**News Flash: First International Meeting on Indigenous Women's Health;
Third International Meeting on Indigenous Child Health: Many Voices into
One Song**

**March 2009, Albuquerque, NM**

**Women's Health March 4-6, 2009**

**Children's Health March 6-8, 2009**

**(The 6^th^ is an overlap day with both groups participating)**

**See "From Your Colleagues" for initial announcement and mark your
calendar now!**

![](media/image1.jpeg){width="6.000694444444444in" height="1.11875in"}

 

Chief Clinical Consultant's Corner

Volume 6, No. 8, 2008

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

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

**Colorectal Cancer Screening and Surveillance**

What to do with patients with polyps -- Hope Baluh, MD

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

**Neil Murphy, MD Alaska Native Medical Center**

-Welcome Jean Howe, MD, MPH as the new OB/GYN Chief Clinical Consultant

#### Theresa Cullen, MD, Chief Information Officer, IHS {#theresa-cullen-md-chief-information-officer-ihs .Style-Heading-4-+-Arial-14-pt-Underline}

-2008 Indian Health Information Management Conference, "Managing Health
Information Technology to Improve Performance and Outcomes"

#### David Gahn, MD Kabul, Afghanistan {#david-gahn-md-kabul-afghanistan .Style-Heading-4-+-Arial-14-pt-Underline}

-Afghanistan Update

**Lois Goode, Whiteriver, AZ**

-Scott Gaustad named next Physical Rehabilitation Services Chief
Clinical Consultant

#### Elaine Locke and Yvonne Malloy, ACOG {#elaine-locke-and-yvonne-malloy-acog .Style-Heading-4-+-Arial-14-pt-Underline}

-ACOG/IHS Postgraduate Course on Obstetric, Neonatal and Gynecologic
Care

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

##### Obstetrics

-Improving neonatal outcome through practical shoulder dystocia training

-Progesterone for the prevention of preterm birth: a systematic review\
-Effect of Timing of Umbilical Cord Clamping at Birth of Term Infants on
Mother and Baby Outcomes (Cochrane Update)

-Length of rupture of membranes in the setting of premature rupture of
membranes at term and infectious maternal morbidity

-How physicians cope with stillbirth or neonatal death: a national
survey of obstetricians

**Gynecology**

-The relationship of bleeding patterns to daily reproductive hormones in
women approaching menopause

\- Bilateral oophorectomy and depressive symptoms 12 months after
hysterectomy

-Two-year outcomes after sacrocolpopexy with and without Burch to
prevent stress urinary incontinence

\- Comparison of the treatment outcome of pubovaginal sling,
tension-free vaginal tape, and transobturator tape for stress urinary
incontinence with intrinsic sphincter deficiency

**Child Health**

-Universal newborn hearing screening: systematic review to update the
2001 US Preventive Services Task Force Recommendation

\- Children at High Risk Should Be Screened for Elevated Cholesterol

\- Cardiovascular Risk Factors and the Metabolic Syndrome in Pediatric
Nonalcoholic Fatty Liver Disease

\- Epidemiology and treatment of painful procedures in neonates in
intensive care units

**Chronic Illness and Disease**

\- Prevalence and Correlates of Subclinical Atherosclerosis in Alaska
Eskimos;

The GOCADAN Study

#### - Diabetes and Depression Linked {#diabetes-and-depression-linked .Style-Heading-4-+-Arial-14-pt-Underline}

\- Hearing Loss More Common with Diabetes

\- Management of Non--ST-Elevation Acute Coronary Syndromes in Men vs.
Women;

A role for conservative management in low risk women

\- Topiramate Improves Quality of Life and Physical Health in
Alcohol-Dependent Adults

And more...

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

American College of Obstetricians and Gynecologists

\- ACOG Practice Bulletin #95 Anemia in Pregnancy

##### American Family Physician

\- The Mirror Lies: Body Dysmorphic Disorder

**Agency for Healthcare Research and Quality**

###################### - USPSTF Reaffirms Recommendation for Screening Pregnant Women for Asymptomatic Bacteriuria {#uspstf-reaffirms-recommendation-for-screening-pregnant-women-for-asymptomatic-bacteriuria .unnumbered}

**Ask a Librarian**

-Health Services Research Library (HSRL); a branch of the National
Institutes of Health Library

*Your information partner*

**Behavioral Health Insights**

\- Percentage of Adults with Symptoms of Serious Psychological Distress

\- Conference Information/OBOT (Buprenorphine) Certification Training

**Breastfeeding**

\- The Case of the Dwindling Milk Supply

**CCC Corner Digest**

**Domestic Violence**

\- SBIRT Program to Screen for Substance Abuse, Domestic Violence in
Pregnant Women in Louisiana

**Elder Care News**

\- No Upper Age Limit for Benefit from Screening Mammography for Women
without Significant Comorbidities

**Family Planning**

#### - Cochrane Database---Interventions for Emergency Contraception {#cochrane-databaseinterventions-for-emergency-contraception .Style-Heading-4-+-Arial-14-pt-Underline}

#### - IGT, Breastfeeding, and Contraception {#igt-breastfeeding-and-contraception .Style-Heading-4-+-Arial-14-pt-Underline}

**Featured Website**

# -The Joint Commission (formerly JCAHO); 

# -**Sentinel Event Alert on** Behaviors that Undermine a Culture of Safety

**Frequently asked questions**

\- Q. [How to Strengthen Your Patient's Pelvic Floor
Muscles?](http://www.ihs.gov/MedicalPrograms/MCH/W/MatPT.cfm#pelvic)

**Indian Child Health Notes**

\- Blood Lead Screening in American Indian/Alaska Native Children

\- *Pentacel®*: A new Vaccine not Suitable for American Indian/Alaska
Native Infants

\- Asthma prevalence among US children in underrepresented minority
populations

**Information Technology**

\- iCare Population Management GUI version 1.1 Released

International Health

-Number range CHAPTERCervical cancer screening where resources are
scarce

#### MCH Alert

\- Safety of Dental Treatment in Pregnant Women

\- Impact of a Prenatal Substance Abuse Treatment Program on Perinatal
Outcomes

-Annual Study Released on Women's Health Outcomes in U.S. Hospitals

-HRSA Report Studies Safety Net Health Centers

#### MCH Headlines

## -Three Maternal Risk Factors Associated with Elevated Risk of Postneonatal Mortality among Alaska Native Population

## -What Every Parent Needs to Know About\... Inhalant Abuse

-Pediatric Environmental Health Toolkit Available for Download

-Preventing Alcohol, Tobacco, and Other Substance-exposed Pregnancies: A
Community Affair

#### Medical Mystery Tour

\- Fetal Heart Monitoring

#### Medscape

**Menopause Management**

\- Gallbladder Disease Risk Lower with Transdermal vs. Oral Hormone
Therapy

**Midwives Corner**

\- Including the *Non*-rational in Midwifery

**Navajo News**

\- Survey of Full-Scope Navajo OB Sites

**Nurses Corner**

\- Screening, Brief Intervention, and Referral to Treatment (SBIRT)
Endorsed by National Emergency Nurses Association

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

# - Impact of Periodic Follow-Up Testing Among Urban American Indian Women with Impaired Fasting Glucose

**Oklahoma Perspective**

**-**Meet Dr. George Chiarchiaro, Oklahoma MCH Coordinator

Osteoporosis

\- **National Osteoporosis Foundation Releases New Clinical
Recommendations for Low Bone Mass and Osteoporosis Incorporating
Absolute Fracture Risk**\
Patient Education

\- The Risk of Death by Age, Sex, and Smoking Status in the United
States

Perinatology Picks

\- Protein/Creatinine ratio in preeclampsia: a systematic review

#### - Delivery mode and severe intraventricular hemorrhage in single, very low birth weight, vertex infants -Signal ambiguity resulting in unexpected outcome with external fetal heart rate monitoring  {#delivery-mode-and-severe-intraventricular-hemorrhage-in-single-very-low-birth-weight-vertex-infants--signal-ambiguity-resulting-in-unexpected-outcome-with-external-fetal-heart-rate-monitoring .Style-Heading-4-+-Arial-14-pt-Underline}

-Fetomaternal hemorrhage during external cephalic version

Primary Care Discussion Forum

STD Corner

\- Frequency of Adolescent Self-Cutting As A Predictor of HIV Risk

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

#### - Why young adults hold the key to assessing the obesity epidemic in children {#why-young-adults-hold-the-key-to-assessing-the-obesity-epidemic-in-children .Style-Heading-4-+-Arial-14-pt-Underline}

**Women's Health Headlines**

\- Dating Violence and Abuse Affecting Young Adolescents

-Family Violence Prevention Fund; National Conference on Health and
Domestic Violence

New Orleans, Louisiana

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

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

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

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

**Colorectal Cancer Screening and Surveillance**

**What to do with patients with polyps,** by Dr. Hope Baluh

Periodic screening for colon cancer in asymptomatic patients results in
decreased mortality from this common and frequently fatal disease. As
public awareness of the benefits of colon cancer screening has increased
so has the demand for colonoscopy services. Evidence-based guidelines
developed separately by the US Preventive Services Task Force, a
consortium of five US medical and surgical GI societies, and the
American Cancer Society recommend that all asymptomatic, average-risk
people over age 50 years be offered screening with annual fecal occult
blood tests and/ or flexible sigmoidoscopy every 5 years because these
options are strongly supported by direct scientific studies. Colonoscopy
is recommended when either of these tests is positive. The guidelines
also include doing direct screening with air-contrast barium enema every
5 years or colonoscopy every 10 years. Periodic colonoscopy is also
recommended for patients with an above average risk for colorectal
cancer. Patients with an increased risk profile include those with a
personal or family history of colorectal cancer or adenomatous polyps,
as well as those with longstanding chronic inflammatory bowel disease.

Public surveys indicate that less than 40% of the at-risk population has
yet to be screened. Once screened, patients with increased risk factors
benefit from surveillance. Determining optimal intervals for
surveillance often requires knowing the patient's family history and
findings from initial screening procedures including pathology reports.

The following are guidelines for screening and surveillance:

**Indication Interval**

[Screening]{.underline}

Average risk 10 y(begin at age 50 y)

Single first degree relative (FDR) with cancer 10 y (begin at age 40 y)

(or adenomas) at age [\>]{.underline} 60 y

[\>]{.underline}2 FDRs with cancer (or adenomas) or 1 FDR 5 y (begin at
age 40 y or 10 y

Diagnosed at age \<60 y younger, whichever is earlier)

Prior endometrial or ovarian cancer diagnosed 5 y

at age \<50 y

Hereditary nonpolyposis colorectal cancer 1-2 y

(HNPCC) begin age 20-25

[Postadenoma resection]{.underline}

1-2 tubular adenomas of \<1 cm 5-10 y

3-10 adenomas or adenoma with villous features, 3 y

[\>]{.underline} 1 cm with high grade dysplasia

\> 10 adenomas \< 3 y

Sessile adenoma of [\>]{.underline} 2 cm, removed piecemeal 2-6 months

(in order to inspect site for residual polyp)

[Other Follow-Up]{.underline}

Postcancer resection Clear colon, then 1 y then 3 y, then 5 y,

Ulcerative colitis, Crohn's colitis surveillance 2-3 y until 20 y after
onset of

After 8 y of pancolitis or 15 y of left-sided colitis symptoms, then 1 y

Davila RE et al ASGE guideline: colorectal cancer screening and
surveillance. Gastrointest Endosc. 2006 Apr;63(4):546-57 Erratum in:
Gastrointest Endosc. 2006 May;63(6):892.

<http://www.ncbi.nlm.nih.gov/pubmed/16564851>

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

**AI/AN peoples are more likely to be diagnosed with advanced stage
disease**

I would like to thank Dr. Hope Baluh, the IHS Chief Clinical Consultant
for Surgery, for reviewing the current recommendations for colonoscopy
screening and the appropriate intervals for follow-up of polyps and
other high-risk conditions. Colon cancer screening guidelines are only
one example of the guidelines available online at
<http://www.guidelines.gov/>. At this website it is possible to view and
download a wide range of guidelines as well as to make comparisons
between recommendations from several organizations.

The overall incidence of colon cancer for American Indians and Alaska
Natives (AI/AN) is declining as is the trend nationally for the general
population. However AI/AN peoples are more likely to be diagnosed with
advanced stage disease and there are wide disparities in access to care.
For example the prevalence of endoscopy services for Native Americans in
the Southwest has been half that of those available to non-Hispanic
whites.^1^ Efforts are underway at many health care sites to improve
these screening rates.

For those of us whose focus is women's health care, it is also
worthwhile to review the recent Committee Opinion of the American
College of Obstetricians and Gynecologists. In this document, ACOG now
recommends colonoscopy as the preferred method of colon cancer
screening.^2^

^1^Espey DK, Wu XC, Swan J, et al, Annual report to the nation on the
status of cancer, 1975-2004, featuring cancer in American Indians and
Alaska Natives. Cancer. 2007 Nov 15;110(10):2119-52.

<http://www.ncbi.nlm.nih.gov/pubmed/17939129>

^2^American College of Obstetricians and Gynecologists. Colonoscopy and
Colorectal Cancer Screening and Prevention. ACOG Committee Opinion No.
384. Obstet Gynecol 2007;110:1199-1202.
<http://www.ncbi.nlm.nih.gov/pubmed/17978144>

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

**Neil Murphy, MD Alaska Native Medical Center**

**Welcome Jean Howe, MD, MPH as the new OB/GYN Chief Clinical
Consultant**

Dr. Jean Howe took over the reins of the OB/GYN Chief Clinical
Consultant role on June 1, 2008 and has yet to have her feet touch the
ground. Jean has the perfect background and energy to do a great job as
Chief Clinical Consultant, so we look forward to a wonderful future for
the care of Native Women.

Many of you know Jean already, as she has been participating as the
Deputy Chief Clinical Consultant since 2004. As such Jean has excelled
in many of the [national functions of the CCC and knows the
territory.](http://www.ihs.gov/NonMedicalPrograms/nc4/obgyn.asp)
Originally from Vermont and trained at the University of Colorado, Dr.
Howe has been an OB/GYN at Chinle Hospital for almost 11 years and
department Chief for 10 years. She also currently serves as the Navajo
Area OB/GYN consultant. Dr. Howe completed the Johns Hopkins Masters in
Public Health program in 2005. Her areas of interest include preventive
services, contraception, international health, and diabetes in
pregnancy.

**What does an OB/GYN Chief Clinical Consultant really do?**

The OB/GYN CCC role seems to be a bit unique among the CCCs largely
because of its close relationship over the years with the benchmark
women's health professional group, American College of Obstetricians and
Gynecologists. In addition, the OB/GYN CCC has many national functions
that you may interact with everyday and not realize it.

The OB/GYN CCC participates in the annual ACOG/IHS Area site visits
which review the care of Native women and young children on-site. The
OB/GYN CCC serves as consultant to the ACOG Fellows in Service Program
that places ACOG Fellows in short term positions throughout Indian
Country. The OB/GYN CCC also participates in the planning of the annual
ACOG / IHS Obstetric, Neonatal and Gynecologic Care Postgraduate Course
which is thorough multi-day primer and update on the basics of women's
health and early child health.

Recently the OB/GYN CCC has been the editor of the Chief Clinical
Consultant Corner newsletter since its inception 6 years ago. In
addition, the OB/GYN CCC coordinates the single most complete clinical
website on the [www.ihs.gov](http://www.ihs.gov/) which has become a
template for many other websites since 2000. The OB/GYN CCC has also
been a lightning rod for increasing communication among the various
staff groups by creating listserv(s) for maternal child health, the
primary care discussion forum, midwives, and OB/GYNs.

**What have** **OB/GYN Senior Clinicians / Chief Clinical Consultant
done over the years?**

The most unique aspect of the OB/GYN CCC is that the role is built on
long standing relationships. The first relationship, as described above,
is that between ACOG and the Indian Health system...the second
relationship is with you. When is the last time that you heard that a
former CCC, or Senior Clinician as they used to be termed, was
coordinating the IHS Colposcopy Course, serving a member of the ACOG
Committee on American Indian Affairs, or authoring a column in the CCC
Corner national newsletter?

If you said, 'just last month', then you are right to all three. Case(s)
in point are the active roles that Drs. William Haffner, Alan Waxman and
Neil Murphy continue to play in improving the health care of Native
women. Here is a brief history on the former OB/GYN Senior Clinicians /
CCCs.

It all began with David L Hall. Dr. Hall was an OB/GYN in Shiprock and
later at Gallup Indian Medical Center and served as OB/GYN Senior
Clinician from 1972- 1980. These very formative years included the era
when much of the care to Native women was provided by general medical
officers with very little specific training in Women's Health.

Dr. Hall's successor was William Haffner, the IHS OB/GYN Senior
Clinician from 1980 to 1994. Dr. Haffner's central theme was to
facilitate the transition from the era of the general medical officer to
more completely trained women's health providers. To that end Dr.
Haffner worked at increasing the number, skills, and quality of OB/GYN
and CNM providers throughout the IHS full-service OBG hospitals. Bill
helped advance and promote a degree of standardization of obstetric care
through education and development of a common prenatal record to meet
U.S. standards of care at all IHS programs providing prenatal or
full-service obstetric care. Dr. Haffner encouraged professional
collaborations with ACOG and ACNM to maximize the quality of care and
promote advocacy for Indian women\'s health.

Dr. Haffner was pivotal in the development a basic primer / update
course in Native women's health which became the benchmark for all
Indian Health care providers. Ultimately, with the help of ACOG this
became an annual course, ACOG / IHS Obstetric, Neonatal and Gynecologic
Care Postgraduate Course, which included an excellent Reference Text of
which he remains the Editor.

Dr. Haffner had worked in the USPHS 1971 -- 2001 with 1971 -- 1981 of
that being at Gallup Indian Medical Center. Dr. Haffner was the PHS
Chief Medical Officer 1990 - 1994. Dr. Haffner is a Professor and was
Chair of the OB/GYN Department, F. Edward Hebert School of Medicine,
1992 -- 2003. Bill has been the Acting Associate Dean for Faculty
Development since 2006 and is in clinical practice at the National Naval
Medical Center. In [2002 Dr. Haffner received the ACOG Distinguished
Service
Award.](http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/HaffnerACOGHonor81202.doc)

Alan Waxman was OB/GYN Senior Clinician from 1994 -- 2000. Dr. Waxman's
central theme was promoting a uniform standard of care for all AI/AN
women regardless of what IHS or tribal facility they received care at.
Dr. Waxman made sure that those standards were based on benchmark best
practices, which often relied on ACOG Practice Bulletins and Committee
Opinions. One great example is that Dr. Waxman developed, and continues
to direct, the IHS Colposcopy Courses. This program emphasizes training
primary care providers in advanced cervical cancer screening techniques.
Ultimately, those primary care staff who participate in the IHS
Colposcopy Courses can work toward providing colposcopy at their home
service unit.

Dr. Waxman had worked in IHS 1976 -- 2000, primarily at Gallup Indian
Medical Center, but with two very rewarding years at the Alaska Native
Medical Center. Alan had been the OB/GYN Chief Clinical Consultant for
the Navajo Area IHS 1980-2000. Dr. Waxman is currently on the faculty of
the University of New Mexico, Department of Obstetrics and Gynecology
and is a Consultant to the ACOG Committee on American Indian Affairs.

Dr. Neil Murphy served as OB/GYN CCC from 2000 to 2008. As Drs. Haffner
and Waxman had done most the 'heavy lifting' already, Dr. Murphy choose
to increase access to evidence based information and improve
communication in the widespread Indian Health system.

In 2000 Dr. Murphy began to create the MCH suite of websites that offers
up to the moment evidence based resources to all tribal and Indian
Health staff and patients. The MCH complex of websites, which now
contains hundreds of pages and thousands of subpages, includes online
continuing medical education modules, a monthly online newsletter,
hundreds of frequently asked questions, and a wide variety of MCH
specific content. The MCH site also serves as a portal for easy access
to UpToDate, the Indian Health virtual online library, and the ACOG
Postgraduate Course Reference text, to name a few others. In 2004 the
monthly online newsletter added a printed version to increase access for
staff without easy Internet access and for those whom a printed
newsletter was more easily utilized in the moments between patients or
while on the move.

Dr. Murphy initiated several listserv(s) to increase communication
including the Primary Care Discussion Forum for more in depth discussion
which was then posted online for others to benefit from. Dr. Murphy also
transformed the biennial clinicians meeting from a small primarily
business meeting of department chiefs to a large educational conference
to include all the major stakeholders in Native Women's Health. This
meeting now regularly features internationally known speakers and in
2009 it will be held in conjunction with the international Native Child
Health meeting to increase communication across borders on areas of
joint clinical relevance.

Dr. Murphy remains a staff physician at Alaska Native Medical Center and
continues to coordinate the Indian Health MCH web based resources.

**Haffner Native Women's Health Award**

Another example of the unique value of the OB/GYN CCC role is the
William H.J. Haffner American Indian/Alaska Native Women's Health Award.
The ACOG Committee on American Indian Affairs is raising money for a new
award that would recognize an individual who has made a major
contribution to improving the health care of American Indians / Alaska
Natives.

The William H.J. Haffner American Indian/Alaska Native Women's Health
Award is named after ACOG Fellow Dr. Haffner, an ob-gyn professor at the
Uniformed Services University of the Health Sciences, Bethesda, MD. Dr.
Haffner worked for the federal Indian Health Service for many years and
has been involved with ACOG's Indian health programs since their
inception. (see above)

To donate to the Haffner Award Fund, please make checks out to \"ACOG\"
and mail to Yvonne Malloy, ACOG, 409 12th St. SW, Washington, DC 20024,
or by e-mail at <YMalloy@acog.org>.

**Jean Howe welcomes your thoughts and input**

Dr. Howe [is very interested in establishing a
dialogue](http://www.ihs.gov/NonMedicalPrograms/nc4/obgyn.asp) and/or
networking with anyone involved in women\'s health or maternal child
health, especially as it applies to Native or indigenous peoples around
the world. Please don\'t hesitate to contact her by
[e-mail](mailto:nmurphy@SouthCentralFoundation.com?Subject=Question for Dr. Murphy, the OBGYN Chief Clinical Consultant)
at <Jean.Howe@ihs.gov> or by phone at 928-674-7422.

#### Theresa Cullen, MD, Chief Information Officer, IHS {#theresa-cullen-md-chief-information-officer-ihs-1 .Style-Heading-4-+-Arial-14-pt-Underline}

**2008 Indian Health Information Management Conference, "Managing Health
Information Technology to Improve Performance and Outcomes"**

**December 15 -- 19, 2008; Phoenix, Arizona**

The Office of Information Technology is pleased to announce the Indian
Health Information Management Conference for 2008. The IHIMC began as
the IHS Technology Conference, and has been held annually since the mid
1980s. The purpose of the IHIMC and its antecedent conferences is to
provide for the demonstration and discussion of Information Technology
tools, as the IHS IT community supports health care delivery in Indian
Country. IHIMC is a forum for technical leadership, direction and
support in the promotion of quality health care through collaboration
and active participation in the development of policy and national
standards of care regarding the health of American Indian/Alaska Native
people in Federal (IHS), Tribal and Urban settings (I/T/U). We hope to
see you there!

