**News Flash(s)**

**Please change your bookmark to the new MCH Portal url**

**The MCH website(s) were completely re-designed.  **

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

**New Vaginal Birth After Cesarean Delivery CME/CEU module**

(see Featured Web sites below)

![](media/image1.png){width="5.998611111111111in"
height="1.3034722222222221in"}

 

OB/GYN Chief Clinical Consultant's Corner

Volume 4, No. 2, February 2006

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

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

Results of a Well-Defined Protocol for a Trial of Labor After Cesarean

#### From your colleagues: page 7 {#from-your-colleagues-page-7 .Style-Heading-4-+-Arial-14-pt-Underline}

**Carolyn Aoyama**

-AHRQ expands women\'s health program to include gender-based research

-2nd Annual Summer Institute in Maternal-Fetal Pharmacology (Summer
Institute)

-Three Women\'s Health Awards

**Nancy Brannin**

Oral misoprostol for cervical priming in non-pregnant women

**Phil Smith**

18^th^ Annual IHS Research Conference

Judy Thierry

-Please Welcome Roy Hoffman: Roy is working on Children with Special
Health Care Needs

-Data to improve the health of mothers and infants: PRAMS

-Western Tobacco Prevention Project - NPAIHB Tribal Tobacco Policy
Workbook

-2005 NPAIHB Tobacco Policy on Pregnant Women

-WIC participant characteristics: Aggregate AIAN data

**Judy Whitecrane**

-13th Annual Mayo Clinic Nicotine Dependence Conference

-3rd Annual Spit Tobacco Summit, Mayo Clinic

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

##### Obstetrics: page 10

-Term breech trial: The original term breech trial recommendations
should be re-evaluated

-Late postpartum eclampsia: a preventable disease?

-Ensure that newborn infants are protected from hepatitis B virus (HBV)
infection, CDC

-Ginger is effective means for reducing postoperative nausea and
vomiting: Meta-analysis

-Obstetric Characteristics Predict Risk of Sudden Infant Death Syndrome

and more....

**Gynecology: page 14**

-Superiority of Liquid-Based Cytology for Cervical Screening Questioned

-LEEP: Treatment of Cervical Neoplasia Linked to Preterm Births

-Restricted activities after gynecologic surgery: No greater impact than
rising from a chair

-Continued frequent screening of women with normal pap: Costly and
benefits

-Protective Effect of Progesterone or Estrogen: Ovarian Cancer

and more....

**Child Health: page 17**

-Broad-spectrum antibiotics during labor linked to late-onset serious
infections in infants

-Over Bundling: Winter and SIDS

-Your female patient athletes: Treatment of stress fractures: the
fundamentals

-Screening and Counseling for Obesity in Children

-AAP Recommendations for Treating Children After a Disaster

**Chronic Illness and Disease: page 18**

-Dietary intervention alone of little benefit in preventing disease

-Cardiovascular Disease in American Indians and Alaska Natives

-Cold Sores: Famciclovir for the Treatment of Recurrent Genital and
Labial Herpes Lesions

-Percentage of Persons Aged [\>]{.underline}18 Years Reporting Severe
Headache or Migraine

-Substandard preventive care for diabetes more likely: Multiple low
priority visits

and more....

#### Features: page 23 {#features-page-23 .Style-Heading-4-+-Arial-14-pt-Underline}

##### American Family Physician

###### -Vaginal Birth after Cesarean (continued)

-No Difference Among New Antidepressants

-Are Alpha-glucosidase Inhibitors Effective for Control of Type 2
Diabetes?

-Gabapentin for Pain: Balancing Benefit and Harm

American College of Obstetricians and Gynecologists

Patient Safety in the Surgical Environment

**Agency for Healthcare Research and Quality**

## -Nearly half of urban AI/AN travel back to their reservation to visit during the year

## -Women with moderate PID: Similar reproductive outcomes - inpatient and outpatient care

-Misconceptions about cancer screening may be common among women

-Women who suffer from obesity less likely to undergo Pap testing

-Women who are at high risk of developing preeclampsia: Cytokine
genotypes may identify

**Ask a Librarian**

Birth News Highlights: Young mothers; VBACs down; Early Prenatal Care;
Low birth weight

**Breastfeeding**

-Dose-dependent association between duration of breastfeeding and risk
of overweight

-ACOG, AAP Develop First Collaborative Physician-Focused Breastfeeding
Handbook

-Quality of consumer related breastfeeding education: Web Site evaluates

-Health LITERACY: Breastfeeding is to be seen as normative

-GAO recommends removal of WIC logo from any formula marketing
                   

**CCC Corner Digest**

\-[Link between GDM and Type 2 DM can be
broken](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_AOM.cfm)

\-[Integrating prevention of mother-to-child HIV transmission into
routine antenatal
care](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_Coll.cfm)

\-[Bed Rest for pregnancy related hypertension: Not
recommended](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_HT.cfm#ob)

\-[Prior Function and Relationship, More Than Hormones, Affect Sexual
Function in
Midlife](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_HT.cfm#gyn)

\-[Oral Contraceptives and Dysmenorrhea in Adolescents:
RCT](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_HT.cfm#child)

**-**[Waking up to Sleep Deprivation: Countermeasures for Daytime
Sleepiness](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_HT.cfm#chrIll)

\-[New studies shows a 15% reduction for the risk of diabetes for every
year of
lactation](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_Feat.cfm#breast)

\-[Emergency Contraception Use Not Associated With Risky Sexual
Behavior](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_Feat.cfm#fp)

\-[Vaginal Birth after Cesarean  New Perinatology Corner Module -- 2
credits](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_Feat.cfm#webSite)

**-**[CC: I feel really cold and my side hurts, plus I am shaking all
over](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_Feat.cfm#mmtour)
 

\-[Shoulder Dystocia Prevention: plus the 'CCC Deliver Through
Maneuver](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_Feat.cfm#MidWives)'

\-[Depo-Provera available in a lower dose: limited data to assess 104mg
SQ vs. 150mg
IM](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_Feat.cfm#navajo)

\-[Should Pregnant Women Be Tested for Herpes
Susceptibility?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_Feat.cfm#periPicks)

\-[Cardiology Topics for Primary Care Providers -- February 15,
2006](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_Feat.cfm#pcf)

\-[Clinician-Delivered Intervention During Routine Care Reduces
Unprotected Sexual
Behavior](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_Feat.cfm#std)

\-[Antidepressants Are No Match for
Poverty](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_Feat.cfm#stillW)

**Domestic Violence**

Child Abuse Prevention for Nurses, Psychologists, Social Services, and
Community

**Elder Care News**

Euthanasia: The Dutch Experience

Over active bladder therapies on CNS functioning in elderly patients:
First-line therapies

**Family Planning**

-Progestin-Releasing IUDs for Women with Diabetes

#### -Emergency Contraception- Women with two children who need 30 years of family planning {#emergency-contraception--women-with-two-children-who-need-30-years-of-family-planning .Style-Heading-4-+-Arial-14-pt-Underline}

**Featured Website**

-Maternal Child Health Website Gets a Facelift

-New Vaginal Birth After Cesarean Delivery CME/CEU module

**Frequently asked questions**

-Should a urine test be performed on every pregnant patient each
prenatal visit?

-Can we use medical therapy in the setting of spontaneous abortion
(SAB)?

-How do I manage patients with recurrent vulvovaginal candidiasis?

-Does IHS have any policy on distribution of the morning after pill?

-Does the IHS have a procedure for payment in pregnancy termination?

and more....

**Indian Child Health Notes**

\- To Bag or Not to Bag: Is a bag urine specimen ever reliable?

\- An updated immunization for Native Americans from Dr. Singleton

\- The latest literature reviews from Dr. Esposito

**Information Technology**

-What is the latest on an OB/GYN solution for the PCC, PCC+ and EHR?

#### -Patient Safety and Health IT - Exploring and Expanding the Intersections, AHRQ

-New PCC PATCH released

-National Release - BMC Referred Care Information System, Version 4.0

International Health

-Summer opportunity for undergraduate students

-Attitudes toward the use of quarantine in a public health emergency in
four countries

#### MCH Alert

-Cultural Competency into Medical Education and Training

-Potential Environmental Risks to Women

#### Medical Mystery Tour

#### How not to give Acetaminophen: Listen up any parents or grandparents {#how-not-to-give-acetaminophen-listen-up-any-parents-or-grandparents .Style-Heading-4-+-Arial-14-pt-Underline}

#### Medscape

**Menopause Management**

#### -American Heart Association Does Not Recommend Isoflavone Supplements -Black cohosh / St. John\'s wort combined: Decreases psychological climacteric complaints  {#american-heart-association-does-not-recommend-isoflavone-supplements--black-cohosh-st.-johns-wort-combined-decreases-psychological-climacteric-complaints .Style-Heading-4-+-Arial-14-pt-Underline}

-Nonhormonal Therapies for Hot Flashes in Menopause

**Midwives Corner**

-When Should We Clamp the Umbilical Cord? Preterm vs Term Infants

-Liability in triage: management of EMTALA regulations and common
obstetric risks

-Withholding coaching during maternal pushing is not harmful

-Injuries to the Brachial Plexus: Mechanisms and Management

-Centering Association National Conference

and more....

**Navajo News**

#### Who do you contact in Navajo Area for MCH issues?  {#who-do-you-contact-in-navajo-area-for-mch-issues .Style-Heading-4-+-Arial-14-pt-Underline}

**Nurses Corner**

-New Mexico Indian Nurses Association Annual Symposium 2006

-Drugs containing PHENYLPROPANOLAMINE are being recalled

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

-Trends in Spina Bifida and Anencephalus in the United States, 1991-2003

-Community Based Cancer Control: A Seminar for AI/AN Health Advocates

**Oklahoma Perspective**

Who do you contact in Oklahoma Area for MCH issues?

Osteoporosis

-Cost-effectiveness of Drug Treatment for Osteopenia

-Vitamin D Levels During Pregnancy Affect Childhood Bone Mass

Patient Education

#### -Non-hormonal Options for Hot Flashes {#non-hormonal-options-for-hot-flashes .Style-Heading-4-+-Arial-14-pt-Underline}

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

-Keeping Your Heart Healthy Through Good Nutrition and Exercise

Perinatology Picks

-Focus on preventable causes of stillbirth: 3 articles

-'Integrated Screening' is the most efficient: Risk cutoff levels
determine strategies

-Emergency cervical cerclage improves perinatal outcome compared with
bed rest

-Cervical cerclage: Can the patient who could benefit from this
procedure be identified?

-Prophylactic cerclage of a short cervix according to interleukin-8 in
cervical mucus

Primary Care Discussion Forum

Cardiology Topics for Primary Care Providers -- February 15, 2006

STD Corner

-Efficacy and safety of azithromycin for treatment of C. trachomatis in
pregnancy

-Hormonal contraception use and risk of STIs: A systematic review

-New National Women and Girls HIV/AIDS Awareness Day: March 10, 2006

-2006 Price Fellowships for HIV Prevention Program

-A clinician's guide to condoms, spermicides, microbicides, and
lubricants

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

-The underlying pathology for heart disease in women

-Waist-to-Hip Ratio Is a Better Predictor for MI Than BMI

-Sulfonylureas Linked to Heart Deaths

-Getting Sufficient Sleep Helps Reduce Weight Gain

-Intensive Monitoring and Treatment Required for Gestational Diabetes

and more....

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

#### What's new on the ITU MCH web pages page 49

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

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

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

## Results of a Well-Defined Protocol for a Trial of Labor After Cesarean 

**OBJECTIVE:** It has been claimed that a trial of labor after cesarean
carries higher maternal and fetal risks than planned cesarean delivery.
Because the management of such patients in our department differs from
that described in some studies, and is perhaps more cautious, we
hypothesized that the outcome may be better.

**METHODS:** We identified women with 1 previous low uterine segment
cesarean who had delivered a cephalic singleton infant at gestational
age 34 weeks or more from January 2000 through May 2005. Our policy is
to encourage such women to undergo a trial of labor unless cesarean
delivery is indicated. Unless otherwise indicated, our policy is to wait
for spontaneous labor. We do not use prostaglandins, and recommend
cesarean delivery if the cervix is unripe.(Bishop score \< 6). We
compared the outcome between women who underwent a trial of labor and
women who underwent planned cesarean delivery.

**RESULTS:** A trial of labor was attempted by 841 women (80%
successful), and 467 underwent planned cesarean delivery. Uterine
rupture was observed in 1 woman 18 hours after vaginal delivery. There
was no difference in major or minor maternal morbidity. There was no
serious neonatal morbidity. Among the planned cesarean patients,
hospital stay was longer, and there were more admissions to the neonatal
intensive care unit.

**CONCLUSION:** With our well-defined protocol, a trial of labor after
cesarean seems to be as safe for the mother and infant as planned
cesarean delivery, and the hospital stay is shorter.

## **Gonen, R et al.** Results of a Well-Defined Protocol for a Trial of Labor After Prior Cesarean Delivery. [Obstet Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006 Feb;107(2):240-5.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16449107&dopt=Abstract>

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

The Indian Health system has just released a great new CME module on
Vaginal Birth after Cesarean delivery. The free online module offers
many helpful resources for clinical management and public health
decision making, e. g., should my facility provide VBAC?

The module highlights the Northern New England Quality Improvement
Network which has carefully looked at the literature and then applied it
to clinical settings in New England. The CME / CEU module is available
here: <http://www.ihs.gov/MedicalPrograms/MCH/M/VB01.cfm>

**Risking system**

#### Northern New England Perinatal Quality Improvement Network

Low Risk Patient:

-   1 prior low transverse cesarean delivery

-   Spontaneous onset labor

-   No need for augmentation

-   No repetitive FHR abnormalities

-   Patients with a prior successful VBAC are especially low risk.\
    (However, their risk status escalates the same as other low risk
    patients)

Medium Risk Patient:

-   Induction of labor

-   Pitocin augmentation

-   2 or more prior low transverse cesarean deliveries\*

-   \< 18 months between prior cesarean delivery and current delivery

High Risk Patient:

-   Repetitive non-reassuring FHR abnormalities not responsive to
    clinical intervention. /li\>

-   Bleeding suggestive of abruption

-   2 hours without cervical change in the active phase despite adequate
    labor

\* NB: \'Two prior uterine scars and no vaginal deliveries\' is listed
as a circumstance under which trial of labor should not be attempted by
the American College of Obstetricians and Gynecologists [ACOG Practice
Bulletin No.
54](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15229039&query_hl=6),
\'Vaginal birth after previous cesarean delivery\'.

Here is one suggested management system

#### Management system

#### Low risk

Notify Pediatrics, Anesthesia, and operating room crew of admission\
OB/GYN on campus during active phase\
Perinatal Guidelines of Care, ACOG, observed

#### Medium risk

Notify Pediatrics, Anesthesia, and operating room crew of admission\
Operating room on campus in active phase or other plan if crew is busy

#### High risk

OB/GYN, Anesthesia, and Pediatrics available\
No other acute care responsibilities\
Rapid decision to incision

**Northern New England Perinatal Quality Improvement Network**

<http://www.nnepqin.org/nneob/servlet/HomePage>

**Other helpful background: See American Family Physician below**

The American Academy of Family Practice provides an Evidence Based
approach to the trial of labor after cesarean.

**AAFP Recommendation 4 is the most controversial.** TOLAC should not be
restricted to facilities with surgical teams present throughout labor
because there is no evidence that these additional resources result in
improved outcomes. A management plan for uterine rupture and other
potential emergencies requiring rapid cesarean section should be
available and documented for each woman undergoing TOLAC. This
recommendation differs from the current American College of Obstetrics
and Gynecology (ACOG) guidelines and policy (grade C).

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

**Carolyn Aoyama, HQE**

**AHRQ expands women\'s health program to include gender-based
research**

AHRQ is expanding its research on women\'s health to include
gender-based analysis, a field that is receiving increased emphasis
within the Department of Health and Human Services and among other
stakeholders. To lead the Agency\'s involvement in this coordinated
effort, AHRQ has designated Rosaly Correa-de-Araujo, MD, M.Sc., Ph.D.,
as the Director of Women\'s Health and Gender-Based Research.

In her new role, Dr. Correa will direct the development of an intramural
and extramural research agenda that will initially focus on gender
analysis across diverse racial and ethnic groups on the quality and
outcomes of care for chronic conditions. This new field of inquiry has
created a broad range of research opportunities and, consequently, the
chance to improve treatment and disease outcomes through interventions
that address the specific needs of women and men of any age, race,
ethnicity, or socioeconomic status. Dr. Correa will continue to direct
all women\'s health priority issues for the Agency in close coordination
with other Federal partners.

[**http://www.ahrq.gov/research/sep05/0905RA41.htm**](http://www.ahrq.gov/research/sep05/0905RA41.htm)

**2nd Annual Summer Institute in Maternal-Fetal Pharmacology (Summer
Institute)**

July 23-29, 2006 in Denver, CO

The goal is to foster the development of a critical mass of researchers
and clinicians in this neglected area. The course aims at clinical and
non-clinical scientists who are considering academic careers in studying
therapeutics during pregnancy, the perinatal period, and lactation.
Presently, the pregnant mother and her unborn baby are rarely included
in therapeutic studies, leading to serious orphaning from the benefits
of drug therapy. The National Institute of Child Health and Human
Development (NICHD) and the Office of Research on Women\'s Health (ORWH)
at the National Institutes of Health (NIH) and the Institute of Human
Development, Child and Youth Health (IHDCYH) at the Canadian Institutes
of Health Research (CIHR) are pleased to announce the Summer Institute.
[**http://www.circlesolutions.com/summerinstitute**](http://www.circlesolutions.com/summerinstitute/index.cfm)

**Three Women\'s Health Awards**

The following three awards will be presented at our special awards
luncheon at the Snowmass Institute\'s 22^nd^ Annual Conference on
Achieving Success in Women\'s Health in Charlotte, NC, May 7-9, 2006

 

[Next Generation of Women\'s Health Leaders 2006]{.underline}

Awarded by Spirit of Women & The Snowmass Institute

Recognizes a young woman who is a upcoming leader in women\'s health

 

[Lifetime Achievement Award in Women\'s Health 2006]{.underline}

Awarded by Bon Secours Richmond Health System & The Snowmass Institute

Recognizes a person who has been dedicated to women\'s health for 20+
years

 

[Innovation in Women\'s Health 2006]{.underline}

Awarded by The Snowmass Institute & Berry & Associates

Recognizes a significant innovation achievement or project in women\'s
health

 

Please go to
[www.snowinst.com/womens-health-conference.htm](http://www.snowinst.com/womens-health-conference.htm)
click on

AWARDS IN WOMEN\'S HEALTH for applications and information on each
award.

**Nancy Brannin, Santa Fe**

**Oral misoprostol for cervical priming in non-pregnant women**

I read about the misoprostol for hysteroscopy in CCC Corner, and wanted
to pass along that the midwives on the ACNM clinical listserv just had a
discussion of using it for two other purposes:

1.) IUD insertion in nulliips (including previous C/S but never
dilated).

One gives 400 mcg to take the night before the insertion, and it makes
it much easier and less traumatic

2.) EMBs, or even Paps, in postmenopausal women with stenotic cervices

Reference:

Oral misoprostol for cervical priming in non-pregnant women

Endometrial biopsy and hysteroscopy are important investigations in
women presenting with abnormal vaginal bleeding. Endometrial biopsy is
often performed as an outpatient procedure by endometrial aspiration.
Difficulty in entering the internal cervical os may be encountered,
especially in nulliparous women. The same problem may occur during
hysteroscopy or dilatation and curettage. It is well known that use of a
cervical priming agent is effective in reducing complications during
cervical dilatation in pregnant women. However, its use in non-pregnant
women is not well established. We compared oral misoprostol versus
placebo for a cervical priming effect in non-pregnant women prior to
hysteroscopy. The cumulative force required for cervical dilatation was
significantly lower whereas the baseline cervical dilatation was
significantly greater in the misoprostol group. We conclude that oral
misoprostol is effective for pre-operative cervical dilatation in
non-pregnant women.\
\
PIP: Difficulties with entering the internal cervical os in nonpregnant
women (especially nulliparous women) can hinder performance of
endometrial aspiration or hysteroscopy in patients presenting with
abnormal vaginal bleeding. This study investigated the usefulness of
oral misoprostol\--shown to be effective in cervical dilatation in first
and third trimester abortion\--for preoperative cervical dilatation in
non-pregnant women. 44 nulliparous women presenting to Hong Kong\'s
Queen Mary Hospital for diagnostic hysteroscopy and endometrial biopsy
and curettage were randomly assigned to receive either 400 mcg of
misoprostol 12 hours prior to the procedure (n = 21) or placebo (n =
23). Pretreatment with misoprostol significantly reduced the amount of
force required to dilate the cervix to 8 mm from 103.7 Newtons in
controls to 40.0 Newtons in women treated with misoprostol. The mean
baseline cervical dilatation was significantly greater in the
misoprostol group (6.0 mm) than in controls (3.3 mm). There were no
immediate intraoperative complications and all women were discharged
within 12 hours of the procedure. Another potential use of misoprostol
is for cervical dilatation prior to IUD insertion in nulliparous women.

Ngai SW, et al Oral misoprostol for cervical priming in non-pregnant
women. Hum Reprod. 1997 Nov;12(11):2373-5.

[**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9436666&dopt=Abstract**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9436666&dopt=Abstract)

#### Phil Smith, HQE {#phil-smith-hqe .Style-Heading-4-+-Arial-14-pt-Underline}

# 18^th^ Annual IHS Research Conference

# April 24-26, 2006

-   Albuquerque, NM

-   Discovering Pathways to Better Health for AI/AN

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

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

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

**Please welcome Roy Hoffman**

**Roy is on a 2 month MCH program rotation on Children with Special
Health Care Needs**

Please welcome Roy Hoffman, MD, MPH, FAAP - a Preventive Medicine
resident from Johns Hopkins University.  Roy graduated medical school
from the State University of New York at Stony Brook and completed a
pediatrics residency at the Children's Hospital of Pittsburgh.  Before
starting his second residency in preventive medicine, he worked for a
year as a contract pediatrician with the IHS at both Fort Defiance
Indian Hospital and Blackfeet Community Hospital.  He will be doing a
practicum rotation at IHS headquarters in Maternal Child Health under
Dr. Judith Thierry from mid February to mid April.  The focus of his
rotation project will be to look more closely at AI/AN children with
special health care needs (CSHCN).  He will be analyzing the data
already collected by the National Center for Health Statistics as part
of the National Survey of Children's Health (NSCH).  A telephone
interview survey of parents, NSCH includes over 60 measures: Physical
and Dental Health, Emotional and Mental Health, Health Insurance
Coverage; Health Care Access and Quality, Community and School
activities, Family health and Activities, and Neighborhood Safety and
support. <Judith.Thierry@ihs.gov>

**Data to improve the health of mothers and infants: PRAMS**

Pregnancy Risk Assessment Monitoring System (PRAMS) allows the CDC,
states, Tribes and Urban Indian programs to monitor changes in maternal
and child health indicators (e.g., unintended pregnancy, prenatal care,
breast-feeding, smoking, drinking, and infant health).  Birth
certificate information combined with mail out survey data to women in
participating states allow for findings to be applied to the state\'s
entire population of women who have recently delivered a live born
infant.

