# ![](media/image1.jpeg){width="5.992361111111111in" height="1.33125in"} {#section .Style-Style-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5...1}

 

Chief Clinical Consultant's Corner

Volume 6, No. 3, March 2008

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

#### Abstract of the Month page 6 {#abstract-of-the-month-page-6 .Style-Heading-4-+-Arial-14-pt-Underline}

-Minorities underrepresented in both public and private umbilical cord
blood banking

  

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

Burt Attico

#### More advantages with folic acid supplementation in pregnancy {#more-advantages-with-folic-acid-supplementation-in-pregnancy .Style-Heading-4-+-Arial-14-pt-Underline}

Sally Bremner

MRSA in the Community: A Growing Threat to Young People

Scott Giberson

-Antiretroviral Corner Articles

-Division of Behavioral Health HIV/AIDS Collaborative Regional Trainings
2008

-IHS HIV/AIDS Work Plan Released

-Early Planning Resources for National Native HIV/AIDS Awareness Day

-IHS HIV Podcast: Collaboration between DHHS Office of HIV/AIDS Policy
and IHS HIV Program

**Melissa Toffolon-Weiss**

HPV brochure for AI/AN: available for broad dissemination

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

##### Obstetrics page 10

-Evidence Favors Late Cord Clamping in Infants

-Continuous suturing for perineal closure vs interrupted methods - Less
pain

-Minor trauma in pregnancy: Commonly used measures not predictive

-Amphetamine hospitalizations doubled: Familiarize yourself with the
adverse outcomes

-Pregnant smokers reluctant to use smoking cessation medications
recommended

**Gynecology page 12**

-Biofeedback Reduces Psychological Burden in Older Women With Urge UI

-Not enough evidence to evaluate routine antibiotic prophylaxis with
SAB: Cochrane

-Intracervical catheter placement: Less pain during an saline infusion
sonohysterography

-Acupuncture in dysmenorrhea: improvements in pain and quality of life

-The diagnosis and management of endometrial cancer are reviewed

**Child Health page 13**

## -Sex education: Providers need to fill gaps in adolescent knowledge: Comment by Beth Crow

-Physical Activity Twice Weekly Helps Prevent Teens From Becoming
Overweight Adults

-Early menarche associated with increased all-cause mortality

-School-Associated Student Homicides \-\-- United States, 1992---2006

-Mediterranean diet in pregnancy helps ward off childhood asthma and
allergy

**Chronic Illness and Disease page 15**

-Diuretics most effective blood pressure medicine for people with
metabolic syndrome

-\'Aspirin resistance\' linked to increased cardiovascular events and
death

-Chantix (varenicline)- Associated With Reports Of Changes In Behavior:
FDA

-Older Women More Susceptible to Depression Than Older Men

-Chronic constipation more pronounced in women and the elderly

....and more

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

American College of Obstetricians and Gynecologists page 18

-Fatigue and Patient Safety

-ACOG Statement on Home Births

-Alcohol and Pregnancy: Know the Facts

-Asthma in Pregnancy

-Surrogate Motherhood

##### American Family Physician

-Treating Eating Disorders in Primary Care

-End-of-Life Care: Guidelines for Patient-Centered Communication

-CDC Reports on Lead Exposure in Women of Childbearing Age

-Dietary Supplements for Osteoarthritis

**Agency for Healthcare Research and Quality**

-Providers want to learn from mistakes but say current error-reporting
systems are inadequate

-Maternal, baby, and episiotomy factors contribute to high rates of
maternal birth trauma in Iowa

-Effectiveness of Second-Generation Antidepressants in Pharmacologic
Treatment

-Nurse midwives deliver more babies in hospitals than homes in
Washington State

-Study of young Head Start children links overweight to worsened asthma

**Ask a Librarian**

Cervical Cancer Community-Based Research Project in a Native American
Community

**Behavioral Health Insights**

PTSD: A technique that works for me

**Breastfeeding**

Promoting, Protecting, Supporting

**CCC Corner Digest**

\-[Concern for rising Cesarean rates in Native American
populations](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08aom)

\-[Save the Dates!! Earn up to 28 hours of CME/CE specific to Indian
Health](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08col)

\-[Knowledge of cervical length / fetal fibronectin: Shorter evaluation
and
PTB](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ht#ob)

\-[Misoprostol is as effective as manual vacuum aspiration in SAB of
\<12
weeks](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ht#gyn)

\-[Secondhand smoke during infancy linked in dose-response fashion with
allergies](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ht#child)

\-[\'Awake\' during surgery: Examining intraoperative
awareness](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ht#chrIll)

\-[Elective and risk--reducing
salpingo-oophorectomy](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#acog)

\-[Prevention and Treatment of Sexually Transmitted Diseases: An
Update](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#afp)

\-[Cervical Cancer Community-Based Research Project in a Native American
Community](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#lib)

\-[Autism
Screening](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#bhi)

\-[Breast Pumps: The good, the bad, and the
ugly](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#bf)

\-[National Report: National Indian Child
Welfare](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#dv)

\-[Palliative / End of Life Care Training- SAVE THE DATES -- March and
April
Courses](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#ecn)

\-[Continuous Oral Contraception May Not Reduce Bleeding Days but May
Improve
Sx](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#fp)

\-[New and Improved MCH Conferences page - More user
friendly](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#fws)

\-[Multiple Chlamydia species pose an unexpected challenge for blindness
prevention](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#ih)

\-[Insights on Implementing Cultural and Linguistic Competence in
MCH](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn01.cfm?module=2008&option=janFeat#alert)

\-[Announcing the 2008 PREVENT Child Maltreatment
Institute](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#mchh)

\-[St. John\'s wort for depression in a young
woman](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#mmt)

\-[Smoking Status as a Predictor of Hip Fracture Risk in Postmenopausal
Women](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#meno)

\-[AI / AN women - successful at this; Evidence supports this; Women
benefit from
this](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#midw)

\-[Judy Whitecrane: Tireless Improvement of Care for Native American
women](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#midw)

\-[Biliary Gallstone Disease and
Pregnancy](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#navajo)

\-[AWHONN -- numerous on line courses -- materials and fees
listed](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#nCrnr)

\-[Cesarean Delivery: What are the risks and
benefits?](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#okp)

\-[Patients Prefer \"Tell Back- Collaborative Inquiry\" Method to Assess
Understanding](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#pi)

\-[Women with cardiovascular risk factors may be predisposed to
pre-eclampsia](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#peri)

\-[Mental health issues in children and adolescents --Starts in
March](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#pcf)

\-[The cervical cancer risk is still increased 25 years after treatment
for CIN
3](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#std)

\-[Resolving to Lose Weight in the New
Year?](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#still)

\-[Women\'s Leadership
Scholarship](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#whh)

**Domestic Violence**

-IHS-sponsored training in sexual assault forensic examination

-Report cites high rate of violence against Native women

-Resource for interrupting the cycle violence

-Affects of cueing on providers discussion of intimate partner violence

#### -Women who have had physical abuse during pregnancy: risk of preterm delivery

**Elder Care News**

-Exciting opportunity to develop new resources in geriatrics

#### -2008 End-of-Life Nursing Education Consortium Schedule announced {#end-of-life-nursing-education-consortium-schedule-announced .Style-Heading-4-+-Arial-14-pt-Underline}

\-[End-of-Life Care in the Setting of Cancer: Withdrawing Nutrition and
Hydration](http://www.medscape.com/viewprogram/8617)

**Family Planning**

-Ringing Endorsement: Women Prefer Contraceptive Ring Over Patch

#### -Misconceptions About OCPs Among Adolescents and Providers {#misconceptions-about-ocps-among-adolescents-and-providers .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Copper containing IUDs are more effective for contraception than other IUDs: Cochrane {#copper-containing-iuds-are-more-effective-for-contraception-than-other-iuds-cochrane .Style-Heading-4-+-Arial-14-pt-Underline}

-Ortho Evra Contraceptive Transdermal Patch: Higher risk of serious
blood clots

#### -Levonorgestrel / Ethinyl Estradiol (Lybrel) for Continuous Contraception {#levonorgestrel-ethinyl-estradiol-lybrel-for-continuous-contraception .Style-Heading-4-+-Arial-14-pt-Underline}

**Featured Website**

#### Meeting notes now online: [2007 Native Women's Health and MCH Conference](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/Intro Slide and Eval Sli14.ppt)

**Frequently asked questions**

How can we actually reduce infant mortality in AI/AN?

**Indian Child Health Notes**

-Honey, dextromethorphan, and no treatment on nocturnal cough and sleep
quality

-Respiratory syncytial virus season and hospitalizations in the Alaskan
Yukon-Kuskokwim Delta

-Health disparities persisting and in some cases, sadly widening.

**Information Technology**

iCare Training

International Health

-Good intentions and unintended consequences

-Peanuts +Vegetable oil +milk powder+vitamins + minerals = Plumpynut

-CCGHE Launches Online HIV Training Course in Zambia

-Stunting In First Two Years Of Life Leads To Huge Negative Consequences
In Later Life

#### MCH Alert

-Maternal depression as a risk factor affecting child readiness and
school readiness

-Role of nurses in oral health of children and women

-Relationship between air pollution and postneonatal infant mortality

-Influence of multiple social risk factors on children's health

#### MCH Headlines

-Findings from the National Survey of Children\'s Health includes Native
Americans

-Medicaid Reimbursement for Car Seats Is Cost-Effective Health Policy\
-2008 MCH EPI Grand Rounds Schedule 7 one-hour calls

#### Medical Mystery Tour

#### St. John\'s wort for depression in a young woman: The answers {#st.-johns-wort-for-depression-in-a-young-woman-the-answers .Style-Heading-4-+-Arial-14-pt-Underline}

#### Medscape

\-[Turning Adverse Drug Events Into Better Patient
Care](http://www.medscape.com/viewprogram/8715)

######### -A Rational Approach to Constipation

-Angiogenesis as a Strategic Target for Ovarian Cancer Therapy

-Premenstrual Dysphoric Disorder Resource Center Update

**Menopause Management**

-Calcium supplements may increase heart attacks in older women

-Postmenopausal Systemic Hormone Therapy: Putting Risks Into Perspective

-Black Cohosh and Menopausal Symptoms

**Midwives Corner**

-Perineal warm packs reduce 3^rd^ and 4^th^ degree lacerations, pain and
urinary incontinence

-The Business of Being Born

-Factors for the fear of childbirth in first-time mothers

-Women's fear of childbirth boosts cesareans

**Navajo News**

Adnexal Masses during Pregnancy

**Nurses Corner**

-Integrating Nursing and Behavioral Health

-UCLA post-doc program for nurses

#### -New Report on American Indian/Alaskan Native Disparity & Strengths from RWJ {#new-report-on-american-indianalaskan-native-disparity-strengths-from-rwj .Style-Heading-4-+-Arial-14-pt-Underline}

![](media/image2.png){width="4.002083333333333in"
height="2.220833333333333in"}-Creating a Healing Community: Partnerships
to Improve the Care of Indian People

#### -Fraud - SPAM {#fraud---spam .Style-Heading-4-+-Arial-14-pt-Underline}

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

-Cervical Cancer Awareness

-United States Life Tables, 2004

**Oklahoma Perspective**

Cesarean Delivery: What are the risks and benefits?

Osteoporosis

-SSRI Use and Bone Loss in Older Women

#### -Nonpharmacologic Management of Osteoporosis to Minimize Fracture Risk {#nonpharmacologic-management-of-osteoporosis-to-minimize-fracture-risk .Style-Heading-4-+-Arial-14-pt-Underline}

-Supplementation With Calcium and Vitamin D: Efficacy Against Fracture
and Total Mortality

#### -The Impact of Adherence and Persistence in the Pharmacological Management of Osteoporosis {#the-impact-of-adherence-and-persistence-in-the-pharmacological-management-of-osteoporosis .Style-Heading-4-+-Arial-14-pt-Underline}

Patient Education

#### -Assuring Quality Care for People With Limited Health Literacy {#assuring-quality-care-for-people-with-limited-health-literacy .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Knowing Importance of Prenatal Folic Acid May Affect Neural Tube Defect Incidence {#knowing-importance-of-prenatal-folic-acid-may-affect-neural-tube-defect-incidence .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Anorexia and Bulimia: What You Should Know {#anorexia-and-bulimia-what-you-should-know .Style-Heading-4-+-Arial-14-pt-Underline}

Perinatology Picks

-Usefulness of middle cerebral artery Doppler of the fetus at risk for
anemia

-Results indicate the presence of dyslipidemia in women with spontaneous
preterm birth

-High maternal weight increases risk of neonatal mortality, especially
after preterm PROM

# -Caffeine intake during pregnancy increases the risk of miscarriage 

-Prognosis of fetal cystic hygroma detected during the first trimester
is poor, NT is crucial

Primary Care Discussion Forum

Mental health issues in children and adolescents -- Starts March 2008

STD Corner

#### -Routine HIV Screening in the Emergency Department  {#routine-hiv-screening-in-the-emergency-department .Style-Heading-4-+-Arial-14-pt-Underline}

-New Updates to U.S. HIV Treatment Guidelines

-SAMHSA opportunity for funding community based organizations

-IHS HIV Program and SAMHSA sign Memorandum of Understanding (MOU) on
Jan 16, 2008

-FDA Approves Etravirine (TMC125)

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

-Diabetes A Stronger Risk Factor For Death In Women than In Men

-Pedometers help people lose weight even without changes in diet

-New Position Statement for Glucose Intolerance in PCOS

-Low-Carbohydrate Diets Rich in Vegetable Sources of Fat and Protein:
Reduce Diabetes

**Women's Health Headlines**

-Women and HIV/AIDS: PINN POINT ON WOMEN'S HEALTH

-APN brochures

-Knowing What Works in Health Care: A Roadmap for the Nation

-SAMHSA Compendium of primary mental health activities now online

-DV Announcements: Grants, trainings and resources shared by various
project faculty

###### Save the Dates: Upcoming events of interest page 58

#### What's new on the ITU MCH web pages page 59

Meeting notes now online: [2007 Native Women's Health and MCH
Conference](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/Intro Slide and Eval Sli14.ppt)

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

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

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

**Minorities underrepresented in both public and private umbilical cord
blood banking**

ABSTRACT:

Two types of banks have emerged for the collection and storage of
umbilical cord blood---public banks and private banks. Public banks
promote allogenic (related or unrelated) donation, analogous to the
current collection of whole blood units in the United States. Private
banks were initially developed to store stem cells from umbilical cord
blood for autologous use (taken from an individual for subsequent use by
the same individual) by a child if the child develops disease later in
life. If a patient requests information on umbilical cord blood banking,
balanced and accurate information regarding the advantages and
disadvantages of public versus private banking should be provided. The
remote chance of an autologous unit of umbilical cord blood being used
for a child or a family member (approximately 1 in 2,700 individuals)
should be disclosed. The collection should not alter routine practice
for the timing of umbilical cord clamping. Physicians or other
professionals who recruit pregnant women and their families for
for-profit umbilical cord blood banking should disclose any financial
interests or other potential conflicts of interest.

Umbilical Cord Blood Banking. ACOG Committee Opinion No. 399. American
College of Obstetricians and Gynecologists. Obstet Gynecol
2008;111:475--7.

<http://www.ncbi.nlm.nih.gov/pubmed/18238991>

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

**Providers should give balanced information when discussing cord blood
banking**

Minorities are a particularly underrepresented in both modalities of
banking, especially American Indians and Alaska Natives. This deficiency
could have significant implications for our (now) young patients later
in their lives. The Indian Health system should cooperate fully with
both groups of banking methods.

The MCH Frequently Asked Questions page has long had a discussion of the
advantages and disadvantages of AI/AN cord blood banking which includes
a template Disclaimer Form.

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/CordStem4206.doc>

ACOG recommends providers give balanced information to their pregnant
patients who are considering cord blood banking, presenting both the
advantages and disadvantages of public vs. private cord blood banks.

ACOG also advises physicians who recruit patients for for-profit cord
blood banking to disclose their financial interests or other potential
conflicts of interest to pregnant women and their families.

Blood from a newborn\'s umbilical cord, once considered a waste product
that was routinely discarded along with the placenta, is now considered
to contain potentially life-saving stem cells. Private banks were
initially developed to store cord blood stem cells from newborns, for a
fee, for potential future use by the same child or a family member if
he/she developed disease later in life. Today, there are public banks
that store, for free, stem cells that can be used by anyone needing them
similar to how public blood banks work.

\"Patients need to be aware that the chances are remote that the stem
cells from their baby\'s banked cord blood will be used to treat that
same child---or another family member---in the future,\" said Anthony R.
Gregg, MD, chair of ACOG\'s Committee on Genetics. ACOG\'s Committee
Opinion is a joint document produced by the Committee on Obstetric
Practice and the Committee on Genetics.

Although ACOG takes no position for or against cord blood banking, it
recommends that physicians disclose that there is no reliable estimate
of a child\'s likelihood of actually using his or her own saved cord
blood later. Some experts estimate this likelihood at 1 in 2,700, while
others argue the rate is even lower. Physicians should also disclose to
their patients that it is unknown how long cord blood can successfully
be stored.

Pregnant women should be aware that stem cells from cord blood cannot
currently be used to treat inborn errors of metabolism or other genetic
diseases in the same individual from which they were collected because
the cord blood would have the same genetic mutation. \"Cord blood
collected from a newborn that later develops childhood leukemia cannot
be used to treat that leukemia for much the same reason,\" said Dr.
Gregg.

Federal legislation was passed in 2005 that provides funding for
continued growth of a national cord blood registry in the US. Several
states have laws requiring physicians to inform patients about cord
blood banking options. Physicians should consult with their state
medical association for more information about their individual state
laws.

ACOG Press Release

<http://www.acog.com/from_home/publications/press_releases/nr02-01-08-2.cfm>

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

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

#### More advantages with folic acid supplementation in pregnancy {#more-advantages-with-folic-acid-supplementation-in-pregnancy-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Folic Acid in Early Second Trimester May Reduce Risk of Preeclampsia. For preeclampsia prevention, folic acid supplementation in the late first trimester or early second trimester, the most critical time window for preeclampsia development, may be the most important.\" As to dose, \"current guidelines for folic acid supplementation recommend 4 mg or 5 mg for women with high risk of pregnancy for neural tube defects. In a previous analysis of women at high-risk of eclampsia because of chronic hypertension, diabetes, history of preeclampsia, or multi-fetal gestation, we found a dose-response relationship, with further reduction of the risk of preeclampsia with higher doses of folic acid. {#folic-acid-in-early-second-trimester-may-reduce-risk-of-preeclampsia.-for-preeclampsia-prevention-folic-acid-supplementation-in-the-late-first-trimester-or-early-second-trimester-the-most-critical-time-window-for-preeclampsia-development-may-be-the-most-important.-as-to-dose-current-guidelines-for-folic-acid-supplementation-recommend-4-mg-or-5-mg-for-women-with-high-risk-of-pregnancy-for-neural-tube-defects.-in-a-previous-analysis-of-women-at-high-risk-of-eclampsia-because-of-chronic-hypertension-diabetes-history-of-preeclampsia-or-multi-fetal-gestation-we-found-a-dose-response-relationship-with-further-reduction-of-the-risk-of-preeclampsia-with-higher-doses-of-folic-acid. .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: Supplementation of multivitamins containing folic acid in the second trimester is associated with reduced risk of preeclampsia. {#conclusion-supplementation-of-multivitamins-containing-folic-acid-in-the-second-trimester-is-associated-with-reduced-risk-of-preeclampsia. .Style-Heading-4-+-Arial-14-pt-Underline}

[Wen
SW](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Wen SW"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlusDrugs1)
et al Folic acid supplementation in early second trimester and the risk
of preeclampsia. Am J Obstet Gynecol. 2008 Jan;198(1):45.

<http://www.ncbi.nlm.nih.gov/pubmed/18166303>

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

#### Sally Bremner, Anchorage {#sally-bremner-anchorage .Style-Heading-4-+-Arial-14-pt-Underline}

**MRSA in the Community: A Growing Threat to Young People**

This month we're dealing with the other resistant staphylococcal
infection which is a growing menace in the community. No one has
regarded minor skin infections as much to be worried about in the past,
but we must change this perception. CA-MRSA is on the rampage -- and
sports, athletics and PE are healthy, energetic activities we want to
promote. It's a matter of education and vigilance. Please take the time
to read this issue carefully and click on the resource links. I have
included some great articles -- some which must be obtained through your
library or HSIS as free full text was simply not available. There is
also an excellent brochure from N.Y. Dept of Health, that may be printed
off and handed out to athletes and parents, and a one-page clinical
guideline that can provide clear direction for hospital and clinic
personnel.

<http://consortiumlibrary.org/hsis/about/newsletters/Jan08.pdf>

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

#### Scott Giberson, HQE {#scott-giberson-hqe .Style-Heading-4-+-Arial-14-pt-Underline}

**Antiretroviral Corner Article - January**

-Each month our IHS HIV website features an article related to
antiretroviral (ARV) therapy in its ***ARV Corner*** section. Given the
dynamic nature of ARV therapy, it is clinically relevant to stay as
up-to-date as possible on new findings, research and guidelines. Last
year (2007) was a markedly 'active' year with regards to ARV and HIV.
January's *ARV Corner* article**: 'Top 10 ARV/HIV Stories of 2007'** are
summarized and discussed. Although I may add some editorial commentary,
the bulk of work and drafting of the articles is done by a small and
talented group of HIV Pharmacists within IHS that volunteer to draft up
the *ARV Corner* article each month.  Please review January's article as
it may be useful for your clinical practice. The article is also
accessible on the HIV webpage at
[www.ihs.gov/medicalprograms/hivaids/](http://www.ihs.gov/medicalprograms/hivaids/)
. Acknowledgements to our 'authors' and I/T/U HIV Pharmacists: LT
Heather Huentelman, PIMC, Phoenix, AZ; LT Kim Woodhull, ANMC, Anchorage,
AK; LCDR Keri Chin, GIMC, Gallup, NM

**-AIDS.gov** recently launched a **blog** about effective ways of using
new media tools in the fight against HIV/AIDS. Each week AIDS.gov will
cover a different new media topic, some posts will focus on specific
tools (podcasts, mobile applications, wikis), while others are broader
in scope, such as 508 compliance and accessibility. Each Tuesday morning
AIDS.gov will post information from an interview with leading new media
and HIV/AIDS professionals using new media tools. They will summarize
the interview and reflect on ways AIDS.gov and others can implement what
they've learned. I encourage you to check out this important new blog at
[http://blog.aids.gov](http://blog.aids.gov/)   

**Division of Behavioral Health HIV/AIDS Collaborative Regional
Trainings set for 2008!   **

The IHS HIV Program works with the IHS Division of Behavioral Health
(DBH) on training proposals submitted to HHS for Minority AIDS
Initiative (MAI) funding.  Over the last 3 years, the DBH proposals have
been funded and the trainings have been rolled out by the IHS Division
of Behavioral Health across 8 different IHS Areas.  In 2008, the
Division of Behavioral Health will continue its collaborative HIV
trainings in Tulsa, Spokane, Rapid City and Tucson. Please see attached
flyer for more details. For more information or to register please go
to:
[www.kauffmaninc.com/IHSAIDStrainings](http://www.kauffmaninc.com/IHSAIDStrainings)
or contact Victor Paternoster: 509 • 747 • 4994 or
<ihsaidstrainings@kauffmaninc.com>

Training Purpose:

1\. To develop the behavioral health capacity of participants through
the learning and implementation of effective behavioral health models
and techniques related to HIV/AIDS in American Indian and Alaska Native
populations.

2\. To instruct participants on effective methods of linking community
members to critical HIV/AIDS-related services and resources.

Target Audience:

I/T/U Behavioral health providers, health care providers, community
health workers.

        

**IHS HIV/AIDS Work Plan Released**

I am pleased to inform you that the IHS HIV/AIDS Administrative Work
Plan (Strategic Plan) has been approved for release. This is a
culmination of work from multiple stakeholders, professionals, many
community members and advocates both internal and external to IHS. This
is an IHS document, which will remain fluid and may be adjusted as new
initiatives arise. That said, it represents a good blueprint of
activities and truly represents the principles of the program enumerated
within.  This Plan is intended for use by the IHS HIV/AIDS Program and
IHS personnel. Although not required, this plan may also be utilized or
referenced by Tribal and Urban programs as well as Native organizations
and multiagency leads / partners involved with HIV/AIDS activities for
the American Indian / Alaska Native (AI/AN) population. The IHS will
utilize this HIV/AIDS Work Plan to:

-   Serve as the model for the planning process that can be referenced,
    reproduced, evaluated, and adjusted;

-   Identify components and priority areas needed for this comprehensive
    HIV/AIDS working document;

-   Guide IHS / Tribal / Urban (I/T/U) health personnel with activities
    that are both collaborative and integrative;

-   Develop a focused process to enhance efficiency and avoid redundancy
    of initiatives within and external to IHS;

-   Develop a consistent process for strategic planning;

-   Enumerate framework for future planning;

-   Serve as a monitoring and evaluation tool of activities to be
    reviewed on an ongoing basis;

-   Achieve the highest quality program that serves the mission and
    supports Director's initiatives;

-   Serve as a 3-year administrative blueprint for further development
    and progression of the IHS HIV/AIDS Program;

Please review at your convenience and pass along to colleagues as you
see fit. Apologies for any visual quality issues. To avoid any random
changes, it was distributed via .pdf, which affected some clarity within
the pages. Once again, thank you to those that contributed and reviewed
this document. For document contact: <Scott.Giberson@ihs.gov>

In the very near future, the document will be available on-line at our
IHS HIV webpage:
[www.ihs.gov/medicalprograms/hivaids/](http://www.ihs.gov/medicalprograms/hivaids/)

**Early Planning Resources for National Native HIV/AIDS Awareness Day**

The Native Capacity Building Assistance (CBA) Network unveiled its
Toolkit and Resources for 2nd Annual Native HIV/AIDS Awareness Day. This
includes a media toolkit and posters, which are just part of the
resources available for Native Communities to assist them with any event
or activity planning for that Day. Please refer to the attached document
and the following link for more information about the CBA Network and
the upcoming planning for the National Native HIV/AIDS Awareness Day.
More announcements and information will be distributed in the coming
month. The IHS and CBA Network are working together on additional
initiatives to assist each other in planning efforts across the nation
to raise awareness of this day of observance for HIV/AIDS. Thank you for
your time. Link to CBA Network:
<http://www.ihs.gov/MedicalPrograms/HIVAIDS/index.cfm?module=links&option=cba#top>

**IHS HIV Podcast as a collaborative effort between DHHS Office of
HIV/AIDS Policy and the IHS HIV Program.**

It will assist with basic information about IHS and the IHS HIV program
as well as provide an advanced medium (podcast) to share with others and
raise awareness about HIV.

