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OB/GYN Chief Clinical Consultant's Corner

Volume 5, No. 6, June/July 2007

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

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

A new diagnostic category: 'First Trimester GDM'

#### From your colleagues page 9 {#from-your-colleagues-page-9 .Style-Heading-4-+-Arial-14-pt-Underline}

Gordon Belcourt

FTC Releases Reports on Cigarettes and Smokeless Tobacco

Ben Garnett

Control over schedule: Most important predictor of provider work-life
balance and burnout

Scott Giberson

\-[Names-Based Reporting for All U.S. States by End of
2007](http://www.thebodypro.com/kaiser/2007/apr3_07/hiv_reporting.html?mb80h)

-Medicare Part D still has to make improvements for HIV patients and
providers

-U.S. AIDS Drug Assistance Program Waiting Lists growing

-HRSA's Special Projects of National Significance

-Behavioral Health HIV/AIDS Collaborative Training

and more.....

**Roberta Ward**

FDA Proposes New Warning Labeling About Suicidal Thinking / Behavior In
Young Adults

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

##### Obstetrics page 11

-Placental problems with previous caesarean delivery: Abruptio, previa

-Late Pregnancy Bleeding (ALSO serialization)

-Admission for nephrolithiasis during pregnancy: 80% risk of preterm
delivery

-Postpartum Depression Screening: Recommendations for Practice

-Fetal or infant death a traumatic event for parents: Assist grieving
parents

and more.....

**Gynecology page 13**

-Discharge 24 Hours After Vaginal Hysterectomy Safe, Acceptable

-Laparoscopic and fixed multiple dose methotrexate most effective for
ectopic

-Extended Oral Contraceptives Decrease Premenstrual Symptoms

-Fluoroquinolones No Longer Recommended for Treatment of Gonococcal
Infections

-Interventions to Reduce Hemorrhage During Myomectomy for Fibroids

and more.....

**Child Health page 15**

-Forty percent of 3-month-olds watch TV, DVDs, or videos

-Guidelines for School-Based STD Screening in Indian Country

-Urinary symptoms in adolescent females: STI or UTI?

-Sexually transmitted infections in preadolescent children

-Adjustments in opthalmia neonatorum (ON): Gonorrhea in pregnancy

**Chronic Illness and Disease page 16**

-Malabsorption of Oral Antibiotics in Pregnancy after Gastric Bypass
Surgery

-Sleeping Poorly \... and Maybe Depressed: Co morbidity in Formal Sleep
Studies

-Barriers to Smoking Cessation Services in Underserved Communities

-Management of Hypertriglyceridemia

-AHA Guidelines for CVD Prevention in Women Focus on Lifetime Risk
Factors 

#### Features page 17 {#features-page-17 .Style-Heading-4-+-Arial-14-pt-Underline}

American College of Obstetricians and Gynecologists

-Endometrial ablation. ACOG Practice Bulletin

-Seeking and Giving Consultation

-Disruptive Behavior

-Patents, Medicine, and the Interests of Patients

##### American Family Physician

-Therapies for Overactive Bladder- Nonpharmacologic vs. Anticholinergic

-Exercise Is an Effective Intervention in Overweight and Obese Patients

-Evaluation and Treatment of Acute Low Back Pain

-Restless Legs Syndrome: Pramipexole

**Agency for Healthcare Research and Quality**

AHRQ breastfeeding evidence review

**Ask a Librarian**

Quick Check for Drugs and Lactation

**Breastfeeding**

-Long-Term Breastfeeding among Native American Women

\-[Systematic review and meta-analysis confirms long-term positive
effects of
breastfeeding](http://www.who.int/child-adolescent-health/publications/NUTRITION/ISBN_92_4_159523_0.htm)

-FAQs - Breastfeeding and maternal illness

#### -RCT of very early mother-infant skin-to-skin contact and breastfeeding status {#rct-of-very-early-mother-infant-skin-to-skin-contact-and-breastfeeding-status .Style-Heading-4-+-Arial-14-pt-Underline}

**CCC Corner Digest**

-Social Change Might Save More Lives Than Medical Advances

-New HPV Brochures for Clinicians, CDC

-More stillbirths after previous cesarean delivery

-Young women with CIN: Any treatment increases preterm delivery - LEEP

-Public Opinion vs. Science Concerning Sex Education

-New Guideline for Screening Mammography for Women 40 to 49 Yrs

-Premature Rupture of Membranes, Practice Bulletin

-Quick Check for Drugs and Lactation

-Breastfeeding - it's all about synergy

-Extended OCP Regimen; Acceptable Breakthrough Bleeding

-Must See Website: Indian Health Service HIV-AIDS Program

-Ethics of medicine with economically vulnerable populations: 2nd in
series

-Do you walk around your vehicle before getting in it? You should

-Which Indian Health facilities lead the U.S. in national benchmarks?

-Emergence of a range of nonhormonal treatments for vasomotor symptoms

-Ultrasound affects mice brains in negative ways

-BTL: Nearly 1/2 of women under 25 yo request information on reversal

-Two summer programs for high school students

-Calcium Supplementation May Not Benefit Healthy Children

-Preconception counseling for women with DM and HTN: Which meds?

-Electronic Health Record (EHR) Implementation: Worth the effort?

-HIV/AIDS among AI/AN Fact Sheet

-New recommendations for gestational weight gain may be required

-Weaving it all together: 2007 Behavioral Health Conference

**Domestic Violence**

-The failure to protect Indigenous women from sexual violence in the USA

-Adverse sequelae of physical and sexual abuse in adulthood

-WH Pregnancy and DV education online session

\-[Domestic Violence and Your Patient\'s Health: Asking the Right
Questions](http://mp.medscape.com/cgi-bin1/DM/y/hBNXD0Ou5N60SzO0IRML0Ei)

**Elder Care News**

[Gynecologic Assessment of the Elderly Patient\
](http://mp.medscape.com/cgi-bin1/DM/y/hBNXD0Ou5N60SzO0IUVk0ER)

**Family Planning**

-Reasons for unprotected intercourse

-Adolescent sexual behavior: Strategies for reducing pregnancy and
childbearing

-Effect of Medicaid Family Planning Expansions on Unplanned Births

-Guidelines for Selection of Contraception in Women with Rheumatic
Diseases

**Featured Website**

MCHB Launches Web Site to Increase Awareness of Perinatal Depression

**Frequently asked questions**

What are the Unnecessary Tests done in Obstetrics and Gynecology?

**Indian Child Health Notes**

-Acute pain relief in children

-Pertussis: Secular Trends in the United States

-Persistence of racial disparities in fatal injuries to very young
children

**Information Technology**

How can we improve HIV screening in pregnancy? Preliminary GPRA Related
Results

International Health

Social context of maternal deaths and morbidity

#### MCH Alert

-Progress toward meeting Healthy People 2010 Maternal, Infant, and Child
objectives

-Mental disorders and nicotine dependence among pregnant women

#### MCH Headlines

-Improve the system - Improve the care: Underpinnings

-Drive It Right Kits

-Have you heard of: 'the Baby bottle tooth decay germ' aka Streptococcus
mutans? 

-Newly completed Pregnancy and Postpartum Quitline Toolkit

-K-12 Oral Health Education Curriculum

and more.....

#### Medical Mystery Tour

#### Which Indian Health facilities lead the entire U.S. in obstetric benchmarks? {#which-indian-health-facilities-lead-the-entire-u.s.-in-obstetric-benchmarks .Style-Heading-4-+-Arial-14-pt-Underline}

#### Medscape

-Urinary Tract Infections: A Primer for Clinicians

-Management of Breast Cysts Revisited

-CDC Issues New Treatment Recommendations for Gonorrhea 

\-[Optimizing Once-Daily Antiretroviral Regimens for Treatment-Naive
Patients With
HIV](http://mp.medscape.com/cgi-bin1/DM/y/hBOmG0Ou5N60Dzc0IWZw0GH)

**Menopause Management**

-Earlier hormone therapy closer to menopause tended to have reduced CHD
risk

#### -Low dose transdermal estradiol gel effective for postmenopausal symptoms {#low-dose-transdermal-estradiol-gel-effective-for-postmenopausal-symptoms .Style-Heading-4-+-Arial-14-pt-Underline}

-Updated Statement on Hormone Therapy 

**Midwives Corner**

Ultrasound affects mice brains in negative ways: First, do no harm

**Navajo News**

Adjustable Urethral Slings Offer Hope for Complex Incontinence Problems

**Nurses Corner**

#### Personal Digital Assistants: Practical Advice for Nurses in 2007 {#personal-digital-assistants-practical-advice-for-nurses-in-2007 .Style-Heading-4-+-Arial-14-pt-Underline}

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

CDC's Pregnancy Information Center

Lead Exposure Among Females of Childbearing Age

**Oklahoma Perspective**

Cesarean Delivery on Maternal Request

Osteoporosis

-Let's put DEXA and other radiation risks into perspective

-Cortisol Levels and BMD Among Premenopausal Women With Depression 

Patient Education

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

#### -Low Back Pain {#low-back-pain .Style-Heading-4-+-Arial-14-pt-Underline}

Perinatology Picks

-Placental cultures and histology poor predictors of infectious status
of the amniotic fluid

-Free beta-HCG outperforms intact HCG in a multimarker protocol

-Forum: Periodontal Health and Birth Outcomes - HRSA MCHB

-PREMAG inconclusive, but improvements of outcome are of potential
significance

-Insulin Glargine Use During Pregnancy Not Linked to Fetal Morbidity

and more.....

Primary Care Discussion Forum

Electronic Health Record (EHR) Implementation: Worth the effort?

STD Corner

-Guidelines for School-Based STD Screening in Indian Country

-Fluoroquinolones No Longer Recommended for Treatment of Gonococcal
Infections

-Let\'s talk about HIV counseling and testing -- New Facilitators\'
guide

-Does your lab have capacity to culture N gonorrhoeae for treatment
failures? 

# -Urinary symptoms in adolescent females: STI or UTI?

and more.....

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

-High rate of diabetes among indigenous people not due to thrifty gene

-Aspirin may be less effective heart treatment for women than men

-Cholesterol Could be Key to Treating Fetal Alcohol Syndrome

-Apples during pregnancy could reduce asthma risk in offspring

**Women's Health Headlines**

-Women's Early Drinking Problems More Likely to Escape Diagnosis

-Women and Health Coverage: The Affordability Gap

-WomenHeart Symposium 2007

###### Save the Dates: Upcoming events of interest page 59

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

Implementation and Use of an Electronic Health Record within IHS

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

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

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

**A new diagnostic category: 'First Trimester GDM'**\
Here is a common question: Does my patient have gestational diabetes or
did she have previously undiagnosed diabetes?

Your patient just came in for a prenatal visit in the first trimester.
She has risk factors for diabetes in pregnancy, e. g., previous
macrosomic infant, previous GDM, etc... (see other risk factors
below\*). As per your facility's guidelines, you obtain an initial
diabetes screen. The subsequent 3 hour 100 g OGTT also comes back
abnormal. You manage her pregnancy as a previously undiagnosed diabetic
patient. After pregnancy her follow-up 2 hour 75 g OGTT is normal. Did
your patient really have pre-existing diabetes or just gestational
diabetes? The answer is important to know because it has long term
implications for her entire lifetime.

**Background**

In our Native American/Alaska Native pregnant populations, where
diabetes mellitus is so common, it is often difficult to decide if a
pregnant woman has gestational diabetes mellitus (GDM), or type 2
pre-gestational diabetes mellitus (PGDM) e.g., pre-existing DM. While
the usual GDM screen is 24-28 weeks, many service units screen women at
their first prenatal visit. This is probably more common if the woman
has other risk factors besides her ethnicity.

What are the pros and cons of making the diagnosis early?

How do we decide if our client was actually diabetic between
pregnancies?

**Consider this case:**

A 34 y/o Native American G4P3 presents for her first prenatal visit at
10 weeks by dates. Her BMI is 34.7 kg/M2. Her three prior children all
weighed over 9 pounds, but her deliveries were uncomplicated. She thinks
she may have been told she had GDM with her last pregnancy, but never
followed up after the baby was born. Her mother is a type 2 diabetic, as
are several other family members. She admits to being thirsty a lot, but
she doesn't have to get up at night to go to the bathroom more than
once.

Should she be screened now for GDM?

Might she have undiagnosed PGDM?

This is more than a matter of semantics. How we decide on a specific
diagnosis has long term health implications for the individual involved.
A review of the definitions is probably in order at this point. Using
the American Diabetes Association (ADA) definition, "A fasting plasma
glucose level \>126 mg/dL (7.0 mmol/L), or a casual plasma glucose level
\>200 mg/dL (11.1 mmol/L), meets the threshold for the diagnosis of
diabetes, if confirmed on a subsequent day, and precludes the need for
any glucose challenge." The woman who meets those criteria quite clearly
has PGDM. Likewise, the woman with a history of type 2 diabetes between
pregnancies, on medical therapy, is easy to classify.

Women with type 1 diabetes are also usually quite obvious by history.
But how about the pregnant woman found to have two fasting glucose
values \>100 mg/dL?

Or two post prandial values \>140 mg/dL? Are such women "pre-diabetic",
or "gestational diabetics" or "PGDM"?

Do they need any further glucose challenge now during early pregnancy?

**The effects of pregnancy on glucose metabolism**

Here is why first trimester glucose results can be confusing. Evolution
has set up the physiology of pregnancy to provide maximum substrate for
the survival and development of the fetus. Post prandial glucose, fatty
acid, and amino acid excursions are higher, thus readily enabling the
fetus to siphon off maternal nutrients for its needs. This occurs, in
the case of glucose, by active diffusion across the placental membrane.
Nevertheless, especially during early pregnancy, a state of relative
maternal hypoglycemia is customarily observed, especially in the
pre-prandial state. In addition, the nausea and vomiting provoked by
high human chorionic gonadotrophin levels leads to maternal catabolic
state.

This situation may complicate the diagnosis of diabetes by the usual
criteria. In the first trimester, fasting glucose are expected to be
lower, and post prandial glucose values may or may not yet be elevated.
Every woman may occupy somewhat different positions on this "bell curve"
of responses. Dr. O'Sullivan set up the glucose challenge test we use
today to be carried out in the early third trimester, when pregnancy has
definitely shifted to a different, much more anabolic state, induced by
high human chorionic somatomammotrophin, cortisol, and estrogen.

A first trimester glucose challenge may provide confusing results. In a
woman with the risk factors below, seeing what her fasting and two-hour
post meal glucose excursions are may be more helpful. If the values
quoted above, comparable to those obtained in non-pregnant women, are
obtained, PGDM is quite likely.

Glycosylated hemoglobin levels (HbA1C) levels offer limited assistance
in non-type 1 pregnant diabetics. Because of the physiologic
hemodilution of pregnancy, which will also dilute HbA1C, they almost
always look great! However, this "physiologic anemia" does not develop
until the mid second trimester, and an elevated early trimester HbA1C
value (\>6.5%) may be an important clue to the woman's pre-gestational
carbohydrate metabolism. Likewise, since embryogenesis is complete by 9
weeks gestation, interventions aimed at lowering glucose after that time
are not likely to have a significant impact on the prevention of
hyperglycemia-induced teratogenesis. It would have been great to have
found this woman pre-conceptually, established good control, and put her
on folate, but now, our interventions may not be timely at all.
Conversely, women with a first trimester HbA1C \>8.5% have an incidence
of fetal anomalies of upwards of 20 per cent. Such women certainly
deserve referral for a second trimester comprehensive ("level 2")
targeted ultrasound to carry out a detailed survey of the fetal anatomy.

Our recommendation would be against labeling women as pre-gestational
diabetics if they don't meet the ADA criteria [\>]{.underline} 126 mg/dL
fasting and/or [\>]{.underline}200 mg/dL post prandial glucose. (See
First trimester GDM below)

We have searched extensively and have not been able to find a single
evidence-based recommendation as to the validity of first trimester
glucose screening, just textbook "expert opinions". Please note the
usual criteria are only based on giving our clients their 50 g 1-hour
glucose challenge (and possible 3-hour diagnostic 100 g glucose
tolerance test) at the recommended interval of 24-28 weeks, during "the
anabolic phase" of pregnancy.

We should avoid labeling women as pre-existing diabetic, and instead
care for them as they have GDM just with a slightly higher level of
suspicion. They may have GDM which can be controlled with diet and
exercise (class A1), or need medical therapy (insulin or glyburide),
i.e., GDM, class A2. Perhaps a significant number of the latter group
actually *do* have PGDM which can be determined post partum.

**A new diagnostic category: First Trimester GDM**

We suggest patients whose first diagnosis of glucose intolerance is in
the first trimester simply be called 'First Trimester GDM'. Here is an
approach to last part of her Progress note:

Assessment:

1\. IUP, 8 wks.

2\. 1^st^ Trimester GDM

-possible pregestational DM, status to be determined pp

Plan:

-monitor for development of GDM-A2

-will require increased surveillance if becomes GDM-A2

-otherwise manage as GDM-A1

-need to re-test for glucose intolerance postpartum

We would manage the First trimester GDM patient according to their and
their fetus' needs now, and establish a definitive diagnosis later. If
you have a high level of suspicion initially, you can order a spot urine
Protein/ Creatinine ratio, or a 24-hour urine for creatinine clearance
and total protein, as well as arrange a baseline dilated retinal exam.
If the patient requires medical therapy, she will also need fetal
surveillance after 32 weeks. There are also psychological benefits with
more accurate diagnoses.

Those patients with abnormal OGTTs diagnosed after completion of the
first trimester should simply be diagnosed with 'gestational diabetes
mellitus'.

From a public health standpoint, it will behoove us to assiduously
follow up such a woman as presented in the case vignette at six weeks
post partum. Significant numbers of Native American women with GDM will
become overt type 2 diabetics within five years of the index pregnancy.
Post partum we need to be sure she gets her 75 g 2-hour screen, or
fasting glucose evaluated by the usual adult criteria, in order to
establish the level of abnormal carbohydrate metabolism. If normal, then
she should be re-screened with a fasting glucose every 3 years.

When the results of the large international multi-center Hyperglycemia
and Pregnancy Outcomes (HAPO) study, which is using the 75 g glucose
tolerance test to diagnose GDM, are published, we will have the evidence
to enable us to simplify the whole process.

In summary, the term 'First Trimester GDM' raises the appropriate level
of suspicion among your fellow providers, while providing the patient
the most accurate diagnosis for the rest of her lifetime.

Your comments on what works for you at your service units are welcome.

George J. Gilson, MD (ANMC)

John B. Miller, M.D. (Zuni)

Neil Murphy, M.D. (ANMC)

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

Drs. Gilson, Miller, and Murphy raise a excellent point about the
challenges of managing an early diagnosis of gestational diabetes.

Their proposed new diagnostic category, First Trimester GDM, highlights
the increased risk status of these women, without making a diagnosis of
pre-gestational diabetes until confirmatory testing has been conducted
after delivery. We have seen a number of women in similar circumstances
in our practice and find that they benefit greatly from intensive
education during pregnancy, although assuring completion of  postpartum
testing remains challenging.

The use of this new diagnostic category would help identify these women
for intensified efforts for postpartum follow-up and provide efficient
communication of risk to other members of the health care team. It would
be worthwhile to consider adding this new diagnostic category in your
facility's Diabetes in Pregnancy guidelines when you next update them...
Jean Howe, MD

**Risk factors triggering a GDM screen at the first prenatal visit**

**History**

-macrosomic infants over 4000g (8 lbs. 14 oz.)

-family history of first degree relatives with diabetes

-gestational diabetes in a previous pregnancy

-overweight\
(pre-pregnancy weight ≥ 110 % of ideal body weight\
(pre-pregnancy weight BMI ≥ 27)\
-prior term intrauterine fetal demise\
-prior infant with a birth defect or congenital anomaly\
-habitual abortion ( ≥ 3 consecutive SAB)

**Current pregnancy:**

-age over 35 years\
-unexplained polyhydraminos\
-persistent glycosuria

**Online Resource**

Diagnosis and Classification of Diabetes Mellitus Diabetes Care
30:S42-S47, 2007

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17192378>

**Other References**

1.  American Diabetes Association. Gestational diabetes mellitus
    (Position Statement). Diabetes Care 2002; 25 (S1): S94-96.

2.  ibid. Diabetes Care 2003; 26 (S1): S103-105.

3.  ibid. Diabetes Care 2004; 27 (S1): S88-90.

4.  American Diabetes Association. Standards of medical care in diabetes
    (Position Statement). Diabetes Care 2005; 28 (S1): S4-36.

5.  Omori Y, Jovanovic L. Proposal for the reconsideration of the
    definition of gestational diabetes. Diabetes Care 2005; 28:2592-3.

6.  Nahum GG, Huffaker BJ. Correlation between first- and early
    third-trimester glucose screening test results. Obstet Gynecol 1990;
    76:709-13.

7.  Omori Y, et al. Comparison of diagnostic criteria of impaired
    glucose tolerance, borderline, and gestational diabetes mellitus:
    Blood glucose curve and immunoreactive insulin responses. Diabetes
    1991; 40 (S2): 30-4.

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

#### Gordon Belcourt, Montana Wyoming Tribal Leaders {#gordon-belcourt-montana-wyoming-tribal-leaders .Style-Heading-4-+-Arial-14-pt-Underline}

**FTC Releases Reports on Cigarettes and Smokeless Tobacco**

Here is what we are up against or Sales Volume and Marketing Expenditure
Data

The number of cigarettes sold or given away, as well as the amount spent
on advertising and promotion by the five largest cigarette companies in
the United States, decreased in 2004 and 2005, according to a report
released today by the Federal Trade Commission. In a separate report on
smokeless tobacco, the FTC said the number of pounds sold by the five
largest manufacturers rose for each year from 2002 to 2004, then
decreased in 2005, while advertising and promotional expenditures
fluctuated during that period, with the most spent in 2005.\
The FTC has issued cigarette reports since 1967 and smokeless tobacco
reports since 1987. This year's reports contain statistics on sales
volumes and marketing expenditures -- for cigarettes for the years 2004
and 2005 and for smokeless tobacco for the years 2002-2005. The
cigarette report also updates other information contained in previous
reports, such as the market share of filtered versus non-filtered
cigarettes. This year's smokeless tobacco report has new categories of
information than past years, such as sales data broken down by package
size.

According to information from the companies and their subsidiaries,

-   no company solicited the appearance of any cigarette product in any
    motion picture or television show, or granted permission for the
    appearance of any cigarette product in any motion picture or
    television show.

-   In 2004, the number of cigarettes sold and given away decreased 1.1
    percent from 2003 levels.

-   In 2005, the number fell another 2.4 percent. Advertising and
    promotional expenditures fell from \$15.15 billion in 2003 to
    \$14.15 billion in 2004, and then to \$13.11 billion in 2005.

-   For both years, the single largest subcategory of promotional
    allowances was price discounts paid to cigarette retailers or
    wholesalers in order to reduce the price of cigarettes to consumers.

The smokeless tobacco report has sales and advertising and promotional
expenditures by tobacco type:

-   dry snuff,

-   moist snuff,

-   plug/twist, and

-   Loose-leaf chewing tobacco.

-   The five largest domestic manufacturers had \$2.13 billion in sales
    in 2001.

-   The amount of sales rose each year from 2002 through 2004, to \$2.62
    billion in 2004, but dropped to \$2.61 billion in 2005. Advertising
    and promotional expenditures fluctuated in this time period, with
    the lowest point of \$231.08 million in 2004 and the highest point
    of \$250.79 million in 2005.

[Copies](http://www.ftc.gov/os/2007/04/index.shtm#26) of the reports are
available from the FTC's Web site at
[http://www.ftc.gov](http://www.ftc.gov/)

<http://www.ftc.gov/opa/2007/04/cigaretterpt.shtm>

<http://www.vectorgroupltd.com/abtus.asp>  

**Ben Garnett, Anchorage**

**Control over schedule: Most important predictor of provider work-life
balance and burnout**

RESULTS: Both women and men report being highly satisfied with their
careers (79% compared with 76%, P\<.01), having moderate levels of
satisfaction with work-life balance (48% compared with 49%, P=.24), and
having moderate levels of emotional resilience (51% compared with 53%,
P=.09). Measures of burnout strongly predicted career satisfaction
(standardized beta 0.36-0.60, P\<.001). The strongest predictor of
work-life balance and burnout was having some control over schedule and
hours worked (standardized beta 0.28, P\<.001, and 0.20-0.32, P\<.001,
respectively). Physician gender, age, and specialty were not strong
independent predictors of career satisfaction, work-life balance, or
burnout. CONCLUSION: This national physician survey suggests that
physicians can struggle with work-life balance yet remain highly
satisfied with their career. Burnout is an important predictor of career
satisfaction, and control over schedule and work hours are the most
important predictors of work-life balance and burnout. LEVEL OF
EVIDENCE: II.

