New CCCC Columnists

Violence Against Native Women

-Rachel Locker

-Denise Grenier

![](media/image1.jpeg){width="5.992361111111111in"
height="1.1111111111111112in"}

 

OB/GYN Chief Clinical Consultant's Corner

Volume 5, No. 4, April 2007

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

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

# Quadrivalent Human Papillomavirus Vaccine: Final ACIP Recommendations

Comments by Amy Groom

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

Gordon Belcourt

-Project Safe Neighborhoods

-Recent changes affecting maternal mortality data

-What is known about the outcomes of school health programs?

Stephen Heath

When Things Go Wrong: Responding to Adverse Events

Scott Giberson

HHS National HIV/AIDS Mobilization Campaign

Rhonda Johnson

The Disparities Solution Center: Disparities Leadership Program

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

##### Obstetrics page 12

-GPRA Reporting: HIV Prenatal Screening by Brigg Reilley / Scott
Giberson

-Obstetric Causes of Cerebral Palsy Are Uncommon

-Significantly higher rehospitalization rates and costs with planned
cesareans

-Fish During Pregnancy May Boost Childrens\' IQ

-Induction after 41 completed weeks or later is associated with fewer
perinatal deaths

and more .....

**Gynecology page 17**

-Ultrasonography Detects Malignant Adnexal Masses

-High rates of complications after sling surgery suggest the need for
quality improvement

-Surgery versus medical therapy for heavy menstrual bleeding

\- Inside-out for transobturator tape placement was closer to
neurovascular structures

-Monsel\'s paste and fulguration with ball electrode appear be equally
effective

and more .....

**Child Health page 19**

-Newborn male circumcision: Improved outcomes with pediatric
hospitalists

-Eleven medications account for one-third of errors that harm
hospitalized children

-Croup: Single dose of prednisolone less effective than single dose of
dexamethasone

-Use of Child Restraints in 2006: New NHTSA Research Note

-Failure to thrive: No associations found with social class or parental
education

**Chronic Illness and Disease page 20**

# -New Findings Support Fetal Overnutrition Hypothesis

-Obesity surgeries have jumped dramatically since 1998, AHRQ

-High BP in Pregnancy Increases Risk for Future Atherosclerosis

-Switching from tamoxifen to aromatase inhibitor improves survival in
breast cancer

-Telephone Counseling Improves Smoking Cessation Rates

and more .....

#### Features page 22 {#features-page-22 .Style-Heading-4-+-Arial-14-pt-Underline}

American College of Obstetricians and Gynecologists

-Ob-Gyns Encouraged to Help Reduce Colorectal Cancer Deaths in Women

-Medical Futility - Committee Opinion

##### American Family Physician

-Treatment of the Common Cold

-Cough: Diagnosis and Management: Practice Guidelines

-Common Oral Lesions: Part I. Superficial Mucosal Lesions

-Common Oral Lesions: Part II. Masses and Neoplasia

-Iron Deficiency Anemia

and more .....

**Agency for Healthcare Research and Quality**

-Diagnostic errors are typically the result of multiple individual and
system breakdowns

-Some pregnant women are still prescribed medications with the potential
to harm the fetus

-Shifting from a culture of blame to a culture of safety could help
prevent medical errors

**Ask a Librarian**

### **The CDC website should be bookmarked: Pelvic Inflammatory Disease**

**Breastfeeding**

-Inquiring families want to know - what about breastfeeding and......

-Breast-Feeding Enhances Vision Development in Infants

#### -Simple antenatal preparation to improve breastfeeding practice: RCT {#simple-antenatal-preparation-to-improve-breastfeeding-practice-rct .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Longer duration of lactation associated with favorable changes in metabolic risk factors {#longer-duration-of-lactation-associated-with-favorable-changes-in-metabolic-risk-factors .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Postpartum Mastitis and Community-Acquired Methicillin-Resistant S. Aureus {#postpartum-mastitis-and-community-acquired-methicillin-resistant-s.-aureus .Style-Heading-4-+-Arial-14-pt-Underline}

**CCC Corner Digest**

-Healing words: The power of \'I\'m sorry\' in medical practice

-Ryan White HIV / AIDS Treatment Modernization Act of 2006

-GDM Guidelines: Major discrepancies to identify GDM and predict
pregnancy outcome

-Cystocoele Repair: The Mesh Controversy

-Review and Comment: Newborn record form IHS-298 and its revision

-Does Delay in Diagnosis of Breast Cancer Impact Prognosis?

-ACOG Opposes Sex Selection for Family Planning Purposes

-ACOG Calls on Employers to Support Breastfeeding

-Abstinence counseling vs family planning: Which is more effective?

-The MCH Coordinators Site has a clean new look, plus new functionality

-How many rubella vaccines does a mother really need to get?

-Sexual behavior in context: A public health perspective

-Scrub Club

-Prolonged second stage with an epidural

-Maternal positioning and pain relief: Promoting effective pushing

-Clomiphene "bests" Metformin in a NEJM study

-A \"Small Fall\" and a Trip to the Emergency Department

-Indian Health Surveillance Report---Sexually Transmitted Diseases 2004

-Ultrasound is better at finding Neural Tube Defects than AFP

-Adolescent with knee pain, Web M+M, Terry Cullen - Moderator

-A First: STD Rates Available by IHS Area

-Fertility rises as weight drops

-Women\'s Health Week will be celebrated May 13-19, 2007

-2^nd^ methamphetamine issue of the IHS Primary Care Provider online

**Domestic Violence**

-Violence Threatens the Health of Pregnant Women and Newborns

-Intimate Partner Violence in Pregnancy: Clinicians Guidelines Tutorial,
CDC

-Health Cost Higher for Survivors of Domestic Violence

**Elder Care News**

-Guidelines for Palliative Care Services in the Indian Health: Now
Online

-3rd annual American Indian and Alaska Native Long Term Care Conference

-Disability among older Americans continues significant decline

**Family Planning**

#### -Non-latex versus latex male condoms for contraception {#non-latex-versus-latex-male-condoms-for-contraception .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Population effect of increased access to emergency contraceptive pills {#population-effect-of-increased-access-to-emergency-contraceptive-pills .Style-Heading-4-+-Arial-14-pt-Underline}

**Featured Website**

**Indian Health Service Methamphetamine Initiative Site**

**Frequently asked questions**

-Does misoprostol aid prior to IUD insertion?

-What are Pilates?

**Indian Child Health Notes**

-Iron deficiency in infancy may have permanent cognitive effects

-Same health issues facing the developing world are in force in Indian
Country

**Information Technology**

-2007 Physician Quality Reporting Initiative Webpage Is Now Available

-HIPPA mandated standard unique identifiers for health care providers:
NPPES

International Health

Testing New Drugs on the World's Poorest Patients

#### MCH Alert

How science has revolutionized the understanding of drug addiction

Disparities in Fetal and Perinatal Mortality

#### MCH Headlines

Training opportunity -- Infant mental health

The Magic of Play

Cervical Cancer in America

A MUST tool for multidisciplinary teams reviewing infant / child deaths

Remember the car seat video I sent out in the past year about being 4'9"
tall?

and more .....

#### Medical Mystery Tour

#### Prolonged second stage with an epidural {#prolonged-second-stage-with-an-epidural .Style-Heading-4-+-Arial-14-pt-Underline}

#### Medscape

######### -Exercise in the Age of Evidence-Based Medicine: A Clinical Update

######### -Genital Warts: Best Practices for Diagnosis and Management

######### -Routine Testing for HIV Infection: CDC Screening Recommendations 

-Preventing STD-Related Cancers: An Update on Vaccination Strategies

-How to Optimize the Management of Acid-Peptic Disorders

and more .....

**Menopause Management**

Oral, not Transdermal, Estrogen Increases Risk for VTE in Women 

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

#### -Unopposed estradiol: Anticipate uterine bleeding and endometrial biopsy {#unopposed-estradiol-anticipate-uterine-bleeding-and-endometrial-biopsy .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Nonhormonal therapies for menopausal hot flashes: systematic review  {#nonhormonal-therapies-for-menopausal-hot-flashes-systematic-review .Style-Heading-4-+-Arial-14-pt-Underline}

**Midwives Corner**

-The spirituality of presence in midwifery care

-History and Evidence Base for Normal Birth

**Navajo News**

Sharing strategies to meet ACOG standards with limited resources

**Nurses Corner**

-Adverse Drug Events Among Patients in a Tertiary Care Medical Center

#### -Family Support in Patient-Centered Care: New Guidelines Issued {#family-support-in-patient-centered-care-new-guidelines-issued .Style-Heading-4-+-Arial-14-pt-Underline}

#### -A Call to Action for Caregivers and Patients: Imaging X-rays Cause Cancer {#a-call-to-action-for-caregivers-and-patients-imaging-x-rays-cause-cancer .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Role of Exercise in Treating Postpartum Depression: A Review {#role-of-exercise-in-treating-postpartum-depression-a-review .Style-Heading-4-+-Arial-14-pt-Underline}

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

# -QuickStats: Birth Rates\* Among Females Aged 15\--19, by State

-Fetal and Perinatal Mortality, United States, 2003

**Oklahoma Perspective**

Cesarean Delivery on Maternal Request

Osteoporosis

Bisphosphonate Related Osteonecrosis of the Jaws

Patient Education

# -Anemia: When Low Iron Is the Cause

# -Iron Deficiency Anemia in Infants and Children: How to Prevent It

-Does Diabetes Run in Your Family?  

# -Canker Sores: What Are They and What Can You Do About Them?

#### -The Common Cold: What You Should Know {#the-common-cold-what-you-should-know .Style-Heading-4-+-Arial-14-pt-Underline}

and more .....

Perinatology Picks

-What is the best management plan for the woman with suspected preterm
labor?

-Short Interval Between Pregnancy and Cervical Conization May Raise
Preterm Birth Risk

-Concern about women taking bromocriptine long term for
hyperprolactinemia?

-Results caution against a repeat dose of glucocorticoid in high-risk
pregnancies

-If normal ultrasound at 22-24 weeks the risk of developmental delay is
not increased

and more .....

Primary Care Discussion Forum

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

STD Corner

#### -HPV Vaccine FAQs {#hpv-vaccine-faqs .Style-Heading-4-+-Arial-14-pt-Underline}

-Updated CDC Guidelines for the Treatment of STDs

#### -CDC Releases Data on HIV-Related Risk Behaviors in U.S. High School Students {#cdc-releases-data-on-hiv-related-risk-behaviors-in-u.s.-high-school-students .Style-Heading-4-+-Arial-14-pt-Underline}

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

Northern Women at Most Risk: Vitamin D Deficiency Widespread During
Pregnancy

**Women's Health Headlines**

-Can you dispense birth control agents to minors without parental
consent?

-Welcome to the Indian Health Service Methamphetamine Initiative Site

###### Save the Dates: Upcoming events of interest page 63

#### What's new on the ITU MCH web pages page 64

-Can one dispense birth control agents to minors without parental
consent?

-Are birthing center regulations less restrictive than hospitals?

-How many rubella vaccines does a mother really need to get?

**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}

# Quadrivalent Human Papillomavirus Vaccine: Final ACIP Recommendations, CDC

Genital human papillomavirus (HPV) is the most common sexually
transmitted infection in the United States, causing an estimated 6.2
million new infections every year. Persistent genital HPV infection can
cause cervical cancer in women.

In June 2006, the quadrivalent HPV vaccine types 6,11,16,18, under the
trade name GARDASIL™ (manufactured by Merck and Co.), was licensed for
use among females aged 9\--26 years for prevention of HPV-type--related
cervical cancer, cervical cancer precursors, vaginal and vulvar cancer
precursors, and anogenital warts. This report presents recommendations
by the Advisory Committee on Immunization Practices (ACIP) on the use of
the HPV vaccine.

#### Recommendations for Routine Use and Catch-Up

**Routine Vaccination of Females Aged 11\--12 Years**

ACIP recommends routine vaccination of females aged 11\--12 years with 3
doses of quadrivalent HPV vaccine. The vaccination series can be started
as young as age 9 years.

**Catch-Up Vaccination of Females Aged 13\--26 Years**

Vaccination also is recommended for females aged 13\--26 years who have
not been previously vaccinated or who have not completed the full
series. Ideally, vaccine should be administered before potential
exposure to HPV through sexual contact; however, females who might have
already been exposed to HPV should be vaccinated. Sexually active
females who have not been infected with any of the HPV vaccine types
would receive full benefit from vaccination. Vaccination would provide
less benefit to females if they have already been infected with one or
more of the four vaccine HPV types. However, it is not possible for a
clinician to assess the extent to which sexually active persons would
benefit from vaccination, and the risk for HPV infection might continue
as long as persons are sexually active. Pap testing and screening for
HPV DNA or HPV antibody are not needed before vaccination at any age.

**Dosage and Administration**

The vaccine should be shaken well before administration. The dose of
quadrivalent HPV vaccine is 0.5 mL, administered intramuscularly (IM),
preferably in the deltoid muscle.

**Recommended Schedule**

Quadrivalent HPV vaccine is administered in a 3-dose schedule. The
second and third doses should be administered 2 and 6 months after the
first dose.

Minimum Dosing Intervals and Management of Persons Who Were Incorrectly
Vaccinated

The minimum interval between the first and second doses of vaccine is 4
weeks. The minimum recommended interval between the second and third
doses of vaccine is 12 weeks. Inadequate doses of quadrivalent HPV
vaccine or vaccine doses received after a shorter-than-recommended
dosing interval should be readministered.

**Interrupted Vaccine Schedules**

If the quadrivalent HPV vaccine schedule is interrupted, the vaccine
series does not need to be restarted. If the series is interrupted after
the first dose, the second dose should be administered as soon as
possible, and the second and third doses should be separated by an
interval of at least 12 weeks. If only the third dose is delayed, it
should be administered as soon as possible.

**Simultaneous Administration with Other Vaccines**

Although no data exist on administration of quadrivalent HPV vaccine
with vaccines other than hepatitis B vaccine, quadrivalent HPV vaccine
is not a live vaccine and has no components that adversely impact safety
or efficacy of other vaccinations. Quadrivalent HPV vaccine can be
administered at the same visit as other age appropriate vaccines, such
as the Tdap and quadrivalent meningococcal conjugate (MCV4) vaccines.
Administering all indicated vaccines together at a single visit
increases the likelihood that adolescents and young adults will receive
each of the vaccines on schedule. Each vaccine should be administered
using a separate syringe at a different anatomic site.

**Cervical Cancer Screening Among Vaccinated Females**

Cervical cancer screening recommendations have not changed for females
who receive HPV vaccine. HPV types in the vaccine are responsible for
approximately 70% of cervical cancers; females who are vaccinated could
subsequently be infected with a carcinogenic HPV type for which the
quadrivalent vaccine does not provide protection. Furthermore, those who
were sexually active before vaccination could have been infected with a
vaccine type HPV before vaccination. Health-care providers administering
quadrivalent HPV vaccine should educate women about the importance of
cervical cancer screening.

#### Groups for Which Vaccine is Not Licensed 

Vaccination of Females Aged \<9 Years and \>26 Years

Quadrivalent HPV vaccine is not licensed for use among females aged \<9
years or those aged \>26 years. Studies are ongoing among females aged
\>26 years. No studies are under way among children aged \<9 years.

**Vaccination of Males**

Quadrivalent HPV vaccine is not licensed for use among males. Although
data on immunogenicity and safety are available for males aged 9\--15
years, no data exist on efficacy in males at any age. Efficacy studies
in males are under way.

#### Special Situations Among Females Aged 9\--26 Years

**Equivocal or Abnormal Pap Test or Known HPV Infection**

Females who have an equivocal or abnormal Pap test could be infected
with any of approximately 40 high-risk or low-risk genital HPV types.
Such females are unlikely to be infected with all four HPV vaccine
types, and they might not be infected with any HPV vaccine type.
Vaccination would provide protection against infection with HPV vaccine
types not already acquired. With increasing severity of Pap test
findings, the likelihood of infection with HPV 16 or 18 increases and
the benefit of vaccination would decrease. Women should be advised that
results from clinical trials do not indicate the vaccine will have any
therapeutic effect on existing HPV infection or cervical lesions.

Females who have a positive HC2 High-Risk test conducted in conjunction
with a Pap test could have infection with any of 13 high-risk types.
This assay does not identify specific HPV types, and testing for
specific HPV types is not conducted routinely in clinical practice.
Women with a positive HC2 High-Risk test might not have been infected
with any of the four HPV vaccine types. Vaccination would provide
protection against infection with HPV vaccine types not already
acquired. However, women should be advised that results from clinical
trials do not indicate the vaccine will have any therapeutic effect on
existing HPV infection or cervical lesions.

**Genital Warts**

A history of genital warts or clinically evident genital warts indicates
infection with HPV, most often type 6 or 11. However, these females
might not have infection with both HPV 6 and 11 or infection with HPV 16
or 18. Vaccination would provide protection against infection with HPV
vaccine types not already acquired. However, females should be advised
that results from clinical trials do not indicate the vaccine will have
any therapeutic effect on existing HPV infection or genital warts.

**Lactating Women**

Lactating women can receive HPV vaccine.

**Immunocompromised Persons**

Because quadrivalent HPV vaccine is a noninfectious vaccine, it can be
administered to females who are immunosuppressed as a result of disease
or medications. However, the immune response and vaccine efficacy might
be less than that in persons who are immunocompetent.

#### Vaccination During Pregnancy 

Quadrivalent HPV vaccine is not recommended for use in pregnancy. The
vaccine has not been causally associated with adverse outcomes of
pregnancy or adverse events in the developing fetus. However, data on
vaccination during pregnancy are limited. Until additional information
is available, initiation of the vaccine series should be delayed until
after completion of the pregnancy. If a woman is found to be pregnant
after initiating the vaccination series, the remainder of the 3-dose
regimen should be delayed until after completion of the pregnancy. If a
vaccine dose has been administered during pregnancy, no intervention is
needed. A vaccine in pregnancy registry has been established; patients
and health-care providers should report any exposure to quadrivalent HPV
vaccine during pregnancy (telephone: 800-986-8999).

#### Precautions and Contraindications 

**Acute Illnesses**

Quadrivalent HPV vaccine can be administered to persons with minor acute
illnesses (e.g., diarrhea or mild upper respiratory tract infections
with or without fever). Vaccination of persons with moderate or severe
acute illnesses should be deferred until after the patient improves.

**Hypersensitivity or Allergy to Vaccine Components**

Quadrivalent HPV vaccine is contraindicated for persons with a history
of immediate hypersensitivity to yeast or to any vaccine component. Data
from passive surveillance in Vaccine Adverse Event Reporting System
(VAERS) indicates that recombinent yeast derived vaccines pose a minimal
risk for anaphylaxic reactions in persons with a history of allergic
reactions to Saccharomyces cerevisiae (baker\'s yeast).

**Preventing Syncope After Vaccination**

Syncope (i.e., vasovagal or vasodepressor reaction) can occur after
vaccination, most commonly among adolescents and young adults. Among
reports to VAERS for any vaccine that were coded as syncope during
1990\--2004, a total of 35% of these episodes were reported among
persons aged 10\--18 years. Through January 2007, the second most common
report to VAERS following receipt of HPV vaccine was syncope . Vaccine
providers should consider observing patients for 15 minutes after they
receive HPV vaccine.

MMWR March 12, 2007 / 56(Early Release);1-24
<http://www.cdc.gov/mmwr/preview/mmwrhtml/rr56e312a1.htm>

#### [Editorial comment:]{.underline} Amy Groom, Steve Holve, and Ros Singleton

**Strategy for a Successful HPV Vaccine Rollout in Indian Country**

The Advisory Committee on Immunization Practices (ACIP) recommends that
the human papillomavirus (HPV) vaccine be routinely administered to
females 11 -- 12 years of age, with catch up vaccination for women 13 --
26 years. The full recommendation can be found at the link below. This
vaccine is available at no charge through the Vaccines for Children
program for all VFC-eligible women 9 -- 18 years, per the VFC
resolution, link below.

The quadrivalent HPV vaccine is remarkably effective. In studies, the
vaccine was 100% effective in preventing carcinoma in situ (CIN) 2/3
from 16/18 which are associated with 70% of cervical cancer, but this
success comes at a cost. In the private sector, the vaccine costs \$120
per dose or \$360/person for a complete series of three vaccinations.
IHS and tribal sites that are eligible and order through the VA
Pharmaceutical Prime Vendor (PPV) can get the vaccine at \$84.17/dose.

While the quadrivalent HPV vaccine was placed on the CDC federal
contract in October of 2005, and is currently available through VFC in
most states, some states have been delayed in the roll out of the
vaccine or have had to restrict access to the vaccine to certain age
groups due to limitations in VFC and state funds. Eventually coverage
with HPV vaccine for all VFC eligible female patients 9 -- 18 years of
age should be available.

IHS recommends implementation of the full ACIP recommendation, targeting
females 11 -- 12 year olds with routine vaccination, and catch up
vaccination for 13 -- 18 or 13-26 year olds where possible. In states
where HPV vaccine is not yet available for 11 -- 18 year olds due to
limits in supply and/or funding, IHS recommends the following:\
\
1. Target girls 11-12 years old and 17-18 years old with HPV vaccine
starting this summer and fall. This will capture older girls who will
lose their VFC eligibility if we don\'t try to immunize them this year.

2\. Ensure that each state has reliable numbers of the IHS female user
population 9 -- 18 years of age. This may assist states in lobbying the
CDC for additional funds for HPV vaccine which should ultimately allow
for full implementation of the ACIP recommendation for VFC-eligible
patients seen by IHS and tribal facilities.

3\. If a state is unable or unwilling to provide vaccine to at least the
11 -1 2 year olds and 17 -- 18 year olds, than consideration should be
given for the agency to approach the CDC about increasing funding to
ensure that AI/AN girls receive the HPV vaccine to which they are
entitled by statute.

In order to vaccinate women 19 -- 26 years old, the following strategies
may help to offset the cost:

> **Medicaid** - If Medicaid covers HPV vaccine for this age group in
> your state, contact your billing department to see how to bill for
> this vaccine. If you have a single fee for Medicaid visits, you may be
> able to schedule vaccinations with a billable provider (e.g.
> physician, nurse practitioner, physician assistant or midwife; not a
> nurse only visit) which may allow clinics to recover the cost of this
> immunization. The Alaska Native Medical Center (ANMC) in Anchorage has
> come up with a method to bill Medicaid by writing a prescription for
> HPV vaccine so that it can be billed separate from the clinic visit.
>
> **Merck Vaccine Patient Assistance Program (PAP)** -The Merck PAP
> allows patients over age 19 years who meet certain income and
> insurance coverage criteria to obtain HPV vaccine for free. Sites
> purchase some vaccine up front, and for patients who are approved by
> the Merck program, the vaccine is replaced by Merck to the dispensing
> pharmacy on a quarterly basis. The applicant must apply from a
> facility that is not 'wholly owned and operated by the government'.
> Hence, all tribal and urban facilities would qualify, plus those IHS
> facilities that receive additional funding, other than federal
> funding, e. g., grants, contracts, private funding, etc. If you are in
> doubt whether your facility qualifies, please contact (800) 293-3881
> toll free 8:00 AM--8:00 PM EST Monday -- Friday. If your facility does
> not qualify, then the patient could apply from a different facility,
> e. g., private, or semi-governmental clinic.

The application process is straightforward. Sites usually hear within
the hour if the application is approved, though it can take up to 4
hours. The application is available at the link below.

See also the **STD Corner** below which has other Frequently Asked
Questions on HPV vaccine.

**Resources:**

**CDC Recommendations**

<http://www.cdc.gov/nip/recs/provisional_recs/hpv.pdf>\
\
**Vaccines For Children Resolution**

<http://www.cdc.gov/nip/vfc/acip_resolutions/0606hpv.pdf>

**Merck Vaccine Patient Assistance Program Home**

<http://www.merck.com/merckhelps/vaccines/home.html>

**Merck Vaccine Patient Assistance Program Application**\
<http://www.merck.com/merckhelps/vaccines/mvpap_app.pdf>

Human papillomavirus vaccination. ACOG Committee Opinion No. 344.
American College of Obstetricians and Gynecologists. Obstet Gynecol
2006;108:699--705.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16946235>

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

**Gordon Belcourt, Montana Wyoming Tribal Leaders**

**Project Safe Neighborhoods**

Application deadline dates have changed: PSN applications for FY 2007
are due by 8:00 p.m. e.t. on April 5, 2007 and Anti-Gang Initiative
applications for FY 2007 are due by 8:00 p.m. e.t. on April 12, 2007
<http://www.ojp.usdoj.gov/BJA/grant/psn.html>

**Recent changes affecting maternal mortality data**

In the National Vital Statistics System (NVSS), maternal deaths
increased with the introduction of the ICD \[International
Classification of Disorders\]-10 and when the separate pregnancy status
question switched from being supplemental information available from
some state certificates to an item expected to be included on all state
certificates.

In 1915, the maternal mortality rate was 607.9 deaths per 100,000 live
births for the birth registration area. In 2003, the maternal mortality
rate was 12.1 deaths per 100,000 live births in the United States.
Despite this tremendous overall improvement, maternal mortality
continues to be a significant public health issue and commands an
enormous amount of attention. One of the consequences of this intense
scrutiny is that enhanced surveillance efforts have been developed to
actively identify deaths of women near the time of pregnancy. Death
certificates are a common tool for researchers interested in this topic
and serve several roles; for example, the source of National Vital
Statistics System (NVSS) maternal mortality data and one of the sources
used in pregnancy mortality surveillance efforts to identify cases.

Following the rules and regulations of the ICD, the NVSS has provided
maternal death counts since 1900 and maternal mortality rates since
1915. It remains a valuable source of information on trends and is
characterized by universal coverage and consistent data collection.
However, the NVSS does not identify as many events as active
surveillance

The authors found that

\* Maternal mortality fluctuates from year to year but was 12.1 deaths
per 100,000 live births in 2003.

\* The implementation of the ICD-10 in 1999 resulted in about a 13%
increase in the number of deaths identified as maternal deaths between

1998 and 1999.

\* The rate increased again between 2002 and 2003 after a separate
pregnancy question became a standard item on the U.S. Standard
Certificate of Death.

The authors conclude that \"because most states have yet to adopt the
standard format of the separate pregnancy question, it is likely that
maternal and late maternal death rates in all states will continue to be
subject to increases because of the adoption of questions rather than
actual increases in maternal mortality.\"

Hoyert DL. 2007. Maternal mortality and related concepts. Vital Health
Statistics 3(33).
[[http://www.cdc.gov/nchs/data/series/sr_03/sr03_033.pdf]{.underline}](http://www.cdc.gov/nchs/data/series/sr_03/sr03_033.pdf)

**What is known about the outcomes of school health programs?**

Includes some key questions excerpted below AND links to CDC Healthy
People 2010 Chapter 7 -- education goals.

KEY QUESTIONS

■ What is known about the outcomes of school health programs? Is there a
link between school health programs and better child health or academic
performance? How do the different staffing patterns affect the quality
and service capacity of school health programs?

■ What is the role of K-12 school systems in protecting the health of
children and delivering health care? Are schools an adjunct or core part
of the health care safety net for children?

■ What are some challenges to administering school health programs? How
can local, state, and federal agencies coordinate oversight and revenue
streams to more effectively improve children's health and academic
success?

■ What is the appropriate federal role in addressing the multiple
factors influencing child health and academic success? What are the
current federal streams from the Departments of Agriculture, Education,
and Health and Human Services? To what extent should Medicaid be used to
fund school health services? To what extent are these funding streams
coordinated with one another, or might they be coordinated better?

■ Does the government have a responsibility to set national health
standards for schools, and by extension, to fund health programs that
support public health needs and academic performance benchmarks?

W.D.C. SBHC policy meeting announcement
<http://www.nhpf.org/announcements/FS_SchoolHealth_03-09-07.pdf>

THE LINK to the 2010 healthy People Chapter 7 community and Education
objectives

A MUST OPEN AND SCROLL AND READ DOCUMENT THAT WILL HELP FRAME WHAT YOU
ARE ALREADY DOING, provide measures for future grants.