Sampling methodology allows State-specific data and comparisons among
participating states. 

Learn more about PRAMS:
 <http://www.cdc.gov/reproductivehealth/PRAMS/index.htm>

Map of states:
<http://www.cdc.gov/reproductivehealth/PRAMS/PRAMSStates.htm>

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

**Western Tobacco Prevention Project - NPAIHB Tribal Tobacco Policy
Workbook**

In 2005, the Western Tobacco Prevention Project (WTPP) of the Northwest
Portland Area Indian Health Board (NPAIHB) published a revised Tribal
Tobacco Policy Workbook was collaboratively written by over 100 tribal
educators, leaders, agencies, and community members, bringing together
the wisdom and experience of Tribes from throughout the nation. Based on
the original 1995 Tribal Tobacco Policy Workbook, the guide was
significantly expanded to include information on clinic-based systems of
care, youth prevention policies, taxes, secondhand smoke policies,
casino-based policies, policies that support cessation, and policies to
encourage the traditional use of sacred tobacco. Including numerous
examples and policy templates, it was designed to provide step-by-step
guidance for writing, passing and enforcing tobacco-related policies
that reflect local cultural protocols in AI/AN communities.

Whether this is your first attempt at creating a tobacco-related policy
for your Tribe, or you are moving on to new areas for change, this
workbook will provide you with approachable steps, usable templates, and
concrete examples. The Tribal Tobacco Policy Workbook can also be
downloaded from our website at
[www.westerntobaccoprevention.org](http://www.westerntobaccoprevention.org/) under
\"Publications\".

**2005 NPAIHB Tobacco Policy on Pregnant Women**

Page 194 pregnant women - Search by word: infant, child, women, pregnant
throughout the document
<http://www.westerntobaccoprevention.org/publications.php>

**WIC participant characteristics: Aggregate AIAN data**

This may be helpful as you look at key variables and frame research
questions. A \"summary\" with key tables excerpted that might help you
review first before you surf through the entire 200+ page document is
available. WIC / USDA\'s Food and Nutrition Branch - Ursuline Singleton
(703) 305-2722 <usingleton@usda.gov> or
<http://www.fns.usda.gov/oane/MENU/Published/WIC/WIC.htm>

**Judy Whitecrane, Phoenix**

**13th Annual Mayo Clinic Nicotine Dependence Conference**\
***\"Innovations in the Treatment of Tobacco Dependent Patients\"***\
May 16 - 18, 2006

Rochester, Minnesota

Post-conference workshop on May 19.\
[www.mayo.edu/cme](../www.mayo.edu/cme) Or you may contact
<cme@mayo.edu> to request a brochure or any information.

**3rd Annual Spit Tobacco Summit**\
October 16 - 19, 2006

Rochester, Minnesota

Mayo Clinic\
[www.mayo.edu/cme](../www.mayo.edu/cme) Or you may contact
<cme@mayo.edu> to request a brochure or any information.

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

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

**Term breech trial: The original term breech trial recommendations
should be re-evaluated**\
OBJECTIVE: On the basis of the end points of neonatal morbidity and
death, the authors of the term breech trial concluded unequivocally that
cesarean delivery was safer for breech babies.

STUDY DESIGN: Analysis of the original and new data gives rise to
serious concerns as far as study design, methods, and conclusions are
concerned. In a substantial number of cases, there was a lack of
adherence to the inclusion criteria. There was a large
interinstitutional variation of standard of care; inadequate methods of
antepartum and intrapartum fetal assessment were used, and a large
proportion of women were recruited during active labor. In many
instances of planned vaginal delivery, there was no attendance of a
clinician with adequate expertise.

RESULTS: Most cases of neonatal death and morbidity in the term breech
trial cannot be attributed to the mode of delivery. Moreover, analysis
of outcome after 2 years has shown no difference between vaginal and
abdominal deliveries of breech babies.

CONCLUSION: The original term breech trial recommendations should be
withdrawn.

[Glezerman
M](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Glezerman+M"%5BAuthor%5D).
Five years to the term breech trial: the rise and fall of a randomized
controlled trial. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Jan;194(1):20-5

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16389006>

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

This review joins a growing body of literature that raises serious
questions about the Hannah term breech trial that concluded
unequivocally that cesarean delivery was safer for breech babies. One of
the major questions is the reasons for the Hannah results may have been
the short term nature of their follow-up. Other studies have shown
outcomes after 2 years that show no difference between vaginal and
abdominal deliveries of breech babies. We all need to critically follow
this growing body of literature so that we can adequately counsel our
patients.

**Late postpartum eclampsia: a preventable disease?**\
CONCLUSION: Current obstetric treatment in the United States has
resulted in a shift of eclampsia toward the postpartum period, with most
cases being seen as late post partum. To reduce the rate of late
postpartum eclampsia, efforts should be directed to the education of the
health care providers and patients regarding the importance of prompt
reporting and evaluation of symptoms of preeclampsia during the
postpartum period

[Chames
MC](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Chames+MC"%5BAuthor%5D)
et al Late postpartum eclampsia: a preventable disease? [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2002
Jun;186(6):1174-7.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12066093&query_hl>

**Ensure that newborn infants are protected from hepatitis B virus (HBV)
infection, CDC**

**Recommendations for Prenatal Care Providers**

Management of all pregnant women:

·Test all pregnant women for hepatitis B surface antigen (HBsAg) during
each pregnancy.

·Transfer a copy of the original laboratory report of the pregnant
woman's HBsAg test result to the patient's medical record in the
delivery hospital.

·Inform pregnant women of the importance of newborn hepatitis B
vaccination.

·Vaccinate pregnant women who are at risk for HBV infection.

**Management of pregnant women with chronic HBV infection:**

·Inform HBsAg-positive women of HBV transmission risks and ways to
prevent HBV infection, including the importance of postexposure
prophylaxis for newborn infants and hepatitis B vaccination of
household, sexual, and needle-sharing contacts.

·Refer HBsAg-positive women to an appropriate case-management program to
ensure that their newborn infants receive timely postexposure
prophylaxis and follow-up.

·Provide or refer HBsAg-positive women for appropriate medical
management of their chronic HBV infection.

**Recommendations for Delivery Hospitals**

·Implement standing orders to ensure that, except in rare circumstances
(see statement for additional details), all newborns with birth weights
of greater than or equal to 2 kilograms receive hepatitis B vaccine
before discharge.

·Implement policies and procedures to ensure that all infants born to
HBsAg-positive mothers and all infants born to mothers with unknown
HBsAg status are identified and receive appropriate immunoprophylaxis.
These policies and procedures should include the following standing
orders:

-Review HBsAg test results for all pregnant women at the time of
admission for labor and delivery.

-Conduct HBsAg testing as soon as possible after admission for pregnant
women who do not have a documented HBsAg result and for pregnant women
identified as being at risk for HBV infection during pregnancy (e.g.,
\>1 sex partner in the previous 6 months, evaluation or treatment for a
sexually transmitted disease, recent or current injection-drug use,
HBsAg-positive sex partner).

-Administer hepatitis B vaccine and hepatitis B immune globulin within12
hours of birth to all infants born to HBsAg-positive mothers.

-Administer hepatitis B vaccine within 12 hours of birth to all infants
born to mothers with unknown HBsAg status.

-Document on the infant's medical record the maternal HBsAg test results
and the infant's hepatitis B immunization.

**Recommendations for Health Departments**

·Provide or assure case-management services to ensure that 1) all
pregnant women are tested for HBsAg during each pregnancy, and 2)
infants born to HBsAg-positive women and infants born to women with
unknown HBsAg status receive recommended immunoprophlaxis and follow-up.

Before hepatitis B vaccination became routine in the United States,
transmission of HBV infection perinatally and during early childhood
caused an estimated 30%-40% of chronic HBV infections. Approximately 25%
of chronically infected children die prematurely from cirrhosis or liver
cancer. The majority of chronically infected persons remain asymptomatic
until the onset of cirrhosis or end-stage liver disease.

These recommendations update the ACIP strategy to eliminate HBV
transmission in the United States. This strategy has been implemented
with considerable success and has resulted in a substantial decline in
hepatitis B incidence in the United States. However, challenges remain
to eliminate perinatal and childhood HBV transmission. In particular,
CDC estimates that only about half of expected births to HBsAg-positive
mothers are identified for case management, which is needed to maximize
on-time delivery of postexposure immunoprophylaxis. In addition, errors
in management of infants born to HBsAg-positive mothers and infants born
to mothers with unknown HBsAg status have kept many of these infants
from receiving appropriate immunoprophylaxis to prevent HBV infection.
<http://www.cdc.gov/mmwr/PDF/rr/rr5416.pdf>

Centers for Disease Control and Prevention Centers for Disease Control
and Prevention

**Ginger is effective means for reducing postoperative nausea and
vomiting: Meta-analysis**

.CONCLUSIONS: This meta-analysis demonstrates that a fixed dose at least
1 g of ginger is more effective than placebo for the prevention of
postoperative nausea and vomiting and postoperative vomiting. Use of
ginger is an effective means for reducing postoperative nausea and
vomiting.

[Chaiyakunapruk
N](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Chaiyakunapruk+N"%5BAuthor%5D)
et al The efficacy of ginger for the prevention of postoperative nausea
and vomiting: a meta-analysis. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Jan;194(1):95-9

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16389016>

**Obstetric Characteristics Predict Risk of Sudden Infant Death
Syndrome**

CONCLUSIONS: A model that uses maternal characteristics and outcome at
birth is predictive of the risk for SIDS. This model is presented in a
simple form that allows calculation of the individual risk for SIDS.

[Smith
GC](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Smith+GC"%5BAuthor%5D),
[White
IR](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="White+IR"%5BAuthor%5D).
Predicting the risk for sudden infant death syndrome from obstetric
characteristics: a retrospective cohort study of 505,011 live births.
[Pediatrics.](javascript:AL_get(this, 'jour', 'Pediatrics.');) 2006
Jan;117(1):60-6.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16396861&query_hl>

**Correlates of intake of folic acid-containing supplements among
pregnant women**

CONCLUSION: This study identifies correlates of folic acid supplement
intake, which may contribute to the design of interventions to improve
intake during early pregnancy.

[Carmichael
SL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Carmichael+SL"%5BAuthor%5D)
et al. Correlates of intake of folic acid-containing supplements among
pregnant women. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Jan;194(1):203-10.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16389033>

Treatment of Vaginal Infections During Pregnancy

Bacterial vaginosis and infection with *Trichomonas vaginalis* have been
associated with preterm labor and preterm birth. Although the mechanism
is unclear, it has been suggested that the infection may spread from the
vagina to the uterus. Three meta-analyses have recommended that women at
high risk for preterm birth be screened and appropriately treated for
bacterial vaginosis and *T. vaginalis* infection.

The authors conclude that antibiotic therapy appears to reduce bacterial
vaginosis but does not reduce the risk of preterm birth or other adverse
outcomes. Similarly, they conclude that antibiotic treatment of *T.
vaginalis* infection is not beneficial and that the use of metronidazole
may be harmful. Killing the organisms may cause inflammation or release
a virus that increases the risk of preterm birth.

Okun N, et al. Antibiotics for bacterial vaginosis or *Trichomonas
vaginalis* in pregnancy: a systematic review. Obstet Gynecol April
2005;105:857-68.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15802417&query_hl>

**Newborn screening educational gap: what prenatal care providers do vs
what is expected**

CONCLUSION: Pregnant women and state professionals rely on prenatal care
providers to educate pregnant women about newborn screening; however,
many providers do not appear to view it as part of their responsibility.
Therefore, the state needs to improve communication with both providers
and the public about newborn screening.

[Faulkner
LA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Faulkner+LA"%5BAuthor%5D),
et al The newborn screening educational gap: what prenatal care
providers do compared with what is expected. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Jan;194(1):131-7.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16389022>

**Spirometry is related to perinatal outcomes in pregnant women with
asthma**

CONCLUSION: Lower pulmonary function during pregnancy is associated with
increased gestational hypertension and prematurity in the pregnancies of
women with asthma, which may be due to inadequate asthma control or
factors that are associated with increased asthma severity.\
[Schatz
M](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Schatz+M"%5BAuthor%5D),
et al Spirometry is related to perinatal outcomes in pregnant women with
asthma. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Jan;194(1):120-6.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16389020>

**Preeclampsia Associated With Later Kidney Problems in Mother**

Pregnant women who develop preeclampsia and who have a low birth weight
infant seem to be at increased risk of later kidney problems, according
to a report in the January 18th online issue of the Journal of the
American Society of Nephrology. The risk of kidney disease is highest in
women with both factors.

It is well known that preeclampsia is associated with later
cardiovascular disease in the mother. Our study is the first to document
a strong relationship between preeclampsia and low birth weight
offspring and later clinical kidney disease in the mother.

Conclusion: Women who have preeclampsia and give birth to offspring with
low birth weight and short gestation have a substantially increased risk
for having a later kidney biopsy.\
[Vikse
BE](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Vikse+BE"%5BAuthor%5D),
et al Adverse Perinatal Outcome and Later Kidney Biopsy in the Mother.
[J Am Soc
Nephrol.](javascript:AL_get(this, 'jour', 'J Am Soc Nephrol.');) 2006
Jan 18;\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16421228&query_hl>

**The Fidgety Fetus Hypothesis**

RESULTS---Phase I confirmed that there is little variability in fetal
movements (i.e., fetal kicks did not significantly deviate from one
another on a day-to-day basis). In phase II, the fetal monitoring strips
illustrated that the active fetuses (defined as
![](media/image2.png){width="7.291666666666667e-2in"
height="0.10416666666666667in"}4 FHR accelerations in a 20-min period)
were always active, and the inactive fetuses were always inactive. The
mean birth weight percentile, corrected for gestational age, in the
active group was 37 vs. 63% in the inactive group (*P* = 0.05). In phase
III, the fetal monitoring strips showed an inverse correlation between
the mean number of FHR accelerations and the birth weight of the fetus,
corrected for gestational age. The mean birth weight percentile in the
active group was 37 vs. 62% in the inactive group (*P* = 0.0017).

CONCLUSIONS---The fetus appears to play a role in determining its own
destiny. Increased fetal activity may minimize the impact of
hyperglycemia on subsequent birth weight. The inactive fetus appears to
be at a higher risk for glucose-mediated macrosomia.

Zisser H, Jovanovic L et al The Fidgety Fetus Hypothesis: Fetal activity
is an additional variable in determining birth weight of offspring of
women with diabetes\
Diabetes Care 2006 29: 63-67.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16373897&query_hl>

**All patients in labor should be considered at risk for the development
of shoulder dystocia**

Knowledge of the maneuvers used for the alleviation of shoulder dystocia
is relevant not only for obstetric residents and attending house staff
but also for family practitioners, nurses, and nurse midwives. The
performance of shoulder dystocia \"drills\" can be helpful not only to
coordinate a teamwork approach to this obstetric emergency but also to
provide an opportunity to practice the maneuvers. Shoulder dystocia
continues to represent an immense area of clinical interest because it
typically occurs without prediction. All patients in labor should be
considered at risk for the development of shoulder dystocia.

[Gherman
RB](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Gherman+RB"%5BAuthor%5D).
Shoulder dystocia: prevention and management. [Obstet Gynecol Clin North
Am.](javascript:AL_get(this, 'jour', 'Obstet Gynecol Clin North Am.');)
2005 Jun;32(2):297-305,

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15899362&query_hl>

**Relationship between social support and alcohol use in pregnant
women**

In this sample of well-educated and employed pregnant women and their
partners, social support was not predictive of prenatal alcohol use.

\* Characteristics that increased overall maternal social support were
the woman\'s being married, having more education, and having a job that
was more prestigious than her partner\'s.

\* Characteristics that decreased overall maternal social support were
first pregnancy and increased woman\'s age.

\* Social support was not predictive of prenatal alcohol use or
birthweight.

\* Early pregnancy drinking prior to study enrollment was the most
predictive of subsequent consumption, whether measured by quantity or
frequency.

\* Marital status predicted prenatal drinks per day, whereas lifetime
alcohol use predicted percentage of prenatal drinking days.

Prior use and early pregnancy drinking were the most predictive of
subsequent prenatal consumption, underscoring the importance of
screening pregnant women for drinking.

McNamara TK, Orav J, Wilkins-Haug L, et al. 2006. Social support and
prenatal alcohol abuse. Journal of Women?s Health 25(1):70-76
[[http://www.liebertonline.com/doi/abs/10.1089/jwh.2006.15.70]{.underline}](http://www.liebertonline.com/doi/abs/10.1089/jwh.2006.15.70)

**Partnership focuses on maintenance of health weight among women of
childbearing age**

Promoting Healthy Weight Among Women of Reproductive Age outlines
factors that influence weight, demographics of weight among women of
reproductive age, and the impact of overweight and obesity on perinatal
outcomes. The paper was produced by the Association of Maternal and
Child Health Programs and CityMatCH Women\'s Health Partnership, a
project to build state and local capacity to promote safe motherhood and
enhance women\'s health before, during, and after pregnancy. A
description of the theoretical frameworks underpinning the
AMCHP/CityMaTCH project efforts are presented, along with resources and
community-based interventions for assisting women of reproductive age to
maintain a healthy weight. The paper is available at
[[http://www.amchp.org/aboutamchp/publications/Healthy%20Weight.pdf]{.underline}](http://www.amchp.org/aboutamchp/publications/Healthy Weight.pdf)

**AmniSure rapid immunoassay versus standard methods for rupture of
membranes**

The purpose of this study was to compare the AmniSure rapid immunoassay
with standard methods for diagnosing rupture of fetal membranes.
Patients presenting with signs/symptoms of membrane rupture between 15
and 42 weeks of gestation were invited to participate. Standard/control
methods were performed to establish a diagnosis and compare it with
AmniSure results. AmniSure performance metrics and their 95% confidence
intervals were calculated. A total of 203 patients agreed to
participate. Discrepancies between the control method and AmniSure were
noted in seven cases. In these cases, true positives and negatives were
determined by retesting with the control method and AmniSure and by
noting sonographic evidence of low amniotic fluid. In the final
analysis, the AmniSure diagnostic test demonstrated a sensitivity of
98.9%, specificity of 100%, positive predictive value of 100%, and a
negative predictive value of 99.1%. AmniSure is highly accurate in
diagnosing fetal membrane rupture

[Cousins
LM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Cousins+LM"%5BAuthor%5D),
et al AmniSure placental alpha microglobulin-1 rapid immunoassay versus
standard diagnostic methods for detection of rupture of membranes. [Am J
Perinatol.](javascript:AL_get(this, 'jour', 'Am J Perinatol.');) 2005
Aug;22(6):317-20
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16118720&query_hl>

and

Technical Innovations in Clinical Obstetrics, Contemporary OB/GYN,
September 15, 2005, Vol 50\
<http://www.contemporaryobgyn.net/obgyn/issue/issueDetail.jsp?id=6950>

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

**Superiority of Liquid-Based Cytology for Cervical Screening
Questioned**

INTERPRETATION: We saw no evidence that liquid-based cytology reduced
the proportion of unsatisfactory slides, or detected more high-grade
lesions in high-quality studies, than conventional cytology. This review
does not lend support to claims of better performance by liquid-based
cytology. Large randomised controlled trials are needed.

[Davey
E](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Davey+E"%5BAuthor%5D)
et al Effect of study design and quality on unsatisfactory rates,
cytology classifications, and accuracy in liquid-based versus
conventional cervical cytology: a systematic review.
[Lancet.](javascript:AL_get(this, 'jour', 'Lancet.');) 2006 Jan
14;367(9505):122-32.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16413876&query_hl>

**LEEP: Treatment of Cervical Neoplasia Linked to Preterm Births**

CONCLUSION: Women with a history of LEEP, cold knife conization, and
cryotherapy all independently have shorter cervical lengths than
low-risk controls and similar lengths to women with previous spontaneous
preterm birth. Loop electrosurgical excision procedure and cold knife
conization are associated with spontaneous preterm birth less than 37
weeks, and transvaginal ultrasonography predicts preterm birth in women
who have had LEEP. LEVEL OF EVIDENCE: II-2. [Crane
JM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Crane+JM"%5BAuthor%5D),
et al Transvaginal Ultrasonography in the Prediction of Preterm Birth
After Treatment for Cervical Intraepithelial Neoplasia. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Jan;107(1):37-44.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16394037&query_hl>

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

This is a recurrent finding. The CCC Corner has reported the same
finding as recently as September 2004. To repeat...

For young women who have not yet completed reproduction, LEEP may not be
the best therapeutic option for treating CIN, especially of low
malignant potential. Women who clearly require surgical intervention may
be better served with other procedures, such as cryotherapy, or
observation.

**LEEP - not the best for treating young women who have not completed
reproduction**

<http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN0904_HT.cfm#gyn>

**Treatment for cervical intraepithelial neoplasia and risk of preterm
delivery**

<http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN0904_HT.cfm#ob>

**Preterm Labor and PPROM: Perinatology Corner (see Background)**\
<http://www.ihs.gov/MedicalPrograms/MCH/M/PTL_2.cfm>

**Restricted activities after gynecologic surgery: No greater impact
than rising from a chair**

RESULTS: Median peak abdominal pressures ranged from 48 (lifting 8 lb
from a counter) to 150 (lifting 35 lb from the floor), with much
variation. Many activities did not raise the intra-abdominal pressure
more than simply getting out of a chair, including lifting 8, 13, and 20
lb from a counter, lifting 8 or 13 lb from the floor, climbing stairs,
walking briskly, or doing abdominal crunches. Body mass index and
abdominal circumference each correlated positively with peak, but not
net, pressures. Age and grip strength were not associated with abdominal
pressure.

CONCLUSION: Some activities commonly restricted postoperatively have no
greater effect on intra-abdominal pressures than unavoidable activities
like rising from a chair. How lifting is done impacts intra-abdominal
pressure. Many current postoperative guidelines are needlessly
restrictive. Further research is needed to determine whether increased
intra-abdominal pressure truly promotes pelvic floor disorders. LEVEL OF
EVIDENCE: III

[Weir
LF](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Weir+LF"%5BAuthor%5D),
et al Postoperative Activity Restrictions: Any Evidence? [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Feb;107(2):305-309.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16449116&dopt=Abstract>

**Continued frequent screening of women with normal pap: Costly and
benefits limited**

CONCLUSION: As the number of prior normal Pap tests increases, the costs
per life-year saved increase substantially. Resources should be
prioritized for screening those never or rarely screened women. LEVEL OF
EVIDENCE: II-2.