[Keeton
K](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Keeton+K"%5BAuthor%5D),
et al Predictors of physician career satisfaction, work-life balance,
and burnout. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007
Apr;109(4):949-55.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17400859&dopt=Abstract>

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

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

[**Names-Based Reporting for All U.S. States by End of
2007**](http://www.thebodypro.com/kaiser/2007/apr3_07/hiv_reporting.html?mb80h)\
Names-based HIV reporting will be implemented throughout the United
States by the end of 2007. This transition began when the Ryan White
CARE Act tied funding for HIV services to the institution of names-based
reporting. The last three states to use code-based reporting \-- Hawaii,
Vermont and Maryland \-- are now slated to switch to the new system by
the end of the year.\
Although all U.S. states will soon officially use names-based reporting,
most states still permit individuals to test anonymously. (see ID
Society link below

**Survey suggests Medicare Part D still has to make improvements for HIV
patients and providers**\
According to preliminary results from an informal survey of U.S. HIV
health care providers conducted by the American Academy of HIV Medicine
and the HIV Medicine Association. Bureaucratic hurdles, high co-pays and
plans that won\'t cover necessary medications prevent many HIV-infected
patients from getting their antiretrovirals and other drugs, the survey
found. Of the 561 HIV health care providers who answered the survey, 83%
said their HIV-infected patients had trouble getting their prescriptions
filled since joining a Medicare drug plan. Seventy-nine percent also
said they were spending more time now than before making sure Medicare
patients obtained their medications. (see ID Society link below)

**U.S. AIDS Drug Assistance Program Waiting Lists growing**\
As we already know, all AI/AN are eligible for ADAP services if they
qualify in their respective states -- the same for all
races/ethnicities. However, nearly 600of HIV-infected patients (all
races/ethnicities) in Alaska, Montana, Puerto Rico and South Carolina
are waiting to receive antiretrovirals through their state\'s or
territory\'s AIDS Drug Assistance Program (ADAP), the National Alliance
of State and Territorial AIDS Directors (NASTAD) reports. According to
NASTAD\'s latest \"ADAP Watch\" report, the number of patients on
waiting lists is likely to keep growing. (It is already up by 269
patients since last September.) The current level of federal funding,
NASTAD says, falls short of what is needed to provide treatment to poor,
uninsured and underinsured HIV-infected patients in the United States.
(see ID Society link below)

**HRSA's Special Projects of National Significance**

For the last 5 years (2001-2006), HRSA's Special Projects of National
Significance (SPNS) has funded a specific \"AI/AN HIV Initiative\". 2006
marked it's final year and subsequently the timeline for reporting
outcomes in 2007. The meeting, held in Rockville, (info from HRSA
HIV/AIDS Bureau) capped off this Initiative and provided a link to the
HRSA TARGET Center library where some of the final products may be
posted (unsure of timeline).  The focus of this meeting was on
presenting findings and lessons learned throughout the five years of
engaging AI/AN in HIV primary care, substance abuse, and mental health
services in Alaska, Washington State, California, New Mexico, and North
Carolina.  \'Dissemination products developed from this initiative will
be made available in the future through the TARGET Center and the HRSA
clearinghouse.  See the TARGET Center TA Library for products focusing
on AI/AN populations. The HRSA/SPNS team, project leads and IHS HIV
Program will be reviewing the projects and outcomes. For the purpose
of sharing successful projects and increasing interagecy transparency,
we will attempt to obtain permission to post any outcome information /
tools / resources / model practices/etc on the IHS HIV/AIDS webpage (in
addition to HRSA\'s Target Center) and continue to work together to
further disseminate the information. 

<http://www.careacttarget.org/librarysearch.asp>

**Behavioral Health HIV/AIDS Collaborative Training**

The most recent IHS Behavioral Health HIV/AIDS Collaborative Training
was executed in Anchorage, Alaska May 2-3. Participants included
professionals from many facilities /program across the Alaska Area and
beyond including Anchorage, Bethel and Kotzebue. Topics discussed
included stigma and discrimination, motivational interviewing, data
collection and HIV testing and resources to name a few. The training had
representation from the Alaska Native Tribal Health Consortium and from
Alaska Area Office senior officials. We are grateful to all their
support and dedicated work, which made for a successful event. The final
HIV Behavioral Health training with FY06 funds will take place in the
Portland Area in early August. More detailed information on the FY06
trainings can be found at
<http://www.ihs.gov/generalweb/webapps/sitelink/site.asp?link=http://kauffmaninc.com/IHSAIDStrainings/>
and our IHS HIV website at <http://www.ihs.gov/MedicalPrograms/hivaids/>

[**Sexual Health Web Site Offers Resources for Providers Treating
MSM**](http://www.thebodypro.com/redirect/updates/web070321h.html?mb80h)\
STDCheckup.org, a Web site funded by the STD Control Branch of the
California Department of Health Services, offers clinicians information
on diagnosing and managing sexually transmitted diseases (STDs) in men
who have sex with men (MSM). The \"Resources for Clinicians\" section of
the site includes information on routine and periodic sexual history
taking, laboratory screening for STDs, risk-reduction counseling,
guidance for creating a safe clinical environment for MSM patients, and
a downloadable toolkit in PDF format. The Body PRO offers information on
STDs other than HIV.

<http://www.idsociety.org/HIVMA_Template.cfm?Section=Home&CONTENTID=18416&TEMPLATE=/ContentManagement/ContentDisplay.cfm>

**Roberta Ward, Anchorage**

**FDA Proposes New Warning Labeling About Suicidal Thinking / Behavior
In Young Adults**

FDA notified healthcare professionals that the Agency proposed that
makers of all antidepressant medications update the existing black box
warning on the prescribing information for their products to include
warnings about the increased risks of suicidal thinking and behavior in
young adults ages 18 to 24 years old during the first one to two months
of treatment. The proposed labeling changes also state that scientific
data did not show this increased risk in adults older than 24 years of
age and that adults 65 years of age and older taking antidepressants
have a decreased risk of suicidality. The proposed updates apply to the
entire category of antidepressants. Individuals currently taking
prescribed antidepressant medications should not stop taking them and
should notify their healthcare professional if they have concerns.

Manufacturers of antidepressant medications will have 30 days to submit
their revised product labeling and revised Medication Guides to FDA for
review. See the FDA press release for the list of products affected by
the proposed antidepressant product labeling changes.

[[http://www.fda.gov/medwatch/safety/2007/safety07.htm#Antidepressant]{.underline}](http://www.fda.gov/medwatch/safety/2007/safety07.htm#Antidepressant)

# 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}

**Placental problems with previous caesarean delivery: Abruptio,
previa**

Research shows a link between the development of placenta praevia and
placental abruption during the subsequent pregnancies of women who
previously had a caesarean section.

CONCLUSION: Caesarean section for first live birth is associated with a
47% increased risk of placenta praevia and 40% increased risk of
placental abruption in second pregnancy with a singleton.

[Yang
Q](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Yang+Q"%5BAuthor%5D),
et al Association of caesarean delivery for first birth with placenta
praevia and placental abruption in second pregnancy.
[BJOG.](javascript:AL_get(this, 'jour', 'BJOG.');) 2007
May;114(5):609-13.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17355267>

**Late Pregnancy Bleeding (ALSO serialization)**

Effective management of vaginal bleeding in late pregnancy requires
recognition of potentially serious conditions, including placenta
previa, placental abruption, and vasa previa. Placenta previa is
commonly diagnosed on routine ultrasonography before 20 weeks\'
gestation, but in nearly 90 percent of patients it ultimately resolves.
Women who have asymptomatic previa can continue normal activities, with
repeat ultrasonographic evaluation at 28 weeks. Persistent previa in the
third trimester mandates pelvic rest and hospitalization if significant
bleeding occurs. Placental abruption is the most common cause of serious
vaginal bleeding, occurring in 1 percent of pregnancies. Management of
abruption may require rapid operative delivery to prevent neonatal
morbidity and mortality. Vasa previa is rare but can result in fetal
exsanguination with rupture of membranes. Significant vaginal bleeding
from any cause is managed with rapid assessment of maternal and fetal
status, fluid resuscitation, replacement of blood products when
necessary, and an appropriately timed delivery. Am Fam Physician
2007;75:1199-206.

<http://www.aafp.org/afp/20070415/1199.html>

**Admission for nephrolithiasis during pregnancy: 80% risk of preterm
delivery**

CONCLUSION: Although the incidence of nephrolithiasis requiring hospital
admission during pregnancy is relatively low, these women have an
increased risk of preterm delivery. This has potential implications for
counseling of pregnant women with kidney stones requiring hospital
admission. Additionally, it may prompt definitive treatment of small,
asymptomatic stones in women during reproductive years. LEVEL OF
EVIDENCE: II

[Swartz
MA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Swartz+MA"%5BAuthor%5D),
et al Admission for nephrolithiasis in pregnancy and risk of adverse
birth outcomes. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007
May;109(5):1099-104.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17470589&dopt=Abstract>

**Postpartum Depression Screening: Recommendations for Practice**

Conclusions: Postpartum depression screening improves recognition of the
disorder, but improvement in clinical outcomes requires enhanced care
that ensures adequate treatment and follow-up.

Gjerdingen DK,Yawn BP Postpartum Depression Screening: Importance,
Methods, Barriers, and

Recommendations for Practice J Am Board Fam Med 2007;20 280-288

[[http://www.jabfm.org/cgi/content/abstract/20/3/280?etoc]{.underline}](http://www.jabfm.org/cgi/content/abstract/20/3/280?etoc)

**Fetal or infant death is a traumatic event for parents: Measures to
assist grieving parents**

CONCLUSION: Although care after perinatal death often adheres to
published guidelines, substantial room for improvement is apparent.
Parents with perinatal losses report few choices during labor and
delivery and inadequate communication about burial options and autopsy
results. Hospitals, nurses, and doctors should increase parental choice
about timing and location of delivery and postpartum care, encourage
parental contact with the deceased infant, and facilitate provision of
photos and memorabilia.

[Gold
KJ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Gold+KJ"%5BAuthor%5D),
et al Hospital Care for Parents After Perinatal Death. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007
May;109(5):1156-1166.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17470598&dopt=Abstract>

**[Iron Deficiency Anemia Screening Recommended Pregnant
Women](http://www.medscape.com/viewprogram/7033): Rating B**

-The USPSTF recommends routine screening for iron deficiency anemia in
asymptomatic pregnant women. **Rating: B Recommendation**

-The U.S. Preventive Services Task Force (USPSTF) concludes that
evidence is insufficient to recommend for or against routine screening
for iron deficiency anemia in asymptomatic children aged 6 to 12 months.
**Rating: I Recommendation**

## Screening and Supplementation for Iron Deficiency Anemia, U.S. Preventive Services Task Force

Release Date: May 2006 <http://www.ahrq.gov/clinic/uspstf/uspsiron.htm>

<http://www.medscape.com/viewarticle/555899>

**The route of delivery of twins is determined by presentation and
operator skill**

A trial of labor and vaginal delivery are usually indicated in
vertex-vertex twins. For vertex-nonvertex twins, vaginal birth is
preferred, with the second twin being delivered by breech extraction,
unless it is significantly larger than the first. Cesarean delivery is
indicated if the first twin is nonvertex and for all cases of
monoamniotic or potentially viable conjoined twins. There is a limited
role for trial of labor after cesarean delivery in twin gestations. In
my opinion, combined vaginal-cesarean birth is the riskiest method for
mother and infants and should be avoided if possible.

[Cruikshank
DP](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Cruikshank+DP"%5BAuthor%5D).
Intrapartum management of twin gestations. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007
May;109(5):1167-76.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17470599&dopt=Abstract>

**Treating Asthma and Co morbid Allergic Rhinitis in Pregnancy**

This article presents the specific recommendations from the most recent
APWG report and from other systematic reviews about which asthma and
allergic rhinitis drugs should be preferred during pregnancy. Of the
corticosteroids, budesonide has the most data and is listed as Pregnancy
Category B (no evidence of risk in humans). Other inhaled and intranasal
corticosteroids have less data and are listed as Pregnancy Category C
but may be continued during pregnancy if the patient\'s asthma was well
controlled with the medication before pregnancy. Family physicians
should help their patients control allergic rhinitis and asthma during
pregnancy, encouraging adherence to needed medications.

Yawn B, Knudtson M Treating Asthma and Comorbid Allergic Rhinitis in
Pregnancy J Am Board Fam Med 2007;20 289-298
[[http://www.jabfm.org/cgi/content/abstract/20/3/289?etoc]{.underline}](http://www.jabfm.org/cgi/content/abstract/20/3/289?etoc)

**Insufficient evidence to show that the addition of rectal misoprostol
is superior**

CONCLUSIONS: There is insufficient evidence to show that the addition of
rectal misoprostol is superior to the combination of oxytocin and
ergometrine alone for the treatment of primary PPH.

[Mousa
HA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Mousa+HA"%5BAuthor%5D),
[Alfirevic
Z](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Alfirevic+Z"%5BAuthor%5D).
Treatment for primary postpartum hemorrhage [Cochrane Database Syst
Rev.](javascript:AL_get(this, 'jour', 'Cochrane Database Syst Rev.');)
2007 Jan 24;(1):CD003249

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17253486>

**New Guidelines Recommend Universal Prenatal Screening for Down
Syndrome (CME)**

<http://www.medscape.com/viewarticle/550256?src=0_nl_cme_8>

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

**Discharge 24 Hours After Vaginal Hysterectomy Safe, Acceptable**

CONCLUSIONS: Vaginal hysterectomy performed as a 24-hour day case
procedure appears to be as safe as traditional inpatient management,
with a high rate of early discharge and a low rate of readmission. This
may have additional advantages for the woman and healthcare provider
alike.

[Penketh
R](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Penketh+R"%5BAuthor%5D),
et al prospective observational study of the safety and acceptability of
vaginal hysterectomy performed in a 24-hour day case surgery setting.
[BJOG.](javascript:AL_get(this, 'jour', 'BJOG.');) 2007 Apr;114(4):430-6

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17378817>

**Laparoscopic and methotrexate in a fixed multiple dose regimen most
effective for ectopic**

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/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Hajenius+PJ"%5BAuthor%5D)
et al Interventions for tubal ectopic pregnancy. [Cochrane Database Syst
Rev.](javascript:AL_get(this, 'jour', 'Cochrane Database Syst Rev.');)
2007 Jan 24;(1):CD000324

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17253448>

**Extended Oral Contraceptives Decrease Premenstrual Symptoms**

Conclusion: The use of a 168-day extended regimen of drosperinone in
combination with ethinyl estradiol decreased premenstrual symptoms
compared with a standard 21/7 regimen. This was particularly true for
women who had more premenstrual symptoms during the 21/7 regimen.

Coffee AL, et al. Oral contraceptives and premenstrual symptoms:
comparison of a 21/7 and extended regimen. Am J Obstet Gynecol November
2006;195:1311-9. <http://www.aafp.org/afp/20070415/tips/4.html>

**Fluoroquinolones No Longer Recommended for Treatment of Gonococcal
Infections**

In the United States, gonorrhea is the second most commonly reported
notifiable disease, with 339,593 cases documented in 2005. Since 1993,
fluoroquinolones (i.e., ciprofloxacin, ofloxacin, or levofloxacin) have
been used frequently in the treatment of gonorrhea because of their high
efficacy, ready availability, and convenience as a single-dose, oral
therapy. However, prevalence of fluoroquinolone resistance in Neisseria
gonorrhoeae has been increasing and is becoming widespread in the United
States, necessitating changes in treatment regimens.

Beginning in 2000, fluoroquinolones were no longer recommended for
gonorrhea treatment in persons who acquired their infections in Asia or
the Pacific Islands (including Hawaii); in 2002, this recommendation was
extended to California. In 2004, CDC recommended that fluoroquinolones
not be used in the United States to treat gonorrhea in men who have sex
with men (MSM). This report, based on data from the Gonococcal Isolate
Surveillance Project (GISP), summarizes data on
fluoroquinolone-resistant N. gonorrhoeae (QRNG) in heterosexual males
and in MSM throughout the United States. This report also updates CDC\'s
Sexually Transmitted Diseases Treatment Guidelines, 2006 regarding the
treatment of infections caused by N. gonorrhoeae. On the basis of the
most recent evidence, CDC no longer recommends the use of
fluoroquinolones for the treatment of gonococcal infections and
associated conditions such as pelvic inflammatory disease (PID).
Consequently, only one class of drugs, the cephalosporins, is still
recommended and available for the treatment of gonorrhea.

Update to CDC\'s Sexually Transmitted Diseases Treatment Guidelines,
2006: Fluoroquinolones No Longer Recommended for Treatment of Gonococcal
Infections. MMWR Morb Mortal Wkly Rep. 2007 Apr 13;56(14):332-336. 

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5614a3.htm>

**Interventions to Reduce Haemorrhage During Myomectomy for Fibroids**

(ACOG Cochrane Update)

AUTHORS' CONCLUSIONS: There is limited evidence from a few RCTs that
misoprostol, vasopressin, bupivacaine plus epinephrine, tourniquet, and
mesna may reduce bleeding during myomectomy. There is no evidence that
oxytocin and morcellation have an effect on intraoperative blood loss.
There is need for adequately powered RCTs to shed more light on the
effectiveness, safety, and costs of different interventions in reducing
blood loss during myomectomy.

Kongnyuy EJ, Wiysonge CS. Interventions to reduce hemorrhage during
myomectomy for fibroids. Cochrane Database of Systematic Reviews 2007,
Issue 1. Art. No.: CD005355. DOI: 10.1002/14651858.CD005355

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17470606>

**Laxative improves recovery of gastrointestinal function after
fast-track hysterectomy**

RESULTS: Time to first postoperative defecation was a median of 45 hours
in the laxative group and a median of 69 hours in the placebo group (P
\< .0001). There were no significant differences between groups in pain
scores, postoperative nausea and vomiting and the use of morphine or
antiemetics. Postoperative hospitalization was a median of 1 day in the
laxative group and of 2 days in the placebo group (P = .41).

CONCLUSION: Laxative improves recovery of gastrointestinal function
after fast-track hysterectomy but has no significant effect on pain and
postoperative nausea and vomiting.

[Hansen
CT](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Hansen+CT"%5BAuthor%5D),
et al Effect of laxatives on gastrointestinal functional recovery in
fast-track hysterectomy: a double-blind, placebo-controlled randomized
study [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2007
Apr;196(4):311.e1-7

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17403400>

**Insufficient evidence for nerve interruption in the management of
dysmenorrhoea**

AUTHORS\' CONCLUSIONS: There is insufficient evidence to recommend the
use of nerve interruption in the management of dysmenorrhoea, regardless
of cause. Future methodologically sound and sufficiently powered RCTs
should be undertaken.

[Proctor
ML](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Proctor+ML"%5BAuthor%5D),
et al Surgical interruption of pelvic nerve pathways in dysmenorrhea: a
systematic review of effectiveness [Cochrane Database Syst
Rev.](javascript:AL_get(this, 'jour', 'Cochrane Database Syst Rev.');)
2005 Oct 19;(4):CD001896

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16235288>

**A mild treatment strategy for in-vitro fertilization: a randomized
non-inferiority trial**

INTERPRETATION: Over 1 year of treatment, cumulative rates of term live
births and patients\' discomfort are much the same for mild ovarian
stimulation with single embryos transferred and for standard stimulation
with two embryos transferred. However, a mild IVF treatment protocol can
substantially reduce multiple pregnancy rates and overall costs.

[Heijnen
EM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Heijnen+EM"%5BAuthor%5D),
et al A mild treatment strategy for in-vitro fertilization: a randomized
non-inferiority trial
[Lancet.](javascript:AL_get(this, 'jour', 'Lancet.');) 2007 Mar
3;369(9563):743-9.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17336650>

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

**Forty percent of 3-month-olds watch TV, DVDs, or videos**

CONCLUSIONS: Parents should be urged to make educated choices about
their children\'s media exposure. Parental hopes for the educational
potential of television can be supported by encouraging those parents
who are already allowing screen time to watch with their children.

[Zimmerman
FJ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Zimmerman+FJ"%5BAuthor%5D),
et al Television and DVD/Video Viewing in Children Younger Than 2 Years.
[Arch Pediatr Adolesc
Med.](javascript:AL_get(this, 'jour', 'Arch Pediatr Adolesc Med.');)
2007 May;161(5):473-9

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17485624>

**Guidelines for School-Based STD Screening in Indian Country**

I'm pleased to announce that our office has just released "Guidelines
for School-Based STD Screening in Indian Country". A PDF of the document
or hard copies are available, so please let me know if you would like
one. Also, the link will be up on our website soon, url below.

Thanks so much to everyone who helped to put these together. We look
forward to your feedback. Also, please let us know if you need our
technical assistance to implement school-based STD screening in your
area. Lori

Table of Contents Page

1 Introduction

2 Getting Started

3 Forming a Team

4 Making a Plan

5 Making the Pitch

6 Making it Happen

7 Making it Stick

Tel: 505-248-4202 or <lori.deravello@ihs.gov>

<http://www.ihs.gov/medicalprograms/epi/index.cfm>

# Urinary symptoms in adolescent females: STI or UTI?

RESULTS: In the full sample, prevalence of UTI and STI were 17% and 33%,
respectively. Neither urinary symptoms nor UTI was significantly
associated with STI. Further analyses are reported for the 154 (51%)
with urinary symptoms: Positive urine leukocytes, more than one partner
in the last three months and history of STI predicted STI. Urinalysis
results identified four groups: (1) Normal urinalysis-67% had no
infection; (2) Positive nitrites or protein-55% had UTI; (3) Positive
leukocytes or blood-62% had STI; and (4) Both nitrites/protein and
leukocytes/blood positive-28% had STI and 65% had UTI. Those without a
documented UTI were more likely to have trichomoniasis than those with a
UTI, and 65% of those with sterile pyuria had STI, mainly trichomoniasis
or gonorrhea.

CONCLUSIONS: Adolescent females with urinary symptoms should be tested
for both UTI and STIs. Urinalysis results may be helpful to direct
initial therapy.

Huppert JS, Biro F, Lan D, Mortensen JE, Reed J, Slap GB. Urinary
symptoms in adolescent females: STI or UTI? J Adolesc Health. 2007
May;40(5):418-24. Epub 2007 Mar 9.  

<http://www.jahonline.org/article/PIIS1054139X06006112/abstract>

**Sexually transmitted infections in preadolescent children**

Pediatric nurse practitioners may be called on to conduct an assessment
for sexual abuse of a young child. Depending on the type of sexual
contact, a decision may have to be made to obtain cultures for sexually
transmitted infections (STIs). Recognizing the symptoms of STIs in
preadolescent children, along with having knowledge of the modes of
transmission, diagnostics, and treatment, are part of the clinical
decision. The impact of STI in preadolescent children has physical and
emotional consequences for the child and family, along with legal
consequences for an accused perpetrator. Knowledge about types of sexual
contact that necessitate STI cultures, incubation periods, and
symptomatology is essential. Accurate techniques and appropriate
selection of culture materials are necessary. Proper positioning of the
child for obtaining cultures can decrease the potential for discomfort
during the examination. Gonorrhea, Chlamydia trachomatis, herpes simplex
virus, human papillomavirus virus, syphilis, Trichomonas vaginalis,
hepatitis B, and HIV are reviewed.

Lewin LC.Sexually transmitted infections in preadolescent children. J
Pediatr Health Care. 2007 May-Jun;21(3):153-61. 

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17478304>

**Adjustments in opthalmia neonatorum (ON): Gonorrhea in pregnancy**

Redbook- For routine prophylaxis of infants immediately after birth, a
1% solution of silver nitrate, or 1% tetracycline or 0.5% erythromycin
ophthalmic ointment, OU with subsequent irrigation. Prophylaxis delay
for up to 1 hour for bonding.  Term Infants born to GC infected mom
125mg IV or IM ceftriaxone.   The 1993 Pediatrics article (below)
suggests that for women receiving PN care: Silver nitrate eye
prophylaxis caused no sustained deleterious effects and even provided
some benefit to infants born to women without Neisseria gonorrhoeae.
However, the effect was modest and against microorganisms of low
virulence. The results suggest that parental choice of a prophylaxis
agent including no prophylaxis is reasonable for women receiving
prenatal care and who are screened for sexually transmitted diseases
during pregnancy (cited online April 25, 2007)

Of interest is the WHO Bulletin 2000 -- Iodine cost effective and
clinically effective in developing countries for prophylaxis of ON 

<http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S0042-96862001000300017&lng=es&nrm=iso&tlng=en>

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

#### Redbook article {#redbook-article .Style-Heading-4-+-Arial-14-pt-Underline}

#### [[http://pediatrics.aappublications.org/cgi/content/abstract/92/6/755]{.underline}](http://pediatrics.aappublications.org/cgi/content/abstract/92/6/755) {#httppediatrics.aappublications.orgcgicontentabstract926755 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Malabsorption of Oral Antibiotics in Pregnancy after Gastric Bypass
Surgery**

Gastric bypass surgery, by definition, changes the absorption
capabilities of the stomach and small intestine. The use of oral
medications in patients post gastric bypass may need to be adjusted by
medical providers to account for this absorption change. The following
case exemplifies this dilemma in a pregnant patient status post gastric
bypass surgery with a complicated urinary tract infection.

Magee SR et al Malabsorption of Oral Antibiotics in Pregnancy after
Gastric Bypass Surgery J Am Board Fam Med 2007;20 310-313

[[http://www.jabfm.org/cgi/content/abstract/20/3/310?etoc]{.underline}](http://www.jabfm.org/cgi/content/abstract/20/3/310?etoc)

**Sleeping Poorly \... and Maybe Depressed: Co morbidity in Formal Sleep
Studies**

In this survey of 100 patients referred to our sleep center, we found
that a very high proportion (53%) of them had also been diagnosed with
depression. This is consistent with other estimates of co morbidity
between depression, insomnia, and obstructive sleep
apnea.[6](http://www.jabfm.org/cgi/content/full/20/3/320?etoc#R6%23R6)
This high concordance serves as a reminder that when primary care
physicians diagnose depression, they should question their patient
closely about sleep complaints, especially obstructive breathing
patterns and insomnia.

When patients present, as they frequently do, with hypersomnolence,
fatigue, irritability, low energy, or diminished cognitive function, the
provider\'s antennae likely will be raised to diagnose and treat
depression. These findings serve as a small reminder that they need to
be aware that common primary sleep pathologies such as obstructive sleep
apnea or insomnia may also account for these symptoms.

Sorscher AJ Sleeping Poorly \... and Maybe Depressed: Co morbidity in
Patients Referred for Formal Sleep Studies J Am Board Fam Med 2007;20
320-321

[[http://www.jabfm.org/cgi/content/full/20/3/320?etoc]{.underline}](http://www.jabfm.org/cgi/content/full/20/3/320?etoc)

**Barriers to Smoking Cessation Services in Underserved Communities**

Conclusion: \"Safety net\" providers encounter barriers to providing
smoking cessation services that are similar to barriers faced by
clinicians serving more affluent and non-minority populations, but also
encounter additional barriers that apply most particularly to the
underserved.

Blumenthal DS Barriers to the Provision of Smoking Cessation Services
Reported by

Clinicians in Underserved Communities J Am Board Fam Med 2007;20 272-279

[[http://www.jabfm.org/cgi/content/abstract/20/3/272?etoc]{.underline}](http://www.jabfm.org/cgi/content/abstract/20/3/272?etoc)

**Management of Hypertriglyceridemia (see Patient Education)**

Hypertriglyceridemia is associated with an increased risk of
cardiovascular events and acute pancreatitis. Along with lowering
low-density lipoprotein cholesterol levels and raising high-density
lipoprotein cholesterol levels, lowering triglyceride levels in
high-risk patients (e.g., those with cardiovascular disease or diabetes)
has been associated with decreased cardiovascular morbidity and
mortality. Although the management of mixed dyslipidemia is
controversial, treatment should focus primarily on lowering low-density
lipoprotein cholesterol levels. Secondary goals should include lowering
non-high-density lipoprotein cholesterol levels (calculated by
subtracting high-density lipoprotein cholesterol from total
cholesterol). If serum triglyceride levels are high, lowering these
levels can be effective at reaching non-high-density lipoprotein
cholesterol goals. Initially, patients with hypertriglyceridemia should
be counseled about therapeutic lifestyle changes (e.g., healthy diet,
regular exercise, tobacco-use cessation). Patients also should be
screened for metabolic syndrome and other acquired or secondary causes.
Patients with borderline-high serum triglyceride levels (i.e., 150 to
199 mg per dL \[1.70 to 2.25 mmol per L\]) and high serum triglyceride
levels (i.e., 200 to 499 mg per dL \[2.26 to 5.64 mmol per L\]) require
an overall cardiac risk assessment. Treatment of very high triglyceride
levels (i.e., 500 mg per dL \[5.65 mmol per L\] or higher) is aimed at
reducing the risk of acute pancreatitis. Statins, fibrates, niacin, and
fish oil (alone or in various combinations) are effective when
pharmacotherapy is indicated. Am Fam Physician 2007;75:1365-1371, 1372.

<http://www.aafp.org/afp/20070501/1365.html>

**AHA Guidelines for CVD Prevention in Women Focus on Lifetime Risk
Factors (CME)**

<http://www.medscape.com/viewarticle/552777?src=sr>

# 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}

**Endometrial ablation. ACOG Practice Bulletin No. 81**

**Summary of Recommendations and Conclusions**

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

-   For women with normal endometrial cavities, resectoscopic
    endometrial ablation and nonresectoscopic endometrial ablation
    systems appear to be equivalent with respect to successful reduction
    in menstrual flow and patient satisfaction at 1 year following index
    surgery.

-   Resectoscopic endometrial ablation is associated with a high degree
    of patient satisfaction but not as high as hysterectomy.

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

-   Hysterectomy rates associated with both resectoscopic endometrial
    ablation and nonresectoscopic endometrial ablation are at least 24%
    within 4 years following the procedure.

-   Women undergoing endometrial ablation with previous or concomitant
    laparoscopic sterilization are at low risk for the development of
    cyclic or intermittent pelvic pain subsequent to the procedure.

-   Patient satisfaction and reduction in menstrual blood flow after
    endometrial ablation in women with normal endometrial cavities is
    similar to that experienced by women using the
    levonorgestrel-secreting intrauterine system.

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

-   Patients who choose endometrial ablation should be willing to accept
    normalization of menstrual flow, not necessarily amenorrhea, as an
    outcome.

-   Premenopausal patients undergoing endometrial ablation should be
    counseled to use appropriate contraception.

-   in women with endometrial cavities that exceed device limitations.

-   The endometrium of all candidates for endometrial ablation should be
    sampled, and histopathologic results should be reviewed before the
    procedure.

-   Women with endometrial hyperplasia or uterine cancer should not
    undergo endometrial ablation.

-   Performance of nonresectoscopic endometrial ablation in patients
    with prior classic cesarean delivery or transmural myomectomy may
    increase the risk of damage to surrounding structures. If
    endometrial ablation is to be performed in such patients, it may be
    best to perform resectoscopic endometrial ablation with laparoscopic
    monitoring. Safety of nonresectoscopic endometrial ablation in women
    with low transverse cesarean delivery has not been adequately
    studied.

-   For resectoscopic endometrial ablation, it is recommended that a
    fluid management and monitoring system that provides "real-time"
    output of fluid balance be used.

Endometrial ablation. ACOG Practice Bulletin No. 81. American College of
Obstetricians and Gynecologists. Obstet Gynecol 2007; 109:1233--48.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17470612>

**Seeking and Giving Consultation**

ABSTRACT: Consultations usually are sought when practitioners with
primary clinical responsibility recognize conditions or situations that
are beyond their level of expertise or available resources. One way to
maximize prompt, effective consultation and collegial relationships is
to have a formal consultation protocol. The level of consultation should
be established by the referring practitioner and the consultant. The
referring practitioner should request timely consultation, explain the
consultation process to the patient, provide the consultant with
pertinent information, and continue to coordinate overall care for the
patient unless primary clinical responsibility is transferred. The
consultant should provide timely consultation, communicate findings and
recommendations to the referring practitioner, and discuss continuing
care options with the referring practitioner.

Seeking and Giving Consultation. ACOG Committee Opinion No. 365.
American College of Obstetricians and Gynecologists. Obstet Gynecol
2007;109:1255--9.

 <http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17470614>

**Disruptive Behavior**

ABSTRACT: Disruptive behavior may have a negative effect on patient
care. Consequently, it is important that a systematic process be in
place to discourage, identify, and remedy episodes of disruptive
behavior.

Disruptive Behavior. ACOG Committee Opinion No. 366. American College of
Obstetricians and Gynecologists. Obstet Gynecol 2007; 109:1261--2.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17470615>

**Patents, Medicine, and the Interests of Patients**

ABSTRACT: Many basic scientists and clinicians support the right to
obtain and enforce patents on drugs, diagnostic tests, medical devices,
and most recently, genes. Although those who develop useful drugs,
diagnostic and screening tests, and medical technologies have the right
to expect a fair return for their efforts and risks, current
interpretations of patent law have the potential to impede rather than
promote scientific and medical advances. Policies regarding the
patenting of scientific inventions, discoveries, and improvements must
balance the need for the open exchange and use of information with the
need to make the pursuit of such knowledge financially rewarding.

Patents, Medicine, and the Interests of Patients. ACOG Committee Opinion
No. 364. American College of Obstetricians and Gynecologists. Obstet
Gynecol 2007;109:1249--53.

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

## AFP, American Family Physician {#afp-american-family-physician .Style-Heading-2-+-14-pt}

Therapies for Overactive Bladder- Nonpharmacologic vs. Anticholinergic

Clinical Question: Cochrane Briefs

How do nonpharmacologic therapies compare with anticholinergic
medications in patients with overactive bladder (i.e., urinary urgency)?

Evidence-Based Answer

Anticholinergic medications are more effective than bladder training in
reducing the number of voids per day. Combining an anticholinergic
medication with bladder training is more effective than either therapy
alone.

Practice Pointers

Overactive bladder can be associated with urge incontinence, urinary
frequency, and nocturia. Causes of chronic bladder irritation include
urinary tract infection; pelvic surgery; estrogen deficiency; diabetes;
multiple sclerosis; medications (e.g., neuroleptics, diuretics);
cerebral ischemia; dementia; and overflow incontinence.1

The most common treatments for overactive bladder are anticholinergic
medications, bladder training, pelvic floor muscle training,
biofeedback, and electric stimulation of the detrusor muscles. Compared
with placebo, persons taking anticholinergic medications for overactive
bladder have about five fewer trips to the bathroom and four fewer
leakage episodes per week. Patients taking anticholinergic medications
also report modest improvements in quality of life.2

This Cochrane review included randomized or quasi-randomized controlled
trials that compared anticholinergic medications with nonpharmacologic
therapies for overactive bladder or urinary urge incontinence in adults.
Thirteen trials (1,770 total participants treated for three to 12 weeks)
were identified; however, most trials were small and protocols varied,
making it difficult to draw many firm conclusions.

Bladder training was the most effective nonpharmacologic treatment
studied. Six trials (288 total participants) compared anticholinergic
medications (4 mg of tolterodine \[Detrol\], 45 mg of propantheline
\[Pro-Banthine\], or 5 to 45 mg of oxybutynin \[Ditropan\] daily).
Overall, anticholinergic medications improved symptoms compared with
bladder training alone (relative risk = 0.73; 95% confidence interval,
0.59 to 0.90). Combining bladder training with an anticholinergic
medication improved symptoms compared with either treatment alone.
Patients receiving combined treatment had about 5 percent fewer voids
per day, and about 15 percent of patients reported a greater change from
baseline in the sensation of urgency.

No trials of pelvic floor muscle training or surgery were found. No
significant difference between anticholinergic medications and
electrostimulation was found. About one third of patients taking
anticholinergic medications experienced adverse effects such as dry
mouth, headache, constipation, dizziness, decreased visual acuity, and
tachycardia.

Alhasso AA, et al. Anticholinergic drugs versus non-drug active
therapies for overactive bladder syndrome in adults. Cochrane Database
Syst Rev 2006;(4):CD003193.

<http://www.aafp.org/afp/20070501/cochrane.html>

Exercise Is an Effective Intervention in Overweight and Obese Patients

Clinical Scenario: Cochrane for Clinicians

A 52-year-old overweight man with hypertension and diabetes has made
some dietary changes, but he has not initiated an exercise program for
weight loss. He wonders if exercise will really make a difference.

Clinical Question

How effective is exercise in reducing body weight and improving cardiac
risk factors in overweight or obese patients?

Evidence-Based Answer

Exercise leads to a weight loss of 1 lb, 2 oz to 16 lb, 12 oz (0.5 to
7.6 kg), compared with a 3-oz (0.1-kg) weight loss to a weight gain of 1
lb, 9 oz (0.7 kg) with no treatment. Patients participating in
higher-intensity exercise lose 3 lb, 5 oz (1.5 kg) more than those
participating in low-intensity exercise. Regardless of whether the
patient loses weight, exercise improves diastolic blood pressure and
triglyceride, high-density lipoprotein, and glucose levels. When a
low-calorie diet is compared with exercise alone, a low-calorie diet
leads to more weight loss (6 lb, 3 oz to 29 lb, 16 oz \[2.8 to 13.6 kg\]
versus 1 lb, 2 oz to 16 lb, 12 oz). However, trials with three to 12
months of follow-up show that participants who combine a low-calorie
diet with exercise lose 2 lb, 7 oz (1.1 kg) more than those who only
diet.

Shaw K, Gennat H, O\'Rourke P, Del Mar C. Exercise for overweight or
obesity. Cochrane Database Syst Rev 2006;(4):CD003817.

<http://www.aafp.org/afp/20070501/cochrane.html>

**Evaluation and Treatment of Acute Low Back Pain (See Patient
Education)**

Acute low back pain with or without sciatica usually is self-limited and
has no serious underlying pathology. For most patients, reassurance,
pain medications, and advice to stay active are sufficient. A more
thorough evaluation is required in selected patients with \"red flag\"
findings associated with an increased risk of cauda equina syndrome,
cancer, infection, or fracture. These patients also require closer
follow-up and, in some cases, urgent referral to a surgeon. In patients
with nonspecific mechanical low back pain, imaging can be delayed for at
least four to six weeks, which usually allows the pain to improve. There
is good evidence for the effectiveness of acetaminophen, nonsteroidal
anti-inflammatory drugs, skeletal muscle relaxants, heat therapy,
physical therapy, and advice to stay active. Spinal manipulative therapy
may provide short-term benefits compared with sham therapy but not when
compared with conventional treatments. Evidence for the benefit of
acupuncture is conflicting, with higher-quality trials showing no
benefit. Patient education should focus on the natural history of the
back pain, its overall good prognosis, and recommendations for effective
treatments. Am Fam Physician 2007;75:1181-8, 1190-2.

<http://www.aafp.org/afp/20070415/1181.html>

Restless Legs Syndrome: Pramipexole (Mirapex)

Pramipexole (Mirapex) is a non-ergot selective dopamine receptor agonist
that has been used since 1997 for the treatment of idiopathic
Parkinson\'s disease. It is now labeled for the treatment of moderate to
severe restless legs syndrome (RLS),1 which is defined as having
symptoms at least two to three days per week for at least three months
and having a baseline score higher than 15 on the 40-point International
Restless Legs Syndrome Study Group Rating Scale.2

Bottom Line

Although many patients with RLS do not need pharmacologic therapy,
pramipexole is one option for treating moderate to severe symptoms. As
with other agents used to manage RLS, potentially serious adverse
reactions are possible. Am Fam Physician 2007;75

<http://www.aafp.org/afp/20070415/steps.html>

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

**AHRQ breastfeeding evidence review**

Breastfeeding and Maternal and Infant Health Outcomes in Developed
Countries. 

It can be downloaded at AHRQ Publications Clearinghouse at
<AHRQPubs@ahrq.hhs.gov> or by calling the Clearinghouse at
800-358-9295. 

#### 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}

**Quick Check for Drugs and Lactation**

When you need to know if a drug you prescribe is safe for breastfeeding
mothers, here is a new and easy to use database to check.

LactMed is a peer-reviewed database of drugs to which breastfeeding
mothers may be exposed. LactMed is part of the National Library of
Medicine's Toxicology Data Network (TOXNET) and contains over 450 drug
records. Data include information on the levels of drugs in the breast
milk and infant blood, and possible adverse effects on the nursing
infant. There are suggested alternatives to those drugs when available.
All data are derived from the scientific literature and fully
referenced.

LactMed can be accessed using the Health Services Research Library
website at
[http://hsrl.nihlibrary.nih.gov](http://hsrl.nihlibrary.nih.gov/)

-Find PubMed in the left panel and click.

-Once you are in PubMed, click on TOXNET located on their left panel.

-Next, select LactMed from the list. In the search box, enter the drug
you are interested in.

**Sample Record for Prozac (abbreviated for space)**

DRUG LEVELS AND EFFECTS:

SUMMARY OF USE DURING LACTATION:

The average amount of drug in breast milk is higher with fluoxetine than

with most other SSRIs and the active metabolite, norfluoxetine, is

detectable in the serum of most breastfed infants during the first 2

months postpartum and a few thereafter.......

DRUG LEVELS:

Fluoxetine is metabolized to norfluoxetine which has antidepressant

activity that is considered to be equal to fluoxetine. In a pooled
analysis of serum levels from published studies and 1unpublished case,
the authors found that 20 mothers taking an average daily dosage of 28
mg (range 10 to 80 mg) had an average milk fluoxetine

level of 76 mcg/L (range 23 to 189 mcg/L)........

EFFECTS IN BREASTFED INFANTS:

Colic, decreased sleep, vomiting and watery stools occurred in a
6-day-old

breastfed infant probably caused by maternal fluoxetine.......

POSSIBLE EFFECTS ON LACTATION:

Fluoxetine has caused increased prolactin levels and galactorrhea in

nonpregnant, nonnursing patients. The clinical relevance of

these findings in nursing mothers is not known. .......

AAP CATEGORY (comment from the American Academy of Pediatrics)

Effect on nursing infant is unknown but may be of concern.

ALTERNATE DRUGS TO CONSIDER:

Nortriptyline

**REFERENCES:**

1\. Weissman AM, Levy BT, Hartz AJ et al. Pooled analysis of
antidepressant levels in lactating mothers, breast milk, and nursing
infants. Am J Psychiatry. 2004;161:1066-9.

2\. Kristensen JH, Ilett KF, Hackett LP et al. Distribution and
excretion of fluoxetine and norfluoxetine in human milk. Br J Clin
Pharmacol. 1999;48:521-7

##### 

LactMed can be accessed using the Health Services Research Library
website at
[http://hsrl.nihlibrary.nih.gov](http://hsrl.nihlibrary.nih.gov/)

##### 

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

**Long-Term Breastfeeding among Native American Women**

Available for purchase the two versions of the "video features Native
American women telling in their own words of their experience in
learning and teaching breastfeeding in the context of community and
family tradition. The discussions include: New mothers\' questions,
managing at the hospital, working and breastfeeding, sexuality, birth
control, attitudes towards extended nursing, fathers\' roles, tandem
nursing, and more.

<http://www.glitc.org/pages/bfvideo.html>

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

[**Systematic review and meta-analysis confirms long-term positive
effects of
breastfeeding**](http://www.who.int/child-adolescent-health/publications/NUTRITION/ISBN_92_4_159523_0.htm)

The World Health Organization\'s Department of Child and Adolescent
Health, in collaboration with the epidemiology unit in the University of
Pelotas, Brazil, conducted this systematic review and meta-analysis of
studies to assess the association between breastfeeding and blood
pressure, diabetes and related indicators, serum cholesterol, overweight
and obesity, and intellectual performance. Two reviewers independently
evaluated study quality, using a standardized protocol, and disagreement
was resolved by consensus rating. Subjects who were breastfed
experienced lower mean blood pressure and total cholesterol, as well as
higher performance in intelligence tests. Prevalence of
overweight/obesity and type-2 diabetes was lower among breastfed
subjects. All effects were statistically significant but for some
outcomes their magnitude was relatively modest.

 

This review confirms what has been widely known for years; that
breastfeeding helps infants achieve the highest attainable standard of
health.

#### [**http://www.who.int/child-adolescent-health/New_Publications/NUTRITION/ISBN_92_4_159523_0.pdf**](http://www.who.int/child-adolescent-health/New_Publications/NUTRITION/ISBN_92_4_159523_0.pdf) {#httpwww.who.intchild-adolescent-healthnew_publicationsnutritionisbn_92_4_159523_0.pdf .Style-Heading-4-+-Arial-14-pt-Underline}

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

**FAQs - Breastfeeding and maternal illness**

Is breastfeeding okay if mom the gets sick? Most of the time, the answer
is yes. The following review is from CDC and references listed below.

**When breastfeeding is not recommended:**

-   The baby is diagnosed with galactosemia, a rare genetic metabolic
    disorder occurring in 1 in

47,000 births. There is little data on the prevalence of galactosemia in
AI/AN

communities.

-   The baby's mother:

    -   Has been infected with or recently exposed to the human
        immunodeficiency virus (HIV)

    -   Is taking antiretroviral medications

    -   Has untreated, active tuberculosis

    -   Is infected with human T-cell lymphotropic virus type I or type
        II

    -   Is using or is dependent upon an illicit drug

    -   Is taking prescribed cancer chemotherapy agents, such as
        antimetabolites that interfere with DNA replication and cell
        division

    -   Is undergoing radiation therapies; however, such nuclear
        medicine therapies require only a temporary interruption in
        breastfeeding

**What about stomach flu?**

Yes, moms with diarrhea from food and water sources can keep
breastfeeding. The recommendations to increase fluid intake and use oral
rehydration salts work well with breastfeeding.

If medication is needed consider kaolin-pectin (Kaopectate) or
loperamide (Immodium, Maalox) . Both are described by the American
Academy of Pediatrics (AAP) as "usually compatible with breastfeeding,"
with kaolin-pectin being preferable to loperamide.

Avoid suggesting anitdiarrheal medications that have bismuth
subsalicylate compounds (Pepto-Bismol). They are considered by both AAP
and Hale to be of concern because the baby can absorb significant levels
of salicylates and pose a theoretical risk of Reye's syndrome.

For more information go to [www.cdc.gov](http://www.cdc.gov/) travelers'
health.

**Can a mom breastfeed if she contracts hepatitis A?**

Yes, she can continue and gamma globulin treatment is compatible with
breastfeeding. Encourage the mom to use effective hand washing
techniques and food safety recommendations to protect her baby, whether
she is breastfeeding or bottle-feeding.

**What if she has hepatitis B (HBV) ?**

Is it safe for a mom infected with HBV to breastfeed her baby right
after birth?

Yes. HBV transmission through breastfeeding was not reported. CDC
recommends:

-   All babies born to HBV-infected moms need to receive hepatitis B
    immune globulin and the

first dose of hepatitis B vaccine within 12 hours of birth, the second
dose of vaccine at

aged 1--2 months, and the third dose at aged 6 months.

-   The infant needs to be tested after completing the vaccine series,
    at aged 9--18 months to

confirm that the vaccine worked and the infant is not infected with HBV
through exposure

to the mother's blood during the birth process.

**What if the mom's nipples are cracked and bleeding?**

Like hepatitis C, both viruses are spread by infected blood. There is
not enough data to make recommendations at this point. Until more
information is available, the wisest course is to encourage the mom to
temporarily interrupt breastfeeding her baby until she is healed.
Although sore nipples seem to last forever, they usually heal quickly,
often within 24 hours. It is helpful to pump and dump during this time.
Since both hepatitis b and c are resilient viruses, it would be prudent
to discard the breast pump when through.

**What about HBV vaccinations for a breastfeeding mom?**

It is okay for a breastfeeding mom to receive HBV vaccinations. The
vaccines contain noninfectious HBsAg particles and are given to newborns
also.

For more information, refer to CDC. A Comprehensive Immunization
Strategy to Eliminate Transmission of Hepatitis B Virus Infection in the
United States. MMWR, Recommendations and Reports, December 23, 2005 /
54(RR16);1-23

**What about mom with hepatitis C (HCV) -- is it safe for her to
breastfeed?**

Yes, like HBV, there is no evidence that breastfeeding spreads HCV.

**What if the mom in infected with HCV and has cracked and bleeding
nipples?**

See recommendations above for HBV and cracked and bleeding nipples.

For more information, refer to CDC. Recommendations for prevention and
control of Hepatitis C virus (HCV) infection and HCV-related chronic
disease. MMWR, October 16, 1998, 47(RR-19):1--39.

What if a mom becomes infected with West Nile Virus, is it safe for her
to breastfeed her baby?

So far, there is no evidence that it is harmful for a mom infected with
West Nile Virus to breastfeed infant. In According to CDC, there have
been 4 documented cases of West Nile Virus transmission through breast
milk (1 in 2002 and 3 in 2003) with no recognizable illness in the baby.
As a result, CDC recommends that moms with West Nile Virus illness
continue breastfeeding because the benefits of breast milk are thought
to outweigh the theoretical risk of harm to the baby.

For more information go to <http://www.cdc.gov/ncidod/dvbid/westnile/>

**Resources**

American Academy of Pediatrics\' Breastfeeding and the Use of Human
Milk, available at:

<http://aappolicy.aappublications.org/cgi/content/abstract/pediatrics;115/2/496>

American Academy of Pediatrics Committee on Drugs. (2001) The transfer
of drugs and other chemicals into human milk. Pediatrics 108:776-789.

Department of Health and Human Services, Centers of Disease Control and
Prevention, [www.cdc.gov](http://www.cdc.gov/)

Hale, T. (2006) Medications and Mothers' Milk. 12^th^ edition. Amarillo,
TX: Pharmasoft Publishing.

Lawrence RA, Lawrence R. (2005) Breastfeeding: A guide for the medical
professional, 6th Edition. St. Louis: Mosby.

Need fast information about drugs and breastfeeding? Go to Lactnet at
[www.toxnet.nlm.nih.gov](http://www.toxnet.nlm.nih.gov/)

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

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

#### RCT of very early mother-infant skin-to-skin contact and breastfeeding status {#rct-of-very-early-mother-infant-skin-to-skin-contact-and-breastfeeding-status-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Conclusion: Very early skin-to-skin contact enhanced breastfeeding success during the early postpartum period. No significant differences were found at 1 month. {#conclusion-very-early-skin-to-skin-contact-enhanced-breastfeeding-success-during-the-early-postpartum-period.-no-significant-differences-were-found-at-1-month. .Style-Heading-4-+-Arial-14-pt-Underline}

[Moore
ER](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Moore+ER"%5BAuthor%5D),
et al Randomized controlled trial of very early mother-infant
skin-to-skin contact and breastfeeding status. J Midwifery Womens
Health.  2007;52(2):116-125.

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17336817**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17336817) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgidbpubmedcmdretrievedoptabstractpluslist_uids17336817 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### [**http://www.medscape.com/viewarticle/555315?src=mp**](http://www.medscape.com/viewarticle/555315?src=mp) {#httpwww.medscape.comviewarticle555315srcmp .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

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

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

-Social Change Might Save More Lives Than Medical Advances

-New HPV Brochures for Clinicians, CDC

-More stillbirths after previous cesarean delivery

-Young women with CIN: Any treatment increases preterm delivery - LEEP

-Public Opinion vs. Science Concerning Sex Education

-New Guideline for Screening Mammography for Women 40 to 49 Yrs

-Premature Rupture of Membranes, Practice Bulletin

-Quick Check for Drugs and Lactation

-Breastfeeding - it's all about synergy

-Extended OCP Regimen; Acceptable Breakthrough Bleeding

-Must See Website: Indian Health Service HIV-AIDS Program

-Ethics of medicine with economically vulnerable populations: 2nd in
series

-Do you walk around your vehicle before getting in it? You should

-Which Indian Health facilities lead the U.S. in national benchmarks?

-Emergence of a range of nonhormonal treatments for vasomotor symptoms

-Ultrasound affects mice brains in negative ways

-BTL: Nearly 1/2 of women under 25 yo request information on reversal

-Two summer programs for high school students

-Calcium Supplementation May Not Benefit Healthy Children

-Preconception counseling for women with DM and HTN: Which meds?

-Electronic Health Record (EHR) Implementation: Worth the effort?

-HIV/AIDS among AI/AN Fact Sheet

-New recommendations for gestational weight gain may be required

-Weaving it all together: 2007 Behavioral Health Conference

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

#### May newsletter here {#may-newsletter-here .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0507.cfm**](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0507.cfm) {#httpwww.ihs.govmedicalprogramsmchmobgyn0507.cfm .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

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

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

**The failure to protect Indigenous women from sexual violence in the
USA**

The Amnesty International report entitled "Maze of Injustice -- The
failure to protect Indigenous women from sexual violence in the USA" is
an important and timely reminder for all individuals and agencies that
provide services to American Indian and Alaska Native (AI/AN) women. The
Amnesty International report calls attention to the disproportionate
impact on Indian women, focusing on three disparate communities that
vary with respect to law enforcement, jurisdiction, and health care and
support services. This report helps remind us that no one is immune from
sexual violence.

The Indian Health Service (IHS) and our health care providers need to be
aware of the prevalence of sexual assault and the need to address acute
injuries as well as the long term negative health effects of sexual
violence. As a result of this report, the IHS will help develop a
prototype policy on sexual assault that can be used by facilities to
help ensure the provision of best practices and culturally appropriate
medical and supportive care for victims.

The health care response to intimate partner violence (IPV) has been
improved by the existence of policies and procedures at all IHS
facilities. Screening for IPV has improved as well, with aggregate
national rates exceeding Agency targets. IPV policies and procedures,
screening and education for health care providers are the result of
Agency clinical performance measures developed to improve care.

The Indian Health Service and the Administration for Children and
Families (ACF) jointly fund activities at twenty IHS, Tribal and Urban
facilities to help improve the health care response to domestic
violence. This work is led by multi-disciplinary teams of health service
staff and tribal and community domestic violence advocates. The IHS-ACF
project seeks to build a sustainable response to domestic violence that
prioritizes safety and autonomy for victims and provides outreach and
education, utilizing the experience and commitment of community members.
Partners in this collaborative effort include the Family Violence
Prevention Fund (FVPF), Mending the Sacred Hoop Technical Assistance
(MSHTA) Project and Sacred Circle. MSHTA and Sacred Circle specialize in
developing sexual assault and domestic violence policies and programs in
Indian Country.

 

Sexual assault has long been recognized as a dynamic of domestic
violence. In response to the alarming statistics of sexual assault
experienced by AI/AN women, several of the project sites, including the
Cherokee Indian Hospital and Zuni Comprehensive Community Health Center,
have trained sexual assault nurse examiners (SANE) who are on call and
available for emergency room care. For other sites, identifying and
cooperating with pre-existing sexual assault community resources have
been key to strengthening their response. At the Kanza Health Center in
Oklahoma, the Dearing House, a nearby child advocacy center, was
instrumental in improving exams for pediatric/adolescent sexual assault
cases identified in the clinic. The Warm Springs Health and Wellness
Center's Domestic Violence team leaders collaborated with the local
Victims of Crime office to assist high school students in the production
of a film about sexual assault against children and teens. This effort
complements the efforts at the Warm Springs facility and community
hospital where SANE nurses are available for follow-up. Both
institutions maintain policies and procedures on sexual assault. Many of
the domestic violence project sites expanded their work beyond the walls
of the health care facility, and the focus has increasingly moved toward
prevention.

The experience of the IHS-ACF project sites demonstrates that chances
for success for improving the health care response to domestic violence
are greatest when health care teams and local domestic violence advocacy
groups collaborate in the delivery of services to women. This model of
care can be combined with existing best practices to improve the health
care response to victims of sexual assault. Clinical guidelines have
been shown to improve the quality of care for a number of health
conditions, such as type 2 diabetes. Similarly, the incorporation of
guidelines and policies concerning domestic violence and sexual assault
will strengthen the ability of our providers and health care system to
address sexual violence against American Indian and Alaska Native women.
Our expectation should be that the health care response will be
consistently safe, professional, timely, accessible, culturally and
personally respectful, and coordinated with law enforcement and legal
and community services. We must not re-victimize women who seek care in
our hospitals and clinics.

IHS-ACF Domestic Violence Project

Project Faculty, IHS and FVPF

**Sexual Violence Resources:**

**Amnesty International: Native American and Alaska Native Women**

<http://www.amnestyusa.org/Womens_Human_Rights/Join_Voices_with_Native_American_and_Alaska_Native_Women/page.do?id=1021163&n1=3&n2=39&n3=1410>

**Amnesty Internation, home page**

[www.AmnestyUSA.org](http://www.amnestyusa.org/)

**Mending the Sacred Hoop Technical Assistance (MSHTA) Project**

[www.msh-ta.org](http://www.msh-ta.org/)

**Sexual Assault Forensic Examiner Technical Assistance**

[[www.safeta.org]{.underline}](http://www.safeta.org/)

 

**National Sexual Violence Resource Center**

[[www.ncvrc.org]{.underline}](http://www.ncvrc.org/)

 

**National Protocol for Sexual Assault Medical Forensic Examinations,
September 2004**

[[http://www.ncjrs.gov/pdffiles1/ovw/206554.pdf]{.underline}](http://www.ncjrs.gov/pdffiles1/ovw/206554.pdf)

 

**Southwest Center for Law and Policy** - free legal training and
technical assistance to tribal communities and to organizations and
agencies serving Native people:

[[www.swclap.org]{.underline}](http://www.swclap.org/)

 

**Tribal Law and Policy Institute -** education, research, training, and
technical assistance programs which promote the enhancement of justice
in Indian country and the health, well-being, and culture of Native
peoples.

[[www.tlpi.org]{.underline}](http://www.tlpi.org/)

**Other**

**Physical and sexual abuse in adulthood are associated with complaints
concerning general and reproductive health and a poor sex life**

CONCLUSION: Abusive experiences were common in gynecologic outpatients.
Women with abusive experiences had ill health and poor sexual life more
often than the controls. In contrast to the results of previous studies,
most of the women did not want to be asked about abuse by their
gynecologist. LEVEL OF EVIDENCE: II

[Pikarinen
U](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Pikarinen+U"%5BAuthor%5D),
et al Experiences of Physical and Sexual Abuse and Their Implications
for Current Health. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007
May;109(5):1116-1122\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17470592&dopt=Abstract>

**WH Pregnancy and DV education online session**

Excerpts

-- Video vignettes and text walk you through a 15 minute session with a
WH client, mom with child in pediatric setting, adolescent clients and
considerations in screening gay and lesbian clients - with audio,
patient interviews and Q&A:

"Physical Abuse during Pregnancy"

In a 1996 review, in studies that asked about violence more than once
during personal interviews or asked later in pregnancy, the prevalence
of physical abuse during pregnancy ranged from 7.4% to 20.1%. The
results of this review indicated that abuse during pregnancy occurs more
frequently than gestational diabetes or preeclampsia. Even more
disturbing: Homicide is the second leading cause of traumatic death for
pregnant and postpartum women in the United States accounting for 31% of
maternal injury deaths.

AND the maternal child dyad

"Effects of IPV on Children"  In families in which IPV occurs, it is not
only the woman\'s life that is at risk; identifying and intervening on
behalf of battered women is perhaps one of our most effective ways to
prevent child abuse as well. The effects of IPV can also adversely
affect the mental and physical development of children from infancy into
adulthood. Infants who have witnessed violence have eating and sleeping
problems, decreased responsiveness to adults, and increased crying.

Exposure to violence increases the likelihood of children experiencing
the following:

FTT

HA

Bed wetting

Speech disorders

Vomiting and diarrhea

Furthermore, the effects of such exposure follow the child throughout
his or her life. A 1998 study reported the following risks in persons
with 4 or more adverse childhood experiences: 4- to 12-fold risk for
alcoholism, drug abuse, depression, and suicide attempts as well as a 2-
to 4-fold risk of smoking, poor self-rated health, having 50 or more
sexual intercourse partners, and sexually transmitted diseases. Finally
the many resources include patient and provider information, CME slides,
etc. <http://www.medscape.com/viewarticle/553333_3>

[**Domestic Violence and Your Patient\'s Health: Asking the Right
Questions**](http://mp.medscape.com/cgi-bin1/DM/y/hBNXD0Ou5N60SzO0IRML0Ei)\
<http://www.medscape.com/viewprogram/6760?src=mp>

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

[**Gynecologic Assessment of the Elderly Patient\
**](http://mp.medscape.com/cgi-bin1/DM/y/hBNXD0Ou5N60SzO0IUVk0ER)Review
physiologic changes associated with aging, normal and abnormal physical
findings, symptoms and conditions commonly encountered, and age-specific
aspects of pelvic examination

<http://www.medscape.com/viewarticle/554398>

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

**Reasons for unprotected intercourse**

# RESULTS: Of 7856 respondents, 33% felt they could not get pregnant at the time of conception, 30% did not really mind if they got pregnant, 22% stated their partner did not want to use contraception, 16% cited side effects, 10% felt they or their partner were sterile, 10% cited access problems and 18% selected \"other.\" Latent class analysis showed seven patterns of response, each identifying strongly with a single reason. CONCLUSIONS: Almost half of women with viable unintended pregnancies ending in a birth felt they could not/would not get pregnant at the time of conception. Most women identified with a single reason for having unprotected intercourse.

Nettleman MD, Chung H, Brewer J, et al. 2007. Reasons for unprotected
intercourse: Analysis of the PRAMS survey. Contraception 75(5):361-366.

# [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17434017**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17434017)

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

**Adolescent sexual behavior and strategies for reducing early pregnancy
and childbearing**

With One Voice 2007: America\'s Adults and Teens Sound Off About Teen
Pregnancy assesses public opinion on adolescent pregnancy. The survey is
the fifth in a series of nationally representative surveys conducted by
the National Campaign to Prevent Teen Pregnancy that have asked
adolescents (ages 12-19) and adults (ages 20 and older) a consistent,
core set of questions about adolescent pregnancy and related issues.

#### Topics include parental and other adult influence; abstinence and contraception; regret, virginity, older partners, and attitudes about adolescent sex; gender differences; religion; social norms and beliefs; and media. Data are presented in charts and, where available, results from previous surveys (2001-2006) are included. A description of the survey methodology and a summary are also provided. The survey is intended to provide insights for policymakers, program administrators, families, and others about adolescent pregnancy and factors that influence adolescents\' decisions about sex. [[http://www.teenpregnancy.org/resources/data/pdf/WOV2007_fulltext.pdf]{.underline}](http://www.teenpregnancy.org/resources/data/pdf/WOV2007_fulltext.pdf) {#topics-include-parental-and-other-adult-influence-abstinence-and-contraception-regret-virginity-older-partners-and-attitudes-about-adolescent-sex-gender-differences-religion-social-norms-and-beliefs-and-media.-data-are-presented-in-charts-and-where-available-results-from-previous-surveys-2001-2006-are-included.-a-description-of-the-survey-methodology-and-a-summary-are-also-provided.-the-survey-is-intended-to-provide-insights-for-policymakers-program-administrators-families-and-others-about-adolescent-pregnancy-and-factors-that-influence-adolescents-decisions-about-sex.-httpwww.teenpregnancy.orgresourcesdatapdfwov2007_fulltext.pdf .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Effect of Medicaid Family Planning Expansions on Unplanned Births**

Overall, Medicaid family planning expansions led to lower birth rates,
The authors found that

\* Average annual birthrates were significantly lowered by income-based
expansions; a statistically significant effect of postpartum expansions
was not found.

\* Significant maternal and infant health care cost offsets were
identified in all income-expansion states for which data are available.

Theses health care cost offsets exceeded total program costs in most
cases.

Overall, our results suggest that both types of Medicaid family planning
expansions either yield financial benefits to states or, at the very
least, are cost neutral. The experience of these early family planning
expansions should be a guide for other states considering family
planning benefit expansions.

#### Lindrooth RC, McCullough JS. 2007. The effect of Medicaid family planning expansions on unplanned births. Women\'s Health Issues 17(2):66-74. [[http://www.jiwh.org/content.cfm?sectionid=84&IssueSelected=137]{.underline}](http://www.jiwh.org/content.cfm?sectionid=84&IssueSelected=137) {#lindrooth-rc-mccullough-js.-2007.-the-effect-of-medicaid-family-planning-expansions-on-unplanned-births.-womens-health-issues-17266-74.-httpwww.jiwh.orgcontent.cfmsectionid84issueselected137 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Guidelines for Selection of Contraception in Women with Rheumatic Diseases {#guidelines-for-selection-of-contraception-in-women-with-rheumatic-diseases .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.medscape.com/viewprogram/6990?sssdmh=dm1.265392&src=nlcmealert**](http://www.medscape.com/viewprogram/6990?sssdmh=dm1.265392&src=nlcmealert) {#httpwww.medscape.comviewprogram6990sssdmhdm1.265392srcnlcmealert .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

**MCHB Launches Web Site to Increase Awareness of Perinatal Depression**

Depression During and After Pregnancy: A Resource for Women, Their
Families, and Friends contains tips on identifying depression in mothers
and offers steps to help treat it successfully. The Web site was
launched by the Health Resources and Services Administration\'s Maternal
and Child Health Bureau to increase awareness among women and health
professionals of the impact and pervasiveness of perinatal depression.

Selected topics include steps a woman can take if she believes she is at
risk of, or is experiencing, perinatal depression. A section of the Web
site is devoted to information for families and friends.

A list of print and electronic resources is also provided.

[[http://www.mchb.hrsa.gov/pregnancyandbeyond/depression]{.underline}](http://www.mchb.hrsa.gov/pregnancyandbeyond/depression)

An accompanying 22-page booklet is also available at
[[ftp://ftp.hrsa.gov/mchb/pregnancyandbeyond/depression.pdf]{.underline}](ftp://ftp.hrsa.gov/mchb/pregnancyandbeyond/depression.pdf)

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

**Q. What are the Unnecessary Tests done in Obstetrics and Gynecology?**

**A. Here are a few examples**

#### 1.) Unnecessary Testing by Clinicians and Independent Companies

Certain once-broadly accepted monitoring tests that were used routinely
have not been supported by outcome data. Examples from obstetric
practice include electronic fetal heart rate monitoring and fetal pulse
oximetry. Routine electronic fetal heart rate monitoring has not been
demonstrated to decrease the rate of cerebral palsy, but has been linked
to increases in the overall rate of cesarean delivery. It has also been
determined that routine use of fetal pulse oximetry is not associated
with either reduced rates of cesarean delivery or improvement in the
condition of newborns.\[ Although these tests are not recommended for
routine assessment, they remain in use in many hospitals in the United
States.

Other monitoring tests may be misused. One example of this is fetal
ultrasonography. Although it is helpful in estimating gestational age,
identifying twin pregnancies, and detecting genetic anomalies, the
American College of Obstetrics and Gynecology (ACOG) position is that
routine ultrasonographic screening during pregnancy is not mandatory.
They deem routine use reasonable when requested by a patient. Most women
in the United States undergo at least 1 or 2 ultrasounds during
pregnancy; this level of exposure has never been associated with
significant risk and use may provide significant benefits. However, some
expectant couples have followed the lead of actors Tom Cruise and Katie
Holmes and purchased (for costs ranging between \$15,000 and \$200,000)
their own ultrasound machines, which they use daily.

There are some data (mostly from other vertebrates) suggesting that
prolonged and frequent use of fetal ultrasound can cause abnormalities
in fetal brain development, behavior, and body weight. Even though such
findings have not been substantiated in humans, the US Food and Drug
Administration (FDA) considers promotion, selling or leasing of
ultrasound equipment for the purpose of making \"keepsake fetal videos\"
an unapproved use of a medical device. Such use may also violate state
laws and regulations.

#### Risks of Unnecessary Testing

Before considering a full-body scan or other non-proven screening test,
individuals should be made aware of the potential risks. False-positive
test results are extremely common among individuals with no signs or
symptoms of disease; multiple tests increase the likelihood of
false-positive results. Such alarming, yet incorrect test results, can
lead to further unnecessary investigations, additional patient costs,
heightened anxiety, and risk to future insurability. Conversely, true
positive results can lead to the over diagnosis of conditions that would
not have become clinically significant, thus leading to further risky
interventions.^\[1\]^

Examples of potentially harmful screening methods and possible outcomes
include:

-   Pelvic ultrasounds on asymptomatic women to search for ovarian
    cancer could lead to unnecessary laparoscopies and biopsies, with
    attendant complications; and

-   Screening all current and former smokers in the United States for
    lung cancer with a CT scan would identify more than 180 million lung
    nodules, the vast majority of which would be benign. Millions of
    patients with nodules could needlessly undergo invasive needle lung
    biopsies and/or removal of parts of their lungs, resulting in many
    cases of impaired breathing, pneumothorax, hemorrhage, infection,
    and even death.

Even commonly recommended tests carry a sometimes large risk of a
false-positive result. For example, among women in their early 40s with
abnormal mammograms, it was shown that approximately 57 women without
cancer underwent further diagnostic workup for every 1 woman found to
have a malignancy.

**On the other hand....Evidence-based Screening**

Space limitation precludes a thorough discussion of an evidence-based
approach to screening tests, but this section provides a brief overview
of criteria for appropriate screening. Tests to screen for disease in
the pre-symptomatic stages should meet certain criteria before being
recommended. These criteria include\]:

-   The disease being screened for must be reasonably common and have a
    significant effect on either duration or quality of life;

-   Acceptable, effective treatment must exist, and the condition must
    have an asymptomatic period during which detection and treatment can
    improve outcome;

-   Treatment during the asymptomatic period must be superior to
    treatment once symptoms occur; and

-   The screening test must be safe, affordable, and have adequate
    sensitivity (i.e., the test is usually positive in those with
    disease) and specificity (the test is usually negative in those
    without disease).

Examples of gynecologic- or obstetrically-related screening tests
meeting these criteria include Pap smears, mammography, oral glucose
tolerance testing during pregnancy, and universal testing of newborns
for certain congenital disorders. Other general tests of proven value
include blood pressure monitoring for those older than 21 years of age,
cholesterol tests for those 35 to 65 years of age, and abdominal
ultrasounds for persons (especially men) with coronary risk factors
and/or positive family history to screen for abdominal aortic aneurysms.

Regrettably, many well-established screening tests are underused,
especially among nonwhites, those of lower socioeconomic status (SES),
and those with inadequate or no health insurance. Such underuse has been
clearly linked with increased risk for adverse outcome. For example, SES
differences in access to and use of screening mammography have been
associated with advanced stage at time of breast cancer diagnosis and
lower survival rates, especially among African-Americans. SES
differences in the use of prenatal testing for trisomy 21 have also been
associated with disparities in the live-birth prevalence of Down
syndrome. Because incidence of this disease does not vary according to
SES, it has been demonstrated that early prenatal diagnosis leads to a
higher rate of elective termination of pregnancy by individuals of
higher SES

**Causes and Consequences of the Unwarranted Use of Costly and
Unscientific (Yet Profitable) Screening Modalities?**

<http://www.medscape.com/viewarticle/552964?src=mp>

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

**June / July 2007**

-Acute pain relief in children

-Pertussis: Secular Trends in the United States

-Persistence of racial disparities in fatal injuries to very young
children

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

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

**Brigg Reilley / John Redd, HQW**

**How can we improve HIV screening in pregnancy? Preliminary GPRA
Related Results**

As you read the following, think about the classic '3 things you should
take away from a presentation,'

1.) Prenatal HIV screening is the responsibility of all clinics whether
we like it or not

2.) Most service units have a prenatal HIV screening problem, but we are
not aware of it

3.) There are gaps that that staff can identify and fix, improving both
actual screening rates and reported screening rates.

In some clinics, there can be a 'not my job' syndrome.

People say things along the lines of: 1) We refer the women out anyway;
2) We don't have an HIV counselor, and it's not my role to counsel and
3) What if it IS positive? We can't do anything about it anyway.

All of these reasons are essentially irrelevant -- and, as noted below,
the successful small clinics assume responsibility for the first few PN
visits, which includes getting the lab panels done, even if the woman
will eventually be referred out.

**Background**

Current national standards of care for prenatal care specifically
recommend that all pregnant women be routinely screened for a variety of
diseases for which early detection is beneficial to the mother or child.
Routine infectious disease screening includes tests for HIV, syphilis,
gonorrhea, chlamydia, and hepatitis B surface antigen. Early detection
of HIV is critical because it can reduce the risk of mother-to-child
transmission from approximately 25% with no intervention to less than 1%
with intervention.

National IHS policy is that prenatal HIV screening in IHS should be
conducted on all women in IHS through "opt-out" testing. The IHS 2005
Executive Summary states "The Indian Health Service has issued guidance
recommending universal prenatal HIV testing using the "opt-out"
approach. In "opt-out" testing, HIV tests are included in the standard
battery of prenatal tests and women are informed that an HIV test is
being conducted and that they have a right to refuse it. Information
regarding HIV is included as part of a patient's prenatal education. As
more practitioners adopt opt-out testing, prenatal HIV screening rates
should increase."

IHS considers prenatal HIV screening an important indicator of the
quality of care provided by the Agency. As a result, HIV screening
during prenatal care is one of the core Government Performance and
Results Act (GPRA) measurements, with the IHS goal being to reach 100%.
GPRA considers a service unit 'responsible' for HIV screening if there
is \>1 visit during the time frame of pregnancy.

For the most recent year, GPRA statistics show that percentage of IHS
prenatal patients tested during pregnancy for HIV varies considerably by
IHS Area, from 17% to 84%. The national IHS rate is about 65%.

Clearly, these rates can and should improve.

**The IHS Division of Epidemiology & Disease Prevention Prenatal HIV
Screening Project**

In response to these results, IHS, through the Minority AIDS Initiative
and the IHS Division of Epidemiology & Disease Prevention, has funded
the ongoing IHS Prenatal HIV Screening Project. In brief, this is the
methodology of this phase of the project:

Charts that were considered 'misses' by GPRA (i.e. prenatal care but no
HIV screening) are being reviewed in 20 IHS sites (thus far, charts have
been reviewed at 12 sites) across the country. The misses were
identified by running a simple logic (a set of commands that we can give
to any service unit that is interested).

In general, most service units have said they are sure that they have
tested every prenatal patient for HIV, and usually express surprise at
their low GPRA scores.

**Results**

These results are part of an ongoing study and are considered
preliminary.

The two main categories of 'misses' as 1) data and 2) clinical. Sites
that have \< 80% reported HIV screening rates generally have some sort
of data or clinical gap in screening, or often both.

[On the clinical side, the main misses were:]{.underline}

-not using opt-out, including still using a consent form

-not testing at all, mainly among women who are late presenters, or skip
appointments, or have otherwise 'non-routine' prenatal care, although it
is arguable that this group is actually at highest risk

-a provider determining that an HIV test is not needed because there are
'no risk factors' or -carrying over an HIV test from a previous
pregnancy

-assuming that the test was done (or will be done) at the previous (or
next) service unit to see the patient.

[In the data category, the main errors were:]{.underline}

-not entering HIV tests results from a contract lab into the facility's
computer

-not entering HIV tests results done by an another facility

-not entering HIV test refusals into the facility's computer

(note: to enter refusals in the EHR takes a couple extra steps, which
should be fixed in the next version).

**Preliminary Recommendations to IHS Service Units**

-Review the policy of universal prenatal HIV testing via "opt-out" with
all clinicians, whether or not they usually see prenatal patients.

-Run the SU's patient list to find charts that are misses and 'diagnose'
the SU's gaps.

-Bundle HIV and the other routine prenatal ID serum tests into a
"prenatal panel" that can be ordered in one step by clinicians. Tests
done 'a la carte' result in greater misses for HIV and other IDs,
especially in patients with complications and missed appointments.

-Perform prenatal testing before transferring to a higher level of care.
Small facilities should remember that GPRA will consider them
responsible for prenatal HIV testing if the patient is seen by them.
Transfers out with no lab tests done, and with no follow up to obtain
results on test done elsewhere, result in low scores.

-Make prenatal opt-out HIV screening absolutely routine, both in policy
and in practice. Sites with lower scores tend to 'bottleneck' testing in
a way that makes it an exceptional event rather than the rule. For
example, a provider may be unable to test without a specific consent
form (and the form isn't easily available), and without using a specific
person to obtain consent (and that person isn't in clinic today). These
reasons for low testing rates are no longer acceptable in the world of
universal prenatal opt-out HIV screening.

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

**Act now: Make HIV screening a routine test in pregnancy**

Brigg Reilley and John Redd emphasize that the above results are just
part of an ongoing investigation, but felt strongly in the importance of
this data to allow a preliminary release. The full analysis will follow.

In the meantime, there are clear 'provider related' and 'system related'
obstacles to routine prenatal HIV screening and documentation that can
be addressed now. Pending the final results, these simple statements are
true:

-All pregnant patients should be educated about and offered HIV
screening in pregnancy

-HIV screening in pregnancy is your responsibility. Don't wait for the
next provider or facility to do perform the screening

-HIV screening in pregnancy is a routine part of care. It does not need
a separate written consent and can be 'bundled' in with the other
initial prenatal labs

-Many of the patients who miss the initial screen, e.g., due to missed
appointments etc... are those patients at highest risk. Please continue
to try to obtain the HIV screen right up to and including the time of
delivery.

**Other Resources:**

**Division of Epidemiology and Disease Prevention**

<http://www.ihs.gov/medicalprograms/epi/index.cfm>

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

**Social context of maternal deaths and morbidity**

Fair warning: the three pieces I'm recommending here are not freely
available online. But all should be available through your librarian,
and for providers who are interested in the social context of maternal
deaths and morbidity, they are well worth seeking out.

A northern Nigerian proverb tells us "the world is a pregnant woman" --
suggesting that life, like pregnancy, is uncertain and perilous. But why
is it so much more perilous in some places than others? Biomedical and
public health perspectives on the problem have tended to identify
shortfalls in clinical care, and have led to interventions designed to
improve skills training: not long ago the training of TBAs was the
flavor of the day, and more recently the focus has shifted to the
improvement of emergency obstetric care in health centers.
Anthropologists Craig Janes and Lewis Wall (also an Ob/Gyn) bring a
different perspective to their studies of pregnancy-related mortality in
the disparate settings of Nigeria and Mongolia, both arguing that rising
maternal death rates reflect not just health sector deficiencies, but
larger social upheavals and overarching economic structures.

In Mongolia, for example, herders have been organized since the 13th
century into collective structures -- first feudal, then socialist --
that regulated access to valued resources including land, livestock and
water (and under the socialists, health care and education). These
collective structures were rapidly dismantled when Mongolia initiated
the so-called "shock therapy" program of economic reforms in 1990. Food
shortages, widespread unemployment and localized famine, growing
inequality, and deterioration of the public health sector rapidly
followed. Though this initial shock has now stabilized, reproductive
health and maternal mortality statistics continue to be poorer than they
were under socialism. Women, Janes suggests, appear to be particularly
vulnerable to the economic stresses occasioned by de-collectivization,
household food insecurity, and migration, in part because the
deconstruction of the collective has isolated women -- economically and
socially -- at the single-household level.

Nigeria has had similar problems with a deteriorating public health
sector and economy. Wall's article demonstrates how highly patriarchal
social and religious structures compound these national problems,
resulting in rising rates of maternal death, obstetric fistula disease
and perhaps even peripartum cardiomyopathy. Where women depend on
powerful men for both the social permission and the economic resources
required to travel to the hospital, tragedy can all too easily follow.

For a more intimate narrative take on issues of gender, maternity and
risk in North Africa, consider Kris Holloway's new book Monique and the
Mango Rains. Holloway was a Peace Corps volunteer in Mali 1989-1991,
where she worked closely with Monique Dembele, a Malian community health
worker and midwife. Monique had minimal training and even more minimal
facilities but a burning drive to improve health care \-- and
particularly childbirth safety \-- in a rural village. This nicely
written, extremely accessible book (requiring no clinical background to
enjoy) neither pathologizes nor romanticizes Malian village life, and
deals in a fair and approachable way with issues of sexuality and
patriarchy.

All three of these readings challenge conventional medical wisdom by
suggesting that a narrow focus on improving one or another aspect of
formal health sector care \-- absent an understanding of and attention
to the larger social and political contexts of women's lives \-- will
not be enough to substantially reduce maternal deaths in the Third
World.

**Resources**

Holloway K. Monique and the Mango Rains: Two Years with a Midwife in
Mali. Longview, IL: Waveland Press, 2007

Wall LL. Dead mothers and injured wives: the social context of maternal
morbidity and mortality among the Hausa of northern Nigeria. Studies in
Family Planning 29(4):341-359, 1998

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=9919629>

Janes CR, Chuluundorj O. Free markets and dead mothers: the social
ecology of maternal mortality in post-socialist Mongolia. Medical
Anthropology Quarterly 18(2):230-257, 2004

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=15272806>

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

**Progress toward meeting Healthy People 2010 Maternal, Infant, and
Child objectives**

Healthy People 2010 Midcourse Review: Maternal, Infant and Child Health
highlights results from an assessment of progress toward achieving the
Healthy People (HP) 2010 maternal, infant, and child health goals and
objectives through the first half of the decade. The purpose of the
midcourse review, which was led by the Centers for Disease Control and
Prevention and the Health Resources and Services Administration, is to
assess data trends; consider new science and available data; and, if
appropriate, revise the objectives to ensure that HP 2010 remains
current, accurate, and relevant to public health priorities. Topics
include modifications to objectives and sub-objectives, progress toward
Healthy People 2010 targets, progress toward elimination of health
disparities, opportunities and challenges, and emerging issues.

[[http://www.healthypeople.gov/data/midcourse/pdf/FA16.pdf]{.underline}](http://www.healthypeople.gov/data/midcourse/pdf/FA16.pdf)

**Mental disorders and nicotine dependence among pregnant women**

These data suggest that cigarette use and nicotine dependence are not
uncommon among women who are pregnant in the United States, with more
than one in four pregnant women using cigarettes during pregnancy, and
approximately one in ten having a diagnosis of nicotine dependence. The
authors found that

\* Among pregnant women in the United States, 21.7% reported that they
smoked cigarettes and 12.4% met criteria for nicotine dependence.

\* Among pregnant women who smoked cigarettes, 45.1% met criteria for at
least one mental disorder; among pregnant women with nicotine
dependence, 57.5% met criteria for at least one mental disorder.

\* After adjustment for differences in demographic characteristics and
co-morbid mental disorders, the associations between major depressive
disorder, dysthymia, and panic disorder remained significantly
associated with nicotine dependence among pregnant women.

Results suggest an urgent need for smoking cessation and nicotine
dependence treatment and that mental health outreach programs might be
indicated in conjunction with prenatal care, especially in underserved
areas.

Goodwin RD, Keyes K, Simuro N. 2007. Mental disorders and nicotine
dependence among pregnant women in the United States. Obstetrics and
Gynecology 109(4):875-883.
[[http://www.greenjournal.org/cgi/content/abstract/109/4/875]{.underline}](http://www.greenjournal.org/cgi/content/abstract/109/4/875)

**MCH Headlines Judy Thierry HQE**

**Improve the system - Improve the care: Underpinnings**

The title of the American Native Women's Health and Maternity Care
Conference to be held August 15 - 17, 2007 at the Marriott - Louisiana,
Blvd., Albuquerque, NM has as one of its three objectives to "outline
the underpinnings of an optimal WH and MCH health care system
/environment in the ITU".

-Underpinnings like a foundation, like the joists in a floor are about
strength and unity.

-Underpinnings like the lining of a coat or jacket provide durability,
form and fit.

The 18.5 credit 2.5 day conference is YOUR conference. Workgroups,
professional reports and updates, state of the art practice across ITU's
and plenary discussions from national leaders and women's health
advocates are designed to 'fit' your practice and the community you
serve.

Wanda Jones, Deputy Assistant Secretary, Office for Women's Health (OWH)
Department of Health and Human Services will identify the challenges for
Women's Health in 2007 and the strategies for addressing those issues.
She will describe OWH mission and initiatives impacting on AIAN women
(underserved, women of color, health disparities and citizens of
sovereign nations). <http://www.4women.gov/owh/about/welcome.cfm>

Ms. Stacy Bohlen, Executive Director National Indian Health Board will
provide remarks on NIHB's educational and advocacy role, the key
partnerships and collaborations that support American Indian and Alaska
Native women and their families and communities. Recent testimony by a
board member requested increased support for diabetes and chronic
disease. <http://www.nihb.org/index.php>

Empowering women is a precept of Centering Pregnancy R. Evidence based
group prenatal care taken up by Zuni, Chinle, Kayenta and Tuba, among
other practice communities will present a paradigm shift in care that is
client centered, founded on building trust among the women.
<http://www.centeringpregnancy.com/>

A pre-meeting training on Monday and Tuesday will take place at the
Marriot -- please contact <judith.thierry@ihs.gov> if you are
interested.

Special Care Program at PIMC presented by Judy Whitecrane, CNM serves
A/OD at risk pregnant women 'where they are at' in a sensitive,
confidential and behaviorally integrated health care approach.

Provider Self Care? Terese Grant from the Center on Human Development
and Disability, University of Washington will engage participants in
appreciating the importance of a system that values self-care, respite,
retreats, networking and day-to-day support of staff who work with
high-risk women.

"Improve the System -- Improve the Care" planning committee has designed
many workshops and plenary objectives to address the effects of violence
on AIAN women and the clinical and community response. Domestic Violence
and Sexual Assault strategies and potential alternatives for serving
victims of sexual assault in direct Tribal and urban Indian locations
will be addressed by - Connie Monahan, New Mexico Statewide Sexual
Assault Nurse Examiner (SANE) Coordinator.

Please join us

**Native Women's Health and MCH Conference, 2007**

<http://www.ihs.gov/MedicalPrograms/MCH/F/CN01.cfm#Aug07>

**Drive It Right Kits**

Talking to teens about safe driving to 19,000 high schools across the
country.   Drive it Right, Talking to teens about safe driving is
arriving at schools across the country just in time to incorporate them
into National Youth Traffic Safety Month projects.

Allstate Insurance Company has a limited amount of Drive it Right,
Talking to teens about safe driving kits available to NOYS member
organizations on a first request basis. 

These materials include Educator Resource Materials, a poster, and a
supporting video.  NOYS has previewed this resource and supports the
content and use of the materials to address youth traffic safety. 

16 page work book with questionnaires divided into:

\# LICENSE TO TEACH -- FOR teachers

\# LICENSE TO DRIVE - STUDENTS

• It's Your Road

Introduction and background information on driving issues

that affect teens.

• Crash Test

A list of questions to gauge teens pre-existing knowledge and

attitudes about teen driving issues and to spark genuine dialogue.

• What's It Worth?

Checklist of what teens could lose by driving carelessly.

• Split-second Decision

Real world, driving-related scenarios to make teens think about

how they would react.

• Simple Tips to Stay Alive

Quick tips to help students improve their driving habits.

• What Are You Going to Do About It?

Ideas for teen-directed initiatives they could implement during

your Teen Safe Driving Campaign.

• Tips for Creating a Drive It Right Pledge

Culminating pledge that students will create and sign, promising

to keep themselves and their friends safe.

[www.discoveryschool.com/100days](http://www.discoveryschool.com/100days)
** ** Contact Sandy Spavone at <sspavone@noys.org>

**Have you heard of:  "oral health risk assessment"..."fluoride
varnish"..."early childhood caries"..."the Baby bottle tooth decay germ
-aka Streptococcus mutans? **

While most of these terms are part of our clinical vocabulary we still
have long way to go to reduce and prevent caries in infants and young
children.  In the coming months ten American Indian and Alaska Native
communities will be getting an oral health check-up -- training that
is! 

Dentists from academic and private practice will be supporting
pediatricians, dentists, dental hygienists, and oral health community
stakeholders who submitted applications on how they wanted to work with
their communities in early childhood oral health.  Sites will receive
\$2,000 in free in-kind consultation services for onsite technical
assistance. 

The American Academy of Pediatrics' Oral Health Initiative along with
the Bright Futures Educational Center is providing these awards in
partnership with the Indian Health Service Maternal and Child Health
Program and the Division of Oral Health.   Preceptors will be making
their way for a one-day training designed by the individual sites. 
Proposed plans include updates with WIC, Head Start Programs, primary
care providers, oral health providers and community dental consultants
to refresh their early childhood oral health knowledge and skills.
Components of the one-day preceptorship will include how to: conduct
oral health risk assessments, oral health exams, apply varnish and learn
how to expand community and parent participation in this number one
infectious disease.  The preceptorships will build upon existing
activities bringing up-to-date information on infant and toddlers oral
health. 

The ten awardees' coordinating the preceptorships and visiting
preceptors are:

-   Chinle Comprehensive Health Care Facility, Chinle, AZ  - Kristi Nix,
    MD  - Jay Shirley, DMD  Marietta, Georgia 

-   Consolidated Tribal Health Project, Inc. Redwood Valley, CA - Mary
    Ann Gonzalez, DDS - Leslee Singleton Huggins, BS, DDS, MS , Tyler,
    TX

-   Fort Defiance Indian Hospital: Fort Defiance, AZ -- Michael
    Bartholomew, MD - Ronald Winder, DDS, Tulsa, Oklahoma 

-   Gallup Indian Medical Center, Gallup, NM -  Kevin Sweeney, MD -
    Adriana Segura-Donly DDS, MS, San Antonio, Texas

-   Oneida Dental Clinic: Oneida, WI - Barb Ayres, RDH - Kavita Kohli,
    DDS, New York, N.Y. 

-   Pine Ridge Indian Hospital - Delores Starr - Hakan Koymen, DDS, MS,
    Perry Hall, MD

-   Port Gamble S'Klallam Health Department: Kingston, WA  - Dorie
    Salem-Soule, RDH - Rama Oskouian, DMD, Woodville, WA

-   Seminole Tribe of Florida: Hollywood. FL - Kerri Cook-Descheene,
    Dental Prevention Coordinator - Jonathan Shenkin, DDS, MPH , Bangor,
    ME

-   Tulalip Indian Health Clinic: Tulalip, WA - Marion Fulkomer, MD -
    Rama Oskouian, DMD, Woodville, WA

-   White Earth Health: Ogema, MN - Karry Cassidy, Hygiene Supervisor -
    TBA

Interested in applying for the second round? 
                                                  

Contact Wendy Nelson at <Wnelson@aap.org> for an application.

**Newly completed Pregnancy and Postpartum Quitline Toolkit**

For a one per person hard copy of the Quitline Toolkit sent to you
(include your mailing address) Email Lauren DiBiase
<ldibiase@schsr.unc.edu>

Online availability at <http://www.helppregnantsmokersquit.org/>

K-12 Oral Health Education Curriculum

The Missouri Dept. of Health and Senior Services has completed a K-12
Oral Health Education Curriculum power point presentation series. The
presentations can be downloaded free-of-charge by clicking on the
grade(s) specific icons. These presentations can be used by school
health nurses or teachers, as well as by other health care/child care
professionals, in conjunction with their health curriculum. The
presentations are available online at:
[http://www.dhss.mo.gov/oralhealth/OralHealthEducation.html]{.underline}

**American Academy of Pediatrics on state mandated benefits for
childhood vaccinations**

AI/AN CHILDREN are covered under VACCINES FOR CHILDREN (VFC). THIS CHART
IS HELPFUL TO SEE THE Larger SAFTY NET  

<http://cme.kff.org/Key=12433.7c.F.C.PFdksq>

**2005 - State by state AIAN % population breakout State ranking**   
<http://factfinder.census.gov/servlet/GRTTable?_bm=y&-geo_id=01000US&-_box_head_nbr=R0203&-ds_name=ACS_2005_EST_G00_&-_lang=en&-format=US-30&-_sse=on>

**National Children\'s Study - by county:    It is Pregnant women who
are enrolled and their offspring followed for 2 decades**

<http://www.nationalchildrensstudy.gov/about/locations/>

**Infant Mortality Statistics from the 2004 Period Linked Birth/Infant
Death Data Set**

Objectives---This report presents 2004 period infant mortality
statistics from the linked birth/infant death data file by a variety of
maternal and infant characteristics. The linked file differs from the
mortality file, which is based entirely on death certificate data.

Methods---Descriptive tabulations of data are presented and interpreted.
Excluding rates by cause of death, the infant mortality rate is now
published with two decimal places.

Results---The U.S. infant mortality rate was 6.78 infant deaths per
1,000 live births in 2004 compared with 6.84 in 2003. Infant mortality
rates ranged from 4.67 per 1,000 live births for Asian and Pacific
Islander mothers to 13.60 for non-Hispanic black mothers. Among
Hispanics, rates ranged from 4.55 for Cuban mothers to 7.82 for Puerto
Rican mothers. Infant mortality rates were higher for those infants
whose mothers were born in the 50 States and the District of Columbia,
were unmarried, or were born in multiple births. Infant mortality was
also higher for male infants and infants born preterm or at low birth
weight. The neonatal mortality rate declined from 4.63 in 2003 to 4.52
in 2004 while the postneonatal mortality rate was essentially unchanged.
Infants born at the lowest gestational ages and birth weights have a
large impact on overall U.S. infant mortality. More than one-half (55
percent) of all infant deaths in the United States in 2004 occurred to
the 2 National Vital Statistics Reports, Vol. 55, No. 14, May 2, 2007 2
percent of infants born at less than 32 weeks of gestation. Still,
infant mortality rates for late preterm (34--36 weeks of gestation)
infants were three times those for term (37--41 week) infants. The three
leading causes of infant death---Congenital malformations, low
birthweight, and SIDS---taken together accounted for 45 percent all
infant deaths. Results from a new analysis of preterm-related causes of
death show that 36.1 percent of infant deaths in 2004 were due to
preterm-related causes. The preterm-related infant mortality rate for
non-Hispanic black mothers was 3.3 times higher, and the rate for Puerto
Rican mothers was 75 percent higher than for non-Hispanic white mothers.

Infant Mortality Statistics from the 2004 Period Linked Birth/Infant
Death Data Set\
by T.J. Mathews, M.S., and Marian F. MacDorman, Ph.D., Division of Vital
Statistics

<http://www.cdc.gov/nchs/data/nvsr/nvsr55/nvsr55_14.pdf>

**Trends in Preterm-Related Infant Mortality by Race and Ethnicity:
United States, 1999-2004**\
Objectives---This report examines trends in preterm-related causes of
infant death in the United States by maternal race and ethnicity.

Methods---A grouping of preterm-related causes of infant death was
created by identifying causes of death that were a direct cause or
consequence of preterm birth.

Cause-of-death categories were considered to be preterm-related when 75%
or more of total infant deaths attributed to that cause were born
preterm, and the cause was

considered to be a direct consequence of preterm birth based on a
clinical evaluation and review of the literature. Trends in
preterm-related causes of death were

examined by maternal race and ethnicity.

Results---In 2004, 36.1% of all infant deaths in the United States were
preterm related, up from 34.5% in 1999. The preterm-related infant
mortality rate for non-

Hispanic black mothers was 3.3 times higher and the rate for Puerto
Rican mothers was 75% higher than for non-Hispanic white mothers. The
preterm-related infant

mortality rate for non-Hispanic black mothers was higher than the total
infant mortality rate for non-Hispanic white, Mexican, and Asian or
Pacific Islander (API)

mothers.

Discussion---The leveling off of the U.S. infant mortality decline since
2000 has been attributed in part to an increase in preterm and low
birthweight (LBW) births.

Continued tracking of this group of preterm-related causes of infant
death will improve our understanding of trends in infant mortality and
perinatal health in the

United States.

Trends in Preterm-Related Infant Mortality by Race and Ethnicity: United
States, 1999-2004\
by Marian F. MacDorman, Ph.D., Division of Vital Statistics; William M.
Callaghan, M.D., M.P.H., Division of Reproductive Health, National
Center for Chronic Disease Prevention and Health Promotion; T.J.
Mathews, M.S.; Donna L. Hoyert, Ph.D.; and Kenneth D. Kochanek, M.A.,
Division of Vital Statistics, National Center for Health Statistics

<http://www.cdc.gov/nchs/products/pubs/pubd/hestats/infantmort99-04/infantmort99-04.htm>

**Kids Count Tables: Child and youth demographics -- by race, by state,
health, economic**

Annie E. Casey Foundation has launched a new and improved website

IF YOU ARE DRAFTING ANY PROPOSAL YOU WANT TO REFERENCE THIS WEBSITE FOR
COMPARISON DATA.

-   CHILD WELFARE - National Foster Care Month focuses
    national attention on the needs of children and youth in foster
    care. The campaign encourages more citizens to get involved \--
    whether as their foster parents, volunteers, mentors, or employers,
    or in other ways. The Annie E. Casey Foundation and its direct
    services agency, Casey Family Services, are among the partner
    organizations involved in promoting stable and permanent family
    connections for children.

-   COMMUNITY CHANGE

-   ECONOMIC SECURITY

-   EDUCATION

-   HEALTH

-   JUVENILE JUSTICE

-   SPECIAL INTEREST AREAS.

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

**New Resource for Children's Health Information**

SCHIP and child health coverage by state, with state to state
comparisons, state to US comparisons lacks AIAN specifics.
Statehealthfacts.org now includes a children's health section that
offers customized fact sheets for each state, a directory of all
children's health topics on the site, and the latest children's health
research from KCMU and headlines from kaisernetwork.org

<http://cme.kff.org/Key=12433.7c.P.C.Mzc7Px>

Definitions: Persons of Hispanic origin may be of any race; all other
racial/ethnic groups are non-Hispanic.

\"Other\" includes Asian-Americans, Pacific Islanders, American Indians,
Aleutians, Eskimos and persons of \"Two or More Races\".
                                                           

These groups have been combined due to their small populations in many
states which prevent meaningful statistical analyses of the groups
individually.

The distribution of the U.S. population by Race/Ethnicity is: White,
195,289,747 (66.7%), Black, 35,539,912 (12.1%), Hispanic, 43,077,106
(14.7%), American Indian, 1,654,861 (0.6%), Asian-Americans and Pacific
Islanders, 12,915,910 (4.4%), and Two or More Races, 4,469,902 (1.5%).

Two chards from fact sheet:

<http://www.kff.org/medicaid/upload/7610.pdf>

![](media/image2.png){width="3.4270833333333335in" height="2.53125in"}

![](media/image3.png){width="4.114583333333333in" height="2.6875in"}

**Link to the AAP Government Affairs "state by state" LEGISLATION
REPORT**

TOC FOR your specific interests.  When sessions convene / adjourn /
governor / state budgets /... to booster seats to guns to helmets
to...tobacco.

<http://www.aap.org/advocacy/statelegrpt.pdf>

![](media/image4.png){width="3.65625in" height="2.7708333333333335in"}

**Birth characteristics single and multirace women**

![](media/image5.png){width="3.2395833333333335in"
height="2.5833333333333335in"}

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

#### Which Indian Health facilities lead the entire U.S. in national obstetric benchmarks? {#which-indian-health-facilities-lead-the-entire-u.s.-in-national-obstetric-benchmarks .Style-Heading-4-+-Arial-14-pt-Underline}

#### You saw the above question last month in the May CCC Corner.  {#you-saw-the-above-question-last-month-in-the-may-ccc-corner. .Style-Heading-4-+-Arial-14-pt-Underline}

#### Here is the rest of the story... {#here-is-the-rest-of-the-story .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### First, let me tell you two characteristics common to both facilities. Both have strong certified nurse midwife programs and both are 638 facilities, e.g., operated by tribal Boards under Self Determination legislation. {#first-let-me-tell-you-two-characteristics-common-to-both-facilities.-both-have-strong-certified-nurse-midwife-programs-and-both-are-638-facilities-e.g.-operated-by-tribal-boards-under-self-determination-legislation. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### ....and now the envelope please....the winners are... the Tuba City obstetrical care unit and the Alaska Native Medical Center obstetrical care unit. {#and-now-the-envelope-please.the-winners-are-the-tuba-city-obstetrical-care-unit-and-the-alaska-native-medical-center-obstetrical-care-unit. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### -Tuba City was recognized for cesarean delivery rate just under 14 percent -- lowest in the State of Arizona for Arizona Perinatal Trust Level II Nurseries {#tuba-city-was-recognized-for-cesarean-delivery-rate-just-under-14-percent-lowest-in-the-state-of-arizona-for-arizona-perinatal-trust-level-ii-nurseries .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### -Alaska Native Medical Center was recognized for best practice in five categories of the American College of Nurse-Midwives (ACNM) 2005 Benchmarking Program for facilities its size.  {#alaska-native-medical-center-was-recognized-for-best-practice-in-five-categories-of-the-american-college-of-nurse-midwives-acnm-2005-benchmarking-program-for-facilities-its-size. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Successful vaginal after cesarean rate 84.1% (63 attempted VBACs) {#successful-vaginal-after-cesarean-rate-84.1-63-attempted-vbacs .Style-Heading-4-+-Arial-14-pt-Underline}

#### Intact perineum 84.1% (1352 vaginal births) {#intact-perineum-84.1-1352-vaginal-births .Style-Heading-4-+-Arial-14-pt-Underline}

#### Patients with prenatal care by 12 weeks 86.9% (1488 births) {#patients-with-prenatal-care-by-12-weeks-86.9-1488-births .Style-Heading-4-+-Arial-14-pt-Underline}

#### Lowest pitocin induction rate 5.4% (1488 births) {#lowest-pitocin-induction-rate-5.4-1488-births .Style-Heading-4-+-Arial-14-pt-Underline}

#### Cesarean delivery rate 9.1% (1488 births) {#cesarean-delivery-rate-9.1-1488-births .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### As no one staff category can accomplish the above in isolation, so I would like to offer congratulations to the entire staffs at both facilities for a job well done. {#as-no-one-staff-category-can-accomplish-the-above-in-isolation-so-i-would-like-to-offer-congratulations-to-the-entire-staffs-at-both-facilities-for-a-job-well-done. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Now, how can we translate that success to other Indian Health sites?  {#now-how-can-we-translate-that-success-to-other-indian-health-sites .Style-Heading-4-+-Arial-14-pt-Underline}

#### The easiest way to start that process is to hear directly from the staff themselves. We have arranged to have members of their staff present at the upcoming 2007 National Indian Women's Health and MCH Conference in Albuquerque, NM August 15- 17, 2007 so you can hear for yourselves. {#the-easiest-way-to-start-that-process-is-to-hear-directly-from-the-staff-themselves.-we-have-arranged-to-have-members-of-their-staff-present-at-the-upcoming-2007-national-indian-womens-health-and-mch-conference-in-albuquerque-nm-august-15--17-2007-so-you-can-hear-for-yourselves. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### The theme of the 2007 National Indian Women's Health and MCH Conference is "Improve the System: Improve the Outcome" so it will explore how we can all work together to raise the AI/AN health status to the highest possible status.  {#the-theme-of-the-2007-national-indian-womens-health-and-mch-conference-is-improve-the-system-improve-the-outcome-so-it-will-explore-how-we-can-all-work-together-to-raise-the-aian-health-status-to-the-highest-possible-status. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### There will be national benchmark organizations (Institute for Healthcare Improvement, American College of Nurse-Midwives, American College of Obstetricians and Gynecologists, Kaiser Family Foundation, etc...), internationally known speakers, and a rather extensive clinical Program.  {#there-will-be-national-benchmark-organizations-institute-for-healthcare-improvement-american-college-of-nurse-midwives-american-college-of-obstetricians-and-gynecologists-kaiser-family-foundation-etc-internationally-known-speakers-and-a-rather-extensive-clinical-program. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### The meeting is only every 3 years, so you and a team from your facility should try your best to attend. You can either use your local facility funds, because there is a program review function, or use your CME /CEU funds. In addition, limited scholarships are available. {#the-meeting-is-only-every-3-years-so-you-and-a-team-from-your-facility-should-try-your-best-to-attend.-you-can-either-use-your-local-facility-funds-because-there-is-a-program-review-function-or-use-your-cme-ceu-funds.-in-addition-limited-scholarships-are-available. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### 2007 National Indian Women's Health and MCH Conference {#national-indian-womens-health-and-mch-conference .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/MedicalPrograms/MCH/F/CN01.cfm#Aug07**](http://www.ihs.gov/MedicalPrograms/MCH/F/CN01.cfm#Aug07) {#httpwww.ihs.govmedicalprogramsmchfcn01.cfmaug07 .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

**About Benchmarking**

Benchmarking is a method for comparing your facilities care processes to
those of the practices in the field that demonstrate the best outcomes. 
Identifying \"best practices\" through benchmarking allows all who
participate in the process to improve and adapt the care they provide in
order to obtain superior outcomes: high satisfaction, patient safety,
effectiveness and efficiency.

**One Example: ACNM**

#### The purpose of the American College of Nurse-Midwives (ACNM) Benchmarking Program is to provide a midwifery-specific mechanism to improve and maintain the superior quality of midwifery care provided to women and children by promoting member awareness of \"best practices.\"  To facilitate this, members are encouraged to participate in benchmarking their practice against other midwifery practices in the country. {#the-purpose-of-the-american-college-of-nurse-midwives-acnm-benchmarking-program-is-to-provide-a-midwifery-specific-mechanism-to-improve-and-maintain-the-superior-quality-of-midwifery-care-provided-to-women-and-children-by-promoting-member-awareness-of-best-practices.-to-facilitate-this-members-are-encouraged-to-participate-in-benchmarking-their-practice-against-other-midwifery-practices-in-the-country. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### ACNM Benchmarking Program {#acnm-benchmarking-program .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.acnm.org/education.cfm?id=842**](http://www.acnm.org/education.cfm?id=842) {#httpwww.acnm.orgeducation.cfmid842 .Style-Heading-4-+-Arial-14-pt-Underline}

**Another Example:**

**Tuba City Regional Health Care Corporation leads the way with healthy
childbirth model**\
*Tuba City Regional Health Care Corporation birth by* cesarean delivery
*is just under 14 percent -- lowest in the State of Arizona for Arizona
Perinatal Trust Level II Nurseries, according to latest data. Certified
nurse mid-wife/obstetrician model practiced is favored by the World
Health Organization*\
\
Citing its collaborative certified nurse mid-wife/obstetrician model for
childbirth, Tuba City Regional Health Care Corporation reported the
lowest birth by cesarean delivery rate in Arizona among Arizona
Perinatal Trust Level II Nurseries for the year 2005 -- just 13.9
percent. The national average is approximately 33%.\
\
For most mothers in labor arriving at the Tuba City obstetrical care
unit (OCU), everything is considered normal, healthy and natural until
signs show otherwise. Midwives care for patients in the OCU 24 hours per
day. Obstetricians are always available when anything abnormal begins to
occur during labor, or for high-risk pregnancies.\
\
The World Health Organization recommends the certified nurse
mid-wife/obstetrician model utilized at Tuba City Hospital.\
\
A cesarean delivery is the birth of a baby by surgery. The doctor makes
an incision in the belly and uterus and then removes the baby. A
c-section is usually performed when a vaginal delivery would lead to
medical complications; although nationwide it is becoming increasingly
more common to have an elective c-section when there is no
contra-indication to having a vaginal birth.\
\
While sometimes necessary, a c-section is major abdominal surgery,
carrying with it a considerable list of risks, such as bleeding,
infection, damage to nearby organs such as the bowel or the bladder,
scar tissue formation, and a higher risk in future pregnancies. When a
c-section is necessary, it can be a life saving technique for both
mother and infant.\
\
Another factor increasing the rates of c-section births is the belief
that 'once a c-section, always a c-section.' Often, pregnant women who
have had a previous c-section aren't necessarily aware that in some
facilities they can still choose to have a natural vaginal birth. The
risks from Vaginal Birth After C-section (VBAC) delivery are low, but
are slightly higher than for a repeat c-section delivery -- this finding
is from a study by the National Institute of Child Health and Human
Development of the National Institutes of Health.\
\
"We are strong advocates for VBAC at this facility for appropriate
candidates, and we have an excellent success rate with no known uterine
ruptures over the last 10 years," said Dr. Amanda Leib, TCRHCC OB/GYN
Chief.\
\
In 2006, among 28 mothers who chose to try to have VBACs at Tuba City
Hospital, there was an 82% success rate. 24 women had successful vaginal
births, and 4 underwent c-sections.\
"The decision for c-section is usually made between the doctor,
certified nurse mid-wife and patient.\
\
There are many reasons why women wind up having c-sections, and the
events leading to such a decision vary depending on the situation," said
Dr. Leib. Some reasons the c-section rate is low at Tuba City Hospital
are that we offer VBACs, we have a certified nurse mid-wife/obstetrician
model which allows more one-on-one attention during labor and delivery
than at other facilities, and that we are very involved with our high
risk patients. We believe in active management before fetal problems
occur."\
\
Barbara Orcutt, CNM, MSN, Director of Nurse Mid-wives at Tuba City
Hospital has been a certified nurse mid-wife for 29 years. She remarked,
"I've been associated with numerous practices and hospitals in various
parts of the country, and the acceptance of certified nurse mid-wifery
here is wonderful. We have a close working relationship with our
obstetricians and we are valued." Certified nurse mid-wives deliver all
of the vaginally born babies at Tuba City Hospital, and are involved in
the labor of women who eventually do have c-sections. There are 5
certified nurse mid-wives currently practicing at Tuba City Hospital.\
\
In addition to following traditional ways, the OB/Gyn Department is
scheduled and run in such a manner that both patient and provider will
very often see a familiar face when a woman is in labor. Certified nurse
mid-wives staff the OCU 24 hours a day, and they work 12-hour shifts so
there is continuity with any one patient with a large block of time.

Our schedules are structured as such that we don't think in terms of
'It's Friday afternoon and I'd better get her delivered before the
weekend,'" said Orcutt.\
\
Dr. Leib continued, "We regularly review our c-section rate and
individual c-sections as a department, looking for ways we can improve
and offer even better patient care."

#### Pregnant women considering a c-section, with no clear medical reason for it, should know that the procedure is not without risk, Canadian doctors caution in a report in February 2007. Dr. Shiliang Liu with the Public Health Agency in Ottawa, Canada, and colleagues, report that the rate of severe complications, such as major bleeding, infection and blood clots, is three times higher overall in women having a planned c-section compared with women who have a natural birth. The researchers used a Canadian database to look at the outcomes of 46,766 women who underwent what doctors deemed to be a low-risk, c-section delivery and nearly 2.3 million women who underwent planned vaginal delivery between April 1991 and March 2005. Liu's team found that the rate of severe complications in the planned cesarean group was 27.3 cases per 1,000 deliveries, compared with 9.0 per 1,000 deliveries in the planned vaginal delivery group. This data adds to a growing body of evidence suggesting that primary elective c-section birth may place both the mother and newborn at greater risk for complications. In 2005 there were 546 live births at Tuba City Hospital, of which 471 were vaginal deliveries. Of the 546, 75 were c-section deliveries -- 40 of which were primary c-sections (first time c-sections), and 35 of which were repeat c-sections. "We have some really fine doctors and providers at Tuba City Hospital and in the Indian Health Service," remarked Orcutt. "We provide excellent maternity care that is based on sound medical evidence and do not engage in the legal protective thinking that pervades obstetrics elsewhere." "It's a wonderful way to practice," Orcutt continued, "just doing the natural thing, the right thing." "Here on the Navajo Reservation, there is still a cultural acceptance of labor and birth as a natural function of the body, and great stoicism in labor. All of this decreases interventions. All of these things factor into our low c-section rate at TCRHCC."  TCRHCC Mission Tuba City Regional Health Care Corporation is a community focused non-profit, health care organization offering a 73-bed acute care referral hospital and a broad range of outpatient care services. It serves a patient population of approximately 75,000 Navajo, Hopi and San Juan Piute, in a 4,400 square mile area. Its mission is to provide accessible, quality, culturally sensitive health care.  Arizona Perinatal Trust Mission The Arizona Perinatal Trust is created to be an independent source of energy and resources to focus efforts on the continuing improvement of the health of Arizona's mothers and babies.  Arizona Perinatal Trust Purpose Based in Casa Grande, Arizona, the Arizona Perinatal Trust (Trust) is a non-profit organization, working to continually improve the quality of care for Arizona's mothers and babies. • Promote, develop and coordinate Arizona's regional perinatal system • Provide, facilitate and support perinatal education • Collaborate with the diverse community of perinatal healthcare providers, • Arizona Health Care Cost Containment System (AHCCCS), and the Arizona Department of  {#pregnant-women-considering-a-c-section-with-no-clear-medical-reason-for-it-should-know-that-the-procedure-is-not-without-risk-canadian-doctors-caution-in-a-report-in-february-2007.-dr.-shiliang-liu-with-the-public-health-agency-in-ottawa-canada-and-colleagues-report-that-the-rate-of-severe-complications-such-as-major-bleeding-infection-and-blood-clots-is-three-times-higher-overall-in-women-having-a-planned-c-section-compared-with-women-who-have-a-natural-birth.-the-researchers-used-a-canadian-database-to-look-at-the-outcomes-of-46766-women-who-underwent-what-doctors-deemed-to-be-a-low-risk-c-section-delivery-and-nearly-2.3-million-women-who-underwent-planned-vaginal-delivery-between-april-1991-and-march-2005.-lius-team-found-that-the-rate-of-severe-complications-in-the-planned-cesarean-group-was-27.3-cases-per-1000-deliveries-compared-with-9.0-per-1000-deliveries-in-the-planned-vaginal-delivery-group.-this-data-adds-to-a-growing-body-of-evidence-suggesting-that-primary-elective-c-section-birth-may-place-both-the-mother-and-newborn-at-greater-risk-for-complications.-in-2005-there-were-546-live-births-at-tuba-city-hospital-of-which-471-were-vaginal-deliveries.-of-the-546-75-were-c-section-deliveries-40-of-which-were-primary-c-sections-first-time-c-sections-and-35-of-which-were-repeat-c-sections.-we-have-some-really-fine-doctors-and-providers-at-tuba-city-hospital-and-in-the-indian-health-service-remarked-orcutt.-we-provide-excellent-maternity-care-that-is-based-on-sound-medical-evidence-and-do-not-engage-in-the-legal-protective-thinking-that-pervades-obstetrics-elsewhere.-its-a-wonderful-way-to-practice-orcutt-continued-just-doing-the-natural-thing-the-right-thing.-here-on-the-navajo-reservation-there-is-still-a-cultural-acceptance-of-labor-and-birth-as-a-natural-function-of-the-body-and-great-stoicism-in-labor.-all-of-this-decreases-interventions.-all-of-these-things-factor-into-our-low-c-section-rate-at-tcrhcc.-tcrhcc-mission-tuba-city-regional-health-care-corporation-is-a-community-focused-non-profit-health-care-organization-offering-a-73-bed-acute-care-referral-hospital-and-a-broad-range-of-outpatient-care-services.-it-serves-a-patient-population-of-approximately-75000-navajo-hopi-and-san-juan-piute-in-a-4400-square-mile-area.-its-mission-is-to-provide-accessible-quality-culturally-sensitive-health-care.-arizona-perinatal-trust-mission-the-arizona-perinatal-trust-is-created-to-be-an-independent-source-of-energy-and-resources-to-focus-efforts-on-the-continuing-improvement-of-the-health-of-arizonas-mothers-and-babies.-arizona-perinatal-trust-purpose-based-in-casa-grande-arizona-the-arizona-perinatal-trust-trust-is-a-non-profit-organization-working-to-continually-improve-the-quality-of-care-for-arizonas-mothers-and-babies.-promote-develop-and-coordinate-arizonas-regional-perinatal-system-provide-facilitate-and-support-perinatal-education-collaborate-with-the-diverse-community-of-perinatal-healthcare-providers-arizona-health-care-cost-containment-system-ahcccs-and-the-arizona-department-of .Style-Heading-4-+-Arial-14-pt-Underline}

#### Health Services/Office of Women's and Children's Health • Increase public awareness of perinatal health.  {#health-servicesoffice-of-womens-and-childrens-health-increase-public-awareness-of-perinatal-health. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Tuba City Regional Health Care Corporation Press Release {#tuba-city-regional-health-care-corporation-press-release .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.tchealth.org/news_033007.html**](http://www.tchealth.org/news_033007.html) {#httpwww.tchealth.orgnews_033007.html .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

[Collins-Fulea
C](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Collins-Fulea+C"%5BAuthor%5D),
et al Improving midwifery practice: the American College of
Nurse-Midwives\' benchmarking project. [J Midwifery Womens
Health.](javascript:AL_get(this, 'jour', 'J Midwifery Womens Health.');)
2005 Nov-Dec;50(6):461-71.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16260360>

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

#### [**http://download.journals.elsevierhealth.com/pdfs/journals/1526-9523/PIIS1526952305003302.pdf**](http://download.journals.elsevierhealth.com/pdfs/journals/1526-9523/PIIS1526952305003302.pdf) {#httpdownload.journals.elsevierhealth.compdfsjournals1526-9523piis1526952305003302.pdf .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

######### Urinary Tract Infections: A Primer for Clinicians (CME)

<http://www.medscape.com/viewarticle/556040>

**Management of Breast Cysts Revisited (CME)**

<http://www.medscape.com/viewarticle/555606>

**CDC Issues New Treatment Recommendations for Gonorrhea (CME)**

[http://www.medscape.com/viewarticle/555228?sssdmh=dm1.269355&src=top10#](http://www.medscape.com/viewarticle/555228?sssdmh=dm1.269355&src=top10)

**[Optimizing Once-Daily Antiretroviral Regimens for Treatment-Naive
Patients With HIV: A Case-Based
Approach](http://mp.medscape.com/cgi-bin1/DM/y/hBOmG0Ou5N60Dzc0IWZw0GH)
(CME)**

<http://www.medscape.com/viewarticle/532220>

######### 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**

**Earlier hormone therapy closer to menopause tended to have reduced CHD
risk**

CONCLUSIONS: Women who initiated hormone therapy closer to menopause
tended to have reduced CHD risk compared with the increase in CHD risk
among women more distant from menopause, but this trend test did not
meet our criterion for statistical significance. A similar
nonsignificant trend was observed for total mortality but the risk of
stroke was elevated regardless of years since menopause. These data
should be considered in regard to the short-term treatment of menopausal
symptoms.

[Rossouw
JE](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Rossouw+JE"%5BAuthor%5D),
et al Postmenopausal hormone therapy and risk of cardiovascular disease
by age and years since menopause
[JAMA.](javascript:AL_get(this, 'jour', 'JAMA.');) 2007 Apr
4;297(13):1465-77

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17405972**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17405972) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgidbpubmedcmdretrievedoptabstractpluslist_uids17405972 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Low dose transdermal estradiol gel effective for postmenopausal symptoms {#low-dose-transdermal-estradiol-gel-effective-for-postmenopausal-symptoms-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. {#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. .Style-Heading-4-+-Arial-14-pt-Underline}

[Simon
JA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Simon+JA"%5BAuthor%5D),
et al Low dose of transdermal estradiol gel for treatment of symptomatic
postmenopausal women: a randomized controlled trial [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007
Mar;109(3):588-96

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17329509>

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

#### Updated Statement on Hormone Therapy (CME) {#updated-statement-on-hormone-therapy-cme .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.medscape.com/viewarticle/551565?src=0_nl_cme_8**](http://www.medscape.com/viewarticle/551565?src=0_nl_cme_8) {#httpwww.medscape.comviewarticle551565src0_nl_cme_8 .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

**Ultrasound affects mice brains in negative ways: First, do no harm**

I was flipping through the November/December issue of Mothering magazine
and found a citation of an interesting research article on the effects
of ultrasound on mice brains. It has scary findings for an intervention
that is often considered routine and benign by providers and patients.

Eugenius, et al\*, found that when fetal mice are exposed to 30 minutes
or more of ultrasound that "a small but statistically significant number
of neurons fail to acquire their proper position and remain scattered
within inappropriate cortical layers and/or in the subjacent white
matter. The magnitude of dispersion of labeled neurons was variable but
systematically increased with duration of exposure to USW." Yikes! This
means that cells in the brain are not all in the right place. Okay,
you're saying these are mice, not humans. In their discussion the
authors discuss this---it might not apply to humans, but then again it
might in a big way:

> First it may not be applicable because "..the distance between the
> exposed cells and transducer in our experiments is shorter than in
> human. Furthermore, the duration of neuronal production and the
> migratory phase of cortical neurons in the human fetus lasts
> ![](media/image6.png){width="0.10416666666666667in"
> height="7.291666666666667e-2in"}18 times longer than in mice (between
> 6 and 24 weeks of gestation, with the peak occurring between 11 and 15
> weeks), compared with the duration of only
> ![](media/image6.png){width="0.10416666666666667in"
> height="7.291666666666667e-2in"}1 week (between E11 and E18) in the
> mouse. Thus, an exposure of 30 min represents a much smaller
> proportion of the time dedicated to development of the cerebral cortex
> in human than in mouse and, thus, could have a lesser overall effect,
> making human corticogenesis less vulnerable to USW" (ultrasound
> mwaves.)
>
> But on the other hand, "There are also some reasons to think that the
> USW may have a similar or even greater impact on neuronal migration in
> the human fetal brain. First, migrating neurons in the human forebrain
> are only slightly larger than in the mouse, and, with the acoustic
> absorption provided by the tissue stand-off pad, the amount of energy
> absorbed within a comparable small volume of tissue during the USW
> exposure was in the same general range. Second, the migratory pathway
> in the convoluted human cerebrum is curvilinear and at least an order
> of magnitude longer. Thus, the number of neurons migrating along the
> same radial glial fascicle, particularly at the later stages of
> corticoneurogenesis, is much larger and their routes are more complex,
> increasing the chance of a cell going astray from its proper migratory
> course. Third, the inside-to-outside settling pattern of isochronously
> generated neurons in primates is more precise than in rodents and
> thus, the tolerance for malpositioning may be smaller. In addition,
> different functional areas in the primate cortex are generated by
> different schedules so that exposure to USW may potentially affect
> selective cortical areas and different layers, depending on the time
> of exposure, potentially causing a variety of symptoms."

These effects of ultrasound are hard to study in humans because the
testing to find ectopic cells in the brain cannot be done in humans
according to the authors. There are some things that are known and are
concerning: "even a small number of ectopic cells might, as a result of
specific position and inappropriate connectivity, be a source of
epileptic discharge or abnormal behavior. Although we have not as yet
generated behavioral data, previous studies in rodents and primates
indicate that prenatal exposure to USW may affect higher brain function
of the offspring. Furthermore, there are numerous human neuropsychiatric
disorders that are thought to be the result of misplacement of cells as
a consequence of abnormal neuronal migration." The authors go on to say
that their research supports the recommendation by the FDA that
medically non-indicated commercial ultrasound videos should not be done.

I find this research concerning for more than just ultrasound videos
offered in malls. I wonder about repeated ultrasounds for medical
indications, dating ultrasounds during the most vulnerable periods of
cell migration in the brain, antenatal testing that has never been shown
to improve outcomes, and, the biggest of all, continuous fetal
monitoring during labor for hours on end. Remember: the ultrasound to
create pictures is pulsed---only 1/100th of the time is actual exposure
to ultrasound---whereas the fetal monitor on L & D is a continuous
deluge of ultrasound---it is not pulsed, the whole time is exposure to
ultrasound and the effects these researchers found increased with time.
Yes, most monitoring is after the time of migration of neurons cited
above, but we do know that the human brain continues to develop in a big
way for the rest of intrauterine life and a long time after, so there
may be are other effects on the brain cells. Anyone heard tell of
increased rates of autism, depression, bipolar disease, behavioral
problems, etc. in the current crop of young 'ens?? Food for thought.....

**Other Resources:**

**Physics and safety of diagnostic ultrasound in obstetrics and
gynecology, UpToDate**

<http://www.uptodateonline.com/utd/content/topic.do?topicKey=antenatl/15779&type=A&selectedTitle=3~549>

**Indications for diagnostic obstetrical ultrasound examination,
UpToDate**

<http://www.uptodateonline.com/utd/content/topic.do?topicKey=antenatl/7451&type=A&selectedTitle=1~549>

\*Eugenius, et al citation available from <Lisa.Allee@ihs.gov>

**Navajo News, John Heusinkveld. Shiprock**

**Adjustable Urethral Slings Offer Hope for Patients with Complex
Incontinence Problems**

This month\'s Navajo News comes from Northern Navajo Medical Center,
which has the highest gynecology surgery volume of the Navajo Area IHS
facilities.

Over the past 10 years, various versions of the mid-urethral sling
operation have dramatically improved the surgical treatment of
urodynamic stress incontinence. The vast majority of patients, whose
incontinence results from urethral hypermobility, can now be cured by a
simple, minimally invasive procedure, preferably in combination with
pelvic floor physical therapy.

Treatment of stress incontinence resulting from problems such as
instrinsic sphincteric deficiency (ISD) and other neuromuscular problems
remains more problematic. Urethral bulking procedures such as collagen
or carbon bead injection can provide temporary relief, but have to be
repeated at intervals in order maintain their effect. Mid-urethral
slings placed via the suprapubic approach appear to be moderately
effective for ISD; however, in order to be effective for this
indication, a sling generally needs to be placed under greater tension
than one placed for urethral hypermobility, and the difference between
continence and retention can be quite small.

A new modification of the suprapubic sling technique appears to be
well-suited for patients with complex problems such as ISD or recurrent
incontinence after previous surgery. In this procedure, a small sling of
mesh is placed under the mid-urethra and attached to 2 polypropylene
threads which pass behind the pubic symphysis and through the lower
extent of the abdominal wall, where they are attached to a small
prosthesis, implanted directly above the rectus fascia via a two to
three centimeter incision in the skin above the symphysis pubis. This
prosthesis contains a tiny spool around which the traction threads are
wound; rotating the spool to the right or left increases or decreases
the level of tension on the threads, which correspondingly adjust the
level of support for the urethra. A small plastic arm attached to the
prosthesis containing the spool is left in place, protruding slightly
through a small gap in the suprapubic incision. On postoperative day one
or two, the bladder is filled, the indwelling catheter is removed, and
the adjustment arm is rotated to the right, increasing support for the
urethra until no leakage is observed with coughing. The cough test is
then repeated with the patient standing, and the level of tension can be
increased if necessary. The patient then voids and the tension can be
reduced if retention occurs. Finally, the adjustment arm is removed and
the gap in the incision is closed.

If a patient with an adjustable sling ever experiences recurrent leakage
or retention, the level of urethral support can be adjusted via a simple
procedure done under local anesthesia, in which the suprapubic incision
is reopened and the adjustment arm is reattached to the prosthesis,
allowing the spool to be turned to the right or left as needed to
increase or decrease the level of urethral support. This procedure can
be repeated as many times as needed throughout the patient\'s life.

In addition to patients with sphincter deficiency, adjustable slings
appear well-suited for patients who have failed a conventional
continence operation, or who present with recurrent leakage after
previous surgical procedures. They can also be used with caution in
patients who are not candidates for other surgical techniques due to
neuromuscular problems affecting the detrusor muscle. These patients
typically utilize the Valsalva maneuver during voiding, and are at high
risk for retention using conventional surgical techniques. An adjustable
sling allows the surgeon to find a level of support that balances
continence with retention.

To our knowledge there are two adjustable sling products currently
approved by the FDA, only one of which is actively being marketed in the
United States. The system described here was developed by the Neomedic
corporation in Spain and is marketed in the US by Tri-Anim under the
brand name Remeex™ (Regulacion Mecanica Externa). A somewhat different
system using a trans-obturator route, Safyre-t™, manufactured by the
South American company Promedon, has received FDA approval but is not
yet being marketed in the US. The Neomedic product has been in
widespread use in Europe since 1999 with an excellent safety record and
good results.

Our early experience with the adjustable sling in Shiprock has been
positive. The surgical technique is virtually identical to placement of
a conventional mid-urethral sling via the suprapubic route. As expected,
adjustable sling placement involves significantly more effort for the
surgeon and the patient than a conventional sling, typically requiring
several days hospitalization in order to implant and adjust the sling.
Although we would not advocate the adjustable sling as a first-line
treatment for most stress incontinence patients, we believe that it is
an excellent option for patients with certain conditions.

Here is a link to a commercial website which contains abstracts from a
group in Spain which has been evaluating the Neomedic product in
long-term trials.

[[http://remeex.com/index.php?id_seccio_menu=37&cnv_idioma=1&idioma_seleccionat=1]{.underline}](http://remeex.com/index.php?id_seccio_menu=37&cnv_idioma=1&idioma_seleccionat=1)

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

#### [**John.Heusinkveld@ihs.gov**](mailto:John.Heusinkveld@ihs.gov) {#john.heusinkveldihs.gov .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Nurses Corner, Sandra Haldane, HQE**

#### Personal Digital Assistants: Practical Advice for Nurses in 2007 {#personal-digital-assistants-practical-advice-for-nurses-in-2007-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.medscape.com/viewarticle/553563?sssdmh=dm1.264275&src=0_tp_nl_0**](http://www.medscape.com/viewarticle/553563?sssdmh=dm1.264275&src=0_tp_nl_0) {#httpwww.medscape.comviewarticle553563sssdmhdm1.264275src0_tp_nl_0 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-36 .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}

**CDC's Pregnancy Information Center**

If you\'re pregnant or planning to get pregnant, you probably have a lot
of questions.  This website will help you learn how to be healthy
(before, during, and after pregnancy) and give your baby a healthy start
to life.

<http://www.cdc.gov/ncbddd/pregnancy_gateway/default.htm>

**Lead Exposure Among Females of Childbearing Age - United States,
2004**

This report summarizes 2004 surveillance data regarding elevated blood
lead levels (BLLs) among females of childbearing age (i.e., aged 16-44
years) in 37 states participating in CDC\'s Adult Blood Lead
Epidemiology and Surveillance program. The results indicated that rates
of elevated BLLs ranged from 0.06 per 100,000 females of childbearing
age at BLLs of \>40 µg/dL to 10.9 per 100,000 females at BLLs of \>5
µg/dL. Primary and secondary prevention of lead exposure among females
of childbearing age is needed to avert neurobehavioral and cognitive
deficits in their offspring.

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

####  {#section-37 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Cesarean Delivery on Maternal Request**

It was in June of last year when I last wrote about the NIH Consensus
conference on Cesarean Delivery on Maternal Request (CDMR). Over the
past year there has been several articles written on the subject. The
most recent of which is published in the New England Journal of Medicine
by Ecker and Frigoletto (excerpted below).

Here at Hasting's Indian Medical Center, we are beginning to explore
this issue through journal clubs and dialogue. We have had more patients
recently requesting Cesarean Delivery over the past year. A review of
the NIH Consensus conference points out that most of the evidence is
weak or non-existent to support planned vaginal or cesarean delivery.
Moderate quality evidence is available for only three outcome variables
(postpartum hemorrhage, maternal length of stay, and neonatal
respiratory morbidity). .

ACOG sent out a news release
[on](http://www.acog.org/from_home/publications/press_releases/nr05-09-06-1.cfm)
May 9, 2006 after the NIH consensus conference. In it they point out
that more research is needed and that CDMR is not recommended for women
planning on having several children due to the risks of placenta previa
and placenta accreta increasing with each cesarean delivery. In
addition, Dr. Zinberg, Deputy Executive Vice President of ACOG states
"ACOG continues to review all of the issues surrounding maternal-request
cesarean, but at this time our position is that cesareans should be
performed for medical reasons."

A number of the articles written have pointed out ACOG's position that a
cesarean delivery on maternal request can be ethically justified at
times. In ACOG's "Surgery and Patient Choice: The Ethics of Decision
Making," ACOG states that "In the absence of significant data on the
risks and benefits of cesarean delivery, the burden of proof should fall
on those who are advocates for a change in policy in support of elective
cesarean delivery (i.e., the replacement of a natural process with a
major surgical procedure."

As many of the articles and editorials written over the past year have
pointed out, caution should be used when a patient requests a cesarean
delivery. Moving slowly in the absence of good evidence is a prudent
option. While support for a women's choice is without question of
paramount importance, performing cesarean deliveries on maternal request
may ultimately lead to a violation of the Hippocratic Oath to do no
harm.

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

**Looking for sanity in the ever increasing cesarean delivery rate**

Ecker and Frigoletto state the key question centers on both the number
needed to treat to avoid one adverse neonatal outcome and the level of
risk that is currently considered acceptable. As practicing
obstetricians, we find that the risk that women are now willing to
assume in exchange for a measure of potential benefit, especially for
the neonate, has changed: for many, the level of risk of an adverse
outcome that was tolerated in the past to avoid cesarean delivery is no
longer acceptable, and the threshold number needed to treat has thus
been reset.

In the face of the resulting continued increase in cesarean deliveries,
our obligation as providers is to educate patients about the trade-offs
entailed in choosing a particular course or intervention and to ensure
that their choices are congruent with their own philosophy, plans, and
tolerance of risk. In areas in which there is still uncertainty, we must
organize clinical trials that will produce the data we require for
counseling patients. For the moment, however, few of the relevant
factors seem likely to change, and the cesarean rate can be predicted to
continue its climb.

The March 2006 National Institutes of Health (NIH) State-of-the-Science
Conference report concluded that there was a need for research that
explicitly compared outcomes of planned cesarean delivery with outcomes
of planned vaginal delivery. Declercq et al examines 6 years of data
from a population-based linked data system to create a refined measure
identifying women with planned cesareans and planned vaginal births and
comparing maternal outcomes and costs associated with these two options.

1.) planned cesarean increases complications and re-hospitalizations and

2.) planned cesarean increases cost

Declercq et al document a small, but consistent growth in planned
primary cesareans, but higher costs, longer hospital stays, and
substantially greater risks of maternal re-hospitalization associated
with these deliveries.

The authors found that

\* The rate of re-admission to a hospital (per 1,000) within 1 month of
delivery for planned vaginal births was significantly lower than that
for planned primary cesarean births (7.5 vs. 19.2). Adjusting for age,
race or ethnicity, and parity, a woman who had a planned primary
cesarean birth was 2.3 times as likely as a woman who had a planned
vaginal birth to be re-admitted in the first month after the birth.

\* The leading reason for re-admission associated with planned primary
cesarean births in the first 30 days after birth was surgical wound
complications. Postpartum infections were a major cause of re-admission
for both groups, with the rate of re-admission for infection after
planned primary cesarean births almost twice as high as that of
infection after planned vaginal births.

\* The average initial maternal (excluding infant) hospital costs in
2003 dollars for a planned primary cesarean birth were 76% higher than
the average initial costs for a planned vaginal birth (\$4,372 vs.
\$2,487).

\* Women who had a planned primary cesarean birth averaged 4.3 days in
their initial stay and 4.4 days in cases of re-admission, compared with

2.4 and 3.9 days, respectively, for those with a planned vaginal birth.

\* Costs associated with a planned primary cesarean birth, compared with
costs associated with a planned vaginal birth, were higher for both
delivery (65%) and postpartum re-admission (11%).

# [Kennare R](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Kennare+R"%5BAuthor%5D), et al just reported that after the first cesarean, the risks increase in next pregnancy. Specifically, cesarean delivery is associated with increased risks for adverse obstetric and perinatal outcomes in the subsequent birth. However, some risks may be due to confounding factors related to the indication for the first cesarean.

Dr. Woitte reminds us to do no harm. Declercq et al and [Kennare
R](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Kennare+R"%5BAuthor%5D),
et al findings suggest that planned primary cesareans are not without
immediate health consequences for mothers and financial implications for
society. Clinicians should be aware of the increased risk for maternal
re-hospitalization after cesarean deliveries to low-risk mothers when
counseling women about their choices.

**Reference:**

Declercq E, Barger M, Cabral HJ, et al. 2007. Maternal outcomes
associated with planned primary cesarean births compared with planned
vaginal births. Obstetrics and Gynecology 109(3):669-677.
[[http://www.greenjournal.org/cgi/content/abstract/109/3/669?etoc]{.underline}](http://www.greenjournal.org/cgi/content/abstract/109/3/669?etoc)
or

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17329519&dopt=Abstract>

[Ecker
JL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Ecker+JL"%5BAuthor%5D),
[Frigoletto FD
Jr](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Frigoletto+FD+Jr"%5BAuthor%5D).
Cesarean delivery and the risk-benefit calculus. [N Engl J
Med.](javascript:AL_get(this, 'jour', 'N Engl J Med.');) 2007 Mar
1;356(9):885-8.
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17329693&dopt=Abstract>

Or <http://content.nejm.org/cgi/content/full/356/9/885>

[Kennare
R](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Kennare+R"%5BAuthor%5D),
et al Risks of adverse outcomes in the next birth after a first cesarean
delivery. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007
Feb;109(2 Pt 1):270-6

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17267823>

**NIH Consensus Conference Report**

[[http://consensus.nih.gov/2006
/2006CesareanSOS027html.htm]{.underline}](http://consensus.nih.gov/2006/2006CesareanSOS027html.htm)

**Patient-Requested Cesarean Update, ACOG Press Release**

<http://www.acog.org/from_home/publications/press_releases/nr05-09-06-1.cfm>

**Surgery and Patient Choice: The Ethics of Decision Making**

#### [**http://www.acog.org/from_home/publications/ethics/ethics021.pdf**](http://www.acog.org/from_home/publications/ethics/ethics021.pdf)  {#httpwww.acog.orgfrom_homepublicationsethicsethics021.pdf .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Let's put DEXA and other radiation risks into perspective**

Average Radiation Doses Associated With Common Imaging Studies

  ------------------------------------- ---------------------------------
  **Diagnostic Examination**            **Effective Dose (mSv)**

  **X-rays**                            

     Chest (PA film)                    0.02

     Head                               0.07

     Cervical spine                     0.3

     Thoracic spine                     1.4

     Lumbar spine                       1.8

     Abdomen                            0.53

     Pelvis/hip                         0.83

     Limbs/joints                       0.06

     Upper GI                           3.6

     Lower GI                           6.4

     Screening mammogram                0.13

  **CT**                                

     Head                               2.0

     Abdomen                            10.0

     Chest                              20-40

     Pulmonary angiography              20-40

  **PET - CT**                          25
  ------------------------------------- ---------------------------------

[[http://www.medscape.com/viewarticle/523000_3]{.underline}](http://www.medscape.com/viewarticle/523000_3)

**DEXA radiation safety and comparison**

As in the above table of other imaging procedures and their exposure

[[http://homepage.mac.com/kieranmaher/digrad/DRPapers/DEXA_Dosimetry.html#BMD]{.underline}](http://homepage.mac.com/kieranmaher/digrad/DRPapers/DEXA_Dosimetry.html#BMD)

**Health Risks from Exposure to Low Levels of Ionizing Radiation: BEIR
VII Phase 2 (2006)**

[[http://books.nap.edu/books/030909156X/html]{.underline}](http://books.nap.edu/books/030909156X/html)

**Patient education**

Nice patient education piece for health education public information Web
site developed and funded by the [American College of Radiology
(ACR)](http://www.acr.org/) and the [Radiological Society of North
America (RSNA)](http://www.rsna.org/). It was established to inform and
educate the public about radiologic procedures and the role of
radiologists in healthcare, and to improve communications between
physicians and their patients."
[[http://www.radiologyinfo.org/en/info.cfm?pg=dexa&bhcp=1]{.underline}](http://www.radiologyinfo.org/en/info.cfm?pg=dexa&bhcp=1)

**Relation of Cortisol Levels and Bone Mineral Density Among
Premenopausal Women With Major Depression **

<http://www.medscape.com/viewarticle/555892>

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

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

#### [**http://www.aafp.org/afp/20070501/1372ph.html**](http://www.aafp.org/afp/20070501/1372ph.html) {#httpwww.aafp.orgafp200705011372ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-38 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Low Back Pain {#low-back-pain-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20070415/1190ph.html**](http://www.aafp.org/afp/20070415/1190ph.html) {#httpwww.aafp.orgafp200704151190ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-39 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Placental cultures and histology poor predictors of infectious status
of the amniotic fluid**

RESULTS: Ninety-two percent of women with positive amniotic fluid
cultures tested with at least one positive placenta culture. Eighty
percent of women who had negative amniotic fluid cultures also tested
with a positive placenta culture. The accuracy of placental cultures in
predicting amniotic fluid infection varied from 44% to 57%. Placental
pathology showed an accuracy of only 58% in diagnosing intraamniotic
inflammation.

CONCLUSION: Placental microbiologic and histologic studies poorly
reflect the infectious and inflammatory status of the amniotic fluid.
Results of such studies should be interpreted with caution in the
management and future counseling of women with preterm labor or preterm
premature rupture of membranes

[Pettker
CM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Pettker+CM"%5BAuthor%5D),
et al Value of placental microbial evaluation in diagnosing
intra-amniotic infection. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007
Mar;109(3):739-49

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17329528>

**Free beta-HCG outperforms intact HCG in a multimarker protocol**

CONCLUSION: The results of our analysis suggest that in a
first-trimester Down syndrome screening protocol free beta-human
chorionic gonadotropin achieves higher sensitivity and lower
false-positive results than intact human chorionic gonadotropin .
Moreover, intact human chorionic gonadotropin does not add substantially
to screening performance until the end of the first trimester.

[Evans
MI](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Evans+MI"%5BAuthor%5D),
et al Meta-analysis of first trimester Down syndrome screening studies:
free beta-human chorionic gonadotropin significantly outperforms intact
human chorionic gonadotropin in a multimarker protocol Am J Obstet
Gynecol. 2007 Mar;196(3):198-205

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17346522>

**Forum: Periodontal Health and Birth Outcomes - HRSA MCHB**

Research to Policy and Practice Forum: Periodontal Health and Birth
Outcomes---Summary of a Meeting of Maternal, Child, and Oral Health
Experts explores the oral health requirements of pregnant women as a
promising strategy for improving maternal and infant health. The report
summarizes presentations of commissioned background papers and other
topics, as well as workgroup discussions from a forum convened by the
Health Resources and Services Administration\'s (HRSA\'s) Maternal and
Child Health Bureau, held on December 11-12, 2006, in Washington, DC.
[[http://www.mchoralhealth.org/PDFs/PeriodontalSummary.pdf]{.underline}](http://www.mchoralhealth.org/PDFs/PeriodontalSummary.pdf)

**PREMAG inconclusive, but improvements of outcome are of potential
significance**

CONCLUSION: Although our results are inconclusive, improvements of
neonatal outcome obtained with MgSO(4) are of potential clinical
significance. More research is needed to assess the protective effect of
MgSO(4) alone or in combination with other neuroprotective molecules.

[Marret
S](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Marret+S"%5BAuthor%5D),
et al Magnesium sulphate given before very-preterm birth to protect
infant brain: the randomized controlled PREMAG trial
[BJOG.](javascript:AL_get(this, 'jour', 'BJOG.');) 2007 Mar;114(3):310-8

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17169012>

**Insulin Glargine Use During Pregnancy Not Linked to Fetal Morbidity**

CONCLUSIONS: The results of this pilot study indicate that insulin
glargine treatment during pregnancy does not appear to be associated
with increased fetal macrosomia or neonatal morbidity.

Price, N et al Use of insulin glargine during pregnancy: a case-control
pilot study. [BJOG.](javascript:AL_get(this, 'jour', 'BJOG.');) 2007
Apr;114(4):453-7

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17261126>

## 

## Proposal for the Reconsideration of the Definition of Gestational Diabetes 

In 1997, the American Diabetes Association (ADA) announced a new
diagnostic criterion for diabetes and set the definition of gestational
diabetes mellitus (GDM). Before 1991, GDM was defined as \"a transient
abnormality of glucose tolerance during pregnancy\". However, the 1997
definition of GDM by the ADA includes diabetes diagnosed during
pregnancy. This definition ignores the added risks to the mother and to
the fetus when the mother has undiagnosed type 2 diabetes. We propose
reconsideration of the definition, which would separate diabetes and
slight abnormal carbohydrate, so-called GDM, to provide a better model
of care for type 2 diabetic pregnant women.

There are three problems concerning an undiagnosed type 2 diabetic woman
that are not major issues in pregnant women who are first diagnosed with
abnormal glucose tolerance in pregnancy that resolves after pregnancy.
First, the entire pregnancy is associated with abnormal carbohydrate
metabolism, not just the second half. The second problem is related to
the rate of congenital malformations of newborns from these pregnant
women. The third is concerned with undiagnosed diabetic retinopathy.

In our Japanese cohort, we observed the results of 75-g oral glucose
tolerance tests (OGTTs) (Japan criteria: two or more values above
fasting glucose \>100 mg/dl, 1-h glucose \>180 mg/dl, and 2-h glucose
\>150 mg/dl) for 1,416 pregnant women who had risk factors for GDM. We
found the frequency of GDM in the first trimester is the highest (33/250
\[13.2%\]), followed by the second (32/417 \[7.7%\]) and third
trimesters (37/749 \[4.9%\]). Similarly, the frequency of type 2
diabetes is the highest in the first trimester at 6.0%, with 2.6% in the
second trimester and 1.3% in the third trimester. Thus, in women with
positive OGTT, GDM accounts for 7.2% and type 2 diabetes diagnosed
during pregnancy accounts for 2.5% of the total pregnant population. In
other words, 35% of women with a positive OGTT have type 2 diabetes
diagnosed for the first time in pregnancy.

In this cohort, the congenital malformation rate from GDM patients was
1.9% and was no different from the rate in the general Japanese
population. In contrast, the congenital malformation rate in infants of
type 2 diabetic mothers diagnosed during pregnancy was higher than that
of children from pregestational diabetic mothers treated during
pregnancy, 12.7 vs. 4%, respectively.

There were no GDM patients with retinopathy. However, the rate of
background retinopathy was 12.7% and proliferative retinopathy was 4.2%
in the type 2 diabetic women diagnosed for the first time during
pregnancy.

Similar rates and complications were seen in a cohort of pregnant women
in Santa Barbara, California, where a total of 49,861 pregnancies
occurred in our Mexican-American population from 1997 to 2004. A total
of 4,133 (8.3%) had a positive OGTT based on the ADA criteria. However,
40% of the GDM women had type 2 diabetes first diagnosed during
pregnancy based on our criteria: acanthosis nicgrans, requiring insulin
before the 12th week of gestation, because they failed to maintain goals
with dietary intervention alone. Five percent of the type 2 women had
retinopathy, and 7% had significant proteinuria at time of diagnosis.

O'Sullivan defined GDM as \"a transient abnormality of glucose tolerance
during pregnancy.\" We should return to this time-honored definition. If
type 2 diabetes is first detected during pregnancy, then it should be
named as such. Data presented here underscores that this is a worldwide
problem.

[Omori
Y](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Omori+Y"%5BAuthor%5D),
[Jovanovic
L](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Jovanovic+L"%5BAuthor%5D).
Proposal for the reconsideration of the definition of gestational
diabetes. [Diabetes
Care.](javascript:AL_get(this, 'jour', 'Diabetes Care.');) 2005
Oct;28(10):2592-3

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16186312&dopt=Abstract>

**Level of angiogenic factors from first to second trimester as
predictors of preeclampsia**

CONCLUSION: Low placenta growth factor and high soluble fms-like
tyrosine kinase-1 increase from first to second trimester are strong
predictors of preeclampsia.

[Vatten
LJ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Vatten+LJ"%5BAuthor%5D),
et al Changes in circulating level of angiogenic factors from the first
to second trimester as predictors of preeclampsia [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2007
Mar;196(3):239.e1-6.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17346536>

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

**Electronic Health Record (EHR) Implementation: Worth the effort?**

Ongoing at this time. You still can join in

Moderator: David Johnson, MD

-Anticipated benefits of an EHR: Demonstrated through experience?

-What are the real costs: Decreased efficiency, IT support requirements,
etc...

### -Effect on the provider -- patient relationship

### 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**

**Guidelines for School-Based STD Screening in Indian Country**

I'm pleased to announce that our office has just released "Guidelines
for School-Based STD Screening in Indian Country". A PDF of the document
or hard copies are available, so please let me know if you would like
one. Also, the link will be up on our website soon, url below.

Thanks so much to everyone who helped to put these together. We look
forward to your feedback. Also, please let us know if you need our
technical assistance to implement school-based STD screening in your
area. Lori

Table of Contents Page

1 Introduction

2 Getting Started

3 Forming a Team

4 Making a Plan

5 Making the Pitch

6 Making it Happen

7 Making it Stick

Tel: 505-248-4202 or <lori.deravello@ihs.gov>

<http://www.ihs.gov/medicalprograms/epi/index.cfm>

**Fluoroquinolones No Longer Recommended for Treatment of Gonococcal
Infections**

In the United States, gonorrhea is the second most commonly reported
notifiable disease, with 339,593 cases documented in 2005. Since 1993,
fluoroquinolones (i.e., ciprofloxacin, ofloxacin, or levofloxacin) have
been used frequently in the treatment of gonorrhea because of their high
efficacy, ready availability, and convenience as a single-dose, oral
therapy. However, prevalence of fluoroquinolone resistance in Neisseria
gonorrhoeae has been increasing and is becoming widespread in the United
States, necessitating changes in treatment regimens.

Beginning in 2000, fluoroquinolones were no longer recommended for
gonorrhea treatment in persons who acquired their infections in Asia or
the Pacific Islands (including Hawaii); in 2002, this recommendation was
extended to California. In 2004, CDC recommended that fluoroquinolones
not be used in the United States to treat gonorrhea in men who have sex
with men (MSM). This report, based on data from the Gonococcal Isolate
Surveillance Project (GISP), summarizes data on
fluoroquinolone-resistant N. gonorrhoeae (QRNG) in heterosexual males
and in MSM throughout the United States. This report also updates CDC\'s
Sexually Transmitted Diseases Treatment Guidelines, 2006 regarding the
treatment of infections caused by N. gonorrhoeae. On the basis of the
most recent evidence, CDC no longer recommends the use of
fluoroquinolones for the treatment of gonococcal infections and
associated conditions such as pelvic inflammatory disease (PID).
Consequently, only one class of drugs, the cephalosporins, is still
recommended and available for the treatment of gonorrhea.

Update to CDC\'s Sexually Transmitted Diseases Treatment Guidelines,
2006: Fluoroquinolones No Longer Recommended for Treatment of Gonococcal
Infections. MMWR Morb Mortal Wkly Rep. 2007 Apr 13;56(14):332-336. 

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5614a3.htm>

**Let\'s talk about HIV counseling and testing -- New Facilitators\'
guide**

To download PDF of 70 page guide  "Tools to build NGO/CBO capacity to
mobilize communities  for HIV counseling and testing to help
non-governmental organizations (NGOs), community based organizations
(CBOs) and other civil society organizations in developing countries
help mobilize communities for HIV counseling and testing (HCT).

The guide covers different aspects of HCT and includes participatory
activities to carry out with NGO/CBO staff. The resource starts out by
providing basic information about testing, and then tries to get
participants to think critically about the advantages of and barriers to
HIV counseling and testing; issues around stigma, discrimination, and
confidentiality; the different medical, social, psychological and
economic needs of people who test either negative or positive for HIV.

#### [**http://www.aidsalliance.org/graphics/secretariat/publications/VCT_Manual.pdf**](http://www.aidsalliance.org/graphics/secretariat/publications/VCT_Manual.pdf) or [**http://www.aidsalliance.org/sw37361.asp**](http://www.aidsalliance.org/sw37361.asp) {#httpwww.aidsalliance.orggraphicssecretariatpublicationsvct_manual.pdf-or-httpwww.aidsalliance.orgsw37361.asp .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-41 .Style-Heading-4-+-Arial-14-pt-Underline}

**Does your lab have capacity to culture N gonorrhoeae for treatment
failures? **

Share with your lab staff and infection control staff!!!

Excerpts:

The US Centers for Disease Control and Prevention (CDC) have issued new
treatment recommendations for gonorrhea, which are published in the
April 13 issue of the Morbidity and Mortality Weekly Report. The new
guidelines recommending cephalosporin treatment are in response to
gonorrhea resistance to fluoroquinolones, which is now widespread in the
United States among heterosexuals and men who have sex with men."

Treat QRNC with Ceftriaxone 125 mg IM x1

Threshold for change of drugs is 5% resistance rates."  (said another
way 95% treatment effectiveness for a drug is sought)

Resistance seen in Asia (2000), Hawaii (2000), California (2002), MSM
(2004), UK (\~2003) and NOW broadly across US.

Fluoroquinolone-resistant N. gonorrhoeae (QRNG)

Men who have sex with men (MSM)

Gonococcal Isolate Surveillance Project (GISP)

ARG = Antibiotic Resistant Gonorrhea

Gonorrhea is under diagnosed and underreported, and we estimate that
about twice that number of people were affected. Incubation period
usually 2 to 7 days. -- Red Book

"Because gonorrhea resistance to penicillin, sulfa drugs, and
tetracycline is already widespread, this limits available options for
gonorrhea treatment to drugs in the cephalosporin class."

\"We are running out of options to treat this serious disease. Increased
vigilance in monitoring for resistance to all available drugs is
essential.\"

"...gonorrhea is largely diagnosed by a convenient DNA test, many
laboratories and providers no longer have the capability of culturing N
gonorrhoeae for drug resistance testing. The CDC is urging health
departments to maintain or develop this capacity and to evaluate any
gonorrhea treatment failures for possible resistance."

"...persistent symptoms of gonococcal infection or whose symptoms recur
shortly after treatment with a recommended or alternative regimen should
be reevaluated by culture for N gonorrhoeae."

"Most cases of gonorrhea in women are asymptomatic and untreated.
However, failure to treat gonorrhea aggressively and early may result in
pelvic inflammatory disease with associated infertility, chronic pelvic
pain, and/or ectopic pregnancy. In men, rare complications of untreated
gonorrhea may include epididymitis, rarely associated with infertility."

"Increase susceptibility to HIV due to inflammation."

"Alternative regimens for uncomplicated gonococcal infections of the
cervix, urethra, and rectum are 2 g of spectinomycin (not available in
the United States) in a single IM dose or cephalosporin single-dose
regimens (ceftizoxime, 500 mg IM; or cefoxitin, 2 g IM, administered
with probenecid, 1 g orally; or cefotaxime, 500 mg IM)."

"Positive isolates should be tested for antimicrobial susceptibility,
and clinicians and laboratories should report treatment failures or
resistant gonococcal isolates to the CDC at the telephone number:
1-404-639-8373, through state and local public health authorities."

Persons in whom gonococcal infection is diagnosed should be treated for
possible coinfection with Chlamydia trachomatis with a single dose of
azithromycin 1 g by mouth or with doxycycline 100 mg twice a day, by
mouth for 7 days, if chlamydial infection has not been ruled out.

<http://www.cdc.gov/std/gonorrhea/arg/>  
<http://www.medscape.com/viewarticle/555228?src=mp>

# Urinary symptoms in adolescent females: STI or UTI?

RESULTS: In the full sample, prevalence of UTI and STI were 17% and 33%,
respectively. Neither urinary symptoms nor UTI was significantly
associated with STI. Further analyses are reported for the 154 (51%)
with urinary symptoms: Positive urine leukocytes, more than one partner
in the last three months and history of STI predicted STI. Urinalysis
results identified four groups: (1) Normal urinalysis-67% had no
infection; (2) Positive nitrites or protein-55% had UTI; (3) Positive
leukocytes or blood-62% had STI; and (4) Both nitrites/protein and
leukocytes/blood positive-28% had STI and 65% had UTI. Those without a
documented UTI were more likely to have trichomoniasis than those with a
UTI, and 65% of those with sterile pyuria had STI, mainly trichomoniasis
or gonorrhea.

CONCLUSIONS: Adolescent females with urinary symptoms should be tested
for both UTI and STIs. Urinalysis results may be helpful to direct
initial therapy.

Huppert JS, Biro F, Lan D, Mortensen JE, Reed J, Slap GB. Urinary
symptoms in adolescent females: STI or UTI? J Adolesc Health. 2007
May;40(5):418-24. Epub 2007 Mar 9.  

<http://www.jahonline.org/article/PIIS1054139X06006112/abstract>

**Sexually transmitted infections in preadolescent children**

Pediatric nurse practitioners may be called on to conduct an assessment
for sexual abuse of a young child. Depending on the type of sexual
contact, a decision may have to be made to obtain cultures for sexually
transmitted infections (STIs). Recognizing the symptoms of STIs in
preadolescent children, along with having knowledge of the modes of
transmission, diagnostics, and treatment, are part of the clinical
decision. The impact of STI in preadolescent children has physical and
emotional consequences for the child and family, along with legal
consequences for an accused perpetrator. Knowledge about types of sexual
contact that necessitate STI cultures, incubation periods, and
symptomatology is essential. Accurate techniques and appropriate
selection of culture materials are necessary. Proper positioning of the
child for obtaining cultures can decrease the potential for discomfort
during the examination. Gonorrhea, Chlamydia trachomatis, herpes simplex
virus, human papillomavirus virus, syphilis, Trichomonas vaginalis,
hepatitis B, and HIV are reviewed.

Lewin LC.Sexually transmitted infections in preadolescent children. J
Pediatr Health Care. 2007 May-Jun;21(3):153-61. 

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17478304>

**Adjustments in opthalmia neonatorum (ON): Gonorrhea in pregnancy**

Redbook- For routine prophylaxis of infants immediately after birth, a
1% solution of silver nitrate, or 1% tetracycline or 0.5% erythromycin
ophthalmic ointment, OU with subsequent irrigation. Prophylaxis delay
for up to 1 hour for bonding.  Term Infants born to GC infected mom
125mg IV or IM ceftriaxone.   The 1993 Pediatrics article (below)
suggests that for women receiving PN care: Silver nitrate eye
prophylaxis caused no sustained deleterious effects and even provided
some benefit to infants born to women without Neisseria gonorrhoeae.
However, the effect was modest and against microorganisms of low
virulence. The results suggest that parental choice of a prophylaxis
agent including no prophylaxis is reasonable for women receiving
prenatal care and who are screened for sexually transmitted diseases
during pregnancy (cited online April 25, 2007)

Of interest is the WHO Bulletin 2000 -- Iodine cost effective and
clinically effective in developing countries for prophylaxis of ON 

<http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S0042-96862001000300017&lng=es&nrm=iso&tlng=en>

####  {#section-42 .Style-Heading-4-+-Arial-14-pt-Underline}

#### 'Redbook' article {#redbook-article-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [[http://pediatrics.aappublications.org/cgi/content/abstract/92/6/755]{.underline}](http://pediatrics.aappublications.org/cgi/content/abstract/92/6/755) {#httppediatrics.aappublications.orgcgicontentabstract926755-1 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-43 .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}

**High rate of diabetes among indigenous people not due to thrifty gene
according to study**

High rates of diabetes among indigenous people across the globe are
rooted in social disadvantage rather than a genetic pre-disposition
specific to indigenous populations.

This article examines one of the oldest gene-based theories of complex
disease causation: the thrifty genotype hypothesis (THG). This
hypothesis is emblematic of the way in which genetic research into
complex disease attracts a high investment of scientific resources while
contributing little to our capacity to understand these diseases and
perpetuating problematic conceptions of human variation. Although there
are compelling reasons to regard the high prevalence of type 2 diabetes
mellitus as a by-product of our biological incapacity to cope with
modern affluent and sedentary lifestyles, there is at present no
consistent evidence to suggest that minority populations are especially
genetically susceptible. Nor is it clear why such genetic differences
would be expected, given the original pan-species orientation of the
TGH. The limitations inherent in current applications of the TGH
demonstrate that genetic research into complex disease demands careful
attention to key environmental, social, and genetic risk factors
operating within and between groups, not the simplistic attribution of
between-group differences to racialized genetics. A robust
interdisciplinary approach to genetic epidemiological research is
proposed.

[Paradies
YC](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Paradies+YC"%5BAuthor%5D),
et al Racialized genetics and the study of complex diseases: the thrifty
genotype revisited [Perspect Biol
Med.](javascript:AL_get(this, 'jour', 'Perspect Biol Med.');) 2007
Spring;50(2):203-27

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17468539>

**Aspirin may be less effective heart treatment for women than men**

A new study shows that aspirin therapy for coronary artery disease is
four times more likely to be ineffective in women compared to men with
the same medical history.

CONCLUSIONS: Additional large studies are required to understand whether
biologically defined aspirin resistance is associated with increased
risk for cardiovascular events, with special attention paid to sex
differences.

[Dorsch
MP](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Dorsch+MP"%5BAuthor%5D),
et al Aspirin resistance in patients with stable coronary artery disease
with and without a history of myocardial infarction. [Ann
Pharmacother.](javascript:AL_get(this, 'jour', 'Ann Pharmacother.');)
2007 May;41(5):737-41

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17456544>

####  {#section-44 .Style-Heading-4-+-Arial-14-pt-Underline}

**Cholesterol Could be Key to Treating Fetal Alcohol Syndrome**

#### Consumption of alcohol by pregnant women can cause fetal alcohol spectrum defects (FASD), a congenital disease, which is characterized by an array of developmental defects that include neurological, craniofacial, cardiac, and limb malformations, as well as generalized growth retardation. FASD remains a significant clinical challenge and an important social problem. Although there has been great progress in delineating the mechanisms contributing to alcohol-induced birth defects, gaps in our knowledge still remain; for instance, why does alcohol preferentially induce a spectrum of defects in specific organs and why is the spectrum of defects reproducible and predictable. In this study, we show that exposure of zebrafish embryos to low levels of alcohol during gastrulation blocks covalent modification of Sonic hedgehog by cholesterol. This leads to impaired Hh signal transduction and results in a dose-dependent spectrum of permanent developmental defects that closely resemble FASD. Furthermore, supplementing alcohol-exposed embryos with cholesterol rescues the loss of Shh signal transduction, and prevents embryos from developing FASD-like morphologic defects. Overall, we have shown that a simple post-translational modification defect in a key morphogen may contribute to an environmentally induced complex congenital syndrome. This insight into FASD pathogenesis may suggest novel strategies for preventing these common congenital defects. {#consumption-of-alcohol-by-pregnant-women-can-cause-fetal-alcohol-spectrum-defects-fasd-a-congenital-disease-which-is-characterized-by-an-array-of-developmental-defects-that-include-neurological-craniofacial-cardiac-and-limb-malformations-as-well-as-generalized-growth-retardation.-fasd-remains-a-significant-clinical-challenge-and-an-important-social-problem.-although-there-has-been-great-progress-in-delineating-the-mechanisms-contributing-to-alcohol-induced-birth-defects-gaps-in-our-knowledge-still-remain-for-instance-why-does-alcohol-preferentially-induce-a-spectrum-of-defects-in-specific-organs-and-why-is-the-spectrum-of-defects-reproducible-and-predictable.-in-this-study-we-show-that-exposure-of-zebrafish-embryos-to-low-levels-of-alcohol-during-gastrulation-blocks-covalent-modification-of-sonic-hedgehog-by-cholesterol.-this-leads-to-impaired-hh-signal-transduction-and-results-in-a-dose-dependent-spectrum-of-permanent-developmental-defects-that-closely-resemble-fasd.-furthermore-supplementing-alcohol-exposed-embryos-with-cholesterol-rescues-the-loss-of-shh-signal-transduction-and-prevents-embryos-from-developing-fasd-like-morphologic-defects.-overall-we-have-shown-that-a-simple-post-translational-modification-defect-in-a-key-morphogen-may-contribute-to-an-environmentally-induced-complex-congenital-syndrome.-this-insight-into-fasd-pathogenesis-may-suggest-novel-strategies-for-preventing-these-common-congenital-defects. .Style-Heading-4-+-Arial-14-pt-Underline}

[Li
YX](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Li+YX"%5BAuthor%5D),
et al Fetal alcohol exposure impairs Hedgehog cholesterol modification
and signaling. [Lab
Invest.](javascript:AL_get(this, 'jour', 'Lab Invest.');) 2007
Mar;87(3):231-40

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17237799**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17237799) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgidbpubmedcmdretrievedoptabstractpluslist_uids17237799 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-45 .Style-Heading-4-+-Arial-14-pt-Underline}

**Apples during pregnancy could reduce asthma risk in offspring**

#### Women who eat apples during pregnancy may reduce the chances of their children developing asthma by the age of five, according to research funded by Asthma UK. {#women-who-eat-apples-during-pregnancy-may-reduce-the-chances-of-their-children-developing-asthma-by-the-age-of-five-according-to-research-funded-by-asthma-uk. .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-46 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Researchers discovered that the children of mothers who ate the most apples during pregnancy were 50% less likely to be diagnosed with asthma by the age of five. The study also determined that mothers who ate more fish during pregnancy reduce the likelihood of their child developing eczema during early life, and those mothers eating more oily fish during pregnancy reduce the likelihood of their child developing hay fever by the age of five. {#researchers-discovered-that-the-children-of-mothers-who-ate-the-most-apples-during-pregnancy-were-50-less-likely-to-be-diagnosed-with-asthma-by-the-age-of-five.-the-study-also-determined-that-mothers-who-ate-more-fish-during-pregnancy-reduce-the-likelihood-of-their-child-developing-eczema-during-early-life-and-those-mothers-eating-more-oily-fish-during-pregnancy-reduce-the-likelihood-of-their-child-developing-hay-fever-by-the-age-of-five. .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-47 .Style-Heading-4-+-Arial-14-pt-Underline}

#### The researchers suggest that the beneficial 'apple-specific' effect could come from powerful antioxidants called flavanoids, which have previously been associated with improved lung function in adults.  The study also noted that apple consumption in the UK has fallen to around 173g per person per day, compared to 207g in 1974. However, more research is needed to establish the exact association between the development of early-life asthma and consumption of these individual foods before recommendations can be made regarding the amount of apples or fish eaten during pregnancy.  Dr Victoria King, Asthma UK's Research Development Manager said: \'Eating a healthy, balanced diet during pregnancy is advisable and this study suggests simple modifications to a pregnant mother's diet that may help protect her child from developing asthma before the age of five. One in ten children in the UK has asthma, therefore, we are pleased to have funded research that could provide a natural way to help reduce the incidence of childhood asthma.\' {#the-researchers-suggest-that-the-beneficial-apple-specific-effect-could-come-from-powerful-antioxidants-called-flavanoids-which-have-previously-been-associated-with-improved-lung-function-in-adults.-the-study-also-noted-that-apple-consumption-in-the-uk-has-fallen-to-around-173g-per-person-per-day-compared-to-207g-in-1974.-however-more-research-is-needed-to-establish-the-exact-association-between-the-development-of-early-life-asthma-and-consumption-of-these-individual-foods-before-recommendations-can-be-made-regarding-the-amount-of-apples-or-fish-eaten-during-pregnancy.-dr-victoria-king-asthma-uks-research-development-manager-said-eating-a-healthy-balanced-diet-during-pregnancy-is-advisable-and-this-study-suggests-simple-modifications-to-a-pregnant-mothers-diet-that-may-help-protect-her-child-from-developing-asthma-before-the-age-of-five.-one-in-ten-children-in-the-uk-has-asthma-therefore-we-are-pleased-to-have-funded-research-that-could-provide-a-natural-way-to-help-reduce-the-incidence-of-childhood-asthma. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.asthma.org.uk/news_media/news/apples_during.html**](http://www.asthma.org.uk/news_media/news/apples_during.html) {#httpwww.asthma.org.uknews_medianewsapples_during.html .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-48 .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 Early Drinking Problems More Likely to Escape Diagnosis**

Men are more likely than women to experience many of the problems
commonly associated with nondependent drinking, according to a new
study. But the authors suggest women are prone to different
alcohol-related problems that are less likely to be diagnosed.

CONCLUSIONS: Significant gender differences were found in approximately
one-third of the symptoms assessed and in the overall scale. Further
examination of the nature of gender differences in alcohol problem
symptoms should be undertaken to investigate whether a gender-neutral
scale should be created or if men and women should be assessed with
separate criteria for alcohol dependence and abuse.

Nichol PE, Krueger RF, Iacono WG. Investigating gender differences in
alcohol problems: a latent trait modeling approach Alcoholism: Clinical
and Experimental Research 31(5), 2007.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17386067>

**Women and Health Coverage: The Affordability Gap**

Although both men and women in the U.S. have a similar risk of being
uninsured, women are more likely to have problems accessing health care
because of costs, a new Commonwealth Fund issue brief finds.\
\
Conducted by researchers Elizabeth M. Patchias and Judith G. Waxman of
the National Women\'s Law Center, the study finds that the high cost of
health care services and premiums is forcing many women, even those with
health insurance, to go without needed care. In fact, 33 percent of
insured women and 68 percent of uninsured women don\'t get the health
care they need because they can\'t afford it. Moreover, a higher
proportion of women than men struggle to pay medical bills.

Women and Health Coverage: The Affordability Gap finds that women are at
a disadvantage because they have greater health care needs and lower
incomes than men. \"Women are more likely than men to go without needed
health care services because of costs, yet they still have higher
out-of-pocket expenses,\" said Waxman.\
\
\"As policymakers and advocates explore how to expand and improve health
coverage, they should ensure that any proposal provides comprehensive
benefits and low cost-sharing.

E. M. Patchias and J. Waxman, Women and Health Coverage: The
Affordability Gap, The Commonwealth Fund, April 2007

<http://www.cmwf.org/publications/publications_show.htm?doc_id=478513&#doc478513>

**WomenHeart Symposium 2007**

I  writing you to ask you to do a two things. First, help us identify
women with heart disease who might be good candidates for the Sixth
Annual, \"Science and Leadership Symposium for Women with Heart
Disease\" to be held in Rochester October 6-10, 2007. Second, help
spread the word about this course to potential applicants via your
network of colleagues, website, media and professional associations.

Mayo Clinic and WomenHeart: The National Coalition for Women with Heart
Disease, are again co-hosting this course, with the goal of developing a
national network of informed and activated women heart patients who will
go back to their communities to educate others and advocate for better
recognition and care for women with heart disease.  Each year since
2002, 60 geographically and ethnically diverse women with heart disease
have been taught basic information about cardiovascular disease,
treatments, and research, and received training in advocacy, community
education and public speaking.  In return for their participation they
are required to perform at least 24 hours of community education and
outreach activities in the first six months after the course. We have
trained more than 300 women from 42 states now, and last year\'s class
was made up of more than 25% women of color. Virtually all past
participants have met their required \"give back\" and most have done
far more, seeking out venues and media to reach and teach other women
and developing a growing number of support networks nationwide to help
the 8 million other women living with heart disease.

Participants will be chosen in a competitive process based on their
responses to the essay questions in the application with an emphasis on 
experience, passion and the likelihood that they will be effective in
their communities, with some consideration of ethnic and geographic
diversity.  You can help this program by encouraging qualified women
with heart disease, particularly women of color and those from medically
underserved areas, who you think might be good candidates, to apply for
the program.  A copy of the application can be accessed from the main
page on the WomenHeart website
[www.womenheart.org](http://www.womenheart.org/).  If accepted, there is
no cost to the participants except for transportation to Rochester (and
there is a scholarship fund for those whom this would be a hardship)

Please spread the word and this forward this to those who would be good
candidates. Sara Sandel at WomenHeart and I are available to discuss any
questions that you or potential applicants might have about the
Symposium or the application process. This is a fairly intense 4 1/2 day
program aimed mainly at those who are at a stage in life and in good
enough health that they wish to move on and give back to other women
their communities.

For those of you who are health care providers, I have attached a
generic introductory letter to send to your eligible patients explaining
the course (personalize as you see fit).  I\'ve also enclosed an
electronic copy of the application. For those of you with media
connections, please help us by spreading the word and encouraging
applications and involvement with WomenHeart. Contact me if you would be
interested in featuring this program via your media outlet. Thanks for
your help in this endeavor. I\'d very much appreciate you forwarding
this to colleagues at other institutions if you could, as we are trying
to achieve a very diverse group of participants.

Hayes, Sharonne N. M.D.

<hayes.sharonne@mayo.edu>

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

**Native Women's Health and MCH Conference**

-   August 15 -17, 2007

-   Albuquerque, NM

-   Questions? Contact <nmurphy@scf.cc>

<http://www.ihs.gov/MedicalPrograms/MCH/F/CN01.cfm#Aug07>

**3rd Annual American Indian and Alaska Native Long Term Care
Conference**

-   September 5-6, 2007

-   Albuquerque, New Mexico

-   Visit
    [http://www.aianlongtermcare.org](http://www.aianlongtermcare.org/)

-   Contact <Bruce.Finke@ihs.gov>

**I.H.S. / A.C.O.G. Obstetric, Neonatal, and Gynecologic Care Course**

-   September 16 -- 20, 2007

-   Denver, CO

-   Contact Yvonne Malloy at 202-863-2580 or <YMalloy@acog.org>

# 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}

**Implementation and Use of an Electronic Health Record within the
Indian Health Service**

[**J Am Med Inform
Assoc.**](javascript:AL_get(this, 'jour', 'J Am Med Inform Assoc.');)
**2007 March-April**

<http://www.ihs.gov/MedicalPrograms/MCH/F/documents/Sequist4207.doc>

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 May 2007 OB/GYN CCC Corner is available at: {#the-may-2007-obgyn-ccc-corner-is-available-at .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0507.cfm**](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0507.cfm) {#httpwww.ihs.govmedicalprogramsmchmobgyn0507.cfm-1 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-49 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Social Change Might Save More Lives Than Medical Advances**

#### From your colleagues page 6 {#from-your-colleagues-page-6 .Style-Heading-4-+-Arial-14-pt-Underline}

**Scott Giberson**

-Stop The Silence

-HIV/AIDS Among American Indians and Alaska Natives: CDC Fact Sheets
available

-Opportunity to obtain technical and capacity building assistance

-Fluoroquinolones No Longer Recommended for Treatment of Gonococcal
Infections

**Amy Groom**

New HPV Brochures for Clinicians, CDC

#### Hot Topics {#hot-topics-2 .Style-Heading-4-+-Arial-14-pt-Underline}

##### Obstetrics page 9

-More stillbirths after previous cesarean delivery

-Pregnant Moms\' Weight Affects Toddlers

-Neonatal Pneumothorax Risk Increased After Early Elective Cesarean
Delivery

-Walking is popular, practical: Predictors of physical activity during
and after pregnancy

-Preterm low birth weight and maternal periodontal status: A likely
association

and more....

**Gynecology page 12**

-Young women with CIN: Any treatment increases the risk of preterm
delivery - LEEP

-Women with C. glabrata show higher mycological cure with boric acid

-Is Pelvic Organ Prolapse Caused by Vaginal Delivery?

-Chance of woman undergoing a hysterectomy can now be accurately
predicted

-Insulin-sensitizing drugs versus the combined oral contraceptive pill
for PCOS

and more....

**Child Health page 14**

-Public Opinion vs. Science Concerning Sex Education

-Young Native-American Children at Higher Risk of Fatal Accidents

-What fluoride varnish are you using? Please respond

-New Guidelines Recommend Against Drug Testing of Teens in School, Home

-Association between adolescent dieting behaviors and weight gain over
time

and more....

**Chronic Illness and Disease page 16**

-Smoking Ban Has Health Benefits for Workers

-New Guideline for Screening Mammography for Women 40 to 49 Years of Age

-MRI Detects Breast Cancer Missed by Mammography

-Low-Dose Aspirin Linked to Lower Risk for All-Cause Mortality in Women

-Intensive Smoking Cessation Intervention Reduces Mortality in High-Risk
Smokers 

and more....

#### Features page 19 {#features-page-19 .Style-Heading-4-+-Arial-14-pt-Underline}

American College of Obstetricians and Gynecologists

-Premature Rupture of Membranes

-Patient Testing: Ethical Issues in Selection and Counseling

##### American Family Physician

-Prevention and Management of Postpartum Hemorrhage

-ACOG Releases Guidelines on Antibiotic Prophylaxis for Gynecologic
Procedures

-Estimating 10-Year Mortality Risk

-Infertility (see also Patient Education)

-ACOG Releases Opinion on Inducing Labor for VBAC

and more....

**Agency for Healthcare Research and Quality**

-AHRQ and the Ad Council encourage patients to ask questions and get
more involved

-Primary care office / quality improvement strategies substantially
affect the cost of care

**Ask a Librarian**

Quick Check for Drugs and Lactation

**Breastfeeding**

-Breastfeeding - it's all about synergy

-Editorial comments on last month's column

-NOMOGRAM from Alcohol and Breast Feeding

**CCC Corner Digest**

-HPV Vaccine: Newest ACIP Recommendations - Comments by Amy Groom

-When Things Go Wrong: Responding to Adverse Events

-HIV Prenatal Screening Can Saves Lives-- B. Reilley / S. Giberson

-Surgery versus medical therapy for heavy menstrual bleeding

-Newborn circumcision: Improved outcomes with pediatric hospitalists

-Obesity surgeries expanding dramatically since 1998, AHRQ

-All Encouraged to Help Reduce Colorectal Cancer Deaths in Women

-Inquiring families want to know - what about breastfeeding and......

-Violence Threatens the Health of Pregnant Women and Newborns

-Guidelines for Palliative Care Services: Now Online

-Welcome to the Indian Health Methamphetamine Initiative Site

-Does misoprostol aid prior to IUD insertion?

-Testing New Drugs on the World's Poorest Patients

-The Magic of Play

-Prolonged second stage: The rest of the story

-Being Present: The spirituality of presence in midwifery care

-Oral, not Transdermal, Estrogen Increases Risk for VTE in Women 

-Prenatal screening: It is recommended for ALL ages

-Assessment of Adverse Drug Events in a Tertiary Care Medical Center

-Cesarean Delivery on Maternal Request

-Bisphosphonate Related Osteonecrosis of the Jaws

-What is the best management plan for preterm labor?

-Electronic Health Record (EHR) Implementation: Worth the effort?

-HPV Vaccine Frequently Asked Questions

-Northern Women at Most Risk: Vit. D Deficiency Widespread in Pregnancy

-Can you dispense birth control to minors without parental consent?

-How many rubella vaccines does a mother really need to get?

**Domestic Violence**

-Intimate partner abuse has no age limit

-Domestic Violence and Your Patient\'s Health: Asking the Right
Questions

**Elder Care News**

Pain reliever propoxyphene associated with hip fracture in elderly

**Family Planning**

-Oral Contraception Regimen and Breakthrough Bleeding

#### -Prescribing a one-year supply of OCs contributes to more continuous use and lower costs {#prescribing-a-one-year-supply-of-ocs-contributes-to-more-continuous-use-and-lower-costs .Style-Heading-4-+-Arial-14-pt-Underline}

-Does Oral Contraceptive Use Affect Breast Cancer Risk?

**Featured Website**

Must See Website: Indian Health Service HIV-AIDS Program

**Frequently asked questions**

What are the actual federal regulations on sterilization? Bilateral
tubal ligation, etc...

**Indian Child Health Notes**

-Infant deaths associated with Cough and Cold Medications- 2005

-Pneumococcal Conjugate Vaccine: Contrasting Alaska Natives and
Navajo/Apaches

-Meeting the needs of regional minority groups: increase the AI / AN
physician workforce.

**Information Technology**

Electronic Health Record (EHR) Implementation: Worth the effort?

International Health

-Ethics of medicine with economically vulnerable populations: Second in
the series

# -One-Visit Screening for Cervical Cancer May Be Feasible in Developing Countries

#### MCH Alert

-Issues that affect adolescent well-being

-Surgeon General Issues National Call to Action on Underage Alcohol Use

-Adolescent sexual behavior and strategies for reducing early pregnancy
and childbearing

#### MCH Headlines

-Do you walk around your vehicle before getting in it? You should

-WHO publication details evidence for the 10 Steps to Baby Friendly

#### -2nd Round Request for Oral Health Preceptorship Applications  {#nd-round-request-for-oral-health-preceptorship-applications .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Do HIV Testing Rates Improve When Written Consent Is No Longer Required? {#do-hiv-testing-rates-improve-when-written-consent-is-no-longer-required .Style-Heading-4-+-Arial-14-pt-Underline}

-You are invited to join a Meth PH Forum

and more....

#### Medical Mystery Tour

-Which Indian Health facilities lead the entire U.S. in national
obstetric benchmarks?

#### Medscape

Bone Density Evaluation in Teens Prevents Future Osteoporosis

**Menopause Management**

#### -Emergence of a range of nonhormonal treatments for vasomotor symptoms {#emergence-of-a-range-of-nonhormonal-treatments-for-vasomotor-symptoms .Style-Heading-4-+-Arial-14-pt-Underline}

-Early Estrogen Therapy May Reduce Cardiovascular Risks

**Midwives Corner**

Ultrasound affects mice brains in negative ways: First, do no harm

**Navajo News**

BTL: One half of women under 25 years request information on reversal

**Nurses Corner**

-Two summer programs for high school students

-Women sacrifice sleep to \"Do It All,\" survey finds

-How Should We Counsel Women About HPV Testing?

-17 Interventions That Work: Lessons Learned from PHNs in the Field

-Reducing turnover of registered nurses and certified nursing assistants

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

Quadrivalent HPV Vaccine: Recommendations of the ACIP

**Oklahoma Perspective**

Cesarean Delivery on Maternal Request

Osteoporosis

-Calcium Supplementation May Not Benefit Healthy Children

-Osteoporosis Patients Likely to Pause Medication

-Impact of Adherence and Persistence in Management of Osteoporosis

-Role and Importance of Calcium in Preventing and Managing Osteoporosis

-Putting the Risk for Osteonecrosis of the Jaw Into Perspective

Patient Education

Infertility

Perinatology Picks

-Preconception counseling for women with diabetes and hypertension

-How should the primary care provider approach medications?

-Re-visiting the issue of \"Amnisure

-Low-dose dopamine for pre-eclampsia with oliguria should not be used
other than in trial

-Probiotics for preventing preterm labour

Primary Care Discussion Forum

Electronic Health Record (EHR) Implementation: Worth the effort?

STD Corner

-HIV/AIDS among AI/AN Fact Sheet

-Protective factors among urban American Indian youths: HIV/AIDS

-HIV-related risk behaviors, perceptions of risk, HIV testing, among
urban AI/AN

#### -Impact of HPV Immunization on Gynecologic Cancers {#impact-of-hpv-immunization-on-gynecologic-cancers .Style-Heading-4-+-Arial-14-pt-Underline}

-Increases in Gonorrhea - Eight Western States, 2000-2005

and more....

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

#### -New recommendations for gestational weight gain in obesity epidemic  {#new-recommendations-for-gestational-weight-gain-in-obesity-epidemic .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Elevated Autoantibodies Linked to Preeclampsia {#elevated-autoantibodies-linked-to-preeclampsia .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Cholesterol Could be Key to Treating Fetal Alcohol Syndrome {#cholesterol-could-be-key-to-treating-fetal-alcohol-syndrome .Style-Heading-4-+-Arial-14-pt-Underline}

**Women's Health Headlines**

-Weaving it all together: 2007 Behavioral Health Conference

-CME/CEU - Quadrivalent Human Papillomavirus Vaccine

-Newly completed Pregnancy and Postpartum Quitline Toolkit

-How to Best Get the HPV Vaccine Information Sheets signed?

-Race/ethnicity, socioeconomic status, and lifetime morbidity burden in
the WHI

###### Save the Dates: Upcoming events of interest page 55

#### What's new on the ITU MCH web pages page 55

-Implementation and Use of an Electronic Health Record within the Indian
Health Service

[J Am Med Inform
Assoc.](javascript:AL_get(this, 'jour', 'J Am Med Inform Assoc.');) 2007
March-April

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>

5/13/07