The podcast (link below) was done in collaboration with the Department
of Health and Human Services Office of HIV/AIDS Policy (OHAP). As we
attempt to implement our strategic plans, one of the goals continues to
be program integration and collaboration with partners external to the
Agency. This is just one example of how we can partner with other
government stakeholders to raise awareness, augment our resources (and
technology) and open discussion about HIV/AIDS in support of our mission
for American Indians and Alaska Natives. This podcast can be accessed on
the IHS HIV Webpage at
[www.ihs.gov/medicalprograms/hivaids/](http://www.ihs.gov/medicalprograms/hivaids/)
under the 'podcast' box in the lower right corner or along with other
HIV podcasts at the AIDS.gov website at
[www.aids.gov](http://www.aids.gov/)[ ]{.underline} (upper right corner,
Conversations with...)

   

**Melissa Toffolon-Weiss, Anchorage**

**HPV brochure for AI/AN: available for broad dissemination**

We have developed a brochure for Alaska Native parents to inform them
about the new HPV vaccine.  We also have a poster.  If you would like
hard copies of these materials sent to you - please contact me.

 

Melissa Toffolon-Weiss, PhD, MPH

Alaska Native Epidemiology Center

Alaska Native Tribal Health Consortium

4000 Ambassador Drive

Anchorage, AK  99508

\(907\) 729-4561

<mmtoffolonweiss@anmc.org>

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

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

Evidence Favors Late Cord Clamping in Infants

**Background:** Most physicians who deliver babies will clamp and cut
the umbilical cord immediately upon delivery, but there is no evidence
that this practice is optimal. Early cord clamping has been shown to
result in a decrease in the neonate\'s blood volume, and may be
associated with hypovolemia and hematopoietic stem cell and iron loss.
Conversely, late clamping may result in complications associated with
high blood volume (e.g., jaundice, respiratory distress, polycythemia).
In the preterm infant, late clamping has been linked to a decreased need
for transfusion and decreased intraventricular hemorrhage. This study is
a systematic review evaluating the timing of cord clamping in term
infants.

**The Study:** Hutton and Hassan reviewed studies addressing the risks
and benefits of early versus late cord clamping, with outcomes related
to respiratory status, anemia, polycythemia, jaundice, and specific
laboratory values.

**Results:** Of 37 studies identified, eight randomized trials and seven
nonrandomized trials, six of which were rated as high quality, were
included. Early clamping was defined in most studies as clamping within
the first 10 seconds of birth, and late clamping was defined as
occurring with cessation of cord pulsations or at three minutes (two
minutes was the minimal cutoff for definition of late clamping in this
meta-analysis).

Of 1,912 newborns represented in the 15 studies identified, 1,001
underwent late clamping and 911 underwent early clamping. Hematocrit
levels, as measured at hours or days after delivery, were higher with
late cord clamping, but the difference was not significant at six
months. Similarly, the higher hemoglobin levels found with late cord
clamping were no longer significant at two to three months of age.

Blood volume in infants with late clamping was higher in some trials and
not significantly different in others, especially with increasing
passage of time. Three trials reported higher blood viscosity with late
clamping. Mean bilirubin levels were similar regardless of clamping
approach. Several trials found higher ferritin levels and iron stores
with late clamping. In terms of clinical outcomes, infants with late
clamping had lower risk of anemia at 24 to 48 hours and at two to three
months of age. When ferritin levels were considered, infants were at
lower risk of anemia at six months as well. There were no differences in
rates of jaundice. Polycythemia risk within the first few days of life
was greater in infants who underwent late cord clamping. Clamping
approach had no apparent effect on tachypnea or respiratory distress, or
neonatal intensive care unit admission.

**Conclusion:** Late cord clamping had a beneficial effect on infants\'
anemia risk and iron stores, an effect that lasted well into the
neonatal period. Increased viscosity and polycythemia were associated
with late clamping, but did not appear to have any clinical adverse
effects. The authors conclude that these findings are particularly
important in geographic areas with few resources, where late cord
clamping would be the most beneficial approach.

Hutton EK, Hassan ES. Late vs early clamping of the umbilical cord in
full-term neonates: systematic review and meta-analysis of controlled
trials. JAMA. March 21, 2007;297(11):1241-1252.
<http://www.ncbi.nlm.nih.gov/pubmed/17374818>

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

**Similar finding in preterm infants**

A study published in the March 2007 issue of Pediatrics looked at the
effects of late cord clamping on cerebral oxygenation in preterm
infants.1 The study of infants at a median age of 30.4 weeks found that
infants with late cord clamping had similar cerebral blood volumes but
higher tissue oxygenation than infants delivered in the conventional
manner. Although this study did not evaluate the clinical impact of this
finding, it does identify another high-risk group that could benefit
from late cord clamping.

Baenziger O, Stolkin F, Keel M, et al. The influence of the timing of
cord clamping on postnatal

cerebral oxygenation in preterm neonates: a randomized, controlled
trial. Pediatrics.

2007;119(3):455-459 <http://www.ncbi.nlm.nih.gov/pubmed/17332197>

**Continuous suturing for perineal closure vs interrupted methods - Less
pain: Cochrane**

AUTHORS\' CONCLUSIONS: The continuous suturing techniques for perineal
closure, compared to interrupted methods, are associated with less
short-term pain. Moreover, if the continuous technique is used for all
layers (vagina, perineal muscles and skin) compared to perineal skin
only, the reduction in pain is even greater.

[Kettle
C](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Kettle C"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlusDrugs1)
et al Continuous versus interrupted sutures for repair of episiotomy or
second degree tears. Cochrane Database Syst Rev. 2007 Oct
17;(4):CD000947.

<http://www.ncbi.nlm.nih.gov/pubmed/17943747>

**Minor trauma in pregnancy: Commonly used measures not predictive of
adverse outcome**

RESULTS: Of the 317 patients evaluated for minor trauma, 9 had a
positive KB test (2.8%). Delivery information was available on 256 (81%)
patients, and there was 1 placental abruption. The 49 cases (19.4%) of
composite outcome could not be predicted.

CONCLUSION: Perhaps it is time to reevaluate the extensive evaluations
often done after minor trauma in pregnancy, particularly because none of
the commonly used objective measures are predictive of adverse outcomes.

[Cahill
AG](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Cahill AG"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlusDrugs1)
et al Minor trauma in pregnancy\--is the evaluation unwarranted? Am J
Obstet Gynecol. 2008 Feb;198(2):208.e1-5.
<http://www.ncbi.nlm.nih.gov/pubmed/18226625>

**Amphetamine hospitalizations doubled: Familiarize yourself with the
adverse outcomes**

RESULTS: From 1998 to 2004, the hospitalization ratio for cocaine abuse
decreased 44%, whereas the hospitalization ratio for amphetamine abuse
doubled. Pregnancy hospitalizations with a diagnosis of amphetamine
abuse were geographically concentrated in the West (82%), and were more
likely to be among women younger than 24 years than the cocaine-abuse or
non-substance-abuse hospitalizations. Most medical conditions were more
prevalent in the amphetamine-abuse group than the non-substance-abuse
group. When the substance abuse groups were compared with each other,
obstetric diagnoses associated with infant morbidity such as premature
delivery and poor fetal growth were more common in the cocaine-abuse
group, whereas vasoconstrictive effects such as cardiovascular disorders
and hypertension complicating pregnancy were more common in the
amphetamine-abuse group. CONCLUSION: As pregnancy hospitalizations with
a diagnosis of amphetamine abuse continue to increase, clinicians should
familiarize themselves with the adverse consequences of amphetamine
abuse during pregnancy and evidence-based guidelines to deal with this
high-risk population. LEVEL OF EVIDENCE: III.

[Cox
S](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Cox S"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlusDrugs1)
et al Hospitalizations with amphetamine abuse among pregnant women.
Obstet Gynecol. 2008 Feb;111(2):341-7.
<http://www.ncbi.nlm.nih.gov/pubmed/18238971>

**Pregnant smokers reluctant to use smoking cessation medications
recommended**

RESULTS: At end of pregnancy, 29.3% of respondents reported discussing a
cessation medication with their obstetric providers, more often nicotine
replacement (26.5%) than bupropion (12.2%) (P=.001). Ten percent of
trial respondents used a medication while pregnant (7.4% nicotine
replacement, 3.4% bupropion, P=.023). Obstetricians discussed medication
with 29.4% of smokers at the postpartum visit; 14.3% of postpartum
smokers used medication. Contrary to guidelines, women who smoked more
cigarettes per day or had already tried quitting during pregnancy were
not more likely to use medication or to discuss medication with their
provider. Medication use was associated with older age, more education,
living with a partner, a previous birth, having an obstetric provider
who discussed medication, and having private health insurance in a state
whose Medicaid program did not cover cessation medications (all P\<.05).

CONCLUSION: Pregnant women are more reluctant to use cessation
medications than clinical guidelines recommend. More pregnant smokers
might use cessation medications if their obstetricians discussed them
routinely and if health insurance covered their cost.

[Rigotti
NA](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Rigotti NA"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlusDrugs1)
et al Smoking cessation medication use among pregnant and postpartum
smokers.Obstet Gynecol. 2008 Feb;111(2):348-55.

<http://www.ncbi.nlm.nih.gov/pubmed/18238972?dopt=Abstract>

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

**Biofeedback Reduces Psychological Burden in Older Women With Urge UI**

In older women with urge urinary incontinence (UI), biofeedback (BFB)
therapy significantly improved psychological burden, especially in those
with a history of depression.

CONCLUSION: In older women with urge UI, BFB significantly improves
psychological burden, especially in those with a history of depression,
in whom psychological burden is linked to change in perception of
control. Psychological factors are relevant outcome measures for UI, and
these data suggest that focusing on UI frequency alone may have
underestimated BFB\'s efficacy and additional therapeutic benefits.

[Tadic
SD](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Tadic SD"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlusDrugs1),
et al Effect of biofeedback on psychological burden and symptoms in
older women with urge urinary incontinence. J Am Geriatr Soc. 2007
Dec;55(12):2010-5

<http://www.ncbi.nlm.nih.gov/pubmed/18028340>

**Not enough evidence to evaluate routine antibiotic prophylaxis with
SAB: Cochrane**

MAIN RESULTS: One study involving 140 women was included. A second
well-conducted trial was excluded because of high losses to follow-up.
No differences were detected in postabortal infection rates with routine
prophylaxis or control. However, compliance with antibiotic treatment
was also low. AUTHORS\' CONCLUSIONS: There is not enough evidence to
evaluate a policy of routine antibiotic prophylaxis to women with
incomplete abortion.

May W et al Antibiotics for incomplete abortion. Cochrane Database Syst
Rev. 2007 Oct 17;(4):CD001779
<http://www.ncbi.nlm.nih.gov/pubmed/17943756>

**Intracervical catheter placement: Less pain during an saline infusion
sonohysterography**

CONCLUSION: Intracervical catheter placement results in significantly
less pain during an saline infusion sonohysterography and also requires
half the saline volume to perform the saline infusion sonohysterogram.
Therefore, routine intracervical balloon placement should be considered
for saline infusion sonohysterogram. LEVEL OF EVIDENCE: I

Spieldoch RL et al Optimal catheter placement during sonohysterography:
a randomized controlled trial comparing cervical to uterine placement.
Obstet Gynecol. 2008 Jan;111(1):15-21.

<http://www.ncbi.nlm.nih.gov/pubmed/18165388>

#### 

**Acupuncture in dysmenorrhea: improvements in pain and quality of
life**

Conclusion Additional acupuncture in patients with dysmenorrhea was
associated with improvements in pain and quality of life as compared to
treatment with usual care alone and was cost-effective within usual
thresholds.

[Witt
CM](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Witt CM"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlusDrugs1)
et al Acupuncture in patients with dysmenorrhea: a randomized study on
clinical effectiveness and cost-effectiveness in usual care.

Am J Obstet Gynecol. 2008 Feb;198(2):166.e1-8.
<http://www.ncbi.nlm.nih.gov/pubmed/18226614>

**The diagnosis and management of endometrial cancer are reviewed**

This review summarizes the epidemiology, prevention, diagnosis and
treatment, and prognosis of endometrial carcinoma. Although the
incidence of disease has remained stable, the death rate has increased
over 100% over the last two decades. Precursor lesions of complex
hyperplasia with atypia are associated with an endometrial carcinoma in
over 40% of cases. The percentage of obese women with endometrial cancer
is increasing. The incidence of endometrial cancer in white women is
twice the incidence in African-American women, but stage for stage,
African-American women have a less favorable prognosis. Preoperative
imaging cannot accurately assess lymph node involvement. Gross
examination of depth of myometrial invasion does not have the
sensitivity, specificity, and positive or negative predictive value to
select women who can have lymphadenectomy safely omitted from the
surgical procedure. In the absence of ideal noninvasive preoperative
testing, surgical staging remains the most accurate method of
determining the extent of disease. There has been an increase in
surgical staging and a decrease in postoperative adjuvant pelvic
radiation therapy over the past two decades. Women with a family history
of hereditary nonpolyposis colorectal colon cancer are at increased risk
for endometrial cancer. Conservative treatment to allow for childbearing
is possible in select situations. Women with endometrial cancer should
be managed by physicians experienced in the treatment of this disease

[Sorosky
JI](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Sorosky JI"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract).
Endometrial cancer. Obstet Gynecol. 2008 Feb;111(2):436-47.

<http://www.ncbi.nlm.nih.gov/pubmed/18238985?dopt=Abstract>

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

## Sex education: Providers need to fill gaps in adolescent knowledge

RESULTS: Representing 91.3% of sampled schools, the teacher survey
response rate was 62.4%. The most frequently taught topics included
HIV/AIDS (97%), STDs (96%), and abstinence-until-marriage (89%). The
least frequently taught topics were emergency contraception (31%),
sexual orientation (33%), condom (34%) and other contraceptive (37%)
use, and abortion (39%). Abstinence-only curricula were used by 74% of
teachers, but 33% of these teachers supplemented with \"other\"
curricula. Overall, two thirds met comprehensiveness criteria based on
topics taught. Curricular material availability was most commonly cited
as having a \"great deal\" of influence on topics taught. Thirty percent
had no training in sex education; training was the only significant
predictor of providing comprehensive sex education in multivariable
analysis.

CONCLUSION: Illinois public school-based sex education emphasizes
abstinence and STDs and is heavily influenced by the available
curricular materials. Nearly one in three sex education teachers were
not trained. Obstetrician-gynecologists caring for adolescents may need
to fill gaps in adolescent knowledge and skills due to deficits in
content, quality, and teacher training in sex education.

[Lindau
ST](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Lindau ST"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlusDrugs1)
et al What schools teach our patients about sex: content, quality, and
influences on sex education. Obstet Gynecol. 2008 Feb;111(2):256-66.

<http://www.ncbi.nlm.nih.gov/pubmed/18238961>

#### [Editorial comment]{.underline}: Beth Crow, Anchorage

**Learning about sexuality is really important for children\'s health,
safety, and confidence**

In order to offer something that our schools lack, I teach Our Whole
Lives (OWL), which is an age appropriate sexual health curriculum
developed by the Unitarian Universalists of the US and Canada in
conjunction with the United Church of Christ. Although there is a
supplemental spiritual curriculum, the core OWL curriculum is secular.
There is a male and female teaching team for each class. The teachers
are trained for whatever age group they want to teach. Our training was
at Planned Parenthood with municipal HIV educators and Planned
Parenthood staff. The curriculum includes communication, gender
identification, gender roles, sexual health and safety, anatomy,
contraception, intercourse (when age appropriate), etc. The curricula is
available for 5-6 year olds, 9-11 year olds, junior high and senior high
school students. Parents are involved in initial meetings and with home
links, but the students are in class with peers and their teaching team.

I think many European countries, in particular, Scandinavia, have
comprehensive sexual health programs, which results in a fraction of the
teen pregnancies and STI\'s that we have in the US. In addition to
universal access to health care and contraception, their schools have
age-appropriate sex education curricula from a very early age.

I do believe that this should be a universal curriculum, and not just
for children of interested parents. Parents often can\'t or won\'t talk
to their children about sexuality, so children learn about sexuality
from the media, school, other children, etc. These are not reliable
sources, even schools, as the article by Landau shows. The sequelae of
inadequate sex education is an increasing rate of teen STI\'s, sexual
violence, and pregnancy. The U.S. needs to be proactive about our health
care spending by instituting a universal, comprehensive,
age-appropriate, sexual education. This will lead to a healthier, more
confident, safer young population.

**Obstet Gynecol Editorial**

[Phipps
MG](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Phipps MG"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlusDrugs1).
Consequences of inadequate sex education in the United States. Obstet
Gynecol. 2008 Feb;111(2):254-5..
<http://www.ncbi.nlm.nih.gov/pubmed/18238960>

**Physical Activity Twice Weekly Helps Prevent Teens From Becoming
Overweight Adults**

School-based and extracurricular physical activities in which teens
participate at least 2 times per week are effective ways to help prevent
them from becoming overweight in adulthood.

CONCLUSION: These data underscore the important role that school-based
and extracurricular physical activity play in reducing the likelihood of
transitioning to overweight as young adults.

[Menschik
D](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Menschik D"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlusDrugs1)
et al Adolescent physical activities as predictors of young adult
weight. Arch Pediatr Adolesc Med. 2008 Jan;162(1):29-33.

<http://www.ncbi.nlm.nih.gov/pubmed/18180409>

**Early menarche associated with increased all-cause mortality**

An inverse association was found between age at menarche and the
all-cause mortality rate (p \< 0.001), with an approximately 2.4% (95%
confidence interval: 1.6, 3.1) reduced mortality per year increase in
age at menarche. The association was stronger in women with an attained
age of less than 70 years (3.9% reduction in mortality) than in women
aged 80 years and above (1.5%). The inverse association could not be
explained by extreme mortality rates in women with very early (10 years)
or late (19 years) menarche or by possible confounding variables such as
birth cohort, place of residence, occupational category (own or
husband\'s occupation), body mass index, age at first delivery, or
parity. Because of lack of data, residual confounding by physical
activity or cigarette smoking could not be ruled out. Women with a
menarche at age 18 years or later had, however, a slightly higher
mortality rate than was predicted by the linear association.

[Jacobsen
BK](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Jacobsen BK"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlusDrugs1)
et al Association of low age at menarche with increased all-cause
mortality: a 37-year follow-up of 61,319 Norwegian women. Am J
Epidemiol. 2007 Dec 15;166(12):1431-7. Epub 2007 Sep 17.
<http://www.ncbi.nlm.nih.gov/pubmed/17875585>

**School-Associated Student Homicides \-\-- United States, 1992---2006**

Homicide is the second leading cause of death among youths aged 5\--18
years in the United States. The finding that \<1% of all homicides in
this population during July 1999\--June 2004 were school associated is
consistent with estimates from previous studies and indicates that the
risk for student-associated homicides in schools is very low.

Overall rates of school-associated student homicide during July
1999\--June 2006 are lower than those reported when the SAVD study was
first conducted (July 1992\--July 1994). Data for 1999\--2006 have
patterns that are similar to those documented previously, with
substantially higher homicide rates among male students and students in
urban areas, and homicides involving single victims occurring more
frequently than those with multiple victims. SAVD data continue to
indicate that individual violent events involving numerous homicides,
such as the 1999 event that involved 15 deaths at Columbine High School
in Colorado, are rare. Most school-associated student homicides continue
to involve a single victim and a single offender.

Because each incident of school violence is different, lethal school
violence cannot be eliminated using a single approach. However, research
on school-associated violent deaths has described patterns in the timing
of violent events and the characteristics of incidents and behaviors
that precede violence (e.g., bullying experiences, suicidal ideation,
and a high prevalence of threats and warning signs) that could be
targets for prevention measures.

Most lethal youth violence does not occur in schools, and most acts of
youth violence do not lead to death. Therefore, youth violence
prevention measures should focus on a range of aggressive behaviors by
addressing risk factors at individual, family, and community levels and
in a range of locales. Such strategies should be guided by reviews of
empirically validated prevention programs and guidelines for promoting
school safety, reducing risk for youth violence and suicide, and
comprehensive crisis planning. The National Youth Violence Prevention
Resource Center provides information about youth violence prevention for
students, parents, researchers, and others (available at
[http://www.safeyouth.org](http://www.safeyouth.org/)).

MMWR Weekly January 18, 2008 / 57(02);33-36

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5702a1.htm>

**Mediterranean diet in pregnancy helps ward off childhood asthma and
allergy**

Mums to be who eat a Mediterranean diet while pregnant could help stave
off the risks of asthma and allergy in their children, suggests research
published ahead of print in Thorax.

CONCLUSION: Our results support a protective effect of a high level of
adherence to the Mediterranean Diet during pregnancy against asthma-like
symptoms and atopy in childhood.

[Chatzi
L](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Chatzi L"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlusDrugs1)
et al Mediterranean Diet in pregnancy protective for wheeze and atopy in
childhood. Thorax. 2008 Jan 15;
<http://www.ncbi.nlm.nih.gov/pubmed/18198206>

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

**Diuretics most effective blood pressure medicine for people with
metabolic syndrome**

CONCLUSIONS: The ALLHAT findings fail to support the preference for
calcium channel blockers, alpha-blockers, or angiotensin-converting
enzyme inhibitors compared with thiazide-type diuretics in patients with
the MetS, despite their more favorable metabolic profiles. This was
particularly true for black participants.

[Wright JT
Jr](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Wright JT Jr"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlusDrugs1),
Clinical outcomes by race in hypertensive patients with and without the
metabolic syndrome: Antihypertensive and Lipid-Lowering Treatment to
Prevent Heart Attack Trial (ALLHAT). Arch Intern Med. 2008 Jan
28;168(2):207-17.

<http://www.ncbi.nlm.nih.gov/pubmed/18227370>

**\'Aspirin resistance\' linked to increased cardiovascular events and
death**

CONCLUSION: Patients who are resistant to aspirin are at a greater risk
of clinically important cardiovascular morbidity long term than patients
who are sensitive to aspirin.

Aspirin \"resistance\" and risk of cardiovascular morbidity: systematic
review and meta-analysis. BMJ. 2008 Jan 26;336(7637):195-8.
<http://www.ncbi.nlm.nih.gov/pubmed/18202034>

**FDA MedWatch- Chantix (varenicline)-Associated With Reports Of Changes
In Behavior**

FDA informed healthcare professionals and consumers of important
revisions to the WARNINGS and PRECAUTIONS sections of the prescribing
information for Chantix regarding serious neuropsychiatric symptoms
experienced in patients taking Chantix. These symptoms include changes
in behavior, agitation, depressed mood, suicidal ideation, and attempted
and completed suicide. While some patients may have experienced these
types of symptoms and events as a result of nicotine withdrawal, some
patients taking Chantix who experienced serious neuropsychiatric
symptoms and events had not yet discontinued smoking. In most cases,
neuropsychiatric symptoms developed during Chantix treatment, but in
others, symptoms developed following withdrawal of Chantix therapy. See
the FDA Information for Healthcare Professionals Sheet for
recommendations and considerations for healthcare professionals on using
Chantix therapy for patients.

Read the complete 2008 MedWatch Safety Summary including a link to the
FDA Public Health Advisory, Healthcare Professional Information Sheet
and the prescribing information for Chantix regarding this issue at:
[[http://www.fda.gov/medwatch/safety/2008/safety08.htm#Varenicline]{.underline}](http://www.fda.gov/medwatch/safety/2008/safety08.htm#Varenicline)

**Chronic constipation more pronounced in women and the elderly**

RESULTS: In all, 5507 (79%) subjects responded to the initial survey and
2298 (55%) subjects responded to the second survey in which chronic
constipation could be defined. Over 12 years, the cumulative incidence
of chronic constipation was 17.4% (14.5, 20.5). Among those less than
age 50 years at baseline, the incidence of chronic constipation differed
by gender (9.2% in men vs. 18.3% in women). In those over 70 years, the
incidence of chronic constipation was more similar for men and women
(20.6% vs. 25.0%). The other risk factor associated with new onset
chronic constipation was the presence of abdominal pain at baseline \[OR
= 2.0 (1.3, 3.0)\]. CONCLUSION: The cumulative incidence of chronic
constipation over more than a decade was almost one in six, and more
pronounced in women and the elderly.

[Choung
RS](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Choung RS"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlusDrugs1),
et al Cumulative incidence of chronic constipation: a population-based
study 1988-2003. Aliment Pharmacol Ther. 2007 Dec;26(11-12):1521-8.

<http://www.ncbi.nlm.nih.gov/pubmed/17919271>

**Older Women More Susceptible to Depression Than Older Men**

Older women are more prone to depression and are more likely to remain
depressed than older men. The Yale team also found that women were less
likely to die while depressed than older men, indicating that women live
longer with depression than men. This factor, along with the higher
likelihood of women becoming depressed and remaining depressed,
collectively contribute to the higher burden of depression among older
women.

CONCLUSION: Among older persons, the higher burden of depression in
women than men seems to be attributable to a greater susceptibility to
depression and, once depressed, to more persistent depression and a
lower probability of death.

[Barry
LC](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Barry LC"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlusDrugs1)
et al Higher burden of depression among older women: the effect of
onset, persistence, and mortality over time. Arch Gen Psychiatry. 2008
Feb;65(2):172-8.