#### Additional conference information available at:  {#additional-conference-information-available-at .Style-Heading-4-+-Arial-14-pt-Underline}

#### [[http://www.ihs.gov/cio/ihimc/]{.underline}](http://www.ihs.gov/cio/ihimc/) {#httpwww.ihs.govcioihimc .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

#### David Gahn, MD Kabul, Afghanistan {#david-gahn-md-kabul-afghanistan-1 .Style-Heading-4-+-Arial-14-pt-Underline}

**Afghanistan Update**

Most of the readers of the CCC Corner know how much emphasis we put on
preconception care, prenatal care, and postpartum care in the United
States. We have special procedures and concerns when someone appears on
L&D in labor with no prenatal care.

Imagine a city of 5 million people where \>95% of the pregnant women
have no prenatal care and the average parity a woman reaches is \>7.
These are the patients that the doctors and midwives at Rabia Balkhi
Hospital in Kabul face daily.

Because recent data show a tremendous amount of maternal and perinatal
mortality associated with cesarean sections, IHS has recently focused
its efforts on improving the care delivered in the operating room as
well as working on the decision process that sends a woman to the OR to
have her baby. In collaboration with CDC, we are operating under the
framework of a quality assurance collaborative on cesarean sections
(QAC/CS) which will eventually involve all 4 maternity hospitals in
Kabul. In July, IHS, with participation from the Department of Defense,
conducted a Surgical Skills Training Workshop at Rabia Balkhi Hospital
using a combination of didactics, skills labs, and practical training in
the OR. IHS medical epidemiologist Dr. Mei Castor, MD is leading the
operational research arm of the QAC/CS, and James Dickens, FNP from the
Center for Medicare and Medicaid Services is focusing on training the OR
staff in the basic principles of operating a safe and effective OR. Dr.
Pat O'Connor, MD from Tuba City, AZ continues to head up the effort in
the pediatrics department.

When a cesarean section is performed, every system in the hospital is
involved: lab, blood bank, supply, housekeeping, facilities, etc. Using
a quality assurance approach focusing on systems and not individual
performance has allowed the Afghans to gradually make sustainable
changes in their hospital with an understanding that quality assurance
is a continuous process. With CDC also involved, we are working on being
able to measure our processes through an improved medical record and a
functioning Quality Assurance Department. We know that if we can't
measure what we are doing, we can't manage it. And if we can't manage
it, we can't change it.

IHS is working on the interagency agreement with HHS/Office of Global
Health Affairs (OGHA) for FY 2009, and hopes to expand its clinical role
in the Afghanistan Health Initiative (AHI). With funding from OGHA, IHS
will be able to continue to staff the AHI to make meaningful and
sustainable changes to a national health care delivery system. Keep your
eyes out for more opportunities to serve the people of Afghanistan, and
feel free to contact me at any time.

 

**Lois Goode, Chief Clinical Consultant-IHS Rehab Services; Whiteriver,
AZ**

**Scott Gaustad named next Physical Rehabilitation Services Chief
Clinical Consultant**

It has been a pleasure and a distinct honor to serve with you on the
NC4. The time has now come for me to "pass the baton".

 

I am very pleased to announce CDR Scott Gaustad as the next Physical
Rehabilitation Services Chief Clinical Consultant as appointed by Dr.
Chuck North.  CDR Gaustad brings to the Indian Health Service a wealth
of clinical experience and knowledge. He has been at Whiteriver IHS
since October 2006. He is a team-player and his leadership skills are
exceptional. I am confident that you will enjoy meeting and working with
Scott.

 

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

#### Elaine Locke and Yvonne Malloy, ACOG {#elaine-locke-and-yvonne-malloy-acog-1 .Style-Heading-4-+-Arial-14-pt-Underline}

**ACOG/IHS Postgraduate Course on Obstetric, Neonatal and Gynecologic
Care**

**September 14-18, 2008; Salt Lake City, Utah**

This annual women's health update for Nurses, Advanced Practice
Clinicians, and physicians provides a four-day schedule of lectures,
workshops, hands-on sessions, and team building. The large
interdisciplinary faculty collaborates to teach clinical and practical
topics as they apply in Indian health settings. Many faculty members are
your colleagues in IHS and Tribal facilities; private sector faculty
also bring a wide range of experience providing Indian health care.
Learn the latest evidence-based approaches to maternal and child health
services, and share problems and solutions with your colleagues from
across Indian country. The course can also serve as a good foundation
for professionals who are new to women's health care or new to the
Indian health system.

In addition to the basic course, you may sign up for the Neonatal
Resuscitation Program, and come away with your certificate from this
convenient pre-course program. The opportunity to fulfill continuing
education requirements in a concentrated format is significant: With the
optional NRP, we can document your participation in seven half-days of
education.

Sign up early! You'll have first chance for support from your facility
and coverage for your time in Salt Lake City. Getting these benefits
lined up takes time, so don't delay and miss out! In addition, early
registration holds your place, and puts you in line for possible
availability of scholarship funds.

Watch your mail for the course brochure and registration form, or
download it from here:

<http://www.ihs.gov/MedicalPrograms/MCH/F/CN01.cfm?module=08&option=9#top>

For more information on the Postgraduate Course or other Indian Health
programs please contact <ymalloy@acog.org>; 800-673-8444, ext 2580; or
visit the ACOG website, [www.acog.org](http://www.acog.org/); under
\"Women's Issues,\" click on \"Indian Health Service\"

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

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

**Improving neonatal outcome through practical shoulder dystocia
training**

OBJECTIVE: To compare the management of and neonatal injury associated
with shoulder dystocia before and after introduction of mandatory
shoulder dystocia simulation training. METHODS: This was a
retrospective, observational study comparing the management and neonatal
outcome of births complicated by shoulder dystocia before (January 1996
to December 1999) and after (January 2001 to December 2004) the
introduction of shoulder dystocia training at Southmead Hospital,
Bristol, United Kingdom. The management of shoulder dystocia and
associated neonatal injuries were compared pretraining and posttraining
through a review of intrapartum and postpartum records of term,
cephalic, singleton births in which difficulty with the shoulders was
recorded during the two study periods.

RESULTS: There were 15,908 and 13,117 eligible births pretraining and
posttraining, respectively. The shoulder dystocia rates were similar:
pretraining 324 (2.04%) and posttraining 262 (2.00%) (P=.813). After
training was introduced, clinical management improved: McRoberts\'
position, pretraining 95/324 (29.3%) to 229/262 (87.4%) posttraining
(P\<.001); suprapubic pressure 90/324 (27.8%) to 119/262 (45.4%)
(P\<.001); internal rotational maneuver 22/324 (6.8%) to 29/262 (11.1%)
(P=.020); delivery of posterior arm 24/324 (7.4%) to 52/262 (19.8%)
(P\<.001); no recognized maneuvers performed 174/324 (50.9%) to 21/262
(8.0%) (P\<.001); documented excessive traction 54/324 (16.7%) to 24/262
(9.2%) (P=.010). There was a significant reduction in neonatal injury at
birth after shoulder dystocia: 30/324 (9.3%) to 6/262 (2.3%) (relative
risk 0.25 \[confidence interval 0.11-0.57\]).

CONCLUSION: The introduction of shoulder dystocia training for all
maternity staff was associated with improved management and neonatal
outcomes of births complicated by shoulder dystocia. LEVEL OF EVIDENCE:
II.

Draycott TJ, Crofts JF, Ash JP, Wilson LV, Yard E, Sibanda T, Whitelaw
A. Improving neonatal outcome through practical shoulder dystocia
training. Obstet Gynecol. 2008 Jul;112(1):14-20.\
<http://www.ncbi.nlm.nih.gov/pubmed/18591302>

**Progesterone for the prevention of preterm birth: a systematic
review**\
OBJECTIVE: We performed a systematic review to assess the benefits and
harms of progesterone administration for the prevention of preterm birth
in women and their infants. DATA SOURCES: The Cochrane Controlled Trials
Register was searched, and reference lists of retrieved studies were
searched by hand. No date or language restrictions were placed. METHODS
OF STUDY SELECTION: Randomized trials comparing antenatal progesterone
for women at risk of preterm birth were considered. Studies were
evaluated for inclusion and methodological quality. Primary outcomes
were perinatal death, preterm birth before 34 weeks, and
neurodevelopmental handicap.

TABULATION, INTEGRATION AND RESULTS: Eleven randomized controlled trials
(2,425 women and 3,187 infants) were included. For women with a history
of spontaneous preterm birth, progesterone was associated with a
significant reduction in preterm birth before 34 weeks (one study, 142
women, RR 0.15, 95% CI 0.04-0.64, number needed to treat 7, 95% CI
4-17), but no statistically significant differences were identified for
the outcome of perinatal death. For women with a short cervix identified
on ultrasound, progesterone was not associated with a significant
difference in perinatal death (one study, 274 participants, RR 0.38, 95%
CI 0.10-1.40), but there was a significant reduction in preterm birth
before 34 weeks (one study, 250 women, RR 0.58, 95% CI 0.38-0.87, number
needed to treat 7, 95% CI 4-25). For women with a multiple pregnancy,
progesterone was associated with no significant difference in perinatal
death (one study, 154 participants, RR 1.95, 95% CI 0.37-10.33). For
women presenting after threatened preterm labor, no primary outcomes
were reported. For women with \"other\" risk factors for preterm birth,
progesterone was not associated with a significant difference in
perinatal death (two studies, 264 participants, RR 1.10, 95% CI
0.23-5.29).

CONCLUSION: Progesterone is associated with some beneficial effects in
pregnancy outcome for some women at increased risk of preterm birth.

Dodd JM, Flenady VJ, Cincotta R, Crowther CA. Progesterone for the
prevention of preterm birth: a systematic review. Obstet Gynecol. 2008
Jul;112(1):127-34. <http://www.ncbi.nlm.nih.gov/pubmed/18591318>

**Effect of Timing of Umbilical Cord Clamping at Birth of Term Infants
on Mother and Baby Outcomes (Cochrane Update)**

BACKGROUND: Policies for timing of cord clamping vary, with early cord
clamping generally carried out in the first 60 seconds after birth,
whereas later cord clamping usually involves clamping the umbilical cord
greater than one minute after the birth or when cord pulsation has
ceased.

OBJECTIVES: To determine the effects of different policies of timing of
cord clamping at delivery of the placenta on maternal and neonatal
outcomes.

SEARCH STRATEGY: We searched the Cochrane Pregnancy and Child birth
Group\'s Trials Register (December 2007).

SELECTION CRITERIA: Randomized controlled trials comparing early and
late cord clamping.

DATA COLLECTION AND ANALYSIS: Two review authors independently assessed
trial eligibility and quality and extracted data.

MAIN RESULTS: We included 11 trials of 2989 mothers and their babies. No
significant differences between early and late cord clamping were seen
for postpartum hemorrhage or severe postpartum hemorrhage in any of the
five trials (2236 women) which measured this outcome (relative risk (RR)
for postpartum hemorrhage 500 mls or more 1.22, 95% (CI) 0.96 to 1.55).
For neonatal outcomes, our review showed both benefits and harms for
late cord clamping. Following birth, there was a significant increase in
infants needing phototherapy for jaundice (RR 0.59, 95% CI 0.38 to 0.92;
five trials of 1762 infants) in the late compared with early clamping
group. This was accompanied by significant increases in newborn
hemoglobin levels in the late cord clamping group compared with early
cord clamping (weighted mean difference 2.17 g/dL; 95% CI 0.28 to 4.06;
three trials of 671 infants), although this effect did not persist past
six months. Infant ferritin levels remained higher in the late clamping
group than the early clamping group at six months.

AUTHORS\' CONCLUSION: One definition of active management includes
directions to administer an uterotonic with birth of the anterior
shoulder of the baby and to clamp the umbilical cord within 30--60
seconds of birth of the baby (which is not always feasible in practice).
In this review delaying clamping of the cord for at least two to three
minutes seems not to increase the risk of postpartum hemorrhage. In
addition, late cord clamping can be advantageous for the infant by
improving iron status which may be of clinical value particularly in
infants where access to good nutrition is poor, although delaying
clamping increases the risk of jaundice requiring phototherapy.

McDonald SJ, Middleton P. Effect of timing of umbilical cord clamping of
term infants on maternal and neonatal outcomes. Cochrane Database of
Systematic Reviews 2008, Issue 2. Art. No.: CD004074. DOI:
10.1002/14651858.CD004074.pub2. Obstet Gynecol. 2008 Jul;112(1):177-8.

<http://www.ncbi.nlm.nih.gov/pubmed/18591323>

**Length of rupture of membranes in the setting of premature rupture of
membranes at term and infectious maternal morbidity**

OBJECTIVE: This study was undertaken to define the time thresholds of
increased risk for infectious maternal morbidities with relationship to
length of ruptured membranes at term. STUDY DESIGN: We designed a
retrospective cohort study of all women with premature rupture of
membranes beyond 37 weeks\' gestation at a single institution.
Dichotomized time thresholds of length of ruptured membranes before
delivery were examined in 2-hour increments using bivariate and
multivariable analyses to assess the rates of chorioamnionitis and
endomyometritis. RESULTS: Among the 3841 women meeting inclusion
criteria, increased rates of chorioamnionitis and endomyometritis were
noted at time thresholds of 12 hours (adjusted odds ratio 2.3 \[95%
confidence interval, 1.2-4.4\]) and 16 hours (adjusted odds ratio 2.5
\[95% confidence interval, 1.1-5.6\]), respectively.

CONCLUSION: We found that when length of time of ruptured membranes
before delivery is examined via dichotomized time thresholds, the risks
of chorioamnionitis and endomyometritis are significantly increased at
12 hours and 16 hours, respectively. These time thresholds derived from
dichotomized time analyses should be considered during risk-based
counseling and labor management in the setting of term premature rupture
of membranes.

Tran SH, Cheng YW, Kaimal AJ, Caughey AB. Length of rupture of membranes
in the setting of premature rupture of membranes at term and infectious
maternal morbidity. Am J Obstet Gynecol. 2008 Jun;198(6):700.e1-5.
<http://www.ncbi.nlm.nih.gov/pubmed/18538159>

**How physicians cope with stillbirth or neonatal death: a national
survey of obstetricians**

OBJECTIVE: To identify U.S. obstetricians\' experiences and attitudes
about perinatal death, their coping strategies, and their beliefs about
the adequacy of their training on this topic.

METHODS: A total of 1,500 randomly selected U.S. obstetricians were
mailed a self-administered survey about their experiences and attitudes
in dealing with perinatal death. Physicians received up to three copies
of the survey, a reminder card, and a \$2 cash incentive. Eight hundred
four physicians (54%) completed the entire survey.

RESULTS: Seventy-five percent of respondents reported that caring for a
patient with a stillbirth took a large emotional toll on them
personally, and nearly one in 10 obstetricians reported they had
considered giving up obstetric practice because of the emotional
difficulty in caring for a patient with a stillbirth. Talking informally
with colleagues (87%) or friends and family (56%) were the most common
strategies used by physicians to personally cope with these situations.
CONCLUSION: Perinatal death has a profound effect on the delivering
obstetrician, and a significant number of participants in our study have
even considered giving up obstetrics altogether. Improved bereavement
training may help obstetricians care for grieving families but also cope
with their own emotions after this devastating event. LEVEL OF EVIDENCE:
II.

Gold KJ, Kuznia AL, Hayward RA. How physicians cope with stillbirth or
neonatal death: a national survey of obstetricians. Obstet Gynecol. 2008
Jul;112(1):29-34. <http://www.ncbi.nlm.nih.gov/pubmed/18591304>

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

**The relationship of bleeding patterns to daily reproductive hormones
in women approaching menopause**

OBJECTIVE: To discover early hormonal predictors of menopause and the
stages of the menopausal transition and to understand the hormonal basis
behind the bleeding abnormalities common in the menopausal transition.

METHODS: A cohort of 804 women aged 42-52 collected first void urine
samples daily for one complete menstrual cycle or 50 days (whichever
came first) once a year for 3 years. Urine was assayed for excreted
levels of follicle-stimulating hormone, luteinizing hormone, estrogen
metabolites, and progesterone metabolites, which were normalized for
creatinine concentration. Anovulation was defined by an algorithm based
on progesterone secretion. Menstrual bleeding parameters were derived
from daily calendars. Correlations among bleeding characteristics,
hormone concentrations, and other potential clinical predictors were
analyzed using multivariable logistic regression models.

RESULTS: An ethnically diverse population of women (mean age of 47) with
a majority in the early perimenopause was studied. Approximately 20% of
all cycles were anovulatory. Short cycle intervals (fewer than 21 days)
were common early in the menopause transition and were associated with
anovulation (44%). Long cycle intervals (more than 36 days) also were
associated with anovulatory cycles (65%). Both short (1-3 days) and long
(more than 8 days) duration of menstrual bleeding were associated with
anovulation (18% and 23%, respectively). Women with anovulatory cycles
were less likely to report heavy menstrual bleeding as compared with
those with ovulatory cycles. Heavy bleeding was not associated with
steroid hormone concentrations but was associated with obesity and with
the self-reported presence of leiomyomata.

CONCLUSIONS: Among women in the early menopause transition,
abnormalities in timing of menstrual bleeding (cycle intervals or
bleeding duration) have a hormonal basis and are frequently associated
with anovulation. In contrast, abnormally heavy periods do not appear to
have a steroid hormonal basis and are less likely after anovulatory
cycles. Heavy periods are associated with obesity and leiomyomata. LEVEL
OF EVIDENCE: II.

Van Voorhis BJ, Santoro N, Harlow S, Crawford SL, Randolph J. The
relationship of bleeding patterns to daily reproductive hormones in
women approaching menopause. Obstet Gynecol. 2008 Jul;112(1):101-8.
<http://www.ncbi.nlm.nih.gov/pubmed/18591314>

**Bilateral oophorectomy and depressive symptoms 12 months after
hysterectomy**

OBJECTIVE: This study was performed to examine whether bilateral
oophorectomy is related to depressive symptoms.

STUDY DESIGN: A secondary analysis of data collected from a cohort study
of 1047 premenopausal women undergoing hysterectomy with or without
concomitant oophorectomy for benign indications was performed. Data on
depressive symptoms, based on the Profile of Mood States survey, were
collected presurgically and 12 months postoperatively.

RESULTS: The effect of bilateral oophorectomy on postoperative
depressive symptoms varied, depending on the presence of baseline
depressive symptoms. Bilateral oophorectomy was associated with a
decrease in risk of depressive symptoms in women without baseline
depressive symptoms (risk ratio \[RR\] 0.36 \[95% confidence interval
(CI), 0.17, 0.78\]) and did not change significantly in those with
baseline depressive symptoms (RR 1.21 \[95% CI, 0.73, 2.00\]).
CONCLUSIONS: Bilateral oophorectomy, in comparison with unilateral or no
oophorectomy, is associated with less risk of postoperative depressive
symptoms in women without baseline depressive symptoms undergoing
hysterectomy.

Rohl J, Kjerulff K, Langenberg P, Steege J. Bilateral oophorectomy and
depressive symptoms 12 months after hysterectomy. Am J Obstet Gynecol.
2008 Jul;199(1):22.e1-5. Epub 2008 Mar 24.

<http://www.ncbi.nlm.nih.gov/pubmed/18359477>

**Two-year outcomes after sacrocolpopexy with and without burch to
prevent stress urinary incontinence**\
OBJECTIVES: To report anatomic and functional outcomes 2 years after
sacrocolpopexy in stress-continent women with or without prophylactic
Burch colposuspension.

METHODS: In the Colpopexy and Urinary Reduction Efforts (CARE) trial,
stress-continent women undergoing sacrocolpopexy were randomized to
receive or not receive a Burch colposuspension. Outcomes included
urinary symptoms, other pelvic symptoms, and pelvic support.
Standardized pelvic organ prolapse quantification examinations and
validated outcome measures including the Pelvic Floor Distress Inventory
and the Pelvic Floor Impact Questionnaire were completed before surgery
and at several postoperative intervals, including at 2 years.

RESULTS: This analysis is based on 302 of 322 randomized participants.
Most were Caucasian (94%), with a mean age of 62+/-10 years
(mean+/-standard deviation). Two years after surgery, 32.0% and 45.2% of
women in the Burch and control groups, respectively, met the stress
incontinence endpoint (presence of symptoms or positive cough stress
test or interval treatment for stress incontinence, P=.026). The apex
was well supported (point C within 2 cm of total vaginal length) in 95%
of women, and this was not affected by concomitant Burch (P=.18). There
was a trend toward fewer urgency symptoms in the Burch group (32.0%
versus 44.5% no Burch, P=.085). Twenty participants experienced mesh or
suture erosions.

CONCLUSION: The early advantage of prophylactic Burch colposuspension
for stress incontinence that was seen at 3 months remains at 2 years.
Apical anatomic success rates are high and not affected by concomitant
Burch. LEVEL OF EVIDENCE: I.

Brubaker L, et al. Two-year outcomes after sacrocolpopexy with and
without burch to prevent stress urinary incontinence. Obstet Gynecol.
2008 Jul;112(1):49-55. <http://www.ncbi.nlm.nih.gov/pubmed/18591307>

**Comparison of the treatment outcome of pubovaginal sling, tension-free
vaginal tape, and transobturator tape for stress urinary incontinence
with intrinsic sphincter deficiency**

OBJECTIVE: The aim of this study was to compare the treatment outcome of
3 sling procedures for stress urinary incontinence with intrinsic
sphincter deficiency.

STUDY DESIGN: This retrospective study included 253 patients who
underwent incontinence surgery (pubovaginal sling \[PVS\] = 87,
tension-free vaginal tape \[TVT\] = 94, and transobturator tape \[TOT\]
= 72) for urodynamic stress incontinence with intrinsic sphincter
deficiency. Analysis of variance, chi(2) test, Fisher\'s exact test,
Kaplan-Meier survival analysis, and Cox proportional hazard regression
were used for statistical analysis.

RESULTS: Overall complication rates were not significantly different. At
2 years postoperatively, the cumulative cure rates of the PVS, TVT, and
TOT groups were significantly different (87.25%, 86.94%, and 34.89%,
respectively; P \< .0001). The risk of treatment failure in women who
received TOT was 4.6 times higher than in women who underwent PVS. The
7-year cumulative cure rates of PVS and TVT groups were 59.10% and
55.09%, respectively.

CONCLUSION: PVS and TVT were more efficacious, but the long-term cure
rates were low.

Jeon MJ, Jung HJ, Chung SM, Kim SK, Bai SW. Comparison of the treatment
outcome of pubovaginal sling, tension-free vaginal tape, and
transobturator tape for stress urinary incontinence with intrinsic
sphincter deficiency. Am J Obstet Gynecol. 2008 Jul;199(1):76.e1-4. Epub
2008 Jan 25. <http://www.ncbi.nlm.nih.gov/pubmed/18221934>

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

**Universal newborn hearing screening: systematic review to update the
2001 US Preventive Services Task Force Recommendation**

OBJECTIVE: This review is an update for the US Preventive Services Task
Force on universal newborn hearing screening to detect
moderate-to-severe permanent, bilateral congenital hearing loss. We
focus on 3 key questions: (1) Among infants identified by universal
screening who would not be identified by targeted screening, does
initiating treatment before 6 months of age improve language and
communication outcomes? (2) Compared with targeted screening, does
universal screening increase the chance that treatment will be initiated
by 6 months of age for infants at average risk or for those at high
risk? (3) What are the adverse effects of screening and early treatment?

