, which can be done locally, with
results provided within several hours, and which only requires 1 mL of
amniotic fluid. Currently, if the FLM is negative or indeterminate,
Providence sends the specimen out for confirmation with an L/S and PG
determination. This is called the "sequential" or "cascade" strategy,
and was likewise proposed over 20 years ago. This takes about 48 hours
for the result, accrues a substantial additional charge, and is probably
not necessary with the accuracy of the current TDx-FLM II.

While most laboratories report specific cut-off points (immature: \<39;
indeterminate: 40-54; mature: \>55 mg/g), gestational age-specific risk
estimates are more accurate (see nomogram hanging in OB Triage and
reference \[11\] below), and do not give just a "yes or no" answer. For
example, a FLM of 50 at 36 weeks predicts a risk of IRDS of 4.3%,
probably an acceptable risk depending on the indication for early
delivery. Like the L/S, amniotic fluid specimens contaminated with
significant quantities of blood, meconium, or bilirubin may give
erroneous results. Insufficient data has been accrued on vaginal pool
amniotic fluid specimens. All tests of fetal lung maturity, including
the L/S, have over a 95% negative predictive value (if the test is
reported mature, there is only a 5% chance of IRDS), but only a 60%
positive predictive value (test reported as immature, but infant does
not develop IRDS).

Amniocentesis for fetal lung maturity is currently only thought to be
useful in 2 clinical situations: 1) between 34-36 weeks where delivery
is thought to be indicated for maternal or fetal reasons, but the need
is not urgent (under 34 weeks: rarely ever mature results, over 36
weeks: rarely ever severe IRDS), and 2) in a woman with unsure dating
with a differential diagnosis of possible fetal growth restriction
(requiring delivery) versus lesser (premature) gestational age. In other
situations, if there is an urgent indication for delivery, the pregnancy
should be delivered regardless of the results of fetal lung maturity
testing.

References

1.  Tait JF, et al. Improved fluorescence polarization assay for use in
    evaluating fetal lung maturity. I. Development of the assay
    procedure. Clin Chem 1986; 32:248-54.

2.  Foerder CA, et al. Improved fluorescence polarization assay for use
    in evaluating fetal lung maturity. II. Analytical evaluation and
    comparison with the lecithin/sphingomyelin ratio. Clin Chem 1986;
    32: 255-9.

3.  Ashwood Er, et al. Improved fluorescence polarization assay for use
    in evaluating fetal lung maturity. III. Retrospective clinical
    evaluation and comparison with the lecithin/sphingomyelin ratio.
    Clin Chem 1986; 32:260-4.

4.  Garite TJ, et al. Fetal maturity cascade: A rapid and cost-effective
    method for fetal lung maturity testing. Obstet Gynecol 1986;
    67:619-22.

5.  Ruch AT, et al. Assessment of fetal lung maturity by fluorescence
    polarization in high-risk pregnancies. J Reprod Med 1993; 38:133-6.

6.  Herbert WNP, et al. Role of the TDx FLM assay in fetal lung
    maturity. Am J Obstet Gynecol 1993; 168:808-12.

7.  ACOG. Assessment of fetal lung maturity. ACOG Educational Bulletin
    #230. November 1996.

8.  Fantz CR, et al. Assessment of the diagnostic accuracy of the
    TDx-FLM II to predict fetal lung maturity. Clin Chem 2002; 48:761-5.

9.  Pinette MG, et al. Fetal lung maturity indices: A plea for
    gestational age-specific interpretation. Am J Obstet Gynecol 2002;
    187:1721-2.

10. Albright TS, et al. Evaluation of the effect of meconium on
    assessment of fetal lung maturity status by TDxFLM II testing.
    Obstet Gynecol 2004; 104:952-6.

11. Parvin CA, et al. Predicting respiratory distress syndrome using
    gestational age and fetal lung maturity by fouorescent polarization.
    Am J Obstet Gynecol 2005; 192:199-207.

**#2 Can a blood test predict pre-eclampsia? and will it help us?**

The pre-eclampsia syndrome, despite having been recognized for
millennia, continues to remain an enigma. Complicating 5 per cent of
pregnancies, it is a leading cause of maternal death and preterm birth
worldwide, and is a major public health problem. Its etiology remains
elusive, and, at present, the only definitive treatment is delivery.
Prediction is also problematic, and no currently available clinical test
is able to determine who will develop the syndrome during pregnancy, or
when. A new line of investigation however may represent a major first
step towards its prediction, prevention, and treatment.

The recent publication in the New England Journal of Medicine by Levine
et al (1) whose abstract appears here, is the latest in a series of
studies (see references below) about several circulating anti-angiogenic
factors that may reflect the etiology, and help us foretell the
development, of pre-eclampsia (PEC). While they are not quite ready for
"prime time" with our clients yet, being aware of ongoing developments
in this field may soon have clinical relevance for us. These studies
have centered around several circulating proteins which influence
vascular endothelial development and homeostasis. Interestingly, these
same molecules most likely play a major role in the propagation of
tumors, as well as in the development of atherosclerosis.

Please bear with me on plowing through what follows, and sorry for all
the abbreviations! It really is pretty cool stuff. Vascular endothelial
growth factor (VEGF) and placental growth factor (PlGF) are two proteins
which promote angiogenesis and induce nitric oxide (NO) and vasodilatory
prostaglandins (PGI2), influencing vascular tone and blood pressure.
Anti-VEGF proteins include soluble fms-like tyrosine kinase 1 (sFlt-1)
and endoglin; their action is to blunt the effects of VEGF. Transforming
growth factor beta-1 (TGFb-1) is a co-receptor that binds endoglin and
downregulates its effect on the vascular endothelium, all maintaining
the crucial balance in vascular tone that provides optimal perfusion of
downstream tissues. When these molecules are circulating they are called
"soluble", and when they are bound to the vascular endothelium they are
called receptors ("non-soluble"). The trophoblast (as well as invasive
neoplasms), big time produces angiogenic and vasodilatory agents to
allow it to invade the maternal vasculature and establish its blood
supply. The failure of the conceptus to establish an adequate blood
supply is thought to result in the pregnancy complications of PEC and
fetal growth restriction. It is postulated that, if this high flow/low
pressure system fails to become established, sFlt-1 binds to VEGF and
PlGF and soluble endoglin binds TGFb-1, resulting in a rise in blood
pressure as a response to attempt to enhance placental perfusion.

