**News Flash: Last meeting of its kind till 2007**

**2004 American Native Women's Health and Maternity Care**

August 4-6, 2004, Albuquerque, New Mexico See 'Save the Dates' below

Great CEU /CME, plus networking for leaders of care of Native women /
MCH

Internationally known faculty, over 35 in all

[Theme:]{.underline} Prevention in Native Women, plus Tracks on DV and
Breastfeeding, and several Adolescent topics

[Target audience]{.underline}: leaders and opinion leaders - Primary
Care, Family Physicians, Nurses, Advance Practice Nurses, Midwives,
Physician Assistants, OB/GYNs, Pediatricians, and others

OB/GYN Chief Clinical Consultant's Corner

Volume 2, No. 6, June 2004

**[Contents:]{.underline}**

**[Abstract(s) of the Month]{.underline}: page 3**

1.) Improving competency in the management of shoulder dystocia with
simulation training

2.) Middle-aged women, regardless of ovarian function, experienced
greater sleep disturbance than do younger controls

[From your colleagues:]{.underline} page 4

From Frank Anderson: Sudden death was the presenting scenario in 75% of
ectopic deaths

**From Donna Brown:** Tobacco use: 1 / 10 deaths worldwide and 5 million
deaths / yr

From Tom Burke: Practical abnormal pap smear and colposcopy guidelines
for both the non-colposcopist and colposcopist

**From Sandra Cook:** Is membrane stripping associated with abruption
placenta?

**From Terry Cullen:** Intimate Partner Violence: Funding available to
Indian Health sites

**From Barbara Fine:** Let me know about your PHN program or individual
PHNs success(s) or achievements; Hearts N' Parks Program: Helps all ages
adopt heart health behaviors

**From Sandra Haldane:** NANAINA Summit 2004; CHILD Profile Statewide
Conference(s)

**From Yolanda Meza:** Centering or group prenatal visits: Exciting
prenatal management program

**From Chuck North:** Making Evidence-base Medicine Doable in Everyday
Practice; Understanding the Risks of Medical Interventions;
Evidence-based Obstetrics & Gynecology  

**From Richard Olson**: American Indian & Alaska Native Health Care
Needs: Papers sought\
**From Judy Thierry:** Helping Pregnant Women Quit Smoking: Progress and
Directions; Interested in SIDS / IMR? Consider attending this....
Prenatal classes : What are you doing?

**[Hot Topics:]{.underline}**

**Obstetrics:** **page 7**

New Perinatology Corner Module available: Syphilis in Pregnancy; Glucose
challenge thresholds \> than 180 mg/dL are NOT DIAGNOSTIC for GDM:
Predictive value for GDM only 50%; Noninvasive Prenatal Testing Cuts
Amniocentesis Use; Vitamin C Reduces Risk of Gestational Diabetes; Oral
Misoprostol an Inexpensive Alternative for Induction of Labor; Physician
characteristics are a major determinant of cesarean delivery; Closure of
subcutaneous fat during cesarean delivery decreases wound disruption;
Fetal Alcohol Syndrome \-\-- Alaska, Arizona, and Colorado; Cervical
cerclage shown not to reduce preterm delivery; Genetic variation linked
to gestational diabetes; 12 suggestions for practice for all personnel
in an obstetric--neonatal unit

**Gynecology:** **page 11**

Test your women\'s health IQ\...; Does Hysterectomy Have an Impact on
Sexuality? Self testing for HPV DNA may be sufficiently sensitive for
the detection of high-risk HPV; Evidence for the management of
mastalgia; Mifepristone for the Treatment of Uterine Leiomyomata:
Systematic Review; USPSTF recommends against routine screening for
ovarian cancer: D recommendation; Study finds that symptoms precede
diagnosis of ovarian cancer; Need some data on the health of women? Quiz
Answers from above

**Child Health:** **page 13**

Adolescent Risk Taking Behavior: Primary Forum Discussion Summary --
Donna Perry; Four causes of death account for 70 percent of deaths among
persons aged 10-24 years; Ways to measure the quality of health services
for children and adolescents; Bicycle Helmet Use by National Safe Kids;
Flu vaccine: New recommendations for children aged 6-23 mo health
workers