METHODS: Medline and Cochrane databases were searched to identify
articles published since the 2002 recommendation. Data from studies that
met inclusion criteria were abstracted, and studies were rated for
quality with predetermined criteria.

RESULTS: A good-quality retrospective study of children with hearing
loss indicates that those who had early versus late confirmation and
those who had undergone universal newborn screening versus none had
better receptive language at 8 years of age but not better expressive
language or speech. A good-quality nonrandomized trial of a large birth
cohort indicates that infants identified with hearing loss through
universal newborn screening have earlier referral, diagnosis, and
treatment than those not screened. These findings are corroborated by
multiple descriptive studies of ages of referral, diagnosis, and
treatment. Usual parental reactions to an initial nonpass on a hearing
screen include worry, questioning, and distress that resolve for most
parents. Cochlear implants have been associated with higher risks for
bacterial meningitis in young children.

CONCLUSIONS: Children with hearing loss who had universal newborn
hearing screening have better language outcomes at school age than those
not screened. Infants identified with hearing loss through universal
screening have significantly earlier referral, diagnosis, and treatment
than those identified in other ways.

Nelson HD, Bougatsos C, Nygren P; 2001 US Preventive Services Task
Force. Universal newborn hearing screening: systematic review to update
the 2001 US Preventive Services Task Force Recommendation. Pediatrics.
2008 Jul;122(1):e266-76. <http://www.ncbi.nlm.nih.gov/pubmed/18595973>

**Children at High Risk Should Be Screened for Elevated Cholesterol**

This clinical report replaces the 1998 policy statement from the
American Academy of Pediatrics on cholesterol in childhood, which has
been retired. This report has taken on new urgency given the current
epidemic of childhood obesity with the subsequent increasing risk of
type 2 diabetes mellitus, hypertension, and cardiovascular disease in
older children and adults. The approach to screening children and
adolescents with a fasting lipid profile remains a targeted approach.
Overweight children belong to a special risk category of children and
are in need of cholesterol screening regardless of family history or
other risk factors. This report reemphasizes the need for prevention of
cardiovascular disease by following Dietary Guidelines for Americans and
increasing physical activity and also includes a review of the
pharmacologic agents and indications for treating dyslipidemia in
children.

Daniels SR, Greer FR; Committee on Nutrition Collaborators (13). Lipid
screening and cardiovascular health in childhood. Pediatrics. 2008
Jul;122(1):198-208.

<http://www.ncbi.nlm.nih.gov/pubmed/18596007>

**Cardiovascular Risk Factors and the Metabolic Syndrome in Pediatric
Nonalcoholic Fatty Liver Disease**

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD), the most common
cause of liver disease in children, is associated with obesity and
insulin resistance. However, the relationship between NAFLD and
cardiovascular risk factors in children is not fully understood. The
objective of this study was to determine the association between NAFLD
and the presence of metabolic syndrome in overweight and obese children.

METHODS AND RESULTS: This case-control study of 150 overweight children
with biopsy-proven NAFLD and 150 overweight children without NAFLD
compared rates of metabolic syndrome using Adult Treatment Panel III
criteria. Cases and controls were well matched in age, sex, and severity
of obesity. Children with NAFLD had significantly higher fasting
glucose, insulin, total cholesterol, low-density lipoprotein
cholesterol, triglycerides, systolic blood pressure, and diastolic blood
pressure than overweight and obese children without NAFLD. Subjects with
NAFLD also had significantly lower high-density lipoprotein cholesterol
than controls. After adjustment for age, sex, race, ethnicity, body mass
index, and hyperinsulinemia, children with metabolic syndrome had 5.0
(95% confidence interval, 2.6 to 9.7) times the odds of having NAFLD as
overweight and obese children without metabolic syndrome.

CONCLUSIONS: NAFLD in overweight and obese children is strongly
associated with multiple cardiovascular risk factors. The identification
of NAFLD in a child should prompt global counseling to address
nutrition, physical activity, and avoidance of smoking to prevent the
development of cardiovascular disease and type 2 diabetes.

Schwimmer JB, Pardee PE, Lavine JE, Blumkin AK, Cook S. Cardiovascular
Risk Factors and the Metabolic Syndrome in Pediatric Nonalcoholic Fatty
Liver Disease. Circulation. 2008 Jun 30. \[Epub ahead of print\]
<http://www.ncbi.nlm.nih.gov/pubmed/18591439>

**Epidemiology and treatment of painful procedures in neonates in
intensive care units**

CONTEXT: Effective strategies to improve pain management in neonates
require a clear understanding of the epidemiology and management of
procedural pain.

OBJECTIVE: To report epidemiological data on neonatal pain collected
from a geographically defined region, based on direct bedside
observation of neonates.

DESIGN, SETTING, AND PATIENTS: Between September 2005 and January 2006,
data on all painful and stressful procedures and corresponding analgesic
therapy from the first 14 days of admission were prospectively collected
within a 6-week period from 430 neonates admitted to tertiary care
centers in the Paris region of France (11.3 millions inhabitants) for
the Epidemiology of Procedural Pain in Neonates (EPIPPAIN) study.

MAIN OUTCOME MEASURE: Number of procedures considered painful or
stressful by health personnel and corresponding analgesic therapy.
RESULTS: The mean (SD) gestational age and intensive care unit stay were
33.0 (4.6) weeks and 8.4 (4.6) calendar days, respectively. Neonates
experienced 60,969 first-attempt procedures, with 42,413 (69.6%) painful
and 18,556 (30.4%) stressful procedures; 11,546 supplemental attempts
were performed during procedures including 10,366 (89.8%) for painful
and 1180 (10.2%) for stressful procedures. Each neonate experienced a
median of 115 (range, 4-613) procedures during the study period and 16
(range, 0-62) procedures per day of hospitalization. Of these, each
neonate experienced a median of 75 (range, 3-364) painful procedures
during the study period and 10 (range, 0-51) painful procedures per day
of hospitalization. Of the 42,413 painful procedures, 2.1% were
performed with pharmacological-only therapy; 18.2% with
nonpharmacological-only interventions, 20.8% with pharmacological,
nonpharmacological, or both types of therapy; and 79.2% without specific
analgesia, and 34.2% were performed while the neonate was receiving
concurrent analgesic or anesthetic infusions for other reasons.
Prematurity, category of procedure, parental presence, surgery, daytime,
and day of procedure after the first day of admission were associated
with greater use of specific preprocedural analgesia, whereas mechanical
ventilation, noninvasive ventilation and administration of nonspecific
concurrent analgesia were associated with lower use of specific
preprocedural analgesia.

CONCLUSION: During neonatal intensive care in the Paris region, large
numbers of painful and stressful procedures were performed, the majority
of which were not accompanied by analgesia.

Carbajal R, et al. Epidemiology and treatment of painful procedures in
neonates in intensive care units. JAMA. 2008 Jul 2;300(1):60-70.
<http://www.ncbi.nlm.nih.gov/pubmed/18594041>

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

**Prevalence and Correlates of Subclinical Atherosclerosis in Alaska
Eskimos. The GOCADAN Study**

BACKGROUND AND PURPOSE: The recent increase in clinical cardiovascular
disease in Alaska Eskimos suggests that changes in traditional lifestyle
may have adverse public health consequences. This study examines the
prevalence of subclinical vascular disease and its relation to risk
factors in Alaska Eskimos.

METHODS: Participants in the population-based Genetics of Coronary
Artery Disease in Alaska Natives (GOCADAN) Study underwent evaluation of
cardiovascular disease risk factors and carotid ultrasound. Outcome
variables were carotid intimal-medial thickness and presence and extent
of atherosclerosis.

RESULTS: In multivariate analyses, intimal-medial thickness and presence
and extent of atherosclerosis were all associated with traditional
cardiovascular disease risk factors but not dietary intake of omega-3
fatty acids. Rates of carotid atherosclerosis were higher than those
reported in 2 large population-based US studies.

CONCLUSIONS: Alaska Eskimos have similar traditional risk factors for
carotid atherosclerosis as other ethnic and racial populations but have
higher prevalences of atherosclerosis, possibly attributable to higher
rates of smoking.

## Cutchins A, Roman MJ, Devereux RB, Ebbesson SO, Umans JG, Zhu J, Weissman NJ, Howard BV. Prevalence and Correlates of Subclinical Atherosclerosis in Alaska Eskimos. The GOCADAN Study. **Stroke. 2008 Jul 10. \[Epub ahead of print\] <http://www.ncbi.nlm.nih.gov/pubmed/18617652>** 

#### Diabetes and Depression Linked {#diabetes-and-depression-linked-1 .Style-Heading-4-+-Arial-14-pt-Underline}

CONTEXT: Depressive symptoms are associated with development of type 2
diabetes, but it is unclear whether type 2 diabetes is a risk factor for
elevated depressive symptoms.

OBJECTIVE: To examine the bidirectional association between depressive
symptoms and type 2 diabetes.

DESIGN, SETTING, AND PARTICIPANTS: Multi-Ethnic Study of
Atherosclerosis, a longitudinal, ethnically diverse cohort study of US
men and women aged 45 to 84 years enrolled in 2000-2002 and followed up
until 2004-2005.

MAIN OUTCOME MEASURES: Elevated depressive symptoms defined by Center
for Epidemiologic Studies Depression Scale (CES-D) score of 16 or
higher, use of antidepressant medications, or both. The CES-D score was
also modeled continuously. Participants were categorized as normal
fasting glucose (\< 100 mg/dL), impaired fasting glucose (100-125
mg/dL), or type 2 diabetes (\> or = 126 mg/dL or receiving treatment).
Analysis 1 included 5201 participants without type 2 diabetes at
baseline and estimated the relative hazard of incident type 2 diabetes
over 3.2 years for those with and without depressive symptoms. Analysis
2 included 4847 participants without depressive symptoms at baseline and
calculated the relative odds of developing depressive symptoms over 3.1
years for those with and without type 2 diabetes. RESULTS: In analysis
1, the incidence rate of type 2 diabetes was 22.0 and 16.6 per 1000
person-years for those with and without elevated depressive symptoms,
respectively. The risk of incident type 2 diabetes was 1.10 times higher
for each 5-unit increment in CES-D score (95% confidence interval
\[CI\], 1.02-1.19) after adjustment for demographic factors and body
mass index. This association persisted following adjustment for
metabolic, inflammatory, socioeconomic, or lifestyle factors, although
it was no longer statistically significant following adjustment for the
latter (relative hazard, 1.08; 95% CI, 0.99-1.19). In analysis 2, the
incidence rates of elevated depressive symptoms per 1000-person years
were 36.8 for participants with normal fasting glucose; 27.9 for
impaired fasting glucose; 31.2 for untreated type 2 diabetes, and 61.9
for treated type 2 diabetes. Compared with normal fasting glucose, the
demographic-adjusted odds ratios of developing elevated depressive
symptoms were 0.79 (95% CI, 0.63-0.99) for impaired fasting glucose,
0.75 (95% CI, 0.44-1.27) for untreated type 2 diabetes, and 1.54 (95%
CI, 1.13-2.09) for treated type 2 diabetes. None of these associations
with incident depressive symptoms were materially altered with
adjustment for body mass index, socioeconomic and lifestyle factors, and
comorbidities. Findings in both analyses were comparable across ethnic
groups.

CONCLUSIONS: A modest association of baseline depressive symptoms with
incident type 2 diabetes existed that was partially explained by
lifestyle factors. Impaired fasting glucose and untreated type 2
diabetes were inversely associated with incident depressive symptoms,
whereas treated type 2 diabetes showed a positive association with
depressive symptoms. These associations were not substantively affected
by adjustment for potential confounding or mediating factors.

Golden SH, et al., Examining a bidirectional association between
depressive symptoms and diabetes. JAMA. 2008 Jun 18;299(23):2751-9.
<http://www.ncbi.nlm.nih.gov/pubmed/18560002>

Full text article at JAMA website:
<http://jama.ama-assn.org/cgi/content/full/299/23/2751>

**Hearing Loss More Common with Diabetes**

BACKGROUND: Diabetes might affect the vasculature and neural system of
the inner ear, leading to hearing impairment.

OBJECTIVE: To determine whether hearing impairment is more prevalent
among U.S. adults with diabetes.

DESIGN: Cross-sectional analysis of nationally representative data.
SETTING: National Health and Nutrition Examination Survey, 1999 to 2004.

PARTICIPANTS: 5140 noninstitutionalized adults age 20 to 69 years who
had audiometric testing.

MEASUREMENTS: Hearing impairment was assessed from the pure tone average
of thresholds over low or mid-frequencies (500, 1000, and 2000 Hz) and
high frequencies (3000, 4000, 6000, and 8000 Hz) and was defined as mild
or greater severity (pure tone average \>25 decibels hearing level \[dB
HL\]) and moderate or greater severity (pure tone average \>40 dB HL).
RESULTS: Hearing impairment was more prevalent among adults with
diabetes. Age-adjusted prevalence of low- or mid-frequency hearing
impairment of mild or greater severity in the worse ear was 21.3% (95%
CI, 15.0% to 27.5%) among 399 adults with diabetes compared with 9.4%
(CI, 8.2% to 10.5%) among 4741 adults without diabetes. Similarly,
age-adjusted prevalence of high-frequency hearing impairment of mild or
greater severity in the worse ear was 54.1% (CI, 45.9% to 62.3%) among
those with diabetes compared with 32.0% (CI, 30.5% to 33.5%) among those
without diabetes. The association between diabetes and hearing
impairment was independent of known risk factors for hearing impairment,
such as noise exposure, ototoxic medication use, and smoking (adjusted
odds ratios for low- or mid-frequency and high-frequency hearing
impairment were 1.82 \[CI, 1.27 to 2.60\] and 2.16 \[CI, 1.47 to 3.18\],
respectively). LIMITATIONS: The diagnosis of diabetes was based on
self-report. The investigators could not distinguish between type 1 and
type 2 diabetes. Noise exposure was based on participant recall.
CONCLUSION: Hearing impairment is common in adults with diabetes, and
diabetes seems to be an independent risk factor for the condition.

Bainbridge KE, Hoffman HJ, Cowie CC. Diabetes and hearing impairment in
the United States: audiometric evidence from the National Health and
Nutrition Examination Survey, 1999 to 2004. Ann Intern Med. 2008 Jul
1;149(1):1-10. Epub 2008 Jun 16.
<http://www.annals.org/cgi/content/full/0000605-200807010-00231v1>

Hirose K. Hearing Loss and Diabetes: You Might Not Know What You\'re
Missing. Ann Intern Med. 2008 Jul 1;149(1):54-5. Epub 2008 Jun 16.
<http://www.annals.org/cgi/content/full/149/1/54>

Summary for Patients:
<http://www.annals.org/cgi/content/full/149/1/I-20>

**Management of Non--ST-Elevation Acute Coronary Syndromes in Men vs.
Women; A role for conservative management in low risk women**

CONTEXT: Although an invasive strategy is frequently used in patients
with non-ST-segment elevation acute coronary syndromes (NSTE ACS), data
from some trials suggest that this strategy may not benefit women.

OBJECTIVE: To conduct a meta-analysis of randomized trials to compare
the effects of an invasive vs conservative strategy in women and men
with NSTE ACS. DATA SOURCES: Trials were identified through a
computerized literature search of the MEDLINE and Cochrane databases
(1970-April 2008) using the search terms invasive strategy, conservative
strategy, selective invasive strategy, acute coronary syndromes,
non-ST-elevation myocardial infarction, and unstable angina.

STUDY SELECTION: Randomized clinical trials comparing an invasive vs
conservative treatment strategy in patients with NSTE ACS.

DATA EXTRACTION: The principal investigators for each trial provided the
sex-specific incidences of death, myocardial infarction (MI), and
rehospitalization with ACS through 12 months of follow-up.

DATA SYNTHESIS: Data were combined across 8 trials (3075 women and 7075
men). The odds ratio (OR) for the composite of death, MI, or ACS for
invasive vs conservative strategy in women was 0.81 (95% confidence
interval \[CI\], 0.65-1.01; 21.1% vs 25.0%) and in men was 0.73 (95% CI,
0.55-0.98; 21.2% vs 26.3%) without significant heterogeneity between
sexes (P for interaction = .26). Among biomarker-positive women, an
invasive strategy was associated with a 33% lower odds of death, MI, or
ACS (OR, 0.67; 95% CI, 0.50-0.88) and a nonsignificant 23% lower odds of
death or MI (OR, 0.77; 95% CI, 0.47-1.25). In contrast, an invasive
strategy was not associated with a significant reduction in the triple
composite end point in biomarker-negative women (OR, 0.94; 95% CI,
0.61-1.44; P for interaction = .36) and was associated with a
nonsignificant 35% higher odds of death or MI (OR, 1.35; 95% CI,
0.78-2.35; P for interaction = .08). Among men, the OR for death, MI, or
ACS was 0.56 (95% CI, 0.46-0.67) if biomarker-positive and 0.72 (95% CI,
0.51-1.01) if biomarker-negative (P for interaction = .09).

CONCLUSIONS: In NSTE ACS, an invasive strategy has a comparable benefit
in men and high-risk women for reducing the composite end point of
death, MI, or rehospitalization with ACS. In contrast, our data provide
evidence supporting the new guideline recommendation for a conservative
strategy in low-risk women.

O\'Donoghue M, et al. Early invasive vs conservative treatment
strategies in women and men with unstable angina and non-ST-segment
elevation myocardial infarction: a meta-analysis. JAMA. 2008 Jul
2;300(1):71-80. <http://www.ncbi.nlm.nih.gov/pubmed/18594042>

## 

## ACC/AHA 2007 Guidelines for the Management of Patients with Unstable Angina/Non--ST-Elevation Myocardial Infarction: 

#### [**http://content.onlinejacc.org/cgi/content/full/50/7/e1**](http://content.onlinejacc.org/cgi/content/full/50/7/e1)  {#httpcontent.onlinejacc.orgcgicontentfull507e1 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Topiramate Improves Quality of Life and Physical Health in
Alcohol-Dependent Adults**

BACKGROUND: Topiramate can improve drinking outcomes via a hypothesized
mechanism of facilitating gamma-aminobutyric acid function and
inhibiting glutaminergic pathways in the corticomesolimbic system. We
sought to determine whether topiramate\'s antidrinking effects are
bolstered by improvements in physical and psychosocial well-being.

METHODS: In a 17-site, 14-week, double-blind, randomized controlled
trial, we compared the effects of topiramate (up to 300 mg/d) vs placebo
on physical health, obsessional thoughts and compulsions about using
alcohol, and psychosocial well-being among 371 alcohol-dependent
subjects who received weekly adherence enhancement therapy.

RESULTS: Topiramate was more efficacious than placebo in reducing body
mass index (calculated as weight in kilograms divided by height in
meters squared) (mean difference, 1.08; 95% confidence interval \[CI\],
0.81-1.34; P \< .001), all liver enzyme levels (P \< .01 for all
comparisons), plasma cholesterol level (mean difference, 13.30 mg/dL;
95% CI, 5.09-21.44 mg/dL; P = .002), and systolic (mean difference, 9.70
mm Hg; 95% CI, 6.81-12.60 mm Hg; P \< .001) and diastolic (mean
difference, 6.74 mm Hg; 95% CI, 4.57-8.90 mm Hg; P \< .001) blood
pressure to about prehypertension levels-effects that might lower the
risk of fatty liver degeneration and cirrhosis as well as cardiovascular
disease. Topiramate compared with placebo significantly (P \< .05 for
all comparisons) decreased obsessional thoughts and compulsions about
using alcohol, increased subjects\' psychosocial well-being, and
improved some aspects of quality of life, thereby diminishing the risk
of relapse and longer-term negative outcomes. Paresthesia, taste
perversion, anorexia, and difficulty with concentration were reported
more frequently for topiramate than for placebo.

CONCLUSION: Topiramate appears to be generally effective at improving
the drinking outcomes and physical and psychosocial well-being of
alcoholic subjects.

Johnson BA, et al. Improvement of physical health and quality of life of
alcohol-dependent individuals with topiramate treatment: US multisite
randomized controlled trial. Arch Intern Med. 2008 Jun
9;168(11):1188-99. <http://www.ncbi.nlm.nih.gov/pubmed/18541827>

**Noninvasive ventilation in acute cardiogenic pulmonary edema**

BACKGROUND: Noninvasive ventilation (continuous positive airway pressure
\[CPAP\] or noninvasive intermittent positive-pressure ventilation
\[NIPPV\]) appears to be of benefit in the immediate treatment of
patients with acute cardiogenic pulmonary edema and may reduce
mortality. We conducted a study to determine whether noninvasive
ventilation reduces mortality and whether there are important
differences in outcome associated with the method of treatment (CPAP or
NIPPV).

METHODS: In a multicenter, open, prospective, randomized, controlled
trial, patients were assigned to standard oxygen therapy, CPAP (5 to 15
cm of water), or NIPPV (inspiratory pressure, 8 to 20 cm of water;
expiratory pressure, 4 to 10 cm of water). The primary end point for the
comparison between noninvasive ventilation and standard oxygen therapy
was death within 7 days after the initiation of treatment, and the
primary end point for the comparison between NIPPV and CPAP was death or
intubation within 7 days.

RESULTS: A total of 1069 patients (mean \[±SD\] age, 77.7±9.7 years;
female sex, 56.9%) were assigned to standard oxygen therapy (367
patients), CPAP (346 patients), or NIPPV (356 patients). There was no
significant difference in 7-day mortality between patients receiving
standard oxygen therapy (9.8%) and those undergoing noninvasive
ventilation (9.5%, P=0.87). There was no significant difference in the
combined end point of death or intubation within 7 days between the two
groups of patients undergoing noninvasive ventilation (11.7% for CPAP
and 11.1% for NIPPV, P=0.81). As compared with standard oxygen therapy,
noninvasive ventilation was associated with greater mean improvements at
1 hour after the beginning of treatment in patient-reported dyspnea
(treatment difference, 0.7 on a visual-analogue scale ranging from 1 to
10; 95% confidence interval \[CI\], 0.2 to 1.3; P=0.008), heart rate
(treatment difference, 4 beats per minute; 95% CI, 1 to 6; P=0.004),
acidosis (treatment difference, pH 0.03; 95% CI, 0.02 to 0.04;
P\<0.001), and hypercapnia (treatment difference, 0.7 kPa \[5.2 mm Hg\];
95% CI, 0.4 to 0.9; P\<0.001). There were no treatment-related adverse
events.

CONCLUSIONS: In patients with acute cardiogenic pulmonary edema,
noninvasive ventilation induces a more rapid improvement in respiratory
distress and metabolic disturbance than does standard oxygen therapy but
has no effect on short-term mortality.