Levine et al, using the archived blood samples from a study you may
recall, "Calcium for the Prevention of Eclampsia and Pre-eclmapsia" (the
"CPEP" trial), (which involved almost 5,000 women, and did not
demonstrate an effect of supplemental calcium on the prevention of the
syndrome...) (6), have found some very interesting associations. This
group's earlier publication (2) found that women who subsequently
developed pre-eclampsia demonstrated increased levels of sFlt-1 and
reduced levels of PlGF about 5 weeks prior to the onset of the syndrome.
Nevertheless, PEC did not develop in all women with high sFlt-1 and low
PlGF levels, and it did develop in some women with low sFlt-1 and high
PlGF.

The current study (1) now produces another missing piece of the puzzle,
endoglin. In the most recent publication, the investigators found that
soluble endoglin levels became markedly elevated 8-12 weeks prior to the
onset of PEC. This increase occurred earlier in women who developed
early PEC (\<37 weeks). Likewise, an increased level of soluble endoglin
was usually accompanied by an increased ratio of sFlt-1:PlGF (free PlGF
was decreased and sFlt-1 was increased). Thus, soluble endoglin and
sFlt-1, two anti-angiogenic proteins operating through separate
mechanisms, combined to produce endothelial dysfunction and severe PEC.
Interestingly, women who developed a growth restricted infant had mild
early elevation of endoglin without an increase of the sFlt-1:PlGF
ratio. Women who developed gestational non-proteinuric hypertension had
similar elevations of soluble endoglin but smaller increases in the
sFlt-1:PlGF ratio. Also, sFlt-1 levels were lower in smokers, confirming
that smoking is protective against PEC, possible through the effect of
nicotine on the angiogenic proteins.

So..., where does us this leave us? First of all, these data are
retrospective and cross-sectional, and come from blood samples that have
been frozen for over 10 years... Nevertheless, they may direct the next
step, prospective longitudinal studies, which may point us more directly
towards prevention and treatment. The World Health Organization (WHO) is
planning just such a multi-national study. Because of the high maternal
and infant morbidity and mortality occasioned by the disease in the
developing world, the ability to predict which women would develop PEC
might allow them to be "risked-out" non-emergently to a higher level
care, or to be candidates for maternity home care so as not to deliver
at home without a skilled birth attendant. The ability to carry out this
same triage might serve us very well in IHS. Perhaps someday soon here
at home, we may see VEGF infusions used to reverse the hypertension and
proteinuria we see in our patients! But might that result in suboptimal
perfusion of the utero-placental unit with a different set of
complications?? Stay tuned for further developments.....

REFERENCES

1.  Levine RJ et al. Soluble endoglin and other circulating
    anti-angiogenic factors in pre-eclampsia. N Eng J Med 2006;
    355:992-1005.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16957146>

2.  Levine RJ et al. Circulating aniogenic factors and the risk of
    pre-eclampsia. N Eng J Med 2004; 350:672-83.

3.  Levine RJ et al. Urinary placental growth factor and risk of
    pre-eclampsia. JAMA 2005; 293:77-85.

4.  Buhimschi CS et al. Urinary angiogenic factors cluster hypertensive
    disorders and identify women with severe pre-eclampsia. Am J Obstet
    Gynecol 2005; 192:734-41.

5.  Venakatesha S et al. Soluble endoglin contributes to the
    pathogenesis of pre-eclampsia. Nat Med 2006; 12:642-9.

6.  Levine RJ et al. Trial of calcium to prevent pre-eclampsia. N Eng J
    Med 1997; 337:69-76.

7.  Maynard SE et al. Excess placental soluble fms-like tyrosine kinase
    1 (sFlt1) may contribute to endothelial dysfunction, hypertension,
    and proteinuria in pre-eclampsia. J Clin Invest 2003; 111:649-58.

8.  Hornig C et al. Soluble VEGF receptors. Angiogenesis 1999; 3:33-9.

#3

**Q. Some providers mentioned that they are recommending that all of
their prenatal patients take a fish oil capsule every day, for the omega
3 fatty acids for fetal brain development, hypertensive disorders, and
depression. Is this something that you are recommending also?**

A.

There are some intriguing initial results psychomotor development of
infants, etc... but there needs to be more evidence. Here are a few of
the areas that need to be resolved: the correct dose is unknown, the
actual quantity in the many supplements is unknown, too much fish oil
could produce a deleterious hypervitaminosis A scenario, and there is no
data on methyl Hg content. Below are a few references. Additional
available upon request

-Tofail F, Kabir I, Hamadani JD, Chowdhury F, Yesmin S, Mehreen F, Huda
SN. Supplementation of fish-oil and soy-oil during pregnancy and
psychomotor development of infants. J Health Popul Nutr. 2006
Mar;24(1):48-56.

-Szajewska H, Horvath A, Koletzko B. Effect of n-3 long-chain
polyunsaturated fatty acid supplementation of women with low-risk
pregnancies on pregnancy outcomes and growth measures at birth: a
meta-analysis of randomized controlled trials. Am J Clin Nutr. 2006
Jun;83(6):1337-44.

-Genuis SJ, Schwalfenberg GK. Time for an oil check: the role of
essential omega-3 fatty acids in maternal and pediatric health. J
Perinatol. 2006 Jun;26(6):359-65.

-Knudsen VK, Hansen HS, Osterdal ML, Mikkelsen TB, Mu H, Olsen SF. Fish
oil in various doses or flax oil in pregnancy and timing of spontaneous
delivery: a randomised controlled trial. BJOG. 2006 May;113(5):536-43.
Epub 2006 Mar 27.

-Shoji H, Franke C, Campoy C, Rivero M, Demmelmair H, Koletzko B. Effect
of docosahexaenoic acid and eicosapentaenoic acid supplementation on
oxidative stress levels during pregnancy. Free Radic Res. 2006
Apr;40(4):379-84.

-Olafsdottir AS, Skuladottir GV, Thorsdottir I, Hauksson A,
Thorgeirsdottir H, Steingrimsdottir L. Relationship between high
consumption of marine fatty acids in early pregnancy and hypertensive
disorders in pregnancy. BJOG. 2006 Mar;113(3):301-9.

-Williams CM, Burdge G. Related Articles, Long-chain n-3 PUFA: plant v.
marine sources.

Proc Nutr Soc. 2006 Feb;65(1):42-50.