**Chronic Illness and Disease:** **page 14**

Disparities in Tobacco Use -- Alaska Natives; Aspirin and other NSAID
effective chemopreventive agents for breast cancer; Increased body
weight was associated with increased cancer death rates; Cigarette
Smoking Among Adults: Related to socioeconomic status; Influencing
Attitudes Toward Mammography Screening; Suicide and Attempted Suicide:
Entire MMWR dedicated to topic; Surgeon General Updates Report on Health
Effects of Smoking

[Features:]{.underline} page 15

**AFP:** POEMS: Breast Augmentation Unlikely to Affect Cancer
Identification; Labor in Water Is Effective Treatment for Slow Labor;
Use Single Course of Corticosteroids for PPROM; Ethinyl Estradiol /
Drospirenone (Yasmin): A Newer Oral Contraceptive; Over-the-Counter
Medications in Pregnancy; Diethylstilbestrol Exposure; Depression in
Later Life: A Diagnostic and Therapeutic Challenge; Prevention and
Treatment of Overweight in Children and Adolescents

**ACOG:** Diagnosis and Treatment of Gestational Trophoblastic Disease;
At-Risk Drinking and Illicit Drug Use: Ethical Issues in Obstetric and
Gynecologic Practice; Pregnancy, Airline Travel and Radiation Exposure

**AHRQ:** Hysterectomy results in better outcomes than medicine with
abnormal uterine bleeding; Cervical cancer screening every 3 yrs after
three or more normal Pap tests is a safe option; USPSTF: Primary care
clinicians should screen / counsel adults to prevent ETOH misuse;
Telecolposcopy reduces barriers to diagnosis of cervical cancer among
rural women; Mammography increases likelihood of breast-conserving
surgery among older women; Findings discount link between estrogen
deficiency and cognitive decline in older women

**Breastfeeding:** Breastfeeding may reduce heart disease risk later in
life; Diabetes prevention and breastfeeding

**Domestic Violence:** Pregnancy-associated assault hospitalizations;
Health care and contraception among adolescents reporting unwanted
sexual intercourse; Patterns of intimate partner violence among
adolescent mothers in the postpartum period; Domestic violence screening
behaviors among pediatricians and family physicians; Domestic violence:
an education program for hospital staff; Violence-inflicted injuries:
reporting laws in the fifty states; Measuring the quality of
hospital-based domestic violence programs;

**Elder Care News:** Ultrasound bone assessment is a reliable predictor
of fracture risk

**Frequently asked questions:** Should Active Management of the Third
Stage of Labor Be Routine? How can my department tell if we providing
effective urinary incontinence procedures? Is membrane stripping
associated with abruption placenta? Is percutaneous drainage of
tubo-ovarian abscess standard of care?

**Hormone Replacement Update**: Regular soy intake may protect against
endometrial cancer

**Information Technology:** Q Man, Collecting Data for the CMS
Initiatives

**International Health** Eating Dirt

**MCH Alert** Blood pressure has increased substantially among children
and adolescents

**Medscape** Understanding Sleep Problems - The Basics

**Office of Women's Health, CDC** Spina Bifida and Anencephaly decreased
by 25% After Folic Acid Mandate; Few Women Regret Sterilization
Procedures

**Osteoporosis** Childbearing reduces hip fracture risk by means that
may be independent of hip BMD; Depot Medroxyprogesterone Acetate Use
Associated With Bone Mineral Density Loss

**Patient Education** Consumer Health Journal

**Primary Care Discussion Forum** Next topic: Adult Asthma, on August 1,
2004, thanks to Charles (Ty) Reidhead, Whiteriver; then on November 1,
2004: Violence against Native women

Moderator: Terry Cullen; Adolescent Risk Taking Behavior Summary - Donna
Perry, now online

**Barbara Stillwater, Alaska Diabetes Prevention and Control** Pediatric
Obesity and Type 2 Diabetes, Cardiovascular Disease Teleconference --
June 23, 2004; DID YOU KNOW -- only 10 miles per week or about 3500
steps per day, can decrease coronary heart disease by 1/3? Dark
Chocolate Improves Endothelial Function in Healthy Adults; Two New RCTs:
Low Carb Diet More Beneficial Than Low Fat Diet; Acarbose Curbs
Atherosclerosis in Pre-Diabetes; 41 MILLION ADULTS NOW REPORTED TO HAVE
PRE-DIABETES: 40% of US Adults; Walking \... A Step in the Right
Direction; How many children are likely to get type 2 diabetes and why
it develops? What are the best ways to treat type 2 diabetes in children
and teens? Fat Distribution In Women Tied To Heart Disease Risks;
Physical Activity Does More Than Burn Calories & Improve Diabetes
Control