Gray A, Goodacre S, Newby DE, Masson M, Sampson F, Nicholl J; 3CPO
Trialists.\
Noninvasive ventilation in acute cardiogenic pulmonary edema.\
N Engl J Med. 2008 Jul 10;359(2):142-51.
<http://www.ncbi.nlm.nih.gov/pubmed/18614781>

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

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

**ACOG Practice Bulletin #95 Anemia in Pregnancy**

**Introduction:** Anemia, the most common hematologic abnormality, is a
reduction in the concentration of erythrocytes or hemoglobin in blood.
The two most common causes of anemia in pregnancy and the puerperium are
iron deficiency and acute blood loss. Iron requirements increase during
pregnancy, and a failure to maintain sufficient levels of iron may
result in adverse maternal--fetal consequences. The purpose of this
document is to provide a brief overview of the causes of anemia in
pregnancy, review iron requirements, and provide recommendations for
screening and clinical management of anemia during pregnancy.

**Summary of Recommendations and Conclusions:**

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

-   Iron supplementation decreases the prevalence of maternal anemia at
    delivery.

***The following recommendation and conclusions are based on limited or
inconsistent scientific data (Level B):***

-   Iron deficiency anemia during pregnancy has been associated with an
    increased risk of low birth weight, preterm delivery, and perinatal
    mortality. Severe anemia with maternal Hgb levels less than 6 g/dL
    has been associated with abnormal fetal oxygenation resulting in
    nonreassuring fetal heart rate patterns, reduced amniotic fluid
    volume, fetal cerebral vasodilatation, and fetal death. Thus,
    maternal transfusion should be considered for fetal indications.

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

-   All pregnant women should be screened for anemia, and those with
    iron deficiency anemia should be treated with supplemental iron, in
    addition to prenatal vitamins.

-   Patients with anemia other than iron deficiency anemia should be
    further evaluated.

-   Failure to respond to iron therapy should prompt further
    investigation and may suggest an incorrect diagnosis, coexisting
    disease, malabsorption (sometimes caused by the use of
    enteric-coated tablets or concomitant use of antacids),
    noncompliance, or blood loss.

**Proposed Performance Measure:**

Percentage of pregnant patients with iron deficiency anemia treated with
supplemental iron in addition to prenatal vitamins.

American College of Obstetricians and Gynecologists. Anemia in
pregnancy. ACOG Practice Bulletin No. 95. Obstet Gynecol
2008;112:201--7.

<http://www.ncbi.nlm.nih.gov/pubmed/18591330>

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

## The mirror lies: body dysmorphic disorder

## Body dysmorphic disorder is an increasingly recognized somatoform disorder, clinically distinct from obsessive-compulsive disorder, eating disorders, and depression. Patients with body dysmorphic disorder are preoccupied with an imagined deficit in the appearance of one or more body parts, causing clinically significant stress, impairment, and dysfunction. The preoccupation is not explained by any other psychiatric disorder. Patients present to family physicians for primary care reasons and aesthetic or cosmetic procedures. Cosmetic correction of perceived physical deficits is rarely an effective treatment. Pharmacologic treatment with selective serotonin reuptake inhibitors and nonpharmacologic treatment with cognitive behavior therapy are effective. Body dysmorphic disorder is not uncommon, but is often misdiagnosed. Recognition and treatment are important because this disorder can lead to disability, depression, and suicide. 

## 

## Hunt TJ, Thienhaus O, Ellwood A. The mirror lies: body dysmorphic disorder. Am Fam Physician. 2008;78(2):217-222, 223-224. [**http://www.aafp.org/afp/20080715/217.html**](http://www.aafp.org/afp/20080715/217.html) 

Patient Handout, "Body Dysmorphic Disorder: What You Should Know"
available at:

[**http://www.aafp.org/afp/20080715/223ph.html**](http://www.aafp.org/afp/20080715/223ph.html)

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

###################### **USPSTF Reaffirms Recommendation for Screening Pregnant Women for Asymptomatic Bacteriuria** {#uspstf-reaffirms-recommendation-for-screening-pregnant-women-for-asymptomatic-bacteriuria-1 .unnumbered}

######################  {#section-6 .unnumbered}

###################### **Summary of Recommendation:** {#summary-of-recommendation .unnumbered}

-   **The USPSTF recommends screening for asymptomatic bacteriuria with
    urine culture for pregnant women at 12 to 16 weeks\' gestation or at
    the first prenatal visit, if later.**\
    Grade: A recommendation

-   **The USPSTF recommends against screening for asymptomatic
    bacteriuria in men and nonpregnant women.**\
    Grade: D recommendation.

**Background:** Asymptomatic bacteriuria is common, and screening for
this condition in pregnant women is a well-established, evidence-based
standard of current medical practice. Screening other groups of adults
has not been shown to improve outcomes.

**Purpose:** To review new and substantial evidence on screening for
asymptomatic bacteriuria, to support the work of the U.S. Preventive
Services Task Force.

**Data Sources:** English-language studies of adults (age \>18 years)
indexed in PubMed and the Cochrane Library and published from 1 January
2002 through 30 April 2007.

**Study Selection:** For benefits of screening or treatment for screened
populations, systematic reviews; meta-analyses; and randomized,
controlled trials were included. For harms of screening, systematic
reviews; meta-analyses; randomized, controlled trials; cohort studies;
case--control studies; and case series of large multisite databases were
included. Two reviewers independently reviewed titles, abstracts, and
full articles for inclusion.

**Data Extraction:** Two reviewers extracted data from studies on
benefits of screening and treatment (including decreases in the
incidence of adverse maternal and fetal outcomes, symptomatic urinary
tract infections, hypertension, and renal function decline).

**Data Synthesis:** An updated Cochrane systematic review of 14
randomized, controlled trials of treatment supports screening for
asymptomatic bacteriuria in pregnant women. A randomized, controlled
trial and a prospective cohort study show that screening nonpregnant
women with diabetes for asymptomatic bacteriuria is unlikely to produce
benefits. No new evidence on screening men for asymptomatic bacteriuria
or on harms of screening was found.

**Limitation:** The focused search strategy may have missed some smaller
studies on the benefits and harms of screening for asymptomatic
bacteriuria.

**Conclusion:** The available evidence continues to support screening
for asymptomatic bacteriuria in pregnant women, but not in other groups
of adults.

Lin K, Fajardo K. Screening for Asymptomatic Bacteriuria in Adults:
Evidence for the U.S. Preventive Services Task Force Reaffirmation
Recommendation Statement*. AHRQ Publication No. 08-05120-EF-3, July
2008.* Agency for Healthcare Research and Quality, Rockville, MD.
<http://www.ahrq.gov/clinic/uspstf08/asymptbact/asbactart.htm>

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

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

**Ask a Librarian,** **Diane Cooper, IHS National Library
Informationist**

**Health Services Research Library (HSRL)**

**-a branch of the National Institutes of Health Library**

***Your information partner***

As your partner at the HSRL, I'm here to help you meet your information
needs. If you need to find information at either patient point-of-care
or as background information for a specific project, I can help. I am
here to save you time and ensure you get the information you need. As
your information needs evolve, I will expand and enhance my skills and
work hard to stay on top of the latest information resources useful to
the Indian Health Service.

**Benefit from a Content Expert**

I have provided clinical and health-related information services to
healthcare providers and systems in academic and rural settings in
Kentucky, Nevada, and California. With a Master's in Library and
Information Science and extensive experience providing information to
providers in outreach areas, I am qualified to provide the Indian Health
Service with up-to-date and credible information services. As your
direct link to the HSRL and partner in your work, I can support you in
the following ways:

-   Help with complex and difficult literature searches to support
    direct patient care and patient care activities

-   Participate and be a partner in IHS projects and development team
    activities

-   Assist in manuscript preparation (verify references; editing)

-   Set up current awareness alerts in your field of interest

-   Create customized databases in bibliographic software programs
    (Endnote; Reference Manager) to organize your information for easy
    retrieval when you need it

-   Provide instruction on how to search literature databases and other
    information resources more efficiently

**Tips to Get You Started**

Here's a tip to make finding information a little easier. Try using
PubMed's "Clinical Queries" for a quick and easy source of
evidence-based medicine information. Let me know if I can help you get
started.

Call me at 301.594.2449 or email me at <cooperd@mail.nih.gov> or
<Diane.Cooper2@ihs.gov> for information.

Health Services Research Library (HSRL)

[http://hsrl.nihlibrary.nih.gov](http://hsrl.nihlibrary.nih.gov/)

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

# QuickStats: Percentage of Adults with Symptoms of Serious Psychological Distress,\* by Age Group and Sex \-\-- National Health Interview Survey, United States, 2007^†^

![](media/image2.png){width="5.873611111111111in"
height="3.323611111111111in"}

\* Results are based on responses to the questions \"During the past 30
days, how often did you feel 1) so sad that nothing could cheer you up,
2) nervous, 3) restless or fidgety, 4) hopeless, 5) that everything was
an effort, or 6) worthless?\" Response codes for the six items for each
person were summed to yield a point value on a 0\--24-point scale. A
value of 13 or more was used to define serious psychological distress.

^†^ Estimates are based on household interviews of a sample of the
civilian, noninstitutionalized U.S. population.

^§^ 95% confidence interval.

CDC/MMWR Commentary:

In 2007, among all adults [\>]{.underline}18 years, women were
significantly more likely than men to have experienced symptoms of
serious psychological distress during the past 30 days. By age group,
adults aged 45\--64 years were more likely than adults aged
[\>]{.underline}65 years to have experienced these symptoms. Overall,
approximately 3% of the U.S. adult population had experienced symptoms
of serious psychological distress during the past 30 days.

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

#### CDC, MMWR, QuickStats: Percentage of Adults With Symptoms of Serious Psychological Distress,\* by Age Group and Sex \-\-- National Health Interview Survey, United States, 2007July 11, 2008 / 57(27);748 [**http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5727a5.htm?s_cid=mm5727a5_e**](http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5727a5.htm?s_cid=mm5727a5_e)  {#cdc-mmwr-quickstats-percentage-of-adults-with-symptoms-of-serious-psychological-distress-by-age-group-and-sex-----national-health-interview-survey-united-states-2007july-11-2008-5727748-httpwww.cdc.govmmwrpreviewmmwrhtmlmm5727a5.htms_cidmm5727a5_e .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Conference Information/OBOT (Buprenorphine) Certification Training**

(Buprenorphine) Certification Training will be available free of charge
to IHS providers October 24 in Flagstaff, Arizona. For details please
contact Dr. Tony Dekker at <Anthony.dekker@ihs.gov>.  This is an
excellent training and expands dramatically your therapeutic
effectiveness with patients with narcotic dependency issues -- as well
as facilitating care for our more complicated chronic pain patients. A
personal DEA number is required for certification and federal physicians
may receive one free of charge even if not currently licensed in the
state of practice. Go to <http://www.usdoj.gov/dea/index.html> to see
the DEA page (good info on pain etc) and go to
<http://www.deadiversion.usdoj.gov/drugreg/index.html> to register for a
new DEA. It is self explanatory and takes less than 5 minutes to apply.

 

**Heads Up** -- Be thinking "**Primary Care Based Behavioral Health**".
Based on programs developed at Group Health and expanding rapidly in the
VA and DOD systems this is a radical revision of the BH role in primary
care and offers demonstrated benefits for patients and providers. A site
with good material is <http://www.mahec.net/ic/>. Be patient -- it loads
slowly but is well worth the wait. Ask your local BH staff "When are you
planning on implementing this?" to get things started.

 

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

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

**The Case of the Dwindling Milk Supply**

Common scenario - mom and baby come for a well child check up. Mom says
she has returned to work and is still breastfeeding. But her breast milk
supply seems to slowing down. The following are questions to consider
asking:

[What kind of pump?]{.underline}

Hospital grade electric pumps work well. They are double sided. They
cost \$600+ to purchase and are usually rented instead for
[\>]{.underline} \$40 per month. There are also pumps that are available
at many department stores for \~\$250. It is intended to be a single
user pump. According to the manufacturer, replacing the attachments will
not reduce the risk of possible cross contamination. Many WIC programs
offer single-user type pumps for clients to keep or will loan hospital
grade pumps. Occasionally insurance companies will reimburse all/part of
pump cost.

Anecdotal comments suggest that while other less expensive pumps may
work for some moms -- they do not have the general success rate of
hospital grade pumps. Mothers describe ineffective output and nipple
damage.

Please note - nipple damage can happen with any pump. The problem can be
caused by attachments that don't fit and/or overzealous pumping.

If a family is interested in a pump, encourage the family to contact
WIC, local breastfeeding coalitions, La Leche League, their health
insurance company, and their employer. Some businesses provide pump
sites for employees. Encourage families to look for pumps that are
designed for daily use and have been clinical tested for maintaining
milk supply. Assure them that pumping/expressing is not supposed to
hurt.

[How often is the mom pumping/expressing?]{.underline}

If the baby is under 6 months, the ideal routine is pumping every 3
hours, double sided for 20 or more minutes. If the mom is able to
incorporate consistent pump times into her daily routine, it will be
easier to maintain supply.

If that is not possible to pump on a routine schedule, encourage the mom
to pump when she can. Pumping every 4 hours, like at a lunch break will
help reduce risk of plugged ducts and mastitis.

Sometimes a baby will reverse his/her long sleep pattern, so the long
sleep is while mom is gone. When mom comes home, the majority of
feedings happen then. The milk supply could be slowing during work time
because of the baby's pattern shift.

An anecdotal tip is to try pumping marathons - after work, pump 20
minutes, rest 20 minutes, repeat twice for a total of 3 sets. Try this
for 2-3 days. It often returns the milk supply.

# Other ideas - 

There are medications reported to increase supply. They include
metoclopramide (Reglan), cisapride (Propulsid), fenugreek, and other
herbs. Unfortunately, there is no consensus regarding their utility or
dosage. For more information, please see resources such as Thomas Hale's
*Medications and Mothers' Milk*, UpToDate (on the ihs.gov web page), and
the NIH lactation and medication search engine at
<http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT>. Also consider
checking with your local NICU for what they suggest for preemie moms who
are pumping.

Did the mom start birth control pills? They can disrupt milk supply,
especially those with estrogen.

Several studies link regular pacifier use with decreased milk supply.
Less (use of pacifiers) could be more (milk).

If the baby's 6 month birthday is close, remind the mom that when solids
start, the baby's need for breast milk will begin slowing down.

For many different reasons, it is not always feasible for moms to pump
or to pump enough\... A mom may have already decided to formula feed
during work time and breastfeed when they get home. With a routine work
schedule, her body will adjust and produce milk when she is home.

For more ideas to supporting/advocating for breastfeeding employees,
check with local breastfeeding coalitions. Helpful web resources include
I.H.S. Lactation in the Workplace policy at
[www.ihs.gov/MedicalPrograms/MCH/M/bf.cfm](http://www.ihs.gov/MedicalPrograms/MCH/M/bf.cfm)
and the United States Breastfeeding Committee web page at
[www.usbreastfeeding.org](http://www.usbreastfeeding.org/).

####  {#section-12 .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}

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

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

#### To view last month's issue on-line, follow this link: {#to-view-last-months-issue-on-line-follow-this-link .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=7_08**](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=7_08) {#httpwww.ihs.govmedicalprogramsmchmob.cfmmodule7_08 .Style-Heading-4-+-Arial-14-pt-Underline}

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

  -----------------------------------------------------------------------
  **SBIRT Program to Screen for Substance Abuse, Domestic Violence in
  Pregnant Women in Louisiana**

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

A program designed to increase healthy outcomes for newborn babies is
coming to Lafayette and New Orleans, Louisiana.  The Healthy Babies
Initiative screens pregnant women for tobacco use, alcohol use, drug
use, domestic violence and depression and assists expectant mothers in
getting treatment.

"This initiative focuses on critical issues that need to be addressed in
order to pursue the vision that all children are born to lead healthy,
productive lives," said DHH Secretary Alan Levine.  "The expansion of
this program is an important step toward healthier outcomes for our
state's most vulnerable citizens."

The program, also called SBIRT, operates through a system of Screening,
Brief Intervention, Referral and Treatment measures.  The women are
screened within medical settings by a physician, nurse or clinician who
identifies women at-risk for substance abuse or other related problems
through a questionnaire process.  The system provides for brief
intervention or brief treatment, and refers those identified as needing
more extensive services to a specialist.

<http://www.dhh.louisiana.gov/news.asp?Detail=1361>

More information from SAMHSA about SBIRT

<http://sbirt.samhsa.gov/about.htm>

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

**No Upper Age Limit for Benefit from Screening Mammography for Women
without Significant Comorbidities**

PURPOSE: Screening mammography guidelines for patients age 80 years and
older are variable. We determined the effect of mammography use on stage
at breast cancer diagnosis and survival among women of this age range.

PATIENTS AND METHODS: We used the linked Surveillance, Epidemiology, and
End Results-Medicare database to evaluate 12,358 women \>or= 80 years of
age diagnosed with breast cancer between 1996 and 2002. Patients were
grouped according to number of mammograms during the 60 months before
diagnosis: nonusers (0 mammograms), irregular users (one to two
mammograms), and regular users (three or more mammograms). Effects of
mammography on disease stage (I to IIa v IIb to IV) and survival were
determined by logistic regression and Cox proportional hazards analyses.

RESULTS: Percentages of women with nonuse, irregular use, and regular
use of mammography during the 5 years preceding diagnosis were 49%, 29%,
and 22%, respectively. On multivariate analysis, patients were 0.37
times less likely to present with late-stage cancer for each mammogram
obtained (odds ratio, 0.63; 95% CI, 0.63 to 0.67). Breast
cancer-specific 5-year survival among nonusers was 82%, that among
irregular users was 88%, and that among regular users was 94%. However,
survival from causes other than breast cancer was also associated with
mammography use, suggesting a bias for healthier patients to undergo
mammography. CONCLUSION: Regular mammography among women \>or= 80 years
of age was associated with earlier disease stage, although improved
survival remains difficult to demonstrate. Health care providers should
consider discussing the potential benefits of screening mammography with
their older patients, particularly for those without significant
comorbidity.

## Badgwell BD, et al. Mammography before diagnosis among women age 80 years and older with breast cancer. **J Clin Oncol. 2008 May 20;26(15):2482-8. Epub 2008 Apr 21.** [**http://www.ncbi.nlm.nih.gov/pubmed/18427152**](http://www.ncbi.nlm.nih.gov/pubmed/18427152) 

**FDA notifies healthcare professionals that both conventional and
atypical antipsychotics are associated with an increased risk of
mortality in elderly patients treated for dementia-related psychosis. **

<http://www.fda.gov/cder/drug/InfoSheets/HCP/antipsychotics_conventional.htm>

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

#### Cochrane Database---Interventions for Emergency Contraception {#cochrane-databaseinterventions-for-emergency-contraception-1 .Style-Heading-4-+-Arial-14-pt-Underline}

BACKGROUND: Emergency contraception is using a drug or copper
intrauterine device (Cu-IUD) to prevent pregnancy shortly after
unprotected intercourse. Several interventions are available for
emergency contraception. Information on the comparative efficacy, safety
and convenience of these methods is crucial for reproductive health care
providers and the women they serve. OBJECTIVES: To determine which
emergency contraceptive method following unprotected intercourse is the
most effective, safe and convenient to prevent pregnancy.

SEARCH STRATEGY: The search included the Cochrane Controlled Trials
Register, Popline, MEDLINE, PubMed, Biosis/Embase, Chinese biomedical
databases and UNDP/UNFPA/WHO/World Bank Special Programme on Human
Reproduction (HRP) emergency contraception database (December 2006).
Content experts and pharmaceutical companies were contacted.

SELECTION CRITERIA: Randomised controlled trials and controlled clinical
trials including women attending services for emergency contraception
following a single act of unprotected intercourse were eligible.

DATA COLLECTION AND ANALYSIS: Data on outcomes and trial characteristics
were extracted in duplicate and independently by two reviewers. Quality
assessment was also done by two reviewers independently. Meta-analysis
results are expressed as relative risk (RR) using a fixed-effects model
with 95% confidence interval (CI). In the presence of statistically
significant heterogeneity a random-effect model was applied.

MAIN RESULTS: Eighty-one trials with 45,842 women were included. Most
trials were conducted in China (70/81). There were more pregnancies with
levonorgestrel compared to mid-dose (25-50 mg) (15 trials, RR: 2.01; 95%
CI: 1.27 to 3.17) or low-dose mifepristone (\<25 mg) (9 trials, RR:
1.43; 95% CI: 1.02 to 2.01). Low-dose mifepristone was less effective
than mid-dose (20 trials, RR:0.67; 95% CI: 0.49 to 0.92), but this
effect was no longer statistically significant when only high quality
trials were considered (6 trials, RR: 0.75; 95% CI: 0.50 to 1.10).
Single dose levonorgestrel (1.5 mg) administration seemed to have
similar effectiveness as the standard 12 hours apart split-dose (0.75 mg
twice) (2 trials, 3830 women; RR: 0.77, 95% CI: 0.45 to 1.30).
Levonorgestrel was more effective than the Yuzpe regimen in preventing
pregnancy (2 trials, RR: 0.51; 95% CI: 0.31 to 0.83). CDB-2914 (a
second-generation progesterone receptor modulator) may be as effective
as levonorgestrel (1 trial, 1549 women; RR:1.89; 95% CI: 0.75 to 4.64)
but the confidence interval is wide and the result compatible with
higher or lower effectiveness. Delay in the onset of subsequent menses
was the main unwanted effect of mifepristone and seemed to be
dose-related.

AUTHORS\' CONCLUSIONS: Mifepristone middle dose (25-50 mg) was superior
to other hormonal regimens. Mifepristone low dose (\<25 mg) could be
more effective than levonorgestrel 0.75 mg (two doses) but this was not
conclusive. Levonorgestrel proved more effective than the Yuzpe regimen.
The copper IUD was another effective emergency contraceptive that can
provide ongoing contraception.

Cheng L, Gülmezoglu AM, Piaggio G, Ezcurra E, Van Look PF. Interventions
for emergency contraception. Cochrane Database Syst Rev. 2008 Apr
16;(2):CD001324. <http://www.ncbi.nlm.nih.gov/pubmed/18425871>

**Intermediate-term glucose tolerance in women with a history of
gestational diabetes: natural history and potential associations with
breastfeeding and contraception**

OBJECTIVE: This study investigated the natural history of glucose
tolerance by using modern definitions in women after delivery of a
pregnancy complicated by gestational diabetes. The association between
deterioration of glucose metabolism and contraceptive methods was also
studied.

STUDY DESIGN: Retrospective chart review of 592 indigent, primarily
Latina women who had been diagnosed with gestational diabetes, monitored
for up to 24 months\' postpartum. RESULTS: At the first postpartum
visit, 230 women (40.2%) had prediabetes or diabetes. Within the first
12 months, 26.4% experienced deterioration. Of the 89 women monitored
for 12-24 months, another 38.5% had prediabetes (n = 13) or diabetes (n
= 11) develop. About 22% of women by using only nonhormonal
contraception experienced worsening of their glucose status, whereas 35%
of combined hormonal contraceptive users and 34% of progestin-only users
worsened. CONCLUSION: Gestational diabetes is a sentinel event signaling
the need for frequent testing postpartum.