-Burdge GC, Sherman RC, Ali Z, Wootton SA, Jackson AA. Docosahexaenoic
acid is selectively enriched in plasma phospholipids during pregnancy in
Trinidadian women\--results of a pilot study.

Reprod Nutr Dev. 2006 Jan-Feb;46(1):63-7.

-Paletz EM, Craig-Schmidt MC, Newland MC. Gestational exposure to
methylmercury and n-3 fatty acids: effects on high- and low-rate operant
behavior in adulthood.

Neurotoxicol Teratol. 2006 Jan-Feb;28(1):59-73.

-Kulkarni A, Downes E, Crook M. Successful outcome of pregnancy in a
patient with familial hypertriglyceridaemia. J Obstet Gynaecol. 2006
Jan;26(1):66-7.

Freeman MP, Hibbeln JR, Wisner KL, Brumbach BH, Watchman M, Gelenberg
AJ. Randomized dose-ranging pilot trial of omega-3 fatty acids for
postpartum depression. Acta Psychiatr Scand. 2006 Jan;113(1):31-5.

-Pontes PV, Torres AG, Trugo NM, Fonseca VM, Sichieri R. n-6 and n-3
Long-chain polyunsaturated fatty acids in the erythrocyte membrane of
Brazilian preterm and term neonates and their mothers at delivery.
Prostaglandins Leukot Essent Fatty Acids. 2006 Feb;74(2):117-23.

**Other**

**Maternal oxygen administration for fetal distress**

CONCLUSION: The administration of supplemental oxygen to laboring
patients with nonreassuring fetal heart rate patterns increases fetal
oxygen saturation substantially and significantly. Fetuses with the
lowest initial oxygen saturations appear to increase the most.

[Haydon
ML](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Haydon+ML"%5BAuthor%5D),
et al The effect of maternal oxygen administration on fetal pulse
oximetry during labor in fetuses with nonreassuring fetal heart rate
patterns. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Sep;195(3):735-8

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16949405>

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

Haydon et al would seem to be encouraging that the administration of
supplemental oxygen to laboring patients with nonreassuring fetal heart
rate patterns increases fetal oxygen saturation substantially and
significantly. Rather, meaningful data could not be gleaned from this
relatively small sample size regarding changes in FHR patterns that were
subsequent to oxygen supplementation.

Unfortunately, there were no consistent changes in FHR after exposure to
oxygen. The specific aspects of these changes could be addressed only in
a much larger study. Haydon et al's findings do not support or refute
the use of supplemental oxygen for any specific nonreassuring FHR
pattern. This would require more patients having each abnormal pattern
type for analysis. Additional studies are necessary to determine the
optimal supplemental oxygen concentration in labor. Larger studies would
be required to evaluate the effects of oxygen therapy in nonreassuring
FHR patterns on neonatal outcomes that include umbilical cord blood
analyses, ventilatory assistance, and neonatal intensive care admission.

At this point the following conclusion from the Cochrane Library\* still
stands: There is not enough evidence to support the use of prophylactic
oxygen therapy for women in labour, nor to evaluate its effectiveness
for fetal distress.

In the meantime, I suggest that we initially give the laboring patient
with a questionable strip a bolus of intravenous fluids to increase
intravascular volume, hence increasing perfusion in addition to other
conservative measures, e. g., position change, oxygen supplementation,
and intrauterine resuscitation.

\*Fawole B, Hofmeyr GJ. Maternal oxygen administration for fetal
distress. Cochrane Database of Systematic Reviews 2003, Issue 4. Art.
No.: CD000136. DOI: 10.1002/14651858.CD000136.

<http://www.ihs.gov/MedicalPrograms/CIR/index.cfm?module=cir_answering_clinical_questions>

**Is there a nuchal translucency measurement above which there is no
added benefit from first trimester serum screening?**

CONCLUSION: During first trimester Down syndrome screening, whenever an
NT measurement of 3.0 mm or greater is obtained there is minimal benefit
in waiting for serum screening results, and no benefit for NT of 4.0 mm
or greater. Differentiation between cystic hygroma and enlarged simple
NT (\> or = 3.0 mm) is now a moot point as both are sufficiently high
risk situations to warrant immediate CVS.

[Comstock
CH](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Comstock+CH"%5BAuthor%5D),
et al Is there a nuchal translucency millimeter measurement above which
there is no added benefit from first trimester serum screening? [Am J
Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Sep;195(3):843-7

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16949423>

**Repeat antenatal corticosteroids do not improve composite neonatal
outcome**

CONCLUSION: Repeat antenatal corticosteroids significantly reduce
specific neonatal morbidities but do not improve composite neonatal
outcome. This is accompanied by reduction in birth weight and increase
in small for gestational age infants.

[Wapner
RJ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Wapner+RJ"%5BAuthor%5D),
et al Single versus weekly courses of antenatal corticosteroids:
evaluation of safety and efficacy. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Sep;195(3):633-42.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16846587>

**Outcomes after first pregnancy with early-onset preeclampsia is
generally favorable**

Recurrence rates for preeclampsia or preterm delivery were not related
to severity of first pregnancy complications, including delivery before
28 weeks of gestation, occurrence of hemolysis, elevated liver enzymes,
and low platelet count syndrome, small-for-gestational age infants, and
to hereditary or acquired thrombophilias.

[van Rijn
BB](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="van+Rijn+BB"%5BAuthor%5D),
et al Outcomes of subsequent pregnancy after first pregnancy with
early-onset preeclampsia. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Sep;195(3):723-8.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16949403>

**Antenatal assessment of chorionicity is accurate; incorrect Dx affect
reliable management**

RESULTS: Chorionicity was correctly assigned antenatally in 392/410
(95.6%) twins. The sensitivity, specificity, and positive and negative
predictive values of monochorionicity assessed \< or = 14 weeks were
89.8%, 99.5%, 97.8%, and 97.5%. Corresponding statistical values for the
second trimester were 88.0%, 94.7%, 88.0%, and 94.7%. Two cases of
inaccurate antenatal diagnoses affected patient counseling or were
associated with adverse clinical outcomes. CONCLUSION: Antenatal
assessment of chorionicity is accurate; however, incorrect diagnoses do
occur and can affect reliable patient counseling and management.

[Lee
YM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Lee+YM"%5BAuthor%5D),
et al Antenatal sonographic prediction of twin chorionicity [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Sep;195(3):863-7.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16949427>

**AFI and birth weight: Is there a relationship in diabetics with poor
glycemic control?**

CONCLUSION: The previously noted relationship between elevated AFI and
BW centiles in the general patient population is linear in diabetic
patients with poor glycemic control.