**What's new on the ITU MCH web pages:** **page 26**

New Perinatology Corner Module available: Syphilis in Pregnancy; FDA
Estrogen and Estrogen with Progestin Therapies: Good patient handouts;

Women\'s Health Information - National Institutes of Health

###### Save the Dates: Upcoming events of interest page 27

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

# [Abstract(s) of the Month]{.underline}

**Do you offer obstetric delivery at your facility? Or have On-Call
schedule on any type?**

**Please consider these two topics on practice style**:

**1. ) Improving competency in the management of shoulder dystocia with
simulation training**

[OBJECTIVE:]{.underline} To determine whether a simulation training
scenario improves resident competency in the management of shoulder
dystocia.

[METHODS:]{.underline} Residents from 2 training programs participated
in this study. The residents were block-randomized by year-group to a
training session on shoulder dystocia management that used an obstetric
birthing simulator or to a control group with no specific training.
Trained residents and control subjects were subsequently tested on a
standardized shoulder dystocia scenario, and the encounters were
digitally recorded. A physician grader from an external institution then
graded and rated the resident\'s performance with a standardized
evaluation sheet. Statistical analysis included the Student t test,
chi(2), and regression analysis, as appropriate. [RESULTS]{.underline}:
Trained residents had significantly higher scores in all evaluation
categories, including timelines of their interventions, performance of
maneuvers, and overall performance. They also performed the delivery in
a shorter time than control subjects (61 versus 146 seconds, P =.003).
[CONCLUSION:]{.underline} Training with a simulation-training scenario
improved performance in the management of shoulder dystocia. LEVEL OF
EVIDENCE: I

Deering S, Improving resident competency in the management of shoulder
dystocia with simulation training. Obstet Gynecol. 2004
Jun;103(6):1224-8.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15172856&dopt=Abstract>

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

This Level I study raises an important point and begs the question of
another. Shoulder dystocia is a rare and potentially devastating problem
that often presents without warning, even in low risk settings. This
study shows the value of individual provider training. Another excellent
example is the Advanced Life Support in Obstetrics (ALSO) Provider
Course. <http://www.aafp.org/also.xml>

The second related issue is how your team, or facility, reacts to
emergency situations.

You may have the best trained individual at the bedside, but she / he
can not necessarily succeed in a vacuum. It is best to be part of a
fully functional team with shared objectives.

This issue will be specifically addressed at the 2004 Native Maternity
Care and Women's Health meeting: Prevention in Women's Health, August
4-6, 2004 in Albuquerque, New Mexico. There will be lectures and
workshops on how facilities and teams can develop successful simulations
and responses to this type of infrequent emergencies, e.g., obstetric or
of any type.

It is highly recommended that a small team of nurses and providers from
your facility attend that meeting. Here is that MCH web site

<http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#August2004>

or contact Neil Murphy for questions <nmurphy@anmc.org> njm

**2.) Middle-aged women, regardless of ovarian function, experienced
greater sleep disturbance than do younger controls**

OBJECTIVE: To distinguish aging from menopause effects on sleep
architecture, we studied an episode of disturbed hospital sleep in
asymptomatic midlife women during the follicular phase of an ovulatory
cycle and three control groups differing by age or menopause status.
METHODS: Fifty-one studies were conducted in four groups of volunteers:
young cycling (YC, 20-30 years, n = 14), older cycling (OC, 40-50 years,
n = 15), ovariectomized receiving estrogen therapy (OVX, 40-50 years, n
= 12), and spontaneously postmenopausal (PM, 40-50 years, n = 10).
Subjects were admitted to the University Hospital General Clinical
Research Center (GCRC) for a first-night sleep study conducted during a
24-hour, frequent blood sampling protocol. RESULTS: Despite similar
estrogen concentrations in the YC (28 +/- 4 pg/ml) and OC (34 +/- 6
pg/ml) groups, OC women had reduced sleep efficiency (79% +/- 2%) vs. YC
(87% +/- 3%; p = 0.009). In the OVX and PM groups where estrogen
concentrations were markedly different, sleep efficiency was also
reduced vs. the YC group (OVX vs. YC, 79% +/- 3% vs. 87% +/- 3%, p =
0.05; PM vs. YC, 75% +/- 3% vs. 87% +/- 3%, p = 0.007). Wake time was
longer in the three older groups (103 +/- 10 minutes, 101 +/- 12
minutes, 123 +/- 12 minutes for OC, OVX, PM, respectively) vs. YC (63
+/- 13 minutes, p \< 0.05). The number of stage shifts was positively
associated with advancing age (rho = 0.3, p \< 0.03) but not with
estrogen concentration. CONCLUSIONS: Aging-related sleep deficits in
response to an experimental stressor occur in midlife women prior to
menopause.