[Kulasingam
SL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Kulasingam+SL"%5BAuthor%5D)
et al Cost-effectiveness of Extending Cervical Cancer Screening
Intervals Among Women With Prior Normal Pap Tests. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Feb;107(2):321-328.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16449119&dopt=Abstract>

**Protective Effect of Progesterone or Estrogen: Ovarian Cancer**

Ovarian carcinoma (OCa) continues to be the leading cause of death due
to gynecologic malignancies and the vast majority of OCa is derived from
the ovarian surface epithelium (OSE) and its cystic derivatives.
Epidemiological evidence strongly suggests that steroid hormones,
primarily estrogens and progesterone, are implicated in ovarian
carcinogenesis. However, it has proved difficult to fully understand
their mechanisms of action on the tumorigenic process. New convincing
data have indicated that estrogens favor neoplastic transformation of
the OSE while progesterone offers protection against OCa development.
Specifically, estrogens, particularly those present in ovulatory
follicles, are both genotoxic and mitogenic to OSE cells. In contrast,
pregnancy-equivalent levels progesterone are highly effective as
apoptosis inducers for OSE and OCa cells. In this regard, high-dose
progestin may exert an exfoliation effect and rid an aged OSE of
pre-malignant cells. A limited number of clinical studies has
demonstrated efficacies of antiestrogens, aromatase inhibitors, and
progestins alone or in combination with chemotherapeutic drugs in the
treatment of OCa. As a result of increased life expectancy in most
countries, the number of women taking hormone replacement therapies
(HRT) continues to grow. Thus, knowledge of the mechanism of action of
steroid hormones on the OSE and OCa is of paramount significance to HRT
risk assessment and to the development of novel therapies for the
prevention and treatment of OCa. [Ho
SM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Ho+SM"%5BAuthor%5D).
Estrogen, progesterone and epithelial ovarian cancer. [Reprod Biol
Endocrinol.](javascript:AL_get(this, 'jour', 'Reprod Biol Endocrinol.');)
2003 Oct 7;1:73.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14577831&query_hl>

**Congenital Adrenal Hyperplasia in Adults: Medical, Surgical and
Psychological Issues**

Our knowledge of the experience of adults with congenital adrenal
hyperplasia (CAH) as they pass through life is only now emerging. In
this review we gather medical, surgical and psychological literature
pertaining to adults with CAH and consider this alongside practical
experience gained from a dedicated adult CAH clinic. There is increasing
awareness for the need for multidisciplinary teams who have knowledge of
CAH particularly with respect to gynaecological surgery and clinical
psychology for women. Routine management of CAH comprises adjustment of
glucocorticoid and mineralocorticoid treatment according to individual
needs balancing biochemical markers, compliance and long term risks.
Bone density is one such long term concern and is not greatly reduced in
most individuals with CAH. More recently, attention has turned to
cardiovascular risk factors and catecholamine deficiency in adults with
CAH. Women with CAH require access to an experienced gynaecologist,
specialised pregnancy care and psychosexual support. The very low
fertility rates for women with CAH previously reported appear to be
improving with time.

[Ogilvie
CM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Ogilvie+CM"%5BAuthor%5D),
et al Congenital adrenal hyperplasia in adults: a review of medical,
surgical and psychological issues. [Clin Endocrinol
(Oxf).](javascript:AL_get(this, 'jour', 'Clin Endocrinol (Oxf).');) 2006
Jan;64(1):2-11.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16402922&query_hl>

**Laparoscopic Excision of Endometrioma Leaves Ovarian Reserve**

CONCLUSION: Laparoscopic excision of endometriomas is associated with a
quantitative but not a qualitative damage to ovarian reserve.

[Ragni
G](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Ragni+G"%5BAuthor%5D),
et al Damage to ovarian reserve associated with laparoscopic excision of
endometriomas: a quantitative rather than a qualitative injury. [Am J
Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2005
Dec;193(6):1908-14.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16325591>

**Advantages Seen With Artery Embolization Over Myomectomy for Uterine
Fibroids**

CONCLUSION(S): The uterine fibroid quality of life score was
significantly improved in both groups. No significant differences were
observed in bleeding improvement, uterine volume reduction, uterine
fibroid quality of life score improvement, and overall quality of life
score improvement between groups. Patients receiving UAE required fewer
days off work, fewer hospital days, and experienced fewer adverse
events.

[Goodwin
SC](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Goodwin+SC"%5BAuthor%5D)
et al Uterine artery embolization versus myomectomy: a multicenter
comparative study. [Fertil
Steril.](javascript:AL_get(this, 'jour', 'Fertil Steril.');) 2006
Jan;85(1):14-21.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16412720&query_hl>

**Toremifen a Feasible Therapy for Moderate to Severe Mastalgia**

CONCLUSIONS: Toremifen effectively relieves moderate and severe cyclical
mastalgia and tends to exert a positive therapeutic effect on
noncyclical mastalgia. In addition, toremifen therapy does not increase
the incidence of intolerable adverse event. Therefore, it is a feasible
therapy for mastalgia, especially cyclical mastalgia.

[Gong
C](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Gong+C"%5BAuthor%5D),
et al A double-blind randomized controlled trial of toremifen therapy
for mastalgia. [Arch
Surg.](javascript:AL_get(this, 'jour', 'Arch Surg.');) 2006
Jan;141(1):43-7.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16415410&query_hl>

**Sexual Dysfunction After Pelvic Surgery**

Pelvic surgeries are among the most common causes of organic sexual
dysfunction in men and women. The impact of nerve-sparing surgery on
potency has been well documented in radical prostatectomy. However, its
impact on potency needs to be evaluated in other pelvic surgeries.
Sexual dysfunction is highly prevalent even after multiple technical
advances in the field of oncological surgeries. The prevalence varies
from 8 to 82%, depending on the type of pelvic surgery. In females,
sexual dysfunction has not been evaluated adequately using validated
questionnaires. However, in subspecialized circles, treatment for female
sexual dysfunction is becoming routine. Currently, physicians have
several options for the treatment of erectile dysfunction (ED) in men.
Since the introduction of oral PDE-5 inhibitors, oral therapy has become
the first-line treatment option for ED, irrespective of etiology.
Currently available treatment options for the female sexual dysfunction
include estrogens, androgens, phosphodiesterase inhibitors, and dopamine
receptor antagonists. Initial reports regarding the role of early
rehabilitation are encouraging and may become the part of routine
practice in the management of ED after pelvic surgery. In this article,
we summarize the sexual dysfunction following pelvic surgeries and their
management.

[Zippe
C](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Zippe+C"%5BAuthor%5D),
et al Sexual dysfunction after pelvic surgery. [Int J Impot
Res.](javascript:AL_get(this, 'jour', 'Int J Impot Res.');) 2006
Jan-Feb;18(1):1-18.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15988545&query_hl>

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

**Broad-spectrum antibiotics during labor linked to late-onset serious
infections in infants**

Group B *Streptococcus* (GBS) infection can cause a life-threatening
blood infection and meningitis in newborns. Over one-third of women
receive antibiotics during labor to prevent the transmission of GBS from
themselves to their newborns. Intrapartum antibiotics (IPA) have been
very successful in preventing early-onset (first week of life) neonatal
GBS infection. However, a new study shows a relationship between
exposure to broad-spectrum IPA and occurrence of late-onset (7-90 days
after birth) serious bacterial infections (SBIs). Infants with
late-onset SBI were more likely to have been exposed to IPA than
uninfected infants. Also, pathogens that caused late-onset SBIs were
more likely to be resistant to ampicillin, if the mother was treated
with ampicillin. Thus, penicillin, an antibiotic that treats a narrow
range of bacteria, is recommended for IPA to prevent GBS instead. The
researchers compared the use of IPA and antibiotic-resistant strains of
bacteria in 90 previously healthy full-term infants hospitalized for
late-onset SBI (case infants) with 92 healthy full-term infants, who
were known not to have an SBI in the first 90 days (control infants).

Considering all types of IPA, nearly twice as many case infants (41
percent) than control infants (27 percent) had been exposed to IPA,
after controlling for hospital of delivery and other factors. The
association was much stronger when IPA was with broad-spectrum
antibiotics. Bacteria that were isolated from infected infants who had
been exposed to IPA were nearly 6 times more likely to exhibit
ampicillin resistance, but not resistance to other antibiotics commonly
used to treat SBI in infants. The researchers recommend that clinicians
find out infants\' exposure to IPA when they are seen for late-onset
SBI, so that they can gauge which antibiotics will be more effective for
treatment.

Glasgow TS, et al. Association of intrapartum antibiotic exposure and
late-onset serious bacterial infections in infants. *Pediatrics*
September 2005, 116(3): 696-702.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16140710&query_hl>

**Over Bundling: Winter and SIDS**

The National Institute of Child Health Development Releases an Alert to
Parents to Winter SIDS Risk and Updated AAP Recommendations According to
the National Institute of Child Health and Human Development (NICHD),
the number of infants who die from Sudden Infant Death Syndrome, or
SIDS, increases in the cold winter months. During these colder months,
parents often place extra blankets or clothes on infants, hoping to
provide them with more warmth. In fact, the extra material may actually
increase infants\' risk for SIDS.

[[http://www.nih.gov/news/pr/jan2006/nichd-18.htm]{.underline}](http://www.nih.gov/news/pr/jan2006/nichd-18.htm)

**Your female patient athletes: Treatment of stress fractures: the
fundamentals**

This article is an introduction to the fundamentals of stress fracture
management. Extrinsic and intrinsic factors, that may play a role in the
development of stress fractures, are discussed and incorporated as
possible treatment options. Different treatment modalities including
ultrasound and electromagnetic fields are addressed, with an emphasis on
literature support.

[Raasch
WG](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Raasch+WG"%5BAuthor%5D),
[Hergan
DJ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Hergan+DJ"%5BAuthor%5D).Treatment
of stress fractures: the fundamentals.

[Clin Sports Med.](javascript:AL_get(this, 'jour', 'Clin Sports Med.');)
2006 Jan;25(1):29-36, vii.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16324971&query_hl>

Screening and Counseling for Obesity in Children

Fifteen percent of patients six to 19 years of age are considered to be
overweight or obese as defined by percentile growth charts. Although
guidelines and surveys have suggested that physicians discuss weight
control with overweight patients at most visits, the rate of treatment
has been low. Cook and associates conducted a study of a nationally
representative sample of well-child visits to determine the frequency
and quality of obesity evaluation and counseling.

The authors conclude that because increased screening for obesity is
associated with increased diagnosis and counseling rates, programs
should target methods that will increase screening rates. They also
suggest that insurance and race discrepancies should be corroborated by
other studies and actively addressed. Because the actual charts were not
reviewed in the study, the reasoning behind the coding or its absence
was not apparent. For example, physicians may have discussed obesity
without coding for it. The authors speculate that lack of time and
inadequate reimbursement also may be barriers to obesity counseling.

This study, which documents the underdiagnosis of childhood obesity at
office visits, does not acknowledge the problem of treatment. Does
office-based, primary care intervention for obesity reduce obesity in
children? According to the U.S. Preventive Services Task Force, the
evidence is insufficient to recommend for or against routine screening
for overweight children.^1^ First, physicians must demonstrate that
their time counseling families of obese children is well spent. If so,
then they will want to make sure that, in terms of diagnosis, no child
is left behind.

<http://www.aafp.org/afp/20060201/tips/6.html>

**Resources:**

Cook S, et al. Screening and counseling associated with obesity
diagnosis in a national survey of ambulatory pediatric visits.
Pediatrics July 2005;116:112-6.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15995040&query_hl>

U.S. Preventive Services Task Force. Screening and interventions for
overweight in children and

adolescents: recommendation statement. Pediatrics 2005;116:205-9.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15995054&query_hl>

AAP Recommendations for Treating Children After a Disaster

The American Academy of Pediatrics (AAP) has released a clinical report
recommending a course of action in treating children who have
experienced or witnessed a disaster, \"Psychosocial Implications of
Disaster or Terrorism on Children: A Guide for the Pediatrician\".

The report outlines several studies that were conducted after the Sept.
11, 2001, terrorist attacks in New York and Washington, D.C. Three
months after the attacks, some children were deeply dependent on parents
for emotional and psychological support. The studies found that
parents\' moods and behaviors after traumatic events may add to a
child\'s fears. Parents also may not recognize symptoms of their
child\'s stress.

After a disaster, children may experience a range of symptoms, from mild
stress reactions to more severe cases of post-traumatic stress disorder
(PTSD). A child with adverse stress reactions lasting longer than one
month after a disaster may be at higher risk of developing PTSD or
violent behaviors later in life. Boys generally display higher rates of
symptoms and require more time to recover than girls. Shy, fearful, or
poorly supported children are at greater risk of developing negative
mental reactions after trauma. Children with indirect exposure to a
disaster on television also face the same risk as those witnessing it
directly.

Physicians treating children after a traumatic event should be aware of
patients who are at risk of adverse reactions or the development of
symptoms of PTSD, and they should educate and counsel parents about the
range of normal emotional and behavioral reactions of children to
disaster. Physicians should help parents recognize the potential
deleterious effects of indirect disaster exposure from news media and
educate them about the importance of helping children understand
information at a developmentally appropriate level.

Physicians should screen for anxiety in all patient encounters after a
disaster. A simple question and expression of concern is an effective,
brief intervention. For many children with supportive families, peers,
and teachers, the reaction to traumatic experience resolves in a few
months. A follow-up screening four to six months after the disaster
would be appropriate to identify children with continuing symptoms who
may need referral for additional services.

<http://pediatrics.aappublications.org/cgi/content/full/116/3/787>

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

**Dietary intervention alone of little benefit in preventing disease**

CONCLUSIONS: Over a mean of 8.1 years, a dietary intervention that
reduced total fat intake and increased intakes of vegetables, fruits,
and grains did not significantly reduce the risk of CHD, stroke, or CVD
in postmenopausal women and achieved only modest effects on CVD risk
factors, suggesting that more focused diet and lifestyle interventions
may be needed to improve risk factors and reduce CVD risk.

[Howard
BV](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Howard+BV"%5BAuthor%5D)
et al Low-fat dietary pattern and risk of cardiovascular disease: the
Women\'s Health Initiative Randomized Controlled Dietary Modification
Trial.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16467234>

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

This study does not prove that diet has not impact on cardiovascular
disease. Rather than total calories of fat consumed, we should monitor
the type of fat, e .g.. trans fats vs monounsaturated fats, total
calories, other modifiable lifestyle changes, e. g., exercise, smoking.
Here are some thoughts for experts in the field.

"It would be easy to misinterpret the results of this study, and it is
important that we get it right,\" Dr. Robert H. Eckel, president of the
American Heart Association, said in a press statement. \"Reducing the
risk of cardiovascular disease is about following an integrated
lifestyle program, rather than concentrating solely on dietary
composition.\"\
\
\"To achieve a significant public health impact on CVD events, a greater
magnitude of change in multiple macronutrients and micronutrients and
other behaviors that influence CVD risk factors may be necessary,\" Dr.
Howard\'s group writes.

In a related editorial, Dr. Cheryl A. M. Anderson and Lawrence J. Appel
from Johns Hopkins University in Baltimore remark that the WHI study did
not address dietary measures that might have had a greater impact in
reducing CVD, such as reducing salt and saturated fats and increasing
potassium and polyunsaturated fats. Even though most of the participants
were overweight or obese, the trial did not focus on lifestyle
interventions that could have had an influence, including weight loss,
physical activity, and avoiding tobacco exposure.

**Cardiovascular Disease in American Indians and Alaska Natives**

Sunday, March 5, 8:00 am - 12:00, Phoenix.

This special program will review the science of translating epidemiology
and clinical trial results into practice in these special populations.
The national program is being offered as part of the American Heart
Association 46th Annual Conference on Cardiovascular Disease
Epidemiology and Prevention which is scheduled for March 2-5 at the
Pointe Hilton Squaw Peak Resort.

[[http://www.americanheart.org/downloadable/heart/113502046449146EpiAdvPrg]{.underline}](http://www.americanheart.org/downloadable/heart/113502046449146EpiAdvPrg)

**Cold Sores: Famciclovir for the Treatment of Recurrent Genital and
Labial Herpes Lesions**

Famciclovir (Famvir, Novartis) is an effective treatment for herpes
zoster and herpes simplex. Two separate studies recently examined the
effectiveness of single high doses of famciclovir for treating recurrent
genital herpes and labial herpes (cold sores). In the randomized,
placebo-controlled studies, patients initiated treatment at the first
onset of symptoms. For the treatment of genital herpes, a 1,000 mg
b.i.d. dose of famciclovir had significant advantages over the placebo,
reducing the time required to heal the lesions, preventing the
development of lesions beyond the papule stage, and improving the time
to resolution of all symptoms. For the treatment of labial herpes, a
single 1,500 mg dose of famciclovir shortened the lesion healing time,
shortened the time to normal skin, and resulted in faster resolution of
pain and tenderness.

[Langley
RG](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Langley+RG"%5BAuthor%5D).
Famciclovir for the treatment of recurrent genital and labial herpes
lesions. [Skin Therapy
Lett.](javascript:AL_get(this, 'jour', 'Skin Therapy Lett.');) 2005
Dec-2006 Jan;10(10):5-7.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16408140&query_hl>

**Percentage of Persons Aged [\>]{.underline}18 Years Reporting Severe
Headache or Migraine**

In 2004, the percentage of adults who experienced a severe headache or
migraine during the preceding 3 months decreased with age, from 18%
among persons aged 18-44 years to 6% among persons aged
[\>]{.underline}75 years. In every age group, the proportion of women
who experienced severe headache or migraine was greater than that of
men.

![](media/image3.png){width="5.750694444444444in"
height="4.436805555555556in"}

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5503a6.htm?s_cid=mm5503a6_e>

**Substandard preventive care for diabetes more likely: Multiple low
priority visits**

Patients who attend relatively few outpatient visits or who attend more
frequent visits for predominantly lower-priority conditions are more
likely to receive substandard preventive care for diabetes. Fenton JJ et
al Quality of Preventive Care for Diabetes: Effects of Visit Frequency
and Competing Demands *Annals of Family Medicine* 4:32-39 (2006)

<http://www.annfammed.org/cgi/content/full/4/1/32>

**Herbal Therapies to Relieve Pain: Efficacy and Adverse Effects**

To find holistic treatment with effective pain relief and few side
effects, Americans spend billions of dollars annually on complementary
and alternative medicine, including herbal therapies. Despite extensive
use, the lack of regulatory scrutiny of these herbal supplements
contributes to the paucity of reliable clinical data assessing their
efficacy and safety. This review summarizes the existing studies
investigating the efficacy of herbal therapies as a treatment for pain.
Possible side effects, potential drug-herb interactions, and information
about common herbal therapies are also summarized. Uses, dosages, routes
of administration, and side effects were summarized. Strength of
empirical evidence also was evaluated. This review found few
well-controlled clinical studies. Furthermore, these studies documented
limited efficacy of herbal therapies to treat pain. The information
presented here may be used to further educate nurses and patients on the
use of herbal therapies as well as direct future research efforts.

[Wirth
JH](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Wirth+JH"%5BAuthor%5D),
et al Use of herbal therapies to relieve pain: a review of efficacy and
adverse effects. [Pain Manag
Nurs.](javascript:AL_get(this, 'jour', 'Pain Manag Nurs.');) 2005
Dec;6(4):145-67.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16337563&query_hl>

**Aspirin prevents cardiovascular disease in healthy adults**

CONCLUSIONS: For women and men, aspirin therapy reduced the risk of a
composite of cardiovascular events due to its effect on reducing the
risk of ischemic stroke in women and MI in men. Aspirin significantly
increased the risk of bleeding to a similar degree among women and men.

[Berger
JS](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Berger+JS"%5BAuthor%5D),
et al Aspirin for the primary prevention of cardiovascular events in
women and men: a sex-specific meta-analysis of randomized controlled
trials. [JAMA.](javascript:AL_get(this, 'jour', 'JAMA.');) 2006 Jan
18;295(3):306-13.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16418466&query_hl>

**Increased cancer-related mortality with type 2 diabetes who use
sulfonylureas or insulin**

CONCLUSIONS: Patients with type 2 diabetes exposed to sulfonylureas and
exogenous insulin had a significantly increased risk of cancer-related
mortality compared with patients exposed to metformin. It is uncertain
whether this increased risk is related to a deleterious effect of
sulfonylurea and insulin or a protective effect of metformin or due to
some unmeasured effect related to both choice of therapy and cancer
risk.

[Bowker
SL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Bowker+SL"%5BAuthor%5D),
et al Increased cancer-related mortality for patients with type 2
diabetes who use sulfonylureas or insulin. [Diabetes
Care.](javascript:AL_get(this, 'jour', 'Diabetes Care.');) 2006
Feb;29(2):254-8.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16443869&query_hl>

Breast Cancer Screening and Socioeconomic Status

The Centers for Disease Control and Prevention (CDC) has released a
report on breast cancer screening for women in 35 major metropolitan
areas in 2000 and 2002. Data for the report were collected from
surveillance surveys and the 2000 U.S. Census.

More than 250,000 women 18 years and older were interviewed to determine
general demographic status and were asked if they had ever had a
mammogram. Those who answered yes were asked the date of their last
mammogram. Analyses for this report focused on women 40 years or older.
Of these women, 9.6 percent had household incomes of less than \$15,000
per year, and 23.7 percent had incomes of \$15,000 to \$34,999 per year.
Overall, 78.5 percent reported having a mammogram during the two years
preceding the study. Among women who reported annual household incomes
of less than \$15,000, 68.4 percent received a mammogram in the
preceding two years; 75.3 percent of women with household incomes of
\$15,000 to \$34,999 and 82.5 percent of women with household incomes of
more than \$50,000 had received a mammogram in the preceding two years.
Women who did not complete high school or were never married and women
who had no health insurance had lower mammography rates than those who
were college graduates or had married, or who had health insurance.

The report shows that women with household incomes of less than \$15,000
per year were less likely to have had a breast cancer screening test in
the past two years than wealthier women, especially those living in
affluent areas. Women with less education also were less likely to have
had a mammogram.

The CDC suggests that women not eligible for Medicaid who do not have
employer-sponsored health care may receive breast and cervical cancer
screening through the CDC\'s National Breast and Cervical Cancer Early
Detection Program (<http://www.cdc.gov/cancer/nbccedp>).