[Vink
JY](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Vink+JY"%5BAuthor%5D),
et al Amniotic fluid index and birth weight: Is there a relationship in
diabetics with poor glycemic control? [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Sep;195(3):848-50.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16949424>

**Doppler peak velocity in the middle cerebral artery can replace
invasive testing**

CONCLUSIONS: Doppler measurement of the peak velocity of systolic blood
flow in the middle cerebral artery can safely replace invasive testing
in the management of Rh-alloimmunized pregnancies.

[Oepkes
D](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Oepkes+D"%5BAuthor%5D),
et al Doppler ultrasonography versus amniocentesis to predict fetal
anemia. [N Engl J
Med.](javascript:AL_get(this, 'jour', 'N Engl J Med.');) 2006 Jul
13;355(2):156-64

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16837679>

**Placental inflammation and viral infection implicated in second
trimester pregnancy loss**

CONCLUSION: These studies demonstrate that spontaneous second trimester
loss is strongly associated with histologic chorioamnionitis and viral
infections.

[Srinivas
SK](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Srinivas+SK"%5BAuthor%5D),
et al Placental inflammation and viral infection are implicated in
second trimester pregnancy loss [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Sep;195(3):797-802

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16949414>

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

#### December 1, 2006

**Causes of Type 2 Diabetes: Old and New Understandings**

**Moderator: Ann Bullock M.D.**

In 2002, the International Diabetes Federation determined that the
medical literature supports 4 etiologies of type 2 diabetes:

\--Genetics

\--Fetal Origins

\--Lifestyle

\--Stress

**We will explore these issues**

-   Diabetes prevention programs focus on lifestyle modification---what
    might these programs look like if lifestyle is only one factor?

-   What else can be learned from the DPP (Diabetes Prevention Program)?

-   Pregnancy and early life risk factors

-   What are the particular roots of the diabetes and obesity epidemics
    in Indian Country

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

Subscribe to the Primary Care listserv

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

Unsubscribe from the Primary Care listserv

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

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

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

**Prevalence of HPV Infection among Men: A Systematic Review of the
Literature**

Background. Human papillomavirus (HPV) infection is estimated to be the
most common sexually transmitted infection; an estimated 6.2 million
persons are newly infected every year in the United States. There are
limited data on HPV infection in heterosexual men.

Results. We included a total of 40 publications on HPV DNA detection and
risk factors for HPV in men; 27 evaluated multiple anatomic sites or
specimens, 10 evaluated a single site or specimen, and 3 evaluated risk
factors or optimal anatomic sites/specimens for HPV detection. Twelve
studies assessed site- or specimen-specific HPV DNA detection. HPV
prevalence in men was 1.3%--72.9% in studies in which multiple anatomic
sites or specimens were evaluated; 15 (56%) of these studies reported
\_20% HPV prevalence. HPV prevalence varied on the basis of sampling,
processing methods, and the anatomic site(s) or specimen(s) sampled. We
included 15 publications reporting HPV seroprevalence. Rates of
seropositivity depended on the population, HPV type, and methods used.
In 9 studies that evaluated both men and women, all but 1 demonstrated
that HPV seroprevalence was lower in men than in women.

Conclusion. HPV infection is highly prevalent in sexually active men and
can be detected by use of a variety of specimens and methods. There have
been few natural-history studies and no transmission studies of HPV in
men. The information that we have reviewed may be useful for future
natural-history studies and for modeling the potential impact of a
prophylactic HPV vaccine. 

Dunne, E et al Prevalence of HPV Infection among Men: A Systematic
Review of the Literature. J Infect Dis 2006:194 (15 October)

<http://www.journals.uchicago.edu/JID/journal/issues/v194n8/36645/36645.web.pdf>

**Other**

**FDA Approves the First Once-a-Day Three-Drug Combination Tablet for
Treatment of HIV-1\
Atripla is a Landmark Achievement of Three Cooperating Companies**

The Food and Drug Administration (FDA) today announced approval of
Atripla Tablets, a fixed-dose combination of three widely-used
antiretroviral drugs, in a single tablet taken once a day, alone or in
combination with other antiretroviral products for the treatment of
HIV-1 infection in adults.

Atripla, the first one-pill, once-a-day product to treat HIV/AIDS,
combines the active ingredients of Sustiva (efavirenz), Emtriva
(emtricitabine) and Viread (tenofovir disoproxil fumarate).
Bristol-Myers Squibb and Gilead Sciences have formed a joint venture to
commercialize Atripla in the United States. The collaboration is the
first of its kind in the field of HIV/AIDS. In certain territories,
Merck holds the rights to efavirenz. All three companies will work
together to ensure the product is available to patients and physicians.
Atripla will be available for use in the United States as a new product
approved under a new drug application (NDA). This would allow the drug
to be considered for purchase for use in 15 other countries included
under the President\'s Emergency Plan for AIDS Relief (PEPFAR). HIV-1
affects people worldwide.

The approval of Atripla comes as the result of an expedited review
process outlined in a guidance by the FDA in May 2004. With today\'s
approval, FDA will have approved seven co-packaged or fixed-dose
combination products since the guidance was issued. For more information
about the FDA\'s Expedited Review Process for HIV/AIDS Drugs, please go
to: <http://www.fda.gov/oc/initiatives/hiv/>

\"This new product offers a welcome option for prescribers who follow
the recommended initiation of HIV-1 treatment with at least three highly
active antiretroviral drugs, a regimen that has the potential to
significantly improve the condition of many patients, and help them
adhere to their regimen to help minimize the development of viral
resistance,\" said Dr. Steven Galson, Director of FDA\'s Center for Drug
Evaluation and Research. \"Because all three components of Atripla have
been in use for some time, their characteristics and effects are well
known.\"\
<http://www.fda.gov/cder/drug/infopage/atripla/default.htm> or
<http://www.fda.gov/cder/drug/infopage/atripla/qa.htm>.