Lukacs JL, Chilimigras JL, Cannon JR, Dormire SL, Reame NE Midlife
women\'s responses to a hospital sleep challenge: aging and menopause
effects on sleep architecture. Womens Health (Larchmt). 2004
Apr;13(3):333-40.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15130262>

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

Lukacs et al point out some of the results of stressors on effective
sleep. I would also submit that anyone who is cared for, works
along-side, or lives with sleep deprived staff of any age or gender, are
similarly impacted in ways both subtle, and not so subtly.

The best approach to on-call scheduling is a topic of never ending
debate. Each method should seek to balance quality of care, preservation
of the circadian rhythm, and one's life outside the workplace.

Should we perform 24 hour shifts? 12 hour shifts? 8 hour shifts? The
data on this topic is vast, though in many cases staffing decisions are
made by 'cherry picking' those articles that seem to best individual
lifestyles.

This will be another topic at the 2004 Native Maternity Care and Women's
Health meeting: Prevention in Women's Health, August 4-6, 2004 in
Albuquerque, New Mexico.

<http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#August2004>

Please let us know how you have successfully solved this perennial
issue, or not. njm

## From your colleagues:

[From Frank Anderson, formerly of Chinle]{.underline}

Sudden death was the presenting scenario in 75% of nonpreventable
ectopic deaths

[CONCLUSION:]{.underline} Ectopic pregnancy treatment has changed in the
last 20 years coincident with a decrease in maternal mortality from
ectopic pregnancy. Sudden death was the presenting scenario in 75% of
nonpreventable ectopic deaths, an increase from previous analyses. A
large racial disparity is apparent. Ideally, pregnancy care should start
as soon as possible after the first missed menses; however, systemwide
changes are needed to create a new norm promoting early access to
pregnancy care and promoting education and testing to rule out pregnancy
abnormalities. LEVEL OF EVIDENCE: II-2

**Frank W. J. Anderson, et al** Sudden Death: Ectopic Pregnancy
Mortality *Obstetrics & Gynecology* 2004;103:1218-1223

[**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15172855&dopt=Abstract**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15172855&dopt=Abstract)

[From Donna Brown, Anchorage]{.underline}

**Tobacco use is responsible for one in 10 adult deaths worldwide and 5
million deaths / yr**

The four major conclusions of the report are 1) smoking harms nearly
every organ of the body, causing many diseases and reducing the health
of smokers in general; 2) quitting smoking has immediate as well as
long-term benefits, reducing risks for diseases caused by smoking and
improving health in general; 3) smoking cigarettes with lower
machine-measured yields of tar and nicotine provides no clear benefit to
health; and 4) the list of diseases caused by smoking has been expanded
to include abdominal aortic aneurysm, acute myeloid leukemia, cataract,
cervical cancer, kidney cancer, pancreatic cancer, pneumonia,
periodontitis, and stomach cancer.