 [http://www.health.gov/healthypeople/document/html/volume1/07ed.htm#\_Toc490550856](http://www.health.gov/healthypeople/document/html/volume1/07ed.htm#__RefHeading___Toc490550856)

**Stephen W. Heath, Albuquerque**

**When Things Go Wrong: Responding to Adverse Events**

A Consensus Statement of the Harvard Hospitals. Burlington,
Massachusetts: Massachusetts Coalition for the Prevention of Medical
Errors. This consensus paper of the Harvard-affiliated
hospitals proposes a full disclosure when adverse events or medical
errors occur, including an apology to the patient. The paper represents
the collaborative effort of a group of clinicians, risk managers, and
patients participating from several Harvard teaching hospitals and the
Risk Management Foundation.

#### [**http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Literature/WhenThingsGoWrongRespondingtoAdverseEvents.htm**](http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Literature/WhenThingsGoWrongRespondingtoAdverseEvents.htm) {#httpwww.ihi.orgihitopicspatientsafetysafetygeneralliteraturewhenthingsgowrongrespondingtoadverseevents.htm .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

#### As the Program is rather extensive, if you didn't have enough reasons already, Stephen Heath will present on the nuances of systematic error and its effect on Risk Management in Indian Health. The Conference will be in Albuquerque, NM August 15- 17, 2007. The theme of the meeting 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 meeting is only every 3 years, so you and a team from your facility should try your best to attend.  {#as-the-program-is-rather-extensive-if-you-didnt-have-enough-reasons-already-stephen-heath-will-present-on-the-nuances-of-systematic-error-and-its-effect-on-risk-management-in-indian-health.-the-conference-will-be-in-albuquerque-nm-august-15--17-2007.-the-theme-of-the-meeting-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.-the-meeting-is-only-every-3-years-so-you-and-a-team-from-your-facility-should-try-your-best-to-attend. .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

**HHS National HIV/AIDS Mobilization Campaign**

As hoped, AI/AN HIV/AIDS activities and initiatives are gaining momentum
-- just in time for our National Native Awareness Day. Our IHS HIV/AIDS
Program is working with HHS's National Mobilization Campaign to help
promote awareness of HIV/AIDS and knowledge of status across the US in
disproportionately impacted populations (This includes African American,
Latino, AI/AI, IDU, incarcerated individuals, etc). Each region has an
HHS Regional HIV Resource Consultant to assist with the Department's
National Mobilization Campaign. Collaborating with the HHS National
Mobilization Campaign will in-turn continue to improve communication,
build capacity, develop linkages and advocate for getting our
communities screened. The National Mobilization Campaign will be ongoing
through most of 2008 and will focus on knowledge of status --also a
principal goal of the IHS HIV/AIDS Program... More information on HHS\'s
National Mobilization Campaign will be forthcoming.

 

The below message is regional in nature (representing HHS Region VIII),
however it is a good example of the HHS Regional HIV Resource Consultant
(Ms Lisa Cohen) reaching out to those community members, leaders and
advocates that would like to be involved or communicate the HIV
awareness message and screening initiative. It is an opportunity for
I/T/U communities to tap into potential resources, materials, points of
contact and coordination efforts.  I will be working with other HHS
regional coordinators over the period of this initiative to make sure
that the IHS HIV program is involved and helping to promote this within
our communities. Please pass this message and the email below along to
those appropriate contacts. <Scott.Giberson@ihs.gov>

National IHS HIV/AIDS Consultant

Office of Clinical and Preventive Services

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

#### Rhonda Johnson, Anchorage {#rhonda-johnson-anchorage .Style-Heading-4-+-Arial-14-pt-Underline}

**The Disparities Solution Center: Disparities Leadership Program**

To address the need for leaders with expertise in addressing
racial/ethnic disparities in health care, [The Disparities Solutions
Center](http://www.mghdisparitiessolutions.org/) will sponsor a
Disparities Leadership Program in 2007.  The Disparities Leadership
Program (DLP) is a yearlong executive education program designed for
leaders from hospitals, health plans and other health care who wish to
implement practical strategies to eliminate racial and ethnic
disparities in health care, particularly through quality improvement.

The DLP will focus on lessons learned and expertise gained from the
development and evolution of programs currently in place at
Massachusetts General Hospital, as well as at several leading health
plans across the country.  The program centers around a formal skills
curriculum, disparities project development, technical assistance, and
group learning/dissemination.  Co-sponsors of this program include the
[National Committee for Quality Assurance](http://www.ncqa.org/) (NCQA)
and [Joint Commission Resources, Inc.](http://www.jcrinc.com/), an
affiliate of the Joint Commission on Accreditation of Healthcare
Organizations (JCAHO).

For more information, please contact The Disparities Solutions Center at
(617) 724-7658 or <disparitiessolutions@parters.org> or
<http://www.massgeneral.org/disparitiessolutions/DLP.html>

# 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}

**GPRA Reporting: HIV Prenatal Screening**

**by Brigg Reilley\* and Scott Giberson**

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 critical for the mother and/or the
child. Routine screening includes tests for HIV, syphilis, gonorrhea,
chlamydia, and hepatitis B surface antigen. Furthermore, the Centers for
Disease Control and Prevention (CDC) recently expanded recommendations
for HIV screening so that more persons will be aware of their HIV
status. Screening based on risk factors alone is no longer recommended
for HIV (1, 2).

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, and the IHS goal is to reach 100%.
Nationally, IHS facilities have a collective prenatal HIV screening rate
of 65%. For the most recent year, GPRA statistics show that levels of
prenatal HIV care range by Area range from 17% to 84%. Although many
facilities screen for HIV appropriately, there is room for improvement.

**[Editorial Comment]{.underline}**

Site visits made by the IHS Division of Epidemiology and Disease
Prevention to IHS clinical units have revealed some of the explanations
for inconsistency in reported prenatal HIV screening rates. While the
results are still preliminary, some patterns are emerging. In general,
if the service unit has a screening rate \<80%, there is generally a
systemic clinical or data gap, often one that may be easily identified
and fixed. If these gaps are addressed, the reported screening rates
have the potential to increase substantially:

**Clinical:**

-Not using "opt-out" HIV testing. Opt-out means that HIV screening is
treated like other routine infectious disease screenings, such as
syphilis. A consent form for HIV testing is no longer recommended or
required by CDC. (However, you must check with state regulations for
specific testing requirements). Some service units in fact now ask
prenatal patients to sign refusals if they wish to forgo HIV testing, so
it is clear to the mother what risk she is taking for her and her baby
if she has undetected HIV.

-Responsibility for performing HIV testing. Some small clinics simply do
an HCG test, followed by basic metabolic blood work, and then refer the
woman elsewhere for prenatal care. However, GPRA considers a service
unit 'responsible' for HIV testing if a pregnant woman is seen more than
once during pregnancy. Small clinics with the highest GPRA rates assume
responsibility for the entire prenatal infectious disease screening,
including HIV, and have integrated prenatal testing into a single
prenatal lab panel.

-Transfer of patients. Women will often be referred from one clinic to
another. Smaller clinics may assume that labs were done at the larger
facility and vice versa, but sometimes, in reality, neither facility has
ordered the test. This is a troublesome finding because it is a lost
opportunity for prenatal care.

-Not testing. Some providers still decide whether or not to test a woman
based on risk factor assessment. This strategy is no longer standard of
care. In addition, some providers have extremely high refusal rates.
Others have expressed a lack of time and that patients need to see an
HIV counselor before testing. All of these perceived obstacles can be
worked out. However, at some facilities, these difficulties persist.

**Data:**

-Not entering historical data. Again, if a woman has more than one visit
during her pregnancy, we should know her HIV serostatus. If the test has
been done at another facility, either prior to or after her appointments
at your facility, GPRA finds the service unit responsible for obtaining
and entering the HIV test.

-Not entering reference lab data. If the test is done by an outside lab,
and the lab is not linked to RPMS, the service unit does not get
'credit' for the test unless it is entered. Some low GPRA rates are tied
to lab slips not being entered in RPMS.

**Other**

The barriers to higher GPRA rates are mainly service unit-based, rather
than patient-based. Patient-based difficulties are harder to resolve.
Some women arrive very late in pregnancy (although rapid HIV tests can
still be used). Some women never return after two appointments.
Admittedly, these cases are difficult to follow up, although some
reviewed charts showed multiple attempts by determined PHNs. While these
types of patients can be the most challenging, they may also be the most
important patients to screen for HIV.

How can we identify what is going wrong in our facility?

Run a simple patient list of women who are pregnant but not screened for
HIV (Brigg Reilley, in the Division of Epidemiology and Disease
Prevention, can email the program commands to anyone interested,
courtesy of Audrey Lynch at PIMC). A quick chart review should reveal if
the service unit has clinical gaps, data gaps, or both. If problems of
the type we have discussed here are solved, the service unit can enjoy
immediate improvement in GPRA rates for prenatal screening.

**References**

1\. Advancing HIV prevention: new strategies for a changing
epidemic---United States, 2003. MMWR April 18, 2003 / 52(15);329-332

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5215a1.htm>

2\. Voluntary HIV testing as part of routing medical
care---Massachusetts, 2002. MWWR June 25, 2004 / 53(24);523-526.

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5324a2.htm>

\*IHS Division of Epidemiology

**Obstetric Causes of Cerebral Palsy Are Uncommon**

**Conclusion:** The authors conclude that there is a high correlation
between MRI findings and clinical findings and that MRI in patients with
cerebral palsy might help predict future medical needs. A high rate of
white matter damage suggests that genetic factors, nutritional factors,
and infections damage the placenta and lead to ischemic events that are
unrelated to management issues during labor and delivery.

The authors postulate a genetic cause of cerebral palsy in children with
normal MRI findings. They indicate that in 19.9 percent of the children
(those with cortical/subcortical damage or basal ganglia damage) the
cerebral palsy could conceivably have had an obstetric cause. Of these
children, at least one fourth were born by cesarean delivery, indicating
that the obstetrician was responding to a problem in labor. In short,
the authors find that malpractice is unlikely to be a cause of most
cerebral palsy cases. In addition, urinary tract infection rates were
higher in mothers with children who had cerebral palsy, and this may be
an area where more aggressive intervention could have a preventive
effect.

Bax M, et al. Clinical and MRI correlates of cerebral palsy: the
European Cerebral Palsy Study. JAMA October 4, 2006;296:1602-8.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17018805>

**Significantly higher rehospitalization rates and costs with planned
cesareans**

RESULTS: Rehospitalizations in the first 30 days after giving birth were
more likely in planned cesarean (19.2 in 1,000) when compared with
planned vaginal births (7.5 in 1,000). After controlling for age,
parity, and race or ethnicity, mothers with a planned primary cesarean
were 2.3 (95% confidence interval \[CI\] 1.74-2.9) times more likely to
require a rehospitalization in the first 30 days postpartum. The leading
causes of rehospitalization after a planned cesarean were wound
complications (6.6 in 1,000) (P\<.001) and infection (3.3 in 1,000). The
average initial hospital cost of a planned primary cesarean of \$4,372
(95% C.I. \$4,293-4,451) was 76% higher than the average for planned
vaginal births of \$2,487 (95% C.I. \$2,481-2,493), and length of stay
was 77% longer (4.3 days to 2.4 days). CONCLUSION: Clinicians should be
aware of the increased risk for maternal rehospitalization after
cesarean deliveries to low-risk mothers when counseling women about
their choices. LEVEL OF EVIDENCE: II.

[Declercq
E](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Declercq+E"%5BAuthor%5D),
et al Maternal Outcomes Associated With Planned Primary Cesarean Births
Compared With Planned Vaginal Births. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007
Mar;109(3):669-677.

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

**Fish During Pregnancy May Boost Childrens\' IQ**

INTERPRETATION: Maternal seafood consumption of less than 340 g per week
in pregnancy did not protect children from adverse outcomes; rather, we
recorded beneficial effects on child development with maternal seafood
intakes of more than 340 g per week, suggesting that advice to limit
seafood consumption could actually be detrimental. These results show
that risks from the loss of nutrients were greater than the risks of
harm from exposure to trace contaminants in 340 g seafood eaten weekly.

[Hibbeln
JR](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Hibbeln+JR"%5BAuthor%5D)
et al Maternal seafood consumption in pregnancy and neurodevelopmental
outcomes in childhood (ALSPAC study): an observational cohort study.
[Lancet.](javascript:AL_get(this, 'jour', 'Lancet.');) 2007 Feb
17;369(9561):578-85

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17307104>

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

**Recommendations that seafood consumption should be limited in
pregnancy contradicted**

Women who eat seafood while pregnant may be boosting their children\'s
IQ in the process. The results of the study were surprising, and
contradict American and British recommendations that pregnant women
should limit seafood and fish consumption to avoid potentially high
levels of mercury.\
Mercury is found in small concentrations in fish and seafood, but can
accumulate in the body. High amounts of the metal can damage the human
nervous system, particularly those in developing fetuses. On the other
hand, seafood - including fish - is also a major source of omega-3 fatty
acids, essential to brain development.\
While experts believe further research is necessary to confirm these
conclusions, the study\'s failure to find evidence of increased harm
from eating fish is significant. Because seafood contain both nutrients
and toxins, it remains a dilemma for regulatory authorities what kinds
of recommendations should exist for pregnant women.\
At 32 weeks into their pregnancy, the women were asked to fill in a
seafood consumption questionnaire. They were subsequently sent
questionnaires four times during their pregnancy, and then up to eight
years after the birth of their child. Researchers examined issues
including the children\'s social and communication skills, their
hand-eye coordination, and their IQ levels. As with any study based on
self-reporting methods, however, the results cannot be considered
entirely definitive.\
These results highlight the importance of including fish in the maternal
diet and lend support to the popular opinion that fish is brain food.
Eating even more than three portions of fish or seafood a week could be
beneficial. Advice that limits seafood consumption might reduce the
intake of nutrients necessary for optimum neurological development.

**Induction after 41 completed weeks or later is associated with fewer
perinatal deaths**

AUTHORS\' CONCLUSION: A policy of labour induction after 41 completed
weeks or later compared to awaiting spontaneous labour either
indefinitely or at least one week is associated with fewer perinatal
deaths. However, the absolute risk is extremely small. Women should be
appropriately counseled on both the relative and absolute risks.

Induction of labour for improving birth outcomes for women at or beyond
term. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007
Mar;109(3):753-4.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17329530&dopt=Abstract>

No support for oral betamimetics in treatment for threatened preterm
labor

Clinical Scenario

A pregnant patient presents to the hospital at 31 weeks\' gestation with
preterm contractions. After the patient receives hydration and
terbutaline (Brethine), the contractions stop.

Clinical Question

Should an oral betamimetic be used as maintenance therapy to prevent
preterm delivery after treatment for threatened preterm labor?

Evidence-Based Answer

There is no evidence to support the use of oral betamimetics for
maintenance therapy after treatment for threatened preterm labor, and
there is a risk of adverse effects with these drugs.

# Dodd JM, Crowther CA, Dare MR, Middleton P Oral betamimetics for maintenance therapy after threatened preterm labour. *The Cochrane Database of Systematic Reviews* 2007 Issue 1

<http://www.cochrane.org/reviews/en/ab003927.html>

**Bleeding patterns after misoprostol vs surgical treatment of early
pregnancy failure: RCT**

CONCLUSION: Bleeding is heavier and more prolonged after medical
treatment with misoprostol than with curettage for early pregnancy
failure; however, bleeding rarely requires intervention.

Davis AR et al Bleeding patterns after misoprostol vs surgical treatment
of early pregnancy failure: results from a randomized trial. [Am J
Obstet Gynecol.  2007;
196(1):31.e1-7](http://www.medscape.com/medline/publicationbrowser/123?pmid=17240222) 

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17240222>

**Controversy Over Keepsake Prenatal Ultrasound Images Without an
Indication**

Is providing expectant parents with an ultrasound \"keepsake\" image of
their unborn child is justifiable without a medical indication? Many
professionals frown on the practice of performing unnecessary ultrasound
scans during pregnancy, out of safety concerns. Nonetheless, for those
who offer \"boutique ultrasonography,\" selling antenatal scans has
become \"a slick business transaction. The practice has expanded with
technology improvements that now allow high definition 3D snapshots of
the fetus and even \'4D\' video. Companies can make up to \$490 from one
CD or DVD.

There is no scientific evidence that 3D or 4D imaging offers any genuine
medical utility, Watts points out. Also, many physicians wonder how
commercial enterprises deal with the discovery of fetal abnormalities.
The nub of the argument is whether or not medically unnecessary
ultrasound exposure is safe. The US Food and Drug Administration states
on its website, Although there is no evidence that these physical
effects can harm the fetus, public health experts, clinicians and
industry agree that casual exposure to ultrasound, especially during
pregnancy, should be avoided. The agency considers commercial fetal
imaging organizations unacceptable because they operate without medical
supervision. In 2002, the FDA announced that \"anyone administering
ultrasound without a prescription is breaking the law.\"

[Watts
G](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Watts+G"%5BAuthor%5D).
First pictures: One for the album.
[BMJ.](javascript:AL_get(this, 'jour', 'BMJ.');) 2007 Feb
3;334(7587):232-3.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17272561>

AGA Releases Position Statement on Gastrointestinal Medication Use
During Pregnancy

Drug treatment of gastrointestinal disease in pregnant women can be
difficult, particularly because U.S. Food and Drug Administration
classifications are not necessarily based on clinical experience or
current literature. The American Gastroenterological Association (AGA)
released a position statement on gastrointestinal medication use in
pregnant women. The report was published in the July 2006 issue of
*Gastroenterology*.

Treatment of gastrointestinal disease after pregnancy is usually
preferred; however, waiting to treat some illnesses (e.g., irritable
bowel syndrome \[IBS\]) could cause adverse outcomes. Because of the
risk of adverse effects or teratogenicity, there are numerous
medications that should never be taken during pregnancy. These include
bismuth (Tritec), castor oil, doxycycline (Vibramycin), methotrexate,
ribavirin (Virazole), sodium bicarbonate, tetracycline, and thalidomide
(Thalomid). If drug treatment is needed, the AGA recommends using the
lowest-risk medications possible, providing the most appropriate and
effective dosage for the patient\'s condition, and evaluating pregnancy
stage and possible dosing adjustments when making treatment decisions.
It also recommends discussing treatment options with the patient before
starting any drug therapy.

If endoscopy with sedation is needed in the third trimester, fetal
monitoring may be necessary. For lighter sedation, a typical dose of
meperidine (Demerol) seems to provide comfort at low risk, and a small
dose of midazolam (Versed) can have a calming effect without causing
drowsiness. Low doses of fentanyl (Duragesic) also can be used.
Consultation with an anesthesiologist or obstetrician is recommended if
deeper sedation is required. When performing colonic lavage, low-risk
treatment options include tap water enemas and polyethylene glycol
solutions. Bipolar cautery that does not require grounding pad placement
should be used for therapeutic interventions.

When treating nausea, vomiting, or hyperemesis gravidarum during
pregnancy, low-risk drug options include metoclopramide (Reglan),
ondansetron (Zofran), prochlorperazine (Compazine), promethazine
(Phenergan), and trimethobenzamide (Tigan). For heartburn, first-line
treatment is over-the-counter calcium-based antacids. Antacids
containing aluminum or magnesium are another low-risk option. Few data
are available on the use of famotidine (Pepcid) and nizatidine (Axid) in
pregnancy; the use of cimetidine (Tagamet) and ranitidine (Zantac) is
preferred. Although omeprazole (Prilosec) has shown some fetal and
embryonic toxicity, it is still a drug of choice because the risk
remains low.

If hepatitis A or B vaccines are needed during pregnancy, both are
considered low risk. For the management of hepatitis C, ribavirin and
interferon are not recommended because they are contraindicated in
pregnancy. Patients with Wilson\'s disease who need regular
penicillamine (Cuprimine) therapy should have the dosage reduced to 250
mg per day by the third trimester; trientine (Syprine) appears to be a
more low-risk option for managing this disease. For cholestasis of
pregnancy, ursodiol (Actigall) has been used successfully without
increasing adverse events. Because of impaired fetal growth, use of
propranolol (Inderal) or any similar class of drugs to treat portal
hypertension is not recommended after the first trimester. If a liver
transplant is needed, cyclosporine (Sandimmune) and tacrolimus (Prograf)
are low-risk options at dosages required for graft survival.

Dietary modifications (e.g., increased fiber intake, reduced fat and
dairy consumption) are considered first-line therapy in the treatment of
IBS. If medication use is necessary to treat constipation, osmotic
laxatives, polyethylene glycol, docusate, senna, bisacodyl, and
tegaserod (Zelnorm) are considered low-risk options. For diarrhea,
loperamide (Imodium) and diphenoxylate with atropine (Lomotil) are
low-risk options, but these agents are not recommended because of their
possible fetal toxicity risk. There are no low-risk options for treating
abdominal pain.

Although most infectious diarrhea episodes are self-limited, there still
are some antibiotic treatment options for use in pregnancy. These
include albendazole (Valbazen), ampicillin, vancomycin, azithromycin
(Zithromax), furazolidone (Furoxone), tinidazole (Tindamax), and
metronidazole (Flagyl). However, physicians should be aware that
although these drugs may not cause an increased risk of birth defects,
some have the potential to cause other adverse effects (e.g.,
gastrointestinal distress), and some recommendations are based on
limited data. For women with IBS, the most favorable option would be to
conceive while in remission. However, 5-aminosalicylates are considered
low risk for maintenance of remission during pregnancy.

<http://www.aafp.org/afp/20070301/practice.html#p2>

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

**Ultrasonography Detects Malignant Adnexal Masses**

**Results:** At surgery, 144 masses (80 percent) were benign, 26 (14
percent) were malignant, and 11 (6 percent) were borderline. The 26
malignant masses included 16 serous adenocarcinomas, three clear cell
carcinomas, and two mucinous adenocarcinomas. Median laparotomy was
performed on 29 women who were found to have benign lesions. Benign,
borderline, and malignant masses did not differ significantly in volume.
Malignant masses had significantly higher density, as measured by mean
gray index, and significantly higher flow index. The most striking
difference between malignant and other masses was in central vessels,
which were present in 69 percent of malignant masses and 15 percent of
benign masses.

**Conclusion:** The authors conclude that the best parameters to
distinguish benign from malignant adnexal masses are detection of
central blood vessels, density (mean gray index), and

Geomini PM, et al. Evaluation of adnexal masses with three-dimensional
ultrasonography. Obstet Gynecol November 2006;108:1167-75.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17077239>

**High rates of complications after sling surgery suggest the need for
quality improvement**

CONCLUSION: Complication rates within 1 year after sling surgery among
Medicare beneficiaries were found to be higher than those reported in
the clinical literature. The high rates of postoperative urinary tract
infections, prolapse, and outlet obstruction suggest the need for
quality improvement measures in the management of women with
incontinence and pelvic prolapse. LEVEL OF EVIDENCE: III.

[Anger
JT](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Anger+JT"%5BAuthor%5D),
et al Complications of sling surgery among female medicare
beneficiaries. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007
Mar;109(3):707-14.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17329524&dopt=Abstract>

**Surgery versus medical therapy for heavy menstrual bleeding**

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

Marjoribanks J; Lethaby A; Farquhar C Surgery versus medical therapy for
heavy menstrual bleeding. Cochrane Database Syst Rev.  2006;
(2):CD003855

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16625593>

**Inside-out for transobturator tape placement was closer to
neurovascular structures**

CONCLUSION: The outside-in technique results in the mesh being placed
farther from the obturator canal and closer to the ischiopubic ramus,
theoretically reducing the risk of neurovascular injury. LEVEL OF
EVIDENCE: II.

[Zahn
CM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Zahn+CM"%5BAuthor%5D),
et al Anatomic comparison of two transobturator tape procedures. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007
Mar;109(3):701-6.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17329523&dopt=Abstract>

**Monsel\'s paste and fulguration with ball electrode appear be equally
effective**

RESULTS: Six patients (2 Monsel\'s and 4 fulguration) required an
alternate method of hemostasis. Patient demographics, postprocedural
discharge, and recurrent dysplasia were comparable between the 2 groups.
Visual analog scale scores and hemostasis time were significantly higher
in the fulguration group. Estimated blood loss, although higher in the
fulguration group, was not significant between groups.

CONCLUSION: Monsel\'s paste and fulguration with ball electrode appear
be equally effective as hemostatic agents after loop electrosurgical
excision procedure.

Lipscomb GH et al A trial that compares Monsel\'s paste with ball
electrode for hemostasis after loop electrosurgical excision procedure.
[Am J Obstet Gynecol.  2006; 194(6):1591-4; discussion
1595](http://www.medscape.com/medline/publicationbrowser/123?pmid=16579924) 
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16579924>

**Clipping better than shaving: Preoperative hair removal to reduce
surgical site infection**

AUTHORS\' CONCLUSIONS: The evidence finds no difference in SSIs among
patients who have had hair removed prior to surgery and those who have
not. If it is necessary to remove hair then clipping results in fewer
SSIs than shaving using a razor. There is insufficient evidence
regarding depilatory cream compared with shaving using a razor. There is
no difference in SSIs when patients are shaved or clipped one day before
surgery or on the day of surgery

Tanner J et a; Preoperative hair removal to reduce surgical site
infection. [Cochrane Database Syst Rev.  2006;
(2):CD004122](http://www.medscape.com/medline/publicationbrowser/123?pmid=16625596)

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16856029>

**Closing the vaginal cuff vertically is superior to horizontal for
preserving vaginal length**

RESULTS: Preoperatively mean vaginal lengths in the horizontal and
vertical groups were statistically similar (7.76 +/- 1.23 cm versus 8.28
+/- 1.39 cm, respectively; P = .21). Postoperatively the groups
statistically differed (6.63 +/- 1.02 cm versus 7.93 +/- 1.18 cm, P \<
.001). The mean change in vaginal length was -1.13 +/- 1.15 cm and -0.35
+/- 0.91 cm, respectively (P = .01). Within-group comparisons revealed a
statistical difference between pre- versus postmean vaginal length in
the horizontal group (7.76 +/- 1.23 cm versus 6.63 +/- 1.02 cm; P \<
.001) and no difference within the vertical group (8.28 +/- 1.39 cm
versus 7.93 +/- 1.18 cm; P = .11). CONCLUSION: Closing the vaginal cuff
vertically is superior to horizontal closure for the purpose of
preserving vaginal length.

Vassallo BJ, et al A randomized trial comparing methods of vaginal cuff
closure at vaginal hysterectomy and the effect on vaginal length. [Am J
Obstet Gynecol.  2006;
195(6):1805-8](http://www.medscape.com/medline/publicationbrowser/123?pmid=17132483)

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17132483>

**Management of vertical incisions with 3 or more centimeters of
subcutaneous fat**

CONCLUSION: Suture approximation or drainage of the subcutaneous tissues
of women with 3 cm or more subcutaneous fat measured in midline vertical
incisions resulted in no significant change in the incidence of overall
wound complications or superficial wound disruption.

Cardosi RJ et al Subcutaneous management of vertical incisions with 3 or
more centimeters of subcutaneous fat. [Am J Obstet Gynecol.  2006;
195(2):607-14; discussion
614-6](http://www.medscape.com/medline/publicationbrowser/123?pmid=16796988) (ISSN:
1097-6868)
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16796988>

**Distension of painful structures in the treatment for chronic pelvic
pain in women**

CONCLUSION: In this open, randomized study, distension of painful pelvic
structures in women with CPP resulted in significant relief of pain and
improvement in quality of life measures.

Heyman J et al Distension of painful structures in the treatment for
chronic pelvic pain in women. [Acta Obstet Gynecol Scand.  2006;
85(5):599-603](http://www.medscape.com/medline/publicationbrowser/123?pmid=16752240)

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16752240>

**Tension-free vaginal tape: Less complications than intravaginal
slingplasty**

CONCLUSION: Both procedures were effective for stress incontinence, but
9% of women treated with the IVS required removal of the tape for
erosions.Meschia M et al Tension-free vaginal tape (TVT) and
intravaginal slingplasty (IVS) for stress urinary incontinence: a
multicenter randomized trial. [Am J Obstet Gynecol.  2006;
195(5):1338-42](http://www.medscape.com/medline/publicationbrowser/123?pmid=16769016) (ISSN:
1097-6868)

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16769016>

**The use of herbs and dietary supplements in gynecology: an
evidence-based review**

Consumers frequently use herbs and dietary supplements to treat chronic
conditions that are poorly responsive to prescription drugs or when
prescription drugs carry a high side effect burden. Women may use herbs
and supplements for chronic gynecologic conditions, such as menopause,
premenstrual syndrome, dysmenorrhea, cyclic mastalgia, and infertility.
This review is an evidence-based evaluation of herbs and supplements for
these conditions. Therapies that carry a higher level of support from
randomized controlled trial evidence include black cohosh for menopause;
vitamins B(1) and E for dysmenorrhea; calcium, vitamin B(6), and
chasteberry for premenstrual syndrome; and chasteberry for cyclic
mastalgia. There were too few trials involving herbs and supplements in
infertility to warrant a solid recommendation, but chasteberry,
antioxidants, and Fertility Blend have some preliminary support.
Midwives may want to consider these alternatives in addition to more
traditional treatment options when meeting with patients.

[Dennehy
CE](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Dennehy+CE"%5BAuthor%5D).
The use of herbs and dietary supplements in gynecology: an
evidence-based review. J Midwifery Womens Health.  2006;51(6):402-409

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17081929>

**No evidence that spinal manipulation is effective for dysmenorrhoea**

CONCLUSIONS: Overall there is no evidence to suggest that spinal
manipulation is effective in the treatment of primary and secondary
dysmenorrhoea. There is no greater risk of adverse effects with spinal
manipulation than there is with sham manipulation.

Proctor ML et al Spinal manipulation for primary and secondary
dysmenorrhoea. [Cochrane Database Syst Rev.  2006;
3:CD002119](http://www.medscape.com/medline/publicationbrowser/123?pmid=16855988) 

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16855988>

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

**Newborn male circumcision: Improved outcomes with pediatric
hospitalists**

In 2004, the Department of Obstetrics and Gynecology at the University
of Michigan decided to stop offering routine circumcision for specialty
and disciplinary, logistic, and educational reasons. The Pediatric
Hospitalist Service assumed responsibility for the procedures and the
educational process with resultant patient and staff satisfaction,
educational, logistical and economic benefits.

[Johnson
TR](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Johnson+TR"%5BAuthor%5D)
et al Why and how a department of obstetrics and gynecology stopped
doing routine newborn male circumcision. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007
Mar;109(3):750-2.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17329529&dopt=Abstract>

**Eleven medications account for one-third of medication errors that
harm hospitalized children**
<http://www.ahrq.gov/research/feb07/0207RA11.htm>

**Croup: Single dose of prednisolone less effective than single dose of
dexamethasone**

RESULTS: Children treated with prednisolone were more likely to
re-present: 19 of 65 children (29%) reattended medical care compared
with 5 of 68 (7%) from the dexamethasone group. The confidence intervals
around this 22% difference in outcome were 8% to 35%, outside the 0% to
7.5% range of equivalence. There were no significant differences in
other outcome measures. CONCLUSION: A single oral dose of prednisolone
is less effective than a single oral dose of dexamethasone in reducing
unscheduled re-presentation to medical care in children with mild to
moderate croup.

Sparrow A, Geelhoed G. Prednisolone versus dexamethasone in croup: a
randomised equivalence trial. Arch Dis Child.  2006; 91(7):580-3 

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16624882>

**Use of Child Restraints in 2006: New NHTSA Research Note**

NHTSA has published its latest observational survey findings on the use
of child restraints in a Research Note entitled, The survey, a core
component of NHTSA's annual National Occupant Protection Use Survey
(NOPUS), analyzes the use of child restraints among children from birth
1 through age 7. This is the only probability-based observational survey
of child restraint use in the U.S.

The majority of young children riding in motor vehicles in the United
States continued to be restrained by some type of child safety seat or
seat belt, with 98 percent of infants and 89percent of children ages 1
to 3 so restrained in 2006. This result is from the National Occupant
Protection Use Survey (NOPUS), which provides the only probability-based
observed data on child restraint use in the United States. The NOPUS is
conducted annually by the National Center for Statistics and Analysis of
the National Highway Traffic Safety Administration (NHTSA).

The 2006 survey also found the following:

• Children between the ages of 4 and 7 continued to be restrained at
somewhat lower rates than younger children, with 78 percent of these
children restrained by a safety seat or seat belt in 2006.

• Most children continued to ride in the rear seat of vehicles. In 2006,
93 percent of infants, 94 percent of children ages 1 to 3, and 91
percent of children ages 4 to 7 rode in the rear seat.

• Child restraint use continued to be higher in the West than other
parts of the country in 2006.

• Child restraint use continued to be lower when the driver was unbelted
than for belted drivers in 2006.

 "Child Restraint Use in 2006 -- Overall Results"

<http://www-nrd.nhtsa.dot.gov/pdf/nrd-30/NCSA/RNotes/2007/810737.pdf>

**Failure to thrive: No associations found with social class or parental
education**

CONCLUSIONS: The most important postnatal factors associated with growth
faltering are the type and efficiency of feeding: no associations were
found with social class or parental education. In the first 8 weeks of
life, weak sucking is the most important symptom for both breastfed and
bottle-fed babies. After 8 weeks, the duration of breast feeding, the
quantity of milk taken and difficulties in weaning are the most
important influences

Emond A et al Postnatal factors associated with failure to thrive in
term infants in the Avon Longitudinal Study of Parents and Children.
[Arch Dis Child.  2007;
92(2):115-9](http://www.medscape.com/medline/publicationbrowser/123?pmid=16905563) 

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16905563>

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

# New Findings Support Fetal Overnutrition Hypothesis

Findings from an epidemiologic study lend further support to the fetal
overnutrition hypothesis: subjects overexposed to glucose, free fatty
acids, and amino acids in utero are at increased risk for obesity later
in life.

According to this hypothesis, it is the mother\'s weight status that
determines the degree of fetal overnutrition. Thus, the hypothesis helps
explain why obesity is often passed from parent to offspring.

Dr. Debbie A. Lawlor and colleagues correlated the maternal body mass
index (BMI) with offspring BMI in 3340 parent-offspring trios drawn from
an Australian birth cohort.

Maternal BMI was assessed at the first antenatal clinic visit and
offspring BMI was determined at age 14. In addition, paternal BMI was
calculated from the mother\'s report of the father\'s height and weight.

The offspring\'s BMI was more closely linked to the mother\'s BMI than
the father\'s, Dr. Lawlor, from the University of Bristol in the UK, and
colleagues note. For a one-standard-deviation increase in maternal and
paternal BMI, offspring BMI increased by 0.362 and 0.239 standard
deviations.

\"There is currently an epidemic of obesity in Western societies,\" the
authors conclude. \"The potential importance of the suggestion, from our
study, that greater maternal size during pregnancy, either through
programming of neuroendocrine pathways or through epigenetic or other
mechanisms, results in greater offspring BMI in later life means that
this issue warrants further investigation.\"

Am J Epidemiol 2007;165:418-424.
<http://www.medscape.com/viewarticle/552903?src=mp>

**Obesity surgeries have jumped dramatically since 1998, AHRQ**

Obesity surgeries for patients between the ages of 55 and 64 in the
United States soared from 772 procedures in 1998 to 15,086 surgeries in
2004---a nearly 2,000 percent increase, according to a new report by the
Agency for Healthcare Research and Quality (AHRQ). The report, the
latest of several studies that AHRQ has done on obesity surgery, also
found a 726 percent increase in surgeries among patients age 18 to 54.
There were a total of 121,055 surgeries performed on patients of all
ages in 2004.

Among the reasons for the dramatic increases is that the mortality
outcomes from obesity surgery have improved greatly. The national death
rate for patients hospitalized for bariatric surgery declined 78
percent, from 0.9 percent in 1998 to 0.2 percent in 2004.

Bariatric surgery has been proven beneficial in obese persons who have
tried and failed to lose excess weight by diet, exercise, and other
means. The various bariatric surgical procedures include gastric bypass
operations, vertical-banded gastroplasty, and gastric banding or
\"lapband.\" Doctors may recommend bariatric surgery for patients who
have a Body Mass Index (BMI) of 40 or greater (an example would be a
person who is 5 feet 2 inches tall and weighs 276 pounds) or a BMI of 35
or more for patients who have serious, obesity-related medical
conditions such as type 2 diabetes or severe sleep apnea.

<http://www.ahrq.gov/research/jan07/0107RA29.htm>

**High BP in Pregnancy Increases Risk for Future Atherosclerosis**

Women with a history of high blood pressure during pregnancy had a 57%
increased risk of having coronary calcification compared with those
women without this condition (OR: 1.57; 95% CI: 1.04 to 2.37). After
adjusting for age, the relation did not change (OR: 1.64; 95% CI: 1.07
to 2.53). We concluded that high blood pressure during pregnancy is
associated with an increased risk of coronary calcification later in
life.

[Sabour
S](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Sabour+S"%5BAuthor%5D),
et al High Blood Pressure in Pregnancy and Coronary Calcification.
[Hypertension.](javascript:AL_get(this, 'jour', 'Hypertension.');) 2007
Feb 5;

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17283250>

**Switching from tamoxifen to aromatase inhibitor improves survival in
breast cancer**

CONCLUSIONS: Switching to an aromatase inhibitor after 2 or 3 years of
tamoxifen therapy significantly improves survival compared with
continuing 2 or 3 years of additional tamoxifen treatment.

[Boccardo
F](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Boccardo+F"%5BAuthor%5D),
et al Switching to an aromatase inhibitor provides mortality benefit in
early breast carcinoma : pooled analysis of 2 consecutive trials.
[Cancer.](javascript:AL_get(this, 'jour', 'Cancer.');) 2007 Feb 12

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17295293>

Telephone Counseling Improves Smoking Cessation Rates

Clinical Question

Does telephone counseling help smokers quit?

Evidence-Based Answer

Telephone counseling can improve long-term smoking cessation rates.
Multiple proactive calls are more effective than a single reactive call.

Practice Pointers

Telephone counseling services (called quitlines, helplines, or hotlines)
may offer counseling for smoking cessation. Telephone counseling can be
a single session in response to a smoker\'s call (i.e., reactive),
multiple sessions initiated by a counselor (i.e., proactive), or a
combination of these types. Telephone counseling services are readily
available to smokers who are planning a quit attempt or to former
smokers trying to avoid a relapse. These services reach an estimated 1
to 6 percent of adult smokers each year, and some target specific
at-risk populations such as pregnant, adolescent, or low-income smokers.

Proactive telephone counseling for smoking cessation helps motivated
quitters stay abstinent. Three or more calls significantly increase the
odds of smoking cessation compared with standard self-help materials or
brief physician advice. Clinicians should identify proactive telephone
counseling services for smoking cessation and provide this information
to patients who want to quit smoking.

Stead LF, et al. Telephone counseling for smoking cessation. Cochrane
Database Syst Rev 2006;(3):CD002850. <http://www.cochrane.org/index.htm>

**Alternative Therapies Worsen Breast Cancer Outcomes**

**Results:** The authors calculated mean 10-year mortality rates for
patients who eventually used standard therapy and for patients who
substituted alternative therapy for standard therapy. For patients who
delayed surgery, the 10-year relative risk of mortality associated with
alternative therapy was estimated at 1.58. For those who refused
chemotherapy, the relative risk was 1.54.

**Conclusion:** The authors conclude that, despite the many assumptions
in the study, the results indicate that substituting alternative therapy
for standard therapy adversely affects outcomes in patients with breast
cancer.

Chang EY, et al. Outcomes of breast cancer in patients who use
alternative therapies as primary treatment. Am J Surg October
2006;192:471-3.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16978951>

**CT screening for lung cancer didn't improve mortality**

CONCLUSIONS: Screening for lung cancer with low-dose CT may increase the
rate of lung cancer diagnosis and treatment, but may not meaningfully
reduce the risk of advanced lung cancer or death from lung cancer. Until
more conclusive data are available, asymptomatic individuals should not
be screened outside of clinical research studies that have a reasonable
likelihood of further clarifying the potential benefits and risks.

[Bach
PB](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Bach+PB"%5BAuthor%5D),
et al Computed tomography screening and lung cancer outcomes.
[JAMA.](javascript:AL_get(this, 'jour', 'JAMA.');) 2007 Mar
7;297(9):953-61

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17341709>

# 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}

**Ob-Gyns Encouraged to Help Reduce Colorectal Cancer Deaths in Women**

Washington, DC \-- In recognition of Colorectal Cancer Awareness Month,
ob-gyns are encouraged to remind all of their patients age 50 and older
to be screened for colorectal cancer. Because ob-gyns are the only
physicians many women see on a regular basis, they can help increase
colorectal cancer screening rates and, thereby, help reduce deaths from
one of the most preventable and treatable types of cancer.

\"Despite the promising decline in colorectal cancer deaths in the US,
many women are still not getting screened for colorectal cancer,\" says
Douglas W. Laube, MD, MEd, president of The American College of
Obstetricians and Gynecologists (ACOG). \"Ob-gyns can really help by
making sure that all eligible patients leave their office with screening
recommendations. ACOG encourages its members to educate women about the
importance of routine colorectal cancer screening.\"

Colon and rectal cancer (colorectal cancer) affects the large intestine
and rectum. It is the third leading cause of cancer death among women in
the US and the second leading cause of cancer deaths overall for all
adults. In most cases, colorectal cancer develops slowly over time. It
often begins as a tissue growth, called a polyp, in the colon or rectum.
Routine screening helps detect these polyps so that they can be removed
before they turn into cancer. In many cases, colorectal cancer has no
symptoms. The following symptoms, however, may indicate colorectal
cancer: a change in bowel habits, bleeding from the rectum, blood in the
stool, stools that are more narrow than usual, abdominal discomfort
(bloating, cramps, or frequent gas pains), loss of appetite, and
weakness and feeling tired.

ACOG recommends that all women age 50 and older be screened for
colorectal cancer by one of the following methods:

-   Annual patient-collected fecal occult blood test (FOBT) or fecal
    immunochemical test (FIT)

-   Flexible sigmoidoscopy once every five years

-   Annual patient-collected FOBT or FIT plus a flexible sigmoidoscopy
    once every five years

-   Double-contrast barium enema once every five years

-   Colonoscopy once every 10 years

Some women may need to be screened for colorectal cancer before age 50
if they:

-   Have a first-degree relative younger than age 60 with colorectal
    cancer or colon polyps

-   Have two or more first-degree relatives of any age with colorectal
    cancer or colon polyps

-   Have had colorectal cancer

-   Have had colon polyps

-   Have had inflammatory bowel disease (IBS), chronic ulcerative
    colitis, or Crohn\'s disease

-   Have a family history of familial adenomatosis polyposis or
    hereditary nonpolyposis colon cancer

In early 2006, the National Colorectal Cancer Roundtable, of which ACOG
is a member, published an evidence-based guide, How to Increase
Colorectal Cancer Screening Rates in Practice. It is available free to
physicians at

[www.nccrt.org/documents/general/increasecolorectalcancerscreeningrates.pdf](http://www.nccrt.org/documents/general/increasecolorectalcancerscreeningrates.pdf)

The guide offers current screening guidelines and features checklists,
chart prompts, tracking sheets, and other tools that physicians can use
in their practice.

<http://www.acog.org/from_home/publications/press_releases/nr03-01-07.cfm>

**Medical Futility - Committee Opinion**

ABSTRACT: The construct of medical futility has been used to justify a
physician's unilateral refusal to provide treatment requested or
demanded by a patient or the family of a patient. It is important that
physicians and their institutions develop a process for dealing with
conflict surrounding the construct of medical futility. Prospective
policies on medical futility are preferable to unilateral decision
making by individual physicians. When there is disagreement, patient and
family values regarding treatment options and the default position of
maintaining life ordinarily should take priority.

Medical Futility. ACOG Committee Opinion No. 362. American College of
Obstetricians and Gynecologists. Obstet Gynecol 2007;109:791--4

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17329542>

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

**Treatment of the Common Cold (see Patient Education)**

The common cold is a viral illness that affects persons of all ages,
prompting frequent use of over-the-counter and prescription medications
and alternative remedies. Treatment focuses on relieving symptoms (e.g.,
cough, nasal congestion, rhinorrhea). Dextromethorphan may be beneficial
in adults with cough, but its effectiveness has not been demonstrated in
children and adolescents. Codeine has not been shown to effectively
treat cough caused by the common cold. Although hydrocodone is widely
used and has been shown to effectively treat cough caused by other
conditions, the drug has not been studied in patients with colds.
Topical (intranasal) and oral nasal decongestants have been shown to
relieve nasal symptoms and can be used in adolescents and adults for up
to three days. Antihistamines and combination antihistamine/decongestant
therapies can modestly improve symptoms in adults; however, the benefits
must be weighed against potential side effects. Newer nonsedating
antihistamines are ineffective against cough. Topical ipratropium, a
prescription anticholinergic, relieves nasal symptoms in older children
and adults. Antibiotics have not been shown to improve symptoms or
shorten illness duration. Complementary and alternative therapies (i.e.,
Echinacea, vitamin C, and zinc) are not recommended for treating common
cold symptoms; however, humidified air and fluid intake may be useful
without adverse side effects. Vitamin C prophylaxis may modestly reduce
the duration and severity of the common cold in the general population
and may reduce the incidence of the illness in persons exposed to
physical and environmental stresses. Am Fam Physician 2007;75:515-20,
522 <http://www.aafp.org/afp/20070215/515.html>

**Cough: Diagnosis and Management: Practice Guidelines**

On a typical day, a family physician will see at least one patient
presenting with cough. Cough can be divided into three categories: acute
(i.e., lasting less than three weeks), subacute (i.e., lasting three to
eight weeks), and chronic (i.e., lasting longer than eight weeks).

*Chest,* January 2006

<http://www.aafp.org/afp/20070215/practice.html>

or

<http://www.chestjournal.org/content/vol129/1_suppl/>

**Common Oral Lesions: Part I. Superficial Mucosal Lesions (see Patient
Education)**

Common superficial oral lesions include candidiasis, recurrent herpes
labialis, recurrent aphthous stomatitis, erythema migrans, hairy tongue,
and lichen planus. Recognition and diagnosis require taking a thorough
history and performing a complete oral examination. Knowledge of
clinical characteristics such as size, location, surface morphology,
color, pain, and duration is helpful in establishing a diagnosis. Oral
candidiasis may present as pseudomembranous candidiasis, glossitis, or
perlèche (angular cheilitis). Oral candidiasis is common in infants, but
in adults it may signify immune deficiency or other illness. Herpes
labialis typically is a mild, self-limited condition. Recurrent aphthous
stomatitis most often is a mild condition; however, severe cases may be
caused by nutritional deficiencies, autoimmune disorders, or human
immunodeficiency virus infection. Erythema migrans is a waxing and
waning disorder of unknown etiology. Hairy tongue represents elongation
and hypertrophy of the filiform papillae and most often occurs in
persons who smoke heavily. Oral lichen planus is a chronic inflammatory
condition that may be reticular or erosive. Certain risk factors have
been associated with each of these lesions, such as poor oral hygiene,
age, tobacco use, and alcohol consumption, and some systemic conditions
may have oral manifestations. Many recommended therapies for oral
lesions are unsupported by randomized controlled trials. Am Fam
Physician 2007;75:501-7.

<http://www.aafp.org/afp/20070215/501.html>

**Common Oral Lesions: Part II. Masses and Neoplasia**

Certain common oral lesions appear as masses, prompting concern about
oral carcinoma. Many are benign, although some (e.g., leukoplakia) may
represent neoplasia or cancer. Palatal and mandibular tori are bony
protuberances and are benign anomalies. Oral pyogenic granulomas may
appear in response to local irritation, trauma, or hormonal changes of
pregnancy. Mucoceles represent mucin spillage into the oral soft tissues
resulting from rupture of a salivary gland duct. Oral fibromas form as a
result of irritation or masticatory trauma, especially along the buccal
occlusal line. Oral cancer may appear clinically as a subtle mucosal
change or as an obvious mass. Oral leukoplakia is the most common
premalignant oral lesion. For persistent white or erythematous oral
lesions, biopsy should be performed to rule out neoplastic change or
cancer. Most oral cancers are squamous cell carcinomas. Tobacco and
heavy alcohol use are the principal risk factors for oral cancer. Family
physicians should be able to recognize these lesions and make
appropriate referrals for biopsy and treatment. Am Fam Physician
2007;75:509-12.

<http://www.aafp.org/afp/20070215/509.html>

**Iron Deficiency Anemia (see Patient Education)**

The prevalence of iron deficiency anemia is 2 percent in adult men, 9 to
12 percent in non-Hispanic white women, and nearly 20 percent in black
and Mexican-American women. Nine percent of patients older than 65 years
with iron deficiency anemia have a gastrointestinal cancer when
evaluated. The U.S. Preventive Services Task Force currently recommends
screening for iron deficiency anemia in pregnant women but not in other
groups. Routine iron supplementation is recommended for high-risk
infants six to 12 months of age. Iron deficiency anemia is classically
described as a microcytic anemia. The differential diagnosis includes
thalassemia, sideroblastic anemias, some types of anemia of chronic
disease, and lead poisoning. Serum ferritin is the preferred initial
diagnostic test. Total iron-binding capacity, transferrin saturation,
serum iron, and serum transferrin receptor levels may be helpful if the
ferritin level is between 46 and 99 ng per mL (46 and 99 mcg per L);
bone marrow biopsy may be necessary in these patients for a definitive
diagnosis. In children, adolescents, and women of reproductive age, a
trial of iron is a reasonable approach if the review of symptoms,
history, and physical examination are negative; however, the hemoglobin
should be checked at one month. If there is not a 1 to 2 g per dL (10 to
20 g per L) increase in the hemoglobin level in that time, possibilities
include malabsorption of oral iron, continued bleeding, or unknown
lesion. For other patients, an endoscopic evaluation is recommended
beginning with colonoscopy if the patient is older than 50. Am Fam
Physician 2007;75:671-8 <http://www.aafp.org/afp/20070301/671.html>

**Treatment Options for Atopic Dermatitis (see Patient Education)**

Atopic dermatitis is a common inflammatory skin condition that usually
affects children. It is a chronic disease, with periods of remission and
flare-ups, that adversely affects the quality of life of patients and
their families. Aggressive therapy with emollients is an important
intervention for patients with atopic dermatitis. Patients should avoid
individual disease triggers and allergens. Topical corticosteroids are
the mainstay of treatment for flare-ups and are the standard to which
other treatments are compared. Topical calcineurin inhibitors should not
be used in patients younger than two years or in those who are
immunosuppressed, and should be second-line therapies in other patients.
Rarely, systemic agents (e.g., cyclosporine, interferon gamma-1b, oral
corticosteroids) may be considered in adults. Am Fam Physician
2007;75:523-8, 530.

<http://www.aafp.org/afp/20070215/523.html>

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

**Diagnostic errors that harm outpatients are typically the result of
multiple individual and system breakdowns**

<http://www.ahrq.gov/research/feb07/0207RA1.htm>

**Some pregnant women are still prescribed medications with the
potential to harm the fetus**

<http://www.ahrq.gov/research/feb07/0207RA14.htm>

**Shifting from a culture of blame to a culture of safety in nursing
homes could help identify and prevent medical errors**

<http://www.ahrq.gov/research/feb07/0207RA2.htm>

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

### **Pelvic Inflammatory Disease: The CDC website should be bookmarked**

### The CDC website is a great resource. 

### Take a little time to remind yourself about the signs, symptoms, and current alternatives for the management of Pelvic Inflammatory Disease, below. Please note the many alternative oral regimens due to drug resistant strains.

PID comprises a spectrum of inflammatory disorders of the upper female
genital tract, including any combination of endometritis, salpingitis,
tubo-ovarian abscess, and pelvic peritonitis. Sexually transmitted
organisms, especially N. gonorrhoeae and C. trachomatis, are implicated
in many cases; however, microorganisms that comprise the vaginal flora
(e.g., anaerobes, G. vaginalis, Haemophilus influenzae, enteric
Gram-negative rods, and Streptococcus agalactiae) also have been
associated with PID. In addition, cytomegalovirus (CMV), M. hominis, U.
urealyticum, and M. genitalium might be associated with some cases of
PID. All women who are diagnosed with acute PID should be tested for N.
gonorrhoeae and C. trachomatis and should be screened for HIV infection.

### **Diagnostic Considerations** 

Acute PID is difficult to diagnose because of the wide variation in the
symptoms and signs. Many women with PID have subtle or mild symptoms.
Delay in diagnosis and treatment probably contributes to inflammatory
sequelae in the upper reproductive tract. Laparoscopy can be used to
obtain a more accurate diagnosis of salpingitis and a more complete
bacteriologic diagnosis. However, this diagnostic tool frequently is not
readily available, and its use is not easy to justify when symptoms are
mild or vague. Moreover, laparoscopy will not detect endometritis and
might not detect subtle inflammation of the fallopian tubes.
Consequently, a diagnosis of PID usually is based on clinical findings.

The clinical diagnosis of acute PID is imprecise. Data indicate that a
clinical diagnosis of symptomatic PID has a positive predictive value
(PPV) for salpingitis of 65%\--90% compared with laparoscopy. The PPV of
a clinical diagnosis of acute PID depends on the epidemiologic
characteristics of the population, with higher PPVs among sexually
active young women (particularly adolescents), among patients attending
STD clinics, or in other settings where the rates of gonorrhea or
chlamydia are high. In all settings, however, no single historical,
physical, or laboratory finding is both sensitive and specific for the
diagnosis of acute PID (i.e., can be used both to detect all cases of
PID and to exclude all women without PID). Combinations of diagnostic
findings that improve either sensitivity (i.e., detect more women who
have PID) or specificity (i.e., exclude more women who do not have PID)
do so only at the expense of the other. For example, requiring two or
more findings excludes more women who do not have PID but also reduces
the number of women with PID who are identified.

Many episodes of PID go unrecognized. Although some cases are
asymptomatic, others are not diagnosed because the patient or the
health-care provider fails to recognize the implications of mild or
nonspecific symptoms or signs (e.g., abnormal bleeding, dyspareunia, and
vaginal discharge). Because of the difficulty of diagnosis and the
potential for damage to the reproductive health of women, even by
apparently mild or subclinical PID, health-care providers should
maintain a low threshold for the diagnosis of PID.

The optimal treatment regimen and long-term outcome of early treatment
of women with asymptomatic or subclinical PID are unknown. The following
recommendations for diagnosing PID are intended to help health-care
providers recognize when PID should be suspected and when they need to
obtain additional information to increase diagnostic certainty.
Diagnosis and management of other common causes of lower abdominal pain
(e.g., ectopic pregnancy, acute appendicitis, and functional pain) are
unlikely to be impaired by initiating empiric antimicrobial therapy for
PID.

Empiric treatment of PID should be initiated in sexually active young
women and other women at risk for STDs if they are experiencing pelvic
or lower abdominal pain, if no cause for the illness other than PID can
be identified, and if one or more of the following minimum criteria are
present on pelvic examination:

-   cervical motion tenderness OR uterine tenderness OR adnexal
    tenderness.

The requirement that all three minimum criteria be present before the
initiation of empiric treatment could result in insufficient sensitivity
for the diagnosis of PID. The presence of signs of lower genital tract
inflammation, in addition to one of the three minimum criteria,
increases the specificity of diagnosis. In deciding upon the initiation
of empiric treatment, clinicians should also consider the risk profile
of the patient for STDs.

More elaborate diagnostic evaluation frequently is needed because
incorrect diagnosis and management might cause unnecessary morbidity.
These additional criteria may be used to enhance the specificity of the
minimum criteria. The following additional criteria can be used to
enhance the specificity of the minimum criteria and support a diagnosis
of PID:

-   oral temperature \>101°F (\>38.3°C),

-   abnormal cervical or vaginal mucopurulent discharge,

-   presence of abundant numbers of WBC on saline microscopy of vaginal
    secretions,

-   elevated erythrocyte sedimentation rate,

-   elevated C-reactive protein, and

-   laboratory documentation of cervical infection with N. gonorrhoeae
    or C. trachomatis.

The majority of women with PID have either mucopurulent cervical
discharge or evidence of WBC on a microscopic evaluation of a saline
preparation of vaginal fluid. If the cervical discharge appears normal
and no WBCs are observed on the wet prep of vaginal fluid, the diagnosis
of PID is unlikely, and alternative causes of pain should be
investigated. A wet prep of vaginal fluid offers the ability to detect
the presence of concomitant infections (e.g., bacterial vaginosis and
trichomoniasis).

The most specific criteria for diagnosing PID include the following:

-   endometrial biopsy with histopathologic evidence of endometritis;

-   transvaginal sonography or magnetic resonance imaging techniques
    showing thickened, fluid-filled tubes with or without free pelvic
    fluid or tubo-ovarian complex, or doppler studies suggesting pelvic
    infection (e.g., tubal hyperemia); and

-   laparoscopic abnormalities consistent with PID.

A diagnostic evaluation that includes some of these more extensive
studies might be warranted in some cases. Endometrial biopsy is
warranted in women undergoing laparoscopy who do not have visual
evidence of salpingitis, as some women with PID have endometritis alone.

### **Treatment** 

PID treatment regimens must provide empiric, broad spectrum coverage of
likely pathogens. Several antimicrobial regimens have been effective in
achieving clinical and microbiologic cure in randomized clinical trials
with short-term follow-up. However, only a limited number of
investigations have assessed and compared these regimens with regard to
elimination of infection in the endometrium and fallopian tubes or
determined the incidence of long-term complications (e.g., tubal
infertility and ectopic pregnancy) after antimicrobial regimens.

All treatment regimens should be effective against N. gonorrhoeae and C.
trachomatis because negative endocervical screening for these organisms
does not rule out upper reproductive tract infection. The need to
eradicate anaerobes from women who have PID has not been determined
definitively. Anaerobic bacteria have been isolated from the upper
reproductive tract of women who have PID, and data from in vitro studies
have revealed that some anaerobes (e.g., Bacteroides fragilis) can cause
tubal and epithelial destruction. In addition, BV also is present in
many women who have PID. Until treatment regimens that do not adequately
cover these microbes have been demonstrated to prevent long-term
sequelae (e.g., infertility and ectopic pregnancy) as successfully as
the regimens that are effective against these microbes, the use of
regimens with anaerobic activity should be considered. Treatment should
be initiated as soon as the presumptive diagnosis has been made because
prevention of long-term sequelae is dependent on immediate
administration of appropriate antibiotics. When selecting a treatment
regimen, health-care providers should consider availability, cost,
patient acceptance, and antimicrobial susceptibility.

Some specialists have recommended that all patients with PID be
hospitalized so that bed rest and supervised treatment with parenteral
antibiotics can be initiated. However, in women with PID of mild or
moderate clinical severity, outpatient therapy can provide short- and
long-term clinical outcomes similar to inpatient therapy. Limited data
support the use of outpatient therapy in women with more severe clinical
presentations. The decision of whether hospitalization is necessary
should be based on the discretion of the health-care provider.

The following criteria for hospitalization are suggested:

-   surgical emergencies (e.g., appendicitis) cannot be excluded;

-   the patient is pregnant;

-   the patient does not respond clinically to oral antimicrobial
    therapy;

-   the patient is unable to follow or tolerate an outpatient oral
    regimen;

-   the patient has severe illness, nausea and vomiting, or high fever;
    and

-   the patient has a tubo-ovarian abscess.

Many practitioners have preferred to hospitalize adolescent women whose
condition is diagnosed as acute PID. No evidence is available suggesting
that adolescents benefit from hospitalization for treatment of PID.
Younger women with mild-to-moderate acute PID have similar outcomes with
either outpatient therapy or inpatient therapy. Further, clinical
response to outpatient treatment is similar among younger and older
women. The decision to hospitalize adolescents with acute PID should be
based on the same criteria used for older women. Whether women in their
later reproductive years benefit from hospitalization for treatment of
PID also is unclear, although women aged \>35 years who are hospitalized
with PID are more likely than younger women to have a complicated
clinical course.

**Parenteral Treatment**

For women with PID of mild or moderate severity, parenteral and oral
therapy appears to have similar clinical efficacy. Many randomized
trials have demonstrated the efficacy of both parenteral and oral
regimens. In the majority of clinical trials, parenteral treatment for
at least 48 hours has been used after the patient has demonstrated
substantial clinical improvement. Clinical experience should guide
decisions regarding transition to oral therapy, which usually can be
initiated within 24 hours of clinical improvement. The majority of
clinicians recommend at least 24 hours of direct inpatient observation
for patients who have tubo-ovarian abscesses.

**Recommended Parenteral Regimen A**\
Cefotetan 2 g IV every 12 hours\
OR\
Cefoxitin 2 g IV every 6 hours\
PLUS\
Doxycycline 100 mg orally or IV every 12 hours

Because of the pain associated with infusion, doxycycline should be
administered orally when possible, even when the patient is
hospitalized. Oral and IV administration of doxycycline provide similar
bioavailability.

Parenteral therapy may be discontinued 24 hours after a patient improves
clinically, and oral therapy with doxycycline (100 mg twice a day)
should continue to complete 14 days of therapy. When tubo-ovarian
abscess is present, many health-care providers use clindamycin or
metronidazole with doxycycline for continued therapy, rather than
doxycycline alone, because it provides more effective anaerobic
coverage.

Clinical data are limited regarding the use of other second- or
third-generation cephalosporins (e.g., ceftizoxime, cefotaxime, and
ceftriaxone), which also might be effective therapy for PID and may
replace cefotetan or cefoxitin. However, these cephalosporins are less
active than cefotetan or cefoxitin against anaerobic bacteria.

**Recommmended Parenteral Regimen B**\
Clindamycin 900 mg IV every 8 hours\
PLUS\
Gentamicin loading dose IV or IM (2 mg/kg of body weight), followed by a
maintenance dose (1.5 mg/kg) every 8 hours. Single daily dosing may be
substituted.

Although use of a single daily dose of gentamicin has not been evaluated
for the treatment of PID, it is efficacious in analogous situations.
Parenteral therapy can be discontinued 24 hours after a patient improves
clinically; continuing oral therapy should consist of doxycycline 100 mg
orally twice a day or clindamycin 450 mg orally four times a day to
complete a total of 14 days of therapy. When tubo-ovarian abscess is
present, many health-care providers use clindamycin for continued
therapy, rather than doxycycline, because clindamycin provides more
effective anaerobic coverage.

#### Alternative Parenteral Regimens 

Limited data support the use of other parenteral regimens, but the
following three regimens have been investigated in at least one clinical
trial, and they have broad spectrum coverage.

Levofloxacin 500 mg IV once daily\*\
WITH OR WITHOUT\
Metronidazole 500 mg IV every 8 hours\
OR\
Ofloxacin 400 mg IV every 12 hours\*\
WITH OR WITHOUT\
Metronidazole 500 mg IV every 8 hours\
OR\
Ampicillin/Sulbactam 3 g IV every 6 hours\
PLUS\
Doxycycline 100 mg orally or IV every 12 hours

\* Quinolones should not be used in persons with a history of recent
foreign travel or partners\' travel, infections acquired in California
or Hawaii, or infections acquired in other areas with increased QRNG
prevalence.

IV ofloxacin has been investigated as a single agent; however, because
of concerns regarding its spectum, metronidazole may be included in the
regimen. Levofloxacin is as effective as ofloxacin and may be
substituted; its single daily dosing makes it advantageous from a
compliance perspective. One trial demonstrated high short-term clinical
cure rates with azithromycin, either alone for 1 week (at least one IV
dose followed by oral therapy) or with a 12-day course of metronidazole.
Ampicillin/sulbactam plus doxycycline is effective coverage against C.
trachomatis, N. gonorrhoeae, and anaerobes and for patients who have
tubo-ovarian abscess.

**Oral Treatment**

Oral therapy can be considered for women with mild-to-moderately severe
acute PID, as the clinical outcomes among women treated with oral
therapy are similar to those treated with parenteral therapy. The
following regimens provide coverage against the frequent etiologic
agents of PID. Patients who do not respond to oral therapy within 72
hours should be reevaluated to confirm the diagnosis and should be
administered parenteral therapy on either an outpatient or inpatient
basis.

**Recommended Regimen A**\
Levofloxacin 500 mg orally once daily for 14 days\*\
OR\
Ofloxacin 400 mg orally twice daily for 14 days\*\
WITH OR WITHOUT\
Metronidazole 500 mg orally twice a day for 14 days

\* Quinolones should not be used in persons with a history of recent
foreign travel or partners\' travel, infections acquired in California
or Hawaii, or infections acquired in other areas with increased QRNG
prevalence.

Oral ofloxacin has been investigated as a single agent in two clinical
trials, and it is effective against both N. gonorrhoeae and C.
trachomatis. Despite the results of these trials, lack of anaerobic
coverage with ofloxacin is a concern; the addition of metronidazole to
the treatment regimen provides this coverage. Levofloxacin is as
effective as ofloxacin and may be substituted. Azithromycin has been
demonstrated in one randomized trial to be an effective regimen for
acute PID. The addition of metronidazole should be considered, as
anaerobic organisms are suspected in the etiology of the majority of PID
cases. Metronidazole will also treat BV, which frequently is associated
with PID.

**Regimen B**\
Ceftriaxone 250 mg IM in a single dose\
PLUS\
Doxycycline 100 mg orally twice a day for 14 days\
WITH or WITHOUT\
Metronidazole 500 mg orally twice a day for 14 days\
OR\
Cefoxitin 2 g IM in a single dose and Probenecid, 1 g orally
administered concurrently in a single dose\
PLUS\
Doxycycline 100 mg orally twice a day for 14 days\
WITH or WITHOUT\
Metronidazole 500 mg orally twice a day for 14 days\
OR \
Other parenteral third-generation cephalosporin\
(e.g., ceftizoxime or cefotaxime)\
PLUS\
Doxycycline 100 mg orally twice a day for 14 days\
WITH or WITHOUT\
Metronidazole 500 mg orally twice a day for 14 days

The optimal choice of a cephalosporin for Regimen B is unclear; although
cefoxitin has better anaerobic coverage, ceftriaxone has better coverage
against N. gonorrhoeae. Clinical trials have demonstrated that a single
dose of cefoxitin is effective in obtaining short-term clinical response
in women who have PID. However, the theoretical limitations in
cefoxitin\'s coverage of anaerobes might require the addition of
metronidazole to the treatment regimen. Metronidazole also will
effectively treat BV, which is frequently associated with PID. No data
have been published regarding the use of oral cephalosporins for the
treatment of PID. Limited data suggest that the combination of oral
metronidazole and doxycycline after primary parenteral therapy is safe
and effective.

#### Alternative Oral Regimens 

Although information regarding other outpatient regimens is limited, one
other regimen has undergone at least one clinical trial and has broad
spectrum coverage. Amoxicillin/clavulanic acid and doxycycline was
effective in obtaining short-term clinical response in a single clinical
trial; however, gastrointestinal symptoms might limit compliance with
this regimen.

Follow-Up

Patients should demonstrate substantial clinical improvement (e.g.,
defervescence; reduction in direct or rebound abdominal tenderness; and
reduction in uterine, adnexal, and cervical motion tenderness) within 3
days after initiation of therapy. Patients who do not improve within
this period usually require hospitalization, additional diagnostic
tests, and surgical intervention.

If no clinical improvement has occurred within 72 hours after outpatient
oral or parenteral therapy (using the criteria for clinical improvement
described previously), an examination should be performed. Subsequent
hospitalization, parenteral therapy, and diagnostic evaluation,
including the consideration of diagnostic laparoscopy for alternative
diagnoses, are recommended in women without clinical improvement. Some
specialists also recommend rescreening for C. trachomatis and N.
gonorrhoeae 4\--6 weeks after therapy is completed in women with
documented infection with these pathogens. All women diagnosed with
acute PID should be offered HIV testing.

**Management of Sex Partners**

Male sex partners of women with PID should be examined and treated if
they had sexual contact with the patient during the 60 days preceding
the patient\'s onset of symptoms. Evaluation and treatment are
imperative because of the risk for reinfection of the patient and the
strong likelihood of urethral gonococcal or chlamydial infection in the
sex partner. Male partners of women who have PID caused by C.
trachomatis and/or N. gonorrhoeae frequently are asymptomatic.

Sex partners should be treated empirically with regimens effective
against both of these infections, regardless of the etiology of PID or
pathogens isolated from the infected woman. Even in clinical settings in
which only women are treated, arrangements should be made to provide
care for male sex partners of women who have PID. When providing care
for male sex partners is not feasible, health-care providers should
ensure that sex partners are referred for appropriate treatment.

**Prevention**

Prevention of chlamydial infection by screening and treating high-risk
women reduces the incidence of PID. Theoretically, the majority of cases
of PID can be prevented by screening all women or those determined to be
at high risk (based on age or other factors) by using DNA amplification
on cervical specimens (in women receiving pelvic examinations) and on
urine specimens (in women not undergoing examinations). Although BV is
associated with PID, whether the incidence of PID can be reduced by
identifying and treating women with BV is unclear.

**Special Considerations**

Pregnancy. Because of the high risk for maternal morbidity and preterm
delivery, pregnant women who have suspected PID should be hospitalized
and treated with parenteral antibiotics.

HIV Infection. Differences in the clinical manifestations of PID between
HIV-infected women and HIV-negative women have not been well-delineated.
In previous observational studies, HIV-infected women with PID were more
likely to require surgical intervention. More comprehensive
observational and controlled studies (published since the 2002 STD
Treatment Guidelines) have demonstrated that HIV-infected women with PID
had similar symptoms when compared with uninfected controls. They were
more likely to have a tubo-ovarian abscess but responded equally well to
standard parenteral and oral antibiotic regimens when compared with
HIV-negative women. The microbiologic findings for HIV- positive and
HIV-negative women were similar, except HIV-infected women had higher
rates of concomitant M. hominis, candida, streptococcal, and HPV
infections and HPV-related cytologic abnormalities. Whether the
management of immunodeficient HIV-infected women with PID requires more
aggressive interventions (e.g., hospitalization or parenteral
antimicrobial regimens) has not been determined.

IUD. Intrauterine contraceptive devices are becoming a popular
contraceptive choice for women. Both levonorgestrel- and
copper-containing devices are marketed in the United States. The risk of
PID associated with IUD use is primarily confined to the first 3 weeks
after insertion and is uncommon thereafter. Given the popularity of
IUDs, practitioners might encounter PID in IUD users. No evidence
suggests that IUDs should be removed in women diagnosed with acute PID.
However, caution should be exercised if the IUD remains in place, and
close clinical follow-up is mandatory. The rate of treatment failure and
recurrent PID in women continuing to use an IUD is unknown. No data
exist on antibiotic selection and treatment outcomes according to type
of IUD (e.g., copper or levonorgestrel).

Sexually Transmitted Diseases Treatment Guidelines, 2006 MMWR August 4,
2006 / 55(RR11);1-94

##### [**http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5511a1.htm**](http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5511a1.htm)

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

**Inquiring families want to know - what about breastfeeding and......**

**-Is it okay if the mom smokes or chews tobacco and breastfeeds?**

According to American Academy of Pediatrics, the risk benefit of
breastfeeding outweighs the potential risk of tobacco metabolites in the
mother's milk. The greater concern is that the baby not be exposed to
second hand smoke.

**-Can a mom still breastfeed if she has pierced nipples?**

La Leche League reports that body piercing, including nipple piercing
has been a common practice throughout history. There have not been
problems reported that are specifically associated with breastfeeding
and pierced nipples. General recommendations include keeping the area
clean and removing nipple jewelry before allowing the baby to
breastfeed. Also, nipple piercing while breastfeeding is probably not
feasible due to the 3 month or longer healing time required. For more
information, consider visiting this web site:

<http://www.lalecheleague.org/llleaderweb/LV/LVJunJul99p64.html>

**Can moms drink alcohol and breastfeed?**

-Yes and maybe. Numerous professional sources including Thomas W. Hale,
R.Ph. Ph.D., University of Texas (author of Medication and Mother's
Milk), American College of Nurse-Midwives, and American Academy of
Pediatrics agree that moderate and occasional consumption of alcohol is
usually compatible with breastfeeding. Important considerations are:

-The baby's age - A newborn has an immature liver and will take longer
to metabolize any of the alcohol that gets into the mom's milk.

-Moms body size - A larger mother can metabolize alcohol more quickly
than a smaller mom.

-Amount of alcohol consumed - Most sources report that waiting 2 hours
for every drink (12 oz beer, 5 oz wine, 1 standard drink - including 1
shot of spirits such as vodka, whiskey, rum, tequila, etc) or until the
mother feels neurologically normal, is a reasonable waiting period.

-A helpful calculator for how long alcohol takes to be metabolized can
be found at:

<http://www.obfocus.com/calculators/alcoholinmilk.htm>

Please note that moms do not need to pump to get rid of the alcohol. A
mom's milk is a dynamic fluid, the milk and alcohol are not trapped. A
mom's liver will metabolize the alcohol in the breastmilk like the
alcohol in her blood stream.

**What about caffeine?**

American College of Nurse-Midwives provides a well documented and
succinct recommendation. From their web site,
[www.gotmom.org](http://www.gotmom.org/)

Though dietary caffeine appears in breast milk, nursing mothers can
safely consume small amounts of caffeine without passing on a
significant amount to the baby. Higher caffeine amounts could
potentially cause problems such as poor sleeping, nervousness,
irritability, and poor feeding, so limiting your caffeine intake makes
sense.

Caffeine tends to build up in babies' systems because their bodies
cannot get rid of it very easily. Try using decaffeinated coffee and
tea, and avoid colas and other carbonated drinks that have added
caffeine. The American Academy of Pediatrics recommends that nursing
women limit consumption to the caffeine equivalent of 1 to 3 cups of
coffee per day.

![](media/image2.jpeg){width="4.010416666666667in" height="3.40625in"}\
(Source: [International Food Information Council
Foundation](http://www.ific.org/))

www.GotMom.org is\
brought to you by\
![](media/image3.png){width="1.0416666666666667in"
height="0.7083333333333334in"}

If you have other asked/unasked questions (and answers) about
breastfeeding, please send them to <suzan.murphy@ihs.gov> for the future
articles.

**Other**

**Breast-Feeding Enhances Vision Development in Infants**

CONCLUSIONS: These findings support the hypothesis that breastfeeding
benefits long-term stereoscopic development. An effect of DHA cannot be
excluded, but the lack of difference in stereoacuity between infants
randomly assigned to DHA-containing and those assigned to control
formula raises the hypothesis that factors in breast milk other than DHA
account for the observed benefits.

[Singhal
A](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Singhal+A"%5BAuthor%5D),
et al Infant nutrition and stereoacuity at age 4-6 y. [Am J Clin
Nutr.](javascript:AL_get(this, 'jour', 'Am J Clin Nutr.');) 2007
Jan;85(1):152-9
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17209191>

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

#### Simple antenatal preparation to improve breastfeeding practice: RCT {#simple-antenatal-preparation-to-improve-breastfeeding-practice-rct-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: Where breastfeeding practices are suboptimal, simple one-encounter antenatal education and counseling significantly improve breastfeeding practice up to 3 months after delivery. Provision of printed or audiovisual educational material is not enough. Health care workers should make every effort to have one face-to-face encounter to discuss breastfeeding with expectant mothers before they deliver. CLINICAL TRIAL REGISTRATION: (www.ClinicalTrials.gov), NCT002770192 LEVEL OF EVIDENCE: I. {#conclusion-where-breastfeeding-practices-are-suboptimal-simple-one-encounter-antenatal-education-and-counseling-significantly-improve-breastfeeding-practice-up-to-3-months-after-delivery.-provision-of-printed-or-audiovisual-educational-material-is-not-enough.-health-care-workers-should-make-every-effort-to-have-one-face-to-face-encounter-to-discuss-breastfeeding-with-expectant-mothers-before-they-deliver.-clinical-trial-registration-www.clinicaltrials.gov-nct002770192-level-of-evidence-i. .Style-Heading-4-+-Arial-14-pt-Underline}

#### Mattar CN at al Simple antenatal preparation to improve breastfeeding practice: a randomized controlled trial. [Obstet Gynecol.  2007; 109(1):73-80](http://www.medscape.com/medline/publicationbrowser/123?pmid=17197590)  {#mattar-cn-at-al-simple-antenatal-preparation-to-improve-breastfeeding-practice-a-randomized-controlled-trial.-obstet-gynecol.-2007-109173-80 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17197590**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17197590) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgidbpubmedcmdretrievedoptabstractpluslist_uids17197590 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Longer duration of lactation associated with favorable changes in metabolic risk factors {#longer-duration-of-lactation-associated-with-favorable-changes-in-metabolic-risk-factors-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: Lactation may attenuate unfavorable metabolic risk factor changes that occur with pregnancy, with effects apparent after weaning. As a modifiable behavior, lactation may affect women\'s future risk of cardiovascular and metabolic diseases. LEVEL OF EVIDENCE: II {#conclusion-lactation-may-attenuate-unfavorable-metabolic-risk-factor-changes-that-occur-with-pregnancy-with-effects-apparent-after-weaning.-as-a-modifiable-behavior-lactation-may-affect-womens-future-risk-of-cardiovascular-and-metabolic-diseases.-level-of-evidence-ii .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Gunderson EP](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Gunderson+EP"%5BAuthor%5D) et al Lactation and Changes in Maternal Metabolic Risk Factors. [Obstet Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007 Mar;109(3):729-738. {#gunderson-ep-et-al-lactation-and-changes-in-maternal-metabolic-risk-factors.-obstet-gynecol.-2007-mar1093729-738. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17329527&dopt=Abstract**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17329527&dopt=Abstract) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmedlist_uids17329527doptabstract .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Postpartum Mastitis and Community-Acquired Methicillin-Resistant S. Aureus {#postpartum-mastitis-and-community-acquired-methicillin-resistant-s.-aureus-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Summary: Community Acquired (CA) MRSA has emerged as an increasingly common pathogen in PPM. Therapy against CA-MRSA should be considered in refractory or severe cases of PPM until wound, drainage, or breast milk cultures can be obtained. Adjunct surgical drainage or aspiration is often warranted in such cases. Additional study is required to determine the utility of routine cultures in postpartum mastitis, the prevalence of CA-MRSA in this emerging problem, and the consequences of CA-MRSA colonization for breastfeeding infants. {#summary-community-acquired-ca-mrsa-has-emerged-as-an-increasingly-common-pathogen-in-ppm.-therapy-against-ca-mrsa-should-be-considered-in-refractory-or-severe-cases-of-ppm-until-wound-drainage-or-breast-milk-cultures-can-be-obtained.-adjunct-surgical-drainage-or-aspiration-is-often-warranted-in-such-cases.-additional-study-is-required-to-determine-the-utility-of-routine-cultures-in-postpartum-mastitis-the-prevalence-of-ca-mrsa-in-this-emerging-problem-and-the-consequences-of-ca-mrsa-colonization-for-breastfeeding-infants. .Style-Heading-4-+-Arial-14-pt-Underline}

#### Pavani Reddy et al Emerg Infect Dis.  2007;13(2):298-301 {#pavani-reddy-et-al-emerg-infect-dis.-2007132298-301 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.medscape.com/viewarticle/551382?src=mp**](http://www.medscape.com/viewarticle/551382?src=mp) {#httpwww.medscape.comviewarticle551382srcmp .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-6 .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}

-Healing words: The power of \'I\'m sorry\' in medical practice

-Ryan White HIV / AIDS Treatment Modernization Act of 2006

-GDM Guidelines: Major discrepancies to identify GDM and predict
pregnancy outcome

-Cystocoele Repair: The Mesh Controversy

-Review and Comment: Newborn record form IHS-298 and its revision

-Does Delay in Diagnosis of Breast Cancer Impact Prognosis?

-ACOG Opposes Sex Selection for Family Planning Purposes

-ACOG Calls on Employers to Support Breastfeeding

-Abstinence counseling vs family planning: Which is more effective?

-The MCH Coordinators Site has a clean new look, plus new functionality

-How many rubella vaccines does a mother really need to get?

-Sexual behavior in context: A public health perspective

-Scrub Club

-Prolonged second stage with an epidural

-Maternal positioning and pain relief: Promoting effective pushing

-Clomiphene "bests" Metformin in a NEJM study

-A \"Small Fall\" and a Trip to the Emergency Department

-Indian Health Surveillance Report---Sexually Transmitted Diseases 2004

-Ultrasound is better at finding Neural Tube Defects than AFP

-Adolescent with knee pain, Web M+M, Terry Cullen - Moderator

-A First: STD Rates Available by IHS Area

-Fertility rises as weight drops

-Women\'s Health Week will be celebrated May 13-19, 2007

-2^nd^ methamphetamine issue of the IHS Primary Care Provider online

#### Link to entire issue, below {#link-to-entire-issue-below .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/documents/CCCC_5_3.pdf**](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/CCCC_5_3.pdf) {#httpwww.ihs.govmedicalprogramsmchmdocumentscccc_5_3.pdf .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-7 .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-8 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Violence Threatens the Health of Pregnant Women and Newborns**

CONCLUSION: Women experiencing intimate partner violence both prior to
and during pregnancy are at risk for multiple poor maternal and infant
health outcomes, suggesting prenatal risks to children from mothers\'
abusive partners.

[Silverman
JG](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Silverman+JG"%5BAuthor%5D)
et al Intimate partner violence victimization prior to and during
pregnancy among women residing in 26 U.S. states: associations with
maternal and neonatal health. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Jul;195(1):140-8.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16813751>

or

<http://www.endabuse.org/newsflash/index.php3?Search=Article&NewsFlashID=787>

**Intimate Partner Violence in Pregnancy: Clinicians Guidelines
Tutorial, CDC**

[[http://www.cdc.gov/reproductivehealth/violence/IntimatePartnerViolence/sld044.htm#44]{.underline}](http://www.cdc.gov/reproductivehealth/violence/IntimatePartnerViolence/sld044.htm#44)

**Health Cost Higher for Survivors of Domestic Violence**

CONCLUSIONS: Women with a history of IPV had significantly higher
healthcare utilization and costs, continuing long after IPV ended. Given
its high prevalence, IPV has a major impact on medical care resource
utilization and efforts to prevent its occurrence and consequences are
clearly indicated.

[Rivara
FP](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Rivara+FP"%5BAuthor%5D),
et al Healthcare utilization and costs for women with a history of
intimate partner violence [Am J Prev
Med.](javascript:AL_get(this, 'jour', 'Am J Prev Med.');) 2007
Feb;32(2):89-96

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17234483>

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

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

**Guidelines for Palliative Care Services in the Indian Health: Now
Online**

The newly released Guidelines for Palliative Care Services in the Indian
Health System provide guidance and common language around what
constitutes a program of palliative care for our IHS, Tribal, and Urban
Indian Health programs as well as a tool for implementation of services.
The Guidelines were adapted from the work of the National Consensus
Project for Quality Palliative Care (NCP) whose purpose is "to promote
the implementation of Clinical Practice Guidelines that ensure care of
consistent and high quality, and that guide the development and
structure of new and existing palliative care services."
<http://www.nationalconsensusproject.org/>.

An interdisciplinary Indian Health workgroup adapted the NCP guidelines
to the Indian Health setting, aiming for guidelines that were feasible
within our system and still provided a high level of quality. This
workgroup had the help of a large number of national experts in
palliative care who reviewed the guidelines and provided valuable
suggestions in their development. For questions or assistance in the
development of palliative care services contact Mary Jo Crissler, Tim
Domer, or Bruce Finke. <Bruce.Finke@ihs.gov>

**Reference:**

**Guidelines for Palliative Care Services in the Indian Health**

<http://www.ihs.gov/NonMedicalPrograms/nc4/Documents/FINALPCGUIDELINES.pdf>

**3rd annual American Indian and Alaska Native Long Term Care
Conference**

Plan now to attend the 3rd annual American Indian and Alaska Native Long
Term Care Conference in Albuquerque, New Mexico, from September 5-6,
2007.

For more information, visit
[http://www.aianlongtermcare.org](http://www.aianlongtermcare.org/)

**Disability among older Americans continues significant decline**

Changes in the health and functioning of the Medicare-enrolled
population aged 65+ are tracked by using the 1982-2004/2005 National
Long-Term Care Surveys. We found a significant rate of decline in the
prevalence of chronic disability that accelerated from 1982 to 2004.
These declines are significant for both persons with less severe chronic
disability, which might be compensated by modifying the built
environment and providing assistive devices, and for persons with more
serious disability, which may be affected by reductions in the incidence
and severity of disease through biomedical interventions. Declines in
chronic disability continued over the 22-year period at a rate fast
enough (i.e., 1.52% per annum) to contribute significantly to the
long-term fiscal stability of the Medicare (and Medicaid) programs.
Changes in the rate and substance of disability declines seem consistent
with the intentions of policy interventions in Medicare and Medicaid.

[Manton
KG](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Manton+KG"%5BAuthor%5D),
et al Change in chronic disability from 1982 to 2004/2005 as measured by
long-term changes in function and health in the U.S. elderly population.
[Proc Natl Acad Sci U S
A.](javascript:AL_get(this, 'jour', 'Proc Natl Acad Sci U S A.');) 2006
Nov 28;103(48):18374-9

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17101963>

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

#### Non-latex versus latex male condoms for contraception {#non-latex-versus-latex-male-condoms-for-contraception-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### AUTHORS\' CONCLUSIONS: Although the nonlatex condoms were associated with higher rates of clinical breakage than their latex comparison condoms, the new condoms still provide an acceptable alternative for those with allergies, sensitivities, or preferences that might prevent the consistent use of latex condoms. The contraceptive efficacy of the nonlatex condoms requires more research. {#authors-conclusions-although-the-nonlatex-condoms-were-associated-with-higher-rates-of-clinical-breakage-than-their-latex-comparison-condoms-the-new-condoms-still-provide-an-acceptable-alternative-for-those-with-allergies-sensitivities-or-preferences-that-might-prevent-the-consistent-use-of-latex-condoms.-the-contraceptive-efficacy-of-the-nonlatex-condoms-requires-more-research. .Style-Heading-4-+-Arial-14-pt-Underline}

#### Gallo MF et a; Non-latex versus latex male condoms for contraception. [Cochrane Database Syst Rev.  2006; (1):CD003550](http://www.medscape.com/medline/publicationbrowser/123?pmid=16437459)  {#gallo-mf-et-a-non-latex-versus-latex-male-condoms-for-contraception.-cochrane-database-syst-rev.-2006-1cd003550 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16437459**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16437459) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgidbpubmedcmdretrievedoptabstractpluslist_uids16437459 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Population effect of increased access to emergency contraceptive pills: Systematic review {#population-effect-of-increased-access-to-emergency-contraceptive-pills-systematic-review .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: Increased access to emergency contraceptive pills enhances use but has not been shown to reduce unintended pregnancy rates. Further research is needed to explain this finding and to define the best ways to use emergency contraception to produce a public health benefit. {#conclusion-increased-access-to-emergency-contraceptive-pills-enhances-use-but-has-not-been-shown-to-reduce-unintended-pregnancy-rates.-further-research-is-needed-to-explain-this-finding-and-to-define-the-best-ways-to-use-emergency-contraception-to-produce-a-public-health-benefit. .Style-Heading-4-+-Arial-14-pt-Underline}

#### Raymond EG; Trussell J; Polis CB Population effect of increased access to emergency contraceptive pills: a systematic review. [Obstet Gynecol.  2007; 109(1):181-8](http://www.medscape.com/medline/publicationbrowser/123?pmid=17197603)  {#raymond-eg-trussell-j-polis-cb-population-effect-of-increased-access-to-emergency-contraceptive-pills-a-systematic-review.-obstet-gynecol.-2007-1091181-8 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17197603**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17197603) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgidbpubmedcmdretrievedoptabstractpluslist_uids17197603 .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

**Welcome to the Indian Health Service Methamphetamine Initiative Site**

This is the online source for information about METH prevention
activities across Indian Country and across the United States...in the
next few months the site will be updated for better viewing and ease of
navigation.

<http://www.ihs.gov/MedicalPrograms/Behavioral/index.cfm?module=BH&option=Meth>

For access to an article on best practice strategies for dealing with
Meth, developed out of Montana, please contact <Carolyn.Aoyama@ihs.gov>

**FYI - this website may be of interest to you**

Thanks to science.gov, we have had great success in the beta stages of
implementing the Science Diversity Center (SDC), we are planning a
larger release sometime in January. We have not only had great input
during the beta stages, averaging about 15,000 \"hits\" a month and
going as high as 24,000 hits, but have also learned about other features
that faculty \"wished\" were included.

The site features the following:

1\. Research grants and awards, including portfolio and folder features.

2\. A \"Career Consultants\" feature which will evolve into a
comprehensive \"Career Center\" in the next few weeks to allow students
to develop personal portfolios as well as secure resumes plus much much
more.

3\. An education initiative that will evolve into two new \"Cabinets,\"
one with searchable learning support materials and the other with an
expanded education feature (We, along with other partners, are having
productive meetings centered on establishing an online-higher education
campus to complement our online high school).

4\. A new unique eMeeting rooms feature that will allow users to
establish online meetings with colleagues.

5\. The establishment of a webinar series (hopefully starting in
February) that highlights funding opportunities at federal agencies for
MSI faculty, administrators and staff. Other webinar series are offered.
During the beta testing of this feature, users have really utilized the
feature. The feedback has been great. It is paying dividends for
participants (no charge to MSIs).

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

National Network of Libraries of Medicine, Pacific Northwest Region

University of Washington nnlm@u.washington.edu

NN/LM PNR 800-338-7657

Box 357155 206/543-8262

Seattle, Washington 98195-7155 206/543-2469 (FAX)

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

**Q. Does misoprostol aid prior to IUD insertion?**

A. Yes, misoprostol appears to soften the cervix and decrease
complications.

**Answer**

Evidence is suggestive that misoprostol is useful for IUD insertions.
Misoprostol softens the cervix and reduces the chance of complications
such as perforation, pain, and bleeding. In addition, RCTs have shown
that misoprostol improves the ease with which the cervix can be dilated
and reduces complications in premenopausal women, postmenopausal women,
and nulliparous women undergoing operative hysteroscopy, though the
studies are small. As with many issues surrounding misoprostol, the
optimum dosing and regimen remain in question. The doses referenced
below range from 200 -- 400 mcg given 12 -24 hours before the procedure.

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

**Other Resources:**

FAQ: For nulliparous women undergoing IUD insertion does cervical
priming with misoprostol or other agents facilitate the insertion?

<http://www.ffprhc.org.uk/admin/uploads/No1456.pdf>

**Q. What are Pilates? (pronounced puh-LAH-teez)**

A. Pilates once a body-conditioning regime known only to elite athletes,
dancers, performers and models, has gone mainstream. Details below

The following is an article referenced from the University of Alaska
Health Sciences Information Service Newsletter : December 2006

<http://consortiumlibrary.org/hsis/site/about/newsletters/Dec06.pdf>

**Pilates : The Mind-Body Workout that Transforms!**

Pilates (pronounced puh-LAH-teez), once a body-conditioning regime known
only to elite athletes, dancers, performers and models, has gone
mainstream. It stresses mind-body synchronization and is based on six
principles and over 500 exercises which emphasize precision rather than
quantity.1 A maximum of 3, 5 or 10 repetitions are initiated and
controlled in the core of the body, and breathing is carefully
synchronized with them. With over 500 Pilates studios in North America
alone, Pilates is the new Fountain of Youth for baby boomers seeking to
extend heir youth and vitality into old age.

How it all began

Born in Germany in 1880, Joseph Pilates was a weak and sickly child.
Determined to improve his health, he took up bodybuilding, skiing,
diving and gymnastics, and became an accomplished boxer and circus
performer. He also studied eastern philosophies, yoga and martial arts,
incorporating the best attributes of each into a unique practice he
called "contrology", which he used to treat the sick and injured during
World War I. Using old hospital beds, unused springs and other surplus
gear at hand, he designed his "signature" equipment to improve muscle
strength in the bedridden, who regained mobility unexpectedly quickly.
In 1926, Pilates moved to New York and with his wife Clara set up his
first studio, attracting modern dancers and other performers. One
student, Romana Kryzanowska, was hand-picked to train authentic Pilates
instructors after Pilates' death in 1960, when the training regimen
became known as Pilates.2 Now in her eighties, Romana is still
teaching.3

What's so special?

Pilates training is designed to strengthen the body core -- the
"powerhouse" of muscles in the deep abdomen, buttocks, and around the
spine. Strengthening these muscles has been found effective in
alleviating and preventing back pain. Body and mind are developed
together. Instructors focus on developing awareness of proper alignment
of the body and isolation of specific muscles, balance, smooth
breathing, mental focus, and graceful flow of the movements. Stretching
and lengthening exercises are done on mats and specially designed
apparatus offering resistance and support, including the Reformer, Arc
Barrel, Cadillac and Wunda Chair.4 Other "props" include the fitness
circle, flex band, and Bosu (a hemisphere with a soft top and firm base,
used to develop balance).

The Benefits

Pilates reshapes and conditions the body for speed, power and precision.
Pilates provides cross-training for athletes, and improves athletic
performance by increasing muscular endurance, mind-body awareness,
understanding of body position and placement, and balance.5 It also
helps the non-athletic: injuries are minimized when the core is strong,
and movement is carefully controlled and coordinated. Athletes such as
Tiger Woods and Jason Kidd, have endorsed Pilates for developing
superior posture, body strength and flexibility.4 Film stars and models
have discovered Pilates to help maintain their sculpted figures. (An
added bonus is "killer" kegels -- you can avoid incontinence as one
ages)

Getting started

A "boot camp" or introductory session with certified Pilates instructors
helps the novice learn to isolate and engage the body's deep core
muscles. Instructors then offer hour-long mat or Reformer sessions with
individuals or small groups, who are allowed to progress at their own
speed. Level I and Level II classes are available. Ongoing correction
ensures the exercises are being done properly. Some health clubs have
incorporated Pilates-inspired exercises into their program, providing an
easy transition for athletes unfamiliar with Pilates, though less
rigorous than the environment of licensed Pilates studios.7 After
correctly mastering the basic techniques, some excellent
self-instruction programs on DVD are available if the student wants to
continue on his/her own.

HSIS Newsletter, 12/06

<http://consortiumlibrary.org/hsis/about/newsletters/Dec06.pdf>

**Resources**

1.  Tomlinson, J. (2003). Core conditioning with Pilates. *Total Health*
    25(2) Mar./Apr. Full text available in Academic Search Premier
    database. <http://sled.alaska.edu/databases/home.html>

2.  Hamilton, J. & D. Simon. (2003) The Pilates story. *New Life
    Journal: Carolina Edition*, 4(3). Full text available in Alt
    HealthWatch database. <http://sled.alaska.edu/databases/home.html>

3.  Romana's Pilates website. <http://www.romanaspilates.com/>

4.  Shulman, L. (2006). Pilates for every "body." Alive: Canadian
    Journal of Health & Nutrition. Feb.:92-93. Full text available in
    Alt Healthwatch database.
    <http://sled.alaska.edu/databases/home.htm>

5.  Kostka, Ericka.(2005). Pilates: A classic workout for a new body.
    <http://tinyurl.com/y5n5ms>

6.  Studio One Pilates (Anchorage) website.
    <http://www.pilatesalaska.com/>

7.  "What is true Pilates."
    <http://www.romanaspilates.com/pgs/aboutpilates.html>

Consortium Library, University of Alaska Anchorage, HSIS Newsletter Home

<http://consortiumlibrary.org/hsis/about/newsletter.php>

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

#### March 2007 {#march-2007 .Style-Heading-4-+-Arial-14-pt-Underline}

-Iron deficiency in infancy may have permanent cognitive effects that
cannot be reversed with later iron therapy

-Same health and socioeconomic issues facing the developing world are in
force in Indian Country

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ICHN307.doc**](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ICHN307.doc) {#httpwww.ihs.govmedicalprogramsmchmdocumentsichn307.doc .Style-Heading-4-+-Arial-14-pt-Underline}

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

**2007 Physician Quality Reporting Initiative Webpage Is Now Available**

The Centers for Medicare & Medicaid Services (CMS) is pleased to
announce that the 2007 Physician Quality Reporting Initiative (PQRI)
webpage is now available.

On December 20, 2006 the President signed the Tax Relief and Health Care
Act of 2006 (TRHCA). Section 101 under Title I authorizes the
establishment of a physician quality reporting system by CMS. CMS has
titled the statutory program the 2007 Physician Quality Reporting
Initiative.

PQRI establishes a financial incentive for eligible professionals to
participate in a voluntary quality reporting program. Eligible
professionals who successfully report a designated set of quality
measures on claims for dates of service from July 1 to December 31,
2007, may earn a bonus payment, subject to a cap, of 1.5% of total
allowed charges for covered Medicare physician fee schedule services.

This newly established webpage will be updated regularly, so check it
often for timely and reliable information from CMS.
<http://www.cms.hhs.gov/PQRI/01_Overview.asp#TopOfPage>

**HIPPA mandated standard unique identifiers for health care providers:
NPPES**

The Administrative Simplification provisions of the Health Insurance
Portability and Accountability Act of 1996 (HIPAA) mandated the adoption
of standard unique identifiers for health care providers, as well as the
adoption of standard unique identifiers for health plans. The purpose of
these provisions is to improve the efficiency and effectiveness of the
electronic transmission of health information. The Centers for Medicare
& Medicaid Services (CMS) has developed the National Plan and Provider
Enumeration System (NPPES) to assign these unique identifiers.

<https://nppes.cms.hhs.gov/NPPES/Welcome.do>

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

**Testing New Drugs on the World's Poorest Patients**

In the film The Constant Gardener, based on the novel by John LeCarré,
the protagonist battles representatives of a nefarious pharmaceutical
company intent on concealing evidence of unethical medical research on
impoverished African subjects. Though fictional, the film and book film
drew public attention to a real and growing phenomenon in which wealthy
pharmaceutical corporations farm out basic medical research to so-called
"CROs" (contract research organizations). In order to secure the large
numbers of human test subjects required to meet the gold standard
criteria for drug approval demanded by the FDA -- the randomized
placebo-controlled double-blind trial -- the CROs turn to economically
vulnerable populations. Increasingly, they look beyond the domestic poor
to international settings where signing up for a research protocol may
provide the patient's best (or only) chance of receiving medical care.
In an era in which drugs are one of the most lucrative businesses
around, human research subjects have thus become a hot international
commodity.

For those who are interested in the facts behind the popular fiction, a
recent book by investigative journalist Sonia Shah explores the
phenomenon of international clinical drug trials at some length. In The
Body Hunters, Shah details the factors driving US-based pharmaceutical
companies, unable to find sufficient numbers of enrollees at home, to
outsource their drug trials to countries like India, South Africa, and
the former Soviet Socialist Republics. Here, she argues, wealthy
corporations benefit from a combination of less restrictive regulatory
environments and more desperate patient populations, the end result of
which is larger enrollments in their trials. While much of this ground
has been trodden before -- one could plausibly argue that she makes very
little original contribution to the discussion -- Shah does a
commendable job of consolidating a wide and unwieldy range of academic,
historical and journalistic investigations in a readable, largely
balanced, and engagingly written book.

In a PLoS Medicine piece, Trudo Lemmens and Paul Miller explore a
related issue: financial compensation of physicians who recruit patients
from their practices to join clinical trials. Though their legal status
remains murky, explicit "finders fees" are clearly prohibited by most
professional medical ethical codes (including that of the AMA).
Nonetheless, various recruitment incentives have been designed to wiggle
through loopholes in these various professional codes, with the net
effect of insuring that "patients have become de facto market products,"
as Lemmens and Miller put it. Like Shah, these authors believe that
institutional review boards have proved inadequate to the task of
protecting vulnerable populations from the powerful vested interests of
big pharma. The authors call for a rethinking of national and
international regulations to prevent "jurisdiction shopping," in which
companies scout the world for those countries with the most favorable
(or least onerous) legal and financial climate for patient recruitment.

The globalization of biomedicine and the increasing interpenetration of
medicine and industry are combining to ensure that formerly distinct
borders -- geopolitical, professional, disciplinary -- are increasingly
fluid, arbitrary, and manipulable. Whose interests will be served and
how the vulnerable will be protected in the context of these shifting
alliances and opportunities are questions of urgent and ongoing
importance to all of us.

Shah S. The Body Hunters: Testing New Drugs on the World's Poorest
Patients. New York: The New Press, 2006

Lemmens T, Miller PB. Regulating the market in human research
participants. PLoS Medicine 3(8):e330, August 2006
[www.plosmedicine.org](http://www.plosmedicine.org/)

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

**How science has revolutionized the understanding of drug addiction**

Drugs, Brains, and Behavior: The Science of Addiction provides
information about drug addiction, including the many harmful
consequences of drug abuse and the basic approaches that have been
developed to prevent and treat it. The 30-page, full-color booklet,
published by the National Institutes on Drug Abuse, discusses the
reasons people take drugs, why some people become addicted while others
do not, how drugs work in the brain, and how addiction can be prevented
and treated. Information about NIDA\'s addiction-research program and
efforts to share findings with professional audiences and the general
public are provided, along with information about NIDA\'s special
initiatives to target students and teachers, designated populations, and
ethnic groups. The booklet is intended for use by health professionals
and the general public in making informed choices in their own lives,
adopting science-based policies and programs that reduce drug abuse and
addiction in their communities, and supporting scientific research that
improves the nation\'s well-being.
[[http://www.drugabuse.gov/scienceofaddiction/sciofaddiction.pdf]{.underline}](http://www.drugabuse.gov/scienceofaddiction/sciofaddiction.pdf)

**Disparities in Fetal and Perinatal Mortality**

Fetal and Perinatal Mortality, United States, 2003 presents detailed
data on fetal and perinatal deaths and mortality rates for the United
States for 2003. For the purposes of the report, published by the
National Center for Health Statistics, fetal mortality refers to the
intrauterine death of a fetus at any gestational age, and perinatal
mortality refers to death around the time of delivery and includes both
fetal deaths (at least 20 weeks of gestation) and early infant

(neonatal) deaths. The authors examine data from the 2003 fetal death
data file and the 2003 period linked birth and infant death data file by
a variety of characteristics, including race and Hispanic origin,
maternal age, marital status, sex of fetus, plurality (multiple
deliveries), birthweight, and period of gestation. Fetal and perinatal
mortality rates by state are provided. A discussion, references, a list
of detailed tables, and technical notes are also included.
[[http://www.cdc.gov/nchs/data/nvsr/nvsr55/nvsr55_06.pdf]{.underline}](http://www.cdc.gov/nchs/data/nvsr/nvsr55/nvsr55_06.pdf)

**MCH Headlines Judy Thierry HQE**

**Training opportunity -- Infant mental health**

July 20 & 21, 2007 NCAST-AVENUW Summer Institute

Risky Beginnings: Examining Case Stories about Effective Intervention
with Young Children & Families - Hyatt Regency Hotel, Bellevue, WA

<http://www.ncast.org/events.asp>

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

**NCAST will be at the August meeting in Albuquerque, too**

Denise Findlay, RN, BSN, the Training Programs & Development Coordinator
from NCAST has graciously agreed to present 1-2 workshops at the
National Indian Women's Health and MCH Conference, August 15- 17, 2007.
Still another reason you should go to the meeting in Albuquerque.
<http://www.ihs.gov/MedicalPrograms/MCH/F/CN01.cfm#Aug07>

**The Magic of Play**

Child care involves PLAY.  Parenting involves play.

For those of you working directly or indirectly with day care programs,
in child care settings, Early and Head Start programs you will find this
short news article "the Magic of Play" interesting and possibly
something you want to begin in your projects and programs.  Cuidando los
Niños a non-profit in Albuquerque, NM  serves children of homeless
families as they  reenter community.   The program meets the needs of
the children while their mother is also supported in seeking housing,
work and educational and social services.  Their article links the child
play and parent 'play' and interaction into a meaningful approach and
intervention. 

<http://www.cuidandolosninos.org/home.html>

**Cervical Cancer in America**

96 page national update on distribution of disease, economic burden, 1
page state-by-state reports, Women In Government is a national
501(c)(3), non-profit, bi-partisan organization of women state
legislators providing leadership opportunities, networking, expert
forums, and educational resources to address and resolve complex public
policy issues. Women In Government leads the nation with a bold,
courageous, and passionate vision that empowers and mobilizes all women
legislators to effect sound policy.

Women In Government. Partnering For Progress 2007: The "State" of
Cervical Cancer Prevention in America. Washington, DC, 2007.

To request free copies of this report or to send inquiries, contact:
Toll free: 1.888.333.0164

E-mail: <resourcecenter@womeningovernment.org>

Web:
[www.womeningovernment.org/prevention](http://www.womeningovernment.org/prevention)

**A MUST reference tool for multidisciplinary teams reviewing infant and
child deaths**

Keeping Kids Safe -- has a comprehensive manual you can download or
order

A review manual available for reviewing child deaths makes a complex
public health and child advocacy activity doable. It frames the local
approaches in this 190 page document answering questions, concerns and
all of the step by step how to's that any review committee would have. 

Useful for hospital M&M, mch case reviews, EMS and PIMR's the final
pages contain specific one-page Guides to Effective Child Death Reviews
by specific causes of death -- SIDS, asthma, children with disabilities,
natural infant and pediatric deaths, suffocation, fires and burns,
drowning, child abuse and neglect, motor vehicle deaths, suicides, teen
homicides. Contact 800-656-2434 or <info@childdeathreview.org> or
<http://www.childdeathreview.org/Finalversionprotocolmanual.pdf>

Home page: <http://www.childdeathreview.org/home.htm> has many resources
including a state -map of the US
<http://www.childdeathreview.org/statistics.htm> links further to other
sites with stats such as perinatal, kids count...!!!

**Remember the car seat video I sent out in the past year about being
4'9" tall?**

A link to a poster to remember those who are nooooottt quiiiiiiiite tall
enough to ride safely in an adult harness virtual POSTER communication
tool and link to a 'must see' 5 minute video \_helps to focus on the
right 'seat' for infants and children of all ages and you will
appreciate what Law Enforcement does to promote child passenger safety. 

From: NHTSA press release: "Since 2000, 38 States have strengthened
their child restraint laws to require booster seat use by children who
have outgrown their child safety seats, but who still cannot ride safely
using adult seat belts.  These booster seat provisions have been enacted
to better protect child passengers in the 4 to 8 age group.  Although
progress has been made in many respects, nearly 1,700 of these children
have been killed and more than 265,000 have been injured in crashes
since 2001.

Knowing that law enforcement agencies appreciate specially designed
tools to facilitate the enforcement of new requirements, this new
six-minute roll-call video was developed to help officers enforce
booster seat requirements during traffic stops.  \"Booster Seats \-- The
Missing Link\" provides meaningful details about the need for booster
seat use, as well as moving personal accounts about booster seats
(including longtime booster seat advocate Autumn Alexander Skeen), and
suggestions for how best to enforce these new requirements."

<http://www.boosterseat.gov/?gclid=CNK0lancs4oCFSh-UAodEDhGCA>

To view the video, please go to
[www.boosterseat.gov](http://www.boosterseat.gov/) and click on the
"Roll-Call Video" link at the bottom of the page. 
<ftp://ftp.nhtsa.dot.gov/WMPVideo/Roll-Call/NHTSA-ver2_pre.wmv>

In conjunction with Child Passenger Safety Week (February 11-17, 2007),
NHTSA announces the availability of a new roll-call video to assist law
enforcement agencies in enforcing booster seat use requirements now in
effect in more than two-thirds of the States, and the District of
Columbia. <http://www.nhtsa.dot.gov/>

**Studies Show Hearing Loss of Any Degree Has Significant Impact on
Children  **

Numerous cognitive and developmental delays, including the ability to
pay attention have been associated with hearing loss. A child\'s ability
to regulate his or her attention (sustaining attention, disregarding
distractions, staying attentive to task goals, etc.) can affect school
readiness and later academic performance. This pilot study shows how
learning and using appropriate parenting techniques can help children
with hearing loss develop these skills. 2006 Convention of the American
Speech- Language-Hearing Association (ASHA).

<http://releases.usnewswire.com/GetRelease.asp?id=76204>

**Pediatric Resource Guide to Infant and Childhood Hearing Loss 2nd
edition - free copy**

I have a \$95 copy of the 'PEDIATRIC RESOURCE GUIDE TO INFANT AND
CHILDHOOD HEARING LOSS 2^ND^ EDITION

Developed by the Center for Early Intervention on Deafness the web site
has multiple resources:

[**CHECKLIST FOR HEARING DEVELOPMENT**]{.underline}

**[0-4 months]{.underline}**

·       Startles to loud sounds during light sleep.

·       Smiles when you talk and smile at him.

·       Cries in response to sudden, loud sounds.

**[4-7 months]{.underline}**

·       Turns toward new and interesting sounds (both sides).

·       Stops playing in response to new and interesting sounds.

**[7-9 months]{.underline}**

·       Enjoys playing with sound toys.

·       Enjoys babbling and making sounds; reciprocal voice play.

**[9-13 months]{.underline}**

·       Turns directly towards the source of sound.

·       Continues to babble and experiment with new sounds.

·       Follows your simple commands when not looking at your face.

<http://www.ceid.org/> or <Judith.Thierry@ihs.gov>

**Fetal and Perinatal Mortality,** **NVSR**

Results---The U.S. fetal mortality rate in 2003 was 6.23 fetal deaths of
20 weeks of gestation or more per 1,000 live births and fetal deaths.
Fetal and perinatal mortality rates have declined slowly but steadily
from 1990 to 2003. Fetal mortality rates for 28 weeks of gestation or
more have declined substantially, whereas those for 20--27 weeks of
gestation have not declined. Fetal mortality rates are higher for a
number of groups, including non-Hispanic black women, teenagers, women
aged 35 years and over, unmarried women, and multiple deliveries. Over
one-half (51 percent) of fetal deaths of 20 weeks of gestation or more
occurred between 20 and 27 weeks of gestation.

Fetal and Perinatal Mortality, United States, 2003  by Marian F.
MacDorman, Ph.D.; Donna L. Hoyert, Ph.D.;  Joyce A. Martin, M.P.H.;
Martha L. Munson, M.S.; and  Brady E. Hamilton, Ph.D., Division of Vital
Statistics

Click on the PDF in the press release for the full report.
<http://www.cdc.gov/nchs>  

![](media/image4.png){width="6.114583333333333in"
height="3.2395833333333335in"}

**12th Annual MCH EPI Conference online presentation archive now live**

Content is broad MCH:  Teens, tobacco, injury, gestational diabetes,
breastfeeding, international health, poster presentations,
prematurity....

Please visit
<http://www.cademedia.com/archives/cdc/mchepi2006/index.htm> to access
video clips, text transcripts and slide presentations from the plenary
and many breakout sessions.

The site is also available through the \'Conferences\' section of
[http://www.mchcom.com](http://www.mchcom.com/).  Please help us to
promote the site by notifying all appropriate audiences and posting to
relevant listserv(s) etc.

**1918 Flu Epidemic Teaching Valuable Lessons**: **Actions Taken
Apparently Were Effective**

New analysis of how American cities responded to the killer Spanish flu
of 1918 suggests that closing schools, banning large gatherings,
staggering work hours and quarantining households of the ill may have
saved tens of thousands of lives.

Which of the many non-pharmaceutical interventions was especially
effective in reducing mortality is unknown, but all would theoretically
be available should pandemic influenza again sweep the country.

The new findings run counter to previous research that concluded that
the public health measures instituted in 1918 may have delayed or
dampened the epidemic in many cities but probably had little effect on
the ultimate death toll.

The new data were presented this week to Centers for Disease Control and
Prevention experts, who are helping to draw up guidelines for what local
health departments might do during the early stage of an influenza
pandemic, when a vaccine would be unavailable and there would be too few
antiviral drugs to go around.....Excerpted from an article by David
Brown Washington Post Staff Writer Wednesday, December 13, 2006.

Week by week flu activity, CDC
<http://www.cdc.gov/flu/weekly/fluactivity.htm>

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

#### Prolonged second stage with an epidural {#prolonged-second-stage-with-an-epidural-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Let's review last month's case briefly.....a primigravid at 41 3/7 weeks with a history of polycystic ovarian syndrome, a 41 lb. weight gain, a known female infant, and one abnormal result on a 3 hour glucose tolerance test had a prolonged second stage with epidural anesthesia. Exam had revealed an estimated fetal weight of "9 + lbs". Her temperature rose to 100.6 F and she was started on intravenous gentamicin and ampicillin. Stage I was desultory after misoprostol cervical ripening and required pitocin augmentation. {#lets-review-last-months-case-briefly..a-primigravid-at-41-37-weeks-with-a-history-of-polycystic-ovarian-syndrome-a-41-lb.-weight-gain-a-known-female-infant-and-one-abnormal-result-on-a-3-hour-glucose-tolerance-test-had-a-prolonged-second-stage-with-epidural-anesthesia.-exam-had-revealed-an-estimated-fetal-weight-of-9-lbs.-her-temperature-rose-to-100.6-f-and-she-was-started-on-intravenous-gentamicin-and-ampicillin.-stage-i-was-desultory-after-misoprostol-cervical-ripening-and-required-pitocin-augmentation. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### As Stage II neared 4 hours the risks and benefits of vacuum assistance were discussed with the patient and it was agreed to proceed. The vacuum extractor was placed during 3 contractions. Subsequently, the fetal presenting part descended to +3/5 with the scalp visible without pushing. The fetal heart tones were reassuring throughout. The patient is noticeably beginning to tire and subjectively seems to be pushing less effectively. {#as-stage-ii-neared-4-hours-the-risks-and-benefits-of-vacuum-assistance-were-discussed-with-the-patient-and-it-was-agreed-to-proceed.-the-vacuum-extractor-was-placed-during-3-contractions.-subsequently-the-fetal-presenting-part-descended-to-35-with-the-scalp-visible-without-pushing.-the-fetal-heart-tones-were-reassuring-throughout.-the-patient-is-noticeably-beginning-to-tire-and-subjectively-seems-to-be-pushing-less-effectively. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### What would you have done at that point? {#what-would-you-have-done-at-that-point .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Allow the patient to push for 30 minutes more and re-evaluate {#allow-the-patient-to-push-for-30-minutes-more-and-re-evaluate .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Notify the OR team and discuss cesarean delivery  {#notify-the-or-team-and-discuss-cesarean-delivery .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Wait for the epidural to completely wear off {#wait-for-the-epidural-to-completely-wear-off .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Apply the vacuum for a second trial {#apply-the-vacuum-for-a-second-trial .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Add clindamycin {#add-clindamycin .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

#### Let's take a 'time out' here {#lets-take-a-time-out-here .Style-Heading-4-+-Arial-14-pt-Underline}

#### A valid argument could be made for virtually all the above choices. Assuming a reassuring fetal tracing there is no magic to a certain numerical length of Stage II, especially if the patient did not have a strong sensation throughout and was allowed to 'labor down' with an epidural. If you choose that course be sure your documentation reflects that the patient was not actively pushing during that period. On the other hand, the delivery provider should be aware that the patient has developed several risk factors that make a successful vaginal delivery fraught with potential difficulty. {#a-valid-argument-could-be-made-for-virtually-all-the-above-choices.-assuming-a-reassuring-fetal-tracing-there-is-no-magic-to-a-certain-numerical-length-of-stage-ii-especially-if-the-patient-did-not-have-a-strong-sensation-throughout-and-was-allowed-to-labor-down-with-an-epidural.-if-you-choose-that-course-be-sure-your-documentation-reflects-that-the-patient-was-not-actively-pushing-during-that-period.-on-the-other-hand-the-delivery-provider-should-be-aware-that-the-patient-has-developed-several-risk-factors-that-make-a-successful-vaginal-delivery-fraught-with-potential-difficulty. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### The one exception would the choice to reapply the vacuum for a second trial. Before we explore that option though, perhaps we may want to re-explore the use of the vacuum the first time. This patient had several risk factors that predispose patients to a possible shoulder dystocia. {#the-one-exception-would-the-choice-to-reapply-the-vacuum-for-a-second-trial.-before-we-explore-that-option-though-perhaps-we-may-want-to-re-explore-the-use-of-the-vacuum-the-first-time.-this-patient-had-several-risk-factors-that-predispose-patients-to-a-possible-shoulder-dystocia. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Risk factors for shoulder dystocia {#risk-factors-for-shoulder-dystocia .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Fetal macrosomia {#fetal-macrosomia .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Glucose Intolerance {#glucose-intolerance .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Operative vaginal delivery {#operative-vaginal-delivery .Style-Heading-4-+-Arial-14-pt-Underline}

#### -History of shoulder dystocia {#history-of-shoulder-dystocia .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Labor abnormalities {#labor-abnormalities .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Postterm pregnancy {#postterm-pregnancy .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Male fetal gender {#male-fetal-gender .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Obesity and high weight gain {#obesity-and-high-weight-gain .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Advanced maternal age {#advanced-maternal-age .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Shoulder-pelvis disproportion {#shoulder-pelvis-disproportion .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Shoulder dystocia is best defined as the need for additional obstetric maneuvers to effect delivery of the fetal shoulders at the time of vaginal delivery. It occurs in 0.2 to 3 percent of all births and represents an obstetric emergency. Shoulder dystocias can be anticipated only rarely, as many occur in the absence of identifiable risk factors. Therefore, all obstetric care providers must be prepared to recognize a shoulder dystocia immediately and proceed through an orderly sequence of steps to effect delivery in a timely manner and minimize risk to the mother and fetus. It should be noted, however, that permanent birth injury, and even fetal death, can result in cases of shoulder dystocia that are appropriately identified and managed. {#shoulder-dystocia-is-best-defined-as-the-need-for-additional-obstetric-maneuvers-to-effect-delivery-of-the-fetal-shoulders-at-the-time-of-vaginal-delivery.-it-occurs-in-0.2-to-3-percent-of-all-births-and-represents-an-obstetric-emergency.-shoulder-dystocias-can-be-anticipated-only-rarely-as-many-occur-in-the-absence-of-identifiable-risk-factors.-therefore-all-obstetric-care-providers-must-be-prepared-to-recognize-a-shoulder-dystocia-immediately-and-proceed-through-an-orderly-sequence-of-steps-to-effect-delivery-in-a-timely-manner-and-minimize-risk-to-the-mother-and-fetus.-it-should-be-noted-however-that-permanent-birth-injury-and-even-fetal-death-can-result-in-cases-of-shoulder-dystocia-that-are-appropriately-identified-and-managed. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### This patient has the majority of the above risk factors. Let us explore a two of the more salient aspects:  {#this-patient-has-the-majority-of-the-above-risk-factors.-let-us-explore-a-two-of-the-more-salient-aspects .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### One abnormal glucose tolerance test result:  {#one-abnormal-glucose-tolerance-test-result .Style-Heading-4-+-Arial-14-pt-Underline}

#### This condition is often overlooked, but is associated with macrosomia. Women with one abnormal value on the oral GTT demonstrate fasting insulin concentrations and insulin resistance comparable to that of women with GDM, and they are more likely to deliver a macrosomic infant than women without GDM or women with GDM that is treated. The management of these patients is controversial. Some have recommended that they be treated the same as women who meet standard criteria for GDM, others have not considered further intervention or recommended repeating the oral GTT in four weeks . Studies have shown that treatment of women with one abnormal GTT value decreases the risk of a macrosomic infant and is cost-effective. {#this-condition-is-often-overlooked-but-is-associated-with-macrosomia.-women-with-one-abnormal-value-on-the-oral-gtt-demonstrate-fasting-insulin-concentrations-and-insulin-resistance-comparable-to-that-of-women-with-gdm-and-they-are-more-likely-to-deliver-a-macrosomic-infant-than-women-without-gdm-or-women-with-gdm-that-is-treated.-the-management-of-these-patients-is-controversial.-some-have-recommended-that-they-be-treated-the-same-as-women-who-meet-standard-criteria-for-gdm-others-have-not-considered-further-intervention-or-recommended-repeating-the-oral-gtt-in-four-weeks-.-studies-have-shown-that-treatment-of-women-with-one-abnormal-gtt-value-decreases-the-risk-of-a-macrosomic-infant-and-is-cost-effective. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Operative vaginal delivery: {#operative-vaginal-delivery-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Operative vaginal delivery is a risk factor for shoulder dystocia. It is not known whether shoulder dystocia is a result of instrument-aided descent of the fetus or is the underlying reason the fetus has not descended naturally. In a classic study, the combination of macrosomia (defined as birth weight greater than 4000 g), prolonged second stage, and midpelvic operative delivery was associated with a 21 percent incidence of shoulder dystocia. By comparison, when only prolonged second stage and midpelvic operative delivery were present, the risk fell to 4.57 percent and was 0.16 percent in the absence of these risk factors. One review concluded that instrumental delivery was the intrapartum risk factor most associated with permanent brachial plexus injury. {#operative-vaginal-delivery-is-a-risk-factor-for-shoulder-dystocia.-it-is-not-known-whether-shoulder-dystocia-is-a-result-of-instrument-aided-descent-of-the-fetus-or-is-the-underlying-reason-the-fetus-has-not-descended-naturally.-in-a-classic-study-the-combination-of-macrosomia-defined-as-birth-weight-greater-than-4000-g-prolonged-second-stage-and-midpelvic-operative-delivery-was-associated-with-a-21-percent-incidence-of-shoulder-dystocia.-by-comparison-when-only-prolonged-second-stage-and-midpelvic-operative-delivery-were-present-the-risk-fell-to-4.57-percent-and-was-0.16-percent-in-the-absence-of-these-risk-factors.-one-review-concluded-that-instrumental-delivery-was-the-intrapartum-risk-factor-most-associated-with-permanent-brachial-plexus-injury. .Style-Heading-4-+-Arial-14-pt-Underline}

While operative vaginal delivery is just one of many risk factors, it
represents a 'sin of commission'. In many cases one never knows exactly
what will / will not occur without prior intervention in a rare event
like shoulder dystocia. On the other hand, if one has performed an
operative vaginal delivery, then right or wrong, all the subsequent
events are viewed within the purview of that action. Hence, it becomes a
post hoc assumption that the fetus was 'pulled' into the shoulder
dystocia.

**Back to our case**

In this case, the vacuum extractor was re-applied for 3 more
applications of traction which brought the presenting part to crowning
shortly followed by the 'turtle sign'. Gentle traction, McRoberts, and
nuchal cord release x2 were performed without success. A
procto-episotomy was performed without success, followed by the Woods
screw maneuver without success. Attention was then paid to the posterior
arm and delivery was accomplished after a total of 2 minutes on the
perineum. The parturient was taken to the OR for a 4^th^ degree
laceration repair. The patient notes continued fecal incontinence at
this writing.

The infant had good cord pH(s), but Apgars of 2/5. The infant was
admitted to the special care nursery for one day after resuscitation in
the labor suite due to hypotension and ventilation requirements. The
infant weighted slightly more than 9 pounds and had a fractured
clavicle. The infant was discharged in stable condition after one
subsequent day in the step down unit. There were no neurologic deficits
and the child has done well in well child care.

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

#### In retrospect, though shoulder dsytocia is a rare event and this one was managed quite well, I think there is an element of it being 'lucky rather than good'. Perhaps this represents a 'near miss', if you will. In either case, I submit that if you have what is very likely a macrosomic infant with a prolonged labor, that you not perform operative vaginal delivery.  {#in-retrospect-though-shoulder-dsytocia-is-a-rare-event-and-this-one-was-managed-quite-well-i-think-there-is-an-element-of-it-being-lucky-rather-than-good.-perhaps-this-represents-a-near-miss-if-you-will.-in-either-case-i-submit-that-if-you-have-what-is-very-likely-a-macrosomic-infant-with-a-prolonged-labor-that-you-not-perform-operative-vaginal-delivery. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### In addition, I strongly suggest that when you do attend a macrosomic delivery, that you encourage the fetus to 'deliver through'. In other words, once the fetus is in the final expulsive effort, that you continue the downward momentum until the anterior shoulder is visible, e. g., do not stop the downward progress to suction the oropharynx. {#in-addition-i-strongly-suggest-that-when-you-do-attend-a-macrosomic-delivery-that-you-encourage-the-fetus-to-deliver-through.-in-other-words-once-the-fetus-is-in-the-final-expulsive-effort-that-you-continue-the-downward-momentum-until-the-anterior-shoulder-is-visible-e.-g.-do-not-stop-the-downward-progress-to-suction-the-oropharynx. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### In regard to operative vaginal delivery in this setting, it is perhaps best to remember the [Latin](http://en.wikipedia.org/wiki/Latin) phrase Primum non nocere \"First, do no harm\". {#in-regard-to-operative-vaginal-delivery-in-this-setting-it-is-perhaps-best-to-remember-the-latin-phrase-primum-non-nocere-first-do-no-harm. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Online resources: {#online-resources .Style-Heading-4-+-Arial-14-pt-Underline}

#### Diagnosis and management of pregnancies at risk for shoulder dystocia, UpToDate {#diagnosis-and-management-of-pregnancies-at-risk-for-shoulder-dystocia-uptodate .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.uptodateonline.com/utd/content/topic.do?topicKey=labordel/6688&type=A&selectedTitle=1\~14**](http://www.uptodateonline.com/utd/content/topic.do?topicKey=labordel/6688&type=A&selectedTitle=1~14) {#httpwww.uptodateonline.comutdcontenttopic.dotopickeylabordel6688typeaselectedtitle114 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Screening and diagnosis of gestational diabetes mellitus, UpToDate {#screening-and-diagnosis-of-gestational-diabetes-mellitus-uptodate .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.uptodateonline.com/utd/content/topic.do?topicKey=pregcomp/28647&type=A&selectedTitle=1\~17**](http://www.uptodateonline.com/utd/content/topic.do?topicKey=pregcomp/28647&type=A&selectedTitle=1~17) {#httpwww.uptodateonline.comutdcontenttopic.dotopickeypregcomp28647typeaselectedtitle117 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### References: {#references .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Jovanovic-Peterson L; Bevier W; Peterson CM. The Santa Barbara County Health Care Services program: birth weight change concomitant with screening for and treatment of glucose-intolerance of pregnancy: a potential cost-effective intervention? Am J Perinatol 1997 Apr;14(4):221-8. {#jovanovic-peterson-l-bevier-w-peterson-cm.-the-santa-barbara-county-health-care-services-program-birth-weight-change-concomitant-with-screening-for-and-treatment-of-glucose-intolerance-of-pregnancy-a-potential-cost-effective-intervention-am-j-perinatol-1997-apr144221-8. .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Bevier WC; Fischer R; Jovanovic L Treatment of women with an abnormal glucose challenge test (but a normal oral glucose tolerance test) decreases the prevalence of macrosomia. Am J Perinatol 1999;16(6):269-75. {#bevier-wc-fischer-r-jovanovic-l-treatment-of-women-with-an-abnormal-glucose-challenge-test-but-a-normal-oral-glucose-tolerance-test-decreases-the-prevalence-of-macrosomia.-am-j-perinatol-1999166269-75. .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Langer O et al Management of women with one abnormal oral glucose tolerance test value reduces adverse outcome in pregnancy. Am J Obstet Gynecol 1989 Sep;161(3):593-9. {#langer-o-et-al-management-of-women-with-one-abnormal-oral-glucose-tolerance-test-value-reduces-adverse-outcome-in-pregnancy.-am-j-obstet-gynecol-1989-sep1613593-9. .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Benedetti TJ; Gabbe SG Shoulder dystocia. A complication of fetal macrosomia and prolonged second stage of labor with midpelvic delivery. Obstet Gynecol 1978 Nov;52(5):526-9. {#benedetti-tj-gabbe-sg-shoulder-dystocia.-a-complication-of-fetal-macrosomia-and-prolonged-second-stage-of-labor-with-midpelvic-delivery.-obstet-gynecol-1978-nov525526-9. .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Gherman RB et al Shoulder dystocia: the unpreventable obstetric emergency with empiric management guidelines. Am J Obstet Gynecol. 2006 Sep;195(3):657-72. {#gherman-rb-et-al-shoulder-dystocia-the-unpreventable-obstetric-emergency-with-empiric-management-guidelines.-am-j-obstet-gynecol.-2006-sep1953657-72. .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

######### Exercise in the Age of Evidence-Based Medicine: A Clinical Update

[http://www.medscape.com/viewprogram/6375?sssdmh=dm1.244743&src=top10#](http://www.medscape.com/viewprogram/6375?sssdmh=dm1.244743&src=top10)

######### Genital Warts: Best Practices for Diagnosis and Management

<http://www.medscape.com/viewprogram/6385?src=sr>

######### Routine Testing for HIV Infection: CDC Screening Recommendations for the US Population

######### [**http://www.medscape.com/viewprogram/6673?sssdmh=dm1.247224&src=nlcmealert**](http://www.medscape.com/viewprogram/6673?sssdmh=dm1.247224&src=nlcmealert)

**Preventing STD-Related Cancers: An Update on Vaccination Strategies**

<http://www.medscape.com/viewprogram/6403?src=mp>

**What Primary Care Providers Need to Know, in 2006, to Optimize the
Management of Acid-Peptic Disorders**

<http://mp.medscape.com/cgi-bin1/DM/y/hBIvg0Ou5N60Rrh0IK1Q0EU>

######### 

**Weighing the Evidence: NNRTIs vs Boosted PIs for First-line
Antiretroviral Therapy**

<http://www.medscape.com/viewprogram/5174?sssdmh=dm1.253215&src=0_mp_cmenl_0>

######### 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**

**Oral, not Transdermal, Estrogen Increases Risk for VTE in Women **

CONCLUSIONS: Oral but not transdermal estrogen is associated with an
increased VTE risk. In addition, our data suggest that norpregnane
derivatives may be thrombogenic, whereas micronized progesterone and
pregnane derivatives appear safe with respect to thrombotic risk. If
confirmed, these findings could benefit women in the management of their
menopausal symptoms with respect to the VTE risk associated with oral
estrogen and use of progestogens

[Canonico
M](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Canonico+M"%5BAuthor%5D),
et al Hormone therapy and venous thromboembolism among postmenopausal
women: impact of the route of estrogen administration and progestogens:
the ESTHER study.
[Circulation.](javascript:AL_get(this, 'jour', 'Circulation.');) 2007
Feb 20;115(7):840-5

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17309934**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17309934) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgidbpubmedcmdretrievedoptabstractpluslist_uids17309934 .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

#### [Simon JA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&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):588-596. [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17329509&dopt=Abstract**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17329509&dopt=Abstract) {#simon-ja-et-al-low-dose-of-transdermal-estradiol-gel-for-treatment-of-symptomatic-postmenopausal-women-a-randomized-controlled-trial.-obstet-gynecol.-2007-mar1093588-596.-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmedlist_uids17329509doptabstract .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Unopposed estradiol: Anticipate uterine bleeding and the possibility of endometrial biopsy {#unopposed-estradiol-anticipate-uterine-bleeding-and-the-possibility-of-endometrial-biopsy .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: Short-term, unopposed estradiol therapy with gynecologic monitoring may be an option for the treatment of menopausal symptoms. Menopausal women choosing estradiol therapy, especially if obese, should anticipate uterine bleeding and the possibility of an endometrial biopsy. LEVEL OF EVIDENCE: I. {#conclusion-short-term-unopposed-estradiol-therapy-with-gynecologic-monitoring-may-be-an-option-for-the-treatment-of-menopausal-symptoms.-menopausal-women-choosing-estradiol-therapy-especially-if-obese-should-anticipate-uterine-bleeding-and-the-possibility-of-an-endometrial-biopsy.-level-of-evidence-i. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Steiner AZ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Steiner+AZ"%5BAuthor%5D) et al Unopposed Estradiol Therapy in Postmenopausal Women: Results From Two Randomized Trials. [Obstet Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007 Mar;109(3):581-587. {#steiner-az-et-al-unopposed-estradiol-therapy-in-postmenopausal-women-results-from-two-randomized-trials.-obstet-gynecol.-2007-mar1093581-587. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17329508&dopt=Abstract**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17329508&dopt=Abstract) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmedlist_uids17329508doptabstract .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Nonhormonal therapies for menopausal hot flashes: systematic review and meta-analysis {#nonhormonal-therapies-for-menopausal-hot-flashes-systematic-review-and-meta-analysis .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: The SSRIs or SNRIs, clonidine, and gabapentin trials provide evidence for efficacy; however, effects are less than for estrogen, few trials have been published and most have methodological deficiencies, generalizability is limited, and adverse effects and cost may restrict use for many women. These therapies may be most useful for highly symptomatic women who cannot take estrogen but are not optimal choices for most women. {#conclusion-the-ssris-or-snris-clonidine-and-gabapentin-trials-provide-evidence-for-efficacy-however-effects-are-less-than-for-estrogen-few-trials-have-been-published-and-most-have-methodological-deficiencies-generalizability-is-limited-and-adverse-effects-and-cost-may-restrict-use-for-many-women.-these-therapies-may-be-most-useful-for-highly-symptomatic-women-who-cannot-take-estrogen-but-are-not-optimal-choices-for-most-women. .Style-Heading-4-+-Arial-14-pt-Underline}

#### Nelson HD et al Nonhormonal therapies for menopausal hot flashes: systematic review and meta-analysis. [JAMA.  2006; 295(17):2057-71](http://www.medscape.com/medline/publicationbrowser/123?pmid=16670414) {#nelson-hd-et-al-nonhormonal-therapies-for-menopausal-hot-flashes-systematic-review-and-meta-analysis.-jama.-2006-295172057-71 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16670414**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16670414) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgidbpubmedcmdretrievedoptabstractpluslist_uids16670414 .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

**Being Present**

**The spirituality of presence in midwifery care**

Pembroke and Pembroke have written an article that is a must-read for
all of us that attend women in pregnancy, labor and birth, and,
actually, it is highly relevant in the provision of any kind of health
care. It is essential reading for the student who needs to learn the art
and not just the technical science of what we do and it will remind
experienced providers of the human contact we must strive to achieve
even on the busiest day. I highly recommend that you read the entire
article (if you can not get the full text through PubMed please contact
me and I will email it to you) but here are a few of the juiciest
morsels.

"Presence involves an offering of self (Scoppo, 2003). In being present
to the other, one generously makes available one's personal resources.
To be present as a midwife is to be open, available and receptive to the
needs and preferences of the woman (Berg et al., 1996; Lundberg, 2004)."

"A caring presence involves creating an environment of trust and
security."

The authors present a discussion of spirituality, which is a clear
reminder that our work is not about us and our egos---it is about being
with the other.

"The spiritual person identifies making meaning out of one's existence
on earth as a central human task. The journey into meaning usually
involves self-transcendence. To be spiritual is to break through the
confining and limiting grip of egoism. Egotistic persons are locked up
inside themselves; they have little or no capacity to reach out to
others and to the world around them. Overcoming selfish tendencies in
order to help others is central in an authentic spirituality."

Next they present two concepts that make presence
possible---responsibility and availability. The discussion of
responsibility is based on Buber's work: "He is talking about
'responsiveness', about the ability to respond to the other person and
her needs and aspirations. For Buber responsibility is a deep capacity
to respond to the claims others make on us. It requires an acute
awareness of the other through which she becomes present in her
wholeness and uniqueness."

"In order to be genuinely responsive to a woman, it is necessary to
include oneself in her inner world. That is, one must discover precisely
what it is that she needs and values. Women ask to be sensitively
listened to. Further they ask that the midwife approach them with a
respect for their uniqueness."

The authors discuss availability in terms of receptivity and being open
and "porous" or permeable to the communication from others. They also
discuss hospitality as pivotal and present a fascinating picture of
midwife as host: "Hospitality plays a vitally important role in engaging
on a personal, friendly level with women. We need to ask, however,
whether or not it is appropriate to refer to a midwife as a host. Many
would rather have it that the midwife is the invited guest (Leap, 2000;
Kenedy, 2003). The primary actor in the birthing experience is the
woman. She invites others to be with her as she gives birth. There is
still a place, we contend, for the appellation 'host' in relation to the
midwife's role. It is clearly wrong to refer to him or her as host of
the birthing process. To speak of him or her as host in the context of
the relationship he or she shares with the woman is, however, not only
appropriate but also illuminating. It is illuminating because it reminds
us that the midwife is called upon to mentally establish an open space
that will be filled by the woman's needs and preferences. To be
available to the woman involves listening to her and following her lead
through the process of childbirth (Lundgren, 2004). Midwives need a
certain 'incohesion' in order to be truly receptive. If they fill their
internal spaces with their own commitments and preferences, there is no
place for the woman to make contact."

Read this article. It's important.

The spirituality of presence in midwifery care. Pembroke, NF, Pembroke,
JJ Midwifery 2007 Feb 1
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17275972>

**Other**

**History and Evidence Base for Normal Birth**

The Winter 2007 supplement to the Journal of Perinatal Education
describes the history of the Coalition for Improving Maternity Services
as part of a global effort to promote \"normal birth\" (as established
by universal guidelines for the routine care of women during
uncomplicated labor and childbirth). The supplement presents the
principles underlying the Mother-Friendly Childbirth Initiative (MFCI),
the first consensus declaration in the history of North America in which
a multidisciplinary body of professional organizations and individuals
address the issues of labor and birth. The supplement also identifies
the Ten Steps of Mother-Friendly Care that lay out the practical
application of the philosophy and principles of the MFCI and introduce
the evidence base for the Ten Steps. Discussion and commentary are
provided. The supplement is intended for use by health professionals,
families, and others in supporting normal birth and breastfeeding as the
standard of care for all women. The supplement is available to journal
subscribers at
[[http://www.ingentaconnect.com/content/lamaze/jpe]{.underline}](http://www.ingentaconnect.com/content/lamaze/jpe)

**Navajo News Jean Howe, Chinle**

**New ACOG recommendations challenging for rural IHS sites---a plea for
sharing strategies to meet national standards in the face of limited
resources...**

One new challenge facing Navajo Area prenatal providers, and probably
many others providing care to pregnant women at rural sites throughout
IHS, is what to do about all the new options for prenatal genetic
screening. ACOG recently issued a Practice Bulletin, Screening for Fetal
Chromosomal Abnormalities, which reviews the tests currently available
and acknowledges how confusing this area has become. You know you're in
a difficult situation when ACOG includes a section entitled, "With so
many Down syndrome screening tests available, how do I decide which
tests to offer?"

Before one wades through the array of available tests, it seems
important to acknowledge a couple of new guiding principles that we are
being asked to incorporate into our practice:

1.  It's not just about age any more. Although the risk of Down syndrome
    and other chromosome abnormalities increase with age for individual
    women, most Down syndrome babies are born to young women. It has
    become the standard of care to offer prenatal screening for
    chromosome abnormalities to all women as part of routine prenatal
    care.

2.  It's not just about second trimester screening anymore. There are
    now well-established methods of first trimester screening. We need
    to figure out how to make these testing options available to our
    patients.

Other principles haven't changed at all. Our job as providers is to
share information about screening options and offer non-directive
counseling. It is still the woman's choice to decide what (if any) tests
she would like to have done and her right to decline testing altogether.
Some women seek information to consider termination of pregnancy, others
to make special preparations before the birth of a baby with additional
needs. Also, because of the distance to tertiary care facilities, some
infants may benefit from prenatal diagnosis that allows planned
deliveries in urban centers with additional resources.

There are several markers that can be used to calculate a risk for Down
syndrome. One relatively new test is the nuchal translucency measurement
(NT), a measure of the thickness of the fluid collection at the back of
the fetal neck in the first trimester. To be used for calculating Down
syndrome risk, NT measurements must be performed by certified
sonographers with special training and ongoing monitoring. Optimal NT
measurements are obtained at 12-13 weeks although the test may be
performed from 10 4/7 to 13 6/7 weeks. Not all patients sent for NT
testing will be able to have images successfully obtained. Serum first
trimester measurements include PAPP-A (pregnancy-associated plasma
protein A) and total or free β hCG. Second trimester serum markers
include MSAFP (maternal serum alpha-fetoprotein), hCG, and unconjugated
estriol which are used in calculation of a "triple screen"; with the
addition of inhibin A this becomes a "quad screen". The main focus of
this testing has become the identification of Down syndrome although
some of these markers are also used in the identification of other
conditions, including trisomy 18 and open neural tube defects.

The ACOG Practice Bulletin provides much detail about the different
screening tests, their detection rates, and their false positive rates.
One relevant comparison for any facility still doing second trimester
triple screen testing is the improved detection of Down syndrome with
the change to Quad screening (from \<70% to over 80%). ACOG answers the
question about how to choose with several considerations, including the
following:

"\...If nuchal translucency measurement is not available or cannot be
obtained in an individual patient, a reasonable approach is to offer
serum integrated screening \[with a detection rate of 85-88%\] to
patients who present early and second-trimester screening to those who
present later."

This still leaves a great deal of work to be done. A review of the tests
available through our contracted laboratory provider fails to identify
any test options that combine first and second trimester serum testing
but do not also rely on NT measurements. And as NT measurements are only
available at tertiary care facilities several hours away, this just
isn't a realistic option for wholesale screening for our rural facility,
especially given the narrow window of dates when testing can be done.
So, for our site, and some other sites in Navajo, we've transitioned to
Quad screening but haven't resolved the first trimester dilemma. If you
work at a rural site and have successfully addressed this problem, we'd
like to hear from you. Also, if anyone has found or created a culturally
sensitive patient education brochure about prenatal genetic screening,
please share!

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

**Let's begin a dialogue**

I want to thank Jean Howe for bringing up this issue, as it is a major
concern nationwide. Various suggestions have included that we adapt a
serum screening strategy whereby we only refer the women who have
abnormal results. Each Area would need to negotiate with their lab, or
find a new lab, e. g., is the lab able to integrate the NTD results? The
PAPP-A and free bHCG can be done at 10-13 wks if the patient comes early
enough. If so, then perform the quad screen at 15-20 and integrate the
results, or refer if there is an abnormal 1st trimester result. Patients
who come later can get a quad screen, and refer those with abnormal
results if they so wish.

Let us know how your Area has solved this emerging problem.
<nmurphy@scf.cc>

**Reference:**

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

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17197615>

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

**Nurses Corner, Sandra Haldane, HQE**

**Assessment of Adverse Drug Events Among Patients in a Tertiary Care
Medical Center**

CONCLUSION: Certain age groups, diagnoses, admission sources, types of
insurance, and the use of specific medications or medication classes
were associated with increased AE rates at a tertiary care medical
center.

[Johnston
PE](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Johnston+PE"%5BAuthor%5D),
et al Assessment of adverse drug events among patients in a tertiary
care medical center. [Am J Health Syst
Pharm.](javascript:AL_get(this, 'jour', 'Am J Health Syst Pharm.');)
2006 Nov 15;63(22):2218-27

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17090742**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17090742) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgidbpubmedcmdretrievedoptabstractpluslist_uids17090742 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Family Support in Patient-Centered Care: New Guidelines Issued {#family-support-in-patient-centered-care-new-guidelines-issued-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSIONS: More than 300 related studies were reviewed. However, the level of evidence in most cases is at Cochrane level 4 or 5, indicating the need for further research. Forty-three recommendations are presented that include, but are not limited to, endorsement of a shared decision-making model, early and repeated care conferencing to reduce family stress and improve consistency in communication, honoring culturally appropriate requests for truth-telling and informed refusal, spiritual support, staff education and debriefing to minimize the impact of family interactions on staff health, family presence at both rounds and resuscitation, open flexible visitation, way-finding and family-friendly signage, and family support before, during, and after a death. [Davidson JE](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Davidson+JE"%5BAuthor%5D), et al Clinical practice guidelines for support of the family in the patient-centered intensive care unit: American College of Critical Care Medicine Task Force 2004-2005. [Crit Care Med.](javascript:AL_get(this, 'jour', 'Crit Care Med.');) 2007 Feb;35(2):605-22 {#conclusions-more-than-300-related-studies-were-reviewed.-however-the-level-of-evidence-in-most-cases-is-at-cochrane-level-4-or-5-indicating-the-need-for-further-research.-forty-three-recommendations-are-presented-that-include-but-are-not-limited-to-endorsement-of-a-shared-decision-making-model-early-and-repeated-care-conferencing-to-reduce-family-stress-and-improve-consistency-in-communication-honoring-culturally-appropriate-requests-for-truth-telling-and-informed-refusal-spiritual-support-staff-education-and-debriefing-to-minimize-the-impact-of-family-interactions-on-staff-health-family-presence-at-both-rounds-and-resuscitation-open-flexible-visitation-way-finding-and-family-friendly-signage-and-family-support-before-during-and-after-a-death.-davidson-je-et-al-clinical-practice-guidelines-for-support-of-the-family-in-the-patient-centered-intensive-care-unit-american-college-of-critical-care-medicine-task-force-2004-2005.-crit-care-med.-2007-feb352605-22 .Style-Heading-4-+-Arial-14-pt-Underline}

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17205007>

####  {#section-36 .Style-Heading-4-+-Arial-14-pt-Underline}

#### A Call to Action for Caregivers and Patients: Imaging X-rays Cause Cancer {#a-call-to-action-for-caregivers-and-patients-imaging-x-rays-cause-cancer-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.medscape.com/viewprogram/5063?src=mp**](http://www.medscape.com/viewprogram/5063?src=mp) {#httpwww.medscape.comviewprogram5063srcmp .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Role of Exercise in Treating Postpartum Depression: A Review of the Literature {#role-of-exercise-in-treating-postpartum-depression-a-review-of-the-literature .Style-Heading-4-+-Arial-14-pt-Underline}

#### Limited evidence supports a relationship between participation in exercise and reduction in postpartum depression. Given the reluctance by some women to use antidepressant medication postpartum and the limited availability of psychological therapies, exercise as a therapeutic possibility deserves further exploration. Further research using well-designed randomised controlled trial methodologies are warranted. {#limited-evidence-supports-a-relationship-between-participation-in-exercise-and-reduction-in-postpartum-depression.-given-the-reluctance-by-some-women-to-use-antidepressant-medication-postpartum-and-the-limited-availability-of-psychological-therapies-exercise-as-a-therapeutic-possibility-deserves-further-exploration.-further-research-using-well-designed-randomised-controlled-trial-methodologies-are-warranted. .Style-Heading-4-+-Arial-14-pt-Underline}

[Daley
AJ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Daley+AJ"%5BAuthor%5D),
et al The role of exercise in treating postpartum depression: a review
of the literature. [J Midwifery Womens
Health.](javascript:AL_get(this, 'jour', 'J Midwifery Womens Health.');)
2007 Jan-Feb;52(1):56-62

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17207752**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17207752) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgidbpubmedcmdretrievedoptabstractpluslist_uids17207752 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-38 .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}

# QuickStats: Birth Rates\* Among Females Aged 15\--19 Years, by State

![](media/image5.png){width="5.405555555555556in"
height="3.998611111111111in"}

\*Per 1,000 females in age group.

Age of mother is a predictor of maternal and infant health risk.
Pregnant teens aged 15\--19 years are less likely to receive timely
prenatal care and gain appropriate weight and more likely to smoke
during pregnancy than pregnant women aged \>20 years. These factors are
associated with poor birth outcomes. For example, infants born to
mothers who smoke during pregnancy are 65% more likely to have low
birthweight and 70% more likely to die in infancy than infants born to
nonsmokers. In 2004, the overall U.S. birth rate for mothers aged
15\--19 years was 41.1 births per 1,000 females in that age group. Among
states, rates ranged from 62.6 (Texas) to 18.2 (New Hampshire).

#### [**http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5551a6.htm?s_cid=mm5551a6_e**](http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5551a6.htm?s_cid=mm5551a6_e) {#httpwww.cdc.govmmwrpreviewmmwrhtmlmm5551a6.htms_cidmm5551a6_e .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Fetal and Perinatal Mortality, United States, 2003**

This report presents 2003 fetal and perinatal mortality data by a
variety of characteristics, including maternal age, marital status,
race, Hispanic origin, and state of residence; and by infant
birthweight, gestational age, plurality, and sex. Trends in fetal and
perinatal mortality are also examined. The rate of fetal deaths
occurring at 20 weeks of gestation or more (also known as stillbirths)
declined substantially between 1990 and 2003. Although fetal mortality
rates declined among all racial and ethnic groups from 1990-2003, the
rate for non-Hispanic black women was more than double that of
non-Hispanic white women (11.56 per 1,000 vs. 4.94 per 1,000).

<http://www.cdc.gov/nchs/pressroom/07newsreleases/stillbirths.htm>

####  {#section-40 .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 (ie, 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}

####  {#section-41 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Bisphosphonate Related Osteonecrosis of the Jaws (BRONJ)**

**Again with the Phossy Jaw?**

M. Winkler DDS, MS and K. Martin DDS

In the mid 1800s, English matchstick factory workers started presenting
with horrific jaw bone exposures and infections which led to
disfigurements and sometimes death. This was before the advent of
antibiotics and most of these patients received copper and surgery for
their plight -- with less than desirable results. Eventually, this
disease process became linked to the white phosphorus used in the
matchstick making industry.(Hellstein)

Currently, oral and maxillofacial surgeons and dentists are seeing a
revival of this type of presentation from IV and oral bisphosphonate
drugs. Our current pathogenesis has only been linked to drugs which
contain nitrogen side chains: zolendronic acid, pamidronate,
risedronate, ibandronate, and alendronate. Rates are now reported to be
6-7% with Zolendronic acid, 4+% with Pamidronate, and \<1% with
Alendronate. Early inconsistencies in terminology and diagnosis have
probably led to a lower report of the actual incidence. Another
compounding factor is current literature remains at level 3 studies
only. We lack any randomized controlled trials/prospective studies.
Consequently, our understanding of pathogenesis, progression, treatment,
and identification of risk factors (steroid therapy, hormone
replacement, age, clinical and radiographic presentation) is sorely
lacking. Reports of this type of osteonecrosis are significantly
increasing. The two major initial case reports on BRONJ in 2003 and 2004
have more than doubled their original number of patients.(Marx and
Ruggiero)

Pathogenesis of this disease has not yet been identified, but the
preponderance of evidence and response to treatments suggests a
metabolic origin rather than vascular etiology. Especially considering
hyperbaric oxygen treatments are not effective in treating this disease
(unlike patients with osteoradionecrosis or osteomyelitis). These drugs
are diffused through out the jaws and not just a focal area like
osteomyelitis or a slightly larger area like osteoradionecrosis. There
is NO such thing as debriding until we find healthy bone. This type of
osteonecrosis (consider the bisphosphonate bone response like
osteopetrosis) has only been shown in the jaws with one exception
involving the auditory canal in a patient with maxillary
BRONJ.(Polizzotto) It is believed this is due to the well vascularized
jaw structures and significantly higher bone turnover of the jaws
compared to the long bones, especially in areas of tooth
extractions/implant. (Hughes et al., Rogers et al., Rodan et al., Stepan
et al., Strewler) Couple this with the unique anatomy of the oral
environment: significant bony prominences, exceptionally thin mucosa
tissue covering (\<1mm in some areas), and constant exposure to trauma
(eating, habits, etc.) ...And yes, a potato chip can do you in!

Please realize bisphosphonates are phenomenal drugs and have been and
will continue to be a keystone treatment for osteoporosis and certain
malignancies, but for people with bad habits, in particular bristle
allergies, these drugs pose exponentially more

problems. This is where bad habits catch up to people. Studies have
shown \>80% of inciting events (induction of osteonecrosis) have been
linked to previous dentoalveolar surgeries, e.g., extractions,
etc.(Durie et al) SO, if you have patients in their 50s who still are
not orally stable (poor-fair oral hygiene) and require treatments like
extractions -- this is exactly the type of patient whose bad habits will
be a factor. There are spontaneous inductions noted in both IV and oral
bisphosphonates, but the incidence is significantly higher in IV forms
compared to orals. BRONJ appears to be potency related with zolendronic
acid the highest in vitro potency and alendronate the lowest.(O'connell)
Usually the incidence begins after 2-3 years of use with these
drugs.(Durie et al.) Realize the risk of BRONJ increases with time. With
the long half lives of these drugs (alendronate, the weakest drug, is
greater than 10 years) the incidence of osteonecrosis is unlikely to
decrease with time, even if the drug(s) have been discontinued.
Bottomline for bisphosphonates: if you need it, YA NEED IT!

Some general treatment recommendations include:

PATIENT EDUCATION! Stress what to look for and regular dental care

Discussion with patients: risks, benefits, and options

Visual Inspection of oral cavity by ALL providers at each visit, note
key areas

Routine dental exams -- yes, I realize access to care is a problem

An ounce of prevention is truly worth more than a pound of jaw bone

Hopefully as more information is elucidated and patient education grows
we will better tailor our bisphosphonate therapies (nitrogen vs.
non-nitrogen side chain drugs, loading vs. maintenance dosing, drug
holidays?) and prevent what can be an exceedingly frustrating and
unrewarding disease to manage.

For more information/references use key words: bisphosphonates,
osteonecrosis, jaws

**Online Resources:**

#### Postmenopausal Osteoporosis: Putting the Risk for Osteonecrosis of the Jaw Into Perspective, Medscape {#postmenopausal-osteoporosis-putting-the-risk-for-osteonecrosis-of-the-jaw-into-perspective-medscape .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.medscape.com/viewprogram/6720?sssdmh=dm1.250302&src=nlcmealert**](http://www.medscape.com/viewprogram/6720?sssdmh=dm1.250302&src=nlcmealert) {#httpwww.medscape.comviewprogram6720sssdmhdm1.250302srcnlcmealert .Style-Heading-4-+-Arial-14-pt-Underline}

**American Association of Oral & Maxillofacial Surgery Position Paper**

[aaoms.org]{.underline}

**American Dental Association Position Paper**

[ada.org]{.underline}

**Additional information can be found at:**

Woo, S., et al. Systematic Review: Bisphosphonates and Osteonecrosis of
the jaws. Ann Intern

Med. 2006;144:753-761 Review. Erratum in: Ann Intern Med. 2006 Aug
1;145(3):235. PMID:

16702591 \[PubMed - indexed for MEDLINE\] (good summary)

**References:**

1.  Hellstein, J.and Marek C., Bisphosphonate osteochemonecrosis
    (bis-phossy jaw): is this phossy jaw of the 21st century? J Oral
    Maxillofac Surg. 2005 May;63(5):682-9. Review. PMID: 15883944
    \[PubMed - indexed for MEDLINE\]

2.  Marx, R., Pamidronate (Aredia) and zoledronate (Zometa) induced
    avascular necrosis of the jaws: a growing epidemic. J Oral
    Maxillofac Surg. 2003 Sep;61(9):1115-7. No abstract available. PMID:
    12966493 \[PubMed - indexed for MEDLINE\]

3.  Ruggiero, S., et al., Osteonecrosis of the jaws associated with the
    use of bisphosphonates: a review of 63 cases. J Oral Maxillofac
    Surg. 2004 May;62(5):527-34. PMID: 15122554 \[PubMed - indexed for
    MEDLINE\]

4.  Polizzotto, M., et al., Bisphosphonate-associated osteonecrosis of
    the auditory canal. Br J Haematol. 2006 Jan; ;132(1):114. PMID:
    16371027 \[PubMed - indexed for MEDLINE\]

5.  Hughes, D., Bisphosphonates promote apoptosis in murine osteoclasts
    in vitro and in vivo. J Bone Miner Res. 1995 10:1478-1487. Review
    PMID: 8686503 \[PubMed - indexed for MEDLINE

6.  Rodan, G., et al., Bisphosphonate mechanism of action. Curr Mol Med.
    2002 Sep;2(6):571-7. Review. PMID: 12243249 \[PubMed - indexed for
    MEDLINE

7.  Rogers, M., From molds and macrophages to mevalonate: a decade of
    progress in understanding the molecular mode of action of
    bisphosphonates. Calcif Tissue Int. 2004 Dec;75(6):451-61. Epub 2004
    Aug 31. Review. PMID: 15332174 \[PubMed - indexed for MEDLINE\]

8.  Stepan, J., Mechanisms of action of antiresorptive therapies of
    postmenopausal osteoporosis. Endocr Regul. 2003 Dec;37(4):225-38.
    Review. PMID: 15106819 \[PubMed - indexed for MEDLINE

9.  Strewler, G. Decimal point\--osteoporosis therapy at the 10-year
    mark. N Engl J Med. 2004 Mar 18;350(12):1172-4. PMID: 15028820
    \[PubMed - indexed for MEDLINE\]

10. Durie, B., et al. Osteonecrosis of the jaw and bisphosphonates
    \[Letter\]. N Engl J Med. 2005;353:99-102 PMID: 16000365 \[PubMed -
    indexed for MEDLINE\]

11. O'Connell, M., et al. Osteoporosis and osteomalacia. In: T. Dipiro,
    Editor, Pharmacotherapy A Pathophysiologic Approach (5thed),
    Mcgraw-Hill, New York, NY. 2002 p.1690.

12. Lin, J., et al., Pharmacokinetics of alendronate: an overview. Int J
    Clin Pract Suppl. 1999 Apr;101:18-26. PMID: 12669737 \[PubMed -
    indexed for MEDLINE\]

####  {#section-42 .Style-Heading-4-+-Arial-14-pt-Underline}

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

# Anemia: When Low Iron Is the Cause

<http://familydoctor.org/009.xml>

# Iron Deficiency Anemia in Infants and Children: How to Prevent It

<http://familydoctor.org/751.xml>

**Does Diabetes Run in Your Family?**  \
This is a new brochure on diabetes and family history.

<http://www.cdc.gov/genomics/public/file/print/2007-02_Diabetes_Broch.pdf>

# 

# Canker Sores: What Are They and What Can You Do About Them?

#### [**http://familydoctor.org/613.xml**](http://familydoctor.org/613.xml) {#httpfamilydoctor.org613.xml .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-44 .Style-Heading-4-+-Arial-14-pt-Underline}

#### The Common Cold: What You Should Know {#the-common-cold-what-you-should-know-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20070215/522ph.html**](http://www.aafp.org/afp/20070215/522ph.html) {#httpwww.aafp.orgafp20070215522ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-45 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Atopic Dermatitis: What You Should Know {#atopic-dermatitis-what-you-should-know .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20070215/530ph.html**](http://www.aafp.org/afp/20070215/530ph.html) {#httpwww.aafp.orgafp20070215530ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-46 .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}

**What is the best management plan for the woman with suspected preterm
labor?**

As is well known, the incidence of preterm birth (PTB) is increasing in
the United States, and is currently approaching 13% of all births. Of
importance to us, the incidence of PTB in Native American women is
actually slightly higher than that of the general population. So, when
one of our clients comes in with preterm contractions, and may be in
true preterm labor, what is the best management plan for her?

First, I'd like to review a few salient points about deciding if this is
the real thing. Is she really in true preterm labor and at risk of an
imminent preterm birth? It's often not that easy to decide. The **fetal
fibronectin test (fFN**), while not the greatest test in our
armamentarium, may be quite helpful as a triage tool. If your patient
must be transferred a long distance for tertiary care, the fFN is quite
cost-effective, and will pay for itself many times over compared to a
costly transport and hospitalization. The negative predictive value of
the fFN approaches 98%. If the test is negative, it is very unlikely
that this woman with preterm contractions is actually going to deliver
in the next 7-14 days. The positive predictive value of the test is not
so great, only 12-15%, but it does "up the ante", and make you more
likely to consider transport.

The fFN only requires a 15 second sample taken from the posterior
fornix, and the currently available rapid test will provide an answer in
less than 2 hours. Remember, blood, amniotic fluid, semen, and lubricant
gel, will all make the test positive, so it will not be helpful to you
in those situations. **Remember to collect the fFN before you do your
digital exam!** If you find that there is advanced cervical dilation,
you can toss the sample. However, if, as is common, there are
contractions, but minimal cervical change, the test can be quite helpful
in your decision-making and management.

Another helpful maneuver to decide if the woman who has preterm
contractions, but an unimpressive cervical exam, is actually in true
preterm labor, is to do **"one-shot terbutaline triage"**. While beta
agonists like terbutaline are not currently thought to have a
satisfactory risk-benefit profile to qualify them as primary agents for
tocolysis, they may be helpful to sort out the clinical picture just
described. A single subcutaneous injection of terbutaline 0.25 mg will
usually ameliorate preterm contractions in women not destined to
actually deliver early. Contrary to widespread opinion, **intravenous
fluid boluses are NOT effective at stopping preterm contractions,** and
may be dangerous if given too energetically.

So, let's say that despite the single shot terbutaline, your client has
persistent contractions, and her cervix has gone from fingertip to 1-2
cm over 2 hours of observation. Her fFN returns positive. You decide
this is the real thing, and make plans for hospitalization or transport.
What tocolytic agent is best for her? Actually, none of the currently
available tocolytics are ideal. Likewise, none of the available
tocolytic agents are FDA approved for this indication, they are
currently all "off-label" use. Their main purpose at this time is to try
to buy 48 hours for the administration of **corticosteroids for fetal
lung maturation**. So, if you think this is real preterm labor and that
this fetus is at considerable risk of PTB, your first maneuver should be
to start steroids. Betamethasone 12 mg intramuscularly for 2 doses at 24
hour intervals (over 48 hours) is probably the best choice. If not
available, dexamethasone 6mg intramuscularly every 12 hours x4 doses
(over 48 hours) is also fine. **Steroids are probably the most
important, and most evidence-based, intervention at this time as regards
improving ultimate perinatal outcome.**

Is antibiotic therapy appropriate for this patient? There is no evidence
that antibiotics are of any benefit for idiopathic preterm labor (i.e.,
no evidence of overt chorioamnionitis or urinary tract infection). In
the situation of preterm premature rupture of membranes without labor
however, antibiotics are appropriate, but I won´t discuss that situation
here. However, antibiotics are indicated in idiopathic preterm labor as
**prophylaxis for group B streptococcus (GBS)** carriage. When you
collect your fFN, you should also take a rectovaginal culture for GBS
and begin empiric treatment with penicillin or ampicillin (or cefazolin
or clindamycin if there is a history of penicillin allergy). This should
be continued for 48 hours until the culture is back. Antibiotics may be
stopped if the culture is negative or if labor has stopped.

In order to allow time for steroids, which tocolytic is best? As noted
above, **beta agonists**, such as terbutaline and ritodrine (the latter
no longer manufactured), when used at the doses needed to stop
contractions, have prominent cardiovascular side effects. They carry a
significant risk of pulmonary edema, especially combined with over
vigorous intravenous hydration. **Beta agonists can no longer be
recommended as first line tocolytic agents.**

Likewise, despite overwhelming evidence of its lack of efficacy,
**magnesium sulfate** (MgSO4) tocolysis remains a North American
anomaly. Cochrane reviews have found it to be an ineffective tocolytic
(no significant benefit in preventing preterm birth compared to
placebo). Moreover, the risk of total pediatric mortality was
significantly higher for infants exposed to MgSO4 (RR = 2.8, CI
1.2-6.6). It also has quite unpleasant maternal side effects and
requires an intravenous drip that is cumbersome during transport.
**MgSO4 should no longer be used as a tocolytic.**

How about another calcium channel blocker such as **nifedipine**, the
popular anti-hypertensive? Several meta-analyses have found them to be
superior to beta agonists, and considerably safer. Unfortunately, none
of the individual randomized are sufficiently powered (the largest had
only 95 patients enrolled), and none of them compared nifedipine to
placebo or no treatment.

Calcium channel blockers achieve tocolysis by blocking myometrial L-type
voltage dependent calcium channels. They also block them in vascular
smooth muscle and myocardium. They have been associated with headache,
flushing, hypotension, secondary fetal distress, pulmonary edema
(especially in combination with beta agonists), and myocardial
infarction These adverse effects were most prominent in women with
multiple gestation, preterm labor associated with infection, and women
with underlying cardiovascular disease.

Dosage regimens have not been standardized, and are based on regimens
designed to treat hypertension. A reasonable protocol would be to give
20 mg orally initially, and repeat in 30 minutes if no effect.
Thereafter, 20 mg orally every 6 hours for 48 hours (maximum dose 160
mg) may be given. Maintenance tocolysis with the extended release forms
of the drug have been shown to neither decrease the recurrence of
preterm labor, nor improve perinatal outcomes. **I would consider
nifedipine to be a second line tocolytic agent.**

The next agents available are the non-steroidal anti-inflammatory
agents, of which **indomethacin** is the best studied. These agents are
cyclo-oxygenase inhibitors and block prostaglandin synthesis in the
myometrium. The randomized controlled trials also lack power, but those
available demonstrate efficacy compared to placebo. Indomethacin is
essentially free of maternal side effects. Several retrospective reports
from the early 1990's called attention to an increased incidence of
necrotizing enterocolitis, intraventricular hemorrhage, constriction of
the ductus arteriosus, and oligohydramnios in infants treated in utero
with this agent. These adverse effects became non-significant however
when multivariate analysis corrected for gestational age, and have not
been found to be significant in the prospective studies. NSAIDs do
constrict the ductus, especially in fetuses over 32 weeks, but this
effect is reversed when the drug is stopped, and is uncommon when
administration is limited to 48 hours. A cost-benefit analysis has
clearly demonstrated an improvement in perinatal outcomes with use
versus non-use of indomethacin. The regimen recommended is a loading
dose of 100 mg orally, followed by 50 mg orally every 6 hours, not to
exceed 400 mg in 48 hours. **Based on the evidence for its safety and
efficacy, I would consider indomethacin to be the best first line
tocolytic agent.**

Another drug in this class is **ketorolac**, which we have found to be
very effective in our population. We use an initial dose of 30 mg
intravenously or intramuscularly, and then give 30 mg IV every 6 hours
over 48 hours, not to exceed 240 mg. Because it is given parenterally,
its effect is usually immediate, probably contributing to our seeing a
high success rate with its use. We have seen one case of significant
oligohydramnios, and one case of maternal oliguria (in a woman with
chronic hypertension and mildly increased creatinine), both of which
resolved without sequelae after stopping therapy. There is only one
published study of this agent that I was able to find; it involved 88
women and compared ketorolac to MgSO4 (where it was superior). At this
time its use cannot be considered an evidence-based recommendation.

**In conclusion,** as long as the etiology of "idiopathic" preterm
remains cryptic, we are reduced to using interventions that are
suboptimal. Nevertheless, attempts at an accurate diagnosis, use of
steroids when indicated, and use of indomethacin or nifedipine as our
"best bet" tocolytics, will hopefully be the most efficacious way to
help us reduce the incidence of preterm birth and poor perinatal
outcomes in our population.

**Online Resource:**

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=17012463&dopt=Abstract>

**REFERENCES**

1.  Goldenberg RL. The management of preterm labor. Obstet Gynecol 2002;
    100:1020-37.

2.  King JF, et al. Beta-mimetics in preterm labor: an overview of the
    randomized controlled trials. Br J Obstet Gynaecol 1988; 95:211-22.

3.  Benedetti TJ. Maternal complications of parenteral
    beta-sympathomimetic therapy for preterm labor. Am J Obstet Gynecol
    1983; 145:1-6.

4.  Grimes DA, et al. Magnesium sulfate tocolysis: time to quit. Obstet
    Gynecol 2006; 108:986-9.

5.  King JT, et al. Calcium channel blockers for inhibiting preterm
    labour: a systematic review of the evidence and a protocol for
    administration of nifedipine. Aust NZ J Obstet Gynaecol 2003;
    43:192-8.

6.  van Geijn HP, et al. Nifedipine trials: efficacy and safety aspects.
    BJOG 2005; 112:79-83.

7.  Macones GA, et al. Is there a justification for use of indomethacin
    in preterm labor? Am J Obstet Gynecol 1997; 177:819-24.

**Other**

**Short Interval Between Pregnancy and Cervical Conization May Raise
Preterm Birth Risk**

CONCLUSION: Women with a short conization-to-pregnancy interval are at
increased risk for preterm birth. Women of reproductive age who must
have a conization procedure can be counseled that conceiving within 2 to
3 months of the procedure may be associated with an increased risk of
preterm birth. LEVEL OF EVIDENCE: II.

[Himes
KP](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Himes+KP"%5BAuthor%5D),
[Simhan
HN](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Simhan+HN"%5BAuthor%5D).
Time from cervical conization to pregnancy and preterm birth. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007
Feb;109(2 Pt 1):314-9.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17267830>

**Concern about women taking bromocriptine long term for
hyperprolactinemia?**

CONCLUSIONS: The frequency of clinically important valve regurgitation
was significantly increased in patients taking pergolide or cabergoline,
but not in patients taking non-ergot-derived dopamine agonists, as
compared with control subjects. These findings should be considered in
evaluating the risk-benefit ratio of treatment with ergot derivatives

[Zanettini
R](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Zanettini+R"%5BAuthor%5D)
et al Valvular heart disease and the use of dopamine agonists for
Parkinson\'s disease. [N Engl J
Med.](javascript:AL_get(this, 'jour', 'N Engl J Med.');) 2007 Jan
4;356(1):39-46

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17202454>

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

**Keep this one in the back of your mind**

The valvular heart disease and pulmonary and retroperitoneal fibrosis
seem to be a class effect of the ergot-derived dopamine agonists (these
are bromocriptine, cabergoline, and pergolide but not pramipexole or
ropinirole which are not ergot-derived.)  In reality, this seems
to occur with higher doses of cabergoline, but is sometimes used for
prolactinomas, especially in lower doses. These issues have not yet been
seen with the doses of bromocriptine that we generally use for
prolactinoma, however, we should stay tuned about this.

**Results caution against a repeat dose of glucocorticoid in high-risk
pregnancies**

RESULTS: A total of 249 mothers had been enrolled by the time the study
was discontinued. All of the 159 infants in the betamethasone group and
167 in the placebo group were born before 36 weeks of gestation. The
intact survival rate was unaffected and was lower than anticipated,
because the gestational age-adjusted incidence of respiratory distress
syndrome was higher than the population incidence. The requirement for
surfactant therapy in respiratory distress syndrome was increased in the
betamethasone group. According to posthoc analysis of the data for 206
infants who were delivered within 1 to 24 hours, the betamethasone
booster tended to increase the risk of respiratory distress syndrome and
to decrease intact survival rates

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

Peltoniemi OM et al Randomized trial of a single repeat dose of prenatal
betamethasone treatment in imminent preterm birth. [Pediatrics.  2007;
119(2):290-8](http://www.medscape.com/medline/publicationbrowser/123?pmid=17272618)

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17272618>

**If normal ultrasound at 22-24 weeks the risk of developmental delay is
not increased**

CONCLUSION: Parents should be informed that when the fetus is shown to
be normal by ultrasound at 22-24 weeks of gestation the risk of adverse
neonatal outcome or developmental delay in early childhood is not
increased.

Senat MV et al Long-term outcome of children born after a
first-trimester measurement of nuchal translucency at the 99th
percentile or greater with normal karyotype: a prospective study. [Am J
Obstet Gynecol.  2007;
196(1):53.e1-6](http://www.medscape.com/medline/publicationbrowser/123?pmid=17240232)

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17240232>

**Local anesthesia before amniocentesis does not decrease maternal pain
perception**

RESULTS: Two hundred four women were enrolled; 101 women received local,
102 women received no local, and 1 woman declined the amniocentesis
after randomization. There was no difference in pain perception between
the 2 groups as measured by either the visual analogue scale or the
numeric rating scale (P = .28 and .18 respectively). The correlation
coefficient between the 2 pain scales was strong with 0.86 for the local
group and 0.92 for the no local group, (P \< .001).

CONCLUSION: Administration of local anesthesia before amniocentesis does
not decrease maternal pain perception.

Gordon MC et al. Does local anesthesia decrease pain perception in women
undergoing amniocentesis? [Am J Obstet Gynecol.  2007;
196(1):55.e1-4](http://www.medscape.com/medline/publicationbrowser/123?pmid=17240233) 

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17240233>

**No benefits have been found from the use of diuretics to prevent
pre-eclampsia**

AUTHORS\' CONCLUSIONS: There is insufficient evidence to draw reliable
conclusions about the effects of diuretics on prevention of
pre-eclampsia and its complications. However, from this review, no clear
benefits have been found from the use of diuretics to prevent
pre-eclampsia. Taken together with the level of adverse effects found,
the use of diuretics for the prevention of pre-eclampsia and its
complications cannot be recommended.

Churchill D et al Diuretics for preventing pre-eclampsia. [Cochrane
Database Syst Rev.  2007;
(1):CD004451](http://www.medscape.com/medline/publicationbrowser/123?pmid=17253507) 

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17253507>

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

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

May 1, 2007

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**

#### HPV Vaccine FAQs {#hpv-vaccine-faqs-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Q. Some providers at our facility will not start the HPV vaccine series on a young woman if she will turn 18 before the series can be completed. Is this a common approach? {#q.-some-providers-at-our-facility-will-not-start-the-hpv-vaccine-series-on-a-young-woman-if-she-will-turn-18-before-the-series-can-be-completed.-is-this-a-common-approach .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-48 .Style-Heading-4-+-Arial-14-pt-Underline}

**A.** No, this doesn't make sense from a biologic, or fiscal sense. The
Vaccines for Children program covers [up to age 19]{.underline} (that is
THROUGH age 18 years and 364 days). (See link to the Vaccines for
Children program, below). Biologically, one or two doses are better than
none. (See next question.)

After the patient loses her VFC eligibility, the vaccine is covered by
Medicaid up to 20-21 years old in most states. In addition, Merck has a
Patient Assistance Program (PAP) to provide vaccine to low income women.
(More on PAP below.) PAP covers vaccine for women 19-26 years old who
are less than \~200% of poverty. None of our patients have been denied
so far and it usually takes less than one hour to hear back from Merck
to get their approval.

####  {#section-49 .Style-Heading-4-+-Arial-14-pt-Underline}

**Q. Is there a certain amount of immunity a woman will get from even
one dose (like the hepatitis B vaccine)?**

**A.** In general, it is not yet known how much protection girls/women
would get from receiving only one or two doses of the vaccine. For this
reason, it is very important that girls/women get all three doses of the
vaccine if possible.

We have no information on the efficacy of a partial series. But as noted
above it is reasonable to assume that one or two doses will provide some
protection, although it may not be the same as with a complete 3-dose
series.

####  {#section-50 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-51 .Style-Heading-4-+-Arial-14-pt-Underline}

**Q. Does the HPV vaccine need to be given on an exact schedule? If this
schedule is not followed, does the series have to be started over again?
What is the \"grace period\" the doses can be given in and still be
effective?**

**A.** The series absolutely does NOT need to be given exactly on
schedule. The second dose needs to follow the first by at least 4 weeks,
and the third needs to follow the second by at least 12 weeks. Extended
intervals do NOT require restarting the series. (See pp.14 from the Pink
Book, below.)

**Q. How does the Merck Vaccine Patient Assistance Program (PAP) work?**

**A.** Briefly, the Merck PAP allows patients over age 19 years old to
obtain Gardasil free, if they meet certain income and insurance coverage
criteria. In general the income requirements are less than:

\--\$20,240 for individuals

\--\$27,380 for couples or

\--\$41,300 for a family of four

Different criteria exist for Alaska, Hawaii, Puerto Rico, U.S. Virgin
Islands, and Guam. Merck recognizes that sometimes exceptions need to be
made based on a patient\'s individual circumstances. Individuals who do
not meet these criteria may still qualify for the vaccine program if the
patient has special circumstances of financial and medical hardship.

The applicant must apply from a facility that is not "wholly owned and
operated by the government". Hence, all tribal and urban facilities
would qualify, plus those IHS facilities that receive additional funding
other than federal funding (e. g., grants, contracts, private funding).

If you are in doubt whether your facility qualifies, contact (800)
293-3881 between 8:00 AM--8:00 PM EST Monday -- Friday. If your facility
does not qualify, the patient could apply from a different facility (e.
g., private or semi-governmental clinic).

The application process is very straightforward. To-date none of our
patients who have met the age criteria have been denied. We usually hear
within the hour if the application is approved, though it can sometimes
take up to 4 hours. Fax the completed application form\* to (800)
528-2551

In general, the patient fills out the first page, the case manager fills
out the back page, and the provider signs it. The vaccine is replaced by
Merck to the dispensing pharmacy on a periodic basis (quarterly). The
application process needs to be repeated for each dose.

\* PAP Application Form

<http://www.merck.com/merckhelps/vaccines/mvpap_app.pdf>

Additional background on PAP

<http://www.merck.com/merckhelps/vaccines/home.html>

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

#### Do you still have other HPV vaccine questions? {#do-you-still-have-other-hpv-vaccine-questions .Style-Heading-4-+-Arial-14-pt-Underline}

#### If one has HPV vaccine questions, first go to the CDC FAQ page {#if-one-has-hpv-vaccine-questions-first-go-to-the-cdc-faq-page .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.cdc.gov/nip/vaccine/hpv/hpv-faqs.htm#top**](http://www.cdc.gov/nip/vaccine/hpv/hpv-faqs.htm#top) {#httpwww.cdc.govnipvaccinehpvhpv-faqs.htmtop .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-52 .Style-Heading-4-+-Arial-14-pt-Underline}

#### If your question is not covered there, then contact the National Immunization Program (NIP) Hotline. They will get back to you a timely manner. [**http://www.cdc.gov/nip/webutil/contact/other-contact.htm**](http://www.cdc.gov/nip/webutil/contact/other-contact.htm) {#if-your-question-is-not-covered-there-then-contact-the-national-immunization-program-nip-hotline.-they-will-get-back-to-you-a-timely-manner.-httpwww.cdc.govnipwebutilcontactother-contact.htm .Style-Heading-4-+-Arial-14-pt-Underline}

#### You could also e-mail it to the NIP here [**nipinfo@cdc.gov**](mailto:nipinfo@cdc.gov) {#you-could-also-e-mail-it-to-the-nip-here-nipinfocdc.gov .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-53 .Style-Heading-4-+-Arial-14-pt-Underline}

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

Amy V. Groom, MPH

IHS Immunization Program Manager/CDC Field Assignee

IHS Division of Epidemiology

5300 Homestead RD., NE

Albuquerque, NM  87110

Phone: (505) 248 - 4374

Fax: (505) 248 - 4393

Email: <Amy.Groom@ihs.gov>

####  {#section-54 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Vaccines for Children program {#vaccines-for-children-program .Style-Heading-4-+-Arial-14-pt-Underline}

#### [[http://www.cdc.gov/nip/vfc/acip_resolutions/0606hpv.pdf]{.underline}](http://www.cdc.gov/nip/vfc/acip_resolutions/0606hpv.pdf) {#httpwww.cdc.govnipvfcacip_resolutions0606hpv.pdf .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-55 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Pink Book, CDC, Feb 26, 2007 {#pink-book-cdc-feb-26-2007 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.cdc.gov/nip/publications/pink/genrec.pdf**](http://www.cdc.gov/nip/publications/pink/genrec.pdf) {#httpwww.cdc.govnippublicationspinkgenrec.pdf .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-56 .Style-Heading-4-+-Arial-14-pt-Underline}

General Recommendations on Immunization: Recommendations of the Advisory
Committee on Immunization Practices. MMWR December 2006 / Vol. 55 / No.
RR---18 <http://www.cdc.gov/mmwr/indrr_2006.html>

####  {#section-57 .Style-Heading-4-+-Arial-14-pt-Underline}

A Word document which describes the PAP in greater detail is available.
Contact <nmurphy@scf.cc>

####  {#section-58 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Updated CDC Guidelines for the Treatment of STDs {#updated-cdc-guidelines-for-the-treatment-of-stds .Style-Heading-4-+-Arial-14-pt-Underline}

#### The Centers for Disease Control and Prevention (CDC) updated its 2002 guidelines for the treatment of sexually transmitted diseases (STDs) after consultation with professionals and a systematic review of the evidence. The updated guidelines contain new approaches to patient-centered counseling, expanded discussions of prevention screening for human immunodeficiency virus (HIV) and other STDs, and several diagnosis and treatment updates, discussed below. {#the-centers-for-disease-control-and-prevention-cdc-updated-its-2002-guidelines-for-the-treatment-of-sexually-transmitted-diseases-stds-after-consultation-with-professionals-and-a-systematic-review-of-the-evidence.-the-updated-guidelines-contain-new-approaches-to-patient-centered-counseling-expanded-discussions-of-prevention-screening-for-human-immunodeficiency-virus-hiv-and-other-stds-and-several-diagnosis-and-treatment-updates-discussed-below. .Style-Heading-4-+-Arial-14-pt-Underline}

#### The new guidelines cite further data on the effectiveness of azithromycin for chlamydial infection during pregnancy, and azithromycin is the primary recommended regimen for this indication. {#the-new-guidelines-cite-further-data-on-the-effectiveness-of-azithromycin-for-chlamydial-infection-during-pregnancy-and-azithromycin-is-the-primary-recommended-regimen-for-this-indication. .Style-Heading-4-+-Arial-14-pt-Underline}

#### *Morbidity and Mortality Weekly Report,* August 4, 2006 {#morbidity-and-mortality-weekly-report-august-4-2006 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5511a1.htm**](http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5511a1.htm) {#httpwww.cdc.govmmwrpreviewmmwrhtmlrr5511a1.htm-1 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-59 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CDC Releases Data on HIV-Related Risk Behaviors in U.S. High School Students {#cdc-releases-data-on-hiv-related-risk-behaviors-in-u.s.-high-school-students-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### U.S. high school students who use illicit injection drugs or have unprotected sexual intercourse are at higher risk of human immunodeficiency virus (HIV) infection. The Centers for Disease Control and Prevention (CDC) analyzed data from eight national surveys between 1991 and 2005 to determine if there was any change in the sexual behaviors of these students. A summary of those results was published in the August 11, 2006, issue of *Morbidity and Mortality Weekly Report.* [**http://www.aafp.org/afp/20070215/practice.html**](http://www.aafp.org/afp/20070215/practice.html) {#u.s.-high-school-students-who-use-illicit-injection-drugs-or-have-unprotected-sexual-intercourse-are-at-higher-risk-of-human-immunodeficiency-virus-hiv-infection.-the-centers-for-disease-control-and-prevention-cdc-analyzed-data-from-eight-national-surveys-between-1991-and-2005-to-determine-if-there-was-any-change-in-the-sexual-behaviors-of-these-students.-a-summary-of-those-results-was-published-in-the-august-11-2006-issue-of-morbidity-and-mortality-weekly-report.-httpwww.aafp.orgafp20070215practice.html .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-60 .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}

**Northern Women at Most Risk: Vitamin D Deficiency Widespread During
Pregnancy**

These results suggest that black and white pregnant women and neonates
residing in the northern US are at high risk of vitamin D insufficiency,
even when mothers are compliant with prenatal vitamins. Higher-dose
supplementation is needed to improve maternal and neonatal vitamin D
status

[Bodnar
LM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Bodnar+LM"%5BAuthor%5D)
et al High prevalence of vitamin D insufficiency in black and white
pregnant women residing in the northern United States and their neonates
[J Nutr.](javascript:AL_get(this, 'jour', 'J Nutr.');) 2007
Feb;137(2):447-52

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17237325>

#### Women's Health Headlines, Carolyn Aoyama {#womens-health-headlines-carolyn-aoyama .Style-Heading-4-+-Arial-14-pt-Underline}

**Can you dispense birth control agents to minors without parental
consent?**

If you work in South Dakota, we have clarification on IHS policy as it
relates to State law in the prescription and dispensing of
contraceptives and contraceptive devices to minors thanks to Mary Lynn
Eaglestaff. For copies of the letter from the Chief Counsel in Region
VIII, contact <Carolyn.Aoyama@ihs.gov>

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

**Encourage family communication first. IHS honors State laws and
regulations**

Here is a common question:

I am seeking input regarding I.H.S. policy for parental consent when
providing pregnancy-related, STD, and family planning services to
minors.  I looked it up on the I.H.S. Manual which seems to imply that
state and local regulations apply.   As a federal facility, are we bound
by applicable state law in these matters or does I.H.S. have a federal
policy which supersedes state law?

The first answer is always to encourage complete communication within
the family. In the meantime, yes, the IHS honors State laws and
regulations, so we keep the links below on our Indian Health MCH
website.\*

The best resource to find out what your state allows / requires is here,
State Policies in Brief
<http://www.guttmacher.org/sections/adolescents.php?pub=spib>

Here is a link from the Alan Guttmacher Institute which updates the
State by State information

<http://www.guttmacher.org/index.html>

\*Here are 2 links to FAQs on the MCH page with more information

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/Minorconsent21907.doc>

and

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/MinorsRepro4105.doc>

**Welcome to the Indian Health Service Methamphetamine Initiative Site**

This is the online source for information about METH prevention
activities across Indian Country and across the United States...in the
next few months the site will be updated for better viewing and ease of
navigation.

<http://www.ihs.gov/MedicalPrograms/Behavioral/index.cfm?module=BH&option=Meth>

For access to an article on best practice strategies for dealing with
Meth, developed out of Montana, please contact <Carolyn.Aoyama@ihs.gov>

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

**Advances in Indian Health**

-   May 1-4, 2007

-   Albuquerque, NM

-   26 credits

<http://hsc.unm.edu/cme/2007Web/AIH/AIH2007Index.shtml>

**2007 IHS APN/PA Meeting**

-   May 21-25, 2007

```{=html}
<!-- -->
```
-   Scottsdale, AZ

-   Nearly 20 hours of credit

<http://www.ihs.gov/MedicalPrograms/clinicalSupportCenter/training.cfm#paapn>

**Training Course** **in MCH** **Epidemiology**

-   Albuquerque, New Mexico

-   June 10 - 15, 2007

-   Sponsored by HRSA / MCHB and CDC

<http://www.crpcorp.info/mchtraining2007.htm>

**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>

# 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}

**Can one dispense birth control agents to minors without parental
consent?**

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/Minorconsent21907.doc>

**Are birthing center regulations less restrictive than hospitals?**

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/RegionCare21907b.doc>

**How many rubella vaccines does a mother really need to get?**

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/Rubella21107.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 March 2007 OB/GYN CCC Corner is available at: [**http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0307.cfm**](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0307.cfm) {#the-march-2007-obgyn-ccc-corner-is-available-at-httpwww.ihs.govmedicalprogramsmchmobgyn0307.cfm .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-61 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Abstract of the Month page 5 {#abstract-of-the-month-page-5-1 .Style-Heading-4-+-Arial-14-pt-Underline}

**Healing words: The power of \'I\'m sorry\' in medical practice**

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

Amy Groom

Q&A vaccines, safety contraindications, allergies: Children's Hospital
of Philadelphia site

Burt Attico

Consumer Reports has withdrawn its study on infant safety seats

**Gordon Belcourt**

Cervical Cancer in America

**Scott Giberson**

Ryan White HIV / AIDS Treatment Modernization Act of 2006

March 21^st^: First Annual National Native HIV/AIDS Awareness Day

**Favian Kennedy**

Northern Plains Tobacco Policy Workshop March 8th and 9th, 2007

**Sunnah Kim**

-2007 Native American Child Health Advocacy Award

-Oral Health AIAN Preceptorship Award RFP

-Large data Catalog Available: Health / Well-Being of AI / AN, and Other
Native Americans

-Registration is now open for the 2nd International Meeting on
Indigenous Child Health

**Roberta Ward**

Common Skin Conditions During Pregnancy

#### Hot Topics {#hot-topics-2 .Style-Heading-4-+-Arial-14-pt-Underline}

##### Obstetrics page 12

-GDM Guidelines: Major discrepancies to identify GDM and predict
pregnancy outcome

-Benefit of cesarean for macrosomic infants weighing 4,000-4,999 g
questioned

-Amount of maternal smoking predicts the risk of spontaneous abortion

-First delivery by cesarean begins cascade of risks - obstetric and
perinatal outcomes

Brief motivational intervention decreased the risk of alcohol-exposed
pregnancy: RCT

and more...

**Gynecology page 16**

-Cystocoele Repair: The Mesh Controversy by John Heusinkveld, Shiprock

-Strong evidence for the efficacy of physical therapy for the treatment
for SUI in women

-Risk of preterm delivery increases after all treatment modalities for
CIN

-Report tracks state progress in cervical cancer prevention strategies

-The TVT and the TVT-O procedures perform equally

and more...

**Child Health page 19**

-Review and Comment: Newborn record form IHS-298 and its revision

-Importance of media in adolescent girls\' physical and emotional health
and weight loss

-Does Swaddling Reduce Excessive Crying in Infants?

-Autonomic function or dysfunction and its role in Sudden Infant Death
Syndrome

-Premature Infants Are Susceptible to SSRI, Venlafaxine Exposure In
Utero 

and more...

**Chronic Illness and Disease page 21**

-Does Delay in Diagnosis of Breast Cancer Impact Prognosis?

-Mammographic density and the risk and detection of breast cancer

-Estradiol showed benefit during menstrual migraine, but offset by
estrogen withdrawal

-Mental disorders among primiparous mothers increased several months
after childbirth

-Melanoma unabated: One-time melanoma screen at age 50 deemed cost
effective

and more...

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

American College of Obstetricians and Gynecologists

-ACOG Opposes Sex Selection for Family Planning Purposes

-Pelvic Organ Prolapse. ACOG Practice Bulletin

-Breastfeeding: Maternal and Infant Aspects. ACOG Committee Opinion

##### American Family Physician

-Role of Exercise in Patients with Type 2 Diabetes: Cochrane for
Clinicians

-Acute Uterine Bleeding: Progestin vs. Combination Therapy

**Agency for Healthcare Research and Quality**

-AI/AN are difficult to reach by mail for research or health care
reasons

-Women are more likely to suffer health problems and worse quality of
life due to obesity

-Missed opportunities: Few Americans are screened to prevent colorectal
cancer

-Physicians\' extended work shifts associated with of medical errors and
patient harm

-Extended resident work hours jeopardize both resident health and
patient safety

**Ask a Librarian**

Diet of Pregnant American Indians: Different than Whites?

**Breastfeeding**

-ACOG Calls on Employers for Increased Support for Breastfeeding

-Calcium Important for Nursing Mothers' Oral Health

-Call for Breastfeeding Abstracts: AAP

#### -Simple Antenatal Preparation Improves Breast-Feeding Practice: RCT {#simple-antenatal-preparation-improves-breast-feeding-practice-rct .Style-Heading-4-+-Arial-14-pt-Underline}

**CCC Corner Digest**

**February 2007 Highlights**

-Low hanging fruit: Promotion of healthy lifestyles during and after
pregnancy

-Teamwork Training: Decision to incision times significantly improved

-Outreach workers should follow women with the most severe PAP
abnormalities

-Are you interested in acquiring HPV vaccine to provide to 9 -- 18 year
olds?

-Sleepiness and sleep deprivation are associated with injury

-Guidelines Recommend Universal Screening for Down Syndrome: Regardless
of age

-Diet of Pregnant American Indians: Different than Whites?

-Supporting employee breastfeeding is easier than it sounds

-Continuous Contraceptive Therapy Safely Abolishes Menstrual Cycles

-Vaccine Preventable Diseases, IHS

-Are varicella titers necessary prior to immunization?

-What does the future hold in store?

-F/U: A boy has been born in Chile with a fetus in his stomach

-Local estrogen just as effective for vaginal atrophy in postmenopausal
women

-The Blessed Perineum: PubMed

-Getting Your Patient Back to Work: Return-to-Work Restrictions After
Illness / Injury

-I have to go really far just to exercise . . . er . . . actually no you
don't

-What do patients recall from our counseling?

-Planned cesarean delivery doubles rate of NICU and risk for pulmonary
disorders

-Adolescent with knee pain, Web M+M, Terry Cullen - Moderator

-First Indian Health Special Issue on Methamphetamine is now available
online

-Diabetic Moms\' Babies Have Impaired Sucking Reflexes

-What Causes Breast Cancer?

-Andy Narva moved to NIH, but is still our Renal CCC

-Year End Re-cap of Available Resources from CDC -- OWH

**Domestic Violence**

-Health Care-Based Interventions for Women Who Have Experienced Sexual
Violence

-Child Abuse: Approach and Management

**Elder Care News**

-Older American Indians often have a poorer view of their own health
than their doctors

-Selective Serotonin Reuptake Inhibitors Increase Fracture Risk in Older
Adults

-The decision to hospitalize nursing home residents

-Many nursing home residents suffer from poorly controlled pain

**Family Planning**

Abstinence counseling vs family planning: Which is more effective?

**Featured Website**

The MCH Coordinators Site has a clean new look, plus new functionality

**Frequently asked questions**

How many rubella vaccines does a mother really need to get?

**Indian Child Health Notes**

-A guest editorial for physicians who work with tribal child protective
services

-How will we roll out the new HPV vaccine? Who can we cover?

-Dr. Esposito gets passionate about poor data and unfounded conclusions

**Information Technology**

Have you visited the CRS Performance Improvement Toolbox web page
lately?

International Health

-Sexual behavior in context: A public health perspective

#### -Repair of obstetric vesicovaginal fistulas in Africa {#repair-of-obstetric-vesicovaginal-fistulas-in-africa .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Drugs for preventing malaria in pregnant women improve infant outcome {#drugs-for-preventing-malaria-in-pregnant-women-improve-infant-outcome .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Global struggle against poverty {#global-struggle-against-poverty .Style-Heading-4-+-Arial-14-pt-Underline}

#### MCH Alert

-First steps in implementing mental health screening in schools

-New Organization Focuses on Adolescent Health Care Reform

**MCH Headlines**

-Scrub Club

-Training Course in MCH Epidemiology

-New Child Health USA Report Released

-More on car seats, installment and safety on recheck

-CDC needs feedback on need for Educational resources HPV implementation

and more...

#### Medical Mystery Tour

#### Prolonged second stage with an epidural {#prolonged-second-stage-with-an-epidural-2 .Style-Heading-4-+-Arial-14-pt-Underline}

#### 

#### Medscape

######### -HPV CEU\'s vaccine indications test your knowledge: 5 minute review

-Contraception for a Woman With a History of Fibroids

**Menopause Management**

-Physical Activity Improves Lipid Profile in Postmenopausal Women 

#### -Transdermal Estrogen Suggested for Women With Metabolic Syndrome {#transdermal-estrogen-suggested-for-women-with-metabolic-syndrome .Style-Heading-4-+-Arial-14-pt-Underline}

**Midwives Corner**

Maternal positioning and pain relief measures: Pomoting effective
pushing

**Navajo News**

Clomiphene "bests" Metformin in a NEJM study

**Nurses Corner**

#### -A \"Small Fall\" and a Trip to the Emergency Department {#a-small-fall-and-a-trip-to-the-emergency-department .Style-Heading-4-+-Arial-14-pt-Underline}

-The REACH Program and Alzheimer\'s Caregivers

-Monthly Summaries of Nursing Research: Medscape

#### -Highlights of NPWH 9th Annual Conference \-- Women\'s Health in the New Millennium {#highlights-of-npwh-9th-annual-conference----womens-health-in-the-new-millennium .Style-Heading-4-+-Arial-14-pt-Underline}

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

Indian Health Surveillance Report---Sexually Transmitted Diseases 2004

Health, United States, 2006

**Oklahoma Perspective**

What do patients recall from our counseling?

Osteoporosis

-Early Postmenopausal Hormone Therapy Improves Postural Balance

-Repeat Bone Mineral Density Measurement May Not Predict Fractures in
Older Women 

Patient Education

#### -Tips for Using Medicines Wisely {#tips-for-using-medicines-wisely .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Parvovirus B19: What You Should Know {#parvovirus-b19-what-you-should-know .Style-Heading-4-+-Arial-14-pt-Underline}

Perinatology Picks

-Ultrasound is better at finding NTD than AFP

-Planned cesarean delivery doubles NICU rates and the risk for pulmonary
disorders

-Amniotic Fluid Promising Source of Stem Cells

-Formula that calculates the estimated risk of respiratory distress
syndrome is valid

-Pregnancy Loss After Amniocentesis and CVS

and more...

Primary Care Discussion Forum

Adolescent with knee pain -- Ongoing discussion

STD Corner

-A First: STD Rates Available by IHS Area

-Heterosexual Transmission of Community-Associated Methicillin-Resistant
Sttaph. aureus

-Research Seeks To Expand Understanding of Effects of Alcohol Use on
Developing Brain

-RCT comparing computer-assisted vs face-to-face sexual history taking

-CDC Releases Survey Results on STD Counseling in Adolescents

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

-Fertility rises as weight drops

-FDA Authorizes NovoLog for Pregnant Women With Type 1 Diabetes

#### -Mild Gestational Diabetes Raises Risk of Cryptorchidism {#mild-gestational-diabetes-raises-risk-of-cryptorchidism .Style-Heading-4-+-Arial-14-pt-Underline}

**Women's Health Headlines**

-Women\'s Health Week will be celebrated May 13-19, 2007

-Menstrual Cycle is a Vital Sign

\-[CDC reports decreasing mammogram rates
1999-2002](http://www.ihs.gov/MedicalPrograms/MCH/W/CanBr.cfm#DecrMammo)

-Vulvodynia: a state-of-the-art consensus on definitions, diagnosis and
management

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

#### What's new on the ITU MCH web pages page 50

-Second methamphetamine issue of the IHS Primary Care Provider now
available online!

-Check out new Indian Health STD website

-The History of Maternal Child Health in the United States

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

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>

3/13/07njm