October 7, 2005, *Morbidity and Morality Weekly*

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5439a2.htm>

**Are there any important differences between available nonsteroidal
anti-inflammatory drugs (NSAIDs)?**

trade-off between benefits and harms

**Choice Between Different NSAIDs.** Systematic reviews showed no
important differences in effectiveness between different NSAIDs for the
symptoms of musculoskeletal disorders. Systematic reviews showed that
cyclooxygenase-2 (COX-2) inhibitors reduced symptomatic ulcers compared
with older NSAIDs. However, the COX-2 inhibitor rofecoxib was withdrawn
from the market in 2004 after it was found to increase the risk of
myocardial infarction, and there is good evidence that other COX-2
inhibitors also may increase cardiovascular risk.

unlikely to be beneficial

**NSAIDs in Increased Doses.** Systematic reviews showed that the
benefits of NSAIDs increased towards a maximum value at high doses.
Recommended doses are close to creating the maximum benefit. In
contrast, three systematic reviews showed no ceiling for adverse
effects, which increased in an approximately linear fashion with dose.

What are the effects of cotreatments on reducing the risk of the adverse
gastrointestinal effects of NSAIDs?

trade-off between benefits and harms

**Misoprostol in Persons Who Cannot Avoid NSAIDs.** One systematic
review showed that misoprostol reduced serious gastrointestinal
complications and symptomatic ulcers compared with placebo. The review
did not assess adverse effects of misoprostol. However, another
systematic review showed that misoprostol increased withdrawals caused
by adverse events, mainly diarrhea and abdominal pain, compared with
placebo. Randomized controlled trials (RCTs) provided insufficient
evidence to compare the effects of misoprostol with proton pump
inhibitors (PPIs) or histamine H~2~ blockers.

unknown effectiveness

**H~2~ Blockers in Persons Who Cannot Avoid NSAIDs.** One systematic
review provided insufficient evidence about the effects of H~2~ blockers
on serious gastrointestinal complications and symptomatic ulcers. It
showed that H~2~ blockers reduced endoscopically diagnosed ulcers
compared with placebo, but the clinical relevance of this finding is
uncertain. RCTs provided insufficient evidence to compare the effects of
H~2~ blockers with misoprostol or PPIs.

**PPIs in Persons Who Cannot Avoid NSAIDs.** One systematic review
provided insufficient evidence regarding the effects of PPIs compared
with placebo on serious gastrointestinal complications and symptomatic
ulcers. Another systematic review showed that PPIs reduced
endoscopically diagnosed ulcers compared with placebo, but the clinical
relevance of this finding is uncertain. RCTs provided insufficient
evidence to compare the effects of PPIs with misoprostol or H~2~
blockers.

What are the effects of topical NSAIDs?

likely to be beneficial

**Topical NSAIDs (For Up to Two Weeks).** One systematic review that
included persons with acute musculoskeletal pain conditions showed
limited evidence that topical NSAIDs reduced pain compared with placebo
at one week. One systematic review that included persons with
osteoarthritis showed limited evidence that topical NSAIDs reduced pain
compared with placebo at two weeks but showed no significant difference
between treatments at four weeks.

unknown effectiveness

**Topical NSAIDs (For Longer than Two Weeks).** One systematic review
that included persons with osteoarthritis showed no significant
difference between topical NSAIDs and placebo at four weeks. The review
showed no evidence regarding the effects of topical NSAIDs compared with
placebo for longer than four weeks.

**Topical vs. Systemic NSAIDs or Alternative Analgesics.** Two
systematic reviews showed insufficient evidence to compare topical with
oral NSAIDs for pain in acute musculoskeletal pain conditions or
osteoarthritis. We found no systematic review or RCT comparing topical
NSAIDs with paracetamol for musculoskeletal conditions.

Definition

NSAIDs have anti-inflammatory, analgesic, and antipyretic effects, and
they inhibit platelet aggregation. This chapter focuses on the use of
NSAIDs for the treatment of the symptoms of musculoskeletal conditions.
NSAIDs have no documented effect on the course of musculoskeletal
diseases such as osteoarthritis. NSAIDs inhibit the enzyme COX, which
has two known isoforms, COX-1 and COX-2. NSAIDs often are categorized
according to their ability to inhibit the individual isoforms; newer
NSAIDs predominantly inhibit the COX-2 isoform, and older NSAIDs often
are less specific inhibitors.

Incidence

NSAIDs are widely used. Almost 10 percent of persons in the Netherlands
used a nonaspirin NSAID in 1987, and the overall use was 11 defined
daily doses per 1,000 persons. In Australia in 1994, overall use was 35
defined daily doses per 1,000 persons, with 36 percent receiving NSAIDs
for osteoarthritis, 42 percent for sprain and strain or low back pain,
and 4 percent for rheumatoid arthritis. Thirty-five percent of the
persons receiving NSAIDs were older than 60 years.

Paracetamol is called acetaminophen in the United States.

Gøtzsche PC. Non-steroidal anti-inflammatory drugs. Clin Evid Concise
2005;14:388-9.

<http://www.aafp.org/afp/20060201/bmj.html>

ACSM Recommendations for Endurance Athletes

The American College of Sports Medicine (ACSM) has released
evidence-based recommendations for athletes to prevent hyponatremia and
dehydration during sporting events..

The study reinforces the importance of managing hyponatremia and
dehydration in persons who participate in endurance events such as races
and marathons. The ACSM recommends the following procedures to help
prevent these conditions:

• Work to minimize the risk of hyponatremia and dehydration.
Hyponatremia occurs when the athlete drinks too much liquid, causing the
body\'s sodium levels to dilute. The condition is rare and usually
affects athletes participating in running events lasting longer than
four hours. Dehydration occurs much more frequently, and the ACSM
recommends avoiding over- or underdrinking when running.

• Drink on a schedule to match fluid loss. Athletes should know their
body\'s average hourly sweat rate and drink the appropriate amount of
fluids to replace what was lost each hour. The study also recommends
drinking early and at regular intervals during a race rather than all at
once. Drinking constantly over a set period of time rehydrates more
effectively than rapid fluid replacement.

• Consume salty foods and beverages. Eating foods with high levels of
sodium helps stimulate fluid intake and promote fluid retention. The
ACSM recommends that endurance athletes ingest salty snacks and fluids
to help offset the loss of salt in sweat and prevent hyponatremia

June 2005 issue of *Current Sports Medicine Reports*

<http://www.aafp.org/afp/20060201/practice.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}

###### Vaginal Birth after Cesarean

(continued from Abstract of the Month)

+-----------------------------------------------------------------------+
| **Recommendations for TOLAC: American Academy of Family Practice**    |
+-----------------------------------------------------------------------+
| 1\. Women with one previous cesarean delivery with a low transverse   |
| incision are candidates for and should be offered a trial of labor.   |
| \[SORT rating A\]                                                     |
+-----------------------------------------------------------------------+
| 2\. Patients desiring TOLAC should be counseled that their chance for |
| a successful VBAC is influenced by the following factors: \[SORT      |
| rating B\]                                                            |
+-----------------------------------------------------------------------+
| Positive factors (increased likelihood of successful VBAC)            |
+-----------------------------------------------------------------------+
| Maternal age less than 40 years                                       |
|                                                                       |
| Prior vaginal delivery (particularly prior successful VBAC)           |
|                                                                       |
| Favorable cervical factors                                            |
|                                                                       |
| Presence of spontaneous labor                                         |
|                                                                       |
| Nonrecurrent indication that was present for prior cesarean delivery  |
+-----------------------------------------------------------------------+
| Negative factors (decreased likelihood of successful VBAC)            |
+-----------------------------------------------------------------------+
| Increased number of prior cesarean deliveries                         |
|                                                                       |
| Gestational age greater than 40 weeks                                 |
|                                                                       |
| Birth weight greater than 4,000 g (8 lb, 13 oz)                       |
|                                                                       |
| Induction or augmentation of labor                                    |
+-----------------------------------------------------------------------+
| 3\. Prostaglandins should not be used for cervical ripening or labor  |
| induction, because their use is associated with higher rates of       |
| uterine rupture and decreased rates of successful vaginal delivery.   |
| \[SORT rating B\]                                                     |
+-----------------------------------------------------------------------+
| 4\. TOLAC should not be restricted to maternity care facilities with  |
| available surgical teams present throughout labor, because there is   |
| no evidence that these additional resources result in improved        |
| outcomes.\* \[SORT rating C\]                                         |
|                                                                       |
| At the same time, it is clinically appropriate that a management plan |
| for uterine rupture and other potential emergencies requiring rapid   |
| cesarean delivery should be documented for each woman undergoing      |
| TOLAC. \[SORT rating C\]                                              |
+-----------------------------------------------------------------------+
| 5\. Maternity care professionals need to explore all issues that may  |
| affect a woman\'s decision (e.g., recovery time, safety). \[SORT      |
| rating C\]                                                            |
|                                                                       |
| No evidence-based recommendation can be made about the best way to    |
| present the risks and benefits of TOLAC to patients.                  |
+-----------------------------------------------------------------------+
| TOLAC = trial of labor after cesarean delivery; VBAC = vaginal birth  |
| after cesarean delivery.                                              |
|                                                                       |
| \*-\"Maternity care facilities\" refers to birthing facilities with   |
| labor and delivery units that have the capacity to provide            |
| appropriate monitoring and to provide a timely cesarean delivery when |
| needed.                                                               |
|                                                                       |
| patient-oriented evidence; C = consensus, disease-oriented evidence,  |
| usual practice, expert opinion, or case series. For information about |
| the SORT evidence rating system, see page 1949 or                     |
| <http://www.aafp.org/afpsort.xml>                                     |
|                                                                       |
| Adapted from Wall E, Roberts R, Deutchman M, Hueston W, Atwood LA,    |
| Ireland B. Trial of labor after cesarean (TOLAC), formerly trial of   |
| labor versus elective repeat cesarean delivery for the woman with a   |
| previous cesarean delivery.                                           |
+-----------------------------------------------------------------------+

### 

### AAFP Guidelines for TOLAC

Guidelines for TOLAC, based on patient-centered outcomes (morbidity,
mortality, symptoms, cost, and quality of life), were developed by an
AAFP Task Force and published on the AAFP Web site in July 2005.The
guidelines apply to women with a history of 1 cesarean section and low
transverse incision. The grade levels of the evidence used in the
guidelines are as follows:

-   Grade A \-- Good-quality studies with patient-oriented evidence

-   Grade B \-- Inconsistent or limited patient-oriented evidence

-   Grade C \-- Case series, consensus, usual practice or opinion

#### Summary of the Literature

Seventy-six percent of women undergoing TOLAC are likely to succeed.
Seven observational studies found a reduced success rate (63%) when
induction with oxytocin or augmentation was used, and success was
reduced even further to 51% if prostaglandins were used for induction.
Risk for uterine rupture increased slightly with TOLAC when induction or
augmentation was used.

Maternal death and infant mortality did not differ between TOLAC and
repeated cesarean section. Infection rates were reported as higher with
failed TOLAC than with repeated cesarean section (8% vs 3.5%). Risk for
uterine rupture was estimated at 4.8 per 10,000 women with or without
TOLAC. Risk for infant death from uterine rupture was reported at
1.5/100,000. There was no literature on quality-of-life issues related
to VBAC.

Risk-assessment tools (2 validated scoring systems were
identified)^\[5,\ 6\]^ were only partially useful in predicting
successful vaginal delivery. Individual factors found to be associated
with improved outcomes included demographic (younger than 40 years),
delivery (spontaneous labor, nonrecurrent indication for delivery),
medical (absence of diabetes) and cervical factors. Overall, teaching
hospitals had a higher success rate with TOLAC than did community
hospitals. The influence of TOLAC counseling on patient decision-making
was unclear, as reported in 1 recent review.^\[7\]^ Dr. Wall suggested
that additional factors to consider include perceived recovery time,
presence of children at home, partner availability, perceived
breastfeeding success, and safety.

### Future Research Agenda

Given the limitations of the existing literature,^\[8,9\]^ here are
issues for a future research agenda:

-   The definition of uterine rupture should be standardized.
    Definitions are currently inconsistent across studies. For example,
    uterine dehiscence is included within the definition for some
    studies, making comparisons across studies challenging.

-   Validated instruments for measuring quality of life for mothers
    (including ability to care for the family after delivery) are not
    available. Long-term issues, such as pelvic floor function and,
    again, impact on families, are not considered.

-   Development of decision support and shared decision-making tools is
    needed.

-   Specific management plans appropriate for uterine rupture should be
    developed. It is not certain from the literature if more rapid
    intervention improves outcomes during labor.

-   New technologies should be aimed at identifying women at high risk
    for TOLAC failure and should increase the ability to predict
    morbidity and uterine rupture (eg, locating the placenta with
    imaging, or examining the thickness of the lower uterine wall).

### 

### **Subsequent Data**

Vaginal delivery was attempted by 17,898 women, and 15,801 women has
elective repeated cesarean delivery without labor. Symptomatic uterine
rupture occurred in 124 women who underwent a trial of labor (0.7%).
Hypoxic-ischemic encephalopathy occurred in no infants whose mothers
underwent elective repeated cesarean delivery and in 12 infants born at
term whose mothers underwent a trial of labor (*P*\<.001). Seven of
these cases of hypoxic-ischemic encephalopathy followed uterine rupture
(absolute risk, 0.46 per 1000 women at term undergoing a trial of
labor), and 2 involved death of the infant.

The rate of endometritis was higher in women undergoing TOLAC than in
women undergoing repeated elective cesarean delivery (2.9% vs 1.8%), as
was the rate of blood transfusion (1.7% vs 1.0%). The frequency of
hysterectomy and of maternal death did not differ significantly between
groups (0.2% vs 0.3%, and 0.02% vs 0.04%, respectively). The study
concluded that TOLAC is associated with a greater perinatal risk than is
elective repeated cesarean delivery without labor, although absolute
risks are low. This information is relevant for counseling women about
their options after cesarean section.

### References

1.  Wall EM. Clinical recommendations update: Trial of labor after
    C-section. Programs and abstracts of the American Academy of Family
    Physicians Annual Scientific Assembly; September 28-October 2, 2005;
    San Francisco, California. Program 31.

2.  American Academy of Family Physicians. Trial of labor after cesarean
    (TOLAC), formerly trial of labor versus elective repeat cesarean
    section for the woman with a previous cesarean section; March 2005.
    Available at http://www.aafp.org/x1597.xml. Accessed November 4,
    2005.

3.  Guise JM, McDonagh M, Hashima J, et al. Vaginal birth after cesarean
    section (VBAC). Evidence Report/Technology Assessment No. 71
    (prepared by the Oregon Health & Science University Evidence-based
    Practice Center under contract No. 290-97-0018). AHRQ Publication
    No. 03-E018. Rockville, MD: Agency for Healthcare Research and
    Quality, 2003.

4.  American College of Obstetricians and Gynecologists. ACOG Practice
    Bulletin #54: Vaginal birth after previous cesarean delivery.
    Available at
    http://pt.wkhealth.com/pt/re/ajog/abstract.00000447-200511000-00011.htm;jsessionid=DBKZ8BT7CEy89FgnOOeepRojGk8polr17kqEk46UqU1XaInH2Cck!958525354!-949856144!9001!-1.
    Accessed November 20, 2005.

5.  Flamm B, Geiger A. Vaginal birth after cesarean delivery: an
    admission scoring system. Obstet Gynecol. 1997;90:907-910.

6.  Troyer L, Parisi V. Obstetric parameters affecting success in a
    trial of labor: designation of a scoring system. Am J Obstet
    Gynecol. 1992;167:1099-1104.

7.  Eden KB, Hashima JN, Osterweil P, Nygren P, Guise JM. Childbirth
    preferences after cesarean birth: a review of the evidence. Birth.
    2004;31:49-60.

8.  Dodd C, Crowther J. Vaginal birth after Caesarean versus elective
    repeat Caesarean for women with a single prior Caesarean birth: A
    systematic review of the literature. Aust N Z J Obstet Gynaecol.
    2004;44:387-391.

9.  Guise JM, Berlin M, McDonagh M, Osterweil P, Chan B, Helfand M.
    Safety of vaginal birth after cesarean: a systematic review. Obstet
    Gynecol. 2004;103:420-429.

10. Landon MB, Hauth JC, Leveno KJ, et al. Maternal and perinatal
    outcomes associated with a trial of labor after prior cesarean
    delivery. N Engl J Med. 2004;351:2581-2589.

<http://www.medscape.com/viewarticle/518434?src=mp>

  --------------------------------------------------------- -------------
  Flamm Scoring System Tool                                 

  **Variable**                                              **Point
                                                            Value**

  Age \<40 years                                            2

  **Vaginal birth history**                                 

  Before and after 1st cesarean                             4

  After 1st cesarean                                        2

  Before 1st cesarean                                       1

  None                                                      0

  Reason other than failure to progress for 1st cesarean    1

  **Cervical effacement at admission (%)**                  

  \>75                                                      2

  25-75                                                     1

  \<25                                                      0

  **Cervical dilation \> or = 4 at admission**              1
  --------------------------------------------------------- -------------

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

  ------------- ----------------------------- --------------------------------
  Flamm Scoring                               
  System Tool:                                
  Performance                                 
  of Admission                                
  Score in the                                
  score testing                               
  group                                       

  **Score**     **\# Subjects with score**    **% Subjects with V B A C**

  0 - 2         114                           49.1

  3             329                           59.9

  4             595                           66.7

  5             660                           77.0

  6             360                           88.6

  7             189                           92.6

  8 - 10        158                           94.9

  **Total**     2405                          74.9
  ------------- ----------------------------- --------------------------------

Data from Guise JM, McDonagh M, Hashima J, et al. [[Vaginal birth after
cesarean (VBAC). Evidence Report/Technological Asessment No.
71]{.underline}](http://www.ahrq.gov/clinic/epcsums/vbacsum.htm).
Rockville (MD): Agency for Healthcare Research and Quality; March 2003.
p. 32 Table 3.

###### 

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

No Difference Among New Antidepressants

**Clinical Question:** Which of the newer antidepressants is safer and
more effective?

**Setting:** Various (meta-analysis)

**Study Design:** Meta-analysis (randomized controlled trials)

**Bottom Line:** When it comes to the new nontricyclic antidepressants,
the medical literature does not provide clear guidance as to which one
is more effective, of faster onset, safer, or better tolerated. Sexual
side effects are lower with bupropion, and nausea seems to occur more
often with venlafaxine. Other research has shown these new drugs to be
no more effective or better tolerated than tricyclic antidepressants.
For now, patients should be started on an antidepressant with the
realization that most patients will need to switch to another drug at
least once.

**(Level of Evidence: 1a)**

###### [**http://www.aafp.org/afp/20060115/tips/8.html**](http://www.aafp.org/afp/20060115/tips/8.html)

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

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

Are Alpha-glucosidase Inhibitors Effective for Control of Type 2
Diabetes?

Clinical Scenario

A 55-year-old man with diabetes has used diet to control his glucose
levels for the past six years. His A1C level gradually has risen to 7.5
percent, and he wants to discuss options for medical therapy.

Clinical Question

Is monotherapy with alpha-glucosidase inhibitors effective in reducing
complications and improving glucose control in patients with diabetes?

Evidence-Based Answer

The use of alpha-glucosidase inhibitors has a modest effect on
intermediate diabetes-control endpoints such as postprandial blood
glucose, postprandial insulin levels, and A1C levels. There is no
evidence, however, of improvement in mortality, morbidity, or quality of
life. In comparisons with sulfonylureas, alpha-glucosidase inhibitors
had less effect on intermediate diabetes-control endpoints and had a
greater incidence of adverse effects. The use of alpha-glucosidase
inhibitors had no effect on plasma lipid levels or body weight. Cochrane
for Clinicians Putting Evidence into Practice.
<http://www.cochrane.org/cochrane/revabstr/AB003639.htm>

Gabapentin for Pain: Balancing Benefit and Harm

Clinical Question: Cochrane Brief

Is gabapentin (Neurontin) effective for the treatment of acute and
chronic pain?

Evidence-Based Answer

At high dosages, gabapentin is moderately effective for neuropathic
pain, although adverse effects are experienced as often as benefit.

Practice Pointers

The modest benefit of gabapentin for neuropathic pain must be balanced
against its adverse effects. Whether this trade-off is worthwhile should
be decided by the individual patient. The authors of this review report
that based on preliminary data tricyclic antidepressants (NNT = 2) and
carbamazepine (Tegretol; NNT = 1.7) are at least as effective as
gabapentin and are less expensive (although generic gabapentin costs
about one half as much as Neurontin). It is important that physicians
carefully assess the balance between benefit and harm for their patients
after a therapeutic trial rather than continuing a course of medication
indefinitely.

Wiffen PJ, et al. Gabapentin for acute and chronic pain. Cochrane
Database Syst Rev 2005;(3):CD005452.
<http://www.aafp.org/afp/20060201/cochrane.html>

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

**Patient Safety in the Surgical Environment**

ABSTRACT: Ensuring patient safety in the operating room begins before
the patient enters the operative suite and includes attention to all
applicable types of preventable medical errors (including, for example,
medication errors), but surgical errors are unique to this environment.
Steps to prevent wrong-site, wrong-person, or wrong-procedure errors
have been recommended. Prevention of surgical errors requires the
attention of all personnel involved in the patient\'s care.

Patient Safety in the Surgical Environment. ACOG Committee Opinion No.
328. American College of Obstetricians and Gynecologists. Obstet Gynecol
2006;107:429--33

**Non-ACOG Members**

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16449138&query_hl>

**ACOG Members**

<http://www.acog.org/publications/committee_opinions/co328.cfm>

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

## Nearly half of urban AI/AN travel back to their reservation to visit during the year

The health of American Indians and Alaska Natives (AI/ANs) is worse than
that of the general population in the United States, with a life
expectancy nearly 5 years lower. Of the more than two million AI/ANs
living in the United States today, only 25 percent reside on
reservations, while 60 percent live in cities. Those who live in cities
often travel to reservations, yet little is known how this travel may be
related to health. This study is one of the few to provide information
on AI/AN travel to reservations and its relationship to health status
and use of health services among urban AI/ANs.

Researchers surveyed more than 500 AI/AN adults at a primary care clinic
in Seattle about time spent visiting a reservation during the past year,
and sociodemographic, cultural, and clinical characteristics.
Thirty-four percent of respondents had spent up to 30 days traveling, 14
percent had spent more than 30 days traveling, and 52 percent had not
traveled to reservations. Strong Native American cultural
identification, presence of lung disease, absence of thyroid or mental
problems, and greater dissatisfaction with care were independently
associated with more travel to reservations.

Reservation visits were not consistently linked to self-reported health
outcomes, nor could the researchers determine how often respondents
traveled to the reservation for health care. The findings underscore the
importance of considering the role of culture as well as residence and
patterns of travel in both research and clinical care involving AI/ANs.