[[http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5320a1.htm]{.underline}](http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5320a1.htm)

[[http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5320a5.htm]{.underline}](http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5320a5.htm)

[From Tom Burke, Anchorage]{.underline}

Practical abnormal pap smear and colposcopy guidelines for both the
non-colposcopist and colposcopist

Abnormal pap smear follow-up for the non-colposcopist

[**http://wwwdev.ihs.gov/NonMedicalPrograms/NC4/Documents/AbnLight6204.doc**](http://wwwdev.ihs.gov/NonMedicalPrograms/NC4/Documents/AbnLight6204.doc)

Cervical Cancer Screening Intervals

[**http://wwwdev.ihs.gov/NonMedicalPrograms/NC4/Documents/CervInterv6204.doc**](http://wwwdev.ihs.gov/NonMedicalPrograms/NC4/Documents/CervInterv6204.doc)

Abnormal pap smear follow-up: Full text

[**http://wwwdev.ihs.gov/NonMedicalPrograms/NC4/Documents/AbnPap6104.doc**](http://wwwdev.ihs.gov/NonMedicalPrograms/NC4/Documents/AbnPap6104.doc)

Cervical Cancer Screening Guidelines, ASCCP

[**http://www.asccp.org/pdfs/consensus/algorithms.pdf**](http://www.asccp.org/pdfs/consensus/algorithms.pdf)

**[From Sandra Cook, Bethel]{.underline}**

**Q. Is membrane stripping associated with abruption placenta?**

A. No, in addition, there was no increased risk of maternal or neonatal
infection, but minor maternal discomforts were common

Membrane stripping --- Stripping or sweeping of the membranes is a
widely utilized, but often undocumented, technique. This process
probably causes release of either prostaglandin F2-alpha from the
decidua and adjacent membranes or prostaglandin E2 from the cervix.

The efficacy of membrane stripping was demonstrated in a meta-analysis
of 19 trials in which 17 compared sweeping of membranes to no treatment,
three compared sweeping to prostaglandins, and one compared sweeping to
oxytocin\[33\]. Compared to no intervention, membrane stripping was
associated with reduced duration of pregnancy by three days (95 percent
CI 2 to 4 days), reduced frequency of pregnancy continuing beyond 41
weeks (RR 0.62, 95 percent CI 0.49 to 0.79) and 42 weeks of gestation
(RR 0.28, 95 percent CI 0.15 to 0.50), and reduced frequency of formal
induction (RR 0.57, 95 percent CI 0.48 to 0.68). Overall, seven women
would need to undergo membrane sweeping to avoid one formal induction of
labor. There was no increased risk of maternal or neonatal infection,
but minor maternal discomforts were common. Heterogeneity among studies
limits interpretation of these findings.

<http://www.uptodateonline.com/application/topic.asp?file=labordel/8409&type=A&selectedTitle=1~1>

[From Terry Cullen, Tucson]{.underline}

**Intimate Partner Violence: Funding available to Indian Health sites**

The IHS has had pilot IPV projects in 9 sites for the last 18 months; we
are in the process of funding additional sites with some additional
resources from IHS/ ACF, as well as evaluating our current work. These
sites work closely with the family violence prevention fund, as well as
AI/AN advocacy groups. I assume that this information will be helpful to
your training, as well as the inclusion of information on AI/AN advocacy
groups. We believe that screening MUST be part of a much larger
community effort, and it must involve local IPV/ DV advocates.

The RFP online:
[[www.endabuse.org/health]{.underline}](../www.endabuse.org/health) The
application deadline is July 1, 2004. I\'m happy to talk to any of you
further about this project: [Theresa.Cullen@ihs.gov]{.underline}

[From Barbara Fine, HQE]{.underline}

**Let me know about your PHN program or individual PHNs success(s) or
achievements**

Please email me your PHN program or individual PHNs success or
achievements. I was asked to give a summary of the PHN duties in the
home and communities. I would like to have some special examples to
share in with the generic response and I need you to sit down and send
me an email when great things are being done. We need to tell everyone
the health promotion and disease prevention activities PHNs are doing
through home visits and community assessments.

<Barbara.Fine@ihs.gov>

**Hearts N' Parks Program continues to help all ages adopt heart health
behaviors**

National community-based program focuses on choosing heart-healthy foods
and increasing physical activity to reduce obesity and risk of heart
disease**.** The complete report of 2003 Hearts N' Parks Magnet Center
Performance Data can be found on NRPA's website at
[[www.nrpa.org]{.underline}](../www.nrpa.org) (click on Programs &
Partnerships, Magnet Centers, Hearts N' Parks) and on the NHLBI Web site
at [[www.nhlbi.nih.gov]{.underline}](../www.nhlbi.nih.gov) (click on
Networks and Outreach, Hearts N' Parks).

**CHILD Profile Statewide Anniversary Conference(s)**\
September 29, 2004 - Spