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

 

OB/GYN Chief Clinical Consultant's Corner

Volume 6, No. 2, February 2008

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

#### 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 .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 .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

#### How to strengthen pelvic floor muscles?

**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}

**Concern for rising Cesarean rates in Native American populations**

By Larry Leeman MD, MPH and Eve Espey MD, MPH

**Editorial Note**: The following is in response to a Point /
Counterpoint discussion of trial of labor after cesarean (TOLAC) in
rural hospitals, December CCC Corner\*

We appreciate the willingness to engage in discussion about trial of
labor after cesarean (TOLAC) availability and the approach to cesarean
delivery at W. W. Hastings Hospital. Every facility faces unique factors
in the decision to offer TOLAC services. However, we fear that the high
total cesarean rate and lack of TOLAC services will ultimately result in
worse perinatal outcomes considered from a population level.

Not only is vaginal birth after cesarean (VBAC) highly desired by many
women, but it is preferable to a repeat cesarean delivery in certain
women, including those with a single cesarean delivery who have had a
successful vaginal birth before or after their cesarean delivery.
Evidence suggests that such women should be encouraged to have a TOLAC
particularly if they plan to have additional children[^1]. Given these
data, anesthesia staff should be strongly encouraged to change their
policy and offer^1^ VBAC services in accordance with guidelines similar
to those developed in the Northern New England Perinatal Quality
Improvement Network (NNEPQIN). Ethically, it is difficult to justify
withholding TOLAC when it is the safest option. If services were offered
to this group of women, obstetrical and anesthesia staff could develop
greater comfort with TOLAC and expand the local eligibility criteria.

Annual cesarean rates at some Indian Health facilities in Oklahoma are
\> 37% and short term rates over 40%, hence are above the recently
published 2006 national rates for the total U.S population (31.1%), the
Oklahoma state population (33.3%), and the US Native American population
(27.5%)^2^ We note that the Native American cesarean rate increased 1.5%
from 2005 to 2006, almost double the 0.8% increase for the total US
population. The rising cesarean rate is likely a reflection of both
rising primary cesarean delivery rates and decreased vaginal birth after
cesarean delivery.

Given the limited availability of TOLAC services for women in the
Oklahoma service area, efforts should be made to minimize the primary
cesarean delivery rate. The decision to lower the threshold for primary
cesarean delivery as evidenced by an acceptance of the high rate and an
unwillingness to look at physician specific factors will result in
higher adverse outcomes in future pregnancies^3^, particularly when
combined with the lack of TOLAC services. Women in the Hastings area
with primary cesareans can be anticipated to have cesareans in all
future births placing them at increased risk for placenta accreta,
increta and percreta^5^. These complications of abnormal placentation
may be particularly difficult to address in a rural community hospital
setting.

Although Healthy People 2010 does not include a recommendation for the
total cesarean rate due to varying patient factors, it recommends that
efforts be made to decrease the primary cesarean rate to 15% in women
who are giving birth for the first time^6^. ACOG similarly recommends
that comparative cesarean delivery rates for populations, hospitals, or
physicians should be based on the subgroup of nulliparous women with
term singleton vertex gestations^7^. We would be interested in seeing
the rate for this population at those affected facilities in Oklahoma
Area.

We worked in at the Gallup Indian Medical Center (GIMC) and Zuni-Ramah
Hospitals in the 1990s and continue to work with Native populations in
Albuquerque and New Mexico. Our study of the population based CS rate in
Zuni-Ramah in the 1990s demonstrated a 7.3% cesarean rate despite an
incidence of diabetes and hypertensive disorders well above national
rates^8^. Physician specific practices influence cesarean delivery
rates^9^. We believe that the cesarean delivery review initiated at GIMC
in the early 1990s was important in identifying factors in patient
management that can result in a high cesarean rate.

An important ingredient in reducing cesarean delivery, either in
nulliparous or parous women, is to place value on vaginal delivery. The
attitude that "None of the physicians in our department are concerned
with our cesarean delivery rate" may prove the largest stumbling block
in developing strategies more consistent with national goals.

We suggest that the maternity care providers in Hastings present the
evidence for improved maternal outcomes in women with prior vaginal
delivery to their anesthesia colleagues and make TOLAC available at
least for this group of women. Addressing the high total (and
presumably) primary cesarean rates will require analysis of the
indications and physician specific patterns. Given the increasing
evidence for adverse outcomes with multiple repeat cesareans and the
limited ability of community hospitals to address problems with placenta
accreta, increta and percreta, we support labor management strategies to
reduce cesarean rates in the Native American population in the Oklahoma
Area and nationwide.

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

**An argument for better teamwork: Trial of labor after cesarean in
Indian Country**

First, I want to thank the leaders of the Indian Health Midwives
listserv for raising these important issues, as this discussion was
originally begun in the Midwives Corner feature. Though the current
discussion revolves around Indian Health facilities, it is reflective of
most small rural hospitals and increasingly some larger urban
facilities.

Next, the availability of the trial of labor after cesarean option is
really a 'systems' issue not just a problem confined to midwives or
physicians. To decrease the long term morbidity and mortality associated
with cesarean rates that now exceed 40%, we need to approach this issue
systematically. Specifically, how can we engage our Indian Health
administrative staff to foster an environment whereby anesthesia,
pediatric, and nursing services work together with the provider staff to
decrease excess morbidity in Native women.

Should you offer vaginal birth after cesarean delivery at your facility?

Should your referral facility be offering VBAC?

Let's put some of the above issues into perspective.

What are just a few of the risks that you should currently handle very
well:

Incidence per 100

Shoulder dystocia 0.2 -3.0

Cord Prolapse 0.14 - 0.62

Abruptio placenta, overall 0.4 - 1.3

Abruptio placenta, severe - stillbirth 0.12

Placenta previa, third trimester 0.1 to 0.4

Placenta accreta, overall 0.18

Placenta accreta / previa unscarred 1 - 5

Placenta accreta / previa with 1 Ces Del. 11 to 25

Placenta accreta / previa with 2 Ces 35 to 47

Placenta accreta / previa with \> 3 Ces 50 to 67

Post partum hemorrhage 1 -- 5

Trauma 7

In all but one of the above cases the incidence of these obstetric
emergencies is actually increasing each year.

**If you can't provide VBAC because of the 0.5% risk of uterine rupture,
then should your facility be offering intrapartum care at all?**

If you work at a facility that can not develop a rapid response for a
clinical issue like symptomatic uterine rupture in a VBAC setting, which
happens \~0.5 percent of the time, then your facility, should
re-evaluate its ability to manage obstetric intrapartum care.

Taken on their own individual merit, most of the above common urgencies
and emergencies occur more frequently than 0.5 percent. Taken as an
aggregate, the risks above far outweigh the risks of VBAC. Now seeing
the above risks, if you feel you need to re-evaluate offering obstetric
intrapartum care because the above risks, then please contact me as soon
as possible.

For those facilities that feel they are able to continue to offer
obstetric intrapartum care within the risk environment above, then I
would suggest a program of emergency obstetric drills, pan-ALSO\*\*
certification for all nurses and providers, and an ongoing quality
assurance.

Each of the last three national Indian Women's Health and MCH
Conferences has devoted significant blocks of lecture time and workshops
to improve systems of care and specific content updates. (Link to
Meeting Lecture notes below)

Lastly, there seems to be some confusion as some providers at times
combine the risk of a TOLAC sequela vs the relative success of a vaginal
birth in TOLAC. These are two separate issues that need to be discussed
with our patients separately for a fully informed consent.

**1.) Success of vaginal delivery**

Overall the rate of successful vaginal delivery in TOLAC is actually
quite high, often in the range of 75% in the general population, and
much higher success rate in the AI/AN population at 85-90% over the
years.

A previous successful VBAC is probably the best predictor of future
success; about 90 percent of such women deliver vaginally with trial of
labor. By comparison, women delivered abdominally for dystocia are least
successful, although approximately two-thirds are delivered vaginally.

Among the previous dystocia group, the success rate is higher if
cesarean delivery was performed in the latent phase of labor and lower
if performed after full dilatation. Within the former group, 79% of
women who originally had surgery while still in the latent phase of
labor had a successful trial of labor, compared with 61% of patients who
had an arrest of dilation in the active phase of labor and 65% of those
who had an arrest of descent. (Duff et al Obstet Gynecol 1988 Mar;71 (3
Pt 1):380-4.)

Multivariate logistic regression analysis identified as predictive of
TOL success: previous vaginal delivery (OR 3.9; 95% CI 3.6-4.3),
previous indication not being dystocia (CPD/FTP) (OR 1.7; 95% CI
1.5-1.8), spontaneous labor (OR 1.6; 95% CI 1.5-1.8), birth weight
\<4000 g (OR 2.0; 95% CI 1.8-2.3), and Caucasian race (OR 1.8, 95% CI
1.6-1.9) (all P \< .001).

The overall TOL success rate in obese women (BMI \> or = 30) was lower
(68.4%) than in nonobese women (79.6%) (P \< .001), and when combined
with induction and lack of previous vaginal delivery, successful VBAC
occurred in only 44.2% of cases. (Landon et al The MFMU Cesarean
Registry: factors affecting the success of trial of labor after previous
cesarean delivery. Am J Obstet Gynecol. 2005 Sep;193(3 Pt 2):1016-23. )

The combination of previous cesarean for dystocia, no previous vaginal
delivery, and induced labor had a particularly poor prognosis in the
Flamm system, e. g., fewer than 50 percent of such women achieved a
successful TOL.

A decision analysis model favored TOL if the chance of success was \>50
percent and if the desire for additional pregnancies was 10 to 20
percent. (Mankuta et al Am J Obstet Gynecol 2003 Sep;189(3):714-9.)

Trial of labor success rates: obstetrical and historical factors

  ------------------------------------------------------ --------------------------- -------------------------
  **Characteristic**                                     **VBAC success, percent**   **Odds ratio (95% CI)**

  **Previous CD indication**                                                         

  Dystocia                                               63.5                        0.34 (0.30-0.37)

  NRFWB                                                  72.6                        0.51 (0.45-0.58)

  Other                                                  77.5                        0.67 (0.58-0.76)

  Malpresentation\*                                      83.8                        1.0

  **Previous vaginal delivery**                                                      

  Yes\*                                                  86.6                        1.0

  No                                                     60.9                        0.24 (0.22-0.26)

  **Previous VBAC**                                                                  

  Yes\*                                                  86.6                        1.0

  No                                                     64.4                        0.21 (0.19-0.23)

  **Labor type**                                                                     

  Induction                                              67.4                        0.50 (0.45-0.55)

  Augmented                                              73.9                        0.68 (0.62-0.75)

  Spontaneous                                            80.6                        1.0

  **Admit cervical dilation**                                                        

  \<4                                                    66.8                        0.39 (0.36-0.42)

  ![](media/image2.png){width="8.333333333333333e-2in"   83.8                        1.0
  height="9.236111111111112e-2in"}4\*                                                

  **Birth weight (g)**                                                               

  \<2500                                                 77.2                        1.14 (0.89-1.47)

  2500-3999\*                                            74.9                        1.0

  ![](media/image2.png){width="8.333333333333333e-2in"   62.0                        0.55 (0.49-0.61)
  height="9.236111111111112e-2in"}4000                                               

  **Gestational age (week/day)**                                                     

  37 0/7-40 6/7\*                                        75.0                        1.0

  ![](media/image2.png){width="8.333333333333333e-2in"   64.8                        0.61 (0.55-0.68)
  height="9.236111111111112e-2in"}41                                                 
  ------------------------------------------------------ --------------------------- -------------------------

All overall P values are \<.001; for categorical characteristics, only
the comparison of birth weight \<2500 g to 2500 to 3999 is not
significant (P=.33).\
CI: confidence interval; CD: cesarean delivery; VBAC: vaginal birth
after CD; NRFWB: nonreassuring fetal well-being.\
\* Women with this characteristic served as the reference group.\
Modified from: Landon, MB, Leindecker, S, Spong, CY, et al. Am J Obstet
Gynecol 2005; 193:1016.

Flamm scoring system tool

  ------------------------------------------------ ----------------------
  **Variable**                                     **Point value**

  **Age under 40 years**                           2

  **Vaginal birth history**                        

  Before and after 1st cesarean                    4

  After 1st cesarean                               2

  Before 1st cesarean                              1

  None                                             0

  Reason other than FTP for 1st cesarean           1

  **Cervical effacement at admission**             

  \>75 percent                                     2

  25 percent - 75 percent                          1

  \<25 percent                                      

  Cervical dilation 4 cm or more at admission      1

  **Score (percent)**                              **VBAC successful**

  0 to 2                                           49

  3                                                60

  4                                                67

  5                                                77

  6                                                89

  7                                                93

  8 to 10                                          95
  ------------------------------------------------ ----------------------

FTP: failure to progress.\
Data from: Flamm, BL, Geiger, AM. Obstet Gynecol 1997; 90:907.

**2.) Risks:**

Numerous risk factors have been cited for uterine rupture during labor
in women with a previous CD. However, these risk factors are not
consistent across studies, which are generally hampered by small numbers
of patients with uterine rupture. Unfortunately, no single factor or
combination of risk factors is sufficiently reliable to be clinically
useful for prediction of uterine rupture.

Purported risk factors include maternal age greater than 30 years,
induction of labor, more than one prior CD, postpartum fever,
interdelivery interval less than 18 to 24 months, dysfunctional labor,
and one layer uterine closure. Within this framework of incomplete data
the New England Perinatal Quality Improvement Network (NNEPQIN) has
developed a system to appropriately manage the risks.

**Low Risk Patient:**

-   1 prior low transverse cesarean delivery

-   Spontaneous onset labor

-   No need for augmentation

-   No repetitive FHR abnormalities

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

-   

**Medium Risk Patient:**

-   Induction of labor

-   Pitocin augmentation

-   2 or more prior low transverse cesarean deliveries\*

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

-   

**High Risk Patient:**

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

-   Bleeding suggestive of abruption

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

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

Here is a suggested management system per NNEPQIN

#### 

#### Low risk

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

#### Medium risk

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

#### High risk

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

Please see the Midwives Corner and Oklahoma Perspective, below, for
further discussion on this topic. A complete discussion of risk,
benefits, and systems issues is available in the Perinatology Corner
module: **Vaginal Birth after cesarean**
<http://www.ihs.gov/MedicalPrograms/MCH/M/PNC/VB01.cfm>

**Other Resources:**

Vaginal birth after cesarean (VBAC) in rural hospitals Counterpoint:
David Gahn, M.D.

<http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#MidWives>

**New England Perinatal Quality Improvement Network (NNEPQIN)**

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

**Indian Health Meeting lecture notes**

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

**OB Emergency Drills in Indian Country**

<http://www.ihs.gov/medicalprograms/mch/F/documents/OBEmergDrills.ppt>

**2007 Indian Health Data Summary** (Deliveries, VBAC rates, etc...)

<http://www.ihs.gov/MedicalPrograms/MCH/F/documents/DataTally81107.doc>

\*\* ALSO = **Advanced Life Support in Obstetrics**

<http://www.aafp.org/online/en/home/cme/aafpcourses/clinicalcourses/also.html>

**Leeman and Espey References:**

1 Cahill AG, Stamilio DM, ADibo AO, Pelpert JF, et al. Is vaginal birth
after cesarean (VBAC) or elective repeat cesarean safer in women with a
prior vaginal delivery? Am J Obstet Gynecol 2006; 195:1143-7.

2 Hamilton BE, Martin JA, Ventura SJ. Births: Preliminary data for 2006.
National vital statistics reports; vol 56 no 7. Hyattsville, MD:
National Center for Health Statistics. 2007.

3 [Kennare
R](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Kennare R"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVCitation),
[Tucker
G](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Tucker G"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVCitation),
[Heard
A](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Heard A"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVCitation),
[Chan
A](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Chan A"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVCitation).
Risks of adverse outcomes in the next birth after a first cesarean
delivery. Obstet Gynecol 2007; 109:270-6.

4 Silver RM, Landon MB, Rouse DJ, Leveno KJ, Spong CY, Thom EA, et al.
Maternal morbidity associated with multiple repeat cesarean deliveries.
Obstet Gynecol 2006;107:1226--32.

5 Getahun D, Oyelese Y, Salihu HM, Ananth CV. Previous cesarean delivery
and risks of placenta previa and placental abruption. Obstet Gynecol
2006;107:771--8.

6 U.S. Department of Health and Human Services. Healthy People 2010. 2nd
ed. With Understanding and Improving Health and Objectives for Improving
Health. 2 vols. Washington, DC: U.S. Government Printing Office,
November 2000.

7 American College of Obstetricians and Gynecologists, Task Force on
Cesarean Delivery Rates. Evaluation of cesarean delivery. Washington,
DC: American College of Obstetricians and Gynecologists, 2000.

8 Leeman L, Leeman R. A Native American community with 7% cesarean
delivery rate: Case mix analysis, risk factors and operative
indications. Ann Fam Med. 2003;1:36-43.

9 [Luthy
DA](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Luthy DA"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
[Malmgren
JA](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Malmgren JA"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
[Zingheim
RW](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Zingheim RW"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
[Leininger
C](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Leininger CJ"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus).
Physician contribution to a cesarean delivery risk model. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');)
2003;188:1579-85

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

#### Sally Bremner, Univ. of Alaska Library {#sally-bremner-univ.-of-alaska-library .Style-Heading-4-+-Arial-14-pt-Underline}

#### Hospital-Acquired Infections: What You Should Know {#hospital-acquired-infections-what-you-should-know-1 .Style-Heading-4-+-Arial-14-pt-Underline}

This issue focuses on hospital-acquired infections -- a growing menace
that is adding hugely to healthcare costs, while causing people much
suffering and needless deaths. Increasingly hospitals are being held
accountable, but the situation is grave as microbes continually adapt to
our antibiotic arsenal, and growing ever more resistant.

It's unthinkable to contemplate returning to the pre-antibiotic era, so
read on and learn how you can protect yourself and those you care for.

#### [**http://consortiumlibrary.org/hsis/about/newsletters/Dec07.pdf**](http://consortiumlibrary.org/hsis/about/newsletters/Dec07.pdf) {#httpconsortiumlibrary.orghsisaboutnewslettersdec07.pdf .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Sally Bremner [**afsjb@uaa.alaska.edu**](mailto:afsjb@uaa.alaska.edu) {#sally-bremner-afsjbuaa.alaska.edu .Style-Heading-4-+-Arial-14-pt-Underline}

**Shannon Meyers, PIMC**

**Save the Dates!! Earn up to 28 hours of CME/CE specific to Indian
Health**

![](media/image3.png){width="1.1875in" height="1.1875in"}8th Annual
Advances in Indian Health

UNM Continuing Education Building

1634 University Blvd., NE, Albuquerque, New Mexico

April 29 -- May 2, 2008

The Advances in Indian Health (AIH) Conference is Indian Country's
Primary Care Conference and is offered for primary care physicians,
nurse practitioners, physician assistants, nurses, pharmacists and other
clinicians who work with American Indian and Alaskan Native (AI/AN)
populations at federal, tribal and urban sites. Medical students and
residents who are interested in serving these populations are also
welcome as space allows. Again this year, there is no fee to attend the
conference.

> Special Opportunities at AIH:
>
> -Diabetes Track---new this year and co-sponsored by the IHS Division
> of Diabetes Treatment and Prevention, this will give interested
> attendees the chance to get up to 16 hours of diabetes-specific
> clinical training. Every workshop block will have at least one
> diabetes option in addition to the usual mix of topics at AIH.
>
> -Office Based Opioid Treatment (OBOT) Training led by Drs. Tony Dekker
> and Miriam Komarmy will again be offered at this year's
> conference---on the afternoon/evening of Tuesday April 29th. The first
> 4 hours of the course will be offered as workshop choices for those
> not taking the full OBOT training. Dinner will be provided for those
> taking the full 8 hour training. There will be more information
> regarding this training on the conference brochure or contact Dr.
> Dekker at <dekkerclan@aol.com> or <Anthony.dekker@ihs.gov> We are
> still working to get APN and PA eligibility waivers for the DEA for
> DATA 2000. Please RSVP with Dr. Dekker for this program.
>
> -This year's AIH is in collaboration with the Advanced Practice Nurse
> (APN) and Physician Assistant (PA) groups and is in lieu of their own
> separate meeting this year - a special invitation is extended to all
> PAs and APNs.
>
> Both new and experienced attendees will learn about advances in
> clinical care specifically relevant to AI/AN populations.
> Opportunities to learn from experienced career clinicians who are
> experts in Native people's health will be emphasized. Indian Health
> Service Chief Clinical Consultants and disease control program
> directors will be available for consultation and program development.

The conference format includes three and a half days of lectures and
workshops. In early spring, the brochure will be posted on the UNM CME
web site at [http://hsc.unm.edu/cme]{.underline}. For additional
information please contact Kathy Breckenridge, University of New Mexico
Office of Continuing Medical Education at (505) 272-3942, or email the
UNM Office of Continuing Medical Education to request a brochure at
<CMEWeb@salud.unm.edu>.

If you have attended the conference in the past two years, you are
already on our mailing list and a brochure will be mailed to you.

Presented by: ![](media/image4.png){width="0.90625in"
height="0.84375in"}Indian Health Service & Office of Continuing Medical
Education

**Sunnah Kim, American Academy of Pediatrics**

**Native American Child Health Advocacy Award**

As many of you are aware, the AAP has a national award to recognize an
individual who has made a major contribution to Native American child
health. Do you know a physician or non-physician who is worthy of this
recognition? If so, I would like to encourage you to submit a
nomination.

 

To have your nominee considered for the 2008 Award, please submit your
nomination by February 29, 2008. Please submit a letter of nomination,
along with the candidate\'s contact information to:

Committee on Native American Child Health\
American Academy of Pediatrics\
141 Northwest Point Blvd\
Elk Grove Village, IL 60007\
Fax: 847/434-8729\
<indianhealth@aap.org>

The 2008 Native American Child Health Advocacy Award will be presented
in October 2008 in conjunction with the AAP National Conference and
Exhibition in Boston, MA.

Thanks,

Sunnah

**\
Chuck North, HQE**

**Partnership with Mountain and Plains Educational Resource Center**

I have recently spoken with representatives from the above center in
Denver, Colorado.  They have a vested interest in supporting
occupational and environmental activities within tribal communities
located in Montana, Wyoming, South Dakota, North Dakota, Colorado, New
Mexico and Arizona.  They were successful in getting funding through
NIOSH with the intent of providing services to tribal communities
(<http://www.coloradosph.org/maperc/index.php?option=com_content&task=view&id=15&Itemid=51>). 

They have asked for input related to providing occupational medicine
continuing education.  Some of their current offerings can be found at

[http://hsc.unm.edu/cme/2008Web/Occ%20Med/Occ%20Med%20Brochure%20FINAL.pdf](http://hsc.unm.edu/cme/2008Web/Occ Med/Occ Med Brochure FINAL.pdf)

or

<http://www.rmaoem.org/cme-quar.htm>. 

They are interested in providing services to physicians and nurses
within IHS and tribal communities.  Can you share this information with
your contacts in the Areas and with physicians that have an interest and
are active in occupational medicine within IHS?  Thanks.  Let me know if
you have questions or would like additional contact information for the
staff at the MAP ERC

**Jennifer Staple, Yale University**

**Unite For Sight Volunteer Abroad Opportunities: As Featured Weekly On
CNN**

Currently accepting applications for January 2008 through January 2009. 

Rolling application deadline - the first qualified applicants are
accepted.  Apply today!

[Volunteer Abroad in Summer, Fall, Winter, or
Spr](http://slate.technolutions.com/go?9aa47ab584a1414da3f9bba7254c7b4a&r=http%3A%2F%2Fwww.uniteforsight.org%2Fintl_volunteer)ing

Save Eyes and Lives.  Every Eye, A Life.\
Those who are blind in Africa have a **four times higher mortality
rate**\
60-80% of children who become blind die within 1-2 years

**80% of blindness is curable or preventable**

**How Do I Apply? ** [The application as well as complete details about
Unite For Sight\'s international opportunities are available
at](http://slate.technolutions.com/go?9aa47ab584a1414da3f9bba7254c7b4a&r=http%3A%2F%2Fwww.uniteforsight.org%2Fintl_volunteer)
<http://uniteforsight.org/intl_volunteer/>

**What is Unite For Sight\'s Mission?** Unite For Sight is a 501(c)(3)
nonprofit organization that empowers communities worldwide to improve
eye health and eliminate preventable blindness. 

Unite For Sight\'s work to prevent blindness and restore sight is
**featured weekly on CNN INTERNATIONAL** from September 2007-August 2008

**Who Is Eligible to Participate?** The Unite For Sight internship is
open to individuals 18 years and older, and there is no upper age limit.
Volunteers range from undergraduate students to medical students, public
health students and professionals, nurses, physician\'s assistants,
teachers and educators, Returned Peace Corps Volunteers, doctors,
opticians, optometrists and ophthalmologists.

**What Do Volunteers Do?** Volunteers receive hands-on clinical
experience while assisting doctors in remote, rural villages. 
Volunteers learn about international health and eye care, learn clinical
skills while working with patients and doctors, and, in one program
location, have an opportunity to perform cataract surgery on a goat\'s
eye.

The goal of Unite For Sight and its partner eye clinics and communities
is to create eye disease-free communities.  Unite For Sight's volunteers
(local and visiting) work with partner eye clinics to provide eye care
in communities without previous access.  The eye clinic's eye doctors
and Unite For Sight volunteers jointly provide community-based screening
programs in rural villages.  The clinic's eye doctors diagnose and treat
eye disease in the field, and surgical patients are brought to the eye
clinic for surgery.  Patients receive free surgery funded by Unite For
Sight so that no patient remains blind due to lack of funds.  Volunteers
immediately see the joy on patients\' faces when their sight is restored
after years of blindness.  These memories last a lifetime.

While helping the community, volunteers are in a position to witness and
draw their own conclusions about the failures and inequities of global
health systems. It broadens their view of what works, and what role they
can have to insure a health system that works for everyone and that
leaves no person blind in the future.

**What Do Volunteers Say?**

"During my volunteering experience, I realized that Unite for Sight's
service is a campaign for the salvation of humanity that allows the
light of compassion to shine through each of us. I believe it is this
display of altruism and commitment that makes the organization's service
so virtuous and treasured by both volunteers and patients. After all,
making a difference in the world is not so difficult if only one would
care enough to sacrifice a part of oneself in order to change the world
for the better. My experience as a Unite for Sight volunteer has
inspired me to dedicate my future career to serving underprivileged
communities around the world."---Chiwing "Jessica" Qu, Yale University
Student, Unite For Sight Volunteer in India 2007

\"Without Unite for Sight, I cannot imagine how I could possibly have
seen and learned so much as an undergraduate about medicine, other
cultures, and my own desire and ability to make a difference in others\'
lives.\"\--Charlotte Hogan, Georgetown University Student, Unite For
Sight Volunteer in India 2006 and Ghana 2005

\"I can honestly say that everything I learned in 3 years of medical
school paled in comparison to the 3 week experience I had in Accra
(Ghana) in October 2007 as part of Unite For Sight.  The program
provides volunteers with a unique and hands-on involvement -- being able
to help out to the level of your training and comfort. My experience
taught me that Ghanaian people are the friendliest people I have
interacted with anywhere in the world, that ordinary people involved
with Unite For Sight are making extraordinary differences, and that
sitting in a classroom receiving a world-class education cannot match
real life experiences while volunteering.\"\--Varun Verma, UMDNJ Medical
Student, Unite For Sight Volunteer in Accra, Ghana

# 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}

**Knowledge of cervical length / fetal fibronectin associated with
shorter evaluation and PTB**

CONCLUSION: The knowledge of cervical length and fetal fibronectin was
associated with reduction in length of evaluation in women with cervical
length \> or = 30 mm and in incidence of spontaneous preterm birth in
all women with preterm labor.

[Ness
A](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Ness A"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Does knowledge of cervical length and fetal fibronectin affect
management of women with threatened preterm labor? A randomized trial.
Am J Obstet Gynecol. 2007 Oct;197(4):426.e1-7.
<http://www.ncbi.nlm.nih.gov/pubmed/17904989>

**Sublingual misoprostol associated with higher patient satisfaction
compared with vaginal**

CONCLUSION: Sublingual misoprostol (50 micrograms) is associated with a
significantly higher patient satisfaction rate compared with a similar
dose of vaginal misoprostol. Sublingual administration offers additional
choice to women, in particular those wishing to avoid vaginal
administration.

[Nassar
AH](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Nassar AH"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al A randomised comparison of patient satisfaction with vaginal and
sublingual misoprostol for induction of labour at term. BJOG. 2007
Oct;114(10):1215-21.

<http://www.ncbi.nlm.nih.gov/pubmed/17877674>

**Management of shoulder dystocia: trends in incidence and morbidity**

RESULTS: There were 514 cases of shoulder dystocia among 79,781 (0.6%)
vaginal deliveries with 44 cases of neonatal brachial plexus injury and
36 asphyxiated neonates; two neonates with cerebral palsy died. The
McRoberts\' maneuver was used increasingly to overcome the obstruction,
from 3% during the first 5 years to 91% during the last 5 years. The
incidence of shoulder dystocia, brachial plexus injury, and neonatal
asphyxia all increased over the study period without change in maternal
morbidity frequency. CONCLUSION: The explanation for the increase in
shoulder dystocia is unclear but the introduction of the McRoberts\'
maneuver has not improved outcomes compared with the earlier results.
LEVEL OF EVIDENCE: II.

[MacKenzie
IZ](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="MacKenzie IZ"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Management of shoulder dystocia: trends in incidence and maternal
and neonatal morbidity. Obstet Gynecol. 2007 Nov;110(5):1059-68.

<http://www.ncbi.nlm.nih.gov/pubmed/17978120>

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

#### CDC Issues Guidelines for Preconception Care of Women  {#cdc-issues-guidelines-for-preconception-care-of-women-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### The Centers for Disease Control and Prevention have published national recommendations for improving preconception health and health care in response to unfavorable aspects of the health status of women and children in the United States. The publication explains that the national recommendations are part of a strategic plan for improving preconception health through the provision of clinical care as well as the promotion of changes in individual behaviors, health policy, and public health strategies. The concept of preconception care has been articulated for well over a decade but has not become part of the routine practice of family medicine. Because all women of reproductive age presenting to the primary care setting are candidates for preconception care, the essential and critical role of family physicians in the provision of preconception care is apparent. As a specialty, we are now challenged to devise ways to effectively translate the concept of preconception care into clinical reality. {#the-centers-for-disease-control-and-prevention-have-published-national-recommendations-for-improving-preconception-health-and-health-care-in-response-to-unfavorable-aspects-of-the-health-status-of-women-and-children-in-the-united-states.-the-publication-explains-that-the-national-recommendations-are-part-of-a-strategic-plan-for-improving-preconception-health-through-the-provision-of-clinical-care-as-well-as-the-promotion-of-changes-in-individual-behaviors-health-policy-and-public-health-strategies.-the-concept-of-preconception-care-has-been-articulated-for-well-over-a-decade-but-has-not-become-part-of-the-routine-practice-of-family-medicine.-because-all-women-of-reproductive-age-presenting-to-the-primary-care-setting-are-candidates-for-preconception-care-the-essential-and-critical-role-of-family-physicians-in-the-provision-of-preconception-care-is-apparent.-as-a-specialty-we-are-now-challenged-to-devise-ways-to-effectively-translate-the-concept-of-preconception-care-into-clinical-reality. .Style-Heading-4-+-Arial-14-pt-Underline}

[Dunlop
AL](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Dunlop AL"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract)
et al National recommendations for preconception care: the essential
role of the family physician. J Am Board Fam Med. 2007
Jan-Feb;20(1):81-4.

**Full text**

#### [**http://www.jabfm.org/cgi/content/abstract/20/1/81**](http://www.jabfm.org/cgi/content/abstract/20/1/81) {#httpwww.jabfm.orgcgicontentabstract20181 .Style-Heading-4-+-Arial-14-pt-Underline}

#### PubMed Abstract {#pubmed-abstract .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/pubmed/17204739**](http://www.ncbi.nlm.nih.gov/pubmed/17204739) {#httpwww.ncbi.nlm.nih.govpubmed17204739 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Year end recap {#year-end-recap .Style-Heading-4-+-Arial-14-pt-Underline}

#### Guidelines Recommend Universal Prenatal Screening for Down Syndrome  {#guidelines-recommend-universal-prenatal-screening-for-down-syndrome-1 .Style-Heading-4-+-Arial-14-pt-Underline}

The American College of Obstetrics and Gynecology (ACOG) recommends that
all pregnant women, regardless of their age, be offered screening for
Down syndrome.

\"Historically, maternal age 35 years or older at the time of delivery
has been used to identify women at highest risk of having a child with
Down syndrome, and these women have been offered genetic counseling and
amniocentesis or chorionic villus sampling (CVS),\" write Ray
Bahado-Singh, MD, Deborah Driscoll, MD, and colleagues, of the ACOG
Committee on Practice Bulletins --- Obstetrics, the ACOG Committee on
Genetics, and the Society for Maternal--Fetal Medicine Publications
Committee. \"Biochemical serum screening for Down syndrome in women
younger than 35 years was introduced in 1984, when an association
between low maternal serum alpha-fetoprotein (AFP) levels and Down
syndrome was reported\... The practice of using age cutoffs to determine
whether women should be offered screening or invasive diagnostic testing
has been challenged.\"

These guidelines were developed to review and evaluate the best
available evidence for the use of ultrasonographic and serum markers for
selected aneuploidy screening in pregnancy and to offer practical
recommendations for implementing Down syndrome screening in clinical
practice.

In recent years, numerous markers and strategies for Down syndrome
screening have been developed, as have algorithms combining ultrasound
and serum markers in the first- and second trimesters. Various markers
have included human chorionic gonadotropin (hCG) and unconjugated
estriol used in combination with maternal serum alpha-fetoprotein
levels.

Using all 3 markers (triple screen) has a detection rate for Down
syndrome of approximately 70%, with a positive screen result in
approximately 5% of all pregnancies. Adding inhibin A to the triple test
(quadruple screen) improves the detection rate for Down syndrome to
approximately 80%.

\"Screening with biochemical markers, ultrasonography, or both is being
offered increasingly to the entire pregnant population to provide a more
accurate estimate of individual Down syndrome risk,\" the authors write.
\"Higher sensitivity or detection rates (defined as the percentage of
Down syndrome pregnancies identified with a positive test result) at low
false-positive rates have led to increased use of screening and a
decline in the number of amniocenteses performed.\"

Another screening procedure is evaluation of nuchal translucency, an
early presenting feature of a wide variety of fetal chromosomal,
genetic, and structural abnormalities. Guidelines for the systematic
measurement of nuchal translucency have been standardized, improving the
detection rates for Down syndrome. For screening programs that include
nuchal translucency measurement, specific training for a standardized
method of measurement and ongoing audits of examination quality are
recommended.

An important breakthrough in first-trimester screening for Down syndrome
was achieved by expressing the nuchal translucency measurement as a
multiple of the median and combining it with free β-hCG and
pregnancy-associated plasma protein A (PAPP-A). Maternal serum analytes,
PAPP-A, and hCG or free β-hCG are effective for screening in the first
trimester, but alpha-fetoprotein levels, unconjugated estriol, and
inhibin A are useful only in the second trimester.

Specific guideline recommendations based on good and consistent
scientific evidence (level A) are as follows:

-   First-trimester screening using both nuchal translucency measurement
    and biochemical markers is an effective screening test for Down
    syndrome in the general population. This screening strategy results
    in a higher detection rate than does the second-trimester maternal
    serum triple screen and a comparable rate to the quadruple screen,
    with the same false-positive rates.

-   For first-trimester screening, measurement of nuchal translucency
    alone is less effective than is the combined use of nuchal
    translucency measurement and biochemical markers.

-   Women found to have increased risk for aneuploidy based on
    first-trimester screening should be offered genetic counseling and
    the option of chorionic villus sampling or second-trimester
    amniocentesis.

-   Nuchal translucency measurement for Down syndrome risk assessment
    should be limited to centers and individuals meeting the criteria
    for specific training, standardization, use of appropriate
    ultrasound equipment, and ongoing quality assessment.

-   Women who elect only first-trimester screening for aneuploidy should
    be offered neural tube defect screening in the second trimester.

\"Regardless of which screening tests you decide to offer your patients,
information about the detection and false-positive rates, advantages,
disadvantages, and limitations, as well as the risks and benefits of
diagnostic procedures, should be available to patients so that they can
make informed decisions,\" the authors conclude. \"Patients may decline
Down syndrome screening because they would not use the information in
deciding whether to have a diagnostic test or because they wish to avoid
the chance of a false-positive screening test result. The choice of
screening test depends on many factors, including gestational age at
first prenatal visit, number of fetuses, previous obstetric history,
family history, availability of nuchal translucency measurement, test
sensitivity and limitations, risk of invasive diagnostic procedures,
desire for early test results, and options for earlier termination.\"

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

Screening for fetal chromosomal abnormalities. ACOG Practice Bulletin
No. 77. American College of Obstetricians and Gynecologists. Obstet
Gynecol 2007;109:217--27.

<http://www.ncbi.nlm.nih.gov/pubmed/17197615>

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

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

**Misoprostol in the setting of incomplete abortion series**

**Misoprostol is as effective as manual vacuum aspiration in SAB of \<12
weeks**

CONCLUSION: Misoprostol is as effective as manual vacuum aspiration
(MVA) at treating incomplete abortion at uterine size of \<12 weeks. The
acceptability of misoprostol appears higher. Given the many practical
advantages of misoprostol over MVA in low-resource settings, misoprostol
should be more widely available for treatment of incomplete abortion in
the developing world.

[Shwekerela
B](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Shwekerela B"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Misoprostol for treatment of incomplete abortion at the regional
hospital level: results from Tanzania. BJOG. 2007 Nov;114(11):1363-7

<http://www.ncbi.nlm.nih.gov/pubmed/17803714>

**Oral misoprostol is safe and acceptable as MVA for the treatment of
incomplete abortion**

CONCLUSION: Six hundred micrograms of oral misoprostol is as safe and
acceptable as MVA for the treatment of incomplete abortion. Operations
research is needed to ascertain the role of misoprostol within
postabortion care programmes worldwide.

[Dao
B](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Dao B"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Is misoprostol a safe, effective and acceptable alternative to
manual vacuum aspiration for postabortion care? Results from a
randomised trial in Burkina Faso, West Africa. BJOG. 2007
Nov;114(11):1368-75 <http://www.ncbi.nlm.nih.gov/pubmed/17803715>

**Hysterectomy vs LNG-IUS series**

**Hysterectomy reduces menstrual bleeding, but LNG-IUS effective in
quality of life**

AUTHORS\' CONCLUSIONS: Surgery, especially hysterectomy, reduces
menstrual bleeding at one year more than medical treatments but LNG-IUS
appears equally effective in improving quality of life. The evidence for
longer term comparisons is weak and inconsistent. Oral medication suits
a minority of women long term.

[Marjoribanks
J](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Marjoribanks J"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Surgery versus medical therapy for heavy menstrual bleeding.

Cochrane Database Syst Rev. 2006 Apr 19;(2):CD003855

<http://www.ncbi.nlm.nih.gov/pubmed/16625593>

**Hysterectomy improves sexual functioning vs LNG-IUS among women with
menorrhagia** CONCLUSIONS: Among women with menorrhagia, hysterectomy
improves sexual functioning, whereas LNG-IUS does not have such a
positive effect.

[Halmesmäki
K](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Halmesmäki K"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al The effect of hysterectomy or levonorgestrel-releasing
intrauterine system on sexual functioning among women with menorrhagia:
a 5-year randomised controlled trial. BJOG. 2007 May;114(5):563-8.
<http://www.ncbi.nlm.nih.gov/pubmed/17439564>

**Other**

**Intracervical balloon placement for saline sonohysterography superior
vs intrauterine**

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](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Spieldoch RL"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
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?dopt=Abstract>

**PCA, scheduled intravenous, and scheduled subcutaneous: None appears
to be superior**

CONCLUSION: Given these findings as well as those in previous
literature, no specific method of postoperative analgesia appears to be
superior.

[Bell
JG](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Bell JG"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Randomized trial comparing 3 methods of postoperative analgesia in
gynecology patients: patient-controlled intravenous, scheduled
intravenous, and scheduled subcutaneous. Am J Obstet Gynecol. 2007
Nov;197(5):472.e1-7. <http://www.ncbi.nlm.nih.gov/pubmed/17980179>

**Liquid-based cervical cytology neither more sensitive nor more
specific vs conventional**

CONCLUSION: Liquid-based cervical cytology is neither more sensitive nor
more specific for detection of high-grade cervical intraepithelial
neoplasia compared with the conventional Pap test.

Liquid Compared With Conventional Cervical Cytology: A Systematic Review
and Meta-analysis. Obstet Gynecol. 2008 Jan;111(1):167-177.
<http://www.ncbi.nlm.nih.gov/pubmed/18165406?dopt=Abstract>

**Early feeding after abdominal Gyn surgery is safe and reduces length
of hospital stay**

AUTHORS\' CONCLUSIONS: Early feeding after major abdominal gynaecologic
surgery is safe however associated with the increased risk of nausea and
a reduced length of hospital stay. Whether to adopt the early feeding
approach should be individualized. Further studies should focus on the
cost-effectiveness, patient\'s satisfaction, and other physiological
changes

[Charoenkwan
K](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Charoenkwan K"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Early versus delayed (traditional) oral fluids and food for
reducing complications after major abdominal gynaecologic surgery.
Cochrane Database Syst Rev. 2007 Oct 17;(4):CD004508
<http://www.ncbi.nlm.nih.gov/pubmed/17943817>

#### VI-SENSE test superior to traditional individual tests in diagnosis of vaginal infections {#vi-sense-test-superior-to-traditional-individual-tests-in-diagnosis-of-vaginal-infections .Style-Heading-4-+-Arial-14-pt-Underline}

#### RESULTS: The VI-SENSE test was positive in 226 of 249 patients (90.8%) with bacterial vaginosis or trichomoniasis. Nitrazine pH paper revealed elevated pH in 165 (66.5%) and the amine test was positive in 160 (64.3%) patients. The VI-SENSE test was negative in 217 of 267 patients (81.3%) without trichomoniasis or bacterial vaginosis. The VI-SENSE was positive in 85 of 92 women (92%), with mixed vaginal infection including Candida and bacterial vaginosis or trichomoniasis. Amine test, nitrazine pH paper and physician diagnosis relying only on speculum examination were inferior and positive in only 65 (70%), 59 (64%), and 66 (72%) patients, respectively. CONCLUSION: The VI-SENSE test was found to be superior to traditional individual tests in facilitating preliminary diagnosis of vaginal infections. {#results-the-vi-sense-test-was-positive-in-226-of-249-patients-90.8-with-bacterial-vaginosis-or-trichomoniasis.-nitrazine-ph-paper-revealed-elevated-ph-in-165-66.5-and-the-amine-test-was-positive-in-160-64.3-patients.-the-vi-sense-test-was-negative-in-217-of-267-patients-81.3-without-trichomoniasis-or-bacterial-vaginosis.-the-vi-sense-was-positive-in-85-of-92-women-92-with-mixed-vaginal-infection-including-candida-and-bacterial-vaginosis-or-trichomoniasis.-amine-test-nitrazine-ph-paper-and-physician-diagnosis-relying-only-on-speculum-examination-were-inferior-and-positive-in-only-65-70-59-64-and-66-72-patients-respectively.-conclusion-the-vi-sense-test-was-found-to-be-superior-to-traditional-individual-tests-in-facilitating-preliminary-diagnosis-of-vaginal-infections. .Style-Heading-4-+-Arial-14-pt-Underline}

[Geva
A](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Geva A"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al The VI-SENSE-vaginal discharge self-test to facilitate management
of vaginal symptoms. Am J Obstet Gynecol. 2006 Nov;195(5):1351-6

<http://www.ncbi.nlm.nih.gov/pubmed/16769019>

**Laparoscopic surgery is a cost effective treatment for tubal ectopic
pregnancy**

AUTHORS\' CONCLUSIONS: In the surgical treatment of tubal ectopic
pregnancy laparoscopic surgery is a cost effective treatment. An
alternative nonsurgical treatment option in selected patients is medical
treatment with systemic methotrexate. Expectant management can not be
adequately evaluated yet.

[Hajenius
PJ](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Hajenius PJ"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Interventions for tubal ectopic pregnancy. Cochrane Database Syst
Rev. 2007 Jan 24;(1):CD000324.
<http://www.ncbi.nlm.nih.gov/pubmed/17253448>

**2 techniques of postoperative bladder testing after transvaginal
surgery: RCT**

RESULTS: Sixty subjects were enrolled. The mean time in the
perioperative anesthesia care unit for the backfill group was 199.5
minutes vs 226.6 minutes in the spontaneous voiding group (P = .08).
Subjects randomized to backfill were more likely to adequately empty
their bladders and be discharged home without catheter drainage than
subjects in the spontaneous voiding group (61.5% vs 32.1%, respectively,
P = .02). Multiple logistic regression further demonstrated that the
backfill-assisted technique predicted successful bladder emptying after
vaginal surgery (P = .02). CONCLUSION: Women undergoing transvaginal
outpatient surgery are more likely to empty their bladder effectively
before discharge if they are evaluated with a backfill-assisted voiding
trial.

[Foster RT
Sr](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Foster RT Sr"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al A randomized, controlled trial evaluating 2 techniques of
postoperative bladder testing after transvaginal surgery. Am J Obstet
Gynecol. 2007 Dec;197(6):627.e1-4.

<http://www.ncbi.nlm.nih.gov/pubmed/18060956>

**Abdominal sacrocolpopexy reduces irritative and obstructive symptoms
Prophylactic**

RESULTS: In all women, the mean irritative score decreased from 19.6 +/-
16.3 (mean +/- SD) to 9.1 +/- 10.6; for obstructive symptoms, from 34.8
+/- 21.0 to 6.3 +/- 10.4 (both P \< .001). Preoperative bothersome
irritative symptoms resolved in 74.6% (126 of 169) and obstructive
symptoms in 85.1% (212 of 249), independent of Burch. Fewer women with
Burch had urge incontinence (14.5% vs 26.8%, P = .048) and fulfilled the
stress endpoint (25.0% vs 40.1%, P = .012). [CONCLUSION]{.underline}:
Abdominal sacrocolpopexy (ASC) reduced bothersome irritative and
obstructive symptoms. Prophylactic Burch reduced stress and urge
incontinence.

[Burgio
KL](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Burgio KL"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Bladder symptoms 1 year after abdominal sacrocolpopexy with and
without Burch colposuspension in women without preoperative stress
incontinence symptoms. Am J Obstet Gynecol. 2007 Dec;197(6):647.e1-6.
<http://www.ncbi.nlm.nih.gov/pubmed/18060965>

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

**11th Annual Patty Iron Cloud National Native American Youth
Initiative**

The Association of American Indian Physicians (AAIP) is now accepting
applications for the 11th Annual Patty Iron Cloud National Native
American Youth Initiative which will be held in Washington D.C., June
21- 29, 2008. American Indian/Alaska Native (AI/AN) high school
students, ages 16- 18, who have an interest in the health careers and/or
biomedical research are encouraged to apply. The NNAYI scholarship pays
for travel, lodging, and most meals during the program. NNAYI\'s
curriculum is strategically designed to prepare students for admission
to college and professional schools, as well as for careers in health

and biomedical research.

To accompany the students, AAIP is accepting applications for
counselors, age 21 and older, to serve as role models during the

nine-day program. AI/AN college students and health professionals are
encouraged to apply.

Feel free to share this information with other interested parties.