Rhoades DA, et al. Characteristics associated with reservation travel
among urban Native American outpatients, *Journal of Health Care for the
Poor and Underserved* August 2005 464-474.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16118836&query_hl>

## Women with moderate PID: Similar reproductive outcomes - inpatient and outpatient care

Pelvic inflammatory disease (PID) affects about 8 percent of all women
of reproductive age in the United States. PID can lead to infertility,
tubal pregnancy, and chronic pelvic pain. Over three-fourths of women
treated for PID are managed as outpatients, a move away from
hospital-based management that has accelerated over the past two
decades. A new Pelvic Inflammatory Disease Evaluation and Clinical
Health (PEACH) study found no differences in reproductive outcomes among
women with mild-to-moderate PID regardless of whether they were treated
as inpatients or outpatients.

831 women randomized with clinical signs and symptoms of
mild-to-moderate PID into a multicenter trial. Inpatient treatment
included intravenous cefoxitin and doxycycline, while outpatient
treatment consisted of a single intramuscular injection of cefoxitin and
oral doxycyline. They followed the treatment groups for an average of 84
months. When compared with inpatient treatment, outpatient treatment did
not adversely affect pregnancy frequency, live births, tubal
pregnancies, time to pregnancy, infertility, PID recurrence, or chronic
pelvic pain, regardless of factors such as race, previous PID, the
presence of *Neisseria gonorrhoeae* and/or *Chlamydia trachomatis*
infection, or a high temperature, high white blood cell count, and
pelvic tenderness.

Ness RB, et al Effectiveness of treatment strategies of some women with
pelvic inflammatory disease *Obstetrics & Gynecology* September 2005,
106(3), pp. 573-580.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16135590&query_hl>

**Misconceptions about cancer screening may be common among women**

<http://www.ahrq.gov/research/dec05/1205RA14.htm>

**Women who suffer from obesity less likely to undergo Pap testing**

<http://www.ahrq.gov/research/dec05/1205RA15.htm>

**Women who are at high risk of developing preeclampsia: Cytokine
genotypes may identify**

<http://www.ahrq.gov/research/dec05/1205RA16.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}

**Birth News Highlights**

***Young mothers:*** Birth rates for US women age10-14 were up slightly
in 2004, the latest CDC report indicates. However, for American Indian
women age 10-14, the rate was lower (0.9 live births per 1,000 women).
AI women had a 10% decrease from 2003 to 2004, and, in fact, were the
only group that had a decrease. In order, by populations groups, from
lowest to highest birth rate in age 10-14 year olds: Non-Hispanic white
and Asian or Pacific Islander (tied); American Indian; Hispanic;
non-Hispanic black.

***VBACs down*:** American Indian women had the highest rate of vaginal
births after previous cesarean, 13.3 per 100 live births, in the latest
available data. The rate was down from 2003 (14.1). Nationwide, the rate
was down from 10.6 in 2003 to 9.2 in 2004.

***Early Care*:** About 70% of AI pregnant women received prenatal care
in the first trimester, the lowest percentage of any population group.
Among non-Hispanic whites, about 90% received care in the first
trimester. AI women also had the highest percentage who received no care
or care in the 3rd trimester: about 8%.

***Low birth weight*:** The rate of low birth weight births in the AI
population was in the middle among population groups. Populations with
lower low birth rates: Hispanic and non-Hispanic white; populations with
higher rates: Asian or Pacific Islander, and, at almost double the AI
rate, non-Hispanic black. Contact <cooperd@mail.nih.gov> *National Vital
Statistics Report* 2005 Dec; 54(8); 1-17
<http://www.cdc.gov/nchs/products/pubs/pubd/nvsr/54/54-pre.htm>

##### 

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

**Dose-dependent association between duration of breastfeeding and risk
of overweight**\
[Objectives]{.underline}\
Observational studies suggest a longer duration of breastfeeding to be
associated dose dependently with a decrease in risk of overweight in
later life.

[Methods]{.underline}

The authors performed a comprehensive meta-analysis of the existing
studies on duration of breastfeeding and risk of overweight. Studies
were included that reported the odds ratio and 95% confidence interval
(or the data to calculate them) of overweight associated with
breastfeeding and that reported the duration of breastfeeding and used
exclusively formula-fed subjects as the referent. Seventeen studies met
the inclusion criteria.

[Results]{.underline}

By meta-regression, the duration of breastfeeding was inversely
associated with the risk of overweight (regression coefficient=0.94, 95%
confidence interval (CI): 0.89, 0.98). Categorical analysis confirmed
this dose-response association (\<1 month of breastfeeding: odds ratio
(OR)=1.0, 95% CI: 0.65, 1.55; 1-3 months: OR=0.81, 95% CI: 0.74, 0.88;
4-6 months: OR=0.76, 95% CI: 0.67, 0.86; 7-9 months: OR=0.67, 95% CI:
0.55, 0.82; \>9 months: OR=0.68, 95% CI: 0.50, 0.91). One month of
breastfeeding was associated with a 4% decrease in risk (OR=0.96/month
of breastfeeding, 95% CI: 0.94, 0.98). The definitions of overweight and
age had no influence.

[Conclusion]{.underline}

These findings strongly support a dose-dependent association between
longer duration of breastfeeding and decrease in risk of overweight.\
Harder T Duration of breastfeeding and risk of overweight: a
meta-analysis. Am J Epidemiol 2005 Sep 1;162(5):397-403.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16076830&query_hl>

**ACOG, AAP Develop First Collaborative Physician-Focused Breastfeeding
Handbook**

The American College of Obstetricians and Gynecologists (ACOG) and the
American Academy of Pediatrics (AAP) are pleased to announce the
publication of the first collaborative breastfeeding guide aimed at
physicians. *Breastfeeding Handbook for Physicians* enhances awareness
of the benefits and importance of breastfeeding and increases knowledge
of breastfeeding physiology and practice.

According to ACOG and AAP, the handbook will encourage physicians to
become champions of breastfeeding and to be able to teach, promote, and
support the practice. The handbook covers topics such as:

-   Health benefits of breastfeeding

-   Anatomy and physiology of breastfeeding

-   Management and discussion of breastfeeding during preconception
    visits

-   Transition to lactation in the hospital, including breastfeeding
    technique

-   Postpartum issues, including feeding patterns and infant behavior

-   Breastfeeding issues for the infant and for the mother

-   Breastfeeding technology

-   Breastfeeding and contraception

-   Breastfeeding of infants with special needs

-   The creation of a breastfeeding-friendly medical office

<http://www.acog.org/from_home/publications/press_releases/nr01-25-06.cfm>

**Quality of consumer related breastfeeding education: Web Site
evaluates**

In the 21st century, new mothers are clearly using the Internet for
health education; therefore, it is essential that nurses know which Web
sites can be recommended for accurate breastfeeding information. Five
sites were selected for recommendation, each of which contained all
eight of the AAP content criteria, met all the HITI, and had an
interesting and unique presentation of basic breastfeeding information.
Readability was considered in selecting the top five sites, but a site
was not excluded if it scored over an eighth-grade level. Information in
this article can be used by health professionals to recommend
breastfeeding Web sites and to evaluate Web sites using HITI and AAP
criteria.

Dornan BA, Oermann MH. 2006. Evaluation of breastfeeding Web sites for
patient education. MCN: Maternal and Child Nursing 31(1):18-23.

[[http://www.mcnjournal.com/pt/re/mcn/abstract.00005721-200601000-00006.htm;jsessionid=DCVhvliSsqT10ta89eCGdMySxndjXZrK6ZwTqY29Ugr9maQRQ1cB!600736187!-949856144!9001!-1]{.underline}](http://www.mcnjournal.com/pt/re/mcn/abstract.00005721-200601000-00006.htm;jsessionid=DCVhvliSsqT10ta89eCGdMySxndjXZrK6ZwTqY29Ugr9maQRQ1cB!600736187!-949856144!9001!-1)

**[Health LITERACY]{.underline}: Breastfeeding is to be seen as
normative**

The impact of early infant feeding choice and long term health outcomes
holds potential promise for reducing risk of overweight, diabetes, and
various infections for babies.  There are positive maternal health
outcomes with breastfeeding. Documentation of infant feeding choices in
the PCC is now available. 

The first steps taken in constructing standardized documentation of
infant feeding practices and an early assessment is available through
the use of RPMS Q-man.

[Health LITERACY]{.underline}: Breastfeeding is to be seen as
normative.  The HHS Office for Women's Health Breastfeeding Initiative
states: *Babies were born to be Breastfed. * Campaign materials are
available at:
<http://www.womenshealth.gov/breastfeeding/index.cfm?page=Campaign> or
800-994-9662             

An Easy Guide to Breastfeeding for AIAN's is in PDF format are also
available at the site

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

**GAO recommends removal of WIC logo from any formula marketing
                   **

GAO: "We recommend that the Secretary of Agriculture educate all states
about its policy restricting the use of the WIC acronym and logo and
ensure that all state formula contracts include provisions restricting
the use of these trademarks in infant formula advertisements."

#### GAO: "Although formula manufacturers agree that breastfeeding is best, they market infant formula as an alternative for mothers who do not exclusively breastfeed. A congressional committee asked us to review the potential impact of infant formula marketing on breastfeeding rates, Especially for infants in the WIC program.  {#gao-although-formula-manufacturers-agree-that-breastfeeding-is-best-they-market-infant-formula-as-an-alternative-for-mothers-who-do-not-exclusively-breastfeed.-a-congressional-committee-asked-us-to-review-the-potential-impact-of-infant-formula-marketing-on-breastfeeding-rates-especially-for-infants-in-the-wic-program. .Style-Heading-4-+-Arial-14-pt-Underline}

#### We answered the following Questions:  {#we-answered-the-following-questions .Style-Heading-4-+-Arial-14-pt-Underline}

1\) What are the estimated breastfeeding rates for infants in the
general population and for infants on WIC, and how do these rates
compare to recommended breastfeeding rates?

2\) How is infant formula marketed to women in general and to women on
WIC in particular?

3\) What is known about the impact of infant formula marketing on the
breastfeeding rates of women in the general population and women on
WIC?" <Judith.Thierry@ihs.gov>

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

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

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

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

\-[Link between GDM and Type 2 DM can be
broken](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_AOM.cfm)

\-[Integrating prevention of mother-to-child HIV transmission into
routine antenatal
care](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_Coll.cfm)

\-[Bed Rest for pregnancy related hypertension: Not
recommended](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_HT.cfm#ob)

\-[Prior Function and Relationship, More Than Hormones, Affect Sexual
Function in
Midlife](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_HT.cfm#gyn)

\-[Oral Contraceptives and Dysmenorrhea in Adolescents:
RCT](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_HT.cfm#child)

**-**[Waking up to Sleep Deprivation: Countermeasures for Daytime
Sleepiness](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_HT.cfm#chrIll)

\-[New studies shows a 15% reduction for the risk of diabetes for every
year of
lactation](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_Feat.cfm#breast)

\-[Emergency Contraception Use Not Associated With Risky Sexual
Behavior](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_Feat.cfm#fp)

\-[Vaginal Birth after Cesarean  New Perinatology Corner Module -- 2
credits](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_Feat.cfm#webSite)

**-**[CC: I feel really cold and my side hurts, plus I am shaking all
over](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_Feat.cfm#mmtour)
 

\-[Shoulder Dystocia Prevention: plus the 'CCC Deliver Through
Maneuver](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_Feat.cfm#MidWives)'

\-[Depo-Provera available in a lower dose: limited data to assess 104mg
SQ vs. 150mg
IM](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_Feat.cfm#navajo)

\-[Should Pregnant Women Be Tested for Herpes
Susceptibility?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_Feat.cfm#periPicks)

\-[Cardiology Topics for Primary Care Providers -- February 15,
2006](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_Feat.cfm#pcf)

\-[Clinician-Delivered Intervention During Routine Care Reduces
Unprotected Sexual
Behavior](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_Feat.cfm#std)

\-[Antidepressants Are No Match for
Poverty](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_Feat.cfm#stillW)

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106.cfm**](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106.cfm) {#httpwww.ihs.govmedicalprogramsmchmobgyn0106.cfm .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-9 .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-10 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Child Abuse Prevention for Nurses, Psychologists, Social Services, and
Community**

San Diego May 2006 Parents welcome. CEU\'s (no phys CME)
[www.preventchildabuse.org](http://www.preventchildabuse.org/)

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

**Euthanasia: The Dutch Experience**\
The topic of euthanasia always elicits strong reactions among
practitioners. This article below discusses the differences between
euthanasia, terminal sedation, and palliative care.

Euthanasia and physician-assisted death are concepts that carry an
enormous negative historic burden, as they commonly refer to the
atrocities of the Nazi era. Nevertheless, society and the medical
community have gradually realized that in certain cases of intractable
suffering, properly defined euthanasia may be reconsidered. In
euthanasia, the issues of compassion and patient autonomy contradict
religious dogma and the fear of covert murder. Three countries today
(United States, The Netherlands, and Belgium) have permitted euthanasia
in one form or another under strict regulations. The United Kingdom is
also strongly considering the issue, although current opposition is
strong.

The Dutch were the first to legalize euthanasia, and they have tried to
ensure flawless application of the procedure: A patient with a hopeless
disease should request it, and 2 physicians should concur. However,
although Dutch law requires reporting of cases of euthanasia, the
notification rate was still low (approximately 54% for 2001).

Terminal sedation is essentially the addition of sedation to a dying
patient. Although it is defined differently from euthanasia and appears
more \"natural,\" it has been referred as \"crypto-euthanasia.\" As
stated, almost 1 out of every 2 physicians who have practiced terminal
sedation had, more or less, the goal of hastening death in their minds.

It is impossible to make generalized recommendations or statements on
the issue of euthanasia. Cultural, religious, and ethnic backgrounds
play important roles when death is considered, and universal measures
are guaranteed to contradict the beliefs of some group. As the value of
individual autonomy continues to increase in society, it seems likely
that euthanasia will be adapted by more countries in the future.

One point deserves great caution: financial concerns must not be
permitted to masquerade as legitimate reasons to legalize euthanasia. If
society becomes less vigilant on this issue, we may risk the death of
the weak, the elderly, and the unprotected. Reporting of euthanasia
cases in The Netherlands is low, despite the efforts to monitor
euthanasia closely. One is reluctant to think what implications the
legalization of euthanasia may have in a more lenient environment.

Furthermore, the patient\'s request for euthanasia may result from
anxiety, depression, or other mental problems, and these possibilities
should be taken into account as the patient may change his or her mind
(up to13% of patients changed their minds in a recent Dutch survey
study. Some patients in The Netherlands request euthanasia because they
are \"tired of living\" even if they lack a severe disease. These
requests are not granted. Euthanasia has also been considered in
children, and a \"suicide pill\" has recently been a subject of debate.

Euthanasia today has limited applicability in the ICU. Terminal sedation
is a concept that, if legalized, may help comfort the agony and distress
of the last hours of the gravely ill.

Are the Dutch showing us the way of the future?

Antonios Liolios, MD  (see Medscape below for access details)

<http://www.medscape.com/viewarticle/521142?sssdmh=dm1.178638&src=nlpromo>

**Over active bladder therapies on CNS functioning in elderly patients:
First-line therapies**

Managing Overactive Bladder in the Comorbid Patient (Archived Web
Conference)

<http://www.medscape.com/viewprogram/4154?sssdmh=dm1.179143>

(see Medscape below for access details)

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

Progestin-Releasing IUDs for Women with Diabetes

Women with type 1 diabetes require safe and effective contraception for
several reasons. Pregnancy may accelerate the progression of diabetes
and have significant short- and long-term implications for the mother.
Pregnancy in patients with type 1 diabetes should be planned, because
optimal glycemic control at conception and during early pregnancy
reduces the incidence of congenital abnormalities and fetal growth
problems. However, potential vascular and metabolic concerns limit
contraceptive options for women with diabetes.

Women using levonorgestrel-releasing IUDs do not have significant
changes in A1C levels, daily insulin requirements, or average fasting
blood glucose levels after 12 months of use. The mild changes in
glycemic control with the progestin-containing IUD were identical to
those in women using a copper-containing device and probably were not
clinically significant. Both devices are reliable contraceptive options
for women with diabetes, and the levonorgestrel-containing device may
decrease menstrual blood loss and dysmenorrhea.

Rogovskaya S, et al. Effect of a levonorgestrel intrauterine system on
women with type 1 diabetes: a randomized trial. Obstet Gynecol April
2005;105:811-5.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15802410&query_hl>

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

#### Emergency Contraception- Women with two children who need 30 years of family planning {#emergency-contraception--women-with-two-children-who-need-30-years-of-family-planning-1 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### LINK to Reproductive health tutorial, Title X {#link-to-reproductive-health-tutorial-title-x .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.kaiseredu.org/tutorials/ReproductiveHealth/Reproductive%20Health.html**](http://www.kaiseredu.org/tutorials/ReproductiveHealth/Reproductive Health.html) {#httpwww.kaiseredu.orgtutorialsreproductivehealthreproductive20health.html .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**

**Maternal Child Health Website Gets a Facelift**

In response to your requests for a more useable and access-friendly
website....the OIT staff, with assistance from the websites content
coordinators, have redesigned the Maternal Child Health Websites.

I invite you to browse through the pages and let me know how useful they
are in both your clinical practice and other research and HP/DP
programs. The pages are updated regularly with up to date clinical
information you are sure to find beneficial for our patients.

**MCH Portal**

The MCH Portal gives you really easy access to all the main resources

**Features:**

1.) **Site map:** It's A- Z...no more problems with where this or that
resource is

2.) **Frequently Asked Questions:** A- Z...got more questions? Please
let us know

3.) **What's New**: Find out what has been added since you last used
this web site

4.) **CCC Corner newsletter**: You should at least scan this resource
every month

5.) **Easy access to Main pages:** MCH, Women's Health, DV, Female
Health Systems

6.) **UpToDate:** The UpToDate link is in the top left corner, easy to
see

7.) **Clinical Information Resources:** Virtual online library for
Indian Health staff

8.) **Clinical Guidelines:** What has worked for your Indian Health
colleagues?

[http://www.ihs.gov/MedicalPrograms/MCH/index.cfm](https://hqwebmail.ihs.gov/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/index.cfm)

**Maternal Child Health page**

The new MCH page contains a variety of information pertaining to the
health of women during the reproductive years as well as early childhood
issues

**Features:**

1.) **Perinatology Corner:** Free CME /CEU modules on latest OB topics

2.) **Pregnancy page:** Good resources, organized in A --Z order

3.) **Evidence Based Medicine:** Cochrane, AHRQ, SORT, etc...

4.) **Sexually transmitted infections**

5.) **Nurse Midwives page**

6.) **MCH Coordinators page**

7.) **Family Planning**

8.) **Indian Child Health Notes**: Monthly newsletter from Pediatric CCC
and colleagues

9.) **Breastfeeding page:** New redesign to be released soon

10.) **Cultural Appropriateness**

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

**Female Health Systems page**

The new Female Health Systems contains information on the variety of
systems we use to maximize the health and public health of female AI/AN
patients of all ages.

**Features:**

1.) **MCH Conferences:** Chronologic order. Also links to zillions of
other CME calendars

2.) **ACOG / IHS Course:** Best primer /update for AI/AN women.
Reference text online

3.) **Primary Care Discussion Forum**: Quarterly listserv discussions
with an expert

4.) **Programs and Resources:** What has worked for other Indian Health
folks?

5.) **Databases and Resources:** A lot of statistics have already
compiled. Save some work

6.) **Meeting Lecture Notes:** Power Point presentations, slides from
popular meetings

7.) **Discussion Groups**: Want to discuss topics, or just get periodic
updates?

8.) **Other Helpful Links**: We have already done the surfing for you

9.) **Forms:** Take a look. Don't re-invent the wheel

10.) **Newsletters and Journals**

11.) **Training:** Online, and face to face training opportunities

12.) **Access to care**

13.) **Advanced Practice Nurses / PAs page**

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

**Women's Health page**

The Women's Health page holds information from a multitude of sources
pertaining to the health of women in the post-reproductive time of their
lives. You will find information on the psychosocial aspects of aging,
menopause, osteoporosis, and much more.

**Features**

1.) **Cancer:** Divided by category -- breast, cervical, endometrial,
ovarian, colon, etc..

2.) **Cardiovascular Disease:** Disparities in care of AI/AN women and
prevention

3**.) Diabetes**: Emphasizes prevention and systems approaches

4.) **Mature women**: Hormone replacement, osteoporosis, pelvic physical
therapy

5.) **Mental Health:** Depression and other issues

6.) **Substance Abuse:** Tobacco education, other drugs

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

**Violence Against Native Women page**

The Violence Against Native Women page lists many programs designed to
protect our patients against domestic violence / sexual assault, as well
as information on sexually transmitted diseases.

**Features:**

1.) **Clinical Tools:** Assessment and prevention tools

2.) **Community Action:** Checklists and library

3.) **Current Events:** Training

4.) **Legislative Action**: How to get involved

5.) **Other Helpful links:** We have a lot of surfing for you

6.) **Patient Education:** Emphasizes prevention

7.) **Policies and Procedures:** What has worked well at other Indian
Health sites

8.) **Provider Education:** Tutorials and training

9.) **Public Health:** Who should we screen, and more

10.) **Resources:** Fact sheets and compendiums

11.) **Sexual Assault**: Dispel the myths

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

**New Vaginal Birth After Cesarean Delivery CME/CEU module**

<http://www.ihs.gov/MedicalPrograms/MCH/M/VB01.cfm>

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

**Q. Should a urine test be performed on every pregnant patient each
prenatal visit?**

A. No, routine urine testing in pregnancy is very insensitive and
non-specific.

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/UrinPrenat9405.doc>

**Q. Can we use medical therapy in the setting of spontaneous abortion
(SAB)?**

A. Yes, you can use misoprostol in either complete or incomplete SAB

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/MisoSAB121105.doc>

**Q. How do I manage patients with recurrent vulvovaginal candidiasis?**

A. First make sure of the correct diagnosis, then try these strategies

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/RecYeas122205.doc>

**Q. Does IHS have any policy on distribution of the morning after
pill?**

**A.** Yes, the IHS offers all FDA approved contraceptive agents

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/EC121105.doc>

**Q. Does the IHS have a procedure for payment in pregnancy
termination?**

A. IHS provides support for abortion services in three selected cases

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/TAB121105.doc>

**Q. Can you place an IUD after a term delivery or abortion (SAB or
induced)?**

A. Yes, but there are special precautions you should take

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/IUDsab122305.doc>

**Q. Do we have an Indian health policy /recommendations on positive
skin tests in pregnancy for TB\--and treatment recommendations?**

A. Yes, we have brief policy in Chapter 13 of the IHS Manual.

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/TBpreg121105.doc>

**Q. Is an abnormal Pap smear an** **effect of DES exposure in adult
daughters?**

A. There is an increase risk of HGSIL in DES-exposed daughters

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/DES121105.doc>

**Q. Does there have to be Pediatrician at all emergency deliveries?**

A. The standard is a healthcare worker experienced in neonatal
resuscitation

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/EmerNeoRescus121105.doc>

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

**February 2006 -- Highlights**

\- To Bag or Not to Bag: Is a bag urine specimen ever reliable?