<http://www.ncbi.nlm.nih.gov/pubmed/18250255>

**Antiepileptic Drugs- Had Approximately Twice The Risk of Suicidal
Behavior Or Ideation**

FDA informed healthcare professionals that the Agency has analyzed
reports of suicidality (suicidal behavior or ideation) from
placebo-controlled clinical studies of eleven drugs used to treat
epilepsy as well as psychiatric disorders, and other conditions. In the
FDA\'s analysis, patients receiving antiepileptic drugs had
approximately twice the risk of suicidal behavior or ideation (0.43%)
compared to patients receiving placebo (0.22%). The increased risk of
suicidal behavior and suicidal ideation was observed as early as one
week after starting the antiepileptic drug and continued through 24
weeks. The results were generally consistent among the eleven drugs. The
relative risk for suicidality was higher in patients with epilepsy
compared to patients who were given one of the drugs in the class for
psychiatric or other conditions.\
\
Healthcare professionals should closely monitor all patients currently
taking or starting any antiepileptic drug for notable changes in
behavior that could indicate the emergence or worsening of suicidal
thoughts or behavior or depression.\
\
The drugs included in the analyses include (some of these drugs are also
available in generic form):

Carbamazepine (marketed as Carbatrol, Equetro, Tegretol, Tegretol XR)\
Felbamate (marketed as Felbatol)\
Gabapentin (marketed as Neurontin)\
Lamotrigine (marketed as Lamictal)\
Levetiracetam (marketed as Keppra)\
Oxcarbazepine (marketed as Trileptal)\
Pregabalin (marketed as Lyrica)\
Tiagabine (marketed as Gabitril)\
Topiramate (marketed as Topamax)\
Valproate (marketed as Depakote, Depakote ER, Depakene, Depacon)\
Zonisamide (marketed as Zonegran)\
\
Although the 11 drugs listed above were the ones included in the
analysis, FDA expects that the increased risk of suicidality is shared
by all antiepileptic drugs and anticipates that the class labeling
changes will be applied broadly.

Read the complete 2008 MedWatch Safety Summary including a link to the
Healthcare Professional Sheet regarding this issue at:

<http://www.fda.gov/medwatch/safety/2008/safety08.htm#Antiepileptic>

**Botox And Botox Cosmetic: Reports of Respiratory Compromise And
Death**

FDA issued an early communication about an ongoing safety review
regarding Botox and Botox Cosmetic. **FDA has received reports of
systemic adverse reactions including respiratory compromise and death
following the use of botulinum toxins types A and B for both
FDA-approved and unapproved uses. The reactions reported are suggestive
of botulism, which occurs when botulinum toxin spreads in the body
beyond the site where it was injected**. The most serious cases had
outcomes that included hospitalization and death, and occurred mostly in
children treated for cerebral palsy-associated limb spasticity. Use of
botulinum toxins for treatment of limb spasticity (severe arm and leg
muscle spasms) in children or adults is not an approved use in the U.S.
See the FDA\'s \"Early Communication about an Ongoing Safety Review\"
for Agency recommendations and additional information for healthcare
professionals.\
\
Read the complete 2008 MedWatch Safety Summary including a link to the
FDA\'s Early Communication about an Ongoing Safety Review regarding this
issue at:  <http://www.fda.gov/medwatch/safety/2008/safety08.htm#botox>

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

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

**Fatigue and Patient Safety**

ABSTRACT: It has long been recognized that fatigue can affect human
cognitive and physical function. Although there are limited published
data on the effects of fatigue on health care providers, including
full-time practicing physicians, there is increasing awareness within
the patient safety movement that fatigue, even partial sleep
deprivation, impairs performance. Most of the current literature reviews
resident function after recent work reform changes. However, the
information available from many studies in health care and other
occupations can be applied to the work habits of practicing
obstetrician--gynecologists.

Fatigue and Patient Safety. ACOG Committee Opinion No. 398. American
College of Obstetricians and Gynecologists. Obstet Gynecol
2008;111:471--3

<http://www.ncbi.nlm.nih.gov/pubmed/18238990>

**ACOG Statement on Home Births**

The American College of Obstetricians and Gynecologists (ACOG)
reiterates its long-standing opposition to home births. While childbirth
is a normal physiologic process that most women experience without
problems, monitoring of both the woman and the fetus during labor and
delivery in a hospital or accredited birthing center is essential
because complications can arise with little or no warning even among
women with low-risk pregnancies.

ACOG acknowledges a woman\'s right to make informed decisions regarding
her delivery and to have a choice in choosing her health care provider,
but ACOG does not support programs that advocate for, or individuals who
provide, home births. Nor does ACOG support the provision of care by
midwives who are not certified by the American College of Nurse-Midwives
(ACNM) or the American Midwifery Certification Board (AMCB).

Childbirth decisions should not be dictated or influenced by what\'s
fashionable, trendy, or the latest cause célèbre. Despite the rosy
picture painted by home birth advocates, a seemingly normal labor and
delivery can quickly become life-threatening for both the mother and
baby. Attempting a vaginal birth after cesarean (VBAC) at home is
especially dangerous because if the uterus ruptures during labor, both
the mother and baby face an emergency situation with potentially
catastrophic consequences, including death. Unless a woman is in a
hospital, an accredited freestanding birthing center, or a birthing
center within a hospital complex, with physicians ready to intervene
quickly if necessary, she puts herself and her baby\'s health and life
at unnecessary risk.

Advocates cite the high US cesarean rate as one justification for
promoting home births. The cesarean delivery rate has concerned ACOG for
the past several decades and ACOG remains committed to reducing it, but
there is no scientific way to recommend an \'ideal\' national cesarean
rate as a target goal. In 2000, ACOG issued its Task Force Report
*Evaluation of Cesarean Delivery* to assist physicians and institutions
in assessing and reducing, if necessary, their cesarean delivery rates.
Multiple factors are responsible for the current cesarean rate, but
emerging contributors include maternal choice and the rising tide of
high-risk pregnancies due to maternal age, overweight, obesity and
diabetes.

The availability of an obstetrician-gynecologist to provide expertise
and intervention in an emergency during labor and/or delivery may be
life-saving for the mother or newborn and lower the likelihood of a bad
outcome. ACOG believes that the safest setting for labor, delivery, and
the immediate postpartum period is in the hospital, or a birthing center
within a hospital complex, that meets the standards jointly outlined by
the American Academy of Pediatrics (AAP) and ACOG, or in a freestanding
birthing center that meets the standards of the Accreditation
Association for Ambulatory Health Care, The Joint Commission, or the
American Association of Birth Centers.

It should be emphasized that studies comparing the safety and outcome of
births in hospitals with those occurring in other settings in the US are
limited and have not been scientifically rigorous. Moreover, lay or
other midwives attending to home births are unable to perform
live-saving emergency cesarean deliveries and other surgical and medical
procedures that would best safeguard the mother and child.

ACOG encourages all pregnant women to get prenatal care and to make a
birth plan. The main goal should be a healthy and safe outcome for both
mother and baby. Choosing to deliver a baby at home, however, is to
place the process of giving birth over the goal of having a healthy
baby. For women who choose a midwife to help deliver their baby, it is
critical that they choose only ACNM-certified or AMCB-certified midwives
that collaborate with a physician to deliver their baby in a hospital,
hospital-based birthing center, or properly accredited freestanding
birth center.

<http://www.acog.com/from_home/publications/press_releases/nr02-06-08-2.cfm>

**Alcohol and Pregnancy: Know the Facts**

***Washington, DC*** \-- The recent news story \"Can Pregnant Women
Drink Alcohol in Moderation?\", which aired on *ABC\'s Good Morning
America Weekend*, has created tremendous confusion among women about the
safety of drinking alcohol during pregnancy. The American College of
Obstetricians and Gynecologists (ACOG) strongly urges women not to
ignore the public health warnings associated with consuming alcohol
while pregnant.

ACOG is concerned that this television segment disseminated a
potentially dangerous and mixed message to pregnant women. According to
ACOG, patients who saw the show are asking their ob-gyns for
clarification about whether moderate---or even light---drinking will
impact the health of their baby. Therefore, ACOG reiterates its
long-standing position that no amount of alcohol consumption can be
considered safe during pregnancy.

Maternal alcohol use is the leading known cause of mental retardation
and is a preventable cause of birth defects. Children exposed to alcohol
in utero are at risk for growth deficiencies, facial deformities,
central nervous impairment, behavioral disorders, and impaired
intellectual development. Consuming alcohol during pregnancy also
increases the risk of miscarriage, low birth weight, and stillbirth.

The bottom line according to ACOG: Women should avoid alcohol entirely
while pregnant or trying to conceive because damage can occur in the
earliest weeks of pregnancy, even before a woman knows that she is
pregnant.

<http://www.acog.com/from_home/publications/press_releases/nr02-06-08-1.cfm>

ACOG Patient Education Pamphlet, Alcohol and Pregnancy

[www.acog.org/publications/patient_education/bp132.cfm](http://www.acog.org/publications/patient_education/bp132.cfm)

**Asthma in Pregnancy**

Summary of Recommendations and Conclusions

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

-   It is safer for pregnant women with asthma to be treated with asthma
    medications than it is for them to have asthma symptoms and
    exacerbations.

-   Clinical evaluation of asthma includes subjective assessments and
    pulmonary function tests.

-   The ultimate goal of asthma therapy in pregnancy is maintaining
    adequate oxygenation of the fetus by preventing hypoxic episodes in
    the mother.

-   The step-care therapeutic approach increases the number and dosage
    of medications with increasing asthma severity.

-   Inhaled corticosteroids are first-line controller therapy for
    persistent asthma during pregnancy.

-   Budesonide is the preferred inhaled corticosteroid for use during
    pregnancy.

-   Inhaled albuterol is recommended rescue therapy for pregnant women
    with asthma.

-   Identifying and controlling or avoiding factors such as allergens
    and irritants, particularly tobacco smoke, can lead to improved
    maternal well-being with less need for medication.

-   Continuation of immunotherapy is recommended in patients who are at
    or near a maintenance dose, not experiencing adverse reactions to
    the injections, and apparently deriving clinical benefit.

-   Use of prednisone, theophylline, antihistamines, inhaled
    corticosteroids, b2-agonists, and cromolyn is not contraindicated
    for breastfeeding.

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

-   Asthma self-management skills, including self-monitoring, correct
    use of inhalers, and following a plan for long-term management of
    asthma and promptly handling signs of worsening asthma, enhance
    asthma control.

-   For pulmonary function assessment of patients during outpatient
    visits, spirometry is preferable, but peak expiratory flow
    measurement with a peak flow meter also is sufficient.

-   Ultrasound examinations and antenatal fetal testing should be
    considered for women who have moderate or severe asthma during
    pregnancy.

-   Pregnant patients with asthma, even those with mild or
    well-controlled disease, need to be monitored with PEFR and FEV1
    testing as well as by observing their symptoms during pregnancy.

-   Routine evaluation of pulmonary function in pregnant women with
    persistent asthma is recommended.

-   Because pulmonary function and asthma severity may change during the
    course of pregnancy, routine evaluation of pulmonary function in
    pregnant women with persistent asthma is recommended

Asthma in Pregnancy. ACOG Practice Bulletin No. 90. American College of
Obstetricians and Gynecologists. Obstet Gynecol 2008; 111:457--64.
<http://www.ncbi.nlm.nih.gov/pubmed/18238988>

**Surrogate Motherhood**

ABSTRACT: Ethical responsibilities are described for
obstetrician--gynecologists who choose to participate in surrogacy
arrangements by 1) advising couples who are considering surrogacy, 2)
counseling potential surrogate mothers, 3) providing obstetric services
for pregnant women participating in surrogacy, or 4) offering assisted
reproductive technologies related to surrogacy. Although the obligations
of physicians will vary depending on the type and level of their
involvement, in all cases physicians should carefully examine all
relevant issues related to surrogacy, including medical, ethical, legal,
and psychologic aspects.

Surrogate Motherhood. ACOG Committee Opinion No. 397. American College
of Obstetricians and Gynecologists. Obstet Gynecol 2008;111:465--70.

<http://www.ncbi.nlm.nih.gov/pubmed/18238989>

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

**Treating Eating Disorders in Primary Care (also see Patient
Information)**

Binge-eating disorder, bulimia nervosa, and anorexia nervosa are
potentially life-threatening disorders that involve complex psychosocial
issues. A strong therapeutic relationship between the physician and
patient is necessary for assessing the psychosocial and medical factors
used to determine the appropriate level of care. Most patients can be
effectively treated in the outpatient setting by a health care team that
includes a physician, a registered dietitian, and a therapist.
Psychiatric consultation may be beneficial. Patients may require
inpatient care if they are suicidal or have life-threatening medical
complications, such as marked bradycardia, hypotension, hypothermia,
severe electrolyte disturbances, end-organ compromise, or weight below
85 percent of their healthy body weight. For the treatment of
binge-eating disorder and bulimia nervosa, good evidence supports the
use of interpersonal and cognitive behavior therapies, as well as
antidepressants. Limited evidence supports the use of guided self-help
programs as a first step in a stepped-care approach to these disorders.
For patients with anorexia nervosa, the effectiveness of behavioral or
pharmacologic treatments remains unclear. Am Fam Physician.
2008;77(2):187-195, 196-197. <http://www.aafp.org/afp/20080115/187.html>

**End-of-Life Care: Guidelines for Patient-Centered Communication**

When patients are diagnosed with cancer, primary care physicians often
must deliver the bad news, discuss the prognosis, and make appropriate
referrals. When delivering bad news, it is important to prioritize the
key points that the patient should retain. Physicians should assess the
patient\'s emotional state, readiness to engage in the discussion, and
level of understanding about the condition. The discussion should be
tailored according to these assessments. Often, multiple visits are
needed. When discussing prognosis, physicians should be sensitive to
variations in how much information patients want to know. The challenge
for physicians is to communicate prognosis accurately without giving
false hope. All physicians involved in the patient\'s care should
coordinate their key prognosis points to avoid giving the patient mixed
messages. As the disease progresses, physicians must reassess treatment
effectiveness and discuss the values, goals, and preferences of the
patient and family. It is important to initiate conversations about
palliative care early in the disease course when the patient is still
feeling well. There are innovative hospice programs that allow for
simultaneous curative and palliative care. When physicians discuss the
transition from curative to palliative care, they should avoid phrases
that may convey to the patient a sense of failure or abandonment.
Physicians also must be cognizant of how cultural factors may affect
end-of-life discussions. Sensitivity to a patient\'s cultural and
individual preferences will help the physician avoid stereotyping and
making incorrect assumptions. Am Fam Physician. 2008;77(2):167-174.

<http://www.aafp.org/afp/20080115/167.html>

**CDC Reports on Lead Exposure in Women of Childbearing Age**

Evidence on the adverse health effects of moderate- and low-level blood
lead concentrations is mounting. Public health authorities use higher
levels to define blood lead levels of concern in nonpregnant women (\>=
25 µg per dL \[1.20 µmol per L\]) than in pregnant women (\>= 5 µg per
dL \[0.25 µmol per L\]), in whom maternal and fetal levels are nearly
identical because lead crosses the placenta unencumbered. The difference
in blood lead levels for nonpregnant and pregnant women has received
attention because of the recognition that a proportion of nonpregnant
women with blood lead levels greater than 5 µg per dL may become
pregnant and potentially expose their infants to the adverse health
effects from lead. The Centers for Disease Control and Prevention (CDC)
summarized 2004 surveillance data on elevated blood lead levels among
women of childbearing age (i.e., 16 to 44 years) in 37 states
participating in the CDC\'s Adult Blood Lead Epidemiology and
Surveillance (ABLES) program, and emphasized the need for necessary
surveillance measures to prevent lead exposure in women of childbearing
age.

Adverse health effects in infants born to women with moderately elevated
blood lead levels (i.e., 10 to 15 µg per dL \[0.50 to 0.70 µmol per L\])
include preterm birth, decreased gestational maturity, lower birth
weight, reduced postnatal growth, increased incidence of minor
congenital anomalies, and early neurologic or neurobehavioral deficits.
Some evidence documents associations between prenatal elevated blood
lead levels and decreased intelligence when those children are three to
seven years of age. Estimates have varied widely concerning the number
and rate of women of childbearing age with elevated blood lead levels;
however, conducting surveillance of elevated blood lead levels in this
population is important because approximately one third to one half of
U.S. pregnancies are unplanned. Primary and secondary prevention of lead
exposure among women of childbearing age, which includes identifying and
counseling women who might become pregnant and expose their infant to
lead in utero, is needed to lessen the risk of possible neurobehavioral
and cognitive defects in their children.

Rates of elevated blood lead levels detected in the ABLES program among
women who worked in the manufacturing sector, especially in the industry
that includes battery manufacturing, were much higher than those of the
general population for all lead exposures. These increased rates suggest
that the workplace remains a substantial source of lead exposure, and
physicians should consider work history when determining whether to
measure blood lead levels.

*Morbidity and Mortality Weekly Report,* April 27, 2007

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5616a4.htm>

**Dietary Supplements for Osteoarthritis**

A large number of dietary supplements are promoted to patients with
osteoarthritis and as many as one third of those patients have used a
supplement to treat their condition. Glucosamine-containing supplements
are among the most commonly used products for osteoarthritis. Although
the evidence is not entirely consistent, most research suggests that
glucosamine sulfate can improve symptoms of pain related to
osteoarthritis, as well as slow disease progression in patients with
osteoarthritis of the knee. Chondroitin sulfate also appears to reduce
osteoarthritis symptoms and is often combined with glucosamine, but
there is no reliable evidence that the combination is more effective
than either agent alone. S-adenosylmethionine may reduce pain but high
costs and product quality issues limit its use. Several other
supplements are promoted for treating osteoarthritis, such as
methylsulfonylmethane, Harpagophytum procumbens (devil\'s claw), Curcuma
longa (turmeric), and Zingiber officinale (ginger), but there is
insufficient reliable evidence regarding long-term safety or
effectiveness. Am Fam Physician. 2008;77(2):177-184.

<http://www.aafp.org/afp/20080115/177.html>

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

**Physicians want to learn from medical mistakes but say current
error-reporting systems are inadequate**

<http://www.ahrq.gov/research/feb08/0208RA1.htm>

**A combination of maternal, baby, and episiotomy factors contribute to
high rates of maternal birth trauma in Iowa**

<http://www.ahrq.gov/research/feb08/0208RA11.htm>

**Comparative Effectiveness of Second-Generation Antidepressants in the
Pharmacologic Treatment of Adult Depression: AHRQ Executive Summary**

<http://www.medscape.com/viewprogram/7793?src=sr>

**Nurse midwives deliver more babies in hospitals than homes in
Washington State**

[[http://www.ahrq.gov/research/feb08/0208RA10.htm]{.underline}](http://www.ahrq.gov/research/feb08/0208RA10.htm)

**Study of young Head Start children links overweight to worsened
asthma**

<http://www.ahrq.gov/research/feb08/0208RA6.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}

**Cervical Cancer Community-Based Research Project in a Native American
Community**

The Messengers for Health on the Apsáalooke Reservation project uses a
community-based participatory research (CBPR) approach and lay health
advisors (LHAs) to generate knowledge and awareness about cervical
cancer prevention among community members in a culturally competent
manner. Northern Plains Native Americans, of whom Apsáalooke women are a
part, continue to be disproportionately affected by cervical cancer.
This article examines quantitative and qualitative changes that occurred
in the community since the inception of the Messengers for Health
program. Paired sample t tests are used to evaluate the one-group
pretest and posttest interviews of 83 Apsáalooke women in knowledge,
comfort, and cancer awareness levels. Results reveal cervical cancer
knowledge gains, gains in participants\' comfort discussing cancer
issues, and gains in awareness of cervical cancer and the Messengers
program. Field notes, meeting minutes, and community perceptions are
used to qualitatively evaluate the effectiveness of the Messengers
program. Practice implications are discussed.

[Christopher
S](https://webmail.hhs.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Christopher S"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al A Cervical Cancer Community-Based Participatory Research Project
in a Native American Community. [Health Educ
Behav.](javascript:AL_get(this, 'jour', 'Health Educ Behav.');) 2007 Dec
12

## [**http://www.ncbi.nlm.nih.gov/pubmed/18077653**](http://www.ncbi.nlm.nih.gov/pubmed/18077653)

##### 

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

**PTSD: A technique that works for me**

by Dr. James Lagattuta\*

I would like to share with you a technique I use routinely to work with
client experiencing trauma.  "TIR, or Traumatic Incident Reduction, is a
systematic method of locating, reviewing, and resolving traumatic
events" link below.

With its roots in psychoanalytic as well as desensitization/exposure
literature, it is highly "person-centered, non-judgmental, and
non-evaluative" in its treatment of the client.  The provider becomes a
very active listener gently only asking the client to state when, where,
how long, and what the initial feeling was about the "incident" that
happened, followed by asking that it be first viewed in mind, and then
told to the provider ... and then repeated and repeated. At a certain
point the client is asked if they feel "heavier (H)" or "lighter (L)." 
If lighter, then this incident is "the" root trauma and work on it
continues.  If "heavier," than "is there and earlier, similar incident"
which seems to immediately come to mind, and one goes there and work
continues, with the "H" v "L" question continuing to search out "the"
root incident to which the other trauma, including the presenting one,
is linked.  Once this incident is located and neutralized, energy
involved with subsequent trauma is freed.  This would occur if the
presenting trauma involved a battle incident, or the case I shall
describe. Some details have been altered to ensure confidentiality.

After the Christmas holidays a mother asked if I would see her 18 y.o.
son for a severe depression. The depression started after a multiple car
fender-bender with no physical injuries on an icy road.  It had been
over a month since the incident and the beginning of the second semester
of his HS senior year. He had stopped driving, had not returned to
school, was missing assignments, and was having difficulty with his role
as Captain of the wrestling team.  He had already gotten early selection
to a prestigious college. I explained what I would do during our session
to mother, asking her to explain it to her son and seek his permission
to work together. 

When the son arrived, I reviewed the procedure and asked him to select
an incident to work on.  He chose the recent accident.  We proceeded in
the TIR manner and I asked the "H" v "L" question and his response was
"H."  He then jumped to a fender-bender in which he was involved as he
was driving with his mother with a learner permit at 14.

I asked,   "Heavy or Light?"

He responded, "Heavier." 

He jumped to another fender-bender at age 9 when his mother was
driving. 

As I was getting to a time when I would have asked the "H" v "L"
question he suddenly said, "and I was curled up in a ball and watched
the car run over me."

I responded, "How old were you?"

He said,  "Three."

I stated "Go there to the beginning."

Instead of responding directly he immediately replied with the following
story, "My brother and I were in the back seat of the car \... it was
parked at an incline facing down the hill leading to our house ... dad
went into the house for something ... I jumped out and went to the front
of the car ... was told later my brother jumped into the driver seat,
released the emergency brake and pretended to drive ... I saw the car
rolling toward me, curled up into a ball and looked up watching the car
roll over me." 

Then he suddenly said, "That SOB!!!  Dad came out of the house yelling
at us, blaming us for what was happening and then punished us ... and
when I was 9 he said nearly the same things, and at 14 and last month,
too!!!  I never realized how angry I've been at him all these years. "

 I asked,  "Heavy or Light?" 

He said, "Very light!"

He returned the next week, having driven himself to the appointment,
went back to school and activities, caught up with all work.  He had a
direct talk with dad about his feelings that he had held in over the
years.  He felt he had completed his work and did not need further
assistance, and went on to graduate with honors.

Though simple compared with some more seemingly more painful and complex
trauma, this procedure can at times deal with significant traumas in as
little as one viewing session.

Traumatic Incident Reduction <http://www.healing-arts.org/tir/>

\*Dr. Jim Lagattuta is a long-time therapist in Indian country and has
been a pioneer in adapting exposure-based therapies for helping AI/AN
patients recover from traumatic incidents. The following tale highlights
how he approaches this complicated issue and demonstrates how it is not
always "talking" about traumatic life events that takes the sting out.
Readers should also note that not all therapy requires multiple sessions
-- in this particular case a good outcome was achieved with one session
of focused work.

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

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

**Promoting, Protecting, Supporting**

 2001 HRSA USBC Strategic Plan brochure stresses 6 major areas that
since 1984 have withstood the test of time:

\- Improving professional education in human lactation and breastfeeding

\- develop public education and promotion efforts

\- strengthen the support for breastfeeding in the health care system

\- develop a broad range of support services in the community

\- initiate a national breastfeeding promotion effort directed at
working women; and

\- expand research on human lactation and data collection on
breastfeeding.

Mission and Vision, IV Strategic goals and objectives developed around
the 2010 goals are quite details.   For your review and use.

This will be posted on the IHS breastfeeding web page.

Contact <Judith.Thierry@ihs.gov> to review the strategic plan

####  {#section-7 .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}

#### February 2008 highlights include: {#february-2008-highlights-include .Style-Heading-4-+-Arial-14-pt-Underline}

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

\-[Concern for rising Cesarean rates in Native American
populations](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08aom)

\-[Save the Dates!! Earn up to 28 hours of CME/CE specific to Indian
Health](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08col)

\-[Knowledge of cervical length / fetal fibronectin: Shorter evaluation
and
PTB](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ht#ob)

\-[Misoprostol is as effective as manual vacuum aspiration in SAB of
\<12
weeks](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ht#gyn)

\-[Secondhand smoke during infancy linked in dose-response fashion with
allergies](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ht#child)

\-[\'Awake\' during surgery: Examining intraoperative
awareness](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ht#chrIll)

\-[Elective and risk--reducing
salpingo-oophorectomy](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#acog)

\-[Prevention and Treatment of Sexually Transmitted Diseases: An
Update](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#afp)

\-[Cervical Cancer Community-Based Research Project in a Native American
Community](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#lib)

\-[Autism
Screening](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#bhi)

\-[Breast Pumps: The good, the bad, and the
ugly](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#bf)

\-[National Report: National Indian Child
Welfare](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#dv)

\-[Palliative / End of Life Care Training- SAVE THE DATES -- March and
April
Courses](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#ecn)

\-[Continuous Oral Contraception May Not Reduce Bleeding Days but May
Improve
Sx](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#fp)

\-[New and Improved MCH Conferences page - More user
friendly](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#fws)

\-[Multiple Chlamydia species pose an unexpected challenge for blindness
prevention](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#ih)

\-[Insights on Implementing Cultural and Linguistic Competence in
MCH](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn01.cfm?module=2008&option=janFeat#alert)

\-[Announcing the 2008 PREVENT Child Maltreatment
Institute](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#mchh)

\-[St. John\'s wort for depression in a young
woman](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#mmt)

\-[Smoking Status as a Predictor of Hip Fracture Risk in Postmenopausal
Women](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#meno)

\-[AI / AN women - successful at this; Evidence supports this; Women
benefit from
this](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#midw)

\-[Judy Whitecrane: Tireless Improvement of Care for Native American
women](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#midw)

\-[Biliary Gallstone Disease and
Pregnancy](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#navajo)

\-[AWHONN -- numerous on line courses -- materials and fees
listed](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#nCrnr)

\-[Cesarean Delivery: What are the risks and
benefits?](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#okp)

\-[Patients Prefer \"Tell Back- Collaborative Inquiry\" Method to Assess
Understanding](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#pi)

\-[Women with cardiovascular risk factors may be predisposed to
pre-eclampsia](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#peri)

\-[Mental health issues in children and adolescents --Starts in
March](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#pcf)

\-[The cervical cancer risk is still increased 25 years after treatment
for CIN
3](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#std)

\-[Resolving to Lose Weight in the New
Year?](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#still)

\-[Women\'s Leadership
Scholarship](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#whh)

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/documents/CCCC_v6_02.pdf**](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/CCCC_v6_02.pdf) {#httpwww.ihs.govmedicalprogramsmchmdocumentscccc_v6_02.pdf .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 Denise Grenier, Tucson  {#domestic-violence-denise-grenier-tucson .Style-Heading-4-+-Arial-14-pt-Underline}

**IHS-sponsored training in sexual assault forensic examination**

My office will be sponsoring training in sexual assault forensic
examination for IHS and Tribal physicians, nurses and Advanced Practice
Nurses.  In order to plan the training I need an idea of the number of
people interested in attending.

Please email me if you might be interested in attending.  The training
is 40 hours long (either 4-10 hour days or 5-8 hour days) and will be
held in either Phoenix or Albuquerque this summer -- June or July.   I
will not be able to provide travel support. <Carolyn.Aoyama@ihs.gov>

**Report cites high rate of violence against Native women**

American Indian and Alaska Native women suffer from the highest rates of
domestic violence, according to a new Centers for Disease Control and
Prevention report.

In the largest-ever survey of its kind, 39 percent of Native women said
they were victims of intimate-partner violence. This was by far the
highest rate among women of all racial and ethnic groups.

The survey also showed that nearly 19 percent of Native men were victims
of intimate-partner violence. This was the second-highest rate, behind
African-American men.

Government studies have long shown that Native women suffer from high
rates of domestic violence. But the data published in the current issue
of Morbidity and Mortality Weekly Report provides the most up to date
information about an issue that is gaining national and international
attention.

\"In Alaska, an Alaska Native woman has a likelihood of rape that is
four times higher than a nonnative woman in the state,\" said Sen. Lisa
Murkowski (R-Alaska), the vice chair of the Senate Indian Affairs
Committee, said on January 23 during debate of the Indian Health Care
Improvement Act.

\"But we know it is not only in Alaska that there is this danger of
violence that faces our Native women,\" she said. \"Statistics show that
Native women around the country are two to three times more likely to be
raped than women from other populations in the United States.\"

The CDC report ties domestic violence to the high rates of chronic
diseases and conditions found in Indian Country. According to the
survey, people who are victimized by their current or former partner are
more likely to suffer from asthma, stroke and heart disease, all common
among Native Americans.

Intimate-partner violence, or IPV, is also linked to health risk
behaviors like smoking and binge drinking, according to the CDC. With
the exception of diabetes, high blood pressure and being overweight,
\"reporting of health conditions and risk behaviors was significantly
higher among women who had experienced IPV during their lifetimes
compared with women who had never experienced IPV,\" the report said.

In an editorial note, the authors of the CDC study said the data
doesn\'t prove that adverse health outcomes are directly caused by
domestic violence. They recommend that health care professionals assess
whether intimate-partner violence is a factor in treating patients.

**Resources**

**[Adverse Health Conditions and Health Risk Behaviors Associated with
Intimate Partner Violence \-\-- United States,
2005](http://www.indianz.com/my.asp?url=http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5705a1.htm)
(February 8, 2008)**

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5705a1.htm>

and

[[http://www.indianz.com/Health/]{.underline}](http://www.indianz.com/Health/)

**Resource for interrupting the cycle violence**

Online victim assistance training - VAT Online -- is available through
the Office for Victims of Crime.
[www.ovcttac.org/vatonline](http://www.ovcttac.org/vatonline)

For fact sheets go to: 
[www.ojp.usdoj.gov/ovc/assist/pdftxt/VAtraining_options_fs.pdf](http://www.ojp.usdoj.gov/ovc/assist/pdftxt/VAtraining_options_fs.pdf)

**Affects of cueing on providers discussion of intimate partner
violence**

This study identified potentially important differences in provider
behaviors \[related to discussing intimate partner violence (IPV) with
pregnant women\] as a result of cueing based upon pre-visit assessments.

The intervention included a summary cueing sheet for health
professionals, all of whom received a brief orientation to the use of
the cueing sheets. The authors found that

\* Between June 2006 and June 2007, 286 pregnant women completed a risk
assessment. Most women (223; 78%) reported no risks and were not
randomized; 63 women (22%) reported one or more risks and were assigned
to intervention or control groups.

\* IPV was the most frequently reported risk, followed by smoking. Only
three participants reported drug use, and one reported alcohol use.

\* Of the 37 women who reported IPV, 20 were randomized to the
intervention group. Seventeen intervention participants (85%) reported
having a discussion about IPV with their health professional. Of the 17
participants randomized to the control group, four (23.5%) reported
having a discussion about IPV.

\* Smoking was identified as a risk in 34 participants, and 19 were
randomized to the intervention group. All 19 intervention participants

(100%) reported having a discussion about smoking with their health
professional. Of the 15 participants randomized to the control group, 9

(60%) reported having a discussion about smoking.

The authors conclude that \"risk assessment with provider cueing is a
promising adjunct to prenatal providers\' efforts to address IPV.\"

Calderon SH, Gilbert P, Jackson R, et al. 2008. Cueing prenatal
providers: Effects on discussions of intimate partner violence. American
Journal of Preventive Medicine 34(2)134-137.
[[http://www.ajpm-online.net/article/PIIS0749379707006496/abstract]{.underline}](http://www.ajpm-online.net/article/PIIS0749379707006496/abstract)

#### Women who have had physical abuse during pregnancy: risk of preterm delivery

#### Conclusion: Women who have had physical abuse during pregnancy present a large increase in the risk of preterm delivery, independently from a large set of sociodemographic and behavioral characteristics usually recognized as determinants of preterm birth.

[Rodrigues
T](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Rodrigues T"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlusDrugs1)
et al Physical abuse during pregnancy and preterm delivery. Am J Obstet
Gynecol. 2008
Feb;198(2):171.e1-6.<http://www.ncbi.nlm.nih.gov/pubmed/17905171>

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

**Exciting opportunity to develop new resources in geriatrics**

An exciting opportunity to develop new resources in geriatrics in the
Indian Health system.

Applications are being accepted until April 2 for the Practice Change
Fellows Program. This program, sponsored by The Atlantic Philanthropies
and The John A. Hartford Foundation, is designed to expand the number of
health care leaders who can effectively promote high quality care to
older adults in a wide range of health and health care organizations. 
The short-term goal of this program is to transform health care
professionals working within the broadly defined delivery system into
effective leaders. These leaders will have strong management skills and
content expertise to effectuate practice improvement within their
organizations to better meet the needs of older adults. The long-term
goal is to establish a vigorous network of health care practice change
specialists with the capacity to influence care for this population on a
national scale.

The Practice Change Fellowship is open to nursing, social workers and
physician leaders. Leaders in local health systems (Tribal, Federal, or
Urban), and those working at an Area or regional Tribal level as well as
those working at a national level would be eligible.  The fellowship
comes with funding to support the leadership and improvement activities
(\$45,000 per year for two years) and requires a strong commitment of
support from leadership of the home organization.

You can find the details on the fellowship at
[http://www.practicechangefellows.org](http://www.practicechangefellows.org/details.asp)/

I know that the Advisory Board for the Fellowship Program is very
interested in supporting improvement in geriatric care in the Indian
Health system and I believe that they would look favorably on strong
proposals from IHS, Tribal, and Urban applicants.

Dr. Robert Schreiber, a geriatrician who has volunteered for a number of
years at Rosebud and has helped Rosebud develop a strong clinical
geriatrics program, is involved with the Practice Change Fellowship
program and has offered to provide guidance and advice to potential
applicants.

Please let me know if you have interest or have a candidate at your
facility, Office, or Tribal program who might have interest and who you
see as an effective leader who can help build your geriatric program.
And feel free to contact me with questions

  ----------------------------------------------------- ------------------------------------------------
  ![](media/image3.jpeg){width="1.8958333333333333in"   **  The Practice Change Fellows Program**
  height="0.9895833333333334in"}                        

                                                        
  ----------------------------------------------------- ------------------------------------------------

Bruce Finke, MD

IHS / Nashville Area Elder Health Consultant

Chronic Care Initiative

\(413\) 584-0790

(615) 417-4915 cell

#### 2008 End-of-Life Nursing Education Consortium Schedule announced {#end-of-life-nursing-education-consortium-schedule-announced-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### The End-of-Life Nursing Education Consortium (ELNEC) project is a national education initiative to improve end-of-life care in the United States. Launched in February 2000, the ELNEC provides nurses and nurse educators with essential training in end of life / palliative care and provides participants with the knowledge and resources to share this knowledge with other nursing colleagues. {#the-end-of-life-nursing-education-consortium-elnec-project-is-a-national-education-initiative-to-improve-end-of-life-care-in-the-united-states.-launched-in-february-2000-the-elnec-provides-nurses-and-nurse-educators-with-essential-training-in-end-of-life-palliative-care-and-provides-participants-with-the-knowledge-and-resources-to-share-this-knowledge-with-other-nursing-colleagues. .Style-Heading-4-+-Arial-14-pt-Underline}

#### ELNEC - 2008 Course Schedule - American Association of Colleges of Nursing {#elnec---2008-course-schedule---american-association-of-colleges-of-nursing .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aacn.nche.edu/elnec/CourseSchedule.htm**](http://www.aacn.nche.edu/elnec/CourseSchedule.htm) {#httpwww.aacn.nche.eduelneccourseschedule.htm .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### [**http://www.aacn.nche.edu/elnec/**](http://www.aacn.nche.edu/elnec/) {#httpwww.aacn.nche.eduelnec .Style-Heading-4-+-Arial-14-pt-Underline}

[**End-of-Life Care in the Setting of Cancer: Withdrawing Nutrition and
Hydration**](http://www.medscape.com/viewprogram/8617)

<http://www.medscape.com/viewarticle/569277>

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

**Ringing Endorsement: Women Prefer Contraceptive Ring Over Patch**

#### In the first study to directly compare a contraceptive vaginal ring and skin patch, more women indicated overall satisfaction with the vaginal ring, researchers report  {#in-the-first-study-to-directly-compare-a-contraceptive-vaginal-ring-and-skin-patch-more-women-indicated-overall-satisfaction-with-the-vaginal-ring-researchers-report .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: Women satisfied with combined oral contraceptives and interested in a nondaily method are more likely to continue using the contraceptive ring than the contraceptive patch. LEVEL OF EVIDENCE: I. {#conclusion-women-satisfied-with-combined-oral-contraceptives-and-interested-in-a-nondaily-method-are-more-likely-to-continue-using-the-contraceptive-ring-than-the-contraceptive-patch.-level-of-evidence-i. .Style-Heading-4-+-Arial-14-pt-Underline}

[Creinin
MD](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Creinin MD"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract),
et al Multicenter Comparison of the Contraceptive Ring and Patch: A
Randomized Controlled Trial. Obstet Gynecol. 2008 Feb;111(2):267-277.

#### [**http://www.ncbi.nlm.nih.gov/pubmed/18238962?dopt=Abstract**](http://www.ncbi.nlm.nih.gov/pubmed/18238962?dopt=Abstract) {#httpwww.ncbi.nlm.nih.govpubmed18238962doptabstract .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Misconceptions About Oral Contraception Pills Among Adolescents and Physicians {#misconceptions-about-oral-contraception-pills-among-adolescents-and-physicians .Style-Heading-4-+-Arial-14-pt-Underline}

#### RESULTS: The prevalence of incorrect beliefs was exceedingly high in the whole adolescent study group and relatively high among the physicians. The prevalence of incorrect beliefs was comparable between COCP users and non-users, regarding the 10 misconceptions investigated. The duration of COCP use did not influence the prevalence of misconceptions about the pill. Age did not serve as a confounding factor for all misconceptions. {#results-the-prevalence-of-incorrect-beliefs-was-exceedingly-high-in-the-whole-adolescent-study-group-and-relatively-high-among-the-physicians.-the-prevalence-of-incorrect-beliefs-was-comparable-between-cocp-users-and-non-users-regarding-the-10-misconceptions-investigated.-the-duration-of-cocp-use-did-not-influence-the-prevalence-of-misconceptions-about-the-pill.-age-did-not-serve-as-a-confounding-factor-for-all-misconceptions. .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSIONS: Lack of informative communication between COCP-prescribing physicians and users and mistaken knowledge of the caring physicians may contribute to adolescent ignorance of the COCP. Focusing on adolescent-specific disbeliefs could lead to construction of better educational programs in schools and clinics {#conclusions-lack-of-informative-communication-between-cocp-prescribing-physicians-and-users-and-mistaken-knowledge-of-the-caring-physicians-may-contribute-to-adolescent-ignorance-of-the-cocp.-focusing-on-adolescent-specific-disbeliefs-could-lead-to-construction-of-better-educational-programs-in-schools-and-clinics .Style-Heading-4-+-Arial-14-pt-Underline}

[Hamani
Y](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Hamani Y"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlusDrugs1)
et al Misconceptions about oral contraception pills among adolescents
and physicians. Hum Reprod. 2007 Dec;22(12):3078-83.

#### [**http://www.ncbi.nlm.nih.gov/pubmed/17905749**](http://www.ncbi.nlm.nih.gov/pubmed/17905749) {#httpwww.ncbi.nlm.nih.govpubmed17905749 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Copper containing IUDs are more effective for contraception than other IUDs: Cochrane {#copper-containing-iuds-are-more-effective-for-contraception-than-other-iuds-cochrane-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### AUTHORS\' CONCLUSIONS: TCu380A or TCu380S appear to be more effective than other IUDs. No IUD showed consistently lower removal rates for bleeding and pain in comparison to other IUDs. There is no evidence that any particular framed copper device is better suited to women who have not had children. {#authors-conclusions-tcu380a-or-tcu380s-appear-to-be-more-effective-than-other-iuds.-no-iud-showed-consistently-lower-removal-rates-for-bleeding-and-pain-in-comparison-to-other-iuds.-there-is-no-evidence-that-any-particular-framed-copper-device-is-better-suited-to-women-who-have-not-had-children. .Style-Heading-4-+-Arial-14-pt-Underline}

[Kulier
R](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Kulier R"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlusDrugs1),
et al Copper containing, framed intra-uterine devices for contraception.
Cochrane Database Syst Rev. 2007 Oct 17;(4):CD005347.
<http://www.ncbi.nlm.nih.gov/pubmed/17943851>

**Ortho Evra Contraceptive Transdermal Patch: Higher risk of serious
blood clots**

A modified the prescribing information for the Ortho Evra Contraceptive
Transdermal (Skin) Patch to include the results of a new epidemiology
study that found that users of the birth control patch were at higher
risk of developing serious blood clots, also known as venous
thromboembolism (VTE), than women using birth control pills. VTE can
lead to pulmonary embolism. The label changes are based on a study
conducted by the Boston Collaborative Drug Surveillance Program on
behalf of Johnson and Johnson. The patch was studied in women aged
15-44. These findings support an earlier study that also said women in
this group were at higher risk for VTE.\
\
FDA believes that Ortho Evra is a safe and effective method of
contraception when used according to the labeling, which recommends that
women with concerns or risk factors for serious blood clots talk with
their health care provider about using Ortho Evra versus other
contraceptive options.
<http://www.fda.gov/medwatch/safety/2008/safety08.htm#orthoevrapatch>

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

#### Levonorgestrel / Ethinyl Estradiol (Lybrel) for Continuous Contraception {#levonorgestrel-ethinyl-estradiol-lybrel-for-continuous-contraception-1 .Style-Heading-4-+-Arial-14-pt-Underline}

Bottom Line: Lybrel appears to be as safe and effective as other
combined oral contraceptives; however, at this time, there is little
published data about this specific product. Other combined monophasic
oral contraceptives, some of which cost less than Lybrel, can be used
continuously and have been shown to produce similar results. Patients
who choose to take contraceptives continuously should be advised that
they may experience spotting or irregular menses at any time.
[**http://www.aafp.org/afp/20080115/steps.html**](http://www.aafp.org/afp/20080115/steps.html)

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

**Featured Website David Gahn, IHS MCH Portal Web Site Content
Coordinator**

#### Meeting notes now online: [2007 Native Women's Health and MCH Conference](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/Intro Slide and Eval Sli14.ppt)\*

**Kelly Acton, M.D.**

-   [Diabetes in American Indian & Alaska Native
    Women](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/2007 OB GYN conf DM & women.ppt)

**Gail Bolan MD**

-   [Current Issues in STD Management: Implications for Improving
    Women's Reproductive Health
    Outcomes](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/IHS womens STD update 8.16.07.ppt)

**Karen Carey CNM MS**

-   [Obstetric
    Drills](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/McBride - OB Emergency Drills.ppt)

**Peter Cherouny, MD**

-   [Idealized Design of Perinatal Care:
    Plenary](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-15Wed/9-15 am - Cherouny - New Mexico 0815.ppt)

```{=html}
<!-- -->
```
-   [Quality Care in Obstetrics-Clinical Bundles:
    Workshop](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-15Wed/WS 1 AND 20 - New Mexico 0815 breakout.ppt)

**Donald Coustan, M.D.**

-   [GESTATIONAL
    DIABETES](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/9-00am Coustan -- NewMex17.ppt)

```{=html}
<!-- -->
```
-   [Gestational
    Diabetes](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-16Thur/9-00am Coustan -- NewMexicoGDM2007.ppt)

```{=html}
<!-- -->
```
-   [Use of Oral Antidiabetic Agents in Obstetrics:
    Workshop](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-16Thur/Ws 42 - Coustan -- Albuquerque Workshop 2007 oral_1.ppt)

**Scott Deasy, M.D.**

-   [Navajo Nation Breast & Cervical Cancer Prevention
    Program](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8.16.07 Presentation.ppt)

**Willeen Druley, RN, MS, BC, FNP**

-   [Mobile Women's Health
    Unit](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/Mobile Unit-presentation updated 8-7-07.ppt)

**Denise Findlay, RN BSN**

-   [Using the Feeding & Teaching Scales to Plan Effective
    Interventions](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-15Wed/WS 7 - Findlay - Albuquerque PCI.ppt)

```{=html}
<!-- -->
```
-   [Promoting Maternal Mental Health During
    Pregnancy](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-15Wed/WS 10 - Findlay -- Albuquerque PMMH.ppt)

**Terry Friend, CNM**

-   [SCHOOL-BASED HEALTH (BY
    ACCIDENT)](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/SCHOOL PRESENTATION 2.ppt)

**Cindy Gebremariam, RN**

-   [iCare: A population management
    tool](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/iCare presentation Nashville Best Practices Conference 2007_.ppt)

**Scott Giberson, Ph. C, Pharm D, MPH**

-   [IHS HIV Program: Risk and
    Response](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/Women's Health HIV Program Final Aug 14.ppt)

**George Gilson, M.D.**

-   [HIV Infection in Pregnancy: 2007
    Update](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/HIV-2007.ppt)

-   The OB -- Peds interface: " Got issues? "

```{=html}
<!-- -->
```
-   [Prenatal Testing Update
    2007](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/prenataltesting2007.ppt)

**Amy Groom, MPH**

-   [HPV Vaccine
    Implementation](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/Groom HPV Vaccine.ppt)

**Howard Hays, M.D.**

-   [Women's Health Software Application V
    3.0](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/WHPresNAWConference FINAL 2007_08.ppt)

**Mary Henrikson MN, RNC**

-   [Us versus Them and Being in the
    Middle](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-17Fri/8-00 am --Henrickson -- Us Versus Them.ppt)

**Stephen W. Heath, MD, MPH**

-   [Risk Management in Maternal Child
    Health](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/MCH Talk.ppt)

**Lynn Hoefer, DV Advocate**

-   [Ketchikan Indian Clinic Domestic Violence Project: Take Home
    Tips](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/Native Women's Health and MCH Conference 081507.ppt)

```{=html}
<!-- -->
```
-   [Take Home Tips from Alaska IPV/DV Screening Project: Linking
    Culture and Community to
    Action](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/Take Home Tips DV 8-14-07.ppt)

**Diane Jeanotte RN**

-   [Billings Area SIDS / Infant Mortality
    Reduction](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/Jeanotte - August PresentationNO.ppt)

**Wanda K. Jones, Dr. P.H.**

-   [Optimizing Women's Health in the United States:
    Deaths](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-15Wed/Jones Handout -- OWHhandhout-deaths.doc)

```{=html}
<!-- -->
```
-   [Optimizing Women's Health in the United States:
    URLs](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-15Wed/Jones Handout -- OWHhandout-URLs.doc)

**Favian Kennedy, MSW**

-   [Northern Plains Smoke-Free Homes
    Campaign](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/SFH for IHS.pdf)

**Nancy Knapp MPH & Brenda Isaacs**

-   [Integrating Brief Motivation Enhancing Interventions into the
    Primary Care
    Setting](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-15Wed/WS 21 0 Knapp - WISEWOMAN IHS womens health conf Aug 2007-ha.ppt)
    [Integrating Brief Motivation Enhancing Interventions into the
    Primary Care Setting:
    Handout](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-15Wed/WS 21 0 Knapp -Hand Out ONLY.ppt)

**Michele R. Lauria, MD, MS**

-   [Optimizing Care Through Simulations and Structured Communication:
    Plenary](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-15Wed/10-15am - Lauria - New Mexico 2007.ppt)

```{=html}
<!-- -->
```
-   [Vaginal Birth after Cesarean: Still a Viable Option?
    Workshop](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-15Wed/WS 8 - Lauria Indian Health servcie to use.ppt)

**Rachel Locker, M.D.**

-   [Domestic Violence: Screening and
    Documentation](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/MCH DV locker clark.ppt)

**Tami McBride, CNM, MS, RNC**

-   [Obstetric Emergency
    Drills](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/OBEmergDrills.ppt)

-   [Obstetric Drill De-Brief
    Form](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/OBDrillDebriefForm.doc)

**Richard McClain, MD**

-   [MONARC vs. Paravaginal wall Repair: A system and surgeon
    perspective](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/WS 30 - McClain -- Stress Urinary Incontinence Pres.ppt)

**Paul Melinkovich, M.D.**

-   [Denver School-Based Health
    Centers](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/IHS MCH 8 07.ppt)

**Connie Monahan, MPH**

-   [Challenges of SANE in the Clinical Setting
    (Plenary)](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/Nat Am & MCH 07 - genera12.ppt)

```{=html}
<!-- -->
```
-   [Making SANE Work: Operational Details
    (Workshop)](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/Nat Am & MCH 07 - breakout.ppt)

```{=html}
<!-- -->
```
-   [Challenges of SANE in the Clinical
    Setting](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-16Thur/10-15 am - Monahan - Nat Am & MCH 07 - general session.ppt)

```{=html}
<!-- -->
```
-   [Challenges of SANE in the Clinical Setting:
    Handout](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-16Thur/10-15 am - Monahan - HANDOUT ONLY.ppt)

```{=html}
<!-- -->
```
-   [Making SANE Work: Operational
    Details](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-16Thur/WS 40 - Slides - Monahan - Nat Am & MCH 07 - breakout.ppt)

```{=html}
<!-- -->
```
-   [Appendices: Making SANE
    work](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-16Thur/WS 40 - HANDOUT - Monahan - Nat Am & MCH 07 - APPENDICES for.doc)

**Neil Murphy MD**

-   [2007 Data
    Tally](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/HandoutsPres/Dr Muphys 2 -- DataTally81107.doc)

```{=html}
<!-- -->
```
-   [2007 Birth Statistics by
    Facility](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/HandoutsPres/Murphy - Packet BirthStats7904.xls)

```{=html}
<!-- -->
```
-   [2007 Narrative
    Tally](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/HandoutsPres/Dr Murphys 3 -- NarrativeTally81107.doc)

```{=html}
<!-- -->
```
-   [Human Papilloma Virus Vaccine
    2007](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/ABQHPV81607.ppt)

```{=html}
<!-- -->
```
-   [Save the
    World](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/SaveTheWorld81407.ppt)

```{=html}
<!-- -->
```
-   [How to keep
    current](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/HowtokeepcurrentABQ81607.ppt)

**Sue Murphy, RD, MPH, CDE, CLE**

-   [Breastfeeding
    Update](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/Murphy - MCH OB-GYN conf 8-15-07.ppt)

**Tony Ogburn MD**

-   [Contraception for teens: What's
    new?](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/Ogburn - Contraception-adolescents IHS 8-07.ppt)

**Sharon Phelan MD**

-   [Obesity: A weighty
    problem](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/Phelan - OBESITY IHS August 2007.ppt)

**Marilyn Pierce Bulger**

-   [Community Approaches to Reducing Infant Mortality: Nutaqsiivik
    Program](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/Community Approaches To Reducing IM Nutaq.ppt)

-   [Approaches To Reducing Infant Mortality- Nutaqsiivik
    Program](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/Pierce-Bulger - Community Approaches To Reducing IM Nutaq.ppt)

**Usha Ranji, M.S.**

-   [Health Coverage and Access to Care: Key Issues for Native
    Women](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-15Wed/Ranji IHS Conference August 2007.ppt)