#### From Scott Giberson, [**Scott.Giberson@ihs.gov**](mailto:Scott.Giberson@ihs.gov) IHS HIV Principal Consultant {#from-scott-giberson-scott.gibersonihs.gov-ihs-hiv-principal-consultant .Style-Heading-4-+-Arial-14-pt-Underline}

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

**NIH launches new HIV Vaccine awareness campaign**

and support of HIV vaccine research, as well as trust and participation
in the research. The campaign, launched by the National Institute of
Allergy and Infectious Diseases, works with community leaders,
community-based and national organizations, health professionals, and
educators to provide communities most affected by HIV with information
about preventive HIV vaccine research and what they should know about
HIV vaccine. The campaign Web site, which features background
information, how to get involved, an HIV vaccine quiz, frequently asked
questions, and resources, is available at
[[http://www.bethegeneration.org]{.underline}](http://www.bethegeneration.org/)

A campaign toolkit containing brochures, stickers, fact sheets, and
customizable posters (many of which are available in English and
Spanish) is also available at
[[http://www.bethegeneration.org/toolkit.htm]{.underline}](http://www.bethegeneration.org/toolkit.htm)

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

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

### **No improvement in fetal outcome, plus increased maternal morbidity: Who pays for this?** 

### **You do**

### More than one-quarter of all children born in the United States---over 1 million---are delivered by Cesarean section. The national bill for childbirth as a whole in 2003 totaled \$34 billion, with hospital stays for C-section delivery accounting for nearly half this amount---\$15 billion. Medicaid was billed for 43 percent of childbirths overall and 41 percent of those for C-section delivery. Agency for Healthcare Research and Quality, HCUP, *Statistical Brief #11: Hospitalizations Related to Childbirth, 2003* <http://www.hcup-us.ahrq.gov/reports/statbriefs/sb11.jsp>

**Who Responds to Glyburide for Gestational Diabetes?**

Gestational diabetes mellitus is increasingly common and in some
populations occurs in up to 14 percent of mothers. Successful treatment
of gestational diabetes is associated with reduced serious maternal and
fetal morbidity. Oral glyburide (Micronase) is as effective as insulin
in achieving glycemic control and is associated with birth weights
similar to infants whose mothers were treated with insulin. Many
patients prefer oral glyburide to insulin treatment. Glyburide also is
less expensive and less likely to cause hypoglycemia. However, some
women do not achieve adequate glycemic control with glyburide. Kahn and
colleagues studied predictors of failure of glyburide treatment with the
aim of developing a tool to identify those women in whom glyburide
therapy is less likely to be successful, thereby avoiding weeks of
inadequate glycemic control during pregnancy.

+-------------------------+---------+-----------+-----------+--------+
| **Clinical              |         |           |           |        |
| Characteristics and     |         |           |           |        |
| Predictors of Glyburide |         |           |           |        |
| (Micronase) Treatment   |         |           |           |        |
| Failure in Women with   |         |           |           |        |
| Gestational Diabetes**  |         |           |           |        |
+-------------------------+---------+-----------+-----------+--------+
| *Characteristic*        | *Total  | *         | *         | *P     |
|                         | women   | Glyburide | Glyburide | (s     |
|                         | (N =    | failure   | success   | tudent |
|                         | 95)*    | (N = 18)* | (N = 77)* | t-     |
|                         |         |           |           | test)* |
+-------------------------+---------+-----------+-----------+--------+
| Maternal age (years)    | 30 ± 6  | 34 ± 5    | 29 ± 5    | .001   |
+-------------------------+---------+-----------+-----------+--------+
| Maternal BMI (kg per    | 30 ± 7  | 32 ± 8    | 30 ± 6    | .23    |
| m^2^)                   |         |           |           |        |
+-------------------------+---------+-----------+-----------+--------+
| Gravidity               | 3 ± 2   | 4.3 ± 2.7 | 2.7 ± 1.6 | .01    |
+-------------------------+---------+-----------+-----------+--------+
| Parity                  | 1.2 ±   | 2 ± 1.7   | 1 ± 1     | .03    |
|                         | 1.2     |           |           |        |
+-------------------------+---------+-----------+-----------+--------+
| Cigarette smoking       | 8 (8)   | 1 (6)     | 7 (9)     | .7     |
+-------------------------+---------+-----------+-----------+--------+
| History of gestational  | 15 (16) | 5 (28)    | 10 (13)   | .12    |
| diabetes                |         |           |           |        |
+-------------------------+---------+-----------+-----------+--------+
| Gestational age at      | 27 ± 6  | 22.7 ± 7  | 28 ± 5    | .002   |
| diagnosis\              |         |           |           |        |
| of diabetes (weeks)     |         |           |           |        |
+-------------------------+---------+-----------+-----------+--------+
| Gestational age at      | 30 ± 6  | 24 ± 7    | 31 ± 4    | .001   |
| start of glyburide      |         |           |           |        |
| (weeks)                 |         |           |           |        |
+-------------------------+---------+-----------+-----------+--------+
| Fasting blood glucose   | 102 ±   | 112 ± 24  | 100 ± 17  | .045   |
| level on three-hour     | 19      |           |           |        |
| glucose tolerance test  |         |           |           |        |
| (mg per dL)             |         |           |           |        |
+-------------------------+---------+-----------+-----------+--------+
| Weight gain (lb)        | 26 ± 18 | 28 ± 26   | 26 ± 15   | .94    |
+-------------------------+---------+-----------+-----------+--------+
| *BMI = body mass        |         |           |           |        |
| index.*                 |         |           |           |        |
|                         |         |           |           |        |
| *note: Values are mean  |         |           |           |        |
| ± standard deviation or |         |           |           |        |
| n (%).*                 |         |           |           |        |
|                         |         |           |           |        |
| *Adapted with           |         |           |           |        |
| permission from Kahn    |         |           |           |        |
| BF, Davies JK, Lynch    |         |           |           |        |
| AM, Reynolds RM,        |         |           |           |        |
| Barbour LA. Predictors  |         |           |           |        |
| of glyburide failure in |         |           |           |        |
| the treatment of        |         |           |           |        |
| gestational diabetes.   |         |           |           |        |
| Obstet Gynecol          |         |           |           |        |
| 2006;107:1306.*         |         |           |           |        |
+-------------------------+---------+-----------+-----------+--------+

The authors conclude that glyburide is an effective and attractive
treatment option for many mothers with gestational diabetes. Although 80
percent of mothers overall are successful with this therapy, it is most
likely to fail in older, multiparous women with higher blood glucose
levels early in pregnancy. The authors speculate that these women have
increased insulin resistance and may be better treated with early
initiation of insulin therapy.

Kahn BF, et al. Predictors of glyburide failure in the treatment of
gestational diabetes. Obstet Gynecol June 2006;107:1303-9.