\- An updated immunization for Native Americans from Dr. Singleton

\- The latest literature reviews from Dr. Esposito

[www.ihs.gov/MedicalPrograms/MCH/M/documents/IHSchildhealthnotesFeb2006.doc](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/IHSchildhealthnotesFeb2006.doc)

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

**What is the latest on an OB/GYN solution for the PCC, PCC+ and EHR?**

An OB solution is funded and in progress for this year. The following is
a non-binding plan:

Our goal is to provide a seamless MCH module for PCC, PCC+ and EHR /this
fiscal year. The plan is to start OB as soon as well child is done. Most
likely the OB portion will start this Spring. The non-GUI portions of
well child are ready to go except for the pt ed codes. Also waiting for
alpha test site selection. We have started work on the GUI portions of
well child including the ASQ sub-module. Once we learn how to do this,
it will be possible to move on with the OB components for EHR. Stay
tuned for further progress. <Theresa.Cullen@IHS.GOV>

#### 

#### Patient Safety and Health IT - Exploring and Expanding the Intersections, AHRQ

June 4 - 7, 2006, Washington DC

To spread new advances in patient safety and health information
technology (IT), the Agency for Healthcare Research and Quality (AHRQ)
is seeking participation from awardees and other stakeholders in
programming for the AHRQ 2006 Annual Conference on patient safety and
health IT. We invite your ideas for participation in the Annual
Conference by making session presentations, participating in panel
discussions, or leading workshops.  <Figueroa-Venus@norc.org>

**New PCC PATCH released**

Please make sure that this is loaded at your sites by your site manager.
APCH PCC Health Summary v2.0, Patch 14 distribution patch files
<Theresa.Cullen@IHS.GOV>

**National Release - BMC Referred Care Information System, Version 4.0**

This is the new version of RCIS ( referred care). OIT recommends that
you load and utilize this software to help improve clinical care and
practice management at your facility. We are pleased to announce the
release of BMC Referred Care Information System, Version 4.0.   Beta
tested at Phoenix Indian Medical Center, Aroostook Band of MicMac,
Winslow Health Center, Parker Indian Hospital, Fort Defiance and Peach
Springs. <http://www.ihs.gov/Cio/RPMS/appselect.cfm>

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

**Summer opportunity for undergraduate students**

Students with an interest in Native American Health issues, as well as
an interest in pursuing graduate studies in medicine (either MD, MPH, or
PhD programs). I am the director of an innovative program at Harvard
Medical School called the Four Directions Summer Research

Program. The summer of 2006 will mark the 13th year this program has
been running.

More practical issues related to students include:

\- They will stay at the Harvard Medical School dormitory for the 8 week
summer program

\- Living stipends and travel arrangements are provided

There is more information located on our website, including application
materials:

[[http://www.fdsrp.org]{.underline}](http://www.fdsrp.org/) Please feel
free to contact us with any questions at: <info@fdsrp.org>

\(617\) 432-4422 Thomas Sequist, MD MPH

**Attitudes toward the use of quarantine in a public health emergency in
four countries**

Countries worldwide face the threat of emerging infectious diseases. To
understand the public\'s reaction to the use of widespread quarantine
should such an outbreak occur, the Harvard School of Public Health, with
the U.S. Centers for Disease Control and Prevention, undertook a survey
of residents of Hong Kong, Taiwan, Singapore, and the United States. A
sizable proportion of the public in each country opposed compulsory
quarantine. Respondents were concerned about overcrowding, infection,
and inability to communicate with family members while in quarantine.
Officials will need specific plans to deal with the public\'s concerns
about compulsory quarantine policies.

Blendon RJ, DesRoches CM, Cetron MS. 2006. Attitudes toward the use of
quarantine in a public health emergency in four countries. *Health
Affairs* 25 (2006): w15-w25 January 2006
[[http://content.healthaffairs.org/cgi/content/abstract/hlthaff.25.w15]{.underline}](http://content.healthaffairs.org/cgi/content/abstract/hlthaff.25.w15)

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

**Cultural Competency into Medical Education and Training**

A Guide to Incorporating Cultural Competency into Medical Education and
Training explores the need for cultural competency education and
training for health professionals and provides a checklist for a model
cultural competency curriculum for the field of medicine. The guide,
published by the National Health Law Program in collaboration with the
University of North Carolina (UNC) School of Medicine, the UNC School of
Nursing, and Duke University School of Medicine, examines federal
guidelines, state legislative initiatives, and current policies and
curricula of various professional medical and health care organizations
and medical schools related to the provision of cultural competency
training. The guide concludes with a checklist based on the Tool for
Assessing Cultural Competence Training.
[[http://www.healthlaw.org/library.cfm?fa=download&resourceID=77331&appView=folder&print]{.underline}](http://www.healthlaw.org/library.cfm?fa=download&resourceID=77331&appView=folder&print)

**Potential Environmental Risks to Women**

A report titled Environmental Health Information Resources: Healthy
Environments for Healthy Women and Children focuses on resources from
the National Library of Medicine and describes several other major
Internet resources containing information on environmental health risks
to women. The report includes information about (1) general
environmental health resources, (2) resources on environmental exposures
during pregnancy and lactation, and (3) environmental hazards in homes
and public places.
[[http://www.journals.elsevierhealth.com/periodicals/jmwh/article/PIIS1526952305004356/abstract]{.underline}](http://www.journals.elsevierhealth.com/periodicals/jmwh/article/PIIS1526952305004356/abstract)

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

#### Listen up any parents or grandparents: How not to give Acetaminophen {#listen-up-any-parents-or-grandparents-how-not-to-give-acetaminophen .Style-Heading-4-+-Arial-14-pt-Underline}

**Case**

Parents brought their 5-year-old son to the emergency department (ED)
with a 24-hour history of fever, cough, and frontal headache. Physical
examination, vital signs, and laboratory evaluation were unremarkable.
The patient was discharged with a diagnosis of viral syndrome after
receiving one dose of acetaminophen in liquid form. Two days later, the
patient returned to the ED with continuing fever and new rigors,
vomiting, lethargy, and right upper quadrant abdominal pain. Laboratory
evaluation indicated that acetaminophen levels and PT/INR were elevated.

Further discussion with the parents revealed that they misread the
instructions about administering liquid acetaminophen. They gave
multiple doses of 20 mL (48 mg/mL solution equaling 960 mg [per
dose]{.underline}) instead of the correct dose for their 20-kg child (6
mL = 288 mg). The patient was admitted to the hospital, given
intravenous N-acetylcysteine, and his symptoms improved over the
succeeding days. His acetaminophen levels declined, and he was safely
discharged home without further events.

**Commentary: [James E. Heubi, MD](mailto:James.Heubi@cchmc.org)**

Available as an over-the-counter medication in the United States since
1960, acetaminophen is considered safe and effective for the management
of fever and pain in children. Few serious adverse effects have been
reported. A recent study evaluating more than 28,000 children treated
with acetaminophen failed to show any increased risk of acute
gastrointestinal bleeding, acute renal failure, or anaphylaxis.

Despite this enviable safety record, acetaminophen-induced
hepatotoxicity can be lethal when the medicine is taken in
supratherapeutic doses. These include an intentional overdose with a
single dose exceeding 140 mg/kg, unintentional overdose when a child is
given multiple doses of acetaminophen that exceed manufacturer
recommendations, or inadvertent overdose when a child receives
acetaminophen in combination with cough/cold preparations. The frequency
of accidental acetaminophen overdoses causing clinically significant
hepatotoxicity as described in this case is unknown. However, during a
10-year period at five California hospitals, 73 children (younger than
19 years) presented with acetaminophen hepatotoxicity, with 62 of 63
suicidal patients (three required orthotopic liver transplant) and 9 of
10 patients with accidental overdoses surviving. Another study of
acetaminophen hepatotoxicity in accidental overdose cases reported a
wide range of implicated doses, but the most frequent causes involved
administration of adult preparations to children (approximately half of
cases), followed by inaccurate substitution of a higher-concentration
preparation for a lower one. Fifty-five percent of the patients died,
and five underwent liver transplants, with four surviving.

**Pharmacology of Acetaminophen Overdose**

As with single, large overdoses of acetaminophen, hepatotoxicity from
multiple supratherapeutic doses also results when the normal metabolic
pathways in the liver are overwhelmed by the volume of drug, which leads
to a series of molecular events ultimately causing cellular death. The
severity of liver injury is dependent upon the quantity of acetaminophen
ingested, whether the P450 cytochrome system has been induced with drugs
or alcohol, and potentially the nutritional state of the patient. Unlike
acute large ingestions of acetaminophen with suicidal intent, in which a
nomogram helps to predict outcome and need for N-acetylcysteine
treatment, the nomogram offers little value in predicting outcome with
multiple supratherapeutic doses. However, identifying elevated
acetaminophen concentrations in the blood relative to the last dose may
reveal a risk for hepatotoxicity. Although N-acetylcysteine is effective
in preventing serious liver injury with acute toxic ingestions, there is
no proof of its benefit when multiple excessive doses are taken. Once a
patient is identified with hepatotoxicity after chronic overdosage, only
supportive therapy is helpful and, if liver failure develops, liver
transplantation can be lifesaving.

**Safety Strategies**

A number of safety interventions could prevent future acetaminophen
overdoses, and these efforts should target individual providers and
parents, medication labeling practices, and broader health care systems.
First, the key to prevention begins with parental education. Physicians'
office personnel, pharmacists, and all health care providers play an
important role in educating parents regarding the safe use of
over-the-counter medications such as acetaminophen. Education should
begin with instructions about acetaminophen safety, including dosing and
forms of available preparations, as well as emphasizing to parents that
"more is not better" with acetaminophen use. In addition, checking
whether acetaminophen-containing cough/cold preparations are being
inadvertently used with acetaminophen provides an important cautionary
strategy. Finally, preparing illustrative handouts that depict when
acetaminophen is a sole ingredient versus a combination (cough/cold)
product to indicate the concentrations of acetaminophen in each would be
beneficial.

From a medication labeling perspective, encouraging manufacturers to
limit liquid preparations to only a single concentration might prevent
confusion regarding infant/child formulations. Currently, liquid
acetaminophen comes in varying concentrations, thus creating potential
for confusion, particularly for those parents with low health literacy.
Perhaps this was the contributing factor in the case presented. In
addition, highlighting (by bolding in the ingredients) the presence of
acetaminophen in combination products might prevent unintended "double
dosing." Although acetaminophen labeling provides guidelines on
appropriate dosing, they are not weight based . But even weight-based
labeling would not be a panacea, since it relies on accurate
calculations that are more involved than current age-based dosing
guidelines for children. In practice, the age-based guidelines should be
sufficient to prevent the average-size child from receiving excessive
dosing. Lastly, requiring pharmacies or drug manufacturers to prepare a
"handout" (or display) at the point of sale with dosing instructions for
parents might serve to emphasize safe administration practices.

To minimize acetaminophen drug toxicity, encourage weight-based dosing
of 10-15 mg/kg/dose and do not exceed 5 doses in 24 hours. It is also
important to be aware of agents that might amplify acetaminophen
toxicity and adjust dosing accordingly using a pharmacist or a readily
available drug reference resource for guidance. Remind parents that
acetaminophen is a safe and effective therapy but administering it in
greater-than-recommended doses will not be more effective and may be
harmful, even life-threatening.

**Take-Home Points**

-   Acetaminophen hepatotoxicity after multiple supratherapeutic doses
    is a rare and preventable condition.

-   Weight-based administration of acetaminophen is crucial in
    preventing supratherapeutic dosing.

-   In treating infants or small children, select a single dose strength
    of acetaminophen and use it consistently.

-   Always screen for concurrent use of cough/cold preparations
    containing acetaminophen if you plan to recommend acetaminophen for
    a child.

[James E. Heubi, MD](mailto:James.Heubi@cchmc.org)\
University of Cincinnati College of Medicine

#### (from AHRQ Web M + M) [**http://www.webmm.ahrq.gov/**](http://www.webmm.ahrq.gov/) {#from-ahrq-web-m-m-httpwww.webmm.ahrq.gov .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-14 .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**

#### American Heart Association Does Not Recommend Isoflavone Supplements Soy protein and isoflavones (phytoestrogens) have gained considerable attention for their potential role in improving risk factors for cardiovascular disease. This scientific advisory assesses the more recent work published on soy protein and its component isoflavones. In the majority of 22 randomized trials, isolated soy protein with isoflavones, as compared with milk or other proteins, decreased LDL cholesterol concentrations; the average effect was approximately 3%. This reduction is very small relative to the large amount of soy protein tested in these studies, averaging 50 g, about half the usual total daily protein intake. No significant effects on HDL cholesterol, triglycerides, lipoprotein(a), or blood pressure were evident. Among 19 studies of soy isoflavones, the average effect on LDL cholesterol and other lipid risk factors was nil. Soy protein and isoflavones have not been shown to lessen vasomotor symptoms of menopause, and results are mixed with regard to soy\'s ability to slow postmenopausal bone loss. The efficacy and safety of soy isoflavones for preventing or treating cancer of the breast, endometrium, and prostate are not established; evidence from clinical trials is meager and cautionary with regard to a possible adverse effect. For this reason, use of isoflavone supplements in food or pills is not recommended. Thus, earlier research indicating that soy protein has clinically important favorable effects as compared with other proteins has not been confirmed. In contrast, many soy products should be beneficial to cardiovascular and overall health because of their high content of polyunsaturated fats, fiber, vitamins, and minerals and low content of saturated fat. {#american-heart-association-does-not-recommend-isoflavone-supplements-soy-protein-and-isoflavones-phytoestrogens-have-gained-considerable-attention-for-their-potential-role-in-improving-risk-factors-for-cardiovascular-disease.-this-scientific-advisory-assesses-the-more-recent-work-published-on-soy-protein-and-its-component-isoflavones.-in-the-majority-of-22-randomized-trials-isolated-soy-protein-with-isoflavones-as-compared-with-milk-or-other-proteins-decreased-ldl-cholesterol-concentrations-the-average-effect-was-approximately-3.-this-reduction-is-very-small-relative-to-the-large-amount-of-soy-protein-tested-in-these-studies-averaging-50-g-about-half-the-usual-total-daily-protein-intake.-no-significant-effects-on-hdl-cholesterol-triglycerides-lipoproteina-or-blood-pressure-were-evident.-among-19-studies-of-soy-isoflavones-the-average-effect-on-ldl-cholesterol-and-other-lipid-risk-factors-was-nil.-soy-protein-and-isoflavones-have-not-been-shown-to-lessen-vasomotor-symptoms-of-menopause-and-results-are-mixed-with-regard-to-soys-ability-to-slow-postmenopausal-bone-loss.-the-efficacy-and-safety-of-soy-isoflavones-for-preventing-or-treating-cancer-of-the-breast-endometrium-and-prostate-are-not-established-evidence-from-clinical-trials-is-meager-and-cautionary-with-regard-to-a-possible-adverse-effect.-for-this-reason-use-of-isoflavone-supplements-in-food-or-pills-is-not-recommended.-thus-earlier-research-indicating-that-soy-protein-has-clinically-important-favorable-effects-as-compared-with-other-proteins-has-not-been-confirmed.-in-contrast-many-soy-products-should-be-beneficial-to-cardiovascular-and-overall-health-because-of-their-high-content-of-polyunsaturated-fats-fiber-vitamins-and-minerals-and-low-content-of-saturated-fat. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Sacks FM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Sacks+FM"%5BAuthor%5D), et al Soy Protein, Isoflavones, and Cardiovascular Health. An American Heart Association Science Advisory for Professionals From the Nutrition Committee. [Circulation.](javascript:AL_get(this, 'jour', 'Circulation.');) 2006 Jan 17 [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16418439&query_hl**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16418439&query_hl) {#sacks-fm-et-al-soy-protein-isoflavones-and-cardiovascular-health.-an-american-heart-association-science-advisory-for-professionals-from-the-nutrition-committee.-circulation.-2006-jan-17-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids16418439query_hl .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Black cohosh / St. John\'s wort combined: Decreases psychological climacteric complaints  {#black-cohosh-st.-johns-wort-combined-decreases-psychological-climacteric-complaints .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: This fixed combination of black cohosh and St. John\'s wort is superior to placebo in alleviating climacteric complaints, including the related psychological component. LEVEL OF EVIDENCE: I [Uebelhack R](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Uebelhack+R"%5BAuthor%5D) et al Black Cohosh and St. John\'s Wort for Climacteric Complaints: A Randomized Trial. [Obstet Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006 Feb;107(2):247-55. [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16449108&dopt=Abstract**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16449108&dopt=Abstract) {#conclusion-this-fixed-combination-of-black-cohosh-and-st.-johns-wort-is-superior-to-placebo-in-alleviating-climacteric-complaints-including-the-related-psychological-component.-level-of-evidence-i-uebelhack-r-et-al-black-cohosh-and-st.-johns-wort-for-climacteric-complaints-a-randomized-trial.-obstet-gynecol.-2006-feb1072247-55.-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmedlist_uids16449108doptabstract .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Nonhormonal Therapies for Hot Flashes in Menopause (see Patient Education) {#nonhormonal-therapies-for-hot-flashes-in-menopause-see-patient-education .Style-Heading-4-+-Arial-14-pt-Underline}

#### Numerous reports in the medical literature and popular media have discussed the effectiveness of various nonhormonal agents in reducing menopausal hot flash symptoms. Data for these therapies are limited, and most of the studies have been conducted in women with a history of breast cancer. Selective serotonin reuptake inhibitors and venlafaxine have been shown to reduce hot flashes by 19 to 60 percent and were well tolerated by study participants. Soy isoflavones reduced hot flashes by 9 to 40 percent in some trials, but most trials showed no difference compared with placebo. Black cohosh and red clover also have had inconsistent results, with some trials showing benefit and some no difference compared with placebo. Soy isoflavones, black cohosh, and red clover were well tolerated in clinical trials. Other agents that have been used to alleviate hot flashes include belladonna/ergotamine tartrate/phenobarbital combination, dong quai, evening primrose oil, gabapentin, ginseng, mirtazapine, trazodone, vitamin E, and wild yam, but few data regarding their effectiveness have been published. Further randomized controlled trials are needed. Am Fam Physician 2006;73:457-64, 467 {#numerous-reports-in-the-medical-literature-and-popular-media-have-discussed-the-effectiveness-of-various-nonhormonal-agents-in-reducing-menopausal-hot-flash-symptoms.-data-for-these-therapies-are-limited-and-most-of-the-studies-have-been-conducted-in-women-with-a-history-of-breast-cancer.-selective-serotonin-reuptake-inhibitors-and-venlafaxine-have-been-shown-to-reduce-hot-flashes-by-19-to-60-percent-and-were-well-tolerated-by-study-participants.-soy-isoflavones-reduced-hot-flashes-by-9-to-40-percent-in-some-trials-but-most-trials-showed-no-difference-compared-with-placebo.-black-cohosh-and-red-clover-also-have-had-inconsistent-results-with-some-trials-showing-benefit-and-some-no-difference-compared-with-placebo.-soy-isoflavones-black-cohosh-and-red-clover-were-well-tolerated-in-clinical-trials.-other-agents-that-have-been-used-to-alleviate-hot-flashes-include-belladonnaergotamine-tartratephenobarbital-combination-dong-quai-evening-primrose-oil-gabapentin-ginseng-mirtazapine-trazodone-vitamin-e-and-wild-yam-but-few-data-regarding-their-effectiveness-have-been-published.-further-randomized-controlled-trials-are-needed.-am-fam-physician-200673457-64-467 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20060201/457.html**](http://www.aafp.org/afp/20060201/457.html) {#httpwww.aafp.orgafp20060201457.html .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Midwives Corner Jenny Glifort, CNM and Marsha Tahquechi, CNM {#midwives-corner-jenny-glifort-cnm-and-marsha-tahquechi-cnm .Style-Heading-4-+-Arial-14-pt-Underline}

**When Should We Clamp the Umbilical Cord? Preterm vs Term Infants**

Philip and Saigal in their 2004 review article and a 2004 Cochrane
Review reveals that in 24-36 week infants delaying cord clamping may be
associated with fewer transfusions for anemia or low blood pressure, and
less intraventricular hemorrhage than early clamping. In addition,
delayed clamping may help some infants in developing countries.

On the other hand, delayed cord clamping should be avoided in infants of
diabetic mothers, IUGR, and infants with cardiovascular or pulmonary
conditions. In the majority of infants, e.g., near term and term
infants, delayed clamping does not produce significant benefit / harm,
but has been associated with unnecessary adverse effects in numerous
small studies.

In addition, a 2005 Cochrane Review reported that in term patients,
there does appear to be some potential benefit from the use of immediate
placental cord drainage in terms of reducing the length of the third
stage of labour. More research is required to investigate the impact of
cord drainage on the management of the third stage of labour

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

In June 2005 the CCC Corner previously reported fewer transfusions for
anemia or low blood pressure, and less intraventricular hemorrhage in
preterm infants with delayed cord clamping 30 -120 seconds. It should be
noted that these findings and those reported by Philip and Saigal and
the Cochrane Review are based on limited data, e.g., seven studies with
225 infants.

We should use caution in applying delayed cord clamping outside the
setting of selected preterm infants.. In addition, early cord clamping
is associated with untoward effects in one of our more frequent medical
complications in AI/AN women, e.g., infants of diabetic mothers. Delayed
cord clamping should not be applied universally, due to the lack of
benefit in term, or near term infants

To further complicate the issue of delayed cord clamping, a second
Cochrane Review reports potential maternal benefit from the use of
placental cord drainage in terms of reducing the length of the third
stage of labor.

I suggest we continue to follow the literature on this issue closely and
apply delayed cord clamping only in the few selected preterm settings
where clinically proven benefit has been documented.

**Resources:**

**June 2005 CCC Corner**

**Obstetric Hot Topics: Slight delay in umbilical cord clamping better
for preterm infants**

<http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0605_HT.cfm#ob>

Rabe H, Reynolds G, Diaz-Rossello J. Early versus delayed umbilical cord
clamping in preterm infants. The Cochrane Database of Systematic Reviews
2004, Issue 4. Art. No.: CD003248.pub2. DOI:
10.1002/14651858.CD003248.pub2.
<http://www.update-software.com/publications/cochrane/>

Soltani H, Dickinson F, Symonds I. Placental cord drainage after
spontaneous vaginal delivery as part of the management of the third
stage of labour. *The Cochrane Database of Systematic Reviews* 2005,
Issue 4. Art. No.: CD004665.pub2. DOI: 10.1002/14651858.CD004665.pub2.

<http://www.update-software.com/publications/cochrane/>

Philip and Saigal. When Should We Clamp the Umbilical Cord?
Neoreviews.2004; 5: 142-154

[[http://neoreviews.aappublications.org/cgi/content/long/5/4/e142]{.underline}](http://neoreviews.aappublications.org/cgi/content/long/5/4/e142)
or contact <cooperd@mail.nih.gov> for access

**Liability in triage: management of EMTALA regulations and common
obstetric risks**

I am just following up on this topic from the December CCC Corner. The
following information is paraphrased from [Angelini
DJ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Angelini+DJ"%5BAuthor%5D),
[Mahlmeister
LR](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Mahlmeister+LR"%5BAuthor%5D).
Liability in triage: management of EMTALA regulations and common
obstetric risks. [J Midwifery Womens
Health.](javascript:AL_get(this, 'jour', 'J Midwifery Womens Health.');)
2005 Nov-Dec;50(6):472-8.

Two key points:

Yes, in an EMTALA setting a physician has to certify that a patient is
in 'false labor', but a 'qualified medical person' can sign that
certification after consulting with a physician who authorizes the
patient's care. The physician must countersign the certification as
contemporaneously as possible, e. g., 24 hours.

Further, it is the hospital that designates who is a 'qualified medical
person' to provide appropriate medical screening. The 'qualified medical
person' can be a non-physician, e.g., CNM, or RN, etc... If properly
applied, then a system of cooperation between the nurses, CNMs, and
physicians can easily be devised and be within compliance with the
EMTALA directives.

Adequate documentation is the key to success. Each facility should
review the Resources below. The L/D or Triage team should come to
agreement, and then implement a cohesive plan. In the meantime, the ACNM
is working on changing the Federal regulations to allow CNMs to be able
to directly diagnose 'false labor' in EMTALA settings.

The ACNM is actively pursuing a revision of the above regulations. The
Technical Advisory Committee met on June 15-17, 2005. The Minutes
reflect the ACNM proposed changes. The complete minutes can be found
below or contact Deanne Williams, Exec. Director, ACNM

<http://new.cms.hhs.gov/FACA/07_emtalatag.asp>

or via the

CENTERS FOR MEDICARE & MEDICAID SERVICES website

<http://new.cms.hhs.gov/>

**Resources:**

**Midwives Corner, December 2005**

<http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_Feat.cfm#MidWives>

[Angelini
DJ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Angelini+DJ"%5BAuthor%5D),
[Mahlmeister
LR](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&term="Mahlmeister+LR"%5BAuthor%5D).
Liability in triage: management of EMTALA regulations and common
obstetric risks. [J Midwifery Womens
Health.](javascript:AL_get(this, 'jour', 'J Midwifery Womens Health.');)
2005 Nov-Dec;50(6):472-8.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16260361&query_hl=1>

**Withholding coaching during maternal pushing is not harmful**

CONCLUSION: Although associated with a slightly shorter second stage,
coached maternal pushing confers no other advantages and withholding
such coaching is not harmful.

[Bloom
SL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Bloom+SL"%5BAuthor%5D)
A randomized trial of coached versus uncoached maternal pushing during
the second stage of labor. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Jan;194(1):10-3.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16389004>

**Injuries to the Brachial Plexus: Mechanisms and Management**

The February Midwives Corner offers a follow up to last month\'s
shoulder dystocia column. Last month's column focused on strategies to
prevent shoulder dystocia. The 'CCC deliver through maneuver' for
shoulder dystocia prevention was also introduced.

<http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106_Feat.cfm#MidWives>

This following is an introduction to a two part series on brachial
plexus injuries presents a comprehensive review of this complication of
vaginal birth.

Part 1 focus\' on the fetal neuroanatomy and embryological development
of the brachial plexus in relationship to the sequelae of physical
disabilities seen after an injury resulting from birth. Antenatal and
intrapartum risk factors as well as a classification of brachial plexus
injuries are discussed.

Part 2 reviews the physical characteristics of brachial plexus injuries
that result in the various palsies based on the severity of injury.
Recommendations are made for the medical and nursing management of
brachial plexus injuries and the long term outcomes for these infants.

**Part 1:**

**Injuries to the Brachial Plexus: Mechanisms of Injury and
Identification of Risk Factors**

<http://www.medscape.com/viewarticle/510573_print> **Medscape**

**Part 2:**

**Distinguishing Physical Characteristics and Management of Brachial
Plexus Injuries**

<http://www.medscape.com/viewarticle/514539_print> **Medscape**

or go to these **PubMed** links

[Benjamin
K](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Benjamin+K"%5BAuthor%5D)
Part 1. Injuries to the brachial plexus: mechanisms of injury and
identification of risk factors. [Adv Neonatal
Care.](javascript:AL_get(this, 'jour', 'Adv Neonatal Care.');) 2005
Aug;5(4):181-9.\
.<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16084476&query_hl>

[Benjamin
K](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Benjamin+K"%5BAuthor%5D).
Part 2. Distinguishing physical characteristics and management of
brachial plexus injuries. [Adv Neonatal
Care.](javascript:AL_get(this, 'jour', 'Adv Neonatal Care.');) 2005
Oct;5(5):240-51.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16202966&query_hl>

**Centering Association National Conference**

March 26-29 2006, Chapel Hill, NC

From the Centering Pregnancy and Parenting Association! To learn more
about whom else is providing GROUP PRENATAL CARE and the challenges and
victories they\'ve experienced and what strategies will help build
stronger relationships within prenatal care groups.

Brochure and on line registration
[[www.centeringpregnancy.org]{.underline}](../www.centeringpregnancy.org)

**Cesarean Delivery on Maternal Request**

-   March 27-29, 2006

-   Bethesda, MD, or webcast

-   NIH State-of-the-Science Conference

<http://www.ihs.gov/MedicalPrograms/MCH/F/CN01.cfm#Mar06>

**Navajo News Jean Howe, Chinle**

#### Who do you contact in Navajo Area for MCH issues?  {#who-do-you-contact-in-navajo-area-for-mch-issues-1 .Style-Heading-4-+-Arial-14-pt-Underline}

Jean Howe is the OB/GYN Deputy Chief Clinical Consultant (CCC). Jean
participates in many of the [national functions of the
CCC.](http://www.ihs.gov/NonMedicalPrograms/nc4/obgyn.cfm) Originally
from Vermont and trained at the University of Colorado, Dr. Howe has
been an OB/GYN at Chinle Hospital for 7 years. She also currently serves
as the Navajo Area OB/GYN consultant and will complete an MPH program
this May. Her areas of interest include preventive services,
contraception, and diabetes in pregnancy.
<http://www.ihs.gov/NonMedicalPrograms/nc4/obgyn_dccc.cfm>

and

#### Diana Hu, MD is the Acting MCH Consultant/Chief Clinical Consultant in Pediatrics Navajo Area Indian Health Service {#diana-hu-md-is-the-acting-mch-consultantchief-clinical-consultant-in-pediatrics-navajo-area-indian-health-service .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/MCHC14.cfm**](http://www.ihs.gov/MedicalPrograms/MCH/M/MCHC14.cfm) {#httpwww.ihs.govmedicalprogramsmchmmchc14.cfm .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Nurses Corner**

**New Mexico Indian Nurses Association Annual Symposium 2006**

March 16-17, Albuquerque, NM

"Circle of Violence II", 16 credits

Pre-Conference: Preceptor and Mentor Development Workshop, March 14-15,
2006

Brochure available <Sandra.Haldane@ihs.gov>

**Donna Brown, ANMC**

**Drugs containing PHENYLPROPANOLAMINE are being recalled**

STOP TAKING anything containing this ingredient. It has been linked to
increased hemorrhagic stroke (bleeding in brain) among women ages 18-49
in the three days after starting use of medication. Problems were not
found in men, but the FDA recommended that everyone (even children) seek
an alternative medicine. <http://www.fda.gov/opacom/7alerts.html>

#### Office of Women's Health, CDC {#office-of-womens-health-cdc-1 .Style-Heading-4-+-Arial-14-pt-Underline}

**Trends in Spina Bifida and Anencephalus in the United States,
1991-2003**

This Health e-stat provides a 13-year trend for two neural tube defects,
spina bifida and anencephalus. After a significant increase in the spina
bifida rate from 1992 to 1995, there was a significant decline from 1995
to 1999. The rate was stable from 1999 to 2003. The rate for 2003 was
significantly lower than in 1998. The rate of spina bifida in 2003 was
18.89 per 100,000 live births, the lowest rate reported in this
analysis.

<http://www.cdc.gov/nchs/products/pubs/pubd/hestats/spine_anen.htm>

**Community Based Cancer Control: A Seminar for AI/AN Health Advocates**

Grant writing and community based participatory research course

March 12-17, 2006, Seattle, WA.

This is a capacity building course designed for community people with an
interest in cancer prevention and control. The cost of travel, hotel,
meals, and all course materials is covered for participants.
<moriarty@ohsu.edu>

####  {#section-20 .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}

#### Who do you contact in Oklahoma Area for MCH issues?  {#who-do-you-contact-in-oklahoma-area-for-mch-issues .Style-Heading-4-+-Arial-14-pt-Underline}

#### Two contacts are Dr. George Chiarchiaro in the Area Office and Greggory Woitte at Tahlequah. {#two-contacts-are-dr.-george-chiarchiaro-in-the-area-office-and-greggory-woitte-at-tahlequah. .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Dr. George Chiarchiaro is the MCH Coordinator and has a helpful website with many resources [[http://www.ihs.gov/MedicalPrograms/MCH/M/MCHC07.cfm#top]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/M/MCHC07.cfm#top) {#dr.-george-chiarchiaro-is-the-mch-coordinator-and-has-a-helpful-website-with-many-resources-httpwww.ihs.govmedicalprogramsmchmmchc07.cfmtop .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Greggory Woitte at Tahlequah is available at [[Greggory.Woitte@mail.ihs.gov]{.underline}](mailto:Greggory.Woitte@mail.ihs.gov) {#greggory-woitte-at-tahlequah-is-available-at-greggory.woittemail.ihs.gov .Style-Heading-4-+-Arial-14-pt-Underline}

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

Cost-effectiveness of Drug Treatment for Osteopenia

Drug treatment of osteoporosis, defined by the World Health Organization
as bone mineral density greater than 2.5 standard deviations less than
the young healthy mean, has been proven to prevent fractures. It is less
clear, however, whether physicians should treat osteopenia (femoral-neck
T-score of -1.6 to -2.5) in postmenopausal women who do not have a
history of fractures.

The calculated cost per QALY gained from alendronate treatment ranged
from \$70,732 for a 65-year-old woman with a nearly osteoporotic T-score
of -2.4 to \$332,250 for a 75-year-old woman with a nearly normal
T-score of -1.5. The cost per QALY increased with age and decreased with
more negative T-scores. At a T-score threshold of -1.5, even a
55-year-old woman only benefited from alendronate therapy at a cost of
more than \$250,000 per QALY.

Citing a commonly used societal cost-effectiveness threshold of \$50,000
per QALY gained, the authors conclude that alendronate therapy is not a
cost-effective means to prevent fractures in postmenopausal women with
osteopenia and no other risk factors.

When combined with recent data from a Fracture Intervention Trial
subgroup that had femoral-neck T-scores between -1.6 and -2.5, Schousboe
and colleagues' analysis should help organizations make recommendations
about preventive therapies for women with osteopenia.

Drug therapies should be clinically beneficial and consume no more than
a reasonable proportion of societal resources. Although Quandt and
colleagues have found that alendronate therapy in women with osteopenia
reduces vertebral fracture risk, Schousboe's analysis suggests that it
costs more than a reasonable amount. Additionally, any
cost-effectiveness gained from future generic versions is likely offset
by the improbable assumptions of perfect drug adherence and no costs
from gastrointestinal side effects. An editorial^2^ calls on physicians
to base decisions regarding drug therapy on an overall assessment of
fracture risk rather than on T-scores alone. For lower-risk patients,
physicians can still provide primary prevention by encouraging adequate
calcium intake, vitamin D supplements, and weight-bearing exercise.

<http://www.aafp.org/afp/20060115/tips/11.html>

**Resources**

Schousboe JT, et al. Cost-effectiveness of alendronate therapy for
osteopenic postmenopausal women. Ann Intern Med May 3, 2005;142:734-41.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15867405&query_hl>

Quandt SA, et al. Effect of alendronate on vertebral fracture risk in
women with bone mineral

density T scores of -1.6 to -2.5 at the femoral neck: the Fracture
Intervention Trial. Mayo Clin

Proc March 2005;80:343-9.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15757015&query_hl>

McClung MR. Osteopenia: to treat or not to treat? Ann Intern Med May 3,
2005;142:796-7.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15867413&query_hl>

**Vitamin D Levels During Pregnancy Affect Childhood Bone Mass**

INTERPRETATION: Maternal vitamin D insufficiency is common during
pregnancy and is associated with reduced bone-mineral accrual in the
offspring during childhood; this association is mediated partly through
the concentration of umbilical venous calcium. Vitamin D supplementation
of pregnant women, especially during winter months, could lead to
longlasting reductions in the risk of osteoporotic fracture in their
offspring.

[Javaid
MK](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Javaid+MK"%5BAuthor%5D),
et al Maternal vitamin D status during pregnancy and childhood bone mass
at age 9 years: a longitudinal study.
[Lancet.](javascript:AL_get(this, 'jour', 'Lancet.');) 2006 Jan
7;367(9504):36-43.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16399151&query_hl>

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

#### Non-hormonal Options for Hot Flashes {#non-hormonal-options-for-hot-flashes-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20060201/467ph.html**](http://www.aafp.org/afp/20060201/467ph.html) {#httpwww.aafp.orgafp20060201467ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

#### [**http://www.aafp.org/afp/20060115/254ph.html**](http://www.aafp.org/afp/20060115/254ph.html) {#httpwww.aafp.orgafp20060115254ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Keeping Your Heart Healthy Through Good Nutrition and Exercise {#keeping-your-heart-healthy-through-good-nutrition-and-exercise .Style-Heading-4-+-Arial-14-pt-Underline}

#### [[http://www.aafp.org/afp/20060115/265ph.html]{.underline}](http://www.aafp.org/afp/20060115/265ph.html) {#httpwww.aafp.orgafp20060115265ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-23 .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}

**Focus on preventable causes of stillbirth: 3 articles**

**Identification of risk factors for stillbirth helps clinician assess
next pregnancy**

CONCLUSION: Identification of risk factors for stillbirth assists the
clinician in performing a risk assessment for each patient. Unexplained
stillbirths and stillbirths related to growth restriction are the 2
categories of death that contribute the most to late fetal losses. Late
pregnancy is associated with an increasing risk of stillbirth, and
clinicians should have a low threshold to evaluate fetal growth. The
value of antepartum testing is related to the underlying risk of
stillbirth and, although the strategy of antepartum testing in patients
with increased risk will decrease the risk of late fetal loss, it is of
necessity associated with higher intervention rates

[Fretts
RC](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Fretts+RC"%5BAuthor%5D).
Etiology and prevention of stillbirth. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2005
Dec;193(6):1923-35.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16325593&query_hl>

**Certain laboratory tests can be eliminated in the workup of fetal
death**

CONCLUSION: The causes of stillbirth are many and varied, with a large
proportion having no obvious cause. As this study demonstrates, certain
laboratory tests can be eliminated in the workup of fetal death. In the
evaluation of stillbirth a complete systematic method that incorporates
placental pathologic conditions, as well as autopsy findings, should
prove to be beneficial. [Incerpi
MH](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Incerpi+MH"%5BAuthor%5D),
et al Stillbirth evaluation: what tests are needed? [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 1998
Jun;178(6):1121-5.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9662289&query_hl>

**Comprehensive stillbirth assessment services should become routine**

CONCLUSION: Substantial relevant information can be learned from
stillbirth assessment at a modest economic cost. Programs that can
provide comprehensive stillbirth assessment services should become part
of routine pregnancy care.

[Michalski
ST](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Michalski+ST"%5BAuthor%5D),
[Porter
J](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Porter+J"%5BAuthor%5D),
[Pauli
RM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Pauli+RM"%5BAuthor%5D).
Costs and consequences of comprehensive stillbirth assessment. [Am J
Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2002
May;186(5):1027-34.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12015532&query_hl>

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

This is an important topic because we need learn about any preventable
causes of stillbirth to prevent any future tragedies for the family.
Here are some other resources:

**How should I manage a fetal demise?**

**A.** This I.H.S. Primary Provider article discusses the need for
investigation of every loss of pregnancy (intrauterine fetal demise
\[IUFD\], or spontaneous abortion), risk factors, possibly early warning
signs, aspects of counseling and emotional support, and criteria for
protocols.

<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/FetalDem.pdf>

**Q** When should antenatal testing start after a previous IUFD? at 34
weeks? Or prior to the gestational age of the previous IUFD?

**A** Probably neither, unless you know the exact etiology of the prior
IUFD, but there is more.

<http://www.ihs.gov/MedicalPrograms/MCH/M/faqdnlds/IUFtest102804.doc>

**Other topics**

**'Integrated Screening' is the most efficient:** **Risk cutoff levels
determine strategies**

CONCLUSION: Integrated screening is the most efficient of the 3
strategies, but it is possible to select risk cutoffs for both
sequential and contingent strategies that minimize losses in efficiency
while maintaining early detection and early completion. For all of these
strategies, well-designed intervention trials are needed to determine
acceptability to women and providers in primary care settings and to
assess real-world performance. LEVEL OF EVIDENCE: III.

[Palomaki
GE](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Palomaki+GE"%5BAuthor%5D)
et al Comparing three screening strategies for combining first- and
second-trimester down syndrome markers. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Feb;107(2):367-75.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16449126&dopt=Abstract>

**Emergency cervical cerclage improves perinatal outcome compared with
bed rest**

CONCLUSION: Emergency cervical cerclage can be accomplished safely in
women with dilated cervix and bulging membranes. It can reduce preterm
delivery before 32 weeks and improve neonatal survival compared with bed
rest. LEVEL OF EVIDENCE: II-1.\
[Daskalakis
G](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Daskalakis+G"%5BAuthor%5D)
et al Management of cervical insufficiency and bulging fetal membranes.
[Obstet Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');)
2006 Feb;107(2):221-6.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16449104&dopt=Abstract>

**Cervical cerclage: Can the patient who could benefit from this
procedure be identified?**

This editorial critically examines the definition of \"cervical
insufficiency.\" The definition, the clinical ascertainment, efforts to
develop an objective method of diagnosis, as well as the nature of
cervical disease leading to spontaneous mid-trimester spontaneous
abortion and preterm delivery are reviewed. The value and limitations of
cervical sonography as a risk assessment tool for spontaneous preterm
delivery are appraised. The main focus is on the role of cervical
cerclage to prevent an adverse pregnancy outcome. The value of assessing
the presence or absence of endocervical inflammation in the outcome of
cerclage placement is discussed.

[Romero
R](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Romero+R"%5BAuthor%5D),
The role of cervical cerclage in obstetric practice: can the patient who
could benefit from this procedure be identified? [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Jan;194(1):1-9.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16389003>

**Prophylactic cerclage of a short cervix according to interleukin-8 in
cervical mucus**

CONCLUSION: With normal cervical mucus IL-8, cerclage treatment for
cervical shortening may reduce the rate of preterm delivery, but with
elevated cervical mucus IL-8 cerclage may be harmful.

[Sakai
M](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Sakai+M"%5BAuthor%5D),
et al Evaluation of effectiveness of prophylactic cerclage of a short
cervix according to interleukin-8 in cervical mucus. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Jan;194(1):14-9.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16389005>

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

**Cardiology Topics for Primary Care Providers -- February 15, 2006**

Moderator: Jim Galloway, MD

Director, Native American Cardiology Program

**Here are some of the topics to be discussed**

-Role of CRP in cardiac evaluation

-Should we all take statins? or get out of our chairs, work out, lose
weight, diet and get fitness religion?

-Lipid screening guidelines in non-smoking non-diabetic Native Americans

-Newer cardiac imaging techniques (MRI, CT angio) over traditional
catheterization procedures.  

### 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**

**Efficacy and safety of azithromycin for treatment of C. trachomatis in
pregnancy**

BACKGROUND AND OBJECTIVES: Currently, azithromycin is not considered a
first-line treatment for Chlamydia trachomatis in pregnant women. We
evaluated the use, efficacy, and safety of azithromycin compared with
erythromycin and amoxicillin in the treatment of genital chlamydial
infection during pregnancy.

METHODS: This was a retrospective cohort study of pregnant women with
genital chlamydial infection. Data on antibiotics prescribed,
test-of-cure (TOC) results, and maternal and infant complications were
collected from medical records.

RESULTS: Of the 277 women in the study sample, 69% were initially
prescribed azithromycin, 9% amoxicillin, and 19% erythromycin. Eight-one
percent of subjects had a TOC 7 or more days after diagnosis and before
delivery. Treatment efficacy, as defined by a negative TOC, was 97% (95%
confidence interval \[CI\], 92.9-99.2) for azithromycin, 95% (95% CI,
76.2-99.9) for amoxicillin, and 64% (95% CI, 44.1-81.4) for
erythromycin. The efficacy of azithromycin was significantly higher than
erythromycin (P \< 0.0001). There were no significant differences in
efficacy by age, race/ethnicity, concurrent sexually transmitted disease
diagnosis, partner treatment, or substance use. Furthermore, there was
no difference in complications for women or infants exposed to
azithromycin compared with those treated with other regimens.
CONCLUSION: Clinical outcome data from this study population of women
and infants support both efficacy and safety of azithromycin for
treatment of C. trachomatis in pregnancy.

[Rahangdale
L](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Rahangdale+L"%5BAuthor%5D),
et al An Observational Cohort Study of Chlamydia trachomatis Treatment
in Pregnancy. [Sex Transm
Dis.](javascript:AL_get(this, 'jour', 'Sex Transm Dis.');) 2006
Feb;33(2):106-110.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16432482&query_hl>

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

Rahangdale et al is significant because it is one of the first studies
to report successful use of azithromycin in pregnancy. While many of use
azithromycin genital chlamydial infection during pregnancy already,
azithromycin has been considered an alternative therapy, e. g., not
first line therapy. Hopefully with these findings and the upcoming STI
summit in May 2006, we will see azithromycin's status upgraded.