**Brigg Reilley**

-   [Prenatal HIV Screening:
    Workshop](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-15Wed/WS 4 - Reilley - native women conference.ppt)

**Sharon Schindler Rising, MSN, CNM**

-   [Essential Elements of the Centering
    Model](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/HandoutsPres/Suzan Murphy HO - Model overview-4 page-8-07.doc)

**Greg Shorr, M.D.**

-   [PCC+ Obstetric Care
    Module](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/ShorrMCH_aug_07.ppt)

**Melanie Taylor MD, MPH**

-   [Chlamydia Among AI/AN Adolescents: The Stop Chlamydia
    Project](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/Taylor - NewMexPresentation Aug1407.ppt)

**Judy Thierry, DO MPH**

-   [Improve the System, Improve the
    Outcome](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-15Wed/8-00am -Welcome -- slides - thierry.ppt)

-   [PCC+ Obstetric Care
    Module](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/MCH_aug_07.ppt)

**Shelley Thorkelson , CNM MSN CDE**

-   [Case Tracking Strategies Using RPMS , CMS, DMS and Hard
    Copy](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/DM and Preg Program Over12.ppt)

```{=html}
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```
-   [Diabetes in Pregnancy: Case Tracking
    Strategies](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-16Thur/Ws 42 - Handout 2 Thorkelson SJT GDM Flowsheet.doc)

```{=html}
<!-- -->
```
-   [DM & Pregnancy Program Flow
    sheet](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-16Thur/WS 42 - Slides - Thorkelson DM and Preg Program Overview2006.ppt)

**Sheila Warren, MPH, RN, CPHQ**

-   [Patient Safety in Maternal Child
    Health](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/MCH conference 8 2007 sheila.ppt)

**Judy Whitecrane MSN, CNM**

-   [What We Did About Prenatal Substance
    Abuse](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-15Wed/WS 9 - Whitecrane - Special Care Clinic Services-2007.ppt)

**Nancy Whitney, MS, LMHC**

-   [Intervention as Prevention: Working Effectively with Mothers Who
    Abuse Alcohol and Drugs During
    Pregnancy](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-15Wed/WS 16 - Slides (Print 3 slides per pg) Nancy Whitney HANDOUT.ppt)

```{=html}
<!-- -->
```
-   [Parent-Child Assistance Program
    (PCAP)](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-15Wed/WS 16 - HANDOUT 2 Nancy Whitney HANDOUT 2.doc)

**\***
<http://www.ihs.gov/MedicalPrograms/MCH/F/lecNotes.cfm#wHealthConf>

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

**How can we actually reduce infant mortality in AI/AN?**

Marilyn Pierce-Bulger present information on a successful program in
Anchorage

[http://www.ihs.gov/MedicalPrograms/MCH/F/documents/Community%20Approaches%20To%20Reducing%20IM%20Nutaq.ppt](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/Community Approaches To Reducing IM Nutaq.ppt)

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

**February 2008**

-On decreasing the use of antibiotics for acute otitis media

-The RSV Season: Is there relief in sight?

-Childhood cancer mortality trends

[http://www.ihs.gov/MedicalPrograms/MCH/M/ChPedNotes.cfm]{.underline}

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

**iCare Training**

The IHS Office of Information Technology (OIT) and the IHS Clinical
Support Center (Accredited Sponsor) present WebEx training sessions for
the iCare (Population Management) software application. You will be able
to participate in the training from the comfort of your office or
conference room and will not be required to travel to obtain this
training.

iCare is a tool with multiple uses for a wide variety of providers that
presents diverse RPMS data through an easy to use graphical user
interface (GUI).

We will continue to offer a brief intro session that will just
[introduce]{.underline} the software to participants. This session does
not offer any training and CEUs **[will not]{.underline}** be given for
this session

1\. A Brief Introduction to iCare 30 minutes

The 2 standard training sessions are again offered and we are now
offering CEUs for these classes. We recommend these 2 classes be taken
sequentially.

1.  iCare - Nuts and Bolts 2.0 hours

2.  the Practical Use of iCare 1.5 hours

The target audience is [any]{.underline} provider who cares for patients
(e.g. physicians, mid-level providers, nurses, case managers, public
health personnel, pharmacists etc.)

**[NOTE:]{.underline}** **You must register for these classes.** They
are NOT limited to participants in a particular Area; they are open to
all. Below are the agendas and date/times for both classes.

You can choose to register individually or as a group. If you register
individually, all you need is your computer, the ability to sign on to
the internet and a telephone. If you\'d like to attend as a group, one
person will need to register and then sign in at the designated time.
You will need a conference room, conference phone, computer and
projector.  Please ensure someone at your facility is responsible for
taking care of these arrangements.

Please note that these are live, internet-based trainings, not recorded
sessions, and people will be able to ask questions and actively
participate in the class.

**[NOTE:  All training times shown above are for the Mountain Standard
Time (Arizona Time) zone.  Please ensure you adjust the time for your
particular time zone.]{.underline}**

ACCREDITATION:

The Indian Health Service (IHS) Clinical Support Center is accredited by
the Accreditation Council for Continuing Medical Education to sponsor
continuing medical education for physicians.

The IHS Clinical Support Center designates this continuing medical
education as Category 1 credit toward the Physician's Recognition Award
of the American Medical Association. Each physician should claim only
those hours of credit he or she actually spent in the educational
activity.

This Category 1 credit is accepted by the American Academy of Physician
Assistants and the American College of Nurse Midwives.

The Indian Health Service Clinical Support Center is accredited as a
provider of continuing nursing education by the American Nurses
Credentialing Center's Commission on Accreditation.

**[Training Schedule]{.underline}**

1.  **[iCare -- Nuts and Bolts]{.underline}**

> Target Audience -- Patient Care Providers (e.g. physicians, mid-level
> providers, nurses, case managers, public health personnel, pharmacists
> etc.)
>
> **[Agenda]{.underline}**

-   Introductions and Context

-   Set Up

-   Background Processes

-   Establishing and Changing User Preferences

-   Panel Creation

-   Panel Modification

-   Patient Record

**[Session                          Date and Time                Reg
Password]{.underline}**

iCare Nuts and Bolts Tues 03/11/2008 08:00-10:00 MST coyote

Mon 03/24/2008 11:00-13:00 MST coyote

2.  **[The Practical Use of iCare]{.underline}**

> Target Audience -- Patient Care Providers (e.g. physicians, mid-level
> providers, nurses, case managers, public health personnel, pharmacists
> etc.)
>
> **[Agenda]{.underline}**

-   Introductions and Context

-   Scenarios

-   Tips

-   Using the Performance Measure views to improve outcomes

**[Session                         Date and
Time                              Reg Password]{.underline}**

The Practical Use of iCare Tues 03/18/2008 08:30-10:00 MST coyote

Wed 03/26/2008 14:00-15:30 MST coyote

3.  **[A Brief Introduction to iCare]{.underline}**

> Target Audience -- Patient Care Providers (e.g. physicians, mid-level
> providers, nurses, case managers, public health personnel, pharmacists
> etc.) who don\'t have time to attend a longer session.
>
> **[Agenda]{.underline}**

-   Highlights

-   Background Processes

-   Panel Creation and Modification

**[Session Date and Time Reg Password]{.underline}**

A Brief Introduction to iCare Thurs 03/13/2008 14:00-14:30 MST coyote

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

1.  Click this link:

> [https://ihs-hhs.webex.com](https://ihs-hhs.webex.com/)

1.  In the Search box, type in \"iCare\" (do not type in the quotation
    marks) and click the Search button.  **NOTE:  If you do not see the
    Search For box, ensure the Training Center tab is selected at the
    top of the WebEx window.**

2.  All of the scheduled sessions will then be displayed in the window
    below.  Choose the one you want to attend and click "Registration"
    in the Status column.

3.  Enter the Registration password that is shown above that corresponds
    to the class you want to attend.

4.  Click the OK button.

5.  Complete the registration form.

6.  Click the Register button.

7.  A Registration confirmation is displayed that contains all of the
    information for the training session, including the link for the
    session and the password to enter when you are ready to attend the
    session.  Click the OK button to finish.

**[Setup (Software Install) Information:]{.underline}**

You must have the WebEx software installed on your computer prior to
attending the WebEx session.  **[You should setup the software at least
a day before the training session.]{.underline}**  You should not need
anyone such as the Site Manager to install it for you.  Below are the
instructions.

1.  Click this link:

> [https://ihs-hhs.webex.com](https://ihs-hhs.webex.com/)

1.  On the left side of the window, locate Set Up

2.  Click Training Manager

3.  A message is displaying giving you information about the setup
    process. Click the Set Up button

4.  After the software is installed, click the OK button.

**[Attending the Session:]{.underline}**

On the day of the scheduled training, you will receive a confirmation
email. When you are ready to attend the session, connect to the WebEx
session by clicking on the link in that email. You will then need to
connect to the conference line.  The dial information for the conference
line is shown below and is also included in your registration
confirmation message.

Phone Number:  (877) 781-4791

Passcode:         135963#

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

**Good intentions and unintended consequences**

At the turn of the twenty-first century, activists, politicians, and
academics pushed hard for a major increase in international funding to
solve seemingly intractable health problems in the Third World. Two
results are the GAVI Alliance, formed in 2000 to expand mass vaccination
programs (particularly for children), and the Global Fund, created in
2002 to tackle HIV/AIDS, tuberculosis and malaria. Most observers agree
that both organizations have been very successful at bringing together
government, industry and other private funds -- at a scale larger than
imagined possible in the past -- and directing them to programs, private
or governmental, that address these pressing health issues in poor
countries. Two recent analyses, however, raise concerns about some
unintended side effects.

At issue is a shift in the concept of sustainability. Conventional ideas
of sustainability meant that recipient countries would need to gradually
take over any internationally funded health intervention. Because the
cost of vaccines and AIDS drugs is so high, programs involving treatment
of AIDS or prevention of childhood infections were clearly not going to
be sustainable by this definition anytime soon. An innovation of the new
funders was to consider programs "sustainable" if they could be paid for
indefinitely at the international level. If wealthy countries made
long-term pledges to buy drugs and vaccines, the poorest recipients
would only have to be sustainably responsible for provision of basic
health-system needs like transport, nutritional support, and health care
staffing. And therein lies the rub.

The "vertical" programs (those targeted toward a specific problem rather
than general primary health care) funded through these new mechanisms
keep their staff lean and their programs efficient by refusing to
integrate other kinds of care. Where transport is difficult, as in much
of the Third World, villagers may walk for hours to bring a sick or
starving child in for a mass vaccination campaign, but be unable to
speak to anyone about their child's malnutrition, seizure disorder, or
diarrhea -- not to mention the mother's new pregnancy. These primary
health tasks shift downward to untrained laypeople, or to no one at all,
and health systems become more fragmented.

Perhaps even more problematic are the effects on public health sector
staffing. When vertical programs such as those providing antiretrovirals
are part of the public health system, donors pay for the drugs but not
the new staff needed to distribute them and monitor patients. When these
programs are non-governmental, they hire qualified nurses and doctors
away from the public sector, because they can afford to pay more than
the local salary. Most of the time, both types of programs are funded in
any given country. A ministry of health must train, recruit, and pay
salaries for new staff even as existing doctors and nurses are being
hired away by better-funded employers. But governments are required by
the international financial institutions from which they borrow to keep
civil service salaries at a pre-specified cap. Ministries of health are
left with two ugly choices. They can violate the salary cap to recruit
and retain health workers, but lose all development loans (which may
amount to half a country's total budget), or they can keep salaries low
and risk ongoing hemorrhage of qualified health professionals into the
non-governmental sector -- not to mention the strikes, retirements, and
emigration that take their toll on the well-being of patients in public
hospitals and clinics.

The jury is still out on the actual impact of these big new funding
programs on the health problems they target. (Expect early reports for
the Global Fund by later this year.) But it's already clear that in some
of the most heavily targeted areas, maternal and child health indicators
are deteriorating even as vaccination rates rise and deaths from AIDS
begin to plateau. As a doctor in Malawi told me flatly, talking about
hospital staffing and maternal deaths in that country, "these NGOs are
killing us." It may be time to think again about what sustainability
really means, and whose responsibility it really is.

Ooms G. et al. 2007 Medicines Without Doctors: Why the Global Fund Must
Fund Salaries of Health Workers to Expand AIDS Treatment. PLoS Medicine
4(4):e128.

<http://www.ncbi.nlm.nih.gov/pubmed/17439295>

Piller C. and D. Smith 2007 Unintended victims of Gates Foundation
generosity. Los Angeles Times 16 December.

**Peanuts +Vegetable oil +milk powder+vitamins + minerals = Plumpynut**

We estimated that stunting, severe wasting, and intrauterine growth
restriction together were responsible for 2·2 million deaths and 21% of
disability-adjusted life-years (DALYs) for children younger than 5
years. Deficiencies of vitamin A and zinc were estimated to be
responsible for 0·6 million and 0·4 million deaths, respectively, and a
combined 9% of global childhood DALYs. Iron and iodine deficiencies
resulted in few child deaths, and combined were responsible for about
0·2% of global childhood DALYs.

-Iron deficiency as a risk factor for maternal mortality added 115000
deaths and 0·4% of global total DALYs.

-Suboptimum breastfeeding was estimated to be responsible for 1·4
million child deaths and 44 million DALYs (10% of DALYs in children
younger than 5 years).

In an analysis that accounted for co-exposure of these nutrition-related
factors, they were together responsible for about 35% of child deaths
and 11% of the total global disease burden."  

>  

Peanuts +Vegetable oil +milk powder+vitamins + minerals = Plumpynut

Peanuts contain mono-unsaturated fats, which are easy to digest. They
are also very high in calories, which means that a child will get a lot
of energy from just small amounts (important because their stomachs have
shrunk). They are rich in zinc and protein --- both good for the immune
system. Protein is also needed for muscle development.  Peanuts are a
good source of vitamin E, a powerful antioxidant that helps to convert
food into energy. Peanuts are a wonder food, really --- the problem that
we in the West have is that there is such a high incidence of peanut
allergy \...Another theory is that developed countries introduce nuts
relatively late compared with other cultures.

Plumpy\'nut was created by André Briend, who spent years working in
humanitarian crises. He realised that a ready-to-eat supplement that
needs no cooking or added water, and is cheap to produce, could help to
save millions of lives in remote and under-developed areas. Plumpy\'nut
is now produced in Normandy by a company that specialises in food
relief, in partnership with Unicef, the United Nation\'s children\'s
organisation.

The UN says that 150,000 children under 5 are severely malnourished in
Niger and a further 650,000 are moderately malnourished. This translates
into ankles and wrists barely wider than a man\'s thumb
[www.plumpynutinthefield.com/eng/index-eng.php](http://www.plumpynutinthefield.com/eng/index-eng.php)

Black RE Maternal and child undernutrition: global and regional
exposures and health consequences The Lancet, Volume 371, Number 9608,
19 January 2008

[[http://www.thelancet.com/journals/lancet/article/PIIS0140673607616900/fulltext]{.underline}](http://www.thelancet.com/journals/lancet/article/PIIS0140673607616900/fulltext)

**CCGHE Launches Online HIV Training Course in Zambia**

The need for in-depth clinical training about HIV care and treatment in
Zambia is Zambia widely recognized. The CCGHE and JHPIEGO, a Johns
Hopkins affiliate with a country office in Lusaka, Zambia have worked
together to bring a new online course, Management of Adult HIV in
Zambia. The course contains 22 lectures by experts at Johns Hopkins,
JHPIEGO, University Teaching Hospital in Lusaka and Ministry of Health.
Topics include Epidemiology and Infection Prevention, Diagnosing and
Initial Management, Clinical Manifestations of HIV Infection, and
Antiretroviral Therapy. Support for this course was provided in part by
Northwater Foundation.

More than 120 physicians, nurses, pharmacists, program managers, and
researchers have signed up to take the course, which runs from January
16 - February 20, 2008. Course participants will receive CD-ROMS of the
lectures, and take pre and post-tests online toward a Certificate of
Achievement.

Featured Case

6yo female presented to ED with fever of 103°F, change in MS \...

Infectious Disease Grand Rounds Recently Posted

-35 yo female with untreated AIDS who developed a painful, pruritic
rash\...

-31 yo male with AIDS (CD4 = 4) presented with 1 mo h/o SOB, fatigue\...

-34 yo female,1 mo post delivery by C-section, who developed sepsis\...

-17 mo male who developed a 3 day onset of rhinorrhea, fever, low
appetite\...

-9 wk old female who presented with 1d h/o decreased po intake & urine
output\...

<http://www.ccghe.jhmi.edu/assets/CCGHE/Documents/ADVANCE_Health_Information_Executives.pdf>

**Stunting In First Two Years Of Life Leads To Huge Negative
Consequences In Later Life**

Poor fetal growth or stunting in the first two years of life leads to
irreversible damage, including shorter adult height, lower attained
schooling, reduced adult income and decreased offspring birthweight for
women.

#### We conclude that damage suffered in early life leads to permanent impairment, and might also affect future generations. Its prevention will probably bring about important health, educational, and economic benefits. Chronic diseases are especially common in undernourished children who experience rapid weight gain after infancy. {#we-conclude-that-damage-suffered-in-early-life-leads-to-permanent-impairment-and-might-also-affect-future-generations.-its-prevention-will-probably-bring-about-important-health-educational-and-economic-benefits.-chronic-diseases-are-especially-common-in-undernourished-children-who-experience-rapid-weight-gain-after-infancy. .Style-Heading-4-+-Arial-14-pt-Underline}

[Victora
CG](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Victora CG"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlusDrugs1),
et al Maternal and child undernutrition: consequences for adult health
and human capital. Lancet. 2008 Jan 16
<http://www.ncbi.nlm.nih.gov/pubmed/18206223>

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

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

#### 1 of 3 Child Deaths And 11% Of Global Disease Due To Maternal And Child Undernutrition {#of-3-child-deaths-and-11-of-global-disease-due-to-maternal-and-child-undernutrition .Style-Heading-4-+-Arial-14-pt-Underline}

#### More than one third of child deaths and 11% of the total disease burden worldwide are due to maternal and child undernutrition. By doing an analysis that accounted for co-exposure of nutrition-related factors, the authors found that they were together responsible for 35% of child deaths globally and 11% of the total global disease burden. The authors conclude: \"The high mortality and disease burden resulting from these nutrition-related factors make a compelling case for the urgent implementation of interventions, to reduce their occurrence or ameliorate their consequences. {#more-than-one-third-of-child-deaths-and-11-of-the-total-disease-burden-worldwide-are-due-to-maternal-and-child-undernutrition.-by-doing-an-analysis-that-accounted-for-co-exposure-of-nutrition-related-factors-the-authors-found-that-they-were-together-responsible-for-35-of-child-deaths-globally-and-11-of-the-total-global-disease-burden.-the-authors-conclude-the-high-mortality-and-disease-burden-resulting-from-these-nutrition-related-factors-make-a-compelling-case-for-the-urgent-implementation-of-interventions-to-reduce-their-occurrence-or-ameliorate-their-consequences. .Style-Heading-4-+-Arial-14-pt-Underline}

[Black
RE](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Black RE"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlusDrugs1)
et al Maternal and child undernutrition: global and regional exposures
and health consequences. Lancet. 2008 Jan 19;371(9608):243-60.

#### [**http://www.ncbi.nlm.nih.gov/pubmed/18207566**](http://www.ncbi.nlm.nih.gov/pubmed/18207566) {#httpwww.ncbi.nlm.nih.govpubmed18207566 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Maternal depression as a risk factor affecting child readiness and
school readiness**

Reducing Maternal Depression and Its Impact On Young Children: Toward a
Responsive Early Childhood Policy Framework provides an overview of why
it is important to address maternal depression as a central part of the
effort to ensure that all young children enter school ready to succeed.

The issue brief is jointly published by Project THRIVE and Pathways to
Early School Success at the National Center for Children in Poverty
(NCCP). Project THRIVE serves as a resource to the Maternal and Child
Health Bureau-funded State Early Childhood Comprehensive Systems
program. Pathways to Early School Success is NCCP\'s ongoing project to
help policymakers, program administrators, and practitioners reduce
barriers to achievement for young children from families with low
incomes. The brief is based on a meeting to identify and promote
solutions to emerging issues that impact young children\'s healthy
development and school readiness. Topics include how depression affects
parenting and child outcomes, particularly for young children; how often
it occurs in combination with other parental risks, like post-traumatic
stress disorders; and what kinds of strategies can prevent negative
consequences for parents, for their parenting, and for their young
children. State and federal policy responses, recommendations, and a
conclusion are also presented.
[[http://www.nccp.org/publications/pub_791.html]{.underline}](http://www.nccp.org/publications/pub_791.html)

**Role of nurses in oral health of children and women**

The January-February 2008 issue of MCN: The American Journal of
Maternal-Child Nursing focuses on the role of nurses in promoting oral
health in children, adolescents, and women. One of the articles in the
issue presents a Nurse\'s Call to Action to help improve oral health in
women. Another article provides an overview of early childhood caries
and suggestions for actions that nurses can take to improve children\'s
oral health. Other topics addressed in the issue include the health
risks associated with adolescent\'s oral behaviors of adolescents; gaps
in practice and research on pregnancy and oral health and
recommendations to close these gaps; nursing care and management of
pathological oral conditions in women and children; maternal periodontal
disease, pregnancy, and neonatal outcomes; and how nurses can help women
and children with HIV and AIDS who have oral complications. Additional
content focuses on nurse-dentist collaboration, infant nutrition and
oral health, and global oral health in women and children. The journal
is available at
[[http://www.mcnjournal.com]{.underline}](http://www.mcnjournal.com/)

**Relationship between air pollution and postneonatal infant mortality**

A recent review of air pollution and children's health in Europe by the
World Health Organization concludes that \'the evidence is sufficient to
infer a causal relationship between particulate air pollution and
respiratory deaths in the post-neonatal period\' (World Health
Organization 2005).

The authors found that

\* The relationship between course particulate matter and
respiratory-related postneonatal mortality was elevated and significant
in both the single- and the multi-pollutant models.

\* For SIDS, ozone was associated with a significant increased risk in
the single-pollutant models.

The authors conclude that this study provides further support for PM air
pollution as a risk factor for respiratory-related postneonatal infant
mortality and suggests that \[ozone\] may play a role in SIDS.

Woodruff TJ, Darrow LA, Parker JD. 2008. Air pollution and postneonatal
infant mortality in the United States, 1999-2002. Environmental Health
Perspectives 116(1):110-115. Full text available at
[[http://www.ehponline.org/members/2007/10370/10370.pdf]{.underline}](http://www.ehponline.org/members/2007/10370/10370.pdf)

**Influence of multiple social risk factors on children's health**

Social risk factors threaten children\'s health in a cumulative manner
across physical health, oral health, and mental heath domains. The
authors found that

\* Approximately 40% of the children were from families with low
incomes, 32% lived in a household where no resident had an education
beyond high school, 55% had two or more social risk factors, and 24% had
four or more.

\* Low maternal mental health, black race or Hispanic ethnicity, family
income less than 200% of the FPL, low household education, unsafe
neighborhoods, and lack of health insurance increased the odds for less
than very good child health.

\* Low maternal mental health, black race or Hispanic ethnicity, family
income less than 200% of the FPL, low household education, unsafe
neighborhoods, lack of health insurance, and family conflict increased
the odds for less than very good oral health.

\* For child socioemotional problems, low maternal mental health, not
residing in a two-parent household, and family conflict were strong
independent correlates, along with unsafe neighborhoods and family
income less than 200% of the FPL.

\* All the risk factors except lack of insurance increased the odds for
overweight.

\* When risks were combined into a social risk index, controlling for
child age, gender, and number of children in the household, there was a
17-fold increase in the odds for less than very good health and an
almost 11-fold increase in the odds for less than very good oral health
for children with six or more vs. zero social risks; the respective
figure for child socioemotional well-being and overweight status was
about four.

\"The cumulative impact of multiple risks is much greater than the
effect of any one risk acting alone. Programs and policies that address
multiple domains of social risk offer the best hope for achieving
improvements in child health.

Larson K, Russ SA, Crall, JJ, et al. 2008. Influence of multiple social
risks on children\'s health. Pediatrics 121(2):337-344.
[[http://pediatrics.aappublications.org/cgi/content/abstract/121/2/337]{.underline}](http://pediatrics.aappublications.org/cgi/content/abstract/121/2/337)

**MCH Headlines Judy Thierry HQE**

**Findings from the National Survey of Children\'s Health includes
Native Americans**

The authors set out to examine racial/ethnic disparities in medical and
oral health, access to care, and use of services in a national sample.

They used the National Survey of Children\'s Health which was a
telephone survey in 2003-2004 of a national random sample of parents and
guardians of 102,353 children 0 to 17 years old. Disparities in selected
medical and oral health and health care measures were examined for
white, African American, Latino, Asian/Pacific Islander, Native
American, and multiracial children. The authors found many significant
disparities were noted; for example:

-Uninsurance rates were 6% for whites, 21% for Latinos, 15% for Native
Americans, 7% for African Americans, and 4% for Asians or Pacific

Islanders,

-The proportions of children with a usual source of care were as
follows: whites, 90%; Native Americans, 61%; Latinos, 68%; African
Americans, 77%; and Asians or Pacific Islanders, 87%.

-Many disparities persisted for one minority group in multivariate
analyses, including increased odds of suboptimal health status,
overweight, asthma, activity limitations, behavioral and speech

problems, emotional difficulties, uninsurance, suboptimal dental
health,no usual source of care, unmet medical and dental needs,
transportation barriers to care, problems getting specialty care, no
medical or dental visit in the past year, emergency department visits,
not receiving mental health care, and not receiving prescription
medications.

-Certain disparities were particularly marked for specific racial/ethnic
groups: for Latinos, suboptimal health status and teeth condition,
uninsurance, and problems getting specialty care; for African Americans,
asthma, behavior problems, skin allergies, speech problems, and unmet
prescription needs; for Native Americans, hearing or vision problems, no
usual source of care, emergency department visits, and unmet medical and
dental needs; and for Asians or Pacific Islanders, problems getting
specialty care and not seeing a doctor in the past year.

-Multiracial children also experienced many disparities.

The authors conclude that minority children experience multiple
disparities in medical and oral health, access to care, and use of
services. Certain disparities are particularly marked for specific

racial/ethnic groups, and multiracial children experience many

Flores G and Tomany-Korman SC. Racial and Ethnic Disparities in Medical
and Dental Health, Access to Care, and Use of Services in US Children
PEDIATRICS Vol. 121 No. 2 February 2008, pp. e286-e298
<http://www.ncbi.nlm.nih.gov/pubmed/18195000>

**Medicaid Reimbursement for Car Seats Is Cost-Effective Health
Policy**\
A study from The Children\'s Hospital of Philadelphia (CHOP) shows that
distributing **car safety seats among economically disadvantaged
children could be as cost-effective as long-established federal
vaccination programs**. The research, published this week in the journal
Ambulatory Pediatrics, offers insights for state and national lawmakers
involved in setting future healthcare policy, particularly for those
interested in exploring programs with a greater focus on preventive care
for children.\
\
The Vaccines for Children (VFC) program proved to be a smart investment
of public funds to prevent illness and disease, says Flaura Winston,
M.D., Ph.D., an author on the paper and the co-scientific director of
the Center for Injury Research and Prevention at The Children\'s
Hospital of Philadelphia. With this study, we show that **similar public
commitment to reduce the incidence of motor vehicle crash injury - the
leading cause of death and permanent disability among children** - would
also result in significant cost savings and health benefits to society
and affected children.\
\
**The proposed Child Restraint Systems (CRS) Program would provide
access to child restraints and education via a physicians prescription.
Assuming enrollment in a Medicaid-based CRS program at birth, every
child would receive a convertible child safety seat (combined infant and
toddler seat) along with pertinent education when discharged from the
hospital.** At age four the child would receive a belt-positioning
booster seat to be used to about age 8 \[reaches 4 feet 9 inches\]. The
net cost per beneficiary of the 8-year program would be \$32.\
\
Including all medical and relevant societal costs, a program in which
physicians write prescriptions for car seats for Medicaid-eligible
children would achieve the following yearly **cost savings per 100,000
children**:\
Reduce medical costs by \$1 million\
Regain \$100,000 in the cost of parental work loss\
Reduce future victim productivity costs by \$2.7 million.\
\
According to the researchers, without the proposed Medicaid CRS program
in place, injuries to children from vehicle crashes (per 100,000
children) would result in an estimated \$4.2 million in medical costs,
\$350,000 in parental work loss, and \$8.3 million in reduced future
victim productivity. The programs break-even point for society could be
reached after three years. At that time, program costs would balance
savings from averted medical expenses, parental work loss, and victim
future productivity losses.\
\
Until now, the economic benefit of Medicaid providing child restraint
systems to low-income children through physician prescriptions had not
been explored. Moreover, this study compared the cost-effectiveness of
such a program with one that has been proven successful, the VFC
program.\
\
When researchers looked at comparative effectiveness between their
theoretical program and seven vaccines, they found that only Haemophilus
Influenzae B and Measles/Mumps/Rubella vaccinations were more
cost-effective than the CRS disbursement and education program.\
\
Car crashes are the biggest threat to our children's health and
well-being, and economically disadvantaged children are
disproportionately at risk, says Dr. Winston. \"The program we explored
in our study would address the most significant common barriers in
public health issues: access and education.\
\
**Limited pilot testing of the Medicaid CRS program at the state or
community level is the recommended next step in evaluating its real
world applicability, effectiveness, and cost savings**.\
\
**The researchers also call for a policy shift. At a time when
policymakers are considering an overhaul of the health care system in
the U.S., this paper should generate interest in health care policies
that consider prevention as a primary clinical strategy and allow
medical expenses for proven prevention strategies, says Dr. Winston.**\
\
The study utilized several data sources including Partners for Child
Passenger Safety (PCPS), a child-focused crash surveillance system with
State Farm Insurance Company\'s and the National Highway Traffic Safety
Administration\'s Fatality Analysis Reporting System, as well as sources
for standard research methods such as the Task Force on Community
Preventive Services review and the Panel on Cost-Effectiveness in Health
and Medicine.\
\
[Goldstein
JA](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Goldstein JA"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlusDrugs1),
et al Medicaid-Based Child Restraint System Disbursement and Education
and the Vaccines for Children Program: Comparative Cost-effectiveness.
Ambul Pediatr. 2008 Jan;8(1):58-65.
<http://www.ncbi.nlm.nih.gov/pubmed/18191783>

For more information about how to protect children in crashes, visit
<http://www.chop.edu/carseat>

For more information contact Dana Mortensen, 267-426-6092,
<mortensen@email.chop.edu>

**2008 MCH EPI Grand Rounds Schedule 7 one-hour calls**

\*Please note that speakers and topics/titles are subject to change and
announcements will be sent when necessary.

**[March 5, 2008 from 2-3 p.m. ET]{.underline}**\
**Title**: **Fetal Death Case Ascertainment** in Iowa\
**Presenter:** Kimberly Noble Piper, RNC, BS, CPH\
Iowa Department of Public Health

**[April 2, 2008 from 2-3 p.m. ET]{.underline}**\
**Title:** **Low Contraceptive Use** among Florida Women -- Explanations
and Recommendations\
**Presenter:** Lauren B. Zapata, PhD, MSPH\
Centers for Disease Control and Prevention (CDC)**\
**\
**[May 7, 2008 from 2-3 p.m. ET]{.underline}**\
**Topic:** TBD\
**Presenter:** TBD\
\
**[September 3, 2008 from 2-3 p.m. ET]{.underline}**\
**Topic Area:** **Miscarriage\
Presenter:** Kathryn S. Oths, PhD\
The University of Alabama

**[October 1, 2008 from 2-3 p.m. ET]{.underline}**\
**Title:** Analysis, Professional Reward, and Integrity:  How **MCH Epi
Research** Can **Harm** the Health of Women and Children\
**Presenter:** Paul H. Wise, MD, MPH\
Stanford University, Center for Health Policy/Center for Primary Care
and Outcomes Research

**[November 5, 2008 from 2-3 p.m. ET]{.underline}**\
**Title:** **Trends in Chronic Disease** among Iowans\
**Presenters:** Catherine J. Lillehoj, PhD and Joann Muldoon, MS, MA

Iowa Department of Public Health

**[Webcast Requirements:]{.underline}**\
To join the webcast, you must register at least a day ahead of time at:
<http://www.uic.edu/sph/cade/mchepi/>\
\
**[Tips for Webcast Audience:]{.underline}**\
**1.** Register using the same computer that you will use to attend the
webcast - this guarantees, once you have passed the technical check,
that the computer meets the minimum requirements.

**2.** Register well in advance of the event - this gives you time to
troubleshoot and remedy problems in advance of the webcast.

**3.** Use the online technical support at
<http://www.uic.edu/sph/cade/mchepi>, or contact CADE (The Center for
the Advancement of Distance Education at the University of Illinois at
Chicago School of Public Health), if you can\'t resolve technical
problems.

**4.** Connect to the live webcast 20 minutes before the scheduled start
time - this allows your computer to connect and download the
presentation slides in advance of the event.

**5.** Link for technical requirements:
<http://www.uic.edu/sph/cade/mchepi/techreqs.htm>.

Thanks!

-MCH EPI Program
<http://www.cdc.gov/reproductivehealth/MCHEpi/index.htm>

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

#### St. John\'s wort for depression in a young woman {#st.-johns-wort-for-depression-in-a-young-woman .Style-Heading-4-+-Arial-14-pt-Underline}

#### You may recall last month when we posted this question... {#you-may-recall-last-month-when-we-posted-this-question .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### A 28-year-old female with severe major depression has achieved partial symptom remission with a selective serotonin reuptake inhibitor (SSRI) but complains of persistent diarrhea and loss of libido. She asks you about using St. John\'s wort to treat her depression {#a-28-year-old-female-with-severe-major-depression-has-achieved-partial-symptom-remission-with-a-selective-serotonin-reuptake-inhibitor-ssri-but-complains-of-persistent-diarrhea-and-loss-of-libido.-she-asks-you-about-using-st.-johns-wort-to-treat-her-depression .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Appropriate advice would include which of the following? (Select all that are true.) {#appropriate-advice-would-include-which-of-the-following-select-all-that-are-true. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### -St. John\'s wort may be effective in milder forms of major depression {#st.-johns-wort-may-be-effective-in-milder-forms-of-major-depression .Style-Heading-4-+-Arial-14-pt-Underline}

#### -St. John\'s wort is more effective than placebo in patients with severe major depression {#st.-johns-wort-is-more-effective-than-placebo-in-patients-with-severe-major-depression .Style-Heading-4-+-Arial-14-pt-Underline}

#### -St. John\'s wort is better tolerated than prescription antidepressants {#st.-johns-wort-is-better-tolerated-than-prescription-antidepressants .Style-Heading-4-+-Arial-14-pt-Underline}

#### -The combination of St. John\'s wort and SSRIs is safe and effective for major depression. {#the-combination-of-st.-johns-wort-and-ssris-is-safe-and-effective-for-major-depression. .Style-Heading-4-+-Arial-14-pt-Underline}

#### -St. John\'s wort may reduce the efficacy of combined oral contraceptives {#st.-johns-wort-may-reduce-the-efficacy-of-combined-oral-contraceptives .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### The answers are: {#the-answers-are .Style-Heading-4-+-Arial-14-pt-Underline}

#### -St. John\'s wort may be effective in milder forms of major depression {#st.-johns-wort-may-be-effective-in-milder-forms-of-major-depression-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### -St. John\'s wort is better tolerated than prescription antidepressants {#st.-johns-wort-is-better-tolerated-than-prescription-antidepressants-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### -St. John\'s wort may reduce the efficacy of combined oral contraceptives {#st.-johns-wort-may-reduce-the-efficacy-of-combined-oral-contraceptives-1 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Here is some background {#here-is-some-background .Style-Heading-4-+-Arial-14-pt-Underline}

#### The data on efficacy of St. John\'s wort in treating depression are confusing, mixed, and subject to criticism over concerns about lack of standardized preparations, adequacy of blinding of patients, short study duration, and inclusion of patients not meeting criteria for major depression. Most studies show benefit compared with placebo for mild depressive syndromes (including many patients without major depressive disorder who may not require treatment with medication). However, evidence is mixed when analyses of St. John\'s wort compared to placebo are restricted to patients with major depressive disorder. Some studies, however, do suggest that St. John\'s wort is as effective as SSRIs and low-dose tricyclic antidepressants for patients with mild to moderate major depression. Most head-to-head studies show that patients are less likely to discontinue St. John\'s wort because of side effects, compared with standard antidepressants. The combination of St. John\'s wort and SSRIs has not been studied; combining them poses an increased theoretical risk for serotonin syndrome. St. John\'s wort may induce the metabolism of oral contraceptives containing ethinyl estradiol, possibly resulting in an unplanned pregnancy. {#the-data-on-efficacy-of-st.-johns-wort-in-treating-depression-are-confusing-mixed-and-subject-to-criticism-over-concerns-about-lack-of-standardized-preparations-adequacy-of-blinding-of-patients-short-study-duration-and-inclusion-of-patients-not-meeting-criteria-for-major-depression.-most-studies-show-benefit-compared-with-placebo-for-mild-depressive-syndromes-including-many-patients-without-major-depressive-disorder-who-may-not-require-treatment-with-medication.-however-evidence-is-mixed-when-analyses-of-st.-johns-wort-compared-to-placebo-are-restricted-to-patients-with-major-depressive-disorder.-some-studies-however-do-suggest-that-st.-johns-wort-is-as-effective-as-ssris-and-low-dose-tricyclic-antidepressants-for-patients-with-mild-to-moderate-major-depression.-most-head-to-head-studies-show-that-patients-are-less-likely-to-discontinue-st.-johns-wort-because-of-side-effects-compared-with-standard-antidepressants.-the-combination-of-st.-johns-wort-and-ssris-has-not-been-studied-combining-them-poses-an-increased-theoretical-risk-for-serotonin-syndrome.-st.-johns-wort-may-induce-the-metabolism-of-oral-contraceptives-containing-ethinyl-estradiol-possibly-resulting-in-an-unplanned-pregnancy. .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

######### A Rational Approach to Constipation

<http://www.medscape.com/viewarticle/567681?src=sr>

######### [Turning Adverse Drug Events Into Better Patient Care](http://www.medscape.com/viewprogram/8715)

<http://www.medscape.com/viewarticle/569872>

**Angiogenesis as a Strategic Target for Ovarian Cancer Therapy**

<http://www.medscape.com/viewpublication/1166_index>

**Premenstrual Dysphoric Disorder Resource Center Update**

<http://www.medscape.com/resource/pmdd?src=rcupdate#1>

######### 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**

**Calcium supplements may increase heart attacks in older women**

Research suggests that calcium supplements may increase the risk of
heart attack in healthy postmenopausal women

CONCLUSION: Calcium supplementation in healthy postmenopausal women is
associated with upward trends in cardiovascular event rates. This
potentially detrimental effect should be balanced against the likely
benefits of calcium on bone. TRIAL REGISTRATION: Australian Clinical
Trials Registry ACTRN 012605000242628.

[Bolland
MJ](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Bolland MJ"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlusDrugs1)
et al Vascular events in healthy older women receiving calcium
supplementation: randomised controlled trial. BMJ. 2008 Feb
2;336(7638):262-6

#### [**http://www.ncbi.nlm.nih.gov/pubmed/18198394**](http://www.ncbi.nlm.nih.gov/pubmed/18198394) {#httpwww.ncbi.nlm.nih.govpubmed18198394 .Style-Heading-4-+-Arial-14-pt-Underline}

**Postmenopausal Systemic Hormone Therapy: Putting Risks Into
Perspective**

<http://www.medscape.com/viewarticle/569399>

**Black Cohosh and Menopausal Symptoms**

#### [**http://www.medscape.com/viewarticle/569485**](http://www.medscape.com/viewarticle/569485) {#httpwww.medscape.comviewarticle569485 .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

**Perineal warm packs reduce 3^rd^ and 4^th^ degree lacerations, pain
and urinary incontinence**

CONCLUSIONS: The application of perineal warm packs in late second stage
does not reduce the likelihood of nulliparous women requiring perineal
suturing but significantly reduces third- and fourth-degree lacerations,
pain during the birth and on days 1 and 2, and urinary incontinence.
This simple, inexpensive practice should be incorporated into second
stage labor care.

[Dahlen
HG](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Dahlen HG"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlusDrugs1)
et al Perineal outcomes and maternal comfort related to the application
of perineal warm packs in the second stage of labor: a randomized
controlled trial. Birth. 2007 Dec;34(4):282-90.

<http://www.ncbi.nlm.nih.gov/pubmed/18021143>

**The Business of Being Born**

 The American College of Nurse-Midwives (ACNM) congratulates Executive
Producer Ricki Lake and Director Abby Epstein on the release of their
documentary [The Business of Being
Born](http://www.thebusinessofbeingborn.com/), a critique of the
medicalization of childbirth in the U.S. and a celebration of normal
birth and midwifery care.

The film interlaces intimate birth stories with shocking statistics
about the U.S. maternity care system. The film encourages childbearing
women to embrace birth as a powerful---and empowering---life event
rather than view it as an illness in need of medical treatment. 

Certified nurse-midwives (CNMs) are featured prominently in the film,
attending hospital, birth center, and home births. CNMs and certified
midwives (CMs) attend 11% of the vaginal births in the U.S., 97% of
which are in hospitals. While midwife-attended births in the U.S. have
more than doubled since 1990, midwives attend 70% or more of the births
in Western Europe, Britain and Japan, with better outcomes and lower
cost of care.

 

"Lake and Epstein spotlight the high quality care offered by CNMs," says
Lorrie Kline Kaplan, ACNM executive director. "The U.S. cesarean section
rate is rising dramatically. Our infant mortality rates are climbing,
and there are indications that maternal mortality is rising as well.
It's time to sit up and take notice---and work to turn these trends
around."

 

"The vast majority of women in the U.S. and other developed countries
are at low-risk for complications in childbirth, and under the midwifery
model of supportive care, are capable of delivering a baby vaginally and
participating fully in this experience," says ACNM President Eunice K.M.
Ernst, CNM, MPH, DSc (Hon), FACNM.

 

ACNM urges midwifery proponents to support efforts to improve access to
midwifery care. Congress is considering the "Midwifery Care Access and
Reimbursement Equity Act of 2007," (S.507/H.R.864) which would lead to
improved reimbursement for midwives. In many states, CNMs and CMs can't
attend home births or provide services without a written agreement with
a physician. Many hospitals have restrictive rules that make it
difficult for midwives to practice.

 

"We can't all be filmmakers," quips Kaplan. "But if we are in the
fortunate minority who has delivered a baby with the support of a
midwife, we can spread the word by sharing our stories, encouraging
other women to see this uniquely beautiful film, and advocate for
increased access to midwifery care."

 

More facts about midwifery:

1.  There are many types of midwives, so pay attention to credentials.
    The vast majority of midwives are Certified Nurse-Midwives and
    Certified Midwives and ACNM urges consumers to choose a CNM or CM.

```{=html}
<!-- -->
```
1.  CNMs and CMs are highly educated. Most have a master's degree or
    higher. Schools of midwifery reside in such prestigious universities
    as Yale, Georgetown, and Columbia.

2.  CNMs and CMs also provide well-woman and primary health care for
    women in all stages of life.

3.  Most insurers cover midwifery services, including Medicare and
    Medicaid.

4.  CNMs practice in all 50 states and the District of Columbia.

5.  Help us win our battle for fair reimbursement.

 

For more information about the film, visit
[www.thebusinessofbeingborn](http://www.thebusinessofbeingborn/).

It is currently slated for limited release in theaters in January and
February 2008 but supporters can host their own screenings.

<http://www.midwife.org/siteFiles/news/The_Business_of_Being_Born_Jan_08.pdf>

**Factors for the fear of childbirth in first-time mothers (see next
article, too)**

This study is interesting as it demonstrates how the fear of childbirth
can have an affect on some women during pregnancy. These fears are not
irrational and have a social and/or psychological root. Knowing what
factors make some women more prone to this type of fear helps doctors
and midwives to identify those most in need of extra support.

CONCLUSIONS: The prevalence of fear of childbirth among healthy
nulliparous women with singleton pregnancies did not increase during the
study period. Fear of childbirth among nulliparous women was most often
seen in individuals with few social and psychological resources. Testing
the women twice, we found the same prevalence of fear in early and late
pregnancy, but found that half the women who expressed fear during early
pregnancy had no fear later in pregnancy, an effect that was
counterbalanced by a similar number of women who became fearful between
the two interviews.

Laursen M, Hedegaard M, Johansen C. Fear of childbirth: predictors and
temporal changes among nulliparous women in the Danish National Birth
Cohort. BJOG 2008;115:354-360

<http://www.ncbi.nlm.nih.gov/pubmed/18190372>

**Women's fear of childbirth boosts cesareans**

Women suffering from significant childbirth fear indicate that they are
less self-confident, unhappy, afraid that the child will be injured and
don't long for the child. This clearly emphasises the need for pre and
postnatal support.

For each women requesting to have a caesarean, as doctors, we provide
them with a consultation on the advantages and disadvantages of the
procedure.

The overall c-section rate in the UK is high but comparable to other
western countries. If we are to lower the numbers, we need to understand
sympathetically why some women, with no medical reasons, are choosing to
have caesareans.

Healthy women are sometimes criticized for choosing a c-section over a
normal delivery. This study reveals that a psychological reason may be
behind elective caesareans. Some women may be too scared, rather than
too posh, to push.

CONCLUSIONS: Women requesting caesarean section did not always suffer
from clinically significant fear of childbirth. The finding that women
subjected to complicated deliveries had a negative birth experience
emphasizes the importance of postnatal support

Wiklund I, Edman G, Ryding E, Andolf E. Expectation and experiences of
childbirth in primiparae with caesarean section. BJOG 2008;115:324-331.
<http://www.ncbi.nlm.nih.gov/pubmed/18190368>

**Navajo News John Balintona, Shiprock**

**Adnexal Masses during Pregnancy**

The presence of adnexal masses during pregnancy is not uncommon at 0.5%
to 2%. Discovery of an adnexal mass during pregnancy can prove to be a
management dilemma for the obstetric provider. The clinician must
develop and communicate a plan of expectant management versus
intervention that exposes the patient to the least amount of morbidity.

Prior to the routine use of ultrasound in early pregnancy, most masses
were found incidentally or were symptomatic and this often led to prompt
surgical intervention. Now with the near universal prenatal ultrasound,
the majority of masses are found earlier allowing for more conservative
management.

### **Diagnosis**

Adnexal masses have nongynecologic causes, however most are gynecologic
and benign in nature. The age of the patient, prior medical history, and
gestational age may be useful in determining the likely etiology of the
mass. The most common cause is leiomyoma, which may be uncovered in
review of the past medical history. Corpus luteum cysts are common in
the first trimester of gestation. Benign ovarian entities like
functional cysts, benign teratomas, and serous cystadenomas are found in
younger patients. The potential for ovarian malignancy does rise as the
patient ages.

Ultrasound is the primary imaging technique used to detect adnexal
masses and to assess the risk of malignancy. Some experts suggest the
MRI may be useful in the evaluation, especially if the ultrasound
diagnosis is uncertain. Various morphologic characteristics found on
ultrasound may be useful in determining the risk of malignancy in
adnexal masses.

#### Low Risk Moderate - High Risk

Cystic, unilocular Cystic, multilocular

Size; 5 cm or smaller Size; greater than 5 cm

Complex mass

Solid mass

Thick septations

Nodules

Persists past 16 weeks EGA

Laboratory tests are of limited use in the evaluation of adnexal masses
as many of the tumor markers, e.g. CA-125, AFP, BHCG; etc may be
elevated in normal pregnancy.

Occasionally the patient will present with signs and symptoms due to the
mass. These patients may have abdominal pain, back or flank pain,
digestive disorders, furthermore, the patient may appear to have a
gestational size greater than expected due date. The rate of torsion can
be up to 20% and rupture rate can be as high as 10%. Some suggest that
the risk of torsion is increased in masses between 6 cm and 10 cm in
size.

### **Management**

The main management option for the clinician is in choosing expectant
management versus intervention. Expectant management decreases the
potential for invasive procedures, however, can expose the patient for
potential torsion, mass rupture, or obstruction of labor. Surgical
intervention carries its own inherent risks of adverse outcome for
mother and fetus. A rational decision can be made based on natural
history, malignancy risk, and presence of symptoms.

Most ovarian cysts discovered during pregnancy will resolve
spontaneously prior to 16 weeks EGA. This is especially true if the cyst
is less than 5 cm. Observation for small cysts is recommended. It is
reasonable for the obstetric provider to recommend surgical intervention
for cysts that persist after 16 weeks EGA and surgery be indicated for
any adnexal mass that may be causing symptoms such as pain or digestive
difficulties.

Adnexal masses that have morphologic characteristics that are consistent
with a low risk of malignancy may be observed throughout pregnancy. Less
than 1% of adnexal masses found in pregnancy prove to be malignant and
even in these cases, the majority is of low-grade disease. Nevertheless,
any mass that is deemed moderate or high risk should be surgically
removed. If the clinician has strong evidence that malignancy is likely,
it may be prudent to transfer the patient to a facility that can provide
the proper staging surgery and expedient histologic diagnosis.

Adverse fetal outcome is typically associated with abdominal catastrophe
from ovarian torsion or mass rupture during surgery. Uncomplicated
surgery for adnexal masses has not been shown to increase the risk for
fetal loss or preterm delivery. Laparotomy is generally used, but in
certain cases, i.e. early first trimester, benign appearing small cyst,
expertise of the surgeon, laparoscopy may be entertained. Regardless of
the approach, efforts should be made to perform the most conservative
procedure possible.

The following is a summary of scenarios that the author advises surgical
intervention.

#### Strong suspicion for malignancy

Large (\> 8-10cm) masses

Symptomatic complaints

Persistent masses (after 16 weeks EGA)

### **References**

1.  Leiserowitz G. Managing Ovarian Masses During Pregnancy. Obstetrical
    and Gynecologic Survey. 2006. Vol 61. 463-470

2.  Giuntoli R, et al. Evaluation and Management of Adnexal Masses
    During Pregnancy. Clinical Obstetrics and Gynecology. 2006. Vol 49.
    492-505

3.  Ribic-Pucelj M, et al. Surgical Treatment of Adnexal Masses in
    Pregnancy. Journal of Reproductive Medicine. 2007. Vol 52. 273-279

Questions <John.Balintona@ihs.gov>

**Nurses Corner, Sandra Haldane, HQE**

**Integrating Nursing and Behavioral Health**

Wyatt Massi, PsyD, Chief of Behavioral Health Services, is developing an
integrated behavioral health approach for the Fort Peck primary care
clinic and is recruiting for a psych-mental health NP or an APN who is
interested in going back to school for a post-masters psych-mental
health certificate.  

Dr. Massi has "integrated" the behavioral health consultant duties into
a traditional psychiatric nurse practitioner position.  The most common
model for the BHC is using a counselor or psychologist in the position. 
Dr. Massi elected to go with a Psych NP because it was part of the
"deal" that I brokered with my service unit to get the funds for the
position.  At first Dr. Massi thought he was making compromises, but Dr.
Massi came to the conclusion that a NP dedicated to integration is an
ideal person to bridge the gap b/w Primary Care, Health Promotion, and
Behavioral Health.  As a primary care provider, who has come up through
the nursing education system, and has a place as a Behavioral Health
staff member, Dr. Massi thinks this individual will be able to
facilitate a cultural change in the health care environment.  And
hopefully Dr. Massi will save some money on my psychiatrist contracts
while revolutionizing the world of IHS !

Dr Massi is happy to describe the position and the model of care.   This
is a very exciting opportunity.  If you have questions please contact
Dr. Massi directly. 

MassI Wyatt, PsyD

Chief, Behavioral Health Services

Ft. Peck IHS

Poplar, Montana

406-768-3491

**UCLA post-doc program for nurses**

We have extended the deadline - please help to widely disseminate.

Many thanks. Felicia

Felicia Schanche Hodge, Dr.P.H.\
Professor, School of Nursing\
Chair, American Indian Studies\
700 Tiverton Ave., RM 5-940 Factor Bldg.\
Los Angeles, CA 90095-1702\
(310) 267-2255 <fhodge@sonnet.ucla.edu>

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

#### New Report on American Indian/Alaskan Native Disparity & Strengths from RWJ {#new-report-on-american-indianalaskan-native-disparity-strengths-from-rwj-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.rwjf.org/programareas/resources/product.jsp?id=23193&pid=1142**](http://www.rwjf.org/programareas/resources/product.jsp?id=23193&pid=1142) {#httpwww.rwjf.orgprogramareasresourcesproduct.jspid23193pid1142 .Style-Heading-4-+-Arial-14-pt-Underline}

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

![](media/image2.png){width="4.002083333333333in"
height="2.220833333333333in"}**Creating a Healing Community:
Partnerships to Improve the Care of Indian People**

NANAINA SUMMIT XIV

### October 26-29-2008

Radisson Hotel

120 S. Wildwood Dr.

Branson, MO 65616

1-888-566-5290

National Alaska Native American Indian Nurses Association

[www.nanainanurses.org](http://www.nanainanurses.org/)

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

#### Fraud - SPAM {#fraud---spam-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Just wanted to alert you to this SPAM that is being selectively sent to nurses.  {#just-wanted-to-alert-you-to-this-spam-that-is-being-selectively-sent-to-nurses. .Style-Heading-4-+-Arial-14-pt-Underline}

#### For those of you who may not know, as an HHS employee or employee under the umbrella of HHS, and you get email SPAM, you can forward it to [**SPAM@HHS.GOV**](mailto:SPAM@HHS.GOV) {#for-those-of-you-who-may-not-know-as-an-hhs-employee-or-employee-under-the-umbrella-of-hhs-and-you-get-email-spam-you-can-forward-it-to-spamhhs.gov .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

**Cervical Cancer Awareness**

Getting regular Pap tests can save a woman\'s life. Six out of ten
cervical cancers occur in women who have never had a Pap test or have
not been screened in the past five years. Regular Pap tests lower a
woman\'s risk of cervical cancer because they can find early problems
before cancer ever develops.
<http://www.cdc.gov/Features/CervicalCancer/>

**United States Life Tables, 2004**

This report presents period life tables for the United States based on
age-specific death rates in 2004. Both males and females in each race
group experienced increases in life expectancy between 2003 and 2004.
The greatest increase was experienced by black males with an increase of
0.6 year (from 68.9 to 69.5). Life expectancy increased by 0.4 year for
black females (from 75.9 to 76.3), for white females (from 80.4 to
80.8), and for white males (from 75.3 to 75.7).

<http://www.cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_09.pdf>

####  {#section-28 .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}

**Cesarean Delivery: What are the risks and benefits?**

Here are a few of the recent articles that describe the risks and
benefits of cesarean delivery.

**Elective Cesarean Delivery Linked to Higher Risk for Infant
Respiratory Morbidity **

CONCLUSION: Compared with newborns delivered vaginally or by emergency
caesarean sections, those delivered by elective caesarean section around
term have an increased risk of overall and serious respiratory
morbidity. The relative risk increased with decreasing gestational age.

[Hansen
AK](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Hansen AK"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Risk of respiratory morbidity in term infants delivered by
elective caesarean section: cohort study. BMJ. 2008 Jan
12;336(7635):85-7

<http://www.ncbi.nlm.nih.gov/pubmed/18077440>

**Cesarean delivery can be reduced: Identification of barriers to change
is key to success**

CONCLUSIONS: The cesarean delivery rate can be safely reduced by
interventions that involve health workers in analyzing and modifying
their practice. Our results suggest that multifaceted strategies, based
on audit and detailed feedback, are advised to improve clinical practice
and effectively reduce cesarean delivery rates. Moreover, these findings
support the assumption that identification of barriers to change is a
major key to success.

[Chaillet
N](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Chaillet N"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Evidence-based strategies for reducing cesarean section rates: a
meta-analysis. Birth. 2007 Mar;34(1):53-64
<http://www.ncbi.nlm.nih.gov/pubmed/17324180>

**Cesarean delivery increases the risk of maternal and neonatal
morbidity and mortality** CONCLUSIONS: Caesarean delivery independently
reduces overall risk in breech presentations and risk of intrapartum
fetal death in cephalic presentations but increases the risk of severe
maternal and neonatal morbidity and mortality in cephalic presentations.

[Villar
J](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Villar J"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Maternal and neonatal individual risks and benefits associated
with caesarean delivery: multicentre prospective study. BMJ. 2007 Nov
17;335(7628):1025.

<http://www.ncbi.nlm.nih.gov/pubmed/17977819>

The Indian Health system strongly encourages vaginal birth whenever
possible and we have some of the highest VBAC rates in the country. In
fact an Indian Health facility won the ACNM benchmark program award for
highest VBAC rate in the US

<http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0607_Feat.cfm#mmtour>

Overall the Indian Health system has performed VBAC at that high rate
consistently

Here is the data from our recent national meeting. It gives the VBAC
rates around the whole Indian Health system

<http://www.ihs.gov/MedicalPrograms/MCH/F/documents/DataTally81107.doc>

If done under existing guidelines and within the standard of care, VBAC
is fully covered by the Federal Tort Claim system

We should look closely at the NNEPQIN system, as it works with small
rural facilities. In fact, Dr. Lauria presented similar lectures at our
meetings in 2004 and again in 2007. For her 2004 presentation go to this
link and scroll down to her name (in alpha order)

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

Here are just a few of the recent articles that have highlighted on this
topic in the CCC Corner in recent months. There are many others

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

<http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_HT.cfm#ob>

**Vermont, New Hampshire Sections Recognized for Effort\
Project Focuses on VBAC**

<http://www.ihs.gov/MedicalPrograms/MCH/F/ACOG01_vbac.cfm#vbac>

(Dr. Cherouny was a lecturer at out meeting in ABQ)

(Small hospitals in New England have the same problems we have)

**Trial of Labor After Cesarean: Evidence based guidelines**

<http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0805_HT.cfm#ob>

[**VBAC: Is There Such a Thing as Low
Risk?**](http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/NewMexico.ppt)

<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/NewMexico.ppt>

Here is our free Indian Health CME Module on this topic

**Vaginal Birth After Cesarean**

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

Another approach is to look at the morbidity imposed on our AI/AN women
due to all the repeat cesareans

**Placental problems with previous caesarean delivery: Abruptio,
previa**

<http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0607_HT.cfm#ob>

**Postcesarean delivery adhesions associated with delayed delivery of
infant**

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17466702>

**More stillbirths after previous cesarean delivery**

<http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0507_HT.cfm#ob>

**First delivery by cesarean begins cascade of risks - obstetric and
perinatal outcomes**

<http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=17267823&dopt=AbstractPlus>

Here are some things on risks

**Is vaginal birth after cesarean (VBAC) or elective repeat cesarean
safer in women with a prior vaginal delivery?**

<http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16846571>

**VBAC: Smaller attributable risk than previously reported**

<http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_HT.cfm#ob>

As obesity increases in our population, so does the risk of cesarean
complications

**Linear association between maternal pre-pregnancy body mass index and
risk of caesarean section in term deliveries.**

<http://www.ncbi.nlm.nih.gov/pubmed/16972860>

The costs to the system are higher too

**Significantly higher rehospitalization rates and costs with planned
cesareans**

<http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=17329519&dopt=AbstractPlus>

So there is precedent, ongoing successful outcomes, and extensive other
literature to support VBAC in the Indian Health system.

Should VBAC be offered at your facility?

Please see the following for help with that answer:

**February 2008 Abstract of the Month**

<http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08aom>

and

**February 2008 Midwives Corner**

<http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#midw>

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

SSRI Use and Bone Loss in Older Women

[Background]{.underline}: Antidepressants are one of the most commonly
used medication classes in the United States. The recent introduction of
selective serotonin reuptake inhibitors (SSRIs) has resulted in a
dramatic increase in the prescribing of antidepressants in older
patients. The SSRIs work by inhibiting serotonin transport. The older
tricyclic antidepressants (TCAs) work by inhibiting the reuptake of
norepinephrine and serotonin. Recent developments have shown that
serotonin transporters, and medications that affect these transporters,
may play a role in bone metabolism. Concerns have been raised about the
impact of increased use of SSRIs in older patients because this group
has an increased risk of osteoporosis and fractures. Diem and associates
evaluated bone mineral density (BMD) in women 65 years or older to
determine if SSRI use has any effect on bone metabolism.

[Conclusion:]{.underline} The authors conclude that the use of SSRIs in
older women is associated with an increase in the rate of bone loss:
this association does not occur with the use of TCAs. The authors add
that these results should be further investigated with more follow-up to
determine the long-term effect of SSRI use on bone metabolism.

Diem SJ, et al. Use of antidepressants and rates of hip bone loss in
older women: the study of osteoporotic fractures. *Arch Intern Med.*
June 25, 2007;167(12):1240-1245.

<http://www.ncbi.nlm.nih.gov/pubmed/17592096>

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

#### Nonpharmacologic Management of Osteoporosis to Minimize Fracture Risk {#nonpharmacologic-management-of-osteoporosis-to-minimize-fracture-risk-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.medscape.com/viewarticle/567334**](http://www.medscape.com/viewarticle/567334) {#httpwww.medscape.comviewarticle567334 .Style-Heading-4-+-Arial-14-pt-Underline}

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

######### Supplementation With Calcium and Vitamin D: Efficacy Against Fracture and Total Mortality: A Best Evidence Review  [**http://www.medscape.com/viewarticle/569488**](http://www.medscape.com/viewarticle/569488)

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

#### The Impact of Adherence and Persistence in the Pharmacological Management of Osteoporosis {#the-impact-of-adherence-and-persistence-in-the-pharmacological-management-of-osteoporosis-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.medsitecme.com/(vq1wqn55rky2xdysygicd43d)/IDetail/Default_Campaign/Default_Program//302//sponsor.aspx**](http://www.medsitecme.com/(vq1wqn55rky2xdysygicd43d)/IDetail/Default_Campaign/Default_Program//302//sponsor.aspx) {#httpwww.medsitecme.comvq1wqn55rky2xdysygicd43didetaildefault_campaigndefault_program302sponsor.aspx .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

#### Assuring Quality Care for People With Limited Health Literacy {#assuring-quality-care-for-people-with-limited-health-literacy-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.medscape.com/viewarticle/569201**](http://www.medscape.com/viewarticle/569201) {#httpwww.medscape.comviewarticle569201 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Knowing Importance of Prenatal Folic Acid May Affect Neural Tube Defect Incidence {#knowing-importance-of-prenatal-folic-acid-may-affect-neural-tube-defect-incidence-1 .Style-Heading-4-+-Arial-14-pt-Underline}

In 1998, the Food and Drug Administration mandated that folic acid be
added to cereal grain products. A 26% decline in the NTD rate in the
United States was observed from the period before (1995\--1996) to the
period after (1999\--2000) fortification. However, racial/ethnic
disparities persisted, with Hispanic women having the highest rate of
NTDs and the lowest reported consumption of folic acid. A statewide
survey conducted annually in California during the period 2002\--2006
indicated that Hispanic women had the lowest use of supplements
containing folic acid. In addition to the racial/ethnic disparities,
differences of supplement use by age have been reported.

Although year-to-year variation has been observed over time, the
percentage of women of childbearing age who reported consumption of a
daily supplement containing folic acid increased overall from 28% in
1995 to 32% in 2003 (6) and to 40% in 2004 and 2007. One of the Healthy
People 2010 objectives is to increase to 80% the proportion of all women
of childbearing age who consume 400 µg of folic acid daily to reduce
their risk for serious birth defects (objective no. 16-16a) . Thus,
although progress has been made toward this goal, approximately 60% of
women of childbearing age surveyed in 2007 were still not consuming a
daily supplement containing folic acid. Women aged 18\--24 years have
the highest rate of unintended pregnancies in the United States but
remain the least aware of and knowledgeable about folic acid and the
least likely to report consuming a supplement containing folic acid.
These findings warrant the continued promotion of folic acid consumption
among all women of childbearing age and especially among women aged
18\--24 years. Folic acid education that promotes consumption of folic
acid from various sources (e.g., supplements containing folic acid and
fortified foods), in addition to foods rich in folate, can increase the
possibility of all women consuming the recommended daily amount of 400
µg.

The findings in this report are subject to at least two limitations.
First, the low response rate of 32% increases the risk that response
bias might have affected the results. Results should be interpreted with
caution and in the context of other surveys. For certain questions,
recall bias also might have affected results. Second, the survey was
limited to households with landline telephones, and the results might
not be representative of all households. Whether this limitation would
result in overestimates or underestimates in various results is not
predictable.

The findings in this report indicate that women aged 18\--24 years
identified schools or colleges and magazines or newspapers as their
primary sources for folic acid information, so these two channels might
provide important opportunities to reach this population. Research has
indicated that women in this age group are more likely to respond to
folic acid messages that do not focus on pregnancy or infants.
Innovative and effective messages tailored to women aged 18\--24 years
are needed to help change behaviors, increase awareness and knowledge
regarding folic acid consumption, and ultimately reduce the incidence of
NTDs.

[Summary:]{.underline} Knowledge of the importance of taking folic acid
prenatally may be linked to incidence of infant neural tube defects.

#### Use of Supplements Containing Folic Acid Among Women of Childbearing Age \-\-- United States, 2007 MMWR January 11, 2008 / 57(01);5-8 [**http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5701a3.htm**](http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5701a3.htm) {#use-of-supplements-containing-folic-acid-among-women-of-childbearing-age-----united-states-2007-mmwr-january-11-2008-57015-8-httpwww.cdc.govmmwrpreviewmmwrhtmlmm5701a3.htm .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Anorexia and Bulimia: What You Should Know {#anorexia-and-bulimia-what-you-should-know-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20080115/196ph.html**](http://www.aafp.org/afp/20080115/196ph.html) {#httpwww.aafp.orgafp20080115196ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

**Usefulness of middle cerebral artery Doppler of the fetus at risk for
anemia**

The use of Doppler ultrasound evaluation to measure the peak systolic
velocity of the fetal middle cerebral artery (MCA) has been a major
breakthrough in the noninvasive detection of fetal anemia. An elevated
peak MCA velocity of \>1.5 multiples of the median is useful in the
timing of the initial intrauterine transfusion (IUT) in the red
cell--alloimmunized pregnancies. Data reported to date suggest that a
threshold of 1.32 multiples of the median can be used to time the second
IUT; the MCA Doppler evaluation does not appear sensitive for the timing
of subsequent IUTs in these pregnancies. The peak MCA velocity has also
proved useful in the detection of other anemic states that include Kell
alloimmunization, fetal parvovirus infection, fetomaternal hemorrhage,
alphathalassemia, and after-laser therapy for twin-twin transfusion.

[Moise KJ
Jr](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Moise KJ Jr"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlusDrugs1).
The usefulness of middle cerebral artery Doppler assessment in the
treatment of the fetus at risk for anemia. Am J Obstet Gynecol. 2008
Feb;198(2):161.e1-4.

<http://www.ncbi.nlm.nih.gov/pubmed/18226612>

**Results indicate the presence of dyslipidemia in women with
spontaneous preterm birth**

RESULTS: High cholesterol or triglycerides \<or=15 weeks were associated
with a 2.8-fold (1.0-7.9) and 2.0-fold (1.0-3.9) increased risk for
preterm birth \<34 weeks and \>or=34-\<37 weeks, respectively.
Overweight women who delivered \<34 weeks had particularly elevated
early pregnancy concentrations of cholesterol and low-density
lipoprotein; lean women with moderate preterm birth had elevated
triglycerides. There was a reduced triglyceride response in the first
half of pregnancy among women who delivered \<34 weeks. CONCLUSION: Our
results indicate the presence of dyslipidemia in women with spontaneous
preterm birth.

[Catov
JM](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Catov JM"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlusDrugs1)
et al Early pregnancy lipid concentrations and spontaneous preterm
birth. Am J Obstet Gynecol. 2007 Dec;197(6):610.e1-7.
<http://www.ncbi.nlm.nih.gov/pubmed/18060950>

**High maternal weight increases risk of neonatal mortality, especially
after preterm PROM**

CONCLUSION: High maternal weight seems to increase the risk of neonatal
mortality, especially in infants born after preterm PROM. Inflammation
or infection related to obesity may be part of the causal pathway. LEVEL
OF EVIDENCE: II.

[Nohr
EA](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Nohr EA"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlusDrugs1),
Maternal obesity and neonatal mortality according to subtypes of preterm
birth. Obstet Gynecol. 2007 Nov;110(5):1083-90.

<http://www.ncbi.nlm.nih.gov/pubmed/17978123>

# Caffeine intake during pregnancy increases the risk of miscarriage 

RESULTS: An increasing dose of daily caffeine intake during pregnancy
was associated with an increased risk of miscarriage, compared with no
caffeine intake, with an adjusted hazard ratio (aHR) of 1.42 (95%
confidence interval 0.93 to 2.15) for caffeine intake of less than 200
mg/day, and aHR of 2.23 (1.34 to 3.69) for intake of 200 or more mg/day,
respectively. Nausea or vomiting during pregnancy did not materially
affect this observed association, nor did the change in intake pattern
of caffeine during pregnancy. In addition, the magnitude of the
association appeared to be stronger among women without a history of
miscarriage (aHR 2.33, 1.48 to 3.67) than that among women with such a
history (aHR 0.81, 0.34 to 1.94). CONCLUSION: Our results demonstrated
that high doses of caffeine intake during pregnancy increase the risk of
miscarriage, independent of pregnancy-related symptoms.

[Weng
X](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Weng X"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlusDrugs1)
et al Maternal caffeine consumption during pregnancy and the risk of
miscarriage: a prospective cohort study. Am J Obstet Gynecol. 2008 Jan
24

<http://www.ncbi.nlm.nih.gov/pubmed/18221932>

**Prognosis of fetal cystic hygroma detected during the first trimester
is poor, NT is crucial**

RESULTS: Some 72 fetuses had cystic hygroma. The mean size of the cystic
hygroma was 7.9 mm. Chromosomal abnormalities were present in 52.7% of
cases (38/72), including 14 cases (36.8%) of Down syndrome. A total of
34 chromosomally normal pregnancies gave rise to 18 live births (52.9%),
with no visible serious structural abnormalities. The outcome of
pregnancy was unfavourable (miscarriage, elective termination, serious
structural abnormalities) in 77.7% of cases (56/72). The 18 live-born
infants were followed up for 17-98 months. Sixteen infants developed
normally, while 1 developed Noonan\'s syndrome and 1 had a urinary tract
abnormality (pyelo-ureteral junction; PUJ). CONCLUSION: These data
suggest that the prognosis of fetal cystic hygroma detected during the
first trimester is poor, and show that sonographic evaluation of fetal
nuchal translucency thickness in the first trimester is crucial.

[Graesslin
O](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Graesslin O"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlusDrugs1)
et al Characteristics and outcome of fetal cystic hygroma diagnosed in
the first trimester. Acta Obstet Gynecol Scand. 2007;86(12):1442-6. Epub
2007 Sep 6.

<http://www.ncbi.nlm.nih.gov/pubmed/17851808>

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

**Topic:** **Mental health issues in children and adolescents**

**When:** March 2008

**Moderator**: Dr. Frank Armao, Psychiatry staff at Winslow

**Salient points for discussion**

-The complex influence of early life stress and trauma in shaping
development.

-The increased burden of developmental stress as it pertains to Native
Americans.

-How to distinguish teens with relatively normal perturbation in
development from those needing more intensive management and/or referral
to behavioral health.

-What constitutes a significant mood disorder in an adolescent, and what
are the options for management.

-The serious limitations of DSM-IV and current nosology in "diagnosing"
adolescent behavioral health conditions.

**Primary Care Discussion Forum website**

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

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

Subscribe to the Primary Care listserv

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

Unsubscribe from the Primary Care listserv

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

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

directly

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

#### Routine HIV Screening in the Emergency Department Using the New US Centers for Disease Control and Prevention Guidelines: Results From a High-Prevalence Area {#routine-hiv-screening-in-the-emergency-department-using-the-new-us-centers-for-disease-control-and-prevention-guidelines-results-from-a-high-prevalence-area .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://mp.medscape.com/cgi-bin1/DM/y/hBgpH0Ou5N60Jdl0JDLV0EV**](http://mp.medscape.com/cgi-bin1/DM/y/hBgpH0Ou5N60Jdl0JDLV0EV) {#httpmp.medscape.comcgi-bin1dmyhbgph0ou5n60jdl0jdlv0ev .Style-Heading-4-+-Arial-14-pt-Underline}

**New Updates to U.S. HIV Treatment Guidelines**

On January 29, 2008, the U.S. Food and drug Administration (FDA)
announced new updates to the Department of Health and Human Services
(DHHS) [Guidelines for the Use of Antiretroviral Agents in
HIV-1-Infected Adults and
Adolescents](http://aidsinfo.nih.gov/contentfiles/AdultandAdolescentGL.pdf).
These updates supplement the last major revision of the guidelines,
issued December 1, 2007. A summary of the latest changes is presented
below.

Initial Combination Regimens for the Antiretroviral-Naive Patients

-   [Abacavir
    (Ziagen)](http://www.hivandhepatitis.com/hiv_and_aids/ziagen1.html) +
    [3TC (lamivudine;
    Epivir)](http://www.hivandhepatitis.com/hiv_and_aids/epivir_1.html)
    \-- also available together in the Epzicom combination pill \-- has
    been upgraded from an "alternative" to a "preferred"
    nucleoside/nucleotide reverse transcriptase inhibitor (NRTI)
    backbone for patients who test negative for HLA-B\*5701, a genetic
    marker for susceptibility to abacavir hypersensitivity reactions.

-   [AZT (zidovudine;
    Retrovir)](http://www.hivandhepatitis.com/hiv_and_aids/retrovir_1.html) +
    3TC has been downgraded from  "preferred" to an "alternative" NRTI
    background due to potential toxicities.

-   Ritonavir-boosted [saquinavir
    (Invirase)](http://www.hivandhepatitis.com/hiv_and_aids/fortovase_1.html)
    was changed from "acceptable...but inferior to preferred or
    alternative components" to an "alternative" protease inhibitor (PI).

-   The PI [nelfinavir
    (Viracept)](http://www.hivandhepatitis.com/hiv_and_aids/viracept_1.html),
    the 2-NRTI combination of [d4T (stavudine;
    Zerit)](http://www.hivandhepatitis.com/hiv_and_aids/zerit1.html) +
    3TC, and the NRTI-only triple regimen of abacavir + AZT + 3TC are no
    longer recommended for treatment-naive individuals.

-   The panel added a section entitled "Other Treatment Options Under
    Investigation: Insufficient Data to Recommend," which includes
    recent data from clinical trials of ritonavir-boosted [darunavir­
    (Prezista)](http://www.hivandhepatitis.com/hiv_and_aids/prezista_1.html),
    the newly approved CCR5 antagonist [maraviroc
    (Selzentry)](http://www.hivandhepatitis.com/hiv_and_aids/selzentry_maraviroc.html),
    and the new integrase inhibitor [raltegravir
    (Isentress)](http://www.hivandhepatitis.com/hiv_and_aids/raltegravir_isentress_1.html)
    in treatment-naive patients.

-   

Treatment Interruption

-   This section was updated with recent data on short-term and
    long-term treatment interruption. The panel reaffirmed that \--
    aside from unplanned or planned short-term interruption due to
    illnesses \-- long-term treatment interruption is not recommended
    and should only be undertaken in a clinical trial.

Acute HIV Infection

-   The new guidelines include a new table on "Identifying, diagnosing,
    and managing acute HIV-1 infection," replacing the old table of
    signs and symptoms of acute retroviral syndrome.

-   The panel now recommends that treatment-naive patients who plan to
    start therapy before drug resistance test results are available
    should consider using a PI-based regimen, since non-nucleoside
    reverse transcriptase inhibitor (NNRTI) resistance is more common in
    newly infected individuals.

Tuberculosis

-   The panel updated recommendations concerning the timing of
    antiretroviral therapy in patients with active tuberculosis (TB),
    emphasizing overlapping toxicities and possible interactions between
    TB and HIV drugs, and the potential for immune reconstitution
    inflammatory syndrome. They also recommend repeat testing for latent
    TB infection in people whose CD4 count rises above 200 cells/mm3.

Table Updates

-   Various tables were updated to include information on the most
    recently approved antiretroviral drug, the second generation NNRTI
    [etravirine (Intelence, formerly
    TMC125)](http://www.hivandhepatitis.com/hiv_and_aids/etravirine_overview_1.html).

-   Tables were changed to reflect [new
    recommendations](http://www.hivandhepatitis.com/recent/2008/011808_d.html)
    for [atazanavir
    (Reyataz)](http://www.hivandhepatitis.com/hiv_and_aids/atazanavir_1.html)
    dosing in combination with proton pump inhibitors or H2 receptor
    antagonists.

-   The table of "Antiretroviral components that are acceptable as
    initial antiretroviral components but are inferior to preferred or
    alternative components" has been removed.

The complete new version of the treatment guidelines is available on the
[federal government's AIDSInfo Web
site](http://aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf).
The latest changes are highlighted in yellow.

Sources

R Klein and K Struble. Division of Antiviral Drug Products, U.S. Food
and Drug Administration. Updated Adult and Adolescent Treatment
Guidelines. Email announcement. January 29, 2008.

[U.S. Department of Health and Human Services. Guidelines for the Use of
Antiretroviral Agents in HIV-1-Infected Adults and
Adolescents](http://aidsinfo.nih.gov/contentfiles/AdultandAdolescentGL.pdf).
January 29, 2008.

<http://aidsinfo.nih.gov/contentfiles/AdultandAdolescentGL.pdf>

**SAMHSA releases opportunity for funding of cooperative agreements with
community based organizations**

The main purpose of this cooperative agreement program is to assist
grantees in building solid foundations for delivering and sustaining
cutting edge substance abuse and HIV/AIDS prevention services.  This
program aims at expanding the capacity of community-level domestic
public and private nonprofit prevention service entities to prevent and
reduce the onset of substance abuse and HIV transmission among at-risk
racial/ethnic minority populations.  While grantees will have
substantial flexibility in designing their grant projects, all are
required to base their projects on the five steps of SAMHSA's Strategic
Prevention Framework (SPF).  Successful evidenced-based prevention
approaches developed from these cooperative agreements will be shared
with other community service groups throughout the country. 

**Additional Funding opportunities:**

For more information about the following grants, please reply directly
to the Contacts listed in the announcements.

Cable Positive Grant =
<http://www.cablepositive.org/programs-tonycox.html>

Community Participation Research Targeting the Medically Underserved =
<http://grants.nih.gov/grants/guide/pa-files/PAR-08-075.html>

Integration of Food and Nutrition into Prevention, Care, and Treatment
of HIV Infection and AIDS = 
<http://grants.nih.gov/grants/guide/rfa-files/RFA-HD-07-023.html>

Nutrition and Prevention, Care and Treatment of HIV/AIDS =
<http://grants.nih.gov/grants/guide/rfa-files/RFA-HD-07-022.html>

Research on Pathways Linking Environments, Behaviors and HIV/AIDS =
<http://grants.nih.gov/grants/guide/pa-files/PAR-07-143.html>

**The Indian Health Service HIV Program and SAMHSA sign Memorandum of
Understanding (MOU) on Jan 16, 2008.**

This MOU will assist us with sustaining an interagency collaboration
over the next 3 years and will include the potential for multiple
projects. In 2008, SAMHSA and IHS will work closely on HIV training
initiatives and multiple HIV rapid testing/screening projects. As
alluded to in our strategic planning efforts, collaboration between
agencies will result in increased awareness and utilization of common
resources, decreased duplication of effort and increased integration and
quality of services to the American Indian and Alaska Native population.
We are pleased to release this information and appreciate the continued
support from both agencies. <Scott.Giberson@ihs.gov>

**FDA Approves Etravirine (TMC125)**

The FDA approved Intelence (TMC125, etravirine) on Jan 11, 2008, the
latest drug in a class of non-nucleoside reverse transcriptase
inhibitors (NNRTIs). It will be used in combination therapy with
existing AIDS drugs in adult patients who are failing other therapies.
Intelence is made by Johnson & Johnson. NNRTIs block an essential enzyme
that the HIV virus needs in order to replicate within a host T-cell.\
FDA approved the drug based on 24-week studies that showed 60 percent of
patients who took an Intelence-based drug cocktail achieved an
undetectable viral load. In comparison, 40 percent of patients taking a
placebo in an AIDS drug combination attained undetectable levels of HIV.
Intelence can also be used in patients failing other NNRTIs or have
shown resistance to other ARV therapies. Dose is two tablets twice a
day. Side effects: FDA reports skin rashes and nausea. Long term effects
are unknown at this time.
<http://www.thebodypro.com/content/news/art44832.html>

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

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

**Diabetes A Stronger Risk Factor For Death In Women than In Men**

Eighteen years of follow-up shows that men are twice as likely to die
from heart disease as women. However, this gender gap is markedly
reduced when only patients with diabetes are considered.

CONCLUSION: Diabetes is a stronger predictor for IHD mortality in women
than in men, and diabetes attenuates the usual gender gap in IHD
mortality. With both diabetes and established CVD present, the gender
gap is fully attenuated.

[Dale
AC](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Dale AC"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlusDrugs1),
et al Diabetes mellitus and risk of fatal ischaemic heart disease by
gender: 18 years follow-up of 74,914 individuals in the HUNT 1 Study.
Eur Heart J. 2007 Dec;28(23):2924-9

<http://www.ncbi.nlm.nih.gov/pubmed/17947212>

**Pedometers help people lose weight even without changes in diet**

People who participate in a pedometer-based walking program can be
expected to lose a modest amount of weight even without changing their
diet, with more weight loss the longer they stick with the program,
according to a University of Michigan Health System analysis of nine
studies.

CONCLUSION: Pedometer-based walking programs result in a modest amount
of weight loss. Longer programs lead to more weight loss than shorter
programs.

[Richardson
CR](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Richardson CR"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlusDrugs1)
et al A meta-analysis of pedometer-based walking interventions and
weight loss. Ann Fam Med. 2008 Jan-Feb;6(1):69-77

#### [**http://www.ncbi.nlm.nih.gov/pubmed/18195317**](http://www.ncbi.nlm.nih.gov/pubmed/18195317) {#httpwww.ncbi.nlm.nih.govpubmed18195317 .Style-Heading-4-+-Arial-14-pt-Underline}

**New Position Statement for Glucose Intolerance in PCOS**

The new recommendations highlight the high risk for glucose intolerance
in women with PCOS.\
Generally, screening for glucose intolerance is recommended in these
women because it is often asymptomatic. Recommendations have varied with
regards to PCOS and the method and timing of screening for impaired
glucose tolerance. Therefore, an expert panel was created to make
evidence-based recommendations.

 "\[The position statement\] provides evidence and rationale for the
recommendation that women with PCOS be screened for glucose intolerance
at the initial visit, using an oral glucose tolerance test and that the
women be retested every two years," said Nestler, William G. Blackard
Professor of Medicine Chair and division of endocrinology and metabolism
vice chair at Virginia Commonwealth University.

The panel recommended screening with a two-hour OGTT specifically.
However, several panel members recommended alternate screening using an
OGTT only in patients with BMI \>30 or lean patients with other risk
factors.

For high-risk patients, re-screening should occur every two years or
more frequently. The panel members also suggested annual screening for
women found to have IGT.

Intensive lifestyle modification and weight loss should be considered
for PCOS patients with IGT, as it can help delay progression to type 2
diabetes. The panel recommended at least 30 minutes of moderate activity
at least five days a week. They also recommended a hypocaloric diet for
overweight and obese women, with a target weight loss of 5% to 7%.\
Women with PCOS should be screened for glucose intolerance, regardless
of age, weight, BMI or ethnicity, even in the absence of additional risk
factors and a two-hour OGTT should be performed at the initial
diagnosis.

The same screening method should be utilized for adolescents with PCOS
at least once every two year or more frequently if they present with an
abnormal screen.

The position statement was recently published in The Journal of Clinical
Endocrinology & Metabolism, Jan.2008.

[Sattar
N](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Sattar N"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlusDrugs1),
[Nelson
SM](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Nelson SM"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlusDrugs1).
Polycystic ovarian syndrome, biomarkers, and metformin: research, risk,
and reality. J Clin Endocrinol Metab. 2008 Jan;93(1):34-6.

<http://www.ncbi.nlm.nih.gov/pubmed/18178908>

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

**Low-Carbohydrate Diets Rich in Vegetable Sources of Fat and Protein:
Reduce Diabetes**

[Results]{.underline} Women with the highest carbohydrate scores (lowest
carbohydrate intakes) were 40% more likely to be diagnosed with diabetes
than those with the lowest carbohydrate scores (highest carbohydrate
intakes) (P \< 0.0001). Importantly, this effect disappeared after
adjustment for body mass index. Glycemic load and total carbohydrate
intake were positively related to risk of type 2 diabetes (P \< 0.001).
When carbohydrate scores were calculated by using percentages of energy
from only animal fat and protein, there was no relation between the
score and risk of type 2 diabetes. Conversely, when the scores were
calculated by using percentages of energy from only vegetable fat and
protein, lower carbohydrate consumption was associated with an 18%
reduction in diabetes risk.

[Conclusions]{.underline} The data provide additional evidence that
consumption of a low-carbohydrate diet that provides relatively high
amounts of animal fat and protein does not increase the risk of type 2
diabetes in women. However, low-carbohydrate diets rich in vegetables
sources of fat and protein may reduce the risk.

Reference Halton TL, Liu S, Manson JE, Hu FB. Low-carbohydrate-diet
score and risk of type 2 diabetes in women. American Journal of Clinical
Nutrition 2008;87:339-46.

#### [**http://www.ajcn.org/cgi/content/abstract/87/2/339**](http://www.ajcn.org/cgi/content/abstract/87/2/339) {#httpwww.ajcn.orgcgicontentabstract872339 .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

Women and HIV/AIDS

PINN POINT ON WOMEN'S HEALTH

The Office of Research on Women's Health (ORWH) is broadcasting the
eighth in a series of podcasts, "Pinn Point on Women's Health," hosted
by Dr. Vivian W. Pinn, Associate Director for Research on Women's Health
and the Director of the Office of Research on Women's Health. The
monthly podcast discusses the latest news in women's health research and
includes conversations with guests on a variety of subjects.

In the latest podcast, Dr. Pinn talks with Dr. Victoria Cargill,
Director of Minority Research and Clinical Studies, Office of AIDS
Research, Office of the Director, National Institutes of Health. Dr.
Cargill discusses women and HIV/AIDS from the perspective of a
researcher and practicing physician in the community.  Dr. Cargill
emphasized that AIDS continues to be a major health problem for women
and that "African American and Hispanic women are almost 80 percent of
AIDS cases reported in women." This podcast also discusses differences
in how AIDS affects men and women.

"Podcasting" is a relatively new method of distributing audio and video
information via the Internet to iPods and other portable media players
on demand, so that it can be listened to at the user's convenience. The
main benefit of podcasting is that listeners can sync content to their
media player and take it with them to listen to whenever they want.
Because podcasts are typically saved in MP3 format, they can also be
listened to on nearly any computer.

To listen to Dr. Pinn's podcast, visit the ORWH homepage at
<http://orwh.od.nih.gov/> and click on Pinn Point on Women's Health
(podcast). If you need further assistance on how to use podcasts, go to
<http://videocast.nih.gov/faq/podcast/default.asp>.

For questions, contact Marsha Love at the Office of Research on Women's
Health by calling (301) 496-9472 or e-mailing <lovem@od.nih.gov>.

**APN brochures**

This is a status report on the APN brochures:  First, let me apologize
that the brochures have not already been sent.  I requested that a
secretary prepare the requisition to have them printed and sent out, but
I have just discovered that the requisition was never done, and the
brochures were never ordered: I am starting the process from scratch
once again.

Last year we printed 10,000 brochures.   This year I would like to print
enough so you have enough for at least a year. 

The number of brochures you need depends on the number of encounters you
all have and the frequency with which you provide the brochure.  I am
going to estimate that each of you averages about 2500 to 3000
encounters per year.  Believe it or not, I have no way of identifying
the number of APNs by site, so I have no idea how many APNs there are by
Area.   I will estimate that there are an average of 20 APNs by Area,
seeing 3000 patients per year.  That's 60,000 brochures.  So using these
assumptions, I would provide 60,000 brochures to each Area with IHS
facilities (not Alaska or California), and I would order 600,000
brochures. 

It will help me come up with a more precise number for each Area if the
NNLC members please email me the following information:

1)  The number of CNMs at each site (hospital and clinic) in your Area;

```{=html}
<!-- -->
```
1)  The number of NPs at each site (hospital and clinic) in your Area;

2)  The number of CRNAs.

<Carolyn.Aoyama@ihs.gov>

**Knowing What Works in Health Care: A Roadmap for the Nation**

This IOM Report provides a blueprint for a national program to assess
the effectiveness of clinical services and to provide credible, unbiased
information about what really works in health care.

<http://www.nap.edu/catalog.php?record_id=12038>

**SAMHSA** **Compendium of primary mental health activities now online**

The SAMHSA website address below will take you to a compendium of
primary mental health activities that may be helpful to you in your
efforts to improve access to  behavioral health services in primary
care. <http://samhsa.gov/Matrix/matrix_mh.aspx>

**DV Announcements: Grants, trainings and resources shared by various
project faculty**

The following is information about open grants, trainings and resources
shared by various project faculty. If you have announcements, or
questions to send to the group, just send them directly to me and I'll
post to the group.

 

1.  Many of you know Cheryl Neskahi Coan from her leadership with the
    Family Harmony Project and Crownpoint IHS DV Team. She now works
    with the Southwest Center for Law and Policy as their Director of
    Violence Against Women Training. SCLP has ongoing trainings covering
    issues such as child custody, advocates under subpoena and sexual
    assault, just to name a few...visit their website for their full
    schedule: [www.swclap.org](http://www.swclap.org/)