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

**Nearly one out of two women with gestational diabetes also have
periodontal disease**\
In contrast, just over one in ten pregnant women without gestational
diabetes have periodontal disease. The study is the first to demonstrate
a link between poor oral health and diabetes during pregnancy.\
The team of researchers analyzed health data from 256 pregnant women who
participated in the National Health and Nutrition Examination Study III.
Based on their analysis, the researchers recommend that dental care
during pregnancy should be considered as a way to help prevent
gestational diabetes. [Xiong
X](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Xiong+X"%5BAuthor%5D),
et al Periodontal disease and gestational diabetes mellitus. [Am J
Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Oct;195(4):1086-9

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16846573>

**Mothers Who Gain Weight Between Pregnancies Experience Pregnancy
Complications**

FINDINGS: Compared with women whose BMI changed between -1.0 and 0.9
units, the adjusted odds ratios for adverse pregnancy outcomes for those
who gained 3 or more units during an average 2 years

INTERPRETATION: These findings lend support to a causal relation between
being overweight or obese and risks of adverse pregnancy outcomes.
Additionally they suggest that modest increases in BMI before pregnancy
could result in perinatal complications, even if a woman does not become
overweight. Our results provide robust epidemiological evidence for
advocating weight loss in overweight and obese women who are planning to
become pregnant and, to prevent weight gain before pregnancy in women
with healthy BMIs.

[Villamor
E](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Villamor+E"%5BAuthor%5D),
[Cnattingius
S](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Cnattingius+S"%5BAuthor%5D).
Interpregnancy weight change and risk of adverse pregnancy outcomes: a
population-based study.
[Lancet.](javascript:AL_get(this, 'jour', 'Lancet.');) 2006 Sep
30;368(9542):1164-70

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17011943>

**The growing trends in maternal obesity**

How does obesity affect reproductive health and fertility? International
research was initiated to answer these questions and investigate the
impact and consequences of obesity on women's health.

This month's edition of the BJOG journal documents a number of these
articles and is devoted entirely to obesity and its effects on women, in
particular to problems associated with maternal obesity.

There are 16 scientific studies, review articles, and commentaries in
the October issue, conducted by leading experts in the specialty. Topics
covered include: prioritising for IVF and fertility treatment (Farquhar
and Gillett), prevention and management strategies (Krishnamoorthy,
Schram and Hill), difficulties in operating on obese women (Alexander
and Liston), increased need for, and risks associated with,
caesarean-sections (Barau et al), and the impaired effectiveness of
epidurals during labour (Dresner et al).

<http://www.blackwell-synergy.com/toc/bjo/113/10?cookieSet=1>

**Impact of Obesity on PCOS and Reproductive Health**

About 50% of women with PCOS are overweight, and this increase in body
weight has a major influence on the symptoms of PCOS and fertility.

This month's edition of the BJOG journal documents a number of research
articles on the impact of obesity on PCOS and reproductive health. PCOS
is a major health problem affecting women of all ages. The prevalence of
PCOS appears to be rising because of the current epidemic of obesity.
PCOS accounts for 90-95% of women who attend infertility clinics with
anovulation. Some of the symptoms such as unwanted facial and bodily
hair, acne, obesity and infertility have profound effects on the quality
of life for these women."

There are a number of interlinking factors that affect expression of the
syndrome. A gain in weight is associated with a worsening of symptoms
whilst weight loss will improve the disease profile and its symptoms.
The main clinical features are menstrual cycle disturbance and an
increase in male hormones (hyperandrogenism), causing acne, unwanted
bodily and facial hair, and alopecia.

Obesity has a negative impact on spontaneous conception, miscarriage,
pregnancy and the long term health of both mother and child due to both
an increased rate of congenital anomalies and the possibility of
metabolic disease (including diabetes) in later life. In women with PCOS
and a body mass index (BMI) \>35kg/m2, 20% of pregnancies ended with
stillbirth and another 20% had congenital anomalies. The supposed
mechanism that increases stillbirth and congenital anomaly rate includes
insulin resistance and impending or undiagnosed diabetes.

<http://www.blackwell-synergy.com/toc/bjo/113/10?cookieSet=1>

**Metformin Use Increases Vitamin B12 Deficiency**

CONCLUSIONS: Our results indicate an increased risk of vitamin B(12)
deficiency associated with current dose and duration of metformin use
despite adjustment for many potential confounders. The risk factors
identified have implications for planning screening or prevention
strategies in metformin-treated patients.

[Ting
RZ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Ting+RZ"%5BAuthor%5D),
et al Risk factors of vitamin B(12) deficiency in patients receiving
metformin. [Arch Intern
Med.](javascript:AL_get(this, 'jour', 'Arch Intern Med.');) 2006 Oct
9;166(18):1975-9.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17030830>

### **Gestational Diabetes Act 2006 -- Summary**

The proposed act has 3 main components

### -Understanding and Monitoring Gestational Diabetes and Obesity during Pregnancy

-Demonstration Grant Programs

-Research Expansion of Gestational Diabetes and Obesity during Pregnancy

For more details from the American Diabetes Association

<http://www.diabetes.org/advocacy-and-legalresources/federal_legislation/Gestational.jsp>

**Gestational Diabetes Increases the Risk of Cardiovascular Disease**\
Among women with a family history of type 2 diabetes, those with prior
GDM were more likely to have CVD risk factors.\
From the results it was concluded that among women with a family history
of type 2 diabetes, those with prior GDM were even more likely to not
only have CVD risk factors, including metabolic syndrome and type 2
diabetes, but also to have experienced CVD events, which occurred at a
younger age. Thus, women with both a family history of type 2 diabetes
and personal history of GDM may be especially suitable for early
interventions aimed at preventing or reducing their risk of CVD and
diabetes.

[Carr
DB](http://ezproxyhhs.nihlibrary.nih.gov:2067/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Carr+DB"%5BAuthor%5D),
et al Gestational diabetes mellitus increases the risk of cardiovascular
disease in women with a family history of type 2 diabetes. Diabetes Care
29: 2078-2083.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16936156>

**Cardiovascular Risk Higher for Women Than Men With Type 2 Diabetes**\
Women with type 2 diabetes face a higher risk of cardiovascular disease
than do men with type 2 diabetes.

Women were 3.19 times more likely than men to develop cardiovascular
disease, the investigators calculate. After adjustment for age, blood
pressure, body-mass index, dyslipidemia, smoking, and urinary albumin
excretion, the risk increased to 6.4-fold, and adjustment that included
retinopathy increased the risk to 8.23-fold.