**Hormonal contraception use and risk of STIs: A systematic review**

Previous research has suggested that hormonal contraceptive users,
compared with nonusers, may be at increased risk for acquiring sexually
transmitted infections (STIs). We searched the MEDLINE and EMBASE
databases for all articles from January 1966 through February 2005 for
evidence relevant to all hormonal contraceptives and STIs (including
cervical chlamydial and gonococcal infection, human papillomavirus,
trichomoniasis, herpes and syphilis). We used standard abstract forms
and grading systems to summarize and assess the quality of 83 identified
studies. Studies of combined oral contraceptive and depot
medroxyprogesterone use generally reported positive associations with
cervical chlamydial infection, although not all associations were
statistically significant. For other STIs, the findings suggested no
association between hormonal contraceptive use and STI acquisition, or
the results were too limited to draw any conclusions. Evidence was
generally limited in both amount and quality, including inadequate
adjustment for confounding, lack of appropriate control groups and small
sample sizes. The observed positive associations may be due to a true
association or to bias, such as differential exposure to STIs by
contraceptive use or increased likelihood of STI detection among
hormonal contraceptive users.

Mohllajee AP, Curtis KM, Martins SL, Peterson HB. Contraception. 2006
Feb;73(2):154-65. Epub 2005 Nov 2. 
<http://www.contraceptionjournal.org/article/PIIS0010782405003161/abstract>

**New National Women and Girls HIV/AIDS Awareness Day: March 10**

March 10, 2006 marks the first annual National Women and Girls HIV/AIDS
Awareness Day. This day is set to raise awareness on the increasing
impact of HIV/AIDS transmission on women and girls.  In support of this
observance day, the U.S. Department of Health and Human

Services is hosting a National Women and Girls Awareness Day Web site

that offers materials to assist in your efforts to educate, motivate,
and mobilize your local community in the fight against HIV/AIDS!

Women and Girls Day is sponsored by the Office on Women\'s Health.

<http://www.omhrc.gov/hivaidsobservances/women/index.html>

**2006 Price Fellowships for HIV Prevention Program**

The Centers for Disease Control and Prevention (CDC) and the CDC
Foundation announce the 2006 Price Fellowships for HIV Prevention
program. The Price Fellowships program offers the opportunity to three
individuals from community-based and/or non-governmental organizations
(CBO/NGOs), committed to preventing HIV infection, to work closely for
one month with health professionals at CDC.

The individuals selected as Price Fellows spend four weeks (July
31-August 25, 2006) at the Centers for Disease Control and Prevention,
in Atlanta, working with CDC staff. Each Fellow is assigned a mentor to
assist in guiding their prevention project.

To obtain a written description detailing the Price Fellowship program
and an application form please contact the CDC National Prevention
Information Network (NPIN) by calling 1-800-458-5231 and request that
document number E279 be mailed to you. For the program description and
application to be faxed to you via an automated fax-on-demand service,
call 1-800-458-5231; choose option 2, and request document number 5007.

Completed applications will need to be received by April 21, 2006 (No
Faxed or E-mailed applications will be accepted).

Specific questions about the application process and the Fellowship
program may be directed to:

Phyllis K. Storch, MPH, CHES

Centers for Disease Control and Prevention NCHSTP, DHAP-IRS, CBB 1600
Clifton Road, N.E., Mailstop E-40 Atlanta, GA 30333

Phone: 404-639-5221 Fax: 404-639-0944 email: <pstorch@cdc.gov>

**A clinician's guide to condoms, spermicides, microbicides, and
lubricants**

Journal of the American Academy of Physician's Assistants, Vol. 18, No.
12, December 2005

<http://jaapa.com/issues/j20051201/pdfs/condoms1205.pdf>

 

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

**The underlying pathology for heart disease in women**

The diagnoses of coronary microvascular dysfunction or endothelial
dysfunction should be considered in women with chest pain who do not
have obstructive coronary artery disease. It may be advantageous to add
such diagnostic tests when the conventional tests are nondiagnostic. A
revised clinical approach to cardiovascular disease in women may be
designed and tested based on these findings. [Lerman
A](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Lerman+A"%5BAuthor%5D),
[Sopko
G](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Sopko+G"%5BAuthor%5D)
Women and cardiovascular heart disease: clinical implications from the
Women\'s Ischemia Syndrome Evaluation (WISE) Study. Are we smarter? [J
Am Coll
Cardiol.](javascript:AL_get(this, 'jour', 'J Am Coll Cardiol.');) 2006
Feb 7;47(3 Suppl):S59-62. (See many other related articles in
supplement)\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16458173&query_hl>

For more on women and heart disease, visit
<http://www.nhlbi.nih.gov/health/hearttruth/index.htm>

**Waist-to-Hip Ratio Is a Better Predictor for MI Than BMI**

INTERPRETATION: Waist-to-hip ratio shows a graded and highly significant
association with myocardial infarction risk worldwide. Redefinition of
obesity based on waist-to-hip ratio instead of BMI increases the
estimate of myocardial infarction attributable to obesity in most ethnic
groups.

[Yusuf
S](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Yusuf+S"%5BAuthor%5D),
et al Obesity and the risk of myocardial infarction in 27,000
participants from 52 countries: a case-control study.
[Lancet.](javascript:AL_get(this, 'jour', 'Lancet.');) 2005 Nov
5;366(9497):1640-9.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16271645&query_hl>

**Sulfonylureas Linked to Heart Deaths**

INTERPRETATION: Higher exposure to sulfonylureas was associated with
increased mortality among patients newly treated for type 2 diabetes.
The same relation was not observed with metformin. This implies that the
manner in which blood glucose concentration is lowered may be as
important as achieving recommended glucose targets

[Simpson
SH](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Simpson+SH"%5BAuthor%5D),
et al. Dose-response relation between sulfonylurea drugs and mortality
in type 2 diabetes mellitus: a population-based cohort study.
[CMAJ.](javascript:AL_get(this, 'jour', 'CMAJ.');) 2006 Jan
17;174(2):169-74.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16415461&query_hl>

**Getting Sufficient Sleep Helps Reduce Weight Gain**\
Sleep deprivation alters hormones and increases appetite. In young
healthy men, short sleep duration is associated with decreased leptin,
increased ghrelin, and increased hunger and appetite. Getting enough
sleep may help reduce weight gain. Total sleep deprivation in rodents
and in humans has been associated with hyperphagia. Over the past 40
years, self-reported sleep duration in the United States has decreased
by almost two hours. If the findings prove to be reproducible and
generalizable, and the hormonal changes of leptin and ghrelin due to
sleep curtailment cause changes in food intake over time, we might add
sleep duration to the environmental factors that are prevalent in our
society and that contribute to weight gain and obesity. Although
recommendations to get both a better night\'s sleep and more exercise
might superficially seem to be at odds with each other from the
perspective of energy expenditure and energy balance, these simple goals
may well become a part of our future approach to combating obesity.

Ghrelin is an appetite stimulant while leptin is an anorexic hormone
associated with regulation of appetite and hunger in humans. In young
healthy men, short sleep duration is associated with decreased leptin,
increased ghrelin, and increased hunger and appetite.

[Spiegel
K](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Spiegel+K"%5BAuthor%5D)
et al Brief communication: Sleep curtailment in healthy young men is
associated with decreased leptin levels, elevated ghrelin levels, and
increased hunger and appetite. Ann Intern Med. 2004;141:846-850, 885-886

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15583226&query_hl>

**Intensive Monitoring and Treatment Required for Gestational Diabetes**

RESULTS: In patients with HbA(1)c levels \</=6.0%, the glucose levels
obtained by CGMS were significantly better than in patients with HbA(1)c
levels \>6.0%. In women with HbA(1)c levels 6.0-7.0% and \>7.0%, these
levels did not differ. The detection rate of hyper- and hypoglycaemic
episodes was significantly higher in patients with ten or more SMBG
determinations daily than in patients with fewer than ten.
CONCLUSIONS/INTERPRETATION: Treatment of diabetes in pregnant women
should be aimed at achieving HbA(1)c levels within the normal range,
i.e. \</=6.0%. A minimum of ten SMBG determinations daily is necessary
to obtain adequate information of all daily glucose fluctuations.

[Kerssen
A](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Kerssen+A"%5BAuthor%5D),
et al Do HbA(1)c levels and the self-monitoring of blood glucose levels
adequately reflect glycaemic control during pregnancy in women with type
1 diabetes mellitus?
[Diabetologia.](javascript:AL_get(this, 'jour', 'Diabetologia.');) 2006
Jan;49(1):25-8.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16341689&query_hl>

**Section of Chronic Disease Prevention Website, State of Alaska --
Dept. of Public Health**

<http://www.hss.state.ak.us/dph/chronic/>

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

# 18^th^ Annual IHS Research Conference

# April 24-26, 2006

-   Albuquerque, NM

-   Discovering Pathways to Better Health for AI/AN

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

**Advances in Indian Health, 6^th^ Annual**

-   May 2-6, 2006

-   Albuquerque, NM

-   Save the dates brochure

<http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#May06>

**Native Peoples of North America HIV/AIDS Conference**

-   May 3--6, 2006

-   Anchorage, Alaska

-   Embracing Our Traditions, Values, and Teachings
    [www.embracingourtraditions.org](http://www.embracingourtraditions.org/)

-   [National Institutes of Health (NIH),
    DHHS](http://www.embracingourtraditions.org/conf_info.htm)
    <http://www.ou.edu/rec/pdf/Native_Fact_Sheet.pdf>

**ACOG 2006 Annual Clinical Meeting (ACM)**

-   May 6-10, 2006

-   Washington, DC

-   Save the dates brochure
    [http://www.acog.org/abstract%2Dsubmission/](http://www.acog.org/abstract-submission/)

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

-   September 17 -- 21, 2006

-   Denver, CO

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

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

-   NEONATAL RESUSCITATION PROGRAM available

# 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%)}

**Maternal Child Health Website Gets a Facelift**

In response to your requests for a more useable and access-friendly
website...the OIT staff, with assistance from the websites content
coordinators, have redesigned the Maternal Child Health Websites. (See
Featured Website above)

I invite you to browse through the pages and let me know how useful they
are in both your clinical practice and other research and HP/DP
programs. The pages are updated regularly with up to date clinical
information you are sure to find beneficial for our patients. David
Gahn, M.D.

[http://www.ihs.gov/MedicalPrograms/MCH/index.cfm](https://hqwebmail.ihs.gov/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/index.cfm)

There are several upcoming **Conferences**

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

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

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

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

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

# Did you miss something in the last 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 January 2006 OB/GYN CCC Corner is available at: {#the-january-2006-obgyn-ccc-corner-is-available-at .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106.cfm**](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0106.cfm) {#httpwww.ihs.govmedicalprogramsmchmobgyn0106.cfm-1 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Link between GDM and Type 2 DM: Can be Broken**

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

Gestational Diabetes: ACOG / IHS Obstetrics, Neonatal and Gynecologic
Care

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

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

Vitamin D Levels During Pregnancy Affect Childhood Bone Mass

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

#### Chuck North {#chuck-north .Style-Heading-4-+-Arial-14-pt-Underline}

Chew Your Fowl Carefully

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

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

#### -Maternal weight gain during pregnancy - archived web cast {#maternal-weight-gain-during-pregnancy---archived-web-cast .Style-Heading-4-+-Arial-14-pt-Underline}

-April Conference - AIAN children with educational needs - parents,
advocates

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

**Tom and Edie Welty**

Integrating prevention of mother-to-child HIV transmission into routine
antenatal care

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

##### Obstetrics page 10

-Bed Rest for pregnancy related hypertension: Bed rest should not be
recommended

-Simulation training improves resident performance of a simulated
vaginal breech delivery

-Women Coached To Push During Labor Have Little Advantage Over Women Not
Coached

-Follow-up on Paroxetine change from Class C to Class D

-Sufficient evidence to support implementing first-trimester Down
syndrome risk: NIH

-and more....

**Gynecology page 15**

-Prior Function and Relationship, More Than Hormones, Affect Sexual
Function in Midlife

-HPV-16 vaccine provides high-level protection against CIN for at least
3.5 years

-Have you had trouble clearing up vaginal condyloma or CIN?

-Rectocele xenograft repair: Unsatisfying anatomical cure rate 3 years
postoperatively

-Patient-Administered Analgesic Gas Helpful During Colposcopy

-and more....

**Child Health page 16**

-Cerebral Palsy: An Overview

-Oral Contraceptives and Dysmenorrhea in Adolescents

-Controlling Obesity: School, Work, and Leisure

-Screening and Interventions for Overweight in Children and Adolescents:
USPSTF

**Chronic Illness and Disease: page 18**

-Waking up to Sleep Deprivation

-Medications for Migraine Prophylaxis

-Aromatase inhibitors\--a triumph of translational oncology

-Regular Walking Slows Decline in Patients With Peripheral Arterial
Disease

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

##### American Family Physician

## IVF Therapy for Unexplained Infertility - Cochrane for Clinicians {#ivf-therapy-for-unexplained-infertility---cochrane-for-clinicians .Style-Heading-2-+-14-pt}

American College of Obstetricians and Gynecologists

\"Do Not Use\" Abbreviations

-Vaginal Birth Not Associated With Incontinence Later in Life

-Research Finds 40% of Pregnancy-Related Deaths Potentially Preventable

**Agency for Healthcare Research and Quality**

#### -Younger women more satisfied when a reproductive health specialist is their primary provider {#younger-women-more-satisfied-when-a-reproductive-health-specialist-is-their-primary-provider .Style-Heading-4-+-Arial-14-pt-Underline}

-Uterine artery embolization for uterine fibroids is a low-risk
procedure

#### -More high-quality studies needed to gauge safety of induced labor with prior cesarean deliveries {#more-high-quality-studies-needed-to-gauge-safety-of-induced-labor-with-prior-cesarean-deliveries .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Some State-level policies are associated with women\'s mortality rates for certain diseases {#some-state-level-policies-are-associated-with-womens-mortality-rates-for-certain-diseases .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Clinicians are more likely to counsel youth diagnosed with obesity about diet and exercise {#clinicians-are-more-likely-to-counsel-youth-diagnosed-with-obesity-about-diet-and-exercise .Style-Heading-4-+-Arial-14-pt-Underline}

**Ask a Librarian**

Interested in Maternal and Child Health topics**?**

**Breastfeeding**

-Duration of Lactation and Incidence of Type 2 Diabetes

-Special Editorial: Suzan Murphy, new CCCC columnist

-New studies shows a 15% reduction for the risk of diabetes for every
year of lactation

**CCC Corner Digest**

#### -[Routine screening for protein and glucose at each prenatal visit should be abandoned](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_AOM.cfm) {#routine-screening-for-protein-and-glucose-at-each-prenatal-visit-should-be-abandoned .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[How do you know when you have a false positive HIV test in pregnancy?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_Coll.cfm) {#how-do-you-know-when-you-have-a-false-positive-hiv-test-in-pregnancy .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[Paroxetine's pregnancy category changed from C to D](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_HT.cfm#ob) {#paroxetines-pregnancy-category-changed-from-c-to-d .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[Editorial: Vaccine prevents cervical cancer, Gardasil: Preliminary results 100% effective](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_Coll.cfm) {#editorial-vaccine-prevents-cervical-cancer-gardasil-preliminary-results-100-effective .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[Handle abnormal Pap smears differently in adolescents](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_HT.cfm#gyn) {#handle-abnormal-pap-smears-differently-in-adolescents .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[Quick Assessment of Literacy in Primary Care: The Newest Vital Sign](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_HT.cfm#chrIll) {#quick-assessment-of-literacy-in-primary-care-the-newest-vital-sign .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[Inappropriate use of the terms fetal distress and birth asphyxia](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_Feat.cfm#acog) {#inappropriate-use-of-the-terms-fetal-distress-and-birth-asphyxia .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[New studies shows a 15% reduction for the risk of diabetes for every year of lactation](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_Feat.cfm#breast) {#new-studies-shows-a-15-reduction-for-the-risk-of-diabetes-for-every-year-of-lactation .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[New cigarettes with flavors that appeal to youth](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_Feat.cfm#alert) {#new-cigarettes-with-flavors-that-appeal-to-youth .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[CC:   I feel really cold and my side hurts, plus I am shaking all over](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_Feat.cfm#mmtour) {#cc-i-feel-really-cold-and-my-side-hurts-plus-i-am-shaking-all-over .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[WHI clinical trial revisited: Imprecise methodology disqualifies the study\'s outcomes](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_Feat.cfm#mscape) {#whi-clinical-trial-revisited-imprecise-methodology-disqualifies-the-studys-outcomes .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[Post Partum Hemorrhage is the most common cause of maternal mortality worldwide](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_Feat.cfm#MidWives) {#post-partum-hemorrhage-is-the-most-common-cause-of-maternal-mortality-worldwide .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[Liability in Triage: Management of EMTALA Regulations and Common Obstetric Risks](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_Feat.cfm#MidWives) {#liability-in-triage-management-of-emtala-regulations-and-common-obstetric-risks .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[MRSA presents new challenges in treating skin and soft-tissue infections, including in pregnancy...](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_Feat.cfm#navajo) {#mrsa-presents-new-challenges-in-treating-skin-and-soft-tissue-infections-including-in-pregnancy .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[Many new additions to the Indian Health Guidelines / Patient Education web page](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_Coll.cfm) {#many-new-additions-to-the-indian-health-guidelines-patient-education-web-page .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[Meconium Happens](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_Feat.cfm#periPicks) {#meconium-happens .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[Cardiology Topics for Primary Care Providers -- February 15, 2006](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_Feat.cfm#pcf) {#cardiology-topics-for-primary-care-providers-february-15-2006 .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[High-Risk HPV Associated with Chlamydia trachomatis with Female Adolescents](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_Feat.cfm#std) {#high-risk-hpv-associated-with-chlamydia-trachomatis-with-female-adolescents .Style-Heading-4-+-Arial-14-pt-Underline}

#### -[Type 2 diabetes mortality in women: Same as a \"coronary heart disease equivalent\"](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1205_Feat.cfm#stillW) {#type-2-diabetes-mortality-in-women-same-as-a-coronary-heart-disease-equivalent .Style-Heading-4-+-Arial-14-pt-Underline}

\-[21st Annual Midwinter Indian Health OB / PEDS
Conference](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1005_Feat.cfm#dates)
January 27-29, 2006

**Domestic Violence**

-Sexual Assault Services Delivered by SANES

-The Truth About Rape, CDC

#### -Post-traumatic Stress Disorder - Clinical Evidence Concise {#post-traumatic-stress-disorder---clinical-evidence-concise .Style-Heading-4-+-Arial-14-pt-Underline}

**Elder Care News**

Anticholinergic Drugs for Overactive Bladder - Cochrane for Clinicians

**Family Planning**

-Emergency Contraception Use Not Associated With Risky Sexual Behavior

#### -FDA Safety Changes: ParaGard Copper T 380A  {#fda-safety-changes-paragard-copper-t-380a .Style-Heading-4-+-Arial-14-pt-Underline}

-Hysteroscopic Sterilization May Offer Advantages Over Laparoscopic
Procedure

-Emergency Contraception: AAP Review

Featured Website

Vaginal Birth after Cesarean, New Perinatology Corner Module -- 2
credits

**Frequently asked questions**

What factors effect when we should we start colon cancer screening in
low risk adults?

**Indian Child Health Notes**

-Recommendation for Universal Influenza Immunization in Children Age 6
to 23 Months

-Hepatitis A Vaccine: Nice Success Story - New Recommendations

## -Native American Child Health Advocacy Award -- Call for Nominations

**Information Technology**

-Just out: IHS Information Technology News -- January 2006

-Family Medicine Patients' Use of the Internet for Health Information

International Health

-Association Between Reproductive Health-Related Medical Claims and
Criminal Activity or

-Experience of Abuse among Medicaid-enrolled Adolescent Females

-Reproductive Health Claims and Risk of Abuse among Medicaid-enrolled
Adolescent Females

#### MCH Alert

#### Girl Talk: Choices and Consequences of Underage Drinking

#### Medical Mystery Tour

#### CC: I feel really cold and my side hurts, plus I am shaking all {#cc-i-feel-really-cold-and-my-side-hurts-plus-i-am-shaking-all .Style-Heading-4-+-Arial-14-pt-Underline}

#### Medscape

**Menopause Management**

#### WHI Trial Seen Flawed; Alternative Hormone Replacement Regimen Proposed {#whi-trial-seen-flawed-alternative-hormone-replacement-regimen-proposed .Style-Heading-4-+-Arial-14-pt-Underline}

**Midwives Corner**

-Shoulder Dystocia

-The 'CCC Deliver Through' maneuver for Shoulder Dystocia Prevention

-Hurricane-Related Information for Pregnant and Breastfeeding Women

-System errors in intrapartum electronic fetal monitoring: a case review

**Navajo News**

-Depo-Provera available in a lower dose: limited data to assess 104mg SQ
vs. 150mg IM

#### -Who do you contact in Navajo Area for MCH issues?  {#who-do-you-contact-in-navajo-area-for-mch-issues-2 .Style-Heading-4-+-Arial-14-pt-Underline}

**Nurses Corner**

-Fetal Alcohol Syndrome: Nursing Perspective

#### -Seeking Executive Nurse Leaders  {#seeking-executive-nurse-leaders .Style-Heading-4-+-Arial-14-pt-Underline}

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

Oral Fluid Rapid HIV Antibody Tests Being Investigated: Current
protocols should continue to be followed

**Oklahoma Perspective**

Who do you contact in Oklahoma Area for MCH issues?

Osteoporosis

Exercise, Calcium Supplementation May Improve BMD in Postmenopausal
Women 

Patient Education

-Diabetes and Pregnancy Frequently Asked Questions, CDC

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

-Cerebral Palsy in Children: What You Should Know

-Medicines to Prevent Migraine Headaches

Perinatology Picks

Medicines to Prevent Migraine Headaches

Primary Care Discussion Forum

Cardiology Topics for Primary Care Providers -- February 15, 2006

STD Corner

#### Clinician-Delivered Intervention During Routine Clinical Care Reduces Unprotected Sexual Behavior {#clinician-delivered-intervention-during-routine-clinical-care-reduces-unprotected-sexual-behavior .Style-Heading-4-+-Arial-14-pt-Underline}

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

-High-Normal Fasting Blood Sugar Above 87 mg/dL Could Signal Diabetes
Risk

-Antidepressants Are No Match for Poverty

-Now science allows us all an extra 7lb of fat - at no extra risk

-New Guidelines Available to Raise HDL Cholesterol

-Coffee consumption may reduce breast cancer risk

-and more....

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

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

The past CCC Corners are archived at:

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

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

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

or 907 729 3154 (with voicemail)

\*The opinions expressed in the OB/GYN CCC Corner are strictly those of
the authors, and not necessarily those of the Indian Health System, or
the author of this newsletter. If you have any comments, please share
them by joining the Primary Care Discussion Forum where this topic was
recently discussed. To join the Primary Care Listserv, click on
'Subscribe' here
<http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForum.cfm>

2/11/06njm

Revised 4/8/06njm