```{=html}
<!-- -->
```
1.  Violence Against Women Discretionary Grants for Indian Tribal
    Governments announcement (see below my signature for more info)

2.  New SAMHSA compendium of primary mental health activities that may
    be helpful to you in your efforts to improve access to behavioral
    health services in primary care. Visit:
     <http://samhsa.gov/Matrix/matrix_mh.aspx>

3.  Southwest Indigenous Women\'s Coalition in Phoenix, AZ is hiring
    (see attached job announcements).

4.  WHO Foundation: Women Helping Others Offers Support for
    Grassroots Charities Serving Women and Children. Visit:
     <http://www.whofoundation.org/WHO_Funding.htm> for more info.

Questions: <Carolyn.Aoyama@ihs.gov>

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

**Keeping Native Women & Families Healthy & Strong**

-   April 23-25, 2008

-   Milwaukee, WI

-   Great Lakes Tribal Epidemiology Center

-   E-mail contact <EpidemiologyCenter@gmail.com>

**IHS Basic Colposcopy Course**

-   April 9 - 11, 2008

-   Albuquerque, NM

-   Contact
    [[AWaxman@salud.unm.edu]{.underline}](mailto:AWaxman@salud.unm.edu)

**IHS Colposcopy Update & Refresher Course**

-   April 9 - 11, 2008

-   Albuquerque, NM

-   Contact
    [[AWaxman@salud.unm.edu]{.underline}](mailto:AWaxman@salud.unm.edu)

**Training in Palliative and End of Life Care**

-   April 22-24, 2008

-   Flagstaff, AZ

-   Contact Tim Domer MD at <tim.domer@ihs.gov>

**Advances in Indian Health (AIH) Conference**

-   April 29 -- May 2, 2008

-   Albuquerque, New Mexico

-   28 credits, Indian Country's Primary Care Conference

<http://www.ihs.gov/MedicalPrograms/MCH/F/CN01.cfm?module=2008&option=may#top>

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

**Meeting notes now online: [2007 Native Women's Health and MCH
Conference](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/Intro Slide and Eval Sli14.ppt)**

<http://www.ihs.gov/MedicalPrograms/MCH/F/lecNotes.cfm#wHealthConf>

There are several upcoming **Conferences**

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

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

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

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

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

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

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

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

#### The February 2007 CCC Corner is available at: {#the-february-2007-ccc-corner-is-available-at .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08**](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08) {#httpwww.ihs.govmedicalprogramsmchmob.cfmmodule2_08 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Concern for rising Cesarean rates in Native American populations**

#### From your colleagues page 12 {#from-your-colleagues-page-12 .Style-Heading-4-+-Arial-14-pt-Underline}

Sally Bremner

#### Hospital-Acquired Infections: What You Should Know {#hospital-acquired-infections-what-you-should-know .Style-Heading-4-+-Arial-14-pt-Underline}

Shannon Meyers

Save the Dates!! Earn up to 28 hours of CME/CE specific to Indian Health

Sunnah Kim

2008 Native American Child Health Advocacy Award

Chuck North

Partnership with Mountain and Plains Educational Resource Center

Jennifer Staple

Unite For Sight Volunteer Abroad Opportunities:

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

##### Obstetrics page 15

-Knowledge of cervical length / fetal fibronectin associated with
shorter evaluation and PTB

-Sublingual misoprostol associated with higher patient satisfaction
compared with vaginal

-Management of shoulder dystocia: trends in incidence and morbidity

#### -CDC Issues Guidelines for Preconception Care of Women  {#cdc-issues-guidelines-for-preconception-care-of-women .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Guidelines Recommend Universal Prenatal Screening for Down Syndrome  {#guidelines-recommend-universal-prenatal-screening-for-down-syndrome .Style-Heading-4-+-Arial-14-pt-Underline}

**Gynecology page 18**

-Misoprostol in the setting of incomplete abortion

-Hysterectomy vs LNG-IUS

-Intracervical balloon placement for saline sonohysterography superior
vs intrauterine

-PCA, scheduled intravenous, and scheduled subcutaneous: None appears to
be superior

-Liquid-based cervical cytology neither more sensitive nor more specific
vs conventional

and more....

**Child Health page 20**

-11th Annual Patty Iron Cloud National Native American Youth Initiative

-Secondhand smoke during infancy linked in dose-response fashion with
allergies

-Oral health of Aboriginal children

-ACIP Releases 2008 Child and Adolescent Immunization Schedules

**Chronic Illness and Disease page 21**

-\'Awake\' during surgery: Examining intraoperative awareness

-5-day course of nitrofurantoin is effective fluoroquinolone-sparing
treatment of cystitis

-Cardiovascular disease and pre-eclampsia related. Pre-eclampsia and
cancer are not

-Factors Related to Cardiovascular Disease Risk Reduction in Midlife and
Older Women

-Herbal and Dietary Supplement-Drug Interactions in Patients with
Chronic Illnesses

and more....

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

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

-Elective and risk--reducing salpingo-oophorectomy

-Surgery and Patient Choice

-Intraperitoneal Chemotherapy for Ovarian Cancer

##### American Family Physician

-Prevention and Treatment of Sexually Transmitted Diseases: An Update

-CDC Reports a Decrease in the Incidence of Breast Cancer

-Recommendations for Follow-up after Early Breast Cancer Diagnoses

-CDC Evaluates the Effect of Revised Guidelines on Group B Streptococci
Disease

-Premenstrual Syndrome

**Agency for Healthcare Research and Quality**

-Intervention programs that focus on already violent youth are more
effective

-Some women with breast cancer do not receive recommended adjuvant
treatments

-Use of antidepressants by low-income pregnant women up twofold: Fetal
risks?

-Regulatory warnings led to decreased use of antidepressants in children
and adolescents

**Ask a Librarian**

Cervical Cancer Community-Based Research Project in a Native American
Community

**Behavioral Health Insights**

Autism Screening - Guest editor Joshua Cabrera, MD

**Breastfeeding**

Breast Pumps: The good, the bad, and the ugly

**CCC Corner Digest**

-What happens if your patient hears their results as Negative? Positive?
Normal? Abnormal?

-You can make a big difference in women's and children's lives

-Cesarean delivery on request not recommended if desiring several
children, ACOG

-Early feeding within the first 24 hours after major abdominal
gynecologic surgery is safe

-Rapid response team: Implications of findings on mortality rates for
children are dramatic

-Reconsider use of rosiglitazone

-Human Immunodeficiency Virus

-Patient-Controlled Analgesia for Postoperative Pain: Cochrane Briefs

-Child and Adolescent Overweight and Obesity Recommendations

-Teens, Depression, Black Box Warnings and Suicide

-Breastfeeding, it is not just about the baby

-Improving Domestic Violence Law Enforcement Response: Tohono O\'odham
Nation

-Palliative / End of Life Care Training- SAVE THE DATES -- March and
April Courses

-Intrauterine Device and Adolescents, ACOG Committee Opinion

-Preconception Counseling for Women with DM and HTN: New module

-How should we manage a patient with a previous abruptio placenta?

-Disparities, Inequalities, or Inequities?

-Insights on Implementing Cultural and Linguistic Competence in MCH

-Oral Health for Head Start Children: Best Practices

-What was the presenting part? The answer

-ACNM seeks Midwifery Expertise on an as-needed basis

-Informed Refusal, Leaving Against Medical Advice, and Asking Questions

-Scope of Practice - Nurse Practitioner: Regulation, Competency, and
Expansion

-Less errors with standardization of corticosteroid regimens

-Screening for Chlamydial Infection: Recommendation Statement, USPSTF

-Family History more relevant to risk of GDM in nulliparous than in
parous women

-Making a business case for investing in Maternal and Child Health

**Domestic Violence**

-2008 NICWA Annual Conference

-Family violence in health care and public health settings: Accepting
Manuscripts

-National Report: National Indian Child Welfare

-31st Annual Indian School on Alcohol and Other Drug Related Issues -
Save the Date

-Improving Domestic Violence Law Enforcement Response on the Tohono
O\'odham Nation

**Elder Care News**

-2008 Education in Palliative and End-Of-Life Care-Oncology/IHS

-A second training session will be held in Flagstaff AZ April 22-24

-Minimizing Adverse Drug Events in Older Patients

**Family Planning**

-Continuous OCPs May Not Reduce Bleeding Days, but May Improve Symptoms

-Association of OCP Use, Other Contraceptive Methods, and Infertility
with Ovarian Cancer

-Tubal Patency Better With One Dose vs Multiple Methotrexate Doses for
Ectopic

**Featured Website**

New and Improved MCH Conferences page - More user friendly

**Frequently asked questions**

Frequently Asked Questions about Infant Feeding Choice

**Indian Child Health Notes**

-Trajectories of growth among children who have coronary events as
adults

-2008 Childhood Immunization Schedule: Few changes planned.

-Pattern of diarrhea-associated hospitalization and outpatient visits
for AI/AN children by region

**Information Technology**

-Four Directions Summer Research Program Applications Online for Summer
2008

-iCare Training

International Health

Multiple Chlamydia species pose an unexpected challenge for blindness
prevention

#### MCH Alert

New edition of Knowledge Path: Preconception and Pregnancy available

#### MCH Headlines

-Announcing the 2008 PREVENT Child Maltreatment Institute

-Children with special health care needs: Cultural competence compendium

#### Medical Mystery Tour

#### St. John\'s wort for depression in a young woman {#st.-johns-wort-for-depression-in-a-young-woman-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Medscape

-PMDD Spotlight: Women With Histories of Abuse: A Clinically Meaningful
Subgroup?

-HPV Vaccines: Beyond Expectations

-Expanding HIV Testing: Practical Screening Cases to Meet New CDC
Recommendations

-Sexually Transmitted Infections and Cancer: Breaking the Link Through
Vaccination

######### -Hypertension and Soy: A Best Evidence Review

and more....

**Menopause Management**

-Smoking Status as a Predictor of Hip Fracture Risk in Postmenopausal
Women

#### -Low dose transdermal E2 gel delivered the lowest effective dose  {#low-dose-transdermal-e2-gel-delivered-the-lowest-effective-dose .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Vaginal tablets containing 25 mcg or 10 mcg estradiol are effective {#vaginal-tablets-containing-25-mcg-or-10-mcg-estradiol-are-effective .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Levonorgestrel intrauterine system (LNG-IUS) reduces endometrial polyps with tamoxifen {#levonorgestrel-intrauterine-system-lng-ius-reduces-endometrial-polyps-with-tamoxifen .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Aromatase Inhibitors: Hormonal Agents for Treatment and Prevention of Breast Cancer {#aromatase-inhibitors-hormonal-agents-for-treatment-and-prevention-of-breast-cancer .Style-Heading-4-+-Arial-14-pt-Underline}

and more....

**Midwives Corner**

VBACs: Evidence supports them, women want and benefit from them. We need
to provide them

-Judy Whitecrane: Tireless Improvement of Care for Native American women

-53rd ACNM Annual Meeting & Exposition

-ACNM Clinical Bulletin Recommends Intermittent Auscultation

**Navajo News**

Biliary Gallstone Disease and Pregnancy

**Nurses Corner**

-AWHONN -- numerous on line courses -- materials and fees listed

#### -The Last Hours of Living {#the-last-hours-of-living .Style-Heading-4-+-Arial-14-pt-Underline}

-PhD in Nursing Concentration in Health Policy

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

Preconception and Interconception Health Status of Women Who Recently
Gave Birth

**Oklahoma Perspective**

Cesarean Delivery: What are the risks and benefits?

Osteoporosis

\-[Nonpharmacologic Management of Osteoporosis to Minimize Fracture
Risk](http://mp.medscape.com/cgi-bin1/DM/y/hBerL0Ou5N60Jdl0JAIc0Eg)

-HT and Risk of Cardiovascular Disease by Age and Years Since Menopause

-Depression Associated With Low Bone Mineral Density 

Patient Education

-Patients Prefer the Method of \"Tell Back- Collaborative Inquiry\" to
Assess Understanding

-Sexually Transmitted Diseases-Prevention and Treatment for You and Your
Partner

Perinatology Picks

-Women with cardiovascular risk factors may be predisposed to
pre-eclampsia

-Obstetric outcomes in cancer survivors are reassuring

-Booster dose of betamethasone just before preterm birth: Results
caution against

-Conservative management 1^st^ choice for severe hydronephrosis in
pregnancy

Primary Care Discussion Forum

Mental health issues in children and adolescents: March 2008

STD Corner

#### -The cervical cancer risk is still increased 25 years after treatment for CIN 3 {#the-cervical-cancer-risk-is-still-increased-25-years-after-treatment-for-cin-3 .Style-Heading-4-+-Arial-14-pt-Underline}

-HPV Vaccine Acceptance Among Mid-Adult Women

#### -Adding HPV test to the Pap test to screen in mid-30s reduces grade 2 or 3 CIN and cancer  {#adding-hpv-test-to-the-pap-test-to-screen-in-mid-30s-reduces-grade-2-or-3-cin-and-cancer .Style-Heading-4-+-Arial-14-pt-Underline}

-New point of care Chlamydia Rapid Test: Bridging the gap between Dx and
Treatment

-Recurring C. trachomatis Infections in Young Women

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

-Resolving to Lose Weight in the New Year?

-Does being overweight or obese increase subsequent hysterectomy risk?

-Prepregnancy BMI, hypertensive disorders of pregnancy, and long-term
maternal mortality

-Glycemic Profiles During Pregnancy Differ Between Type 1 and Type 2
Diabetes

-Miscarriage and abortion triple chances of future low birth weight
babies

**Women's Health Headlines**

-Women's Leadership Scholarship

-New Resource from the National Center for Cultural Competence

-Ending Violence Against Native Women Training Institute and scholarship
opportunity

-Native Women\'s Health and Well-Being Conference

-Women\'s History Month: March 2008

###### Save the Dates: Upcoming events of interest page 70

#### What's new on the ITU MCH web pages page 71

The past CCC Corners are archived at:

<http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN02.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 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/MCHdiscuss.cfm>

2/17/08njm