Female sex was an independent risk factor for macrovascular disease and
death in our study population of normotensive patients with type 2
diabetes and microalbuminuria.

Further research is needed to fully elucidate the pathogenesis of this
excessive risk in women with type 2 diabetes because, at this point, we
did not find risk indicators that discriminate between women with high
and low risk of cardiovascular disease.

[Zandbergen
AA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Zandbergen+AA"%5BAuthor%5D),
et al Normotensive women with type 2 diabetes and microalbuminuria are
at high risk for macrovascular disease. Diabetes Care 2006;29:1851-1855

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16873791>

### **Diabetes Kills Both Obese And Non-obese Alike**

![](media/image5.png){width="1.0416666666666666e-2in"
height="0.20833333333333334in"}Diabetes is the killer, equally so for
obese or non-obese people with diabetes, say researchers from the
University of Kentucky and the University of Emory, Atlanta, USA. Risk
of death from obesity without diabetes is tiny when compared to risk of
death with diabetes.\
\
The researchers found that obese people, those with a Body Mass Index
(BMI) over 30, who do not have diabetes are not at a greater risk of
death than non-obese people without diabetes.\
\-- 11.9% of all the people had diabetes (types I or II)\
\-- 52% of those with diabetes were obese\
\-- 24% of those without diabetes were obese\
\-- The higher the BMI, the higher was the prevalence of diabetes\
\-- Organ failure risk was linked to older people, males, diabetes
sufferers and those with lower levels of lung function\
\
Morbidly obese patients, those with a BMI over 40, were not examined
separately in this study. It is also possible that the risks for
non-diabetic obese people need more than a three-year study, said the
researchers.\
\
The researchers concluded that the risk of acute organ failure, followed
by death, is more closely linked to whether a person has diabetes than
whether or not he/she is obese.\
\
Slynkova K et al The role of body mass index and diabetes in the
development of acute organ failure and subsequent mortality in an
observational cohort Critical Care 2006, 10:R137 doi:10.1186/cc5051

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16999863>

**More Midlife Physical Activity Leads to More Old-Age Mobility**\
More physical activity in midlife translates to more physical mobility
in old age, researchers conclude in a new study of older adults living
in the Chianti region of Italy.\
Previous studies have shown that physical activity in midlife can help
prevent a variety of chronic diseases. This study shows that greater
physical activity in your 30s, 40s and 50s has beneficial effects well
into the future by helping us maintain our ability to walk and function
at older ages.\"

CONCLUSIONS: Older adults who reported higher levels of physical
activity in midlife had better mobility in old age than less physically
active ones.

Patel KV, et al. Midlife physical activity and mobility in older age:
the In CHIANTI study. Am J Prev Med 31(4), 2006.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16905032>

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

**Best Practices** **and GPRA Tracking**

-   Nov 1-2, 2006

-   Sacramento CA

-   California IHS Area Office, Contact <Elaine.brinn@ihs.gov>

-   <http://www.ihs.gov/MedicalPrograms/MCH/F/documents/BestPracticesFlyer1.pdf>

**22nd Annual Midwinter Indian Health OB/PEDS Conference**

-   For providers caring for Native women and children

-   January 26-28, 2007

-   Telluride, CO

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

**TeenScreen Conference: Second Annual**

-   March 14 and 15, 2007

-   Washington D.C.

-   Contact <TSConference@childpsych.columbia.edu>

**2nd** **International Meeting on Indigenous Child Health**

-   April 20-22, 2007

-   Montreal, Quebec, Canada

-   Solutions, not Problems

-   Joint meeting of IHS, AAP-CONACH, First Nations and several other
    stakeholders

-   <http://www.aap.org/nach/2InternationalMeeting.htm>

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

-   August 15 -17, 2007

-   Albuquerque, NM

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

-   Internationally recognized speakers

-   Save the dates. Details to follow

-   10 months away and counting

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

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

**Special Care Clinic -- Phoenix Indian Medical Center**

<http://www.ihs.gov/MedicalPrograms/MCH/F/documents/PostgraduateCourseonObstetricNeonatalGynecologicCare.ppt>

**Heard about prenatal care and postpartum care? Here is something on
Internatal care**

<http://www.ihs.gov/MedicalPrograms/MCH/F/documents/Internatal10606.ppt>

There are several upcoming **Conferences**

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

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

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

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

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

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

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

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

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

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0906.cfm**](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0906.cfm) {#httpwww.ihs.govmedicalprogramsmchmobgyn0906.cfm .Style-Heading-4-+-Arial-14-pt-Underline}

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

## FDA Approves OTC Access for Plan B for 18 and Older: A 'Catch-22' for AI/AN patients?

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

Carolyn Aoyama:

#### -USPSTF Best Practices - Cervical Cancer Screening {#uspstf-best-practices---cervical-cancer-screening .Style-Heading-4-+-Arial-14-pt-Underline}

#### -USPSTF Breast Cancer Screening Guidelines {#uspstf-breast-cancer-screening-guidelines .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Tips for Improving Access to Mammography {#tips-for-improving-access-to-mammography .Style-Heading-4-+-Arial-14-pt-Underline}

Burt Attico:

-Congenital Anomalies Linked to NSAID Use in First Trimester

Judy Thierry:

Influenza is coming: Are you ready?

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

##### Obstetrics page 7

-Cesarean delivery: Increased risks / costs plus poor postpartum
outcomes -- 4 articles

-S. aureus colonization in pregnant women is 17.1%, MRSA found in the
vaginal-rectal area

-Controlling pregnancy weight gain: adverse neonatal outcomes -- 2
articles

-Electronic fetal monitoring has no effect on perinatal morbidity or
mortality: A Review

-Two-stage protocol for placenta accreta: US first, and then MRI for
inconclusive US

and more.....

**Gynecology page 10**

-See and treat: HPV positive, HSIL cytology, and a high-grade impression
at 2^nd^ colposcopy

-Activity Restriction After Pelvic Floor Surgery?

-Urinary incontinence and age at the first and last delivery

-TVT is effective: Recurrent stress urinary incontinence and/or previous
prolapse surgery

-Diagnosis and Management of Endometriosis

and more.....

**Child Health page 11**

-Metformin Useful for Treating PCOS in Adolescents

-Should Pacifier Use in Infants Be Discouraged?

-Opportunities to prevent injury among children and adolescents: New
fact sheet

-Early-Onset and Late-Onset Neonatal Group B Streptococcal Disease

-Prolonged Bottle-feeding and Iron Deficiency Anemia

**Chronic Illness and Disease page 13**

-Varenicline was significantly more efficacious for smoking cessation

-Clinical Prediction Rule for Stratifying Patients with PE

-Predicting Four-Year Mortality Risk in Older Adults

-Criteria for Diabetes Testing in Asymptomatic Adults

-Light Therapy vs. Fluoxetine for Treatment of SAD

and more.....

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

##### American Family Physician

-Acupressure vs. Physical Therapy for Low Back Pain

-Naltrexone and Counseling Reduce Alcohol Dependence

American College of Obstetricians and Gynecologists

-Human Papillomavirus Vaccination

-HPV Vaccine Shows Promise, at Least in Short Term

**Agency for Healthcare Research and Quality**

-Surgeons vary widely in their approaches to disclosing medical errors
to their patients

-Case management dramatically reduces care use for minority children on
Medicaid

-NICU babies are frequently at risk for misidentification

**Ask a Librarian**

Daily Health Policy News Summaries - New on Your Library Website

**Breastfeeding**

-Engorgement - It only feels like it is going to last forever

-Breastfeeding: Data and Statistics: Breastfeeding Practices --- Results
from 2005 Survey

**CCC Corner Digest**

#### August 2006 Highlights include: {#august-2006-highlights-include .Style-Heading-4-+-Arial-14-pt-Underline}

-Uterine rupture rate hasn't changed for 20 years -- Why have our
practices?

-New Women's Health Work Group Forming: Looking for interested
volunteers

-Update your standing post partum discharge orders: Tdap in pregnancy

-ACOG Releases HPV Vaccine Recommendations for Ob-Gyns

-Emergency Contraception: A Primer for Pediatric Providers

-Antidepressant Discontinuation Syndrome

-Norethindrone More Effective for Menses Suppression

-Induction of Labor for Vaginal Birth After Cesarean Delivery

-Early Milk Supply Issues

-Randomized trial: Screening for intimate partner violence in health
settings

-Is 75 Years an Appropriate Upper Age Limit for Mammography?

-Addressing Depression in Family Planning Services

-HIV/AIDS in Latin America and the Caribbean

-First trimester screening: How would you counsel this patient?

-VBAC: Pendulums and Ecstasy

-Native Alaskan and American Indian Nurses Scholarship Opportunity

-The indications for IUD use have vastly expanded

-Glyburide flows from fetus to mother by placental transport system

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

-Condom Use and the Risk of Genital HPV Infection in Young Women

-Obese Girls: 3 x Risk for Early Death than Slim Counterparts

**Domestic Violence**

Randomized trial assesses screening for intimate partner violence in
health settings

**Elder Care News**

Where is the Indian Health System when it comes to providing palliative
/ end-of-life care?

**Family Planning**

Adolescent perception of sexual abstinence

**Featured Website**

The Indian Health MCH Frequently Asked Question (FAQ) site

**Frequently asked questions**

Are there any cultural barriers/among Native Americans to becoming cord
blood donors?

**Indian Child Health Notes**

**September 2006 -- Highlights**

-Thank you Captain Obvious - Meta analysis shows that drinking sugar
sweetened beverages is linked to obesity

-If you cant beat \'em sue \'em: The intersection of obesity and public
health law

-Pneumococcal vaccine has decreased the rates of otitis media and PE
tube placement in AI/AN children

-Cancer data for adolescent Native Americans

-Mystery person gives \$100,000 to the Committee on Native American
Child Health - Help us decide how to spend it

-Survey Monkey in this issue - let us know what you want

**Information Technology**

HIV Management System, v1.0 - National Release, BKM

International Health

-Health care and indigenous peoples: the other side of the planet

-Planes, trains, automobiles and asthma in China

#### MCH Alert

-Adolescents' Use of Contraception

-New website provides easy access to information on SIDS and infant
death

#### Medical Mystery Tour

#### First trimester screening: How would you counsel this patient? {#first-trimester-screening-how-would-you-counsel-this-patient .Style-Heading-4-+-Arial-14-pt-Underline}

#### Medscape

**Menopause Management**

-Clonidine and Gabapentin Effective for Hot Flashes

#### -Estrogen Alone Does Not Increase Breast Cancer Risk {#estrogen-alone-does-not-increase-breast-cancer-risk .Style-Heading-4-+-Arial-14-pt-Underline}

**Midwives Corner**

-Postpartum Care: Still the neglected step child of perinatal services?

-Midwives applaud new false labor EMTALA regulations

**Navajo News**

Implanon- A single rod contraceptive implant...

**Nurses Corner**

#### Harm Resulting from Inappropriate Telephone Triage in Primary Care {#harm-resulting-from-inappropriate-telephone-triage-in-primary-care .Style-Heading-4-+-Arial-14-pt-Underline}

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

Trends in HIV-Related Risk Behaviors Among High School Student**s**

**Oklahoma Perspective**

The indications for IUD use have vastly expanded

Osteoporosis

Calcium during pregnancy: Higher maternal Vit. D / folate and newborn Wt
/ mineralization

Patient Education

Endometriosis: What You Should Know

Perinatology Picks

-How important is maternal intratpartum glucose to neonatal
hypoglycemia?

-Adverse outcomes with DM are 3-9 times worse vs normal and not improved
in 15 years

-17 hydroxyprogesterone caproate results in cost-savings in women with
prior PTD

-No difference in pregnancy loss: Chorionic villus sampling vs
amniocentesis, 1998 to 2003

-Vitamin Supplements Do Not Prevent Preeclampsia

Primary Care Discussion Forum

Palliative Medicine\'s Role in the Continuity of Care -- Ongoing

STD Corner

**Sexual Education / HIV Education and youth**

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

Weight Loss Should be the Primary Intervention for Risk of Diabetes

###### Save the Dates: Upcoming events of interest page 41

#### What's new on the ITU MCH web pages page 42

The past CCC Corners are archived at:

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

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

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

or 907 729 3154 (with voicemail)

\*The opinions expressed in the OB/GYN CCC Corner are strictly those of
the authors, and not necessarily those of the Indian Health System, or
the author of this newsletter. If you have any comments, please share
them by joining the Primary Care Discussion Forum where this topic was
recently discussed. To join the Primary Care Listserv, click on
'Subscribe' here
<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdiscuss.asp>

10/20/06njm