Deadline for student application is April 18, 2008 and for counselor
application is March 21, 2008. Please visit the NNAYI website:

[[www.aaip.org/programs/nnayi/nnayi.htm]{.underline}](../www.aaip.org/programs/nnayi/nnayi.htm)
to obtain detail information and to access the on-line application.

**Secondhand smoke during infancy linked in dose-response fashion with
allergies**

Swedish children exposed to secondhand tobacco smoke in infancy had a
higher rate of indoor inhalant and food allergies than did children
whose parents didn't smoke. The study found a dose-response relationship
between exposure to smoke and allergy, supporting possible causality and
indicating that exposure in early infancy to tobacco smoke may be
associated with an increased risk of atopic sensitization.

[Lannerö
E](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Lannerö E"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
at al Exposure to environmental tobacco smoke and sensitisation in
children.Thorax. 2007 Dec 18
<http://www.ncbi.nlm.nih.gov/pubmed/18089631>

**Oral health of Aboriginal children**

The Australian Institute of Health and Welfare has released a new
report:

Aboriginal and Torres Strait Islander children in Australia are
disadvantaged in terms of oral health. This publication provides a
summary of Aboriginal and Torres Strait Islander child oral health using
information from the Child Dental Health Survey, the Aboriginal and
Torres Strait Islander Children and Receipt of Hospital Dental Care
Investigation and the Study of Aboriginal and Torres Strait Islander
Child Oral Health in Remote Communities. Throughout the states and

territories studied, Aboriginal and Torres Strait Islander children had
consistently higher levels of dental disease in the deciduous and
permanent dentition than their non-Aboriginal and Torres Strait Islander
counterparts. Aboriginal and Torres Strait Islander children most
affected were those in socially disadvantaged groups and those living in
rural / remote areas. Trends in Aboriginal and Torres Strait Islander
child caries prevalence indicate that dental disease levels are rising,
particularly in the deciduous dentition. Indigenous children aged \<5
years had almost one-and-a-half times the rate of hospitalization for
dental care as other Australian children, and the rate of Indigenous
children receiving hospital dental care rose with increasing geographic

remoteness. Less than 5% of remote Indigenous pre-school children
reported brushing their teeth on a regular basis and many young remote
Indigenous children experienced extensive destruction of their deciduous
teeth. Improving the oral health of Aboriginal and Torres Strait

Islander children in Australia is an important public health and dental
service provision issue.

[[http://www.aihw.gov.au/mediacentre/2007/mr20071214.cfm]{.underline}](http://www.aihw.gov.au/mediacentre/2007/mr20071214.cfm)
Report
[[http://www.aihw.gov.au/publications/index.cfm/title/10411]{.underline}](http://www.aihw.gov.au/publications/index.cfm/title/10411)

ACIP Releases 2008 Child and Adolescent Immunization Schedules

The 2008 recommended immunization schedules for children and adolescents
are unveiled in this issue of *American Family Physician*. There are no
significant additions to this year\'s schedule. Rather, formatting has
been simplified and footnotes have been updated for hepatitis B,
pneumococcal, meningococcal, and influenza vaccines. Two changes are of
note: the expanded age ranges for quadrivalent meningococcal conjugate
vaccine (MCV4; Menactra) and for live, attenuated influenza vaccine
(LAIV; Flumist).

MCV4 replaces the meningococcal polysaccharide vaccine (Menomune) as the
preferred vaccine for children two to 10 years of age with terminal
complement deficiencies, anatomic or functional asplenia, or certain
other high-risk conditions. In addition, MCV4 is recommended for any
previously unimmunized adolescent 11 to 18 years of age.1 Because
adolescents present less often to their physicians for well care, any
visit should be considered an opportunity to provide MCV4, the
quadrivalent human papillomavirus vaccine (Gardasil), and tetanus
toxoid, reduced diphtheria toxoid and acellular pertussis vaccine (Tdap;
Adacel), as well as a second dose of varicella vaccine.

The approval of LAIV by the Advisory Committee on Immunization Practices
(ACIP), as well as the vaccine\'s recommendation by the U.S. Food and
Drug Administration and coverage by the Vaccines for Children Program,
can only help to improve influenza immunization rates for young children
in the United States. Based on the 2005 National Immunization Survey,
only 20.6 percent of children six to 23 months of age were fully
immunized for influenza.2 Estimated rates for full immunization in older
children (24 to 59 months) ranged from 3.0 to 26.9 percent.3

During the 2006-07 influenza season, 73 children died of the disease.4
However, the morbidity and mortality associated with influenza can be
significantly reduced in children. The number needed to vaccinate (NNV)
to prevent one hospitalization for younger children (six to 23 months)
is 1,031 to 3,050.5 For children 24 to 59 months of age, the NNV is
estimated at 4,255 to 6,897.5 Furthermore, one outpatient visit is
prevented for every 12 to 42 children immunized, regardless of age.5

In a rare head-to-head, double-blind, randomized controlled vaccine
trial involving children six to 59 months of age, LAIV significantly
outperformed trivalent inactivated vaccine (TIV).6 Two findings from
this study were notable. First, only 491 culture-confirmed cases of
influenza were identified in the 7,852 vaccine recipients (infection
rate = 6.3 percent), regardless of type. Second, LAIV recipients had a
55 percent decrease in influenza infection compared with TIV recipients
(*P* \< .001).

LAIV is a nasal spray vaccine and is refrigerator stable. The following
conditions are contraindications or precautions for the use of LAIV in
young children:

-concomitant aspirin therapy

-history of recurrent wheezing

-altered immunocompetence

-medical conditions predisposing the patient to influenza complications.

The widespread use of vaccines has profoundly altered children\'s
health. A recent review underscores the declines in the prevalence of
vaccine-preventable diseases (more than 92 percent) and deaths (more
than 99 percent) in the United States.8 However, compared with the
prevaccine prevalence of most vaccine-preventable diseases and their
associated mortality rates, contemporary influenza remains an outlier,
with extremely high prevalence and moderate mortality. New vaccines and
new approaches can help address influenza\'s challenge, but they require
coupling with the efforts of the medical community and within the
medical home9 to ensure the health and safety of children. AFP Practice
Guidelines <http://www.aafp.org/afp/20080101/practice.html>

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

**\'Awake\' during surgery: Examining intraoperative awareness**

Estimates show as many as 2 in every 1,000 patients who receive general
anesthesia remember events that occurred while they were \"under.\"\
\
Given that over 40 million patients undergo general anesthesia each year
in North America, it is not surprising the phenomenon has become the
subject of a new Hollywood movie. Dr Beverley A. Orser from the
University of Toronto and colleagues use the occasion of the recent
release of \"Awake\"---a film depicting a man who experiences
\"anesthesia awareness\" and is conscious, but physically paralyzed
during surgery---to delve deeper into the issue of intraoperative
awareness.\
\
Orser and colleagues said most patients who experience intraoperative
awareness do not experience pain but have \"vague auditory recall or a
sense of dreaming and are not distressed by the experience.\" The
authors add, however, that some patients do experience pain, and it is
occasionally severe.\
\
In a study involving 11,785 patients who had received general
anesthesia, the incidence of awareness was 0.18% in cases in which
neuromuscular blockers were used and 0.10% in the absence of such drugs.
Of the 19 patients who experienced recall, 7 (36%) reported some degree
of pain, ranging from soreness in the throat because of the endotracheal
tube, to severe pain at the incision site. Patients may remember these
events immediately after surgery, or hours or days later.\
\
\"Immense efforts have been made to understand the effects of
anesthetics on physiologic processes and to develop strategies and
technologies to manage the adverse effects of these drugs,\" the authors
said. \"However, certain risks remain, including the possibility of
intraoperative awareness.\"\
\
The authors conclude that intraoperative awareness should be viewed as a
recognized complication, with many features similar to those of other
adverse intraoperative and perioperative events. They add that
anesthesiologists are directing research and patient care efforts toward
reducing the incidence and consequences of this adverse event, but they
suggest that more large-scale studies of the efficacy of
brain-monitoring devices in the prevention of awareness are required.

[Orser
BA](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Orser BA"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Awareness during anesthesia. CMAJ. 2007 Dec 11;

<http://www.ncbi.nlm.nih.gov/pubmed/18073268>

**5-day course of nitrofurantoin is effective fluoroquinolone-sparing
treatment of cystitis**

CONCLUSION: A 5-day course of nitrofurantoin is equivalent clinically
and microbiologically to a 3-day course of trimethoprim-sulfamethoxazole
and should be considered an effective fluoroquinolone-sparing
alternative for the treatment of acute cystitis in women.

[Gupta
K](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Gupta K"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Short-course nitrofurantoin for the treatment of acute
uncomplicated cystitis in women. Arch Intern Med. 2007 Nov
12;167(20):2207-12.

<http://www.ncbi.nlm.nih.gov/pubmed/17998493>

**Cardiovascular disease and pre-eclampsia related. Pre-eclampsia and
cancer are not**

CONCLUSIONS: A history of pre-eclampsia should be considered when
evaluating risk of cardiovascular disease in women. This association
might reflect a common cause for pre-eclampsia and cardiovascular
disease, or an effect of pre-eclampsia on disease development, or both.
No association was found between pre-eclampsia and future cancer.

[Bellamy
L](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Bellamy L"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Pre-eclampsia and risk of cardiovascular disease and cancer in
later life: systematic review and meta-analysis.BMJ. 2007 Nov
10;335(7627):974. Epub 2007 Nov 1

<http://www.ncbi.nlm.nih.gov/pubmed/17975258>

**Factors Related to Cardiovascular Disease Risk Reduction in Midlife
and Older Women**

In this study, qualitative methods were used to better understand
knowledge and awareness about CVD in women, perceived threat of CVD,
barriers to heart-healthy eating and physical activity, and intervention
strategies for behavior change. Most women were aware of the modifiable
risk factors for CVD. Although they realized they were susceptible, they
thought CVD was something they could overcome. Interventions to change
behavior should be hands-on, have a goal-setting component, and include
opportunities for social interaction. It is especially important to
offer interventions as awareness increases and women seek opportunities
to build skills to change behavior.
<http://www.cdc.gov/pcd/issues/2008/jan/06_0156.htm>

**Herbal and Dietary Supplement-Drug Interactions in Patients with
Chronic Illnesses**

Herbs, vitamins, and other dietary supplements may augment or antagonize
the actions of prescription and nonprescription drugs. St. John\'s wort
is the supplement that has the most documented interactions with drugs.
As with many drug-drug interactions, the information for many dietary
supplements is deficient and sometimes supported only by case reports.
Deleterious effects are most pronounced with anticoagulants,
cardiovascular medications, oral hypoglycemics, and antiretrovirals.
Case reports have shown a reduction in International Normalized Ratio in
patients taking St. John\'s wort and warfarin. Other studies have shown
reduced levels of verapamil, statins, digoxin, and antiretrovirals in
patients taking St. John\'s wort. Physicians should routinely ask
patients about their use of dietary supplements when starting or
stopping a prescription drug, or if unexpected reactions occur. Am Fam
Physician. 2008;77(1):73-78. <http://www.aafp.org/afp/20080101/73.html>

**Heart Rhythm Problems with Haloperidol**

A recent FDA alert, along with new labeling, warns health professionals
about the possibility of QT prolongation and Torsades de Pointes (TdP)
in patients treated with the antipsychotic drug Haldol (haloperidol).\
\
The risk appears to be higher when the drug is administered
intravenously or in higher doses than recommended. Injectable
haloperidol is approved only for intramuscular administration, but it\'s
sometimes used intravenously to treat severe agitation.\
\
FDA is advising particular caution if the drug is used in patients who
have other QT-prolonging conditions, including electrolyte imbalance.
Caution should also be used in patients taking drugs known to prolong
the QT interval, and in those who have underlying cardiac abnormalities,
hypothyroidism or familial long QT syndrome. FDA also recommends ECG
monitoring if haloperidol is given intravenously.

Additional Information:

FDA MedWatch Safety Alert. Haloperidol (marketed as Haldol, Haldol
decanoate, and Haldol lactate). September 17, 2007.
<http://www.fda.gov/medwatch/safety/2007/safety07.htm#Haloperidol>

# Features {#features .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}

**Elective and risk--reducing salpingo-oophorectomy**

**ACOG Practice Bulletin No. 89**

**Summary of Recommendations and Conclusions**

The following conclusion is based on good and consistent scientific
evidence (Level A):

-   In women ages 50--79 years who have had a hysterectomy, use of
    estrogen therapy has shown no increased risk of breast cancer or
    heart disease with up to 7.2 years of use.

The following recommendation is based on limited or inconsistent
scientific evidence (Level B):

-   Bilateral salpingo--oophorectomy should be offered to women with
    BRCA1 and BRCA2 mutations after completion of childbearing.

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

-   Women with family histories suggestive of BRCA1 and BRCA2 mutations
    should be referred for genetic counseling and evaluation for BRCA
    testing.

-   For women with an increased risk of ovarian cancer, risk--reducing
    salpingo--oophorectomy should include careful inspection of the
    peritoneal cavity, pelvic washings, removal of the fallopian tubes,
    and ligation of the ovarian vessels at the pelvic brim.

-   Strong consideration should be made for retaining normal ovaries in
    premenopausal women who are not at increased genetic risk of ovarian
    cancer.

-   Given the risk of ovarian cancer in postmenopausal women, ovarian
    removal at the time of hysterectomy should be considered for these
    women.

-   Women with endometriosis, pelvic inflammatory disease, and chronic
    pelvic pain are at higher risk of reoperation; consequently, the
    risk of subsequent ovarian surgery if the ovaries are retained
    should be weighed against the benefit of ovarian retention in these
    patients.

Elective and risk--reducing salpingo-oophorectomy. ACOG Practice
Bulletin No. 89. American College of Obstetricians and Gynecologists.
Obstet Gynecol 2008;111:231--41.

<http://www.acog.com/>

**Surgery and Patient Choice**

ABSTRACT: Acknowledgment of the importance of patient autonomy and
increased patient access to information has prompted more
patient--generated requests for surgical interventions not necessarily
recommended by their physicians. Decision making in obstetrics and
gynecology should be guided by the ethical principles of respect for
patient autonomy, beneficence, nonmaleficence, justice, and veracity.
Each physician should exercise judgment when determining whether
information presented to the patient is adequate. When working with a
patient to make decisions about surgery, it is important for
obstetricians and gynecologists to take a broad view of the consequences
of surgical treatment and to acknowledge the lack of firm evidence for
the benefit of one approach over another when evidence is limited.

Surgery and patient choice. ACOG Committee Opinion No. 395. American
College of Obstetricians and Gynecologists. Obstet Gynecol
2008;111:243--7.

#### [**http://www.ncbi.nlm.nih.gov/pubmed/18165420**](http://www.ncbi.nlm.nih.gov/pubmed/18165420) {#httpwww.ncbi.nlm.nih.govpubmed18165420 .Style-Heading-4-+-Arial-14-pt-Underline}

**Intraperitoneal Chemotherapy for Ovarian Cancer**

ABSTRACT: Postoperative intravenous (IV) chemotherapy for advanced stage
ovarian cancer has been the standard treatment. Recent studies have
found significant survival advantages with the use of adjuvant
intraperitoneal (IP) chemotherapy. Combination IV/IP chemotherapy may be
an option for well counseled, carefully selected patients with optimally
debulked stage III ovarian cancer. However, IV/IP treatment also has
increased rates of pain, fatigue, and hematologic, gastrointestinal,
metabolic, and neurologic toxicities. Given the balance of efficacy,
quality of life, and toxicity, the decision to use IP chemotherapy must
be individualized

Intraperitoneal chemotherapy for ovarian cancer. ACOG Committee Opinion
No. 396. American College of Obstetricians and Gynecologists. Obstet
Gynecol 2008;111:249--51.

<http://www.ncbi.nlm.nih.gov/pubmed/18165421>

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

**Prevention and Treatment of Sexually Transmitted Diseases: An Update**

The Centers for Disease Control and Prevention recently published
revised guidelines for the prevention and treatment of sexually
transmitted diseases. One new treatment strategy is the use of
azithromycin as a primary, rather than alternative, medication for
pregnant women with Chlamydia trachomatis infection. Quinolone-resistant
Neisseria gonorrhoeae infection continues to increase in the United
States; therefore, quinolones are no longer recommended for treatment of
this infection. Expedited partner therapy gives physicians another
option when addressing the need to treat partners of persons diagnosed
with N. gonorrhoeae or C. trachomatis infection. Tinidazole is now
available in the United States and can be used to manage trichomoniasis,
including trichomoniasis resistant to metronidazole. Shorter courses of
antiviral medication can be used for episodic therapy of recurrent
genital herpes. Because of increasing resistance, close follow-up is
required if azithromycin is used as an alternative treatment in the
management of primary or secondary syphilis. Unexpected increases in the
rates of lymphogranuloma venereum have occurred in the Netherlands, and
physicians should remain vigilant for symptoms of this disease in the
United States. Am Fam Physician 2007;76:1827-32, 1833-34

<http://www.aafp.org/afp/20071215/1827.html>

**CDC Reports a Decrease in the Incidence of Breast Cancer**

Although breast cancer is the most commonly diagnosed cancer in U.S.
women, the Centers for Disease Control and Prevention (CDC) reports that
the incidence of breast cancer has decreased since 1999. Data from
population-based cancer registries show that invasive breast cancer
decreased annually between 1999 and 2003; and, after increasing between
1999 and 2002, noninvasive breast cancer decreased between 2002 and
2003.

Data were collected from the CDC\'s National Program of Cancer
Registries and the National Cancer Institute\'s Surveillance,
Epidemiology, and End Results program. The largest decline occurred
between 2002 and 2003 (6.1 percent for invasive disease and 2.7 percent
for noninvasive disease). The decrease in breast cancer occurred across
several age, cancer stage, and racial groups, with the most significant
decrease occurring in women 50 years and older. Factors that may have
contributed to the decrease in breast cancer include mammography
screening, a decrease in the use of hormone therapy, and differences in
risk-factor prevalence, diet, and lifestyle

Centers for Disease Control and Prevention

*Morbidity and Mortality Weekly Report,* June 8, 2007

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5622a1.htm>

**Recommendations for Follow-up after Early Breast Cancer Diagnoses**

[Background:]{.underline} More than 200,000 invasive breast cancer
diagnoses are expected in 2007, and primary care physicians often
encounter issues with screening for recurrence, familial risk, and
complications of breast cancer or treatment. Hayes reviewed
evidence-based guidelines from various organizations on the specific
health needs in patients with early breast cancer and summarized major
recommendations for follow-up in these patients.

[Recommendations:]{.underline} In general, patients with breast cancer
should be evaluated every four to six months during the year after
diagnosis. After the first year, patients should receive annual
evaluations if they are no longer receiving therapy, mammograms, and
assessments for symptoms of recurrence.

In patients with a history of breast cancer, annual screening with
mammography is the standard of care for detecting new primary breast
cancer. Magnetic resonance imaging or high-resolution ultrasonography
may be useful in high-risk patients, although the role of these tests in
other patients has not been determined. Screening for local recurrence
in patients who had breast-conserving therapy (e.g., lumpectomy) is
identical to screening for new primary cancer in the contralateral
breast. However, the reviewing radiologist should be notified of the
patient\'s history because surgery or irradiation may leave residual
findings on the mammogram. Patients with a history of breast cancer
should receive routine age-specific screening for colon and cervical
cancers.

More than 25 percent of all metastases occur five years or more after
the initial diagnosis of breast cancer; therefore, patients should be
routinely assessed for symptoms of metastatic disease (e.g., neurologic
symptoms, bone pain, dyspnea, jaundice). Because specialized testing for
metastasis (e.g., blood testing, tumor marker screening, radiographic
imaging) may have false-positive rates of up to 50 percent, they should
be reserved for patients with symptoms or signs that are associated with
recurrence.

Breast cancer treatments may increase the risk of other cancers (e.g.,
endometrial carcinoma from tamoxifen \[Nolvadex, brand no longer
available\] use; leukemia from chemotherapy; angiosarcoma from
irradiation). Routine screening for treatment-related cancers is not
recommended because the incidence of these cancers is less than 1
percent five years after treatment; however, patients should be educated
about relevant signs and symptoms, and physicians should ask about these
signs and symptoms at follow-up visits.

Although genetic testing is not recommended for all women with breast
cancer, it may be useful in high-risk patients (see accompanying table).
In patients without risk factors for familial cancer syndromes, the risk
of carrying a mutation in a tumor suppressor gene such as BRCA1 or BRCA2
is less than 1 percent.

  -----------------------------------------------------------------------
  **Table. Indications for Genetic Counseling in Patients with a History
  of Breast Cancer**

  Age younger than 40 years at diagnosis

  Ashkenazi Jewish heritage

  Personal history of ovarian cancer or first- or second-degree relative
  with a history of ovarian cancer

  Personal history of bilateral breast cancer or a first- or
  second-degree relative with a history of bilateral breast cancer

  First-degree relative who was younger than 50 years when diagnosed with
  breast cancer

  Two or more first- or second-degree relatives who were diagnosed with
  breast cancer at any age

  Any male relative with a history of breast cancer

  *Adapted with permission from Hayes DF. Follow-up of patients with
  early breast cancer. N Engl J Med 2007;356:2506.*
  -----------------------------------------------------------------------

Patients have a greater risk of osteoporosis if they are treated with
aromatase inhibitors (e.g., anastrozole \[Arimidex\], letrozole
\[Femara\], exemestane \[Aromasin\]) because these drugs have
antiestrogenic effects. Bone mineral density testing should be performed
before initiation of aromatase inhibitor therapy, and testing should be
performed every one to two years in other patients with a history of
breast cancer. Bisphosphonate therapy is preferred in these patients
because raloxifene (Evista) may limit the effectiveness of aromatase
inhibitors. Similarly, raloxifene should be avoided if a patient has
received five years of tamoxifen therapy, because these drugs have
similar mechanisms and because of the risk of breast cancer recurrence
with prolonged tamoxifen use.

Cardiovascular screening and prevention measures, including regular
exercise and monitoring of blood pressure and lipid levels, are
important. No special testing is recommended; however, physicians should
be aware of therapies that may increase the risk of cardiovascular
disease. Chemotherapy with anthracyclines or trastuzumab (Herceptin) may
reduce cardiac function in up to 5 percent of patients, and radiation
therapy to the left chest wall may increase long-term cardiovascular
risk by up to 30 percent. Tamoxifen therapy has also been associated
with a threefold increase in the risk of thromboembolic and
cerebrovascular diseases and should be avoided in patients with a
history of these conditions.

Hayes DF. Follow-up of patients with early breast cancer. N Engl J Med
June 14, 2007;356:2505-13.
<http://www.aafp.org/afp/20071215/tips/4.html>

**CDC Evaluates the Effect of Revised Guidelines on Group B Streptococci
Disease**

In 2002, the Centers for Disease Control and Prevention (CDC), the
American College of Obstetricians and Gynecologists, and the American
Academy of Pediatrics revised guidelines for the prevention of perinatal
group B streptococci (GBS) disease, which included recommending that
health care professionals screen patients to identify candidates for
prophylaxis. The CDC has reviewed surveillance data to compare the rates
of neonatal and pregnancy-related GBS disease before and after the new
guideline was released. Data were reviewed from the two years before
(2000 to 2001) and after (2003 to 2005) the publication of the guideline
revisions.

From 2003 to 2005, the average incidence of early-onset neonatal GBS
disease was 33 percent less than in the pre-guideline revision period;
however, although the incidence decreased steadily among white infants
between 2003 and 2005, it increased by 70 percent during the same period
in black infants. In the years after the guideline revisions, rates of
pregnancy-related and late-onset neonatal GBS disease remained stable
compared with baseline rates.

Although further research is needed, the authors conclude that these
data highlight the need for strategies to reduce the rate of neonatal
GBS disease among black infants, evaluation of missed opportunities for
prevention, and continued monitoring of disease trends.

Centers for Disease Control and Prevention

*Morbidity and Mortality Weekly Report,* July 20, 2007

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5628a1.htm>

Premenstrual Syndrome (Clinical Evidence Concise)

What are the effects of drug treatments in women with premenstrual
syndrome (PMS)?

beneficial

Spironolactone. Randomized controlled trials (RCTs) found that
luteal-phase spironolactone improved psychological and physical symptoms
of PMS over two to six months compared with placebo.

likely to be beneficial

Alprazolam. RCTs found that luteal-phase alprazolam improved most
physical and psychological symptoms of PMS after three to six months\'
treatment compared with placebo, including severe symptoms in women with
premenstrual dysphoric disorder. Mild adverse effects were common.
Benzodiazepines are associated with dependence.

Buspirone. One RCT found that buspirone (luteal or continuous) was more
effective than placebo in improving self-rated global improvement at
four months in women with premenstrual dysphoric disorder. Results for
individual psychological and physical symptoms were inconclusive. Mild
adverse effects were common.

Gonadorelin Analogues for Less Than Six Months. One systematic review
found that gonadorelin analogues reduced overall symptoms of PMS over
three to six months compared with placebo. Women taking gonadorelin
analogues were three times more likely to have adverse effects,
including hot flashes, aches, night sweats, nausea, and headaches, than
women taking placebo. The addition of hormonal add-back therapy to
reduce long-term adverse effects did not reduce effectiveness. However,
treatment with gonadorelin analogues without hormonal add-back for
longer than six months carries a serious risk of osteoporosis, limiting
their usefulness for long-term treatment.

Metolazone. One RCT found that luteal-phase metolazone reduced
premenstrual swelling and weight gain, and improved mood symptoms
compared with placebo.

Nonsteroidal Anti-inflammatory Drugs. RCTs found that luteal-phase
mefenamic acid or naproxen sodium improved physical and psychological
premenstrual symptoms over three to six months compared with placebo.
The RCTs provided little information on adverse effects.

trade-off between benefits and harms

Clomipramine. RCTs found that clomipramine (luteal or continuous)
improved psychological symptoms of PMS over three treatment cycles, but
not physical symptoms. A proportion of women stopped treatment because
of adverse effects, such as drowsiness, nausea, vertigo, and headache.

Danazol. RCTs found that danazol reduced overall premenstrual symptoms
after three months\' treatment compared with placebo, but had important
adverse effects associated with masculinization when used continuously
in the long term.

Selective Serotonin Reuptake Inhibitors (SSRIs). One systematic review
and subsequent RCTs found that SSRIs improved premenstrual symptoms over
two to six cycles compared with placebo, but caused frequent adverse
effects. Current evidence indicates no clear relationship between SSRIs
and increased risk of suicide, but there is concern that SSRIs may
increase the risks of self-harm and suicidal ideation. Regulatory
authorities in Europe, including the United Kingdom, and in the United
States have issued warnings about the use of SSRIs in children and
adolescents.

What are the effects of hormonal treatments in women with PMS?

likely to be beneficial

Contraceptives (Oral). One RCT found that oral contraceptives improved
certain premenstrual symptoms (i.e., appetite, acne, and food cravings)
compared with placebo, but did not improve mood-related symptoms on a
21/7 day schedule. Another RCT found that oral contraceptives improved
mood-related symptoms (e.g., depression, anxiety, mood swings,
irritability) and physical symptoms of premenstrual dysphoric disorder
(e.g., increased appetite, breast tenderness, bloated sensation,
headaches, muscle pain) compared with placebo on a 24/4 day schedule.

trade-off between benefits and harms

Progesterone. One systematic review found an improvement in overall
premenstrual symptoms in women taking luteal-phase progesterone for two
to six months compared with placebo. A second systematic review (of two
RCTs also included in the first review) found no overall improvement in
premenstrual symptoms in women taking luteal-phase progesterone for two
to four months compared with placebo.

Although the first review found a wide range of adverse effects
associated with progesterone (including excessive bleeding,
dysmenorrhea, abdominal pain, nausea, and headache), it found no
significant difference in the frequency of withdrawals caused by adverse
effects.

Progestogens. One systematic review found that progestogens reduced
premenstrual symptoms over three or four cycles compared with placebo.
It found no significant difference between progestogens and placebo in
the proportion of women who withdrew because of adverse effects. The
most common adverse effects associated with progestogens are nausea,
breast discomfort, headache, and menstrual irregularity. Progestogen may
induce PMS symptoms in some women.

unknown effectiveness

Estrogens. Limited evidence from one RCT suggested that continuous
estradiol might improve symptoms of PMS after three months\' treatment
compared with placebo. However, the magnitude of any effect is unclear.
Important adverse effects of estrogen include increased risk of breast
cancer, endometrial cancer, stroke, and venous thromboembolic disease.

Tibolone. One small RCT found limited evidence that continuous tibolone
improved premenstrual symptom score over six months compared with
placebo (multivitamins).

What are the effects of psychological interventions in women with PMS?

unknown effectiveness

Cognitive Behavior Therapy. Weak RCTs provided insufficient evidence to
assess cognitive behavior therapy in women with PMS.

What are the effects of physical therapy in women with PMS?

unknown effectiveness

Acupuncture. One small RCT found that acupuncture was effective in
reducing premenstrual symptoms from baseline scores; however, sham
acupuncture also reduced symptoms.

Bright Light Therapy. One systematic review of small RCTs found no
significant difference between bright light therapy and placebo in
reducing depressive symptoms related to premenstrual dysphoric disorder.

Chiropractic Manipulation. One weak crossover trial provided
insufficient evidence to assess chiropractic manipulation in women with
PMS.

Exercise. We found no systematic review or RCT of exercise in women with
PMS.

Reflexology. One RCT found limited evidence that reflexology was better
than sham reflexology in reducing premenstrual symptoms at eight weeks.

Relaxation. One RCT found limited evidence that relaxation treatment was
better than reading leisure material or charting symptoms in reducing
premenstrual symptoms over five months. Two further weak RCTs provided
insufficient evidence to assess relaxation.

What are the effects of dietary supplements in women with PMS?

beneficial

Pyridoxine. One systematic review found that luteal-phase or continuous
pyridoxine (vitamin B6) was better than placebo in relieving overall
symptoms of PMS over two to six months.

likely to be beneficial

Calcium Supplements. Two RCTs identified by a systematic review found
that calcium supplements improved symptoms compared with placebo.

unknown effectiveness

Evening Primrose Oil. Weak RCTs provided insufficient evidence to assess
the effects of evening primrose oil in women with premenstrual symptoms.

Magnesium Supplements. Weak RCTs provided insufficient evidence to
assess the effects of magnesium supplements in women with PMS.

What are the effects of surgical treatments in women with PMS?

likely to be beneficial

Hysterectomy with Bilateral Oophorectomy. We found no systematic review
or RCT of hysterectomy alone or hysterectomy with bilateral oophorectomy
in women with PMS. Cohort studies have found almost complete eradication
of the symptoms of PMS after hysterectomy plus bilateral oophorectomy
and continuous estrogen placement, and there is consensus that it is
effective. Surgery is rarely used, but may be indicated if there are
coexisting gynecologic problems. (Based on consensus; RCTs unlikely to
be conducted.)

Laparoscopic Bilateral Oophorectomy. We found no systematic review or
RCT of laparoscopic bilateral oophorectomy in women with PMS. Cohort
studies have found almost complete eradication of the symptoms of PMS
after hysterectomy plus bilateral oophorectomy and continuous estrogen
therapy, and there is consensus that it is effective. Surgery is rarely
used, but may be indicated if there are coexisting gynecologic problems.
(Based on consensus; RCTs unlikely to be conducted.)

unknown effectiveness

Endometrial Ablation. We found no systematic review or RCT of
endometrial ablation in women with PMS.

Definition

A woman has PMS if she complains of recurrent psychological or physical
symptoms occurring specifically during the luteal phase of the menstrual
cycle, and often resolving by the end of menstruation.1 The symptoms can
also persist during the bleeding phase.

The definition of severe PMS varies among RCTs, but in recent studies,
standardized criteria have been used to diagnose one variant of severe
PMS-premenstrual dysphoric disorder. These criteria are based on at
least five symptoms, including one of four core psychological symptoms
(from a list of 17 physical and psychological symptoms), being severe
before menstruation starts and mild or absent after menstruation.2,3 The
symptoms are: depression; feeling hopeless or guilty; anxiety or
tension; mood swings; irritability or persistent anger; decreased
interest; poor concentration; fatigue; food craving or increased
appetite; sleep disturbance; feeling out of control or overwhelmed; poor
coordination; headache; aches; swelling, bloating, and weight gain;
cramps; and breast tenderness.

Incidence and Prevalence

Premenstrual symptoms occur in 95 percent of all women of reproductive
age; severe, debilitating symptoms (PMS) occur in about 5 percent of
those women.1

[Etiology]{.underline}

The cause is unknown, but hormonal and other factors (possibly
neuroendocrine) probably contribute.4,5

[Prognosis]{.underline}

Except after oophorectomy, symptoms of PMS usually recur when treatment
is stopped.

**Editor\'s note:** Tibolone is not available in the United States.

A Publication of BMJ Publishing Group
[***http://www.aafp.org/afp/20080101/bmj.html***](http://www.aafp.org/afp/20080101/bmj.html)

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

**Intervention programs that focus on already violent youth are more
effective than other programs for reducing violent behavior**

<http://www.ahrq.gov/research/jan08/0108RA6.htm>

**Some women with breast cancer do not receive adjuvant treatments
recommended by guidelines**

<http://www.ahrq.gov/research/jan08/0108RA7.htm>

**Use of antidepressants by low-income pregnant women has jumped more
than twofold, raising questions about fetal risks**

<http://www.ahrq.gov/research/jan08/0108RA9.htm>

**Regulatory warnings led to decreased use of antidepressants in
children and adolescents in 2004 and 2005**

<http://www.ahrq.gov/research/jan08/0108RA5.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

**Autism Screening**

**Guest editor Joshua Cabrera, MD**

Identifying children with autism early has several benefits; it allows
family to adapt to unusual and challenging behaviors in their toddler,
it leads to early interventions that may improve outcomes[^2]^,^ and it
opens the door for increased services at school. The American Academy of
Pediatrics currently advocates screening for autism at the age of
18months.[^3]

General developmental screening tools may be abnormal when administered
to autistic children, especially language screens. General screens do
not distinguish children with developmental delays from autism, but can
trigger further screening and evaluation. A specific screening tool for
autism is the Checklist for Autism in Toddlers (CHAT)[^4]. This screen
consists of 9 questions asked of the parents and 5 simple in office
tests, administered at the age of 18-24 months. The key elements of the
CHAT assess the child's capacity for shared attention and imaginative
play, both per history and in the office.

A child demonstrates shared attention when pointing to an object of
interest, for example, a stuffed giraffe, and then glancing at another
person's eyes or face to measure if they are also noticing the giraffe.
The examiner also should initiate the test for shared attention by
pointing to an object, demonstrating interest in it, and observing the
child share the examiners attention in the object (usually through
gaze). Autistic children may point as part of an imperative, but not as
part of sharing attention. For example the autistic child may point at
food, and may even lead you by the arm to the food, but will likely not
look at your eyes or face to measure or implore your shared attention.
The second key ability, imaginative play, is abundantly demonstrated in
an office that has age appropriate toys. In the CHAT, developed in the
UK, the examiner uses a cup to pretend to drink tea and asks the toddler
to join in. Using a spoon and play bowl to pretend to scoop up stew or
blue corn mush may be more appropriate for those in the Southwest.
Autistic toddlers may play with toys, but do not play imaginatively with
them at 18mo, focusing instead on sensory qualities such as its sound or
feel. Often their play is repetitive and stereotyped as well. Toddlers
who lack shared attention and imaginative play, by history and on exam,
likely have an autism spectrum disorder. Children who have a mixed
result, for example, whose parents report shared attention, but who can
not do so for the examiner, have a moderate risk of autism.

So what role does autism screening have in day to day practice? Children
who have family histories, who have language delays, or whose parents
express concern for their development in language/social domains,
warrant further screening and evaluation. General screening, advocated
by the AAP, may be the first step to improving outcomes. Becoming
familiar, or having easy access to some form of the CHAT, can improve
its routine use in the office. Its essential elements, shared attention
and imaginative play, can be screened for effectively with brief office
tests and have good specificity for autism spectrum disorders.

For further reading on screening for autism, visit the website
<http://www.autismresearchcentre.com/>

**References:**

[Dev Med Child
Neurol.](javascript:AL_get(this, 'jour', 'Dev Med Child Neurol.');) 2005
Jul;47(7):493-9, [J Eval Clin
Pract.](javascript:AL_get(this, 'jour', 'J Eval Clin Pract.');) 2007
Feb;13(1):120-9

2 "Identification and Evaluation of Children with Autism Spectrum
Disorders" October, 2007. Pediatrics

#### 3 Early Identification of Autism by the CHAT [J R Soc Med.](javascript:AL_get(this, 'jour', 'J R Soc Med.');) 2000 Oct;93(10):521-5. [J Am Acad Child Adolesc Psychiatry.](javascript:AL_get(this, 'jour', 'J Am Acad Child Adolesc Psychiatry.');) 2001 Dec;40(12):1457-63. {#early-identification-of-autism-by-the-chat-j-r-soc-med.-2000-oct9310521-5.-j-am-acad-child-adolesc-psychiatry.-2001-dec40121457-63. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Dr. Cabrera is a psychiatrist boarded in pediatrics, adult psychiatry, child psychiatry who has worked since 2005 in Chinle. He has particular interests in early childhood development and infant psychiatry. {#dr.-cabrera-is-a-psychiatrist-boarded-in-pediatrics-adult-psychiatry-child-psychiatry-who-has-worked-since-2005-in-chinle.-he-has-particular-interests-in-early-childhood-development-and-infant-psychiatry. .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

**Breast Pumps: The good, the bad, and the ugly**

New families usually ask about breast pumps. Many retail pumps work well
for occasional pumping. But, most retail pumps are not clinically
evaluated or labeled so that families know what to expect. For example,
a retail hand or electric pump may work well for the occasional bottle
so mom can go to the store or out to eat, but not work well enough to
maintain a milk supply when mom goes to work or school. It can be
confusing and frustrating for new families and providers.

The following are suggestions for...suggesting a pump:

-If the family needs a pump for once in a while, often a retail breast
pump will work. Also the hand pumps associated from hospital grade
electric pumps producers, such as Medela or Ameda / Egnel will work.

-If the family needs a pump for more than 3-4 hours of routine
separation, encourage them consider a hospital grade electric pump.
Resources for these pumps are:

WIC

If WIC has electric pumps available, the rules are that the mom needs to
be

exclusively breastfeeding. This means the family cannot be receiving
formula from

the WIC program. If the family is getting formula on their own for
occasional use,

that is usually okay. If WIC doesn't have pumps, they might be able to
suggest

local resources.

Locally

If the baby is in a NICU, hospitals often have pump loaners. If not, the
hospital

usually has hospital pump available for moms to use when they are at the
hospital.

Usually they have a breastfeeding consultant or staff members trained in

breastfeeding support. They can be very helpful.

> Encourage families to check with local hospital gift shops. Sometimes
> they have pump loaners/rentals.
>
> The yellow pages/internet - under "breastfeeding" is another place to
> look. Suggest that families look for pump resources that have an IBCLC
> (International Board Certified Lactation Consultant) on staff. Pump
> rentals often cost at least \$30 per month to rent, attachments are
> often \$30 or more.

Ebay

A word of caution: The Medela Pump in Style pumps are designed for
single

person use, the contaminant filter is inside the machine. Replacing the

attachments will not reduce the potential contamination risk.

If your hospital or clinic is interested in having pumps to loan, the
hospital grade pump companies have rental programs. Some companies have
low cost "loss waivers/insurance" so that if a pump is loaned and lost,
the company will assume responsibility. Rental costs to I.H.S. vary,
depending on manufacturer and pump. For example, one I.H.S. facility
reported a current cost of \~ \$125/year for Medela Lactina Plus pumps.
Attachments are \$30-40 per set. For more details, check with local pump
loaner stations or call PIMC Breastfeeding Helpline at 1-877-868-9473.

<Suzan.Murphy@ihs.gov>

####  {#section-11 .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}

#### January 2008 Highlights include: {#january-2008-highlights-include .Style-Heading-4-+-Arial-14-pt-Underline}

-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

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/documents/CCCC_v6_01.pdf**](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/CCCC_v6_01.pdf) {#httpwww.ihs.govmedicalprogramsmchmdocumentscccc_v6_01.pdf .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-12 .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-13 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**2008 NICWA Annual Conference**

Early Bird Registration Ends March 28, 2008! Be a part of the largest
national conference that focuses on American Indian children's issues.
The 2008 NICWA Annual Conference will be located at the Sheraton
Bloomington Hotel at 7800 Normandale Boulevard, Bloomington, MN  55439,
(866) 837-4728 at
[[http://www.starwoodhotels.com/sheraton/property/overview/index.html?propertyID=1493]{.underline}](http://www.starwoodhotels.com/sheraton/property/overview/index.html?propertyID=1493)

Registration form and conference information is available at
[[www.nicwa.org/conference]{.underline}](http://www.nicwa.org/conference)
Questions about registration, please contact Tileah (Tia) Begay at (503)
222-4044 ext.157 or
[[tbegay@nicwa.org]{.underline}](mailto:tbegay@nicwa.org)

**Family violence in health care and public health settings: Accepting
Manuscripts**

The Family Violence Prevention and Health Practice e-journal invites you
to submit manuscripts on addressing family violence in health care and
public health settings. The next issue will look at the relationship
between childhood and adult sexual and physical violence and obesity.
For information on submission guidelines go to the "info for
contributors" tab of the journal:
[[http://www.endabuse.org/health/ejournal/]{.underline}](http://www.endabuse.org/health/ejournal/) 

**National Report: National Indian Child Welfare**

Native children are overrepresented in the nation\'s foster care system
at more than 1.6 times the expected level, according to a new report by
the National Indian Child Welfare Association (NICWA) and the national,
nonpartisan Kids Are Waiting campaign, a project of The Pew Charitable
Trusts. Yet tribal governments are excluded from some of the largest
sources of federal child welfare funding.

The report, titled Time for Reform: A Matter of Justice for American
Indian and Alaskan Native Children, found that nationally, American
Indian and Alaska Native children were reported to the state and found
to be victims of child abuse and neglect at the rate of 16.5 per 1,000
American Indian and Alaska Native children. This rate compares to 19.5
for African American children, 16.1 for Pacific Islander children, 10.8
for White children, and 10.7 for Hispanic children. Native American
children are more likely than children of other races/ethnicities to be
identified as victims of neglect (65.5%), and they are least likely to
be identified as victims of physical abuse (7.3%). \"Giving tribes
direct access to federal child welfare resources is the most important
thing the federal government can do to help American Indian and Alaskan
Native children and families in crisis,\" said Terry L. Cross, Executive
Director of NICWA and member of the Seneca Nation of Indians.\"
<http://www.pewtrusts.org/uploadedFiles/wwwpewtrustsorg/Reports/Foster_care_reform/NICWAReport.pdf>

**31st Annual Indian School on Alcohol and Other Drug Related Issues -
Save the Date**

**April 5-11, 2008**

**ABQ, NM**

<http://www.aitiinc.org/AITI/Welcome.html>

![](media/image6.jpeg){width="5.207638888888889in"
height="6.740972222222222in"}

**Improving Domestic Violence Law Enforcement Response on the Tohono
O\'odham Nation**

The IHS Office of Emergency Services is happy to share with you that
Emerging Leader, Michelle Begay\'s, article \"Improving Domestic
Violence Law Enforcement Response on the Tohono O\'odham Nation\" has
been published in The IHS Primary Care Provider.

It was published in the October edition - October being DV Awareness
Month.

Improving Domestic Violence Law Enforcement Response on the Tohono
O\'odham Nation

Vol. 32 #10 Oct 2007 Issue.

[[http://www.ihs.gov/PublicInfo/Publications/HealthProvider/issues/PROV1007.pdf]{.underline}](http://www.ihs.gov/PublicInfo/Publications/HealthProvider/issues/PROV1007.pdf)

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

**2008 Education in Palliative and End-Of-Life Care-Oncology/IHS
(EPEC-O/IHS)**

March 25-27, 2008; Bloomington, Minnesota

The 2008 Education in Palliative and End-Of-Life Care-Oncology/IHS
(EPEC-O/IHS) will be held March 25 - 27, 2008 in Bloomington, Minnesota.
This intensive, interactive training course is a joint effort between
the IHS and the National Cancer Institute and is evolving into one of
the best opportunities available to develop specific skills related to
caring for patients and families who are facing cancer and other serious
chronic illnesses, and those facing the end of life.

The faculty features the top clinicians in the field. Participation is
open to all physicians, nurses, social workers, and pharmacists across
the Indian health system. All Indian health facilities are encouraged to
support interested physicians, nurses, social workers, pharmacists and
others to attend this course. If a facility wishes to send a team that
would be ideal.

The National Cancer Institute has provided funds to cover travel costs
and per diem for about 35 attendees for this course. We will accept
applications on a first request, first served basis. Please contact
Timothy Domer M.D. by e-mail at <Timothy.domer@ihs.gov>

**A second training session** **will be held in Flagstaff AZ April
22-24.** The location of that training will be forthcoming shortly. You
may apply to attend that course at the same e-mail address.

Your e-mail application must include a statement from the CEO or
Clinical Director indicating Administrations support for this training
and for supporting the development of a process for providing palliative
and End-of-Life care. The Service Unit will be reimbursed for travel and
per diem.

The March training will be held at the Holiday Inn Select International
Airport, 3 Appletree Square, Bloomington, Minnesota 55425. Please make
your hotel room reservations by March 3, 2008 by calling 1-800-465-4329
or (952) 854-9000. Be sure to ask for the "Indian Health Service" group
rate.

The IHS Clinical Support Center is the accredited sponsor for this
meeting. For more information on CME/CEU, contact Gigi Holmes or CDR
Dora Bradley at (602) 364-7777 or <gigi.holmes@ihs.gov>

**Minimizing Adverse Drug Events in Older Patients**

Adverse drug events are common in older patients, particularly in those
taking at least five medications, but such events are predictable and
often preventable. A rational approach to prescribing in older adults
integrates physiologic changes of aging with knowledge of pharmacology.
Focusing on specific outcomes, such as the prompt recognition of adverse
drug events, allows the family physician to approach prescribing
cautiously and confidently. Physicians need to find ways to streamline
the medical regimen, such as periodically reviewing all medications in
relation to the Beers criteria and avoiding new prescriptions to
counteract adverse drug reactions. The incorporation of computerized
alerts and a multidisciplinary approach can reduce adverse drug events.
Am Fam Physician 2007;76:1837-44.

<http://www.aafp.org/afp/20071215/1837.html>

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

**Continuous Oral Contraception May Not Reduce Bleeding Days but May
Improve Sx**

[Conclusions:]{.underline} Continuous oral contraception does not result
in a reduction of bleeding days over a 168d period of observation, but
provides greater suppression of the ovary and endometrium. These effects
are associated with improved patient symptomatology.

[Legro
RS](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Legro RS"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Effects of Continuous versus Cyclic Oral Contraception: A
Randomized Controlled Trial. J Clin Endocrinol Metab. 2007 Dec 4
<http://www.ncbi.nlm.nih.gov/pubmed/18056769>

**Association of Oral Contraceptive Use, Other Contraceptive Methods,
and Infertility with Ovarian Cancer Risk**

In summary, we observed that the protective effect of long duration of
oral contraceptive use waned after 20 years since last use. Among other
contraceptive methods, most were not associated with risk, with the
exception of tubal ligation (inverse association) and IUD use (positive
association). History of infertility was associated with a modestly
increased risk of ovarian cancer. Oral contraceptives are the only known
chemoprotective agent for ovarian cancer. Future studies should continue
to examine the potential waning effect of oral contraceptives with
longer time since last use, as well as continue to explore potential
associations with other contraceptive methods and infertility. Overall,
these results do not support a positive association between circulating
androgen levels and ovarian cancer risk.

[Tworoger
SS](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Tworoger SS"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Plasma Androgen Concentrations and Risk of Incident Ovarian
Cancer.

Am J Epidemiol. 2007 Nov 3;
<http://www.ncbi.nlm.nih.gov/pubmed/17982156>

**Tubal Patency Better With One Dose vs Multiple Methotrexate Doses for
Ectopic**

CONCLUSION(S): In terms of ipsilateral tubal obstruction, multiple-dose
MTX therapy appears to have a greater negative effect on tubal patency
than single-dose therapy.

[Guven
ES](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Guven ES"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Comparison of the effect of single-dose and multiple-dose
methotrexate therapy on tubal patency. Fertil Steril. 2007
Nov;88(5):1288-92.

<http://www.ncbi.nlm.nih.gov/pubmed/17418839>

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

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

**New and Improved MCH Conferences page - More user friendly**

The MCH Conferences page has been redesigned and updated to make it more
user-friendly. The page now appears like a calendar page, so you can
easily scroll through it.

If you are a more visual reader and less text based, then the new format
is great for you

Take a look

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

As always the MCH Conferences sites will present you with latest
information on conferences that are relevant to providing the highest
possible level of care to your patients.

**Other features are**

-An exhaustive list of links to **Other Educational Calendars,** so you
can sort through various conferences by conference location and
educational source, as well as date.

<http://www.ihs.gov/MedicalPrograms/MCH/F/CN03.cfm>

-Do you vaguely remember that Course you heard about last year, or
sometime in the past, but just couldn't make it to that conference?

As many Courses recur, we have archived the past Conference postings
since 2001 so you can look at old brochures, contact information,
etc.....on the **Conference Archive** page

<http://www.ihs.gov/MedicalPrograms/MCH/F/confArch07.cfm>

-Can't get away from your facility right now, but need some continuing
education?

Try the **Online CME Sites** page.

<http://www.ihs.gov/MedicalPrograms/MCH/F/CN02.cfm>

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

**Frequently Asked Questions about Infant Feeding Choice**

BACKGROUND INFORMATION

Why collect this data? Because it is used in the clinical performance
measure called Breastfeeding Rates that is reported in the RPMS Clinical
Reporting System (CRS). While this measure is currently not a GPRA
measure (one reported to Congress and OMB) it is used in support of the
GPRA measure Childhood Weight Control with the goal of lowering the
incidence of childhood obesity in the IHS patient population.
Additionally, facilities can use this data to track infant feeding
patterns and breastfeeding rates within their own patient population.

Research indicates that children who were breastfed have lower
incidences of overweight or obesity. For additional information, please
click the link below to review the article in the March 2007 IHS Primary
Care Provider.

<http://www.ihs.gov/PublicInfo/Publications/HealthProvider/issues/PROV0307.pdf>

How is this data used? It is used in the CRS Breastfeeding Rates topic
in several measures that report:

1.  How many patients approximately 2 months through 1 year of age were
    ever screened for infant feeding choice.

2.  How many patients were screened at the approximate ages of 2 months,
    6 months, 9 months, and 1 year.

3.  How many patients who were screened were either exclusively or
    mostly breastfed at those age ranges.

Users may run the CRS Selected Measures (Local) Reports to view all of
the breastfeeding performance measures. The report also provides the
option to include a list of patients and identifies the dates and ages
they were screened and their infant feeding choice values. Click the
link below to learn how to run this report in CRS, starting on page 206
(as numbered in the document itself, not in Adobe).

<http://www.ihs.gov/misc/links_gateway/download.cfm?doc_id=10716&app_dir_id=4&doc_file=bgp_070u.pdf>

Is Infant Feeding Choice data the same as the data included in the Birth
Measurements section of the EHR and with the PIF (Infant Feeding Patient
Data) mnemonic in PCC? No, it is different. The information collected in
these sections are intended for one-time collection of birth weight,
birth order, age when formula was started, breastfeeding was stopped and
solid foods started, and linking to mother/guardian. Shown below is a
screen shot of this section from EHR. While this information is
important, none of it is used in the logic for the CRS Breastfeeding
Rates measure; only the Infant Feeding Choice data is used.

![](media/image7.png){width="4.5in" height="3.8229166666666665in"}

What are the definitions for the Infant Feeding Choices? The definitions
are shown below and are the same definitions used in both EHR and PCC.

-   Exclusive Breastfeeding: Formula supplementing less than 3 times per
    week (\<3x per week)

```{=html}
<!-- -->
```
-   Mostly Breastfeeding: Formula supplementing 3 or more times per week
    (\>3x per week) but otherwise mostly breastfeeding

-   ½ Breastfeeding, ½ Formula Feeding: Half the time breastfeeding,
    half the time formula feeding

-   Mostly Formula: The baby is mostly formula fed, but breastfeeds at
    least once a week

-   Formula Only: Baby receives only formula

Who should be collecting this information and how often? It depends on
how your facility is set up but any provider can collect this
information. At a minimum, all providers in Well Child and Pediatric
clinics should be collecting this information for patients 45-394 days
old at all visits occurring during that age range. Public Health Nurses
should also be collecting this information. This data can be entered in
EHR or PCC/PCC+, as described below.

ENTERING INFANT FEEDING CHOICE DATA IN EHR

In which version of EHR is Infant Feeding Choice data able to be
entered? EHR Version 1.1, which was deployed nationally on October 3,
2007.

How do I enter Infant Feeding Choice in EHR?

1.  After you have selected the patient and the visit, go to the
    Personal Health section. For some EHR sites, this may be included on
    the Wellness tab.

2.  ![](media/image8.png){width="7.260416666666667in"
    height="3.326388888888889in"}From the Personal Health dropdown list,
    select Infant Feeding, then click the Add button.

NOTE: The age of the patient must be five years or less to be able to
select Infant Feeding; otherwise, Infant Feeding will not be listed in
the dropdown list.

3.  ![](media/image9.png){width="3.1145833333333335in"
    height="1.4583333333333333in"}At the Add Infant Feeding Record
    window, click the appropriate checkbox to select the type of infant
    feeding, and then click the OK button to save the value.

4.  The patient's value for Infant Feeding Choice for this visit is now
    displayed in the Personal Health section, as shown below.

![](media/image10.png){width="6.385416666666667in"
height="2.5729166666666665in"}

ENTERING INFANT FEEDING CHOICE DATA IN PCC/PCC+

Which data entry patch do I need? You will need to have data entry patch
8 (apcd0200.08k) installed, which was released on October 19, 2005.

How do I enter Infant Feeding Choice in PCC?

1.  Create a new visit or select an existing visit to append.

2.  At the Mnemonic prompt, type "IF" (Infant Feeding Choices) and press
    Enter.

![](media/image11.png){width="5.9944444444444445in"
height="4.393055555555556in"}

3.  Type the number corresponding to the type of feeding and press
    Enter. If you do not know the number, type "??" and press Enter to
    see a list of choices.

4.  You are returned to the Mnemonic prompt. Continue with data entry of
    other items.

Stephanie Klepacki

CRS Project Manager/Lead Analyst

November 2, 2007

#### [MCH Coordinator Editorial comment:]{.underline}

**The infant feeding choice functionality is supported in the newly
released EHR 1.1 **

The clinical performance measure called Breastfeeding Rates reported in
the RPMS Clinical Reporting System (CRS) is a measure of interest.  We
wish to emphasize that while this measure is currently not a GPRA
measure (one reported to Congress and OMB) it is used in support of the
GPRA measure Childhood Weight Control with the goal of lowering the
incidence of childhood obesity in the IHS patient population. 
Additionally, facilities can use this data to track infant feeding
patterns and breastfeeding rates within their own patient population in
the first year of life.

To capture this data Stephanie Klepacki, the CRS Project Manager/ Lead
Analyst has developed: Frequently Asked Questions:  Infant Feeding
Choice in EHR.  A team of analysts and clinicians have been involved in
developing and testing this functionality.  Kudos go to Phoenix Indian
Medical Center's Department of Pediatrics, to Sherry Allison,
Information Processing Supervisor and her staff for getting the data
entered pre EHR, and the ever diligent and nurturing Suzan Murphy, RD,
IBLCE who have done the lion's share of the clinical testing.  

From an MCH standpoint expanding this functionality into toddler and
early childhood feeding choices seems a natural next step as later
versions are developed. 

We look forward to your feedback, comments and use of this functionality
in the universal documentation of feeding choice during the first year
of life for our American Indian and Alaska Native families.

Lastly, new to the Indian Health Breastfeeding page\* is the Lactation
Support in the Workplace Toolkit. This document includes information on:
how to get started, drafting local policy, evaluation tools, resources
available on the Indian Health Breastfeeding page, as well as FAQs.

[**Lactation Support Policy in the Workplace\
**http://www.ihs.gov/MedicalPrograms/MCH/M/documents/Lactation%20Support%20in%20the%20Workplace%20TOOLKIT_Breastfeeding%20is%20Good%20Business_October%202007.doc](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/Lactation Support in the Workplace TOOLKIT_Breastfeeding is Good Business_October 2007.doc)

\*Indian Health Breastfeeding page

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

**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}

**Four Directions Summer Research Program Applications Online for Summer
2008**

Helping to create future leaders in Native American health care

Applications are now available online for Summer 2008 Four Directions
Summer Research Program. Application Deadline: February 29, 2008
(postmark)

Four Directions

Summer Research Program

Harvard Medical School and Brigham and Women's Hospital

Boston, MA

For more information and to complete the online application, please
visit [www.fdsrp.org](http://www.fdsrp.org/)

For More Information, Brochures or Applications

Elena Muench

Brigham and Women's Hospital

Office for Multicultural Faculty Careers

Center for Faculty Development and Diversity

1620 Tremont Street, 3-014.04

Boston, MA 02120

\(617\) 525-7644

<FourDirections@partners.org>

**iCare Training**

The IHS Office of Information Technology continues to offer WebEx
training 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.

1\. A Brief Introduction to iCare 30 minutes

The 2 standard training sessions are again offered and we recommend they
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}**

**[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 Mon 01/28/2008 11:00-13:00 MST coyote

Tues 02/12/2008 11:30 -13:30 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 Thur 01/10/2008 10:00-11:30 MST coyote

Wed 01/30/2008 13:30-15:00 MST coyote

Thurs 02/14/2008 13:00-14:30 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 Mon 01/14/2008 14:00-14:30 MST coyote

Mon 02/11/2008 12:00-12:30 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}

**Multiple Chlamydia species pose an unexpected challenge for blindness
prevention**

In the United States, most health care providers hearing the word
"chlamydia" think immediately of the sexually transmitted infection
caused by Chlamydia trachomatis. Chlamydia the STI is common around the
world, but C. trachomatis has long been believed also to be the major
cause of trachoma, an eye infection that is the leading cause of
preventable blindness worldwide. A new report calls into question some
of the conventional wisdom about trachoma, and raises concerns about
treatment and prevention efforts.

Trachoma is spread when ocular or respiratory secretions from an
infected person get into the eyes of an uninfected person (typically
through direct contact, when carried by house flies or other insects, or
by shared towels). It causes a conjunctivitis that ultimately turn the
eyelashes inward, resulting in corneal scratching and ulcerations. Left
untreated, it progresses to blindness over a span of one to four
decades. The disease is found disproportionately in poor countries,
especially in Asia, the Middle East, and Africa, and especially among
women. Dry and dusty places where people are inclined to rub their eyes
and don't have much water to wash may be particularly affected.

Though trachoma was once a serious problem in the United States, it has
been greatly reduced by antibiotic treatment and by provision of clean
water to affected communities. In fact, the CDC claims trachoma has been
eradicated in the U.S., though a 1997 report on eye disease on the
Navajo reservation still listed it as a significant cause of blindness
there. Efforts to wipe out trachoma in the Third World, however, fail
consistently. Cases quickly reappear following mass antibiotic treatment
of affected communities, and may persist or reappear even when testing
fails to demonstrate the presence of C. trachomatis. These anomalies led
researchers to investigate whether another pathogen might be
responsible.

In an endemic community in Nepal, Deborah Dean and colleagues sampled
tears from 146 people in nine affected households and also did eye exams
to stage them for clinical trachoma. PCR testing on the tear samples
showed that half the sample was infected. The surprise was that of those
infected, 35% had only C. trachomatis (and even here there were eight
different genotypes involved), 20% had only C. psittaci, 10% had only C.
pneumoniae, and 35% had more than one species. All three species were
highly correlated with severe eye inflammation consistent with clinical
trachoma, and the researchers conclude that all three are pathogenic.
It's not clear that the same pattern of infection will prevail outside
Nepal. What is clear is that efforts to make a vaccine have just had a
significant setback, and that monotherapy with azithromycin (which may
not work for all Chlamydiaceae) can no longer be counted on to wipe out
the problem.

**Reference:**

Dean D, Kandel RP, Adhikari HK, Hessel T Multiple Chlamydiaceae species
in trachoma: implications for disease pathogenesis and control. PLoS
Medicine 5(1):e14, January 2008

<http://www.ncbi.nlm.nih.gov/pubmed/18177205>

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

**New edition of Knowledge Path: Preconception and Pregnancy available**

The new edition of Knowledge Path: Preconception and Pregnancy is a
guide to resources that analyze perinatal health statistics, describe
effective prenatal care programs, and report on research aimed at
improving access to and quality of prenatal care and improving perinatal
health outcomes. The path, produced by the MCH Library, contains
consumer health resources and resources on specific aspects of
preconception and pregnancy including childbirth, depression, drug and
alcohol use, environmental concerns, fertility and infertility,
nutrition, oral health, and tobacco use.
[[http://www.mchlibrary.info/KnowledgePaths/kp_pregnancy.html]{.underline}](http://www.mchlibrary.info/KnowledgePaths/kp_pregnancy.html)

**MCH Headlines Judy Thierry HQE**

**Announcing the 2008 PREVENT Child Maltreatment Institute**

The 2008 PREVENT Child Maltreatment Institute: Enhancing Leadership for
Child Maltreatment Prevention offers state of the art training to
experienced teams from across the country, who are working to stop child
maltreatment before the first victimization or perpetration occurs.  The
Institute will expand skills to lead evidence-based efforts in the
primary prevention of child maltreatment and provide teams with an
intensive and supportive environment in which to work together with a
trained coach on a prevention initiative.  Participants can expect to
enhance core competencies in the primary prevention of child
maltreatment at the state and/or national level, including:

-   planning and evaluating effective policy interventions and programs;
       

-   stimulating organizational and social change;    

-   critically evaluating the literature and translating science into
    practice;    

-   effectively communicating with media and policy makers through media
    and legislative advocacy,

-   implementing promising practices, and

-   enhancing skills in achieving program sustainability.

The PREVENT Child Maltreatment Institute will include two (2) intensive
three-day, on-site sessions separated by six months of working as a team
at home, with selected distance education calls and guidance from an
experienced coach focused on a team-developed project.  The first
three-day session will be held April 21-23, 2008 for Cohort 1 and April
22-24, 2008 for Cohort 2 at the Sheraton Chapel Hill Hotel, Chapel Hill
North Carolina.  The second session will be conducted in October, 2008.\
\
Multi-organizational teams of up to 5 people will be selected based on
their experience working together, demonstration of leadership in child
maltreatment prevention AND readiness to take an increased leadership
role in making social and organizational changes to prevent child/
maltreatment./ While we will consider multidisciplinary teams from local
communities, the most successful applicants will be teams working in
large metropolitan areas, or at the state, regional or national level
that have already established working relationships. Selected teams are
responsible for travel, lodging, evening meals, and a one-time
non-refundable \$750 team registration fee. For more information and to
submit an application, please see the attached flyer and visit
<http://prevent.unc.edu/education/>.

**Children with special health care needs: Cultural competence
compendium**

New Resource from the National Center for Cultural Competence

The National Center for Cultural Competence (NCCC) has just released a
new monograph on cultural and linguistic competence in systems serving
children and youth with special health care needs and their families. 
The examples are related to State Title V programs, but the monograph
offers insights and lessons that apply to any organization. 

You can access the document at
<http://www.gucchdgeorgetown.net/NCCC/journey/>

Novel use of road signs to emphasize the Negotiations required by
families and providers and systems as they address children and their
special health care needs.

![](media/image12.png){width="4.28125in" height="4.635416666666667in"}

Pg 91 - Alaska Newborn hearing screening program and Community Health
Provider education, ANMC CHA curriculum adaptation

#### 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-1 .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-15 .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-16 .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-17 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Stay tuned to the March issue for the answers and a discussion {#stay-tuned-to-the-march-issue-for-the-answers-and-a-discussion .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

**PMDD Spotlight: Women With Histories of Abuse: A Clinically Meaningful
Subgroup?**

[http://www.medscape.com/viewarticle/565755?sssdmh=dm1.329206&src=0_tp_nl_0#](http://www.medscape.com/viewarticle/565755?sssdmh=dm1.329206&src=0_tp_nl_0)

**HPV Vaccines: Beyond Expectations**

<http://www.medscape.com/viewarticle/567800>

**Expanding HIV Testing: Practical Screening Cases to Meet New CDC
Recommendations**

<http://www.medscape.com/viewarticle/567593>

**Sexually Transmitted Infections and Cancer: Breaking the Link Through
Vaccination**

<http://www.medscape.com/viewprogram/8225?src=nlcmealert>

######### Hypertension and Soy: A Best Evidence Review

<http://www.medscape.com/viewarticle/568288>

[**Treatment Options for Early-Stage Breast Cancer: Information for
Primary Care**](http://www.medscape.com/viewprogram/8342)

<http://www.medscape.com/viewarticle/567114>

[**Top Herbal Products: Efficacy and Safety
Concerns**](http://www.medscape.com/viewprogram/8494)

<http://www.medscape.com/viewarticle/568235>

######### 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**

**Smoking Status as a Predictor of Hip Fracture Risk in Postmenopausal
Women**

The purpose of this study was to determine the effect of cigarette
smoking on the risk of hip fracture for postmenopausal women living in
rural and urban areas of Northwest Texas. Former and current smoking
increased the risk of hip fracture in this population of postmenopausal
women. Residence in a rural county (population \<100,000) also was
associated with increased risk.
<http://www.cdc.gov/pcd/issues/2008/jan/07_0036.htm>

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

#### Low dose transdermal E2 gel delivered the lowest effective dose  {#low-dose-transdermal-e2-gel-delivered-the-lowest-effective-dose-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: The 0.87 g/d dose of this new transdermal E2 gel, which delivers an estimated 0.0125 mg E2 daily, delivered the lowest effective dose for treatment of vasomotor symptoms and vulvovaginal atrophy in a population of postmenopausal women. LEVEL OF EVIDENCE: I. {#conclusion-the-0.87-gd-dose-of-this-new-transdermal-e2-gel-which-delivers-an-estimated-0.0125-mg-e2-daily-delivered-the-lowest-effective-dose-for-treatment-of-vasomotor-symptoms-and-vulvovaginal-atrophy-in-a-population-of-postmenopausal-women.-level-of-evidence-i. .Style-Heading-4-+-Arial-14-pt-Underline}

[Simon
JA](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Simon JA"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Low dose of transdermal estradiol gel for treatment of symptomatic
postmenopausal women: a randomized controlled trial. Obstet Gynecol.
2007 Mar;109(3):588-96.

#### [**http://www.ncbi.nlm.nih.gov/pubmed/17329509**](http://www.ncbi.nlm.nih.gov/pubmed/17329509) {#httpwww.ncbi.nlm.nih.govpubmed17329509 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-21 .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-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: Vaginal tablets with 25 mcg and 10 mcg E2 provided relief of vaginal symptoms, improved urogenital atrophy, decreased vaginal pH, and increased maturation of the vaginal and urethral epithelium. Those improvements were greater with 25 mcg than with 10 mcg E2. Both doses were effective in the treatment of atrophic vaginitis. LEVEL OF EVIDENCE: I {#conclusion-vaginal-tablets-with-25-mcg-and-10-mcg-e2-provided-relief-of-vaginal-symptoms-improved-urogenital-atrophy-decreased-vaginal-ph-and-increased-maturation-of-the-vaginal-and-urethral-epithelium.-those-improvements-were-greater-with-25-mcg-than-with-10-mcg-e2.-both-doses-were-effective-in-the-treatment-of-atrophic-vaginitis.-level-of-evidence-i .Style-Heading-4-+-Arial-14-pt-Underline}

[Bachmann
G](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Bachmann G"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstract)
et al Efficacy of Low-Dose Estradiol Vaginal Tablets in the Treatment of
Atrophic Vaginitis: A Randomized Controlled Trial. Obstet Gynecol. 2008
Jan;111(1):67-76.

#### [**http://www.ncbi.nlm.nih.gov/pubmed/18165394?dopt=Abstract**](http://www.ncbi.nlm.nih.gov/pubmed/18165394?dopt=Abstract) {#httpwww.ncbi.nlm.nih.govpubmed18165394doptabstract .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-22 .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-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: Levonorgestrel intrauterine system (LNG-IUS) reduces the occurrence of de novo endometrial polyp in women treated with tamoxifen for breast cancer. {#conclusion-levonorgestrel-intrauterine-system-lng-ius-reduces-the-occurrence-of-de-novo-endometrial-polyp-in-women-treated-with-tamoxifen-for-breast-cancer. .Style-Heading-4-+-Arial-14-pt-Underline}

[Chan
SS](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Chan SS"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al A randomised controlled trial of prophylactic levonorgestrel
intrauterine system in tamoxifen-treated women. BJOG. 2007
Dec;114(12):1510-5.

<http://www.ncbi.nlm.nih.gov/pubmed/17995495>

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

#### The What, Why and How of Aromatase Inhibitors: Hormonal Agents for Treatment and Prevention of Breast Cancer {#the-what-why-and-how-of-aromatase-inhibitors-hormonal-agents-for-treatment-and-prevention-of-breast-cancer .Style-Heading-4-+-Arial-14-pt-Underline}

#### The third-generation aromatase inhibitors (AIs) anastrozole, exemestane and letrozole have largely replaced tamoxifen as the preferred treatment for hormone receptor - positive breast cancer in postmenopausal women. Approximately 185,000 new cases of invasive breast cancer are diagnosed yearly, and at least half of these women are both postmenopausal and eligible for adjuvant therapy with AIs. In addition, AIs are currently being tested as primary prevention therapy in large randomised trials involving tens of thousands of women at increased risk for breast cancer. Given the volume of use, internists will increasingly see postmenopausal women who are taking or considering treatment with AIs. Physicians need to be able to: (i) briefly discuss the pros and cons of using a selective estrogen receptor modulator such as tamoxifen or raloxifene vs. an AI for risk reduction and (ii) recognise and manage AI-associated adverse events. The primary purpose of this review is to help providers with these two tasks. {#the-third-generation-aromatase-inhibitors-ais-anastrozole-exemestane-and-letrozole-have-largely-replaced-tamoxifen-as-the-preferred-treatment-for-hormone-receptor---positive-breast-cancer-in-postmenopausal-women.-approximately-185000-new-cases-of-invasive-breast-cancer-are-diagnosed-yearly-and-at-least-half-of-these-women-are-both-postmenopausal-and-eligible-for-adjuvant-therapy-with-ais.-in-addition-ais-are-currently-being-tested-as-primary-prevention-therapy-in-large-randomised-trials-involving-tens-of-thousands-of-women-at-increased-risk-for-breast-cancer.-given-the-volume-of-use-internists-will-increasingly-see-postmenopausal-women-who-are-taking-or-considering-treatment-with-ais.-physicians-need-to-be-able-to-i-briefly-discuss-the-pros-and-cons-of-using-a-selective-estrogen-receptor-modulator-such-as-tamoxifen-or-raloxifene-vs.-an-ai-for-risk-reduction-and-ii-recognise-and-manage-ai-associated-adverse-events.-the-primary-purpose-of-this-review-is-to-help-providers-with-these-two-tasks. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.medscape.com/viewarticle/567399?src=mp**](http://www.medscape.com/viewarticle/567399?src=mp) {#httpwww.medscape.comviewarticle567399srcmp .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Herbal practitioners improved menopausal symptoms, esp. hot flushes and low libido {#herbal-practitioners-improved-menopausal-symptoms-esp.-hot-flushes-and-low-libido .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: The treatment package from herbal practitioners improved menopausal symptoms, particularly hot flushes and low libido. This offers evidence to support herbal medicine as a treatment choice during the menopause. {#conclusion-the-treatment-package-from-herbal-practitioners-improved-menopausal-symptoms-particularly-hot-flushes-and-low-libido.-this-offers-evidence-to-support-herbal-medicine-as-a-treatment-choice-during-the-menopause. .Style-Heading-4-+-Arial-14-pt-Underline}

[Green
J](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Green J"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Treatment of menopausal symptoms by qualified herbal
practitioners: a prospective, randomized controlled trial. Fam Pract.
2007 Oct;24(5):468-74.

<http://www.ncbi.nlm.nih.gov/pubmed/17698978>

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

**1.) AI / AN women are really successful at doing this**

**2.) The evidence supports this**

**3.) Women want and benefit from this**

**What is this win^3^ best practice process ?**

**(a.k.a. win / win / win)**

**It is vaginal birth after cesarean**

**(We need to provide them)**

The following is in response to the comments of Dr. David Gahn regarding
VBACs at Hastings Indian Medical Center that appeared in this column in
the December issue of the CCC Newsletter (see link below). This
following is a conglomeration of my and other midwives' responses.

First, here is some overall VBAC information to ponder.

We must all remind ourselves of recent history. The change from pro-VBAC
thinking to pro-repeat cesarean delivery occurred when ACOG came out
with a recommendation (not a requirement) that physicians (doesn't
specify anesthesia) should be immediately available (no definition
supplied).

This recommendation was based on a poorly done study of discharge
diagnosis codes that actually demonstrated the same statistics on
uterine rupture as previous studies of VBAC, but the authors came to
very different conclusions (Lyndon-Rochelle 2001) Unfortunately, much of
this country went wildly swinging to the extreme end of the pendulum's
arc and stopped offering VBACs. Luckily, some kept their heads and a
plethora of research has been published since which show VBAC to be a
safe and reasonable option for the majority of women with a history of
cesarean deliveries and many benefits to VBAC over repeat cesarean
delivery.

(Please see the many citations that have been reviewed in December
Obstetrics section of this publication -- link below plus this month's
Abstract of the Month. More citations were supplied by Neil Murphy and
Sheila Mahoney on the Indian Health Midwives listserv discussion related
to VBACs.)

Among the places that have remained sane and continued to offer VBACs
are many of us in the Indian Health Service (Alaska Native Medical
Center even got an award from the American College Nurse Midwifes) and a
group in the Northeast, the Northern New England Perinatal Quality
Improvement Network (NNEPQIN). (link below) The folks in the New England
coalition have come out with useful guidelines on deciding about VBAC
and providing quality care. Their work also helped us all face a bigger
picture---how we handle emergency surgery in general and how we can
improve. Their suggestions include improving teamwork, communications,
and skills via drills. This has the potential to improve responses to
emergency birth needs beyond the very few situations related to VBACs.
Those of us in IHS who have continued VBACs have shown continued success
with excellent statistics and outcomes (see 2007 Indian Health Data
Tally Sheet below)

Overall, the pendulum is hopefully beginning to swing back towards a
more rational approach to VBACs---there was even a quote from an ACOG
official that suggested a possible move towards revising their
"immediately available" statement (see August 2006 Midwives Corner
below)

Second, let's go over some of the specifics raised by Dr. Gahn. Since,
according to Dr. Gahn, none of the physicians or midwives at Hastings
are anti-VBAC, I thought I would use the responses from other midwives
and myself to formulate some suggestions to help overcome the barriers
to VBACs at Hastings which were elucidated by Dr. Gahn. These
suggestions can also be used by the few other IHS sites that may be
experiencing problems with offering VBAC services.

1)  Have a journal club to present the overwhelming amount of evidence
    that supports providing VBAC services. Make sure to include the
    materials from the Northern New England Perinatal Quality
    Improvement Network and IHS VBAC statistics. Invite (coerce
    attendance, i.e., pizza or desserts, as needed) all members of the
    perinatal team including anesthesia and executive staff members who
    supervise the provider staff. This will help ensure that all
    involved have the information to begin providing evidence based care
    and should help to start the efforts to develop a functional
    interdisciplinary team. This should also help those obstetricians
    who "are not anti-TOLAC/VBAC", but are not on board with the VBAC
    plan to start their process of getting on board.

2)  Start doing drills for obstetrical emergencies. This will help to
    improve skills, as well as, teamwork and communication between
    anesthesia, surgery, midwifery, obstetrics, nursing---your second
    step in team building. This should help a number of issues. It
    should help to impress all on-call staff to do what is necessary to
    improve response time with the goal of your
    med-staff-rules-and-regulations-required 20 minutes becoming
    reliable. Maybe this will help folks come to the conclusion of
    having key personnel located close by---i.e. a call room or on
    campus housing. This would solve the problem of anesthesia not being
    available when a VBAC patient is laboring. When the larger picture
    of response to any emergent surgery is focused upon then the VBAC
    topic, which represents a very small proportion of the potential
    emergency surgeries, is automatically included.

3)  As a department, or even better as an interdisciplinary team or
    service unit, review the World Health Organization and USPHS Healthy
    People 2010 recommendations for cesarean delivery rates. Both of
    these respected and esteemed organizations have clearly and
    repeatedly recommended cesarean delivery rates in the 10-15% range.
    This clearly answers the question about whether a cesarean delivery
    rate of 37%, which is more than double to triple these
    recommendations, is too high and gives a very good indication as to
    what is too high for a cesarean delivery rate.

4)  Re-evaluate how VBAC counseling is done. To provide true informed
    consent the numbers need to be presented clearly. The data
    consistently shows a uterine rupture rate of 0.5-3%\--it is
    important to explain that this means 97-99.5 women out of 100 will
    not have a uterine rupture and out of the few that do, not all will
    have problems. It is, of course, important to discuss the risk of
    uterine rupture to mother and baby, but to put it in this
    perspective of being rare and review the high-quality, careful care
    we provide to women who are VBACing to help prevent problems. It is
    also very important to review the differences in postpartum
    morbidity and risk between a vaginal birth and cesarean delivery,
    (be sure to include the oft ignored higher rates of breastfeeding
    and orgasm difficulties post cesarean delivery.) If, in contrast,
    providers only make a recommendation of repeat cesarean delivery and
    an institution has a policy that only allows for repeat cesarean
    delivery, then they have effectively negated a woman's right to make
    an informed decision in a situation where there is a choice.

5)  Review the postpartum morbidity and risk differences for women post
    vaginal birth vs. post cesarean delivery. This will help to dispel
    the delusion that a woman who has had a cesarean delivery is walking
    out of the hospital "healthy" and bring a more accurate sense of
    respect for what is really happening for that woman. She has just
    had major abdominal surgery and is in recovery from that surgery.
    She is in pain and is at risk for a number of post-surgical
    complications. Her future pregnancies have also now taken on a
    longer list of potential risks. Along with all this she is also a
    new mother with a newborn to care for and feed every 1-2 hours with
    an abdominal incision that she is fully aware of each time she
    moves. This human perspective of the implications of a cesarean
    delivery might help providers to be concerned with their personal
    and institutional cesarean delivery rates.

6)  Consider IHS as a model for the local standard of care. Since we are
    not controlled by insurance companies, we in IHS often have more
    opportunity then our colleagues outside IHS to provide care that is
    evidence-based. VBAC care is one of those situations and we can
    proudly stand up in the maternity care community as a model of
    excellent care.

Most importantly we need to respect the women we care for as the ones
who are giving birth and realize that, therefore, it needs to be up to
them where, how, and with whom they will do so. We are here to provide
information and care---to serve not to dictate.

Please feel free to contact me for any questions or comments and for
requests for links to the above mentioned resources at
<lisa.allee@ihs.gov>.

**Resources**

**Midwives Corner December 2007 CCCC**

<http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#MidWives>

**Indian Health Maternity and Women's Health Data Tally Sheet, 2007**

<http://www.ihs.gov/MedicalPrograms/MCH/F/documents/DataTally81107.doc>

**Lydon-Rochelle M, et al.** [Risk of uterine rupture during labor among
women with a prior cesarean
delivery](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11439945&query_hl=13).
NEJM 2001; 345:3-8. (Level III)

<http://www.ncbi.nlm.nih.gov/pubmed/11439945?dopt=Abstract>

**Obstetric Hot Topics December 2007 CCCC**

<http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_HT.cfm#ob>

**Northern New England Perinatal Quality Improvement Network**

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

**Midwives Corner August 2006 CCCC**

<http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0806_Feat.cfm#MidWives>

**Judy Whitecrane: Tireless Improvement of Care for Native American
women**

CDR Judith Whitecrane started her professional career as a Diploma
Graduate prepared nurse and over the years has continued her education
in a manner which is very inspiring to any nurse. 

Today Ms. Whitecrane is a Post Master\'s Prepared Nurse whose
professional activities involve a concentration in Nurse-Midwifery.

Not only is she on staff at Phoenix Indian Medical Center, but she is
the first non physician to become Vice-President of Medical Staff.  
Maintenance of the hospitals level II Obstetrical certification, Ms.
Whitecrane is the PIMC Coordinator and Liaison to Arizona Perinatal
Trust.  Ms. Whitecrane is the original author of the Prenatal
Questionnaire used through out the Indian Health Service, Tribal and
Urban Centers (I/T/U), widely used in Indian Country.  Ms. Whitecrane
was one of two individuals responsible for the Public Health Nursing
Teen pregnancy program which addressed many issues related to teen
pregnancy.

Annually, Ms Whitecrane has overseen the Advance Practice Nurse/
Physician Assistant Seminar which has been historically held in
Scottsdale, Az.  This national conference has been most successful in
meeting the needs of Advanced Practice Nurses & Physician Assistants.

Ms. Whitecrane serves on the National Nurse Leadership Council as one of
two Advance Practice Nurse Consultants.  In this role she has worked
tirelessly on behalf of the many nurses she represents across the
I/T/U. 

Of specific commendation are her efforts to increase the awareness of
the Advanced Practice Nurse working within our current personnel
system.  Ms. Whitecrane has advocated for the elevation of the Advanced
Practice Nurse position to make it more competitive with the private
sector.  In doing so, she has successfully overseen the updating of the
Advanced Practice Nurse Scope of Practice.  Both of these activities
have been most labor intensive and will have far reaching positive
affects on present and future Advanced Practice Nurses working
throughout the I/T/U. 

Her efforts will not only pave the way for higher pay for the Advanced
Practice Nurse, especially in OB and Anesthesia which continue to be the
hardest positions to fill, but also will serve to promote a better
understanding and provide a firmer framework for facilities who hire
Advanced Practice Nurses, by having a true scope of practice which
better conforms to local, regional and national guidelines and
expectations.

Over the past three years, Ms. Whitecrane has taken on the role of
Chairperson of the OB Task Force.  This OB Task Force has created
significant changes and improvements to our Labor and Delivery Unit at
PIMC.  She has helped in the creation of OB emergency drills which allow
the staff to better learn the necessary skills to help recognize
potential process problems which can be corrected.   This OB Task Force
has also been instrumental in the completion of the remodeling of our
Obstetrical triage area to create a HIPAA compliant unit and allow safer
treatment areas. 

Ms. Whitecrane also started the Special Care Clinic for the
pregnant women with drug abusing problems.  This clinic is working well
and we have seen many good outcomes since its initiation.  She also has
given many lectures to groups wanting to start such a clinic across
I/T/U.  

 

I know that this is long, but Judy has been at PIMC for 26 years and
with IHS for 30 years and has worked tirelessly for the improvement of
care to our Native American patients.   She retired on Jan. 1, 2008, but
her valuable services may be available to worthy causes on a contract
basis.

<Karen.Carey@ihs.gov>

**53rd ACNM Annual Meeting & Exposition**

May 23-29, 2008

Boston, MA

American College of Nurse-Midwives

<http://www.acnm.org/am/index.cfm>

**ACNM Clinical Bulletin Recommends Intermittent Auscultation**

The American College of Nurse-Midwives has issued a clinical bulletin
recommending intermittent auscultation as the "preferred method for
monitoring the fetal heart rate during labor for women who at the onset
of labor are low risk for developing fetal academia." The recommendation
is based on numerous randomized clinical trials and a 2006 Cochrane
review (including more than 33,000 women) which all show no benefit of
continuous electronic fetal monitoring (EFM) over intermittent
auscultation (IA) in terms of perinatal outcomes and significantly
higher intervention and morbidity rates in the EFM groups. Included are
guidelines on how to perform IA, recommendations from other professional
organizations on the frequency of IA, and how to interpret and document
IA. The bulletin recommends using a multiple-count method, but
unfortunately does not come out with a recommendation or instructions
for a specific counting method. References to studies on auscultation
are provided to help in the decision making, however, including one that
has a method of plotting the counts (see Paine's articles below). The
bulletin also sites research that shows patient satisfaction is
associated with amount and quality of caregiver support and involvement
in decision making and, therefore, that giving patients the choice of IA
with it's 1:1 caregiver to patient ratio and frequent human-provided
assessment might increase patient satisfaction.

Comment: Here is another great resource for supporting the move to turn
off the monitors and even take them out of the birthing rooms of low
risk women (and please remember that most women are low risk). We have
all heard over and over and over that continuous EFM does not improve
outcomes, but does increase intervention and morbidity. Isn't it time
yet that we change our practice to fit the evidence? This bulletin says
yes it is time! I have used IA in both home and hospital settings and it
works well to monitor fetal wellbeing. It is also really wonderful how
IA increases the quantity and quality of labor support the patients
receive. If you do not use IA at your facility, I highly recommend
moving towards it. I realize that change is hard, so here are a couple
of suggestions. If your addiction to the monitor is such that you cannot
go cold turkey, then try doing IA with the monitor first and work
towards using a doptone. If your resistance is the 1:1 ratio and
staffing issues then start with using IA when it is slow and 1:1 is not
a problem. As people get use to and more skilled with IA, then creative
ways to provide it when things are busier will appear. And, of course,
when it is too busy and there is not enough staff then use the EFM, but
realize that that decision is due to institutional needs not patient
needs or for improved outcomes. Lastly, print this clinical bulletin and
post it for all to see and check out the articles by Paine, et al for a
great way to do IA and graph it and by the other authors for other
multiple-count methods you can chose from.

**Resources:**

[American College of Nurse
Midwives](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="American College of Nurse Midwives"%5BCorporate Author%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus).
Intermittent auscultation for intrapartum fetal heart rate surveillance.
J Midwifery Womens Health. 2007 May-Jun;52(3):314-9

<http://www.ncbi.nlm.nih.gov/pubmed/17467602>

Full article via Science Direct and Mosby's Nursing Consult:

<http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6W6R-4NKKM9T-Y&_user=4335206&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000000150&_version=1&_urlVersion=0&_userid=4335206&md5=4bcd60b261d6eac99a54d09a215add0f>

<http://www.nursingconsult.com/das/journal/view/849437012/N/19481854?ja=580990&ANCHOR=text&PAGE=1.html>

Paine et al's articles on auscultating fetal heart rate via Pubmed:

Auscultated fetal heart rate accelerations. Part I. Accuracy and
documentation.

<http://www.ncbi.nlm.nih.gov/pubmed/3633984>

Auscultated fetal heart rate accelerations. Part II. An alternative to
the nonstress test.

<http://www.ncbi.nlm.nih.gov/pubmed/3633985>

**Navajo News John Balintona, Shiprock**

**Biliary Gallstone Disease and Pregnancy**

Biliary tract disease is the second most common general surgical
condition encountered in pregnant women. Often the care of these
patients is shared between the obstetric provider and other specialists,
i.e. primary care providers and general surgeons. The purpose of this
review is to discuss salient points in caring for pregnant patients with
biliary gallstone disease. Included in the discussion is the
pathophysiology of gallstones, incidence in pregnancy, evaluation of the
patient, treatment options during pregnancy, and recommendations for
care for obstetric patients with gallbladder disease.

In the United States, cholesterol stones are the most common type of
gallstone. The formation of cholesterol stones is a result of
cholesterol supersaturation and impaired gallbladder motility. Several
risk factors have been associated with the increased occurrence of
gallstones:

### **Risk Factors for Gallstone Formation**

#### Obesity; BMI \> 30 

Pregnancy

Female Gender

Native American Race

Heredity

Increasing Age

Ileal disease

Drugs; estrogens, TPN, ceftriaxone

Cholelithiasis is found in about 20% of women over 40. Literature
suggests that the yearly risk of intervention is about 1 -- 2%.
Therefore, treatment for asymptomatic disease is not warranted.
Complications can occur however, which change the approach and
management of this condition. Acute cholecystitis develops when there is
a complete obstruction of the cystic duct usually with colonization from
bacteria. Choledocholithiasis occurs when gallstones migrate from the
primary site of origin through the cystic duct and into the common bile
duct. Gallstones can trigger an attack of acute pancreatitis by
transiently impacting in the duodenal papilla. Symptoms related to
gallstone disease include steady, nonparyoxsmal pain, usually lasting
more than 4 hours. Anorexia, as well as, nausea and vomiting frequently
occur. Findings such as low-grade fever and leukocytosis (\> 13,000 WBC)
are also indicative of cholecystitis. Pancreatic involvement typically
results in elevated serum amylase and lipase, elevated liver enzymes and
leukocytosis.

The incidence of gallstone disease in pregnancy ranges from 1 in 1000 to
1 in 4000 for symptomatic disease. When taking into account the presence
of asymptomatic cholelithiasis, the literature suggests that 2.5% to 10%
of pregnant women will have this condition demonstrated on ultrasound.
It is believed that several factors predispose pregnancy for the
development of gallstones. First, the gallbladder volume during fasting
and residual volume after contracting is twice that of nonpregnant
patients. Second, Incomplete emptying may result in retention of
cholesterol crystals. The effect of progesterone on smooth muscle
function is though to be the cause of the slow emptying time of the
gallbladder. Biliary sludge is thought to increase in pregnancy, again
increasing the risk for stone formation. The signs and symptoms of
biliary gallstone disease are similar in the pregnant and nonpregnant
patient. Development of cholecystitis and/or pancreatitis during
pregnancy increases the risk of maternal morbidity, as well as, fetal
complications, e.g. preterm labor, low birthweight, fetal loss. Fetal
loss is attributed to a combination of acidosis, hypovolemia, and
hypoxia.

Evaluation of possible gallstone disease is similar among pregnant and
nonpregnant patients. An appropriate history and physical is warranted.
Consideration for other disease processes that are similar in
presentation, such as acute fatty liver of pregnancy, preeclampsia,
infection, etc should occur. Gestational age specific fetal surveillance
and recording of maternal vital signs is warranted. Laboratory data,
which may be helpful in the evaluation, include:

Complete blood count

Serum amylase

Serum lipase

Liver function tests

Serum chemistries

##### Urinalysis

Ultrasonography has been shown to be of greatest importance in the
evaluation of patients with biliary tract disease. Stones as small as 2
mm can be seen and the sensitivity and specificity of this imaging
modality is well over 95%. Findings on ultrasound that are
characteristic for acute cholecystitis include tenderness over the
gallbladder (ultrasound murphy's sign), pericholecystic fluid, and
thickened gallbladder wall. Cholecystoscintigraphy (HIDA) scan is
another radiologic technique used in diagnosis, but is currently
believed to be contraindicated in pregnancy.

Early in the evaluation empiric treatment and intervention can be
initiated. The patient should be placed NPO, and should be resuscitated
with intravenous fluids. Concomitant medical problems should be
stabilized. Consideration should be made for nasogastric suction.
Paraenteral analgesics should be given and broad antibiotic coverage
should be considered especially in cases involving suspected
cholecystitis or pancreatitis. In some facilities, it is standard for a
consultation to be sought from general surgery and the nutrition/dietary
service.

Primary treatment for symptomatic cholelithiasis in nonpregnant patients
remains cholecystectomy. This procedure is safe, relieves symptoms, and
has low recurrence rate. Most general surgeons would recommend immediate
intervention with the exception of gallstone pancreatitis where many
suggest that resolution of the pancreatitis should occur before surgery.
There is a consensus that surgical intervention is warranted in pregnant
patients with obstructive jaundice, acute cholecystitis failing medical
management, pancreatitis, or suspected peritonitis. However, the
management of symptomatic cholelithiasis remains controversial.

Medical management of symptomatic cholelithiasis includes previously
described steps of bowel rest, IV hydration, IV pain control, and
surgical/nutrition consultations. A number of nonsurgical approaches
have been used for gallstone disease. Oral bile acid dissolution
therapy, extracorporeal shock wave lithotripsy, and contact dissolution
have been described, but there is little, if any, experience with these
methods during pregnancy and are therefore not recommended. Some authors
state that up to 80% of patients will get relief from the initial attack
with conservative medical treatment. However, literature also suggests
that the recurrence rate is high, up to 50% with even higher rates if
the initial attack occurs during the second trimester. Some obstetric
providers include symptomatic cholelithiasis as an indication for
elective induction of labor in appropriate candidates. Successful
induction of labor anecdotally relieves the symptoms and shortens the
time to potential surgical therapy. The author believes that induction
of labor at term in properly selected patients is a viable option for
those with symptomatic cholelithiasis.

Surgical intervention remains a viable option even in the pregnant
patient with symptomatic gall bladder disease. As noted above, surgical
management is indicated in cholecystitis and pancreatitis. Several
studies have shown that laparoscopic cholecystectomy is just as safe as
open cholecystectomy and even has a number of advantages as well, e.g.
shorter hospital stay, lower post-op pain, better cosmesis, etc.
Furthermore, several case studies note that the use of the laparoscopic
technique is safe and effective even in the third trimester. No strict
recommendations exist regarding the obstetric aspects with patients
undergoing cholecystectomy but some factors should be considered:

Perioperative fetal monitoring, especially in gestational age past 14
weeks

Adequate maternal hydration prior to surgery

Use of the open (Hassan) technique for insufflation

##### Placement of the patient in the left lateral recumbent position

Pneumoperitoneum pressure less than 15 mm Hg

Corticosteroid injection for fetal maturity in appropriate patients

Prophylactic tocolytic therapy

Other sources cite the use of other interventions to include
percutaneous cholecystostomy and endoscopic retrograde
cholangiopancreatography (ERCP) in selected patients.

Several studies have been published comparing the outcomes of medical
versus surgical management of symptomatic cholelithiasis (with no
evidence of cholecystitis or pancreatitis) during pregnancy. One such
study concluded that surgical management is safe, decreases days in the
hospital, and reduced the rate of labor induction and preterm
deliveries. Furthermore, the rate of relapse of symptoms in those
managed medically was significantly higher. Maternal and fetal mortality
in both groups was shown to be similar. The patient's obstetric provider
should ensure that she receives an adequate consultation regarding the
data and risks regarding surgical intervention.

This review highlighted several salient factors in the role of the
obstetric provider in the care of pregnant patients with biliary
gallstone disease. The author would like to summarize a few points that
are felt to be especially important:

1.  Pregnancy is a risk factor for cholelithiasis.

2.  Asymptomatic cholelithiasis does not warrant intervention.

3.  Symptomatic cholelithiasis can safely be managed medically or
    surgically.

4.  There is a significant recurrence rate for symptomatic
    cholelithiasis in pregnancy.

5.  Induction of labor for appropriately selected term patients with
    symptomatic cholelithiasis is a viable option.

6.  Cholecystitis and pancreatitis increase the risk for maternal and
    fetal morbidity and mortality and therefore should be treated
    aggressively.

7.  The obstetric provider should provide specific recommendations
    regarding the obstetric aspects in patients undergoing surgical
    intervention.

**References:**

1.  Williams Manual of Obstetrics. Pregnancy Complications. 22nd
    Edition. 2007.Chapter 59. Disease of Gallbladder and Pancreas.

2.  Medial Complications During Pregnancy. 5th Edition. 1999.
    Chapter 14. Liver Diseases.

3.  Gabbe Obstetrics. Normal and Problem Pregnancies. 4th Edition. 2002.
    Chapter 14. Surgical Procedures in Pregnancy.

4.  Lu E, et al. American Journal of Surgery. Volume 188. Issue 6.
    Dec 2004. Pages 755-759. Medical Versus Surgical Management of
    Biliary Tract Disease in Pregnancy.

5.  Bellows C, et al. American Family Physician. Volume 72. No. 4.
    August 2005. Management of Gallstones.

Questions <John.Balintona@ihs.gov>

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

**Nurses Corner, Sandra Haldane, HQE**

**AWHONN -- numerous on line courses -- materials and fees listed**

Introduction to Fetal Heart Monitoring\
Self-paced online course introduces fetal heart monitoring (FHM).
Perinatal clinicians will gain tools to interpret FHM data, implement
interventions, and evaluate the effect of interventions on maternal and
fetal well-being.\
\
Five sections cover:

Maternal-fetal overview

Uterine and fetal physiology

Electronic monitoring

Monitoring and interventions

Risk management

Individual and Group fees for courses are also available

Association of Women's Health Obstetric and Neonatal Nurses

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

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

#### The Last Hours of Living {#the-last-hours-of-living-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Clinical competence, willingness to educate, and calm and empathic reassurance are critical to helping patients and families in the last hours of living. Clinical issues that commonly arise in the last hours of living include the management of feeding and hydration, changes in consciousness, delirium, pain, breathlessness, and secretions. Management principles are the same at home or in a healthcare institution. However, death in an institution requires accommodations to assure privacy, cultural observances, and communication that may not be customary. In anticipation of the event, inform the family and other professionals about what to do and what to expect. Care does not end until the family has been supported with their grief reactions and those with complicated grief have been helped to get care {#clinical-competence-willingness-to-educate-and-calm-and-empathic-reassurance-are-critical-to-helping-patients-and-families-in-the-last-hours-of-living.-clinical-issues-that-commonly-arise-in-the-last-hours-of-living-include-the-management-of-feeding-and-hydration-changes-in-consciousness-delirium-pain-breathlessness-and-secretions.-management-principles-are-the-same-at-home-or-in-a-healthcare-institution.-however-death-in-an-institution-requires-accommodations-to-assure-privacy-cultural-observances-and-communication-that-may-not-be-customary.-in-anticipation-of-the-event-inform-the-family-and-other-professionals-about-what-to-do-and-what-to-expect.-care-does-not-end-until-the-family-has-been-supported-with-their-grief-reactions-and-those-with-complicated-grief-have-been-helped-to-get-care .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.medscape.com/viewarticle/542262**](http://www.medscape.com/viewarticle/542262) {#httpwww.medscape.comviewarticle542262 .Style-Heading-4-+-Arial-14-pt-Underline}

**PhD in Nursing Concentration in Health Policy**

The University of New Mexico, College of Nursing has been approved for
the PhD in Nursing Concentration in Health Policy.  It will begin in
Summer, 2008. Application information for the Doctoral program is on the
web. 

Marie L. Lobo, PhD, RN, FAAN\
University of New Mexico, College of Nursing\
<mlobo@salud.unm.edu>

####  {#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}

**Preconception and Interconception Health Status of Women Who Recently
Gave Birth**

This report summarizes data from 26 Pregnancy Risk Assessment Monitoring
System reporting areas that collected data during 2004 and that had
achieved overall weighted response rates of \>70% and had weighted data
available by the time the analysis was conducted in January 2007. Data
are reported on indicators regarding 18 behaviors and conditions that
are relevant to preconception (i.e., prepregnancy) health and health
care and 10 that are relevant to interconception (i.e., postpartum)
health and health care. The number of questions that were administered
varied by site; certain questions were not asked for all reporting
areas. Results varied by maternal age, race/ethnicity, pregnancy
intention, and health insurance status. For certain risk behaviors and
health conditions, mean overall prevalence was higher among women aged
\<20 years, black women, women whose pregnancies were unintended, and
women receiving Medicaid; however, no single subgroup was consistently
at highest risk for all the indicators examined in this report. These
data also can be used to identify specific groups at high risk that
would benefit from targeted interventions and to plan and evaluate
programs aimed at promoting positive maternal and infant health
behaviors, experiences, and reproductive outcomes. In addition, the data
can be used to inform policy decisions that affect the health of women
and infants.
<http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5610a1.htm?s_cid=ss5610a1_e>

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

#### Oklahoma Perspective  {#oklahoma-perspective .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 **Abstract of the Month and Midwives Corner**, above, for
help with that answer.

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

[**Nonpharmacologic Management of Osteoporosis to Minimize Fracture
Risk**](http://mp.medscape.com/cgi-bin1/DM/y/hBerL0Ou5N60Jdl0JAIc0Eg)

Nonpharmacologic therapies for osteoporosis, including orthoses,
exercise, calcium and vitamin D, fall prevention, and kyphoplasty,
complement pharmacotherapy in minimizing fracture risk and maximizing
bone mineral density. In patients who cannot or who choose not to take
antiosteoporotic medications, these interventions have a definitive role
in treatment.

<http://www.medscape.com/viewarticle/567334>

**Postmenopausal Hormone Therapy and Risk of Cardiovascular Disease by
Age and Years Since Menopause**

#### Treating Menopausal Symptoms

It is clear that, in general, not all women require treatment for
menopausal symptoms. Only approximately 10% of women seek medical help
for their symptoms, and it appears that symptoms of nervousness and
tension, which may or may not be related to menopause, have the
strongest effects on quality of life during the climacteric
period.\[8-10\] However, there is a subset of women, particularly those
early in menopause, who truly suffer with menopausal symptoms on a daily
basis. For these women, hormone therapy is particularly effective for
the management of hot flashes, whereas urogenital symptoms are best
managed with localized vaginal treatment.

It should be noted that the analysis of WHI also reached an important
conclusion which directly affects the clinical management of menopausal
symptoms in older women. Not only were women over 60 years of age at
increased risk for coronary heart disease events with hormone therapy,
but older women with moderate or severe menopausal symptoms were
particularly at risk. This is a critical finding which places these
patients and their providers in a conundrum: Hormone therapy is the most
effective treatment for menopausal symptoms, but the very women over 60
who might most benefit from this therapy have the highest risk for
coronary events associated with hormonal treatment.

Clinicians should offer women with significant menopausal symptoms an
overall risk assessment for all of the potential complications of
hormone therapy. This evaluation should focus on taking a complete
history but should also include an assessment of the lipid profile, as
women with increased concentrations of low-density lipoprotein appear to
be at particularly high risk for cardiovascular events associated with
hormone therapy.\[2\] All women over the age of 50 should receive annual
mammography, regardless of the decision to use hormone therapy.

For women with significant menopausal symptoms who do not have a
significant risk for complications of hormone therapy, treatment may be
prescribed at the lowest dose and for the shortest duration possible.
Seventy-five percent of women who try to stop hormone therapy are
successful, and half of women stop using hormone therapy in the first 12
months.\[11\] Therefore, it is reasonable to try to wean off hormone
treatment during the first year. Women whose symptoms return after a
trial without hormone therapy may try to taper off treatment again in 6
months. If patients and clinicians remain vigilant as to the possible
adverse events of hormone therapy, the risk for adverse events should be
relatively small in relation to the improvement in menopausal symptoms.

[http://www.medscape.com//viewarticle/559366?sssdmh=dm1.329206&src=0_tp_nl_0#](http://www.medscape.com//viewarticle/559366?sssdmh=dm1.329206&src=0_tp_nl_0)

**Depression Associated With Low Bone Mineral Density **

CONCLUSIONS: Low BMD is more prevalent in premenopausal women with MDD.
The BMD deficits are of clinical significance and comparable in
magnitude to those resulting from established risk factors for
osteoporosis, such as smoking and reduced calcium intake. The possible
contribution of immune or inflammatory imbalance to low BMD in
premenopausal women with MDD remains to be clarified.

[Eskandari
F](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Eskandari F"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Low bone mass in premenopausal women with depression. Arch Intern
Med. 2007 Nov 26;167(21):2329-36.

<http://www.ncbi.nlm.nih.gov/pubmed/18039992>

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

**Patients Prefer the Method of \"Tell Back- Collaborative Inquiry\" to
Assess Understanding** Conclusions: Patients strongly prefer the Tell
Back-Collaborative inquiry when assessing their understanding. We
recommend that physicians ask patients to restate what they understand
using their own words and that they use a patient-centered approach.

Kemp et al Patients Prefer the Method of \"Tell Back- Collaborative
Inquiry\" to Assess Understanding of Medical Information. J Am Board Fam
Med 2008;21 24-30

#### [**http://www.jabfm.org/cgi/content/abstract/21/1/24?etoc**](http://www.jabfm.org/cgi/content/abstract/21/1/24?etoc) {#httpwww.jabfm.orgcgicontentabstract21124etoc .Style-Heading-4-+-Arial-14-pt-Underline}

**Sexually Transmitted Diseases-Prevention and Treatment for You and
Your Partner**

<http://www.aafp.org/afp/20071215/1833ph.html>

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

**Women with cardiovascular risk factors may be predisposed to
pre-eclampsia**

RESULTS: After adjustment for smoking; previous pre-eclampsia; parity;
maternal age, education, and socioeconomic position; and duration
between baseline measurements and delivery, positive associations were
found between prepregnancy serum levels of triglycerides, cholesterol,
low density lipoprotein cholesterol, non-high density lipoprotein
cholesterol, and blood pressure and risk of pre-eclampsia. The odds
ratio of developing pre-eclampsia for women with baseline systolic blood
pressures greater than 130 mm Hg (highest fifth) was 7.3 (95% confidence
interval 3.1 to 17.2) compared with women with systolic blood pressures
less than 111 mm Hg (lowest fifth). Similar results were found for
nulliparous and parous women. Women who used oral contraceptives at
baseline had half the risk of pre-eclampsia compared with never or
former users (0.5, 0.3 to 0.9).

CONCLUSION: Women with cardiovascular risk factors may be predisposed to
pre-eclampsia.

[Magnussen
EB](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Magnussen EB"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Prepregnancy cardiovascular risk factors as predictors of
pre-eclampsia: population based cohort study. BMJ. 2007 Nov
10;335(7627):978

<http://www.ncbi.nlm.nih.gov/pubmed/17975256>

**Obstetric outcomes in cancer survivors are reassuring**

RESULTS: The mean age at delivery was 29 years (standard deviation 5.66)
and 26 years (standard deviation 5.62) in the exposed and unexposed
groups respectively (P\<.001). Multiple logistic regression showed that
cancer survivors had higher rates of postpartum hemorrhage (odds ratio
\[OR\] 1.56, 95% confidence interval \[CI\] 1.09-2.23) and operative or
assisted delivery (abdominal or vaginal) (OR 1.33, 95% CI 1.14- 1.54).
Preterm delivery (at less than 37 weeks of gesation) was also found to
be higher in this group compared with non-cancer women (OR 1.33, 95% CI
1.01-1.76).

CONCLUSION: While largely reassuring to women intending to become
pregnant after surviving cancer, the results indicate areas of increased
risk that require additional surveillance.

[Clark
H](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Clark H"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Obstetric outcomes in cancer survivors. Obstet Gynecol. 2007
Oct;110(4):849-54. <http://www.ncbi.nlm.nih.gov/pubmed/17906019>

**Booster dose of betamethasone just before preterm birth: Results
caution against**

CONCLUSIONS: According to this study, a single booster dose of
betamethasone just before preterm birth may perturb respiratory
adaptation. These results caution against uncontrolled use of a repeat
dose of glucocorticoid in high-risk pregnancies.

[Peltoniemi
OM](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Peltoniemi OM"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Randomized trial of a single repeat dose of prenatal betamethasone
treatment in imminent preterm birth. Pediatrics. 2007 Feb;119(2):290-8.

<http://www.ncbi.nlm.nih.gov/pubmed/17272618>

**Conservative management 1^st^ choice for severe hydronephrosis in
pregnancy**

CONCLUSION: Double pigtail stent insertion is effective for the
treatment of moderate or severe symptomatic hydronephrosis in pregnancy,
and showed a lower failure rate than the conservative treatment.
However, due to the complications and discomfort with surgical
treatment, conservative treatment should still be the first choice.

[Tsai
YL](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Tsai YL"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Comparative study of conservative and surgical management for
symptomatic moderate and severe hydronephrosis in pregnancy: a
prospective randomized study. Acta Obstet Gynecol Scand.
2007;86(9):1047-50. <http://www.ncbi.nlm.nih.gov/pubmed/17712643>

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

**When:** March 2008

**Topic:** Mental health issues in children and adolescents

**Moderator**: Dr. Frank Armao, Psychiatry staff at Winslow

### 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=26>

Unsubscribe from the Primary Care listserv

<http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=26>

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

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

#### 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-3-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSIONS: Women previously treated for cervical intraepithelial neoplasia grade 3 are at an increased risk of developing invasive cervical cancer and vaginal cancer. This risk has increased since the 1960s and is accentuated in women aged more than 50. The risk is still increased 25 years after treatment. {#conclusions-women-previously-treated-for-cervical-intraepithelial-neoplasia-grade-3-are-at-an-increased-risk-of-developing-invasive-cervical-cancer-and-vaginal-cancer.-this-risk-has-increased-since-the-1960s-and-is-accentuated-in-women-aged-more-than-50.-the-risk-is-still-increased-25-years-after-treatment. .Style-Heading-4-+-Arial-14-pt-Underline}

[Strander
B](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Strander B"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Long term risk of invasive cancer after treatment for cervical
intraepithelial neoplasia grade 3: population based cohort study. BMJ.
2007 Nov 24;335(7629):1077.

<http://www.ncbi.nlm.nih.gov/pubmed/17959735>

**HPV Vaccine Acceptance Among Mid-Adult Women**

Results: Mid-adult women who received the HPV vaccine were more likely
to be younger than 55 years (P \< .001); have had an abnormal
Papanicolaou test (odds ratio \[OR\], 2.15; 95% CI, 1.18--3.92);
understand that HPV causes cervical cancer (OR, 2.39; 95% CI,
1.08--5.30); feel at risk for HPV infection (OR, 2.14; 95% CI,
1.00--4.57), and feel it is important for their partner (OR, 25.20; 95%
CI, 9.66--65.72) and children (OR, 3.54; CI, 0.51--24.56) to get the HPV
vaccine. Monogamous mid-adult women (OR, 0.46; 95% CI, 0.21--1.00);
women who did not want any vaccines (OR, 0.26; 95% CI, 0.07--0.92); and
women who felt it was too late to get the vaccine (OR, 0.18; 95% CI,
0.08--0.44) were less likely to want the HPV vaccine.

Conclusions: These clinical predictors of HPV vaccine acceptance will
help clinicians recognize mid-adult women who may be more receptive to
vaccination.

Ferris DG et al HPV Vaccine Acceptance Among Mid-Adult Women J Am Board
Fam Med 2008;21 31-37
<http://www.jabfm.org/cgi/content/abstract/21/1/31?etoc>

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

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

#### CONCLUSIONS: The addition of an HPV test to the Pap test to screen women in their mid-30s for cervical cancer reduces the incidence of grade 2 or 3 cervical intraepithelial neoplasia or cancer detected by subsequent screening examinations. {#conclusions-the-addition-of-an-hpv-test-to-the-pap-test-to-screen-women-in-their-mid-30s-for-cervical-cancer-reduces-the-incidence-of-grade-2-or-3-cervical-intraepithelial-neoplasia-or-cancer-detected-by-subsequent-screening-examinations. .Style-Heading-4-+-Arial-14-pt-Underline}

Human papillomavirus and Papanicolaou tests to screen for cervical
cancer.

N Engl J Med. 2007 Oct 18;357(16):1589-97.
<http://www.ncbi.nlm.nih.gov/pubmed/17942872>

**New point of care Chlamydia Rapid Test: Bridging the gap between Dx
and Treatment**

CONCLUSIONS: The performance of the Chlamydia Rapid Test with self
collected vaginal swabs indicates that it would be an effective same day
diagnostic and screening tool for Chlamydia infection in women. The
availability of Chlamydia Rapid Test results within 30 minutes allows
for immediate treatment and contact tracing, potentially reducing the
risks of persistent infection and onward transmission. It could also
provide a simple and reliable alternative to nucleic acid amplification
tests in chlamydia screening programmes.

[Mahilum-Tapay
L](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Mahilum-Tapay L"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al New point of care Chlamydia Rapid Test\--bridging the gap between
diagnosis and treatment: performance evaluation study. BMJ. 2007 Dec
8;335(7631):1190-4.

<http://www.ncbi.nlm.nih.gov/pubmed/18055487>

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

Recurring C. trachomatis Infections in Young Women

**Background:** The Institute of Medicine reports that sexually
transmitted infections (STIs) are a \"hidden epidemic\" because the
public and health care professionals underestimate the impact of these
infections. Young women are particularly at risk of STIs because they
tend to have multiple sexual partners, do not recognize long-term
effects of STIs, and tend not to seek STI-related health care. The rate
of *Chlamydia trachomatis* infection in women 15 to 24 years of age is
more than 2,000 cases per 100,000 women. Studies show that 5 to 30
percent of women in this age group receive screening and are positive
for *C. trachomatis*. The impact of this infection in young women
includes increased risk of infertility, chronic pelvic pain, pelvic
inflammatory disease, and human immunodeficiency virus (HIV) infection.
Niccolai and colleagues assessed the frequency and pattern of *C.
trachomatis* recurrence in young women.

**The Study:** The cohort study included adolescent women from 10 public
health clinics. Patients were included if they were 14 to 19 years of
age, sexually active, nulliparous, and HIV negative. Participants were
evaluated at baseline and at six, 12, and 18 months. At each evaluation,
a urine sample was used to test for *C. trachomatis.* Data were also
collected using structured face-to-face interviews and reviews of
medical records and health department reports of *C. trachomatis*
infections. The main outcome measure was the diagnosis of recurrent *C.
trachomatis* infection.

**Results:** For the 411 participants in the study, the mean age was
17.3 years, and the mean follow-up was 4.7 years per person. The average
age of participants at first intercourse was 14.5 years, and the mean
number of lifetime partners was 4.0. *C. trachomatis* infections were
diagnosed in 52.6 percent of participants; of these, 56.9 percent were
diagnosed with recurrent infections. The rate of recurrent infection was
42.1 per 1,000 person-months, and the median time to recurrent infection
was 5.2 months.

**Conclusion:** The authors conclude that recurrent *C. trachomatis*
infections pose a significant health burden in young women. They add
that the recurrence rate in this population may be higher than
previously recognized.

Niccolai LM, et al. Burden of recurrent *Chlamydia trachomatis*
infections in young women: further uncovering the \"hidden epidemic.\"
*Arch Pediatr Adolesc Med.* March 2007(3);161:246-251.

#### [**http://www.ncbi.nlm.nih.gov/pubmed/17339505**](http://www.ncbi.nlm.nih.gov/pubmed/17339505) {#httpwww.ncbi.nlm.nih.govpubmed17339505 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-31 .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}

**Resolving to Lose Weight in the New Year?**

As You Try To Find a Weight Loss Plan for 2008, Here's What You Need to
Know

People who want to lose weight in 2008 but can't decide which
weight-loss plan to follow may want to ask their health care provider
about the American Diabetes Association's (ADA) new Clinical Practice
Recommendations, issued today.

The revised Recommendations, which help health care providers treat
people with diabetes or at risk for diabetes using the most current
evidence available, include a revision in the nutrition section
indicating that diets restricting carbohydrates or fat calorie intake
are equally effective for reducing weight in the short term (up to one
year).

But far more important than which diet you choose is whether you can
stick to it! The ADA also cites scientific evidence showing that how
well a person adheres to a diet is one of the biggest determinants in
whether they'll succeed in losing weight.

**Set Your Goals**\
Set a realistic weight loss goal. Think about losing 5, 10 or 15 pounds.
One of your goals should be to lose a few pounds and be able to keep it
off for a long time. Here are some tips to help you make goals.

-   Identify a support system, family, friends or co-workers, who will
    support your weight loss efforts.

-   Do a self-check on what and when you eat. Keep honest food records
    for about a week. Write down everything you eat or drink. Use these
    records to set a few food goals.

-   Be ready to gradually change your food habits (and perhaps your
    family\'s food habits) for good. Say good bye to some of your
    unhealthy habits and food choices.

-   Do a physical activity self-check. How much exercise do you get? How
    can you work more of it into your day?

"The risks of overweight and obesity are well known.  We recognize that
people are looking for realistic ways to lose weight," said Ann
Albright, PhD, RD, President, Health Care and Education, American
Diabetes Association.  "The evidence is clear that both low-carbohydrate
and low-fat calorie restricted diets result in similar weight loss at
one year.  Short-term weight loss is beneficial, but what is most
important for health is keeping the weight off long-term," said
Albright.  "We also want to continue to emphasize the importance of
regular physical activity, both to aid in maintenance of weight loss,
and also for the positive health gains associated with exercise that are
independent of weight loss."

Monitor Your Health\
The ADA also caution people with diabetes to carefully monitor their
health when following restrictive weight-loss plans. People following
low-carb diets may replace calories from carbohydrate with fat or
protein. That makes it even more important for them to monitor their
lipid profiles (blood fats, including cholesterol and triglycerides). 
High protein diets may also worsen kidney problems. So people who have
kidney disease should consult a physician about the appropriate amount
of protein for them to consume and also be sure to carefully monitor
their kidney functions.

Being overweight or obese and inactive are major contributing factors to
the onset of type 2 diabetes.  Overweight and obesity also complicate
the treatment of diabetes (both type 1 and type 2) and can contribute to
the development of other health problems, such as heart disease and
cancer.  In the United States, rates of type 2 diabetes in adults and
children have risen dramatically in recent years, along with the
national epidemic of obesity.

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

**Does being overweight or obese increase subsequent hysterectomy
risk?**

Women who are overweight from the age of 36 and those who are obese from
the age of 43 and 53 have a higher risk of hysterectomy than underweight
and normal-weight women.

-There are many health difficulties associated with obesity and the MRC
study shows that, particularly after the age of 36, being overweight or
obese can be linked to hysterectomy in later life. There are risks
associated with hysterectomy and these are heightened if the patient is
obese. With a growing prevalence of obesity in the community, the MRC
study findings are a cause of concern.

CONCLUSIONS: These results suggest that variation in hysterectomy rates
may be partially explained by variation in adiposity, and so with the
recent changes in levels of overweight and obesity in populations, there
may be increasing demand for gynaecological treatments in the future.

[Cooper
R](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Cooper R"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Is adiposity across life associated with subsequent hysterectomy
risk? Findings from the 1946 British birth cohort study. BJOG. 2008
Feb;115(2):184-92; discussion 192.

<http://www.ncbi.nlm.nih.gov/pubmed/18081600>

**Prepregnancy BMI, hypertensive disorders of pregnancy, and long-term
maternal mortality**

CONCLUSION: Elevated prepregnancy BMI is associated with increased risk
of hypertensive disorders of pregnancy (HDP), which are in turn is
associated with increased long-term maternal mortality rates. This
association between HDP and mortality rates increases with elevated
prepregnancy BMI.

[Samuels-Kalow
ME](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Samuels-Kalow ME"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Prepregnancy body mass index, hypertensive disorders of pregnancy,
and long-term maternal mortality. Am J Obstet Gynecol. 2007
Nov;197(5):490.e1-6. <http://www.ncbi.nlm.nih.gov/pubmed/17714679>

**Glycemic Profiles During Pregnancy Differ Between Type 1 and Type 2
Diabetes**

CONCLUSIONS: Continuous glucose monitoring reveals clear differences in
the level of glycemic control that exist in women with type 1 and type 2
diabetes. These data will guide therapeutic interventions aimed at
optimizing glycemic control and improving the pregnancy outcomes of both
type 1 and type 2 diabetes.

[Murphy
HR](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Murphy HR"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Changes in the glycemic profiles of women with type 1 and type 2
diabetes during pregnancy. Diabetes Care. 2007 Nov;30(11):2785-91

<http://www.ncbi.nlm.nih.gov/pubmed/17666464>

**Miscarriage and abortion triple chances of future low birth weight
babies**

Women who have miscarried or had an abortion run three times the normal
risk of having a subsequent low birth weight baby.

CONCLUSION: Previous abortion is a significant risk factor for LBW and
PB, and the risk increases with the increasing number of previous
abortions. Practitioners should consider previous abortion as a risk
factor for LBW and PB.

Brown JS et al Previous abortion and the risk of low birth weight and
preterm births.

J Epidemiol Community Health. 2008 Jan;62(1):16-22.

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=18079328**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=18079328) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch18079328 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-32 .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\'s Leadership Scholarship**

Women\'s Leadership Scholarship is a program of the Channel Foundation,
a small, private foundation based in Seattle, Washington, USA that
promotes leadership in women\'s human rights around the globe.
Channel\'s mission is to fund and create opportunities for groups
working in many regions of the world to ensure that women\'s human
rights are respected, protected, and fulfilled.

 

Eligible candidates include women leaders from the Global South and/or
from indigenous groups who also meet all the following criteria:

1\. They are committed to grassroots organizing and the needs of their
communities or indigenous group.

2\. They have proof of a bachelor\'s or a higher degree.

3\. They have at least three years of work experience dealing with
critical human rights concerns, and other social, educational,
environmental, health or economic conditions that negatively affect
their communities.

4\. They have been accepted into a non-doctoral graduate program at an
accredited university for full-time study/research related to their work
experience in human rights, sustainable development, and/or public
health.

5\. They can show evidence of financial need for educational support.

6\. They intend to return to their home countries to work, utilizing
training and research acquired in the study program.

<http://www.nativeleaders.org:80/how.html>

**New Resource from the National Center for Cultural Competence**

The National Center for Cultural Competence (NCCC) has just released a
new monograph on cultural and linguistic competence in systems serving
children and youth with special health care needs and their families.

Many examples are related to State Title V programs, but the monograph
offers insights and lessons that apply to any organization.

You can access the document at
[[http://www.gucchdgeorgetown.net/NCCC/journey/]{.underline}](http://www.gucchdgeorgetown.net/NCCC/journey/)

**Ending Violence Against Native Women Training Institute and
scholarship opportunity**

We are excited to kick off the New Year with our 5 day to be held in
Atlanta, GA, January 28th - February 1, 2008. If you have any questions
contact Coya Artichoker at 605-341-2050. 

We are also pleased to announce this NEW exciting to attend the
Institute!

The Tribal Judicial Institute at the University of North Dakota School
of Law has monies for ten tribal judicial personnel (prosecutors,
judges, probation officers, etc.) to attend the Sacred Circle Domestic
Violence Training Institute in Atlanta, GA on January 28^th^-February
1^st^, 2008.  The scholarship covers airfare, registration and lodging
but will not cover per diem. 

 

If a person is interested in requesting a scholarship, please contact
Melissa Johnson at 701-777-6306

 

Training:

[http://www.sacred-circle.com/SC%20at%20a%20glance2008.pdf](http://www.sacred-circle.com/SC at a glance2008.pdf)

 

Registration:

[http://www.sacred-circle.com/Registration%20from2008.pdf](http://www.sacred-circle.com/Registration from2008.pdf)

**Native Women\'s Health and Well-Being Conference**

National Indian Women\'s Health Resource Center (NIWHRC) conference,
"Native Women\'s Health and Well-Being Conference" which will be held
June 9-11, 2008, in Albuquerque, New Mexico.  

 

The purpose of the conference is to celebrate the 10th year anniversary
of NIWHRC by hosting a conference to raise awareness abut the many
health issues affecting American Indian and Alaska Native women.  The
conference will focus on Mental, Physical, Emotional, and Spiritual well
being form the health prevention/health promotion approach.  They also
plan to have a youth track focusing on Positive Choices and Healthy
Relationships. They are planning for 300 participants and the audience
is targeted toward grassroots native women, women\'s health advocates in
tribal communities, health educations staff, and other health
providers.  It will be certified by CHES. Examples of information and
workshops will include:  Indian Women in Action; HIV Intergenerational
Approach across the lifespan; cardiovascular health, Violence against
women prevention; traditional mentoring, coalition building and
others.  They want to share with others their positive experiences with
some of the OWH programs they have been involved with.

 

Pam Iron, Executive Director

National Indian Women\'s Health Resource Center

<peiron@niwhrc.org>

**Women\'s History Month: March 2008**

National Women\'s History Month\'s roots go back to March 8, 1857, when
women from New York City factories staged a protest over working
conditions. International Women\'s Day was first observed in 1909, but
it wasn\'t until 1981 that Congress established National Women\'s
History Week to be commemorated the second week of March.

In 1987, Congress expanded the week to a month. Every year since,
Congress has passed a resolution for Women\'s History Month, and the
president has issued a proclamation.

**153.6 million**

The number of females in the United States as of Oct. 1, 2007. The
number of males is 149.4 million.

As of July 1, 2006, males outnumbered females through age 41. Starting
at 42, women outnumbered men. At 85 and older, there were more than
twice as many women as men. Source: Population estimates

**Motherhood**

**82.8 million**

Estimated number of mothers of all ages in the United States.

**1.9**

Average number of children that women 40 to 44 had given birth to as of
2004, down from

3.1 children in 1976, the year the Census Bureau began collecting such
data. Likewise, the percentage of women in this age group who were
mothers was 81 percent in 2004, down from 90 percent in 1976.

**Earnings**

**\$32,649**

The median annual earnings of women 16 or older who worked year-round,
full time, in 2006. Women earned 77 cents for every \$1 earned by men.

**98 cents**

The amount women (\$48,586) in the District of Columbia, who worked
year-round, full time, earned for every \$1 their male counterparts
earned (\$49,544) in 2006. Among all states or state equivalents, the
district was where women were closest to earnings parity with men.

Connecticut, Maryland and New Jersey were the only states where median
earnings for women were greater than \$40,000.

**\$61,081**

Median earnings of women working in computer and mathematical jobs, the
highest for women among the 22 major occupational groups. In the
community and social services group, women\'s earnings as a percentage
of men\'s earnings were higher than 90 percent.

**Education**

**32%**

Percent of women 25 to 29 who had attained a bachelor\'s degree or
higher in 2006, which exceeded that of men in this age range (25
percent).

Eighty-eight percent of women and 84 percent of men in this same age
range had completed high school.

**86%**

Percent of women 25 and older who had completed high school as of 2006.

High school graduation rates for women

continued to exceed those of men (85 percent). Source: Educational
Attainment in the United States: 2006

**26.8 million**

Number of women 25 and older with a bachelor\'s degree or more education
in 2006, more than double the number 20 years earlier.

**27%**

Percent of women 25 and older who had obtained a bachelor\'s degree or
more as of 2006. This rate was up 11 percentage points from 20 years
earlier. Source: Educational Attainment in the United States: 2006

**894,000**

The projected number of bachelor\'s degrees that will be awarded to
women in the 2007-08 school year, who are also projected to earn 380,000
master\'s degrees during this period. Women would, therefore, earn 59
percent of the bachelor\'s and 61 percent of the master\'s degrees
awarded during this school year. In addition, women would earn a
majority (52 percent) of first-professional degrees, such as law and
medical.

**Businesses**

More than \$939 billion

Revenue for women-owned businesses in 2002. There were 116,985
women-owned firms with receipts of \$1 million or more.

**Nearly 6.5 million**

The number of women-owned businesses in 2002. Women owned 28 percent of
all nonfarm businesses.

**More than 7.1 million**

Number of people employed by women-owned businesses. There were 7,231
women-owned firms with 100 or more employees, generating \$274 billion
in gross receipts. Nearly one in three women-owned firms operated in
health care and social assistance, and other services, such as personal
services, and repair and maintenance. Women owned 72 percent of social
assistance businesses and just over half of nursing and residential care
facilities. Wholesale and retail trade accounted for 38.2 percent of
women-owned business revenue.

**13%**

Percentage of women-owned firms in California. California had the most
women-owned firms at 870,496. New York was second with 505,077 or 8
percent of all firms. Texas was third in number of firms with 468,705,
accounting for 7 percent of all firms.

**Voting**

**65%**

Percentage of female citizens 18 and older who reported voting in the
2004 presidential election. Sixty-two percent of their male counterparts
cast a ballot.

**Jobs**

**59%**

On average in 2006, the percent of females 16 and older who participated
in the labor force, representing about 70.2 million women.

More than 50 million women worked full time. The participation rate for
males in this age category was 74 percent.

**37%**

Percent of females 16 or older who work in management, professional and
related occupations, compared with 31 percent of males.

**22 million**

Number of female workers in educational services, health care and social
assistance industries. More women work in this industry group than in
any other. Within this industry group, 11 million work in the health
care industry and 8.4 million in educational services.

**39%**

In 2004, among women 20 to 64 who did not work for four or more
consecutive months, the percentage taking care of children or others.

This was the primary reason among such women for not working. By
comparison, 2 percent of corresponding men did not work for this reason.

**60%**

Chances that your taxes will be prepared by a woman, as this is the
percentage of tax preparers who are women. In addition, 77 percent of
travel agents are women, so it is likely a woman will help you plan your
next vacation.

**84,000**

Number of female police officers. In addition, there are about 9,000
women firefighters, 315,000 lawyers, 278,000 physicians and surgeons,
and 37,000 pilots.

**Military**

**202,000**

Total number of active duty women in the military, as of Sept. 30, 2006.

Of that total, 34,000 women were officers, and 168,000 were enlisted.

**15%**

Proportion of members of the armed forces who were women, as of Sept.
30, 2006. In 1950, women comprised less than 2 percent.

**1.7 million**

The number of military veterans who are women.

**Marriage**

**62.4 million**

Number of married women (including those who are separated or have an
absent spouse) in 2006. There were 59.8 million unmarried (widowed,
divorced or never married) women.

**18%**

Percentage of married couples in which the wife earned at least \$5,000
more than the husband in 2006. Among 22 percent of married couples, the
wife had more education than the husband.

**5.6 million**

Number of stay-at-home mothers nationwide in 2006, up from 4.6 million a
decade earlier.

**Computers**

**84%**

Proportion of women with computers in the home in 2003 who made use of
that computer, 2 percentage points higher than the corresponding
proportion for men. This reverses the computer use gender gap exhibited
during the 1980s and 1990s.

**The Spirit of Volunteerism**

**30%**

Percentage of women who volunteer. The corresponding rate for men is 23
percent. Overall, 36 million women perform unpaid volunteer activities

**Sports**

**3 million**

Number of girls who participated in high school athletic programs in the

2005-06 school year. In the 1975-76 school year, only 1.6 million girls
were members of a high school athletic team.

**168,583**

Number of women who participated in an NCAA sport in 2005-06.

Editor\'s note: The preceding data were collected from a variety of
sources and may be subject to sampling variability and other sources of
error.

Facts for Features are customarily released about two months before an
observance in order to accommodate magazine production timelines.

Questions or comments should be directed to the Census Bureau\'s Public
Information

Office: telephone: 301-763-3030; fax: 301-763-3762; or e-mail:
<pio@census.gov>

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

**Training in Palliative and End of Life Care**

-   March 25 -27, 2008

-   Minneapolis, MN

-   Contact Tim Domer MD at <tim.domer@ihs.gov>

**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}

**How to strengthen pelvic floor muscles?**

<http://www.ihs.gov/MedicalPrograms/MCH/W/MatPT.cfm#pelvic>

There are several upcoming **Conferences**

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

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

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

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

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

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

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

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

#### The January 2008 OB/GYN CCC Corner is available at: {#the-january-2008-obgyn-ccc-corner-is-available-at .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn01.cfm?module=2008&option=jan0**](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn01.cfm?module=2008&option=jan0) {#httpwww.ihs.govmedicalprogramsmchmobgyn01.cfmmodule2008optionjan0 .Style-Heading-4-+-Arial-14-pt-Underline}

####  Abstract of the Month page 5 {#abstract-of-the-month-page-5-1 .Style-Heading-4-+-Arial-14-pt-Underline}

What happens if a patient hears their results are Negative? Positive?
Normal? Abnormal?

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

David Gahn

You can make a big difference in women's and children's lives

Scott Giberson

-Second annual Native HIV/AIDS Awareness Day coming March 20, 2008

-Updated U.S. DHHS Guidelines for Treatment of Adults and Adolescents
with HIV

-Funding opportunity for HIV Prevention programs through CDC

**Steve Holve**

Update on Pedvax Hib

**Mary Wachacha**

Seeking 2 Physicians for national IHS Patient Education Protocols and
Codes Committee

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

##### Obstetrics page 14

-Cesarean delivery on request not recommended if desiring several
children, ACOG

-Sense of coherence and symptoms of post-traumatic stress after
emergency caesarean

-Late-preterm (34-36 weeks) infants have higher mortality rate than term
at one year of age

-Spinal analgesia increases the success rate of external cephalic
version from 32% to 67%

-Milk consumption during pregnancy is associated with increased infant
size at birth

**Gynecology page 15**

-Early feeding within the first 24 hours after major abdominal
gynecologic surgery is safe

\-[Abnormal Uterine Bleeding: A Management
Algorithm](http://mp.medscape.com/cgi-bin1/DM/y/hBeIL0Ou5N60PEW0I8OU0Gx)

-Addition of HPV to Pap test to screen in mid-30s for cervical cancer
reduces in CIN 2 or 3

\-[Medical Therapy for Ectopic
Pregnancy](http://mp.medscape.com/cgi-bin1/DM/y/hBeIL0Ou5N60PEW0IwfQ0GL)

-A cautionary case: Balloon occlusion of internal iliac arteries for
abnormal placentation

**Child Health page 16**

-Rapid response team: Implications of findings on mortality rates for
children are dramatic

-What are the effects of lifestyle interventions for the treatment of
childhood obesity?

-Newborn Screening. ACOG Committee Opinion

**Chronic Illness and Disease page 18**

-Reconsider use of rosiglitazone

-Therapy Insight: Management of Graves\' Disease During Pregnancy 

-Antithrombotic therapy and pregnancy: consensus report and
recommendations

-Cholesterol \<10th population percentile was strongly associated with
preterm delivery

-Cisplatin with RT improves long-term progression-free survival in 1B
cervical carcinoma

#### Features page 19 {#features-page-19 .Style-Heading-4-+-Arial-14-pt-Underline}

American College of Obstetricians and Gynecologists

-Human Immunodeficiency Virus

-Ethical Decision Making in Obstetrics and Gynecology

-Invasive Prenatal Testing for Aneuploidy

##### American Family Physician

-Patient-Controlled Analgesia for Postoperative Pain: Cochrane Briefs

-ASA and Clopidogrel Decreases Cardiovascular Events in Acute Coronary
Syndrome

**Agency for Healthcare Research and Quality**

##### -Women leaving the hospital AMA after delivering should be targeted for more services

##### -Full disclosure of medical errors to patients is becoming more and more transparent

-Colorectal cancer screening can be improved at primary care practices

-Family-centered, high quality primary care linked to fewer nonurgent ED
visits by children

**Ask a Librarian**

-Prevention, Assessment, and Treatment of Child and Adolescent
Overweight and Obesity

## -The Healthy Heart Handbook for Women \'07 - 20th Anniversary Edition

**Behavioral Health Insights**

Teens, Depression, Black Box Warnings and Suicide

**Breastfeeding**

-Breastfeeding, it is not just about the baby

-Milk pollution due to alcohol

-Special journal issue offers guidance on promoting and supporting
breastfeeding

#### -Lactation complicated by overweight and obesity: Many challenges {#lactation-complicated-by-overweight-and-obesity-many-challenges .Style-Heading-4-+-Arial-14-pt-Underline}

**CCC Corner Digest**

\-[30 minute rule not a requirement and 'immediately available' defined
locally](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_AOM.cfm)

\-[Random glucose test would have missed 5 of 6 women with
GDM](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Coll.cfm)

\-[Cesarean delivery in Native American women: Low rates explained by
practice
style?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_HT.cfm#ob)

\-[HPV test beats Pap in detecting cancer - Use new  ASCCP Consensus
Guidelines](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_HT.cfm#gyn)

\-[Long-term prognosis for infants after massive fetomaternal
hemorrhage](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_HT.cfm#child)

\-[Heart Disease Kills More Younger
Women](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_HT.cfm#chrIll)

\-[Use of Psychiatric Medications During Pregnancy and
Lactation](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#acog)

\-[Predicting the Likelihood of Successful Vaginal Birth After Cesarean
Delivery](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#afp)

\-[The Healthy Heart Handbook for Women \'07 - 20th Anniversary
Edition](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#AskLib)

\-[Breastfeeding Promotion: Good Public Health Policy: Part 2 of
2](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#breast)

\-[Adolescent primary prevention programs for DV which are school
based](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#dv)

\-[New module: Lack of VZIG and new prenatal assessment of varicella
immunity](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#webSite)

\-[Special Global Issue - Obstetrics and
Gynecology](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#ih)

\-[Tightening the \"holes\" in the Swiss cheese model of patient safety
in
obstetrics](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#alert)

\-[Frequently Asked Questions about Infant Feeding
Choice](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#headlines)

\-[What is the presenting
part?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#mmtour)

-Vaginal birth after cesarean (VBAC) in rural hospitals -
[Counterpoint](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#MidWives)

\-[Which caused more deaths in the United States in 2005, MRSA or
HIV?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#navajo)

\-[2008 Long Term IHS Training-- NURSE ANESTHESIA -- Apply
Soon](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#nurseCorner)

\-[Cancer in American Indians and Alaska
Natives](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#owh)

\-[Methicillin-resistant Staphylococcus aureus in women's
health](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#okie)

\-[A cost decision analysis of 4 tocolytic
drugs](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#periPicks)

\-[Traditional AI/AN Medicine: Incorporating Into I/T/U Clinical
Practice](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#pcf)

\-[Prevention of Mother-to-Child HIV Transmission in Resource-Limited
Settings](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#std)

\-[Hypertension Triples Womens' Risk for
Diabetes](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#stillW)

\-[Alaska Native FASD and Suicidality in a Healthcare
setting](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#wheadlines)

**Domestic Violence**

-Improving Domestic Violence Law Enforcement Response on the Tohono
O\'odham Nation

-Child abuse funding offered: CCTV / Recording Technology Grant Program

**Elder Care News**

-Training in Palliative and End of Life Care -- Offered twice - SAVE THE
DATES

-Physician-pharmacist collaboration reduces inappropriate drug
prescribing in elderly

**Family Planning**

-Intrauterine Device and Adolescents, ACOG Committee Opinion

#### -Prescription contraceptive use increased reflecting state mandates on private insurers {#prescription-contraceptive-use-increased-reflecting-state-mandates-on-private-insurers .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Advance provision of EC does not reduce pregnancy rates, nor affect sexual behavior {#advance-provision-of-ec-does-not-reduce-pregnancy-rates-nor-affect-sexual-behavior .Style-Heading-4-+-Arial-14-pt-Underline}

\-[Ethinyl Estradiol/Drospirenone for the Symptoms of Premenstrual
Dysphoric
Disorder](http://mp.medscape.com/cgi-bin1/DM/y/hBeIL0Ou5N60PEW0IwfG0GB)

**Featured Website**

Preconception Counseling for Women with Diabetes and Hypertension: New
module

**Frequently asked questions**

-How should we manage a patient with a previous abruptio placenta?

-Frequently Asked Questions about Infant Feeding Choice

**Indian Child Health Notes**

**-**No more cough syrup says the FDA

-No more cavities says Dr. Esposito

-Not enough Hib vaccine says Dr. Singleton

**Information Technology**

iCare Training

International Health

Disparities, Inequalities, or Inequities?

#### MCH Alert

Insights on Implementing Cultural and Linguistic Competence in MCH

#### MCH Headlines

-Oral Health for Head Start Children: Best Practices

-Safer infant sleep environment through crib giveaways and education

-Alcohol Screening Brief Intervention: Cooperative Agreement
announcement by SAMHSA

-Child abduction Amber Alert Article

-Childhood Obesity: AMA expert committee recommendations released

#### Medical Mystery Tour

#### -What is the presenting part? {#what-is-the-presenting-part .Style-Heading-4-+-Arial-14-pt-Underline}

#### Medscape

-Making Sense of the Complex:Point of Care Approach to Chronic Pelvic
Pain / Interstitial Cystitis

-Management of Premenstrual Dysphoric Disorder: A Series of Interactive
Cases

-Commonly Administered Vaccines and Associated Illnesses

-Understanding Triglycerides: Beyond LDL Cholesterol

**Menopause Management**

Treating Sexual Difficulties in Menopause

**Midwives Corner**

ACNM seeks Midwifery Expertise on an as-needed basis

**Navajo News**

Which caused more deaths in the United States in 2005, MRSA or HIV?

**Nurses Corner**

-Scope of Practice and the Nurse Practitioner: Regulation, Competency,
and Expansion

-Overweight Children and Adolescents - National Association of School
Nurses

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

-Cancer in American Indians and Alaska Natives

-Vaccination of Pregnant Women (2007 Update)

#### -ACIP Releases 2007-08 Adult Immunization Schedule {#acip-releases-2007-08-adult-immunization-schedule .Style-Heading-4-+-Arial-14-pt-Underline}

**Oklahoma Perspective**

-Methicillin-resistant Staphylococcus aureus in women's health

Osteoporosis

Effects of Steroidal and Nonsteroidal Aromatase Inhibitors on Markers of
Bone Turnover

Patient Education

#### -Assessing Health Literacy in Clinical Practice {#assessing-health-literacy-in-clinical-practice .Style-Heading-4-+-Arial-14-pt-Underline}

-Pregnant or Thinking About Getting Pregnant?

#### -Pregnancy Loss: What You Should Know {#pregnancy-loss-what-you-should-know .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Caring for Your Premature Baby {#caring-for-your-premature-baby .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Meth Abuse: What You Should Know {#meth-abuse-what-you-should-know .Style-Heading-4-+-Arial-14-pt-Underline}

Perinatology Picks

-Less errors with more standardization of corticosteroid regimens

-Conservative checklist protocol for oxytocin: improves maternal and
newborn outcomes

-Does the dose of oxytocin affect uterine rupture in candidates for
VBAC?

-Terbutaline provided more tocolysis with less impact on BP than NTG in
resuscitation

-Exam-indicated cerclage prolongs gestation / improves survival vs
expectant management

and more....

Primary Care Discussion Forum

#### Traditional AI/AN Medicine: Incorporating Into I/T/U Clincial Practice

STD Corner

Screening for Chlamydial Infection: Recommendation Statement, USPSTF

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

#### -Family History more relevant to risk of GDM in nulliparous women than in parous subjects {#family-history-more-relevant-to-risk-of-gdm-in-nulliparous-women-than-in-parous-subjects .Style-Heading-4-+-Arial-14-pt-Underline}

-Hypertensive disorders of pregnancy are predictive of diabetes mellitus
21 years later

-Continuous subcutaneous insulin: No improvement in pregnant diabetic
outcomes

-A fetal weight estimation at 29-34 weeks in diabetic pregnancies: Can
it predict LGA ?

-The Reproductive Phenotype in Polycystic Ovary Syndrome 

**Women's Health Headlines**

-Making a business case for investing in Maternal and Child Health

-Depression and Initiation of Cigarette, Alcohol, and Other Drug Use
among Young Women

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

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

Preconception Counseling for Women with Diabetes and Hypertension: New
Module

The past CCC Corners are archived at:

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

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

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

or 907 729 3154 (with voicemail)

\*The opinions expressed in the OB/GYN CCC Corner are strictly those of
the authors, and not necessarily those of the Indian Health System, or
the author of this newsletter. If you have any comments, please share
them by joining the Primary Care Discussion Forum where this topic was
recently discussed. To join the Primary Care Listserv, click on
'Subscribe' here
<http://www.ihs.gov/MedicalPrograms/MCH/F/MCHdiscuss.cfm>

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