Nelson AL, Le MH, Musherraf Z, Vanberckelaer A. Intermediate-term
glucose tolerance in women with a history of gestational diabetes:
natural history and potential associations with breastfeeding and
contraception. Am J Obstet Gynecol. 2008 Jun;198(6):699.e1-7; discussion
699.e7-8. Epub 2008 Apr 25.
<http://www.ncbi.nlm.nih.gov/pubmed/18439553>

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

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

**Featured Website**

**The "JOINT COMMISSION" (formerly JCAHO)**

**The Joint Commission has released the 2009 standards on-line; press
release follows:**

The Joint Commission's revised standards, rationales and elements of
performance for 2009 are now available online. The standards will take
effect January 1, 2009 and have been placed online to give all health
care organizations time to become familiar with the new language,
ordering and numbering.

The changes are part of the Standards Improvement Initiative (SII),
launched in 2006 as part of The Joint Commission's ongoing quality
improvement efforts. SII focuses on clarifying standards language,
ensuring that standards are program-specific, deleting redundant and
nonessential standards, and consolidating similar standards. While no
new requirements were added, chapter overviews, standards,
introductions, rationales, and elements of performance were designed for
ease of use. In the standards reorganization, requirements were split or
consolidated. Standards have been renumbered and reordered to allow
electronic sorting and to allow the addition of new requirements in the
future.

"The Standards Improvement Initiative represents The Joint Commission's
continuous commitment to make the standards clear, relevant, and
applicable in the specific health care setting in which they are used,"
says Mark R. Chassin, M.D., M.P.P., M.P.H., president, The Joint
Commission. "These changes will better guide health care organizations
in providing patients with the best care possible."

A history tracking report is available online to help organizations see
what changes occurred from previous to revised standards. The history
tracking allows users to see what happened to each standard, its new
number, and how it changed.

The Joint Commission sought extensive input from accredited and
non-accredited health care organizations, advisory groups, payers,
purchasers, consumers, governmental agencies, Joint Commission surveyors
and other experts. Online surveys, interviews, meetings, and focus
groups were all utilized to gather comments and suggestions. The Joint
Commission will engage in extensive education efforts and discussions in
the coming months to assist organizations in understanding the changes.

Other important aspects of the Standards Improvement Initiative include:

-   Phase I of the SII focused on the accreditation programs for
    hospitals, critical access hospitals, ambulatory care, office-based
    surgery, and home care organizations;

-   SII's Phase II for behavioral health care, laboratory and long term
    care accreditation programs began in 2008 and the standards changes
    will take effect in January 2010. The Accreditation Participation
    Requirements, Life Safety Code, and Leadership chapters for these
    programs are online;

-   Changes in the scoring and decision process will take place January
    1, 2009 for all accreditation and certification programs;

-   Single-user license electronic E-ditions of the manuals will be
    provided for the first time;

-   Color-coded tabs in print manuals distinguish standards and
    requirements from accreditation policies and procedures;

-   Accreditation program-specific language used in all manuals;

-   With E-ditions, ability to sort relevant standards and elements of
    performance applicable to the services provided by an individual
    organization;

-   Links from certain EPs to associated requirements in other chapters;
    and

-   Standards and EPs related to a focused area of improvement placed in
    relevant chapters.

    Additional details about the revisions are available on the
    Standards Improvement Initiative web page.

    **Main JC Website:**

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

    **View the press release at:**

<http://www.jointcommission.org/NewsRoom/NewsReleases/nr_sii_gen.htm>

**Direct access to Standards page:**

<http://www.jointcommission.org/Standards/SII/default.htm>

# Joint Commission Issue Sentinel Event Alert on Behaviors that Undermine a Culture of Safety

Intimidating and disruptive behaviors can foster medical errors,
contribute to poor patient satisfaction and to preventable adverse
outcomes, increase the cost of care, and cause qualified clinicians,
administrators and managers to seek new positions in more professional
environments. Safety and quality of patient care is dependent on
teamwork, communication, and a collaborative work environment. To assure
quality and to promote a culture of safety, health care organizations
must address the problem of behaviors that threaten the performance of
the health care team...

Read the full Sentinel Event Alert at:
<http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_40.htm>

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

**Q.** [**How to Strengthen Your Patient's Pelvic Floor
Muscles?**](http://www.ihs.gov/MedicalPrograms/MCH/W/MatPT.cfm#pelvic)

**A.** The Women's Health web page offers many resources to help your
patient improve her symptoms of pelvic prolapse, urinary incontinence,
and pelvic pain.

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

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

**Introduction**

This spring and summer most IHS clinics have had requests for blood lead
level testing for children entering Head Start. This is an attempt to
explain why blood level testing is mandatory for Medicaid eligible AI/AN
children even if the risk of elevated lead levels is likely small in our
patients.

**Blood Lead Screening in American Indian/Alaska Native Children**

In March of 2008 the Office of Head Start issued an Information
Memorandum that reaffirmed the requirement within the Head Start Program
Performance Standards for all children entering the program to be
screened for lead poisoning as per the schedule of well child care
utilized by the EPSDT program.(1). It appeared that many Head Start
programs that serve American Indian/Alaska Native (AI/AN) children were
encountering difficulty in obtaining documentation of the required
screening blood lead levels (BLLs) performed at 12 and 24 months of age.
The Health Director of the IHS Head Start Program asked the Indian
Health Service for guidance on this issue. This request prompted a
review of current standards for screening BLLs in children \< 6 years
old.

Lead is a potent neurotoxin. At higher levels (\>70ug/dL) lead poisoning
can cause encephalopathy and death. Such extreme lead toxicity is now
rare as primary prevention efforts in the past few decades mandated the
removal of lead from gasoline and consumer products. Lead exposure from
paint in older buildings remains a persistent source of exposure to
lead. Recently there has been concern over lead toxicity in toys
imported from China. Unfortunately, even small amounts of lead can have
irreversible effects on brain development in young children. It is
estimated that every 10ug/dL increment in BLLs can decrease IQ scores by
3 to 7 points (2). At present, the accepted definition for elevated BLLs
is \>10ug/dL. However, there is recent research that BLLs even below
10ug/dL may be deleterious (3). Since BLLs \<25ug/dL are clinically
undetectable only screening can detect these cases.

Who should be screened for lead exposure? Data show that lead poisoning
is overwhelmingly a disease of young children in poverty. In the NHANES
III survey in 1994 the overall prevalence of elevated BLLs (\>10ug/dL)
in 1- 5 year olds was 4.4%. However, the prevalence of elevated BLLs was
only 0.9% in upper income children while the rate was as high as 21% in
poor children who lived in older homes. Further analysis showed that 10%
of children enrolled in Medicaid had elevated BLLs. Medicaid enrollees
also accounted for 60% of the total children with BLL \>10ug/dL and 83%
of the children with BLLs\>20ug/dL (4).

Many AI/AN children potentially would fall into the high- risk group
because of widespread poverty in many AI/AN communities. However, few
AI/AN communities have commercial homes built before the 1950s, which
would tend to diminish the likelihood of exposure to lead paint.

The current prevalence of elevated BLLs in AI/AN children is unclear. A
review of Pubmed for the past 20 years with the search terms, "American
Indian", "children" and "lead" disclosed only one article on mining
exposures in Oklahoma. The Indian Health Service has unpublished data
from the mid 1990s on lead levels in 7of 12 Areas. The percentage of
children screened in each area varied widely and not all tribal groups
were included. However, in this limited data set the overall rate of
elevated BLLs after confirmatory testing was \< 1% which was lower than
the national rate.

Given the low prevalence of lead poisoning in AI/AN children tested, it
was agreed that targeted screening of AI/AN children at high risk for
lead exposure was a better strategy than universal testing. Universal
testing was also discouraged by the United States Preventive Services
Task Force (5). No lead screening or targeted lead screening became the
standard in most clinics but was never explicitly made a policy for the
Indian Health Service. A summary of the costs and benefits of lead
screening in AIA/AN children was published in The IHS Primary Care
Provider in 1994 (6).

An informal survey of Indian Health Service/Tribal/Urban (I/T/U) clinics
suggests that most practitioners have assumed that lead exposure is not
a problem in their communities. This lack of lead screening is hardly
unique for I/T/U clinics. Despite the demonstrated elevated risk in poor
children only 20% of Medicaid enrollees nationwide were screened for
BLLs in a recent evaluation by the Office of the Inspector General (7).

However, a review of federal standards indicates BLL testing is a
mandated service for all children eligible for Medicaid and Head Start.
The Center for Medicaid and Medicare Services (CMS) requires that all
Medicaid-eligible children receive a screening blood test at 12 months
and 24 months of age (8). Children between the ages of 36 to 72 months
must also have a BLL test if lead screening has not been done
previously. Head Start is also required to follow the standard of care
set forth by CMS. CMS made this decision based on the demonstrated risk
of elevated BLL in Medicaid enrollees compared to the general
population.

Data show that up to 80% of AI/AN children \< 6 years of age in
reservation communities are eligible for Medicaid and Head Start. With
this high percentage of Medicaid enrollees it is likely more efficient
to screen all AI/AN children \< 6 years old for elevated BLLs. The risk
of elevated BLLs in AI/AN children is likely low, but there is no
recent, comprehensive data, and there is no data that includes all
tribal groups.

Given the high incidence of iron deficiency anemia in AI/AN children
many I/T/U clinics already screen for anemia with a complete blood count
(CBC) at 9 months and 18 months. Testing at 9 months of age is
preferable to testing at12 months as this will result in the earlier
detection of iron deficiency anemia earlier treatment. It is also known
that iron deficiency promotes lead absorption and that repletion of iron
stores will diminish absorption of lead (9 & 10). Therefore, timely
treatment of iron deficiency is one of the best preventive measures to
minimize lead poisoning. BLLs tend to peak at age 24 months so this is
the optimal time for the follow-up test to be done. To minimize the
number of blood draws CBC and lead testing could be combined in the
following schedule:

9-12 months: draw a CBC and lead level

24 months: draw a CBC and lead level

36-72 months -- draw a lead level if not done previously

Management of elevated BLLs (\>10ug/dL) is beyond the scope of this
report. Follow-up should be based on the guidelines published in the AAP
Policy statement lead poisoning published in 2005 (2).

Lead testing will cost I/T/U sites money. This test is usually performed
in a reference lab and a BLL usually costs about \$15. Medicaid pays a
global fee for outpatient visits to most I/T/U clinics so the cost of
the test is not recoverable. However, BLL is a CMS mandate: Failure to
perform a mandated test could jeopardize Medicaid reimbursement. Money
may need to be reprogrammed to I/T/U laboratory budgets to cover this
cost.

Lastly, each clinic will need to track BLLs in their patient population
over the next year. This will let us answer the question of which, if
any, AI/AN children are at risk for lead poisoning. Tribal groups with
low lead levels may be able to request a waiver of BLL testing from CMS
in the future. As important, if some tribal groups are found to be at
elevated risk, appropriate environmental investigation and amelioration
can begin.

**References**

1.  Lead Screening ACF-IM-HS-08-07. Administration for Children and
    Families. U.S. Department of Health and Human Services. Issued
    3/20/08.
    [www.acf.hhs.gov/programs/ohs/policy/im2008/acfimhs_08_07.html](http://www.acf.hhs.gov/programs/ohs/policy/im2008/acfimhs_08_07.html)

2.  Lead Exposure in Children: Prevention, Detection and Management.
    American Academy of Pediatrics Policy Statement. Pediatrics: 2005
    Oct;116(4):1036-1046.

3.  Canfield RL, Henderson CRjr, Cory-Slechta DA, Cox C, Jusko TA,
    Lamphear BP. Intellectual Impairment in children with blood
    concentrations below 10ug per deciliter. N Eng J Med
    2003:348:1517-1526.

4.  Recommendations for blood lead screening of young children enrolled
    in Medicaid: Targeting a group at high risk. MMWR December 08, 2000
    / 49(RR14);1-13.

5.  USPSTF Recommendations for Lead Screening. Pediatrics.
    2006;118:e2514-2518.

6.  Batholomew M Vanderwagen C. Lead screening of Native American
    children: Targeted or Screening? The IHS Primary Care Provider 1999
    August 24(8):125-126.

7.  Lead Poisoning: Federal Health Care Programs are not Effectively
    Reaching At-Risk Children. U.S. General Accounting Office, January
    1999.

8.  EPSDT Benefits: Accessed on June 12, 2008
    [[http://www.cms.hhs.gov/MedicaidEarlyPeriodicScrn/02_Benefits.asp]{.underline}](http://www.cms.hhs.gov/MedicaidEarlyPeriodicScrn/02_Benefits.asp  )

9.  Barton JC, Conrad ME, Nuby S, Harrison L Effects of iron on the
    absorption and retention of lead. J Lab Clin Med. 1978
    Oct;92(4):536-47.

10. A Bradman, B Eskenazi, P Sutton, M Athanasoulis, and L R Goldman
    Iron deficiency associated with higher blood lead in children living
    in contaminated environments. Environ Health Perspect. 2001 October;
    109(10): 1079--1084.

**Infectious Disease Updates**

Steve Holve, MD

**Pentacel®: New May not be Better for American Indian/Alaska Native
Infants**

A new combination vaccine, Pentacel® (DTaP-IPV- Hib \[PRP-T\]), was
recently licensed for use in the United States. This vaccine is not
ideal for American Indian/Alaska Native (AI/AN) infants served in
federal, tribal and urban Indian clinics.

Pentacel® is a vaccine that protects against five serious infections;
diphtheria, tetanus, pertussis, polio, and haemophilus influenzae type b
(Hib).  It is the first combination vaccine in the United States that
includes both poliovirus and haemophilus antigens.  The vaccine is
administered to children at 2, 4, 6, and 15-18 months of age.   

There are currently several Hib vaccines available which vary in the
protein used to make the vaccine more immunogenic. In Pentacel®, the Hib
component of the vaccine is a purified polyribosylribitol phosphate
(PRP) capsular polysaccharide covalently bound to tetanus protein
(PRP-T).  The current Hib vaccine recommended for AI/AN infants has a
meningococcal outer membrane protein (OMP) bound to the PRP molecule and
is designated as a PRP-OMP Hib vaccine.

The Redbook of the American Academy of Pediatrics recommends that for
AI/AN infants the first dose of a Hib conjugate vaccine should contain
PRP-OMP. For AI/AN infants "the administration of a PRP-OMP-containing
vaccine leads to more rapid seroconversion to protective concentrations
of antibody within the first 6 months of life, and failure of use has
been associated with excess cases of Hib disease in young infants in
this population". (1)

 

In 1996 Alaska switched from a PRP-OMP Hib vaccine to combination
HbOC-DTP vaccine (Tetramune®).  During 1996-1997, 17 Hib cases occurred
in Alaska Native children \<5 years of age, increasing the rate of Hib
disease from 19 to 91 cases per 100,000 per year.  8 of the cases
occurred in partially vaccinated children who had received 1 or 2 doses
of HbOC.  Since 2001, Alaska has adopted a schedule using PRP-OMP alone,
and the subsequent rate of Hib disease in Alaska Native infants
decreased to 5.4 per 100,000 per year.(2)

Physicians, pharmacists and immunization coordinators who work for
federal, tribal and urban Indian clinics need to be aware of this change
and insure that their state's VFC program continues to supply a PRP-OMP
Hib vaccine to their AI/AN patients.

1\. 2006 Report of the Committee on Infectious Diseases. American
Academy of Pediatrics; Elk Gove, IL page 89.

2\. Singleton et al., The Alaska Haemophilus influenzae type b
experience: Lessons in controlling a vaccine-preventable disease.
Pediatrics 2006;118:421-429.

**Addendum:**

Questions have arisen over whether this recommendation applies to all
AI/AN children. The above update was written for an audience that works
in federal, tribal and urban Indian clinics. Private clinics near
reservation communities may serve significant numbers of AI/AN
patients and may wish to have a PRP-OMP containing Hib vaccine
available. The risk of invasive Hib disease for AI/AN infants who do not
live on or near reservation communities is unknown.

This issue of increased risk for invasive Hib disease was addressed in
the MMWR in December 2007 due to a decrease in the supply of PRP-OMP Hib
vaccine due to production difficulties. The pertinent summary of the
risk for AI/AN infants is below. Each practitioner should make a
decision based on their assessment of risk of invasive Hib for their
patients. The full posting with references is available at:
[[http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5650a4.htm]{.underline}](http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5650a4.htm)

American Indian/Alaska Native (AI/AN) children also are at increased
risk for Hib disease, particularly in the first 6 months of life. Before
the use of Hib conjugate vaccines, the incidence of Hib disease among
young AI/AN children in AI/AN communities was approximately 10 times
higher than among children of comparable age in the general population.
Compared with PRP-TT conjugate vaccines, the administration of PRP-OMP
vaccines leads to a more rapid seroconversion to protective antibody
concentrations within the first 6 months of life. Failure to use PRP-OMP
vaccines for the first dose is associated with excess cases of Hib
disease in AI/AN infants living in communities where Hib transmission is
ongoing and exposure to colonized persons is likely. Although PRP-OMP
and PRP-TT vaccines are equally effective after completion of the
primary series, availability of more than one Hib vaccine in a clinic
could lead to administration of the wrong vaccine for the first dose in
these populations. For these reasons, CDC recommends that providers who
currently use PRP-OMP\--containing Hib vaccines (PedvaxHIB and Comvax)
to serve predominantly AI/AN children in AI/AN communities continue to
stock and use only PRP-OMP\-- containing Hib vaccines not affected by
the recall and vaccinate according to the routinely recommended
schedules, including the 12\--15 month booster dose. In its vaccine
stockpile, CDC has PRP-OMP\--containing Hib vaccines not affected by the
recall and will prioritize distribution of available PRP-OMP vaccines
for use in AI/AN communities. AI/AN children not in AI/AN communities or
who already receive PRP-TT conjugate vaccines should continue to be
vaccinated with available vaccines according to the routinely
recommended schedules, including the 12\--15 month booster dose.

Recent literature on American Indian/Alaskan Native Health

Michael L. Bartholomew, MD

Brim SN, Rudd RA, Funk RH, Callahan DB. Asthma prevalence among US
children in underrepresented minority populations: American
Indian/Alaska Native, Chinese, Filipino, and Asian Indian. Pediatrics.
2008 Jul;122(1):e217-22.

<http://www.ncbi.nlm.nih.gov/pubmed/18595967>

Asthma continues to be a prevalent childhood disease in the United
States. Recent studies estimate that 8.9% of US children ages 0 to 17
years of age have asthma1. Asthma prevalence among Asian Americans,
specifically subgroups of Asian Americans, and American Indians and
Alaska Natives (AI/AN) has largely been unknown.

Anecdotal reports of the 1960's and 1970's suggested that asthma in
American Indians was rare2. In the 1990s, Clark et al showed that asthma
was more prevalent than once believed when he documented the asthma
burden in Jemez Indian childhood population3. Between 2004-2005, the
prevalence of asthma in AI/AN children was estimated to be 9.9%1.

Many recent studies defining asthma prevalence rates among children have
yielded varied results in regards to age, race, socioeconomic and ethnic
backgrounds. Due to small sample sizes in large scale studies, the
national prevalence of diseases has thus far been difficult to determine
for certain ethnic groups or subgroups.

This study investigates the prevalence of current asthma, lifetime
asthma, and asthma attacks among subpopulations (Chinese, Filipino, and
Asian Indian) of Asian American and AI/AN children ages 2 to 17 years
and place of birth by analyzing aggregate data from the 2001-2005
National Health Interview Surveys. The prevalence of lifetime and
current asthma and the prevalence of 12-month asthma attacks were
calculated from responses to questions posed during the survey. Logistic
regression models were used to determine the association of current
asthma prevalence with race and place of birth by controlling for
certain confounding demographic variables.

Estimates of current asthma prevalence according to race and place of
birth ranged from 4.4% for Asian Indian children to 13.3% in black
children. AI/AN children had an asthma prevalence of 13.0%, while
Filipino and Chinese children had a prevalence of 10.7% and 5.1%,
respectively. White children had a current asthma prevalence of 8.4%.

Lifetime asthma prevalence estimates among races showed a similar trend.
The lifetime prevalence among the races ranged from 9% in Chinese
children to 18.1% for black children. The lifetime asthma prevalence
estimates for AI/AN children was 18 % and for Asian Indian and Filipino
was 9.4% and 15.7% respectively. A high prevalence of current and
lifetime asthma was noted in children born in the United States than in
children born outside the United States (Current asthma: 9.4% vs. 4.3%;
Lifetime asthma: 13.6% vs. 7.3%). The prevalence of asthma attack in the
past 12 months did not vary among races or place of birth.

After controlling for place of birth, gender, age, ethnicity, region,
household income, and health insurance coverage, AI/AN children are 1.82
times likely to report having asthma than their White counterparts.
Black children are 1.57 times likely while Filipino children are 1.64
times likely. Additionally, children born inside the United States were
twice as likely to report having asthma as children born outside the
United States.

This study is not without limitations. The authors cite small sample
sizes of the study populations to be problematic, requiring aggregate
data of 5 years to provide limited statistical power. There is also the
potential for selection bias since the survey was administered in either
the English or Spanish language. Lastly, additional risk factors (BMI
and environmental tobacco smoke exposure) for asthma were not analyzed
due to lack of inclusion in the survey model. Despite these limitations,
the authors concluded that the results support previous assertions that
certain ethnicities including black, AI/AN, and Filipino children as
well as those born in the United States tend to have a
disproportionately higher prevalence of asthma.

**Reference:**

1.  Akinbami L; Centers for Disease Control and Prevention, National
    Center for Health Statistics. The state of childhood asthma, United
    States, 1980-2005. Adv Data. 2006;(381):1-24.

2.  Galloway JM, Goldberg BW, Alpert JS. 1999. Primary Care of Native
    American Patients: Diagnosis, Therapy, and Epidemiology. Boston:
    Butterworth-Heinemann

3.  Clark D, Gollub R, Green WF, Harvey N, Murphy SJ, Samet JM. Asthma
    in Jemez Pueblo schoolchildren. Am J Respir Crit Care Med. 1995
    May;151(5):1625-7.

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

**iCare Population Management GUI version 1.1 Released**

The Indian Health Service Office of Information Technology (OIT) and the
iCare Development team are pleased to announce the release of iCare
Population Management GUI version 1.1.

A release notice from OIT Software Quality Assurance (SQA) has been sent
to all Area CIOs/ ISCs and RPMS site managers.  Because iCare v1.1
provides the ability to display performance data from the newest version
of the RPMS Clinical Reporting System (CRS), users may need access to
this new version as soon as possible. Software installation is required
for both the RPMS server and all end-user workstations; iCare v1.0
client software will **[not]{.underline}** work with v1.1 server
software. 

The beta sites for this version of iCare were:

-   Red Lake

-   United American Indian Involvement Urban Site in Los Angeles, CA

-   Parker Indian Hospital

iCare v1.1 is available for download at
<http://www.ihs.gov/Cio/RPMS/index.cfm?module=home&option=softwarechoice>

The following end user enhancements are included: 

-   iCare will now automatically display national performance data based
    on the most recent version of RPMS Clinical Reporting System (CRS)
    loaded on your facility's server; this should be CRS 2008 (BGP
    v8.0).  That is, an iCare patch will not be required to maintain
    synchronization with new versions of CRS.

-   Individual Health Maintenance Reminders can now be displayed for an
    entire panel in the grid View, not just on an individual Patient
    Record.  The Reminders grid can be sorted, filtered and customized
    by users to display any specific reminders they want to see.

-   An Aggregated Health Maintenance Reminders view is additionally
    provided as a performance overview, similar to the Aggregated
    National Performance view.  The Aggregate view provides the percent
    of eligible patients in the panel who are overdue or on schedule for
    each reminder.

-   The Patient Record has expanded to display most Patient Care
    Component (PCC) data: Elder Care; Exams; Health Factors;
    Immunizations; Lab; Measurement; Medication; Patient Education;
    Procedures; Radiology; Skin Test.  These views are located under the
    new PCC tab; users can select display timeframes and can sort by any
    data column.

-   An existing case management function to enter PCC historical event
    data has been enabled.

-   The Referral Tab on the Patient Record displays data from the
    Referred Care Information System (RCIS).

-   The Diagnostic Tag display on the Patient Record has been expanded
    to show additional data. Including a link to the visit(s) containing
    the specific data that "qualified" the patient for the tag.

-   The Panel Definition Search options have been enhanced to include
    filters for the visit date range by minimum number of visits; past
    appointments; and Community Taxonomies.

All training for iCare is done remotely and is web based.  Specific
information about these sessions and how to register for them can be
found on the IHS iCare Website: 
<http://www.ihs.gov/CIO/ca/icare/index.asp>.

Additionally, several of these sessions have been recorded so that users
can access them at any time.  They are available to you from the WebEx
website:

<https://ihs-hhs.webex.com/mw0305l/mywebex/default.do?siteurl=ihs-hhs>.
Type *iCare* in the search bar and make your selection of which recorded
session you want to access.

IMPORTANT POINTS:

Users will not be able to access the new version of iCare unless their
workstation (client) is updated with v1.1 software.  Depending on your
facility's abilities to automate user workstation updates, Site Managers
may need to manually update software on workstations.

Site Managers are encouraged to deploy the server software on Friday
evening so that background processes can run over the weekend and be
ready for users at the beginning of the week. 

Existing iCare v1.0 panels created by and/or shared with current iCare
users **[will]{.underline}** transfer to iCare version 1.1.

For user support please contact the RPMS help desk at <RPMSHelp@ihs.gov>
or call (888) 830-7280.

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

Number range CHAPTER**Cervical cancer screening where resources are
scarce**

Every year, over a quarter million women worldwide die of cervical
cancer. Cervical cytology has made a huge impact in the wealthier parts
of the world, but cytology programs require substantial infrastructure.
If your region (or even your country) doesn't have a cytologist, or has
no reliable means of transporting Pap tests to a central location or
tracking women down to follow up positive results, cytology makes a poor
screening tool. It's not surprising, then, that today third-world women
are disproportionately affected by cervical cancer. Researchers have
been looking for simple, effective, and affordable screening tests, and
two recent studies take us a step further toward this goal.

Arbyn and colleagues report a new meta-analysis of eleven large
screening studies in India and in Francophone Africa. The studies,
sponsored by the Gates Foundation, enrolled more than 58000 women. Each
woman was screened with two or more of the following methods: VIA
(visual inspection with acetic acid); VILI (visual inspection with
Lugol\'s iodine solution); VIAM (visual inspection with acetic acid and
a magnifying loupe); Pap (standard Papanicolaou screening); or HC2 (HPV
high-risk probe of the Hybrid Capture-2 assay). No matter whether
screening was positive or negative, colposcopy was immediately done on
all women. Negative colposcopy was accepted as a negative result for
purposes of analysis. Positive colposcopy required colposcopic biopsies
which were then interpreted by a pathologist. The authors then compared
sensitivity and specificity of all of these methods for detecting
biopsy-proven CIN2 or worse -- with some surprising results.

The visual inspection methods, especially VILI, performed very well. The
authors were surprised at the poor performance of the HPV test and
speculate that samples may have deteriorated due to high temperatures at
many of the study sites.

The study has two significant weaknesses. First, colposcopy and
colposcopically directed biopsies tend to identify \-- and perhaps more
importantly, to miss \-- the same lesions as the VIA or VILI methods.
Thus its use as the \"gold standard\" in this study probably led to
overestimation of the visual methods as screening tests. (Cone biopsy or
hysterectomy specimens would be better gold standards methodologically,
but impossible to justify ethically.) Second, other studies have showed
much greater variability in the quality of visual methods for screening.
The good performance in this group probably reflects their rigorous
training. All screeners had gone through an intensive 5-day course and
had been proctored for 150-200 exams before they began enrolling
patients, which certainly represents more formal training than I had as
an obstetrician-gynecologist performing screening for cervical cancer!

In real-world situations, then, visual methods have a good (12-13%)
positive predictive value and an acceptable (well over 99%) negative
predictive value. They're affordable, quick, and easy. So what sort of
difference might a very simple visual screening program make? Another
large study shows the savings in women's lives can be substantial.
Investigators working in Tamil Nadu randomized *panchayaths* or
municipal units in one administrative district to \"standard care\" \--
meaning no cervical cancer screening \-- or an intervention in which
study nurses did a single round of VIA screening. Women who were
VIA-positive immediately had colposcopy. When colposcopy suggested
precancerous lesions (low-grade or high-grade) directed biopsies were
taken and cryotherapy or LEEP done immediately. Follow-up of the over
70,000 women in this district used an intention-to-treat model and
lasted seven years from the initiation of the study. Cervical cancer
incidence, cervical cancer mortality, and overall mortality rates were
equal between the two groups the first year of analysis, but there have
been widening gaps every year since. Despite the bolus of patients
diagnosed with cervical cancer in the intervention group at screening,
by the time of this report the intervention group demonstrated a
significant 25% reduction in cervical cancer incidence, and a 35%
reduction in cervical cancer mortality compared with the control group.

Simpler screening methods aren't perfect, but they turn out to be pretty
good. Now it's time to figure out how to get them implemented in the
poorer parts of the world.

Sankaranarayanan R et al. Effect of visual screening on cervical cancer
incidence and mortality in Tamil Nadu, India: a cluster-randomised
trial. Lancet 370:398-406, 2007

<http://www.ncbi.nlm.nih.gov/pubmed/17679017>

Arbyn M et al. Pooled analysis of the accuracy of five cervical cancer
screening tests assessed in eleven studies in Africa and India.
International Journal of Cancer 123 (1): 153-60, 2008

<http://www.ncbi.nlm.nih.gov/pubmed/18404671>

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

**Randomized Controlled Trial Investigates the Safety of Dental
Treatment in Pregnant Women**

\"In this population, periodontal treatment and EDT \[essential dental
treatment\], administered at 13 to 21 weeks\' gestation, did not
significantly increase the risk of any adverse outcome evaluated,\"
state the authors of an article published in the June 2008 issue of the
Journal of the American Dental Association. Collectively, recent
findings suggest that use of oral health services during pregnancy may
be driven more by attitudes than by economics or convenience. Attitudes
and behaviors may be influenced by fear of harm to the pregnant woman or
fetus, fear of litigation, or patient safety concerns. The article
describes safety outcomes related to the provision of oral health care
in pregnant women.

Data for the study were drawn from a multi-center randomized controlled
clinical trial (the Obstetrics and Periodontal Therapy \[OPT\] Trial)
conducted to determine whether periodontal therapy in pregnant women
reduces the risk of preterm delivery. The study sample included women
recruited from obstetrics clinics serving minority and other underserved
groups who are at an elevated risk of experiencing preterm birth. All
women had periodontitis. A total of 413 women were randomly assigned to
receive scaling and root planing at a time before 21 weeks\' gestation.

The 410 women in the control group were monitored during their pregnancy
and treated with scaling and root planing after delivery. Women in both
groups were also evaluated for EDT needs (defined as the presence of
moderate-to-severe caries or fractured or abscessed teeth). The analysis
examined associations between adverse pregnancy outcomes (spontaneous
abortion or fetal death, pregnancy ending before 37 weeks\' gestation,
fetal or congenital anomaly) and EDT, anesthetic use during nonsurgical
periodontal treatment, and combinations of EDT and periodontal
treatment.

The authors found that

-   EDT administered at 13 to 21 weeks\' gestation was not associated
    with an increased risk of experiencing serious medical adverse
    events, preterm (less than 37 weeks\' gestation) deliveries,
    spontaneous abortions or fetal deaths, or fetal anomalies.

-   Use of topical and local anesthetics for scaling and root planing
    was not associated with an increased risk of experiencing these
    adverse events and outcomes.

\"Several ongoing randomized controlled intervention trials should help
to define more precisely the risk of adverse pregnancy outcomes
associated with nonsurgical periodontal procedures, including the risk
of spontaneous abortion and stillbirth,\" state the authors.
\"Nevertheless,\" the authors conclude, \"our study provides evidence
that dental care providers can safely meet the preventive and routine
treatment needs of their pregnant patients.\"

Michalowicz BS, DiAngelis AJ, Novak MJ, et al. 2008. Examining the
safety of dental treatment in pregnant women. The Journal of the
American Dental Association 139(6):685-695. Abstract available at
[[http://jada.ada.org/cgi/content/short/139/6/685]{.underline}](http://jada.ada.org/cgi/content/short/139/6/685).

More information is available from the following MCH Library resource:

Oral Health and Pregnant Women, Infants, Children, and Adolescents at
[[http://www.mchlibrary.info/KnowledgePaths/kp_oralhealth.html]{.underline}](http://www.mchlibrary.info/KnowledgePaths/kp_oralhealth.html)

**Article Evaluates Impact of a Prenatal Substance Abuse Treatment
Program on Perinatal Outcomes**

\"Early Start\'s replicable model of integrating substance abuse
treatment with prenatal care is cost-effective and significantly
decreases negative birth outcomes as well as maternal morbidity,\" state
the authors of an article published in the June 26, 2008, issue of the
Journal of Perinatology. Substance abuse during pregnancy is a serious
problem in the United States; it results in considerable adverse effects
for women and their infants. Kaiser Early Start is a coordinated
prenatal substance abuse treatment program that is part of Kaiser
Permanente Northern California\'s (KPNC\'s) comprehensive prenatal
program. The purpose of the study described in this article was to
provide a comprehensive evaluation of the effect of Early Start on
maternal and neonatal outcomes.

The study cohort included 49,985 female KPNG members who completed Early
Start prenatal substance abuse screening questionnaires between January
1, 1999, and June 30, 2003. Fetal and neonatal outcomes analyzed
included intrauterine fetal demise (IUFD), neonatal-assisted
ventilation, low birthweight, preterm delivery, completed weeks of
gestation, neonatal intensive care unit admission, infant
re-hospitalization within 30 days of discharge from birth
hospitalization, and infant emergency department visits within 180 days
of discharge from birth hospitalization. Maternal outcomes analyzed were
Cesarean delivery, preterm labor, and placental abruption. The authors
defined four study groups. Group 1: screened, assessed positive for
substance abuse, and treated by Early Start (SAT); Group 2: screened,
assessed positive, and not treated (SA); Group 3: screened only and
identified as substance abusers (S), and Group 4: controls (C)

(women with no evidence of substance abuse during pregnancy).

The authors found that:

-   Compared with controls, SAT women had similar or higher rates on
    most risk factors (weekly/daily use of alcohol, methamphetamines,
    THC \[marijuana\], cocaine, heroin, and cigarettes both before and
    after pregnancy), but lower rates than S women. For the most part,
    the rates of SA women were between SAT and S rates.

-   In multivariate analyses, the S group had significantly worse
    outcomes than the SAT group in the following areas: preterm delivery
    (odds ratio \[OR\] = 2.1, 1-3-3.2), placental abruption (OR = 6.8,
    3.0-15.5), and IUFD (OR = 16.2, 6.0-43.8).

The authors conclude that \"The results of this study reflect the
importance of widespread implementation of this model of care as a
national standard.\"

Goler NC, Armstrong MA, Taillac CJ, et al. 2008. Substance abuse
treatment linked with prenatal visits improves perinatal outcomes: A new
standard. Journal of Perinatology \[published online ahead of print on
June 26, 2008\].
[[http://www.nature.com/jp/journal/vaop/ncurrent/abs/jp200870a.html]{.underline}](http://www.nature.com/jp/journal/vaop/ncurrent/abs/jp200870a.html).

Preconception and Pregnancy: Knowledge path at:
<http://www.mchlibrary.info/KnowledgePaths/kp_pregnancy.html>

**Annual Study Released on Women's Health Outcomes in U.S. Hospitals**

The Fifth Annual HealthGrades Women\'s Health Outcomes in American
Hospitals Study identifies outcomes for maternity care and in-hospital
treatment of cardiovascular disease (CVD) in women using data from the
period 2004-2006 in 17 states. The report provides maternal complication
rates for vaginal, clinically indicated Cesarean section (C-section),
and patient-choice (non-clinically indicated) C-section deliveries. The
report also includes neonatal mortality rates for all hospitals
evaluated. Risk-adjusted analysis of in-hospital treatment identifies
mortality rates in CVD and stroke among women. In addition, the report
identifies top-performing hospitals. The report is available at:

[[http://www.healthgrades.com/media/DMS/pdf/HealthGradesWomensHealthStudy2008.pdf]{.underline}](http://www.healthgrades.com/media/DMS/pdf/HealthGradesWomensHealthStudy2008.pdf)

**HRSA Report Studies Safety Net Health Centers**

Health Centers: America's Primary Care Safety Net describes the history
of safety net health center programs; safety net health centers\' role
in providing a medical home; the model of care used, and how connections
are sustained between primary care associations, offices, and other
partners. The report, produced by the Health Resources and Services
Administration's Bureau of Primary Health Care, also discusses the
unprecedented growth of the health center program during the period
2002-2007 and outlines issues related to the program\'s future in the
following areas: work force, health information technology, emergency
management, quality, and performance measurement. Program successes are
discussed, as well. The report is available at:

[[ftp://ftp.hrsa.gov/bphc/HRSA_HealthCenterProgramReport.pdf]{.underline}](ftp://ftp.hrsa.gov/bphc/HRSA_HealthCenterProgramReport.pdf)

**MCH Headlines Judy Thierry HQE**

## Three Maternal Risk Factors Associated with Elevated Risk of Postneonatal Mortality among Alaska Native Population

OBJECTIVE: Compared to non-Natives in Alaska, the Alaska Native
population has a postneonatal mortality rate 2.3 times higher (95% CI
1.9, 2.7). The objective of the study was to identify variables that
account for this elevated risk.

METHODS: The dataset used included birth and death certificate records
for all Alaska-resident live births and infant deaths occurring during
1992-2004. Race was defined as Alaska Native or non-Native. The
association between race and postneonatal mortality was examined using
univariate, stratified and regression analyses. Variables were
considered confounding if they resulted in a change of at least 10% in
the odds ratio between race and postneonatal mortality when added to a
bivariate model, or when removed from a multivariate model.

RESULTS: In stratified analysis, race remained associated with
postneonatal mortality within most categories of marital status,
maternal education, maternal age, prenatal tobacco or alcohol use,
prenatal care utilization, parity and residence. The odds ratio between
race and postneonatal mortality was reduced to 1.3 (95% CI 1.0, 1.6) by
controlling for education, a composite variable of marital status and
the presence of father\'s name on the birth certificate, and prenatal
tobacco or alcohol use.

CONCLUSIONS: A small number of potentially modifiable factors explain
most of the postneonatal mortality disparity between Alaska Natives and
non-Natives, leaving a relatively small increase in risk. These findings
suggest that by targeting Alaska Native women who display these
characteristics, the postneonatal mortality gap may be reduced.

Blabey MH, Gessner BD. Three Maternal Risk Factors Associated with
Elevated Risk of Postneonatal Mortality Among Alaska Native Population.
Matern Child Health J. 2008 Apr 4. \[Epub ahead of print\]
<http://www.ncbi.nlm.nih.gov/pubmed/18389352>

 

Submitted by Vanessa Hiratsuka, MPH; Tobacco Prevention and Control
Program, Section of Chronic Disease Prevention and Health Promotion
State of Alaska, Division of Public Health

 

**MCH Editorial Comment:**

Reducing the post-neonatal mortality gap by addressing a finite number
of modifiable risk factors is as relevant in 2008 as it was in 1992. As
the authors note it is well known that a variety of social and economic
factors are at play in perinatal health disparities.  By adapting
analytic techniques first used by Baker in California and a model by
Greenland, the Alaska team subjected "selected" variables (dependent
variable) to their model observing the effect on the odds ratio (OR)
between race (independent variable) and post neonatal mortality (also a
dependent variable). Similarly during a "deletion cycle" variables were
removed, the OR for race observed and then "re-entered" before another
variable was deleted and an OR observed. Criteria for confounding
variables were those who changed the OR by \< or \> 10%.  Ample tables
and a well referenced discussion support the author's hypothesis
focusing on elevated rates of alcohol and tobacco use, lower education
levels (not completing high school) and "a greater frequency of a
father's name missing on the birth certificate among unmarried mothers"
as three key variables for intervention.   

Quality assurance issues of chart data abstraction and maternal
interview during the birth registration process should be
considered. The advantage of school health as a point of care for a
segment of this vulnerable population, while not suggested, seems a
reasonable and an essential focus.  Attention to children with special
needs and special education needs falls into this category as well.
Continued services during pregnancy and postpartum for school age Alaska
Natives and basic reproductive health services for adolescents (male and
female) is an important investment.  Intimate partner tolerance for
physical and emotional abuse and risky behaviors including alcohol and
tobacco use converge in adolescence or at even younger ages, pressing
for increased mental health and social services located in their
learning environments. Tobacco cessation programs especially for low SES
women are being given more national attention. Lastly attention to
education around building healthy intimate partner relationships and
diffusing stress may be an indirect way to increasing the frequency of
entering a fathers name on a birth certificate -- just a thought.  

## What Every Parent Needs to Know About\... Inhalant Abuse

One out of every five teens in America has used inhalants to get high -
and inhalant abuse can begin at a very young age. The Partnership for a
Drug-Free America created this special section to help parents seeking
specific information, guidance and resources about inhalants.

<http://www.drugfree.org/Parent/Resources/Parents_Guide_to_Inhalants_Prevention>

## 

**Pediatric Environmental Health Toolkit Available for Download**

The Toolkit is a combination of easy-to-use reference guides for health
providers and user friendly health education materials on preventing
exposures to toxic chemicals and other substances that affect infant and
child health. The materials are visually appealing, practical and easy
to use. The Toolkit is endorsed by the American Academy of Pediatrics
(AAP).

<http://www.psr.org/site/PageServer?pagename=pediatric_toolkit>

**Preventing Alcohol, Tobacco, and Other Substance-exposed Pregnancies:
A Community Affair; A Symposium sponsored by the National Institute on
Alcohol Abuse and Alcoholism September 23-24, 2008, Rockville MD**\
A symposium to explore best approaches to getting the message out about
the potential harm caused by risky drinking and by other substance use
during the childbearing years and, in particular, the importance of
abstaining from any and all drinking and smoking during pregnancy.  This
symposium will be a starting point in a national effort to change the
common perception that the use of alcohol and tobacco during pregnancy
is safe.

<http://www.niaaa.nih.gov/NewsEvents/Conferences/Symposium9_08.htm>

#### Medical Mystery Tour Neil Murphy, Alaska Native Medical Center {#medical-mystery-tour-neil-murphy-alaska-native-medical-center .Style-Heading-4-+-Arial-14-pt-Underline}

**Fetal Heart Monitoring**

Everyone knows how to read a fetal heart rate (FHR) tracing, right?

Well let's make sure we are describing fetal heart rate (FHR) tracing
with the same terms.

1.) A complete description of a fetal heart rate (FHR) tracing requires
a qualitative and quantitative description of beat-to-beat variability

True

False

2.) According to standardized National Institute of Child Health and
Human Development (NICHD) definitions, the normal FHR range is 110-160
beats per minute

True

False

3\) According to standardized NICHD definitions, an amplitude range of
between 6 and 25 beats per minute is termed 'marked variability'

True

False

4\) Before 32 weeks, a fetal heart rate acceleration is defined as a
visually apparent increase in rate at least 10 beats per minute above
the baseline lasting between 10 seconds and 2 minutes

True

False

5\) According to standardized NICHD terminology, a variable FHR
deceleration reaches its nadir more than 30 seconds after its onset

True

False

6\) A prolonged FHR deceleration lasts between 2 and 10 minutes

True

False

7\) Fetal heart rate accelerations and moderate variability are highly
predictive of the absence of metabolic academia

True

False

For a discussion of the answers to the above questions, please tune into
the September CCC Corner.

In the meantime, if you want to learn more about the results of the
National Institute of Child Health and Human Development Research
Planning Workshop, go here

Electronic fetal heart rate monitoring: research guidelines for
interpretation. National Institute of Child Health and Human Development
Research Planning Workshop.

Am J Obstet Gynecol. 1997 Dec;177(6):1385-90.

<http://www.ncbi.nlm.nih.gov/pubmed/9423739>

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

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

#### A sample of recent free CME offerings on Medscape: {#a-sample-of-recent-free-cme-offerings-on-medscape .Style-Heading-4-+-Arial-14-pt-Underline}

NAMS Updates Guidelines on Postmenopausal Hormone Therapy 

<http://www.medscape.com/viewarticle/576970>

Postmenopausal Systemic Hormone Therapy: Reaching Consensus at Last on
Benefit and Risk <http://www.medscape.com/viewprogram/14834>

Brief Video May Help Reduce Incidence of Sexually Transmitted Infections

<http://www.medscape.com/viewarticle/576760>

Initial Diagnosis of Erosive Esophagitis: A Case Study Approach for
Primary Care

<http://www.medscape.com/viewprogram/14856>

Comprehensive Thrombosis Guidelines Published

<http://www.medscape.com/viewarticle/576895>

Dietary Fructose Consumption among US Children and Adults: The Third
National Health and Nutrition Examination Survey

<http://www.medscape.com/viewprogram/14898>

######### 

Weight-Loss Interventions Effective in Patients with Type 2 Diabetes 

[http://www.medscape.com/viewarticle/577210](http://www.medscape.com/viewarticle/577210?sssdmh=dm1.366774&src=nldne)

######### 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**

**Gallbladder Disease Risk Lower with Transdermal vs. Oral Hormone
Therapy**

OB![](media/image3.png){width="0.11458333333333333in"
height="9.375e-2in"}Abstract\
[![](media/image4.png){width="0.11458333333333333in"
height="9.375e-2in"}](http://www.bmj.com/cgi/content/full/337/jul10_2/a386#SEC1%23SEC1)Introduction\
[![](media/image4.png){width="0.11458333333333333in"
height="9.375e-2in"}](http://www.bmj.com/cgi/content/full/337/jul10_2/a386#SEC2%23SEC2)Methods\
[![](media/image4.png){width="0.11458333333333333in"
height="9.375e-2in"}](http://www.bmj.com/cgi/content/full/337/jul10_2/a386#SEC3%23SEC3)Results\
[![](media/image4.png){width="0.11388888888888889in"
height="9.236111111111112e-2in"}](http://www.bmj.com/cgi/content/full/337/jul10_2/a386#SEC4%23SEC4)Discussion\
[![](media/image4.png){width="0.11388888888888889in"
height="9.236111111111112e-2in"}](http://www.bmj.com/cgi/content/full/337/jul10_2/a386#BIBL%23BIBL)References

~~OBJOO~~OBOOOBJECTIVE: To determine whether transdermal compared with
oral use of hormone replacement therapy reduces the risk of gallbladder
disease in postmenopausal women.

DESIGN: Prospective cohort study (Million Women Study).

SETTING: Women registered with the National Health Service (NHS) in
England and Scotland.

PARTICIPANTS: 1 001 391 postmenopausal women (mean age 56) recruited
between 1996 and 2001 from NHS breast screening centres and followed by
record linkage to routinely collected NHS hospital admission data for
gallbladder disease.

MAIN OUTCOME MEASURES: Adjusted relative risk and standardised incidence
rates of hospital admission for gallbladder disease or cholecystectomy
according to use of hormone replacement therapy.

RESULTS: During follow-up 19 889 women were admitted for gallbladder
disease; 17 190 (86%) had a cholecystectomy. Compared with never users
of hormone replacement therapy, current users were more likely to be
admitted for gallbladder disease (relative risk 1.64, 95% confidence
interval 1.58 to 1.69) but risks were substantially lower with
transdermal therapy than with oral therapy (relative risk 1.17, 1.10 to
1.24 *v* 1.74, 1.68 to 1.80; heterogeneity P\<0.001). Among women using
oral therapy, equine oestrogens were associated with a slightly greater
risk of gallbladder disease than estradiol (relative risk 1.79, 1.72 to
1.87 *v* 1.62, 1.54 to 1.70; heterogeneity P\<0.001) and higher doses of
oestrogen increased the risk more than lower doses: for equine
oestrogens \>0.625 mg, 1.91 (1.78 to 2.04) *v*
![](media/image5.png){width="7.152777777777777e-2in"
height="0.10486111111111111in"}0.625 mg, 1.76 (1.68 to 1.84);
heterogeneity P=0.02; estradiol \>1 mg, 1.68 (1.59 to 1.77) *v*
![](media/image5.png){width="7.152777777777777e-2in"
height="0.10486111111111111in"}1 mg, 1.44 (1.31 to 1.59); heterogeneity
P=0.003. The risk of gallbladder disease decreased with time since
stopping therapy (trend P=0.004). Results were similar taking
cholecystectomy as the outcome. Standardised hospital admission rates
per 100 women over five years for cholecystectomy were 1.1 in never
users, 1.3 with transdermal therapy, and 2.0 with oral therapy.

CONCLUSION Gallbladder disease is common in postmenopausal women and use
of hormone replacement therapy increases the risk. Use of transdermal
therapy rather than oral therapy over a five year period could avoid one
cholecystectomy in every 140 users.

Bette Liu, Valerie Beral, Angela Balkwill, Jane Green, Siân Sweetland,
Gillian Reeves, for the Million Women Study Collaborators. Gallbladder
disease and use of transdermal versus oral hormone replacement therapy
in postmenopausal women: prospective cohort study

BMJ 2008; 337:a386
<http://www.bmj.com/cgi/content/full/337/jul10_2/a386>

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

**Midwives Corner** **Lisa Allee, CNM, 4 Corners Regional Health Center,
Red Mesa, AZ**

**Including the *Non*-rational in Midwifery**

Parratt and Fahy present a fascinating picture of the art of midwifery.
They describe how midwives can practice using embodied knowledge that
goes beyond the scientific, rational model of care and how women who are
attended by midwives who use this broader-based knowledge can in turn
tap into their own ways of knowing and the combination provides for
superior care and experiences than care based on only rational,
scientific information. Before reading this article please be sure to
notice that the word is *non*-rational and not irrational. The authors
very nicely point out that in the rational-dominated way of thinking
that clings to dichotomies, the opposite of rational is irrational and
since we have all been well initiated into the rational Western
scientific way of thinking, our minds will tend to go directly to this
dichotomy and see non-rational as irrational. Not so. The non-rational
is our embodied knowledge, our inner knowing, that we gain from our
lived experiences and other sources, which are hard to articulate.
Actually, the non-rational overall is very difficult to articulate into
language as it is felt and known in ways that defy words. However,
Parratt and Fahy do well in explaining the importance and benefits of
including the non-rational as the art of practicing midwifery. They use
the issue of safety as one example, pointing out the importance and
validity of approaching each situation as unique and drawing on both the
rational and the non-rational sources of information from both the
midwife and the women in order to respond to any situation at hand in
the best way possible. They also do a wonderful job of pointing out that
there is truly a spectrum to consider in the overall issue of
safety---that the rational-thinking-only dichotomy of safe and unsafe as
the only possibilities is not realistic or helpful. This article affirms
to us all that using our whole being and honoring each woman's whole
being in each pregnancy, labor, and birth is the essence of the art and
science of the midwifery model of care and the reason that midwifery
care is so powerful, successful, satisfying, empowering, and down right
excellent!

Please, if you cannot get to the full-text article via these links, feel
free to contact me and I will send you the article in electronic or hard
copy form---just let me know! Email: <lisa.allee@ihs.gov>

Parratt JA, Fahy KM**,** Including the nonrational is sensible
midwifery. Women Birth. 2008 Mar;21(1):37-42. Epub 2008 Feb 20

PubMed link:

<http://www.ncbi.nlm.nih.gov/pubmed/18243836>

Science Direct full article link:

<http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B82XB-4RWBWV6-1&_user=4335206&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000000150&_version=1&_urlVersion=0&_userid=4335206&md5=9c3ef62b47b6654e2a65ca2538131e18>

**Navajo News John Balintona, MD, Northern Navajo Medical Center**

**Survey of Full-Scope Navajo OB Sites**

Below is a survey of the sites in the Navajo Area that provide
full-scope obstetric services. The survey can be used as a guide for
fellow practitioners and referring sites as to the capabilities of the
various OB sites.

**[Chinle]{.underline} [FTDEF]{.underline} [GIMC]{.underline}
[Shiprock]{.underline} [TCRHCC]{.underline}**

# [Model of Care]{.underline}

## OB First Call CNM CNM CNM CNM,FM CNM

**OB Second OB OB OB OB OB**

**Call**

**Nursery Level I Level I Level II Level II Level I**

**Separate**

**Service NO NO NO YES NO**

**OB/FM/CNM**

**High Risk YES YES YES YES NO**

**Clinic**

**Diabetes Care YES NO NO YES NO**

**Team**

**In-office YES YES YES YES NO**

**U/S**

**Antenatal YES NO YES NO YES**

**Testing Unit**

**Epidural NO YES YES NO YES**

**Service**

### **[VBAC Capabilities]{.underline}**

#### 24 Hour YES YES YES YES YES

**Service**

#### Risk Individualized Individualized Individualized Individualized YES

**Stratification Counseling Counseling Counseling Counseling**

**System**

**Consent YES YES YES YES YES**

**Form**

# 

# Preterm 

**Limit**

#### Weeks EGA 36 36 35 35 32-34

# [Amniocentesis]{.underline}

#### Fetal Lung YES NO NO YES YES

**Maturity**

**Genetics NO NO NO YES YES**

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

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

**Nurses Corner Sandra Haldane, HQE**

**Screening, Brief Intervention, and Referral to Treatment (SBIRT)
Endorsed by National Emergency Nurses Association**

As described by SAMHSA, the Initiative involves implementation of a
system within community and/or medical settings---including physician
offices, hospitals, educational institutions, and mental health
centers---that screens for and identifies individuals with or at-risk
for substance use-related problems. Screening determines the severity of
substance use and identifies the appropriate level of intervention. The
system provides for brief intervention or brief treatment within the
community setting or motivates and refers those identified as needing
more extensive services than provided in the community setting to a
specialist setting for assessment, diagnosis, and appropriate treatment.

**WHY IS SBIRT SO IMPORTANT?**\
Hospitals that have implemented a SBIRT program have seen:

-   Reduced ED visit recidivism.

-   Improved patient safety in the community.

-   Decreased risk for injuries (e.g., falls, ATV, motor vehicle
    crashes).

-   Reduced risk of harm to others due to alcohol use problems (e.g.,
    domestic violence).

-   Reduced alcohol-medication adverse events.

-   Increased intervention impact on ED patients and the community.

-   Reduced health care costs.

-   Adoption of a universal screening policy makes reimbursement more
    likely because alcohol use problems are not tied to the medical
    event.

-   Estimates indicate that approximately 12% of patients will require a
    brief intervention. Almost 50% of patients will be eliminated at
    triage by the first screening question.

**WHY SHOULD I BECOME A SBIRT CHAMPION?**

-   Increased recognition as an ED nurse leader and pioneer. ENA is the
    only nursing specialty organization that has adopted SBIRT.

-   Increased recognition as a trusted professional.

-   Increased opportunity for you to provide prevention efforts in your
    ED and community.

-   Once the SBIRT technique is learned, the technique can be applied to
    other risky behaviors.

-   Increased ED staff satisfaction.

-   Increased opportunity to climb the clinical ladder.

#### Opportunity to obtain CECHs. {#opportunity-to-obtain-cechs. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### [**http://www.ena.org/ipinstitute/SBIRT/Benefits.asp**](http://www.ena.org/ipinstitute/SBIRT/Benefits.asp)  {#httpwww.ena.orgipinstitutesbirtbenefits.asp .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

# Impact of Periodic Follow-Up Testing Among Urban American Indian Women with Impaired Fasting Glucose

INTRODUCTION: Impaired fasting glucose (IFG) often progresses to type 2
diabetes. Given the severity and prevalence of this disease, primary
prevention is important. Intensive lifestyle counseling interventions
have delayed or prevented the onset of type 2 diabetes, but it is not
known whether less intensive, more easily replicable efforts can also be
effective.

METHODS: In a lifestyle intervention study designed to reduce risks for
type 2 diabetes, 200 American Indian women without diabetes, aged 18 to
40 years, were recruited from an urban community without regard to
weight or IFG and block-randomized into intervention and control groups
on the basis of fasting blood glucose (FBG). Dietary and physical
activity behaviors were reported, and clinical metabolic, fitness, and
body composition measures were taken at baseline and at periodic
follow-up through 18 months. American Indian facilitators used a
group-discussion format during the first 6 months to deliver a
culturally influenced educational intervention on healthy eating,
physical activity, social support, and goal setting. We analyzed a
subset of young American Indian women with IFG at baseline (n = 42),
selected from both the intervention and control groups.

RESULTS: Among the women with IFG, mean FBG significantly decreased from
baseline to follow-up (*P* \< .001) and converted to normal (\<5.6
mmol/L or \<100 mg/dL) in 62.0% of the 30 women who completed the
18-month follow-up, irrespective of participation in the group
educational sessions. Other improved metabolic values included
significant decreases in mean fasting blood total cholesterol and
low-density lipoprotein cholesterol levels. The women reported
significant overall mean decreases in intake of total energy, saturated
fat, total fat, total sugar, sweetened beverages, proportion of sweet
foods in the diet, and hours of TV watching.

CONCLUSION: Volunteers with IFG in this study benefited from learning
their FBG values and reporting their dietary patterns; they made dietary
changes and improved their FBG and lipid profiles. If confirmed in
larger samples, these results support periodic dietary and body
composition assessment, as well as glucose monitoring among women with
IFG.

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

#### Allen P, Thompson JL, Herman CJ, Qualls C, Helitzer DL, Whyte AN, et al. Impact of periodic follow-up testing among urban American Indian women with impaired fasting glucose. Prev Chronic Dis 2008;5(3). [**http://www.cdc.gov/pcd/issues/2008/jul/07_0078.htm**](http://www.cdc.gov/pcd/issues/2008/jul/07_0078.htm)  {#allen-p-thompson-jl-herman-cj-qualls-c-helitzer-dl-whyte-an-et-al.-impact-of-periodic-follow-up-testing-among-urban-american-indian-women-with-impaired-fasting-glucose.-prev-chronic-dis-200853.-httpwww.cdc.govpcdissues2008jul07_0078.htm .Style-Heading-4-+-Arial-14-pt-Underline}

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

####  {#section-30 .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}

**Meet Dr. George Chiarchiaro, Oklahoma MCH Coordinator**

Dr. George Chiarchiaro attended the University of California at Long
Beach and graduated from Georgetown University School of Dentistry in
1978. He spent a brief time in the private practice of dentistry and
entered the Indian Health Service in 1980. After serving four years as
dental chief, clinical director, and health systems administrator on the
Rocky Boys Reservation, Dr. Chiarchiaro transferred to Gallup Indian
Medical Center to enter a Dental Advanced General Practice Residency. In
1997 Dr. Chiarchiaro received his Master of Health Administration from
the University of Oklahoma Health Sciences Center.

George Chiarchiaro, DDS, MHA\
Consultant for Dental, Medical Imaging, and MCH\
Division of Health Care Systems\
Oklahoma City Area IHS\
Five Corporate Plaza,\
3625 NW 56th Street,\
Oklahoma City, OK 73112

Phone: (405) 951-3818\
Fax: (405) 951-3916\
Cell: (405) 204-7664

<George.Chiarchiaro@ihs.gov>

**Oklahoma MCH Coordinator Website**

<http://www.ihs.gov/MedicalPrograms/MCH/F/MCHC07.cfm>

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

**National Osteoporosis Foundation Releases New Clinical Recommendations
for Low Bone Mass and Osteoporosis Incorporating Absolute Fracture
Risk**\
The National Osteoporosis Foundation (NOF) is releasing its new
Clinician's Guide to Prevention and Treatment of Osteoporosis
representing a major breakthrough in the way healthcare providers
evaluate and treat people with low bone mass or osteoporosis and the
risk of fractures. NOF's new Clinician's Guide introduces guidelines
beyond Caucasian postmenopausal women to include African-American,
Asian, Latina and other postmenopausal women, and addresses men age 50
and older for the first time.\
\
Osteoporosis is a major public health problem that has both a medical
and economic impact in the U.S. Fractures caused by either osteoporosis
or low bone mass can lead to chronic pain, disability and even death, as
well as psychological symptoms, including depression. Each year broken
bones due to low bone mass or osteoporosis cause over 432,000 hospital
admissions, almost 2.5 million medical office visits and about 180,000
nursing home admissions.\
\
"NOF's new Clinician's Guide dramatically alters the approach to
assessing fracture risk and treatment," said Bess Dawson-Hughes, M.D.,
chair of the Clinician's Guide Development Committee and past president
of NOF. "The Guide provides evidenced-based recommendations to help
healthcare providers better identify people at high risk for developing
osteoporosis and fractures and assures that those at highest risk are
recommended for treatment to lower that risk."\
\
The new Clinician's Guide applies the recently released algorithm on
absolute fracture risk called FRAX® by the World Health Organization
(WHO). FRAX® is also referred to as a 10-year fracture risk model and
10-year fracture probability. This algorithm estimates the likelihood of
a person to break a bone due to low bone mass or osteoporosis over a
period of 10 years.\
\
Absolute fracture risk methodology provides a markedly improved method
to assure that people with the highest fracture risk get treated. Those
at highest risk include postmenopausal women and older men with a
diagnosis of osteoporosis, based on a BMD test T-score of -2.5 or lower,
or those with a clinical diagnosis based on having sustained a hip or
spine fracture. In addition, absolute fracture risk calculations help to
resolve many of the questions about management for people with low bone
mass, also called osteopenia. These are people with a T-score between
-1.0 and -2.5 on their bone mineral density (BMD) test.\
\
The WHO algorithm takes into account not only bone mineral density (BMD)
at the hip but also nine specific clinical risk factors for osteoporosis
and related fractures. NOF has adapted this algorithm for the U.S. and
incorporates not only fracture outcome and mortality data from U.S.
women and men, but also cost effectiveness analysis to determine when it
is cost effective to treat a person with an osteoporosis medication to
prevent a fracture.\
\
"In developing the new Clinician's Guide, NOF is providing healthcare
professionals in the U.S. with the newest advances for diagnosing and
managing osteoporosis," said Ethel Siris, M.D., president of the
National Osteoporosis Foundation. "To be able to better identify and
treat those patients at risk for osteoporosis and costly fractures will
have a positive impact on the medical, emotional and economic burden
that osteoporosis bears on this country."\
\
In the near future, some central DXA (dual-energy x-ray absorptiometry)
machines that test the bone mineral density of the hip and spine should
be able to provide a report that gives information on a person's
absolute fracture risk by incorporating the NOF application of the WHO
algorithm into the bone density machine's computer. Alternatively,
clinicians can also enter a patient's bone mineral density hip T-score
and other risk factor information in a simple web-based version of the
algorithm in the doctor's office to obtain absolute fracture risk in
seconds. The information about absolute fracture risk will help both
healthcare providers and patients decide whether treatment with an
osteoporosis medication is needed.\
\
The new Clinician's Guide also provides recommendations for clinicians
on when to do bone mineral density testing, clinical evaluation, risk
factors for falls and universal recommendations for the prevention of
osteoporosis. NOF summarizes the universal recommendations in its 5
Steps to Bone Health. These 5 Steps advise people to:\
1. Get the daily recommended amounts of calcium and vitamin D.\
2. Engage in regular weight-bearing and muscle-strengthening exercise.\
3. Avoid smoking and excessive alcohol.\
4. Talk to your healthcare provider about bone health.\
5. Have a bone density test and take medication when appropriate.\
\
The new Clinician's Guide recommends that adults over age 50 get 1,200
mg of calcium and 800-1,000 IU of vitamin D3 daily. Vitamin D3 is the
form of vitamin D that best supports bone health. It is also called
cholecalciferol.\
\
The Clinician's Guide was developed by an expert committee of NOF in
collaboration with a multi-specialty council of medical experts in the
field of bone health convened by NOF. The Clinician's Guide provides
recommendations that are intended to serve as a reference for clinical
decision making with individual patients. The recommendations are not
intended to be rigid standards, limits or rules and should not be
interpreted as quality standards. Earlier versions of the updated
Clinician's Guide to Prevention and Treatment of Osteoporosis were
called the Physician's Guide to Prevention and Treatment of
Osteoporosis.\
\
Established in 1984, the National Osteoporosis Foundation is the
nation's leading voluntary health organization solely dedicated to
osteoporosis and bone health. Our mission is to prevent osteoporosis, to
promote lifelong bone health, to help improve the lives of those
affected by osteoporosis and related fractures, and to find a cure. For
more information on osteoporosis and bone health, contact NOF online at
www.nof.org or by telephone (800) 223-9994.

View the guidelines online at:
<http://www.nof.org/professionals/Clinicians_Guide.htm>

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

#### New Tables for Patient Education; The Risk of Death by Age, Sex, and Smoking Status in the United States: Putting Health Risks in Context {#new-tables-for-patient-education-the-risk-of-death-by-age-sex-and-smoking-status-in-the-united-states-putting-health-risks-in-context .Style-Heading-4-+-Arial-14-pt-Underline}

BACKGROUND: To make sense of the disease risks they face, people need
basic facts about the magnitude of a particular risk and how one risk
compares with other risks. Unfortunately, this fundamental information
is not readily available to patients or physicians. We created simple
one-page charts that present the 10-year chance of dying from various
causes according to age, sex, and smoking status. Methods We used the
National Center for Health Statistics Multiple Cause of Death Public Use
File for 2004 and data from the 2004 US Census to calculate age- and
sex-specific death rates for various causes of death. We then combined
data on smoking prevalence (from the National Health Interview Survey)
and the relative risks of death from various causes for smokers vs.
never smokers (from the American Cancer Society\'s Cancer Prevention
Study-II) to determine age-, sex-, and smoking-specific death rates.
Finally, we accumulated these risks for various starting ages in a
series of 10-year life tables. The charts present the 10-year risks of
dying from heart disease; stroke; lung, colon, breast, cervical,
ovarian, and prostate cancer; pneumonia; influenza; AIDS; chronic
obstructive pulmonary disease; accidents; and all causes. Results At all
ages, the 10-year risk of death from all causes combined is higher for
men than women. The effect of smoking on the chance of dying is similar
to the effect of adding 5 to 10 years of age: for example, a 55-year-old
man who smokes has about the same 10-year risk of death from all causes
as a 65-year-old man who never smoked (i.e., 178 vs. 176 of 1000 men,
respectively). For men who never smoked, heart disease death represents
the single largest cause of death from age 50 on and the chance of dying
from heart disease exceeds the chances of dying from lung, colon, and
prostate cancers combined at every age. For men who currently smoke, the
chance of dying from lung cancer is of the same order of magnitude as
the chance dying from heart disease and after age 50 it is about 10
times greater than the chance of dying from prostate or colon cancer.
For women who have never smoked, the magnitudes of the 10-year risks of
death from breast cancer and heart disease are similar until age 60;
from this age on, heart disease represents the single largest cause of
death. For women who currently smoke, the chance of dying from heart
disease or lung cancer exceeds the chance of dying from breast cancer
from age 40 on (and does so by at least a factor of 5 after age 55).

CONCLUSION: The availability of simple charts with consistent data
presentations of important causes of death may facilitate discussion
about disease risk between physicians and their patients and help
highlight the dangers of smoking.

Woloshin S, Schwartz LM, Welch HG. The Risk of Death by Age, Sex, and
Smoking Status in the United States: Putting Health Risks in Context. J
Natl Cancer Inst. 2008 Jun 18;100(12):845-53. Epub 2008 Jun 10.
<http://www.ncbi.nlm.nih.gov/pubmed/18544745>

Abstract also available at:
<http://jnci.oxfordjournals.org/cgi/content/abstract/100/12/845>

#### Editorial: Michael J. Thun, Lindsay M. Hannan, Michael Stefanek. Risky Business: Tools to Improve Risk Communication in a Doctor's Office. J Natl Cancer Inst. 2008 Jun 18;100(12):830-1. Epub 2008 Jun 10. [**http://www.ncbi.nlm.nih.gov/pubmed/18544738**](http://www.ncbi.nlm.nih.gov/pubmed/18544738)  {#editorial-michael-j.-thun-lindsay-m.-hannan-michael-stefanek.-risky-business-tools-to-improve-risk-communication-in-a-doctors-office.-j-natl-cancer-inst.-2008-jun-1810012830-1.-epub-2008-jun-10.-httpwww.ncbi.nlm.nih.govpubmed18544738 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Free full text: [**http://jnci.oxfordjournals.org/cgi/reprint/100/12/830**](http://jnci.oxfordjournals.org/cgi/reprint/100/12/830)  {#free-full-text-httpjnci.oxfordjournals.orgcgireprint10012830 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Perinatology Picks  {#perinatology-picks .Style-Heading-4-+-Arial-14-pt-Underline}

**Protein/Creatinine ratio in preeclampsia: a systematic review**\
OBJECTIVE: To estimate the accuracy of the protein/creatinine ratio in
predicting 300 mg of protein in 24-hour urine collection in pregnant
patients with suspected preeclampsia.

DATA SOURCES: Articles were identified through electronic databases
(MEDLINE, CINHAL, and Cochrane) using the terms \"preeclampsia,\"
\"protein/creatinine ratio,\" and \"diagnosis,\" during the period
January 1966 to October 2007. The relevant citations were hand searched.

METHODS OF STUDY SELECTION: Included studies evaluated patients for
suspected preeclampsia with a 24-hour urine sample and a
protein/creatinine ratio. Only English-language articles were included.
Studies including patients with only chronic illness such as chronic
hypertension, diabetes mellitus, or renal impairment were excluded.
Using the Quality Assessment of Diagnostic Accuracy Studies
questionnaire, we created group 1 satisfying all the required criteria
and group 2 not satisfying all of it. Two researchers independently
extracted the accuracy data. A graph comparing six receiver operating
characteristic curves was plotted.

TABULATION, INTEGRATION, AND RESULTS: Twenty-one studies were
identified, but only seven met our inclusion criteria (1,717 total
patients). Group 1, with three studies, had 510 patients. The studies
evaluated different cut points for positivity of protein/creatinine
ratio from 130 mg/g to 700 mg/g. For protein/creatinine ratio 130-150
mg/g, sensitivity ranged from 90-99%, and specificity ranged from
33-65%; for protein/creatinine ratio 300 mg/g, sensitivity ranged from
81-98% and specificity ranged from 52-99%; for protein/creatinine ratio
600-700 mg/g, sensitivity ranged from 85-87%, and specificity ranged
from 96-97%.

CONCLUSION: Random protein/creatinine ratio determinations are helpful
primarily when they are below 130-150 mg/g, in that 300 mg or more
proteinuria is unlikely below this threshold. Midrange
protein/creatinine ratio (300 mg/g) has poor sensitivity and
specificity, requiring a full 24-hour urine for accurate results. Higher
thresholds have not been adequately studied.

Papanna R, Mann LK, Kouides RW, Glantz JC. Protein/Creatinine ratio in
preeclampsia: a systematic review. Obstet Gynecol. 2008
Jul;112(1):135-44. <http://www.ncbi.nlm.nih.gov/pubmed/18591319>

**Delivery mode and severe intraventricular hemorrhage in single, very
low birth weight, vertex infants**\
OBJECTIVE: To investigate the association between delivery mode and
grade 3-4 intraventricular hemorrhage in singleton, vertex presenting,
very low birth weight (VLBW) (1,500 g or less) liveborn infants.

METHODS: The Israel National VLBW Infant Database includes perinatal and
neonatal data on greater than 99% of all VLBW newborns. A total of 4,658
singleton vertex-presenting infants born at 24-34 weeks were included
(1995-2004). Infants with lethal congenital malformations, delivery room
deaths, and home deliveries were excluded. Our population-based
observational study evaluated the effect of delivery mode and
confounding variables on severe intraventricular hemorrhage using
univariable and multivariable logistic regression analyses.

RESULTS: The rate of severe intraventricular hemorrhage was 10.4%.
Cesarean delivery rate was 54.3%. The rate of severe intraventricular
hemorrhage was 7.7% for infants delivered by cesarean compared with
13.6% in vaginal delivery (P\<.001). However, analysis according to
gestational age showed that the rate of severe intraventricular
hemorrhage was similar in cesarean and vaginal delivery in all
gestational age groups. In the multivariable model, cesarean delivery
had no effect on the odds for severe intraventricular hemorrhage (odds
ratio \[OR\] 0.98, 95% confidence interval \[CI\] 0.77-1.24). Other
factors independently associated with severe intraventricular hemorrhage
included gestational age (OR 0.71, 95% CI 0.68-0.75 for each week
increase), maternal hypertensive disorder (OR 0.43, 95% CI 0.30-0.61),
no antenatal steroids (OR 2.70, 95% CI 2.12-3.45), 1-minute Apgar score
0-3 (OR 1.72, 95% CI 1.33-2.21), delivery room resuscitation (OR 2.16,
95% CI 1.65-2.83), and non-Jewish ethnicity (OR 1.28, 95% CI 1.03-1.59).

CONCLUSION: In this population-based study, the odds for severe
intraventricular hemorrhage were not influenced by mode of delivery in
vertex-presenting singleton VLBW infants after controlling for
gestational age. LEVEL OF EVIDENCE: II.

#### Riskin A, Riskin-Mashiah S, Bader D, Kugelman A, Lerner-Geva L, Boyko V, Reichman B. Delivery mode and severe intraventricular hemorrhage in single, very low birth weight, vertex infants. Obstet Gynecol. 2008 Jul;112(1):21-8. [**http://www.ncbi.nlm.nih.gov/pubmed/18591303**](http://www.ncbi.nlm.nih.gov/pubmed/18591303)  {#riskin-a-riskin-mashiah-s-bader-d-kugelman-a-lerner-geva-l-boyko-v-reichman-b.-delivery-mode-and-severe-intraventricular-hemorrhage-in-single-very-low-birth-weight-vertex-infants.-obstet-gynecol.-2008-jul112121-8.-httpwww.ncbi.nlm.nih.govpubmed18591303 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Signal ambiguity resulting in unexpected outcome with external fetal heart rate monitoring  {#signal-ambiguity-resulting-in-unexpected-outcome-with-external-fetal-heart-rate-monitoring .Style-Heading-4-+-Arial-14-pt-Underline}

We report cases of unexpected adverse fetal outcome from monitored
labors in which the fetal heart rate tracing was interpreted as
reassuring. In these cases, portions from another signal source, usually
maternal, were imperceptibly substituted into the fetal tracing in a way
that masked the evidence of fetal compromise.

Neilson DR Jr, Freeman RK, Mangan S. Signal ambiguity resulting in
unexpected outcome with external fetal heart rate monitoring. Am J
Obstet Gynecol. 2008 Jun;198(6):717-24. Epub 2008 Apr 2.
<http://www.ncbi.nlm.nih.gov/pubmed/18377859>

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

#### CCC Editorial Comment: This article is well-illustrated with images of tracings where the maternal heart rate (or that of the other twin) was displayed in lieu of targeted fetal heart rate tracing in labor. This is a rare problem but one for which maternity care providers must maintain vigilance. The use of a fetal scalp electrode should reveal the actual fetal heart rate. {#ccc-editorial-comment-this-article-is-well-illustrated-with-images-of-tracings-where-the-maternal-heart-rate-or-that-of-the-other-twin-was-displayed-in-lieu-of-targeted-fetal-heart-rate-tracing-in-labor.-this-is-a-rare-problem-but-one-for-which-maternity-care-providers-must-maintain-vigilance.-the-use-of-a-fetal-scalp-electrode-should-reveal-the-actual-fetal-heart-rate. .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Fetomaternal hemorrhage during external cephalic version**\
OBJECTIVE: To estimate the frequency and volume of fetomaternal
hemorrhage during external cephalic version for term breech singleton
fetuses and to identify risk factors involved with this complication.

METHODS: A prospective observational study was performed including all
patients undergoing a trial of external cephalic version for a breech
presentation of at least 36 weeks of gestation between 1987 and 2001 in
our center. A search for fetal erythrocytes using the standard
Kleihauer-Betke test was obtained before and after each external
cephalic version. The frequency and volume of fetomaternal hemorrhage
were calculated. Putative risk factors for fetomaternal hemorrhage were
evaluated by chi(2) test and Mann-Whitney U test.

RESULTS: A Kleihauer-Betke test result was available before and after
1,311 trials of external cephalic version. The Kleihauer-Betke test was
positive in 67 (5.1%) before the procedure. Of the 1,244 women with a
negative Kleihauer-Betke test before external cephalic version, 30
(2.4%) had a positive Kleihauer-Betke test after the procedure. Ten
(0.8%) had an estimated fetomaternal hemorrhage greater than 1 mL, and
one (0.08%) had an estimated fetomaternal hemorrhage greater than 30 mL.
The risk of fetomaternal hemorrhage was not influenced by parity,
gestational age, body mass index, number of attempts at version,
placental location, or amniotic fluid index.

CONCLUSION: The risk of detectable fetomaternal hemorrhage during
external cephalic version was 2.4%, with fetomaternal hemorrhage more
than 30 mL in less than 0.1% of cases. These data suggest that the
performance of a Kleihauer-Betke test is unwarranted in uneventful
external cephalic version and that in Rh-negative women, no further Rh
immune globulin is necessary other than the routine 300-microgram dose
at 28 weeks of gestation and postpartum. LEVEL OF EVIDENCE: II.

Boucher M, Marquette GP, Varin J, Champagne J, Bujold E. Fetomaternal
hemorrhage during external cephalic version. Obstet Gynecol. 2008
Jul;112(1):79-84.

#### [**http://www.ncbi.nlm.nih.gov/pubmed/18591311**](http://www.ncbi.nlm.nih.gov/pubmed/18591311)  {#httpwww.ncbi.nlm.nih.govpubmed18591311 .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

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

### How to subscribe / unsubscribe to the Primary Care Discussion Forum?

Subscribe to the Primary Care listserv

<http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=51>

Unsubscribe from the Primary Care listserv

<http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=51>

Questions on how to subscribe, contact <ANNBULL@nc-cherokee.com>
directly.

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

**Frequency of Adolescent Self-Cutting As a Predictor of HIV Risk**

OBJECTIVE: A wide range exists in the frequency of adolescent
self-cutting behavior; however, the implications of this variability are
relatively unexplored. Although evidence suggesting a relationship
between self-harm and sexual risk behaviors has been identified, little
is known regarding the relationship between frequency of self-cutting
and sexual risk. The present study aimed to test the hypothesis that
adolescents who repeatedly self-cut would report more HIV risk behaviors
and riskier attitudes than those who had engaged in infrequent
self-injury.

METHOD: Adolescents (11-18 years; mean age, 15 years) from intensive
psychiatric treatment programs with a history of self-cutting (N = 105,
53% female) completed measures of self-cutting, sexual risk behaviors,
and risk attitudes.

RESULTS: Frequent self-cutting (more than three times, lifetime) was
associated with being sexually active, using condoms inconsistently, and
sharing cutting instruments. Frequent self-cutters were significantly
more likely to be female and nonwhite, and report low self-restraint.
They also showed a trend toward being more likely to have a history of
sexual abuse. CONCLUSIONS: This study found important differences in
self-cutters based on frequency of cutting. Adolescent self-cutting may
be a spectrum of behavior that ranges from habitual, repeated behavior
contrasted with infrequent, experimental, socially motivated cutting.
The associations between frequent cutting, sexual risk, and low
self-restraint suggest that common underlying mechanisms may determine
these patterns.

Brown LK, Houck CD, Grossman CI, Lescano CM, Frenkel JL. Frequency of
Adolescent Self-Cutting As a Predictor of HIV Risk. J Dev Behav Pediatr.
2008 May 23. \[Epub ahead of print\]

<http://www.ncbi.nlm.nih.gov/pubmed/18520618>

 

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

#### Why young adults hold the key to assessing the obesity epidemic in children {#why-young-adults-hold-the-key-to-assessing-the-obesity-epidemic-in-children-1 .Style-Heading-4-+-Arial-14-pt-Underline}

Despite significant increases in prevalence rates of childhood obesity
in the United States during the past 2 decades, rates of type 2 diabetes
mellitus among children at the population level have not followed a
similar trajectory as those in adults. In this review, hypotheses for
the contrasting findings in children compared with adults are explored,
as are possible links between the trends in childhood obesity rates and
increases in type 2 diabetes among young adults in the United States.
This review concludes with observations about the profound policy
implications from current patterns of type 2 diabetes among youth and
particularly young adults and a proposed research agenda regarding
childhood obesity and type 2 diabetes risk over the life course.

## 

## Lee JM. Why young adults hold the key to assessing the obesity epidemic in children. **Arch Pediatr Adolesc Med. 2008 Jul;162(7):682-7.** [**http://www.ncbi.nlm.nih.gov/pubmed/18606940**](http://www.ncbi.nlm.nih.gov/pubmed/18606940) 

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

####  {#section-40 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Women's Health Headlines Carolyn Aoyama, HQE {#womens-health-headlines-carolyn-aoyama-hqe .Style-Heading-4-+-Arial-14-pt-Underline}

**New Research Indicates That Significant Numbers Of Children As Young
As 11 Are Engaging In Sexual Activity And That Dating Violence And Abuse
Are Part Of Their Relationships**

A new survey reports today that a surprising number of young adolescents
are experiencing significant levels of dating violence and abuse. One in
five children between the ages of 13 and 14 (20%) say their friends are
victims of dating violence and nearly half of all tweens in
relationships say they know friends who are verbally abused. Alarmingly,
40% of the youngest tweens, those between the ages of 11 and 12, report
that their friends are victims of verbal abuse in relationships and
nearly 1 in 10 (9%) say their friends have had sex.

Liz Claiborne Inc. and loveisrespect.org, National Teen Dating Abuse
Helpline, commissioned the survey on Tween and Teen dating relationships
that was conducted by Teenage Research Unlimited (TRU) to explore how
relationships among young adolescents are fueling high levels of dating
violence and abuse.

This very interesting study of "tween" dating violence and abuse
highlights the need to start DV/SA screening at around age 11.  View the
results of the study at:

[http://www.loveisnotabuse.com/pdf/Tween%20and%20Teen%20Dating%20Abuse%20Survey.pdf](http://www.loveisnotabuse.com/pdf/Tween and Teen Dating Abuse Survey.pdf)

The "Love is Not Abuse" website can be found at:
<http://www.loveisnotabuse.com/>

**Family Violence Prevention Fund; National Conference on Health and
Domestic Violence**

**New Orleans, Louisiana; October 8-10, 2009**

The Family Violence Prevention Fund's Fifth National Conference on
Health and Domestic Violence will be held October 8-10, 2009 at the
Sheraton New Orleans Hotel. The National Conference provides valuable
professional education on the latest research and innovative health
prevention and clinical responses to domestic violence. Co-chaired by 35
organizations, including the American Medical Association (AMA), the
American Academy of Nursing (ANA), and the National Network to End
Domestic Violence (NNEDV), the gathering has been hailed as "the best
violence related conference" in the country and is expected to draw more
than 1,000 participants from around the world.

Specialized half and full-day pre-conference institutes will be held on
October 8th followed by the two-day conference, October 9-10, 2009.  The
Conference includes an exhibit hall for vendors.

For more information, contact Anna Marjavi at <anna@endabuse.org>, phone
(415) 252-8900 or visit
[http://www.endabuse.org/health/conference/](http://ent.groundspring.org/EmailNow/pub.php?module=URLTracker&cmd=track&j=215598777&u=2223430).

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

**Sexual Assault Nurse Examiner/Forensic Examiner (SANE/SAFE) Training
Course**

-   August 18-22, 2008

-   Oklahoma City, Oklahoma

-   40 hour didactic portion of SANE/SAFE training

-   For additional information contact Lisa Palucci,
    <lisa.palucci@ihs.gov>, at the IHS Clinical Support Center

**Postgraduate Course on Obstetric, Neonatal and Gynecologic Care**

-   September 14-18, 2008

-   Salt Lake City, Utah

-   Comprehensive Women's Health Update for Nurses, Advanced Practice
    Nurses, and Physicians

-   NRP offered as pre-conference session

-   Contact Yvonne Malloy, <ymalloy@acog.org>, for more information

**2008 Indian Health Information Management Conference, "Managing Health
Information Technology to Improve Performance and Outcomes"**

-   December 15 -- 19, 2008; Phoenix, Arizona

#### Information at: [[http://www.ihs.gov/cio/ihimc/]{.underline}](http://www.ihs.gov/cio/ihimc/) {#information-at-httpwww.ihs.govcioihimc .Style-Heading-4-+-Arial-14-pt-Underline}

>  

**First International Meeting on Indigenous Women's Health/Third
International Meeting on Indigenous Child Health Conference; Many Voices
into One Song**

-   Women's Health March 4-6, 2009

-   Child Health March 6-8, 2009

-   Albuquerque, NM

-   Joint conference of Women's Health and Children's Health Providers
    from Canada and the United States

# What's new on the ITU MCH web pages? {#whats-new-on-the-itu-mch-web-pages-1 .Style-Style-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5...1}

[**About Todd Baughman, Deputy CCC, Physician
Assistants**](http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-pas3.asp)

<http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-pas3.asp>

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/index.cfm>

# Did you miss something in the last Chief Clinical Consultant Corner? {#did-you-miss-something-in-the-last-chief-clinical-consultant-corner .Style-Style-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5...1}

**The July 2008 CCC Corner is available at:\
<http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=7_08ft>**

#### Abstract of the Month {#abstract-of-the-month-2 .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Does a PICC line facilitate treatment of hyperemesis gravidarum? {#does-a-picc-line-facilitate-treatment-of-hyperemesis-gravidarum .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### From your colleagues {#from-your-colleagues-2 .Style-Heading-4-+-Arial-14-pt-Underline}

Scott Giberson

-IHS HIV Program and the Native Capacity Building Assistance Network
sign MOU

-Grant opportunities

Steve Holve

-3rd International Meeting on Indigenous Child Health: Many Voices into
One Song

Elaine Locke and Yvonne Malloy

-ACOG Committee on American Indian Affairs

-Haffner Native Women's Health Award

**-** ACOG/IHS Postgraduate Course on Obstetric, Neonatal and
Gynecologic Care

September 14-18, 2008; Salt Lake City, Utah

#### Hot Topics {#hot-topics-2 .Style-Heading-4-+-Arial-14-pt-Underline}

##### Obstetrics

-Prophylactic antibiotics improve outcomes with 3^rd^ and 4^th^ degree
repair

-Episiotomy increases obstetric laceration risk with subsequent
pregnancies

-Maternal Obesity associated with increased risk of neural tube defects

-Diagnostic accuracy of urinary spot protein:creatinine ratio

## -Cochrane Review: Dietary advice in pregnancy for preventing gestational diabetes mellitus.

**Gynecology**

\- No increased risk with Misoprostol for early pregnancy failure
despite previous uterine surgery

\- Cessation of douching may decrease incidence of bacterial vaginosis

\- Green Tea Extract for treatment of external anogenital warts

\- Only 1 in 10 EDs provide comprehensive medical care for victims of
sexual assault

\- Women with epilepsy often at risk for unintended pregnancy

**Child Health**

-Hypothermia therapy after traumatic brain injury in children not
helpful

## -Obesity and type 2 diabetes risk in midadult life: the role of childhood adversity

-Nearly 1 in 10 Girls Engages in Frequent Binge Eating or Purging

-Irregular menses linked to vomiting

-Ocular Trauma Due to a Water-Bottle Cap

**Chronic Illness and Disease**

-Intensive Glucose Control Does Not Prevent Major Cardiovascular Events
in Type 2 Diabetes

-A collaborative approach to diabetes care in community health centers
can improve care

-Patient factors account for most of the variance in blood sugar levels
among adults with diabetes

-Antidepressants and therapy may be cost-effective for patients with
unexplained symptoms

-Light and Melatonin May Reduce Dementia Symptoms

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

American College of Obstetricians and Gynecologists

\- Medical Management of Ectopic Pregnancy

\- Ethical Issues in Genetic Testing

\- Direct-to-Consumer Marketing of Genetic Testing

\- Professional Liability and Gynecology-Only Practice

\- New interactive site for clinicians serving women with disabilities

##### American Family Physician

\- Food Allergies: Detection and Management

**Agency for Healthcare Research and Quality**

-"Real Men Wear Gowns"

**Ask a Librarian**

\- Health education materials available online in a variety of languages

**Behavioral Health Insights**

\- Chronic Pain Management 101 -- Saying No to Patients

**Breastfeeding**

\- A new look at what works to support breastfeeding in hospitals

\- Recall of Mommy's Bliss Nipple Cream

**CCC Corner Digest**

-Did you miss something? A link to last month's issue

**Domestic Violence**

\- WHO study links domestic violence and poor health; DV an urgent
global health priority

**Elder Care News**

\- Several factors can quickly identify mortality risk among frail
elderly persons

###################### -Living wills should be updated as preferences for change with health status {#living-wills-should-be-updated-as-preferences-for-change-with-health-status .unnumbered}

**Family Planning**

## -Injectable contraception: what should the longest interval be for reinjections?

## -Depo Now: preventing unintended pregnancies among adolescents and young adults

**Featured Website**

\- IHS Head Start Oral Health Resources

**Frequently asked questions**

\- Progesterone for the Prevention of Recurrent Spontaneous Preterm
Birth

**Indian Child Health Notes**

-Cardiovascular Evaluation and Monitoring of Children and Adolescents
with Heart Disease Receiving Medications for ADHD

-Teens and Vaccines; How are we doing?

-Pertussis-Associated Hospitalizations in American Indian and Alaska
Native Infants

**Information Technology**

-New RPMS Scheduling Package Released

-PCC+ v2.6 (Well Child Module) Released

International Health

-New evidence on lead's long-term effects

#### MCH Alert

-AAP Releases Statement on Strategies to Improve Adolescent Health Care

-Report Presents Findings from the 2007 National Youth Risk Behavior
Survey

-Panel Reviews National Study on Environmental and Genetic Effects on
Health in Children\
-Bright Futures for Women's Health and Wellness Releases new Tools on
Emotional Health

#### MCH Headlines

-Bright Futures Web Site Updated

-Resources and Guidance for Fatherhood Programs (10 Promising Practices)

-Now Available: Baby Oral Health Program

-Child Maltreatment Institute: Enhancing Leadership for Child
Maltreatment Prevention

#### Medical Mystery Tour

-A diabetic patient who is finally losing weight

#### Medscape

#### - A sample of recent free CME offerings and other resources on Medscape: {#a-sample-of-recent-free-cme-offerings-and-other-resources-on-medscape .Style-Heading-4-+-Arial-14-pt-Underline}

**Menopause Management**

\- Low-Dose Estradiol Spray to Treat Vasomotor Symptoms

**Midwives Corner**

-Centering Pregnancy Training

**Navajo News**

-Forty one (41) Indian Health Care Providers complete SANE/SAFE course
in Window Rock

**Nurses Corner**

-What Is Forensic Nursing?

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

-Development of ACIP Recommendations for Vaccination during Pregnancy
and Breastfeeding

-Healthy Eating Index (HEI) Scores among Adults, 60 Years of Age and
Over

-HIV/AIDS Surveillance Slide Sets

**Oklahoma Perspective**

-ACOG Committee on Indian Affairs Site Visit

Osteoporosis

\- New evidence that Calcium supplementation may work, at least while
you take them...

Patient Education

-New offerings from the AAFP

Perinatology Picks

-Longer PROM associated with more infections

-Cesarean Delivery does not improve outcome in very low birthweight
vertex fetuses

-Clostridium difficile-associated diarrhea: an emerging threat to
pregnant women

-Mycophenolate mofetil (MMF) may be linked to congenital anomalies

Primary Care Discussion Forum

-New Topic coming soon

STD Corner

## -Chlamydia Positivity in American Indian/Alaska Native Women Screened in Family Planning Clinics, 1997-2004

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

\- Stretching exercises may reduce risk of pre-eclampsia during
pregnancy

**Women's Health Headlines**

**The past CCC Corners are archived at:**

<http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN02.cfm>

The CCC Corner is good way to inform ITU providers about recent updates,
while decreasing the number of e-mail messages.

Let me know if you want to add something to next month's CCC Corner at
<jean.howe@ihs.gov>

or 928-674-7422 (with voicemail).

\*The opinions expressed in the CCC Corner are strictly those of the
authors, and not necessarily those of the Indian Health System, or the
author of this newsletter.

7/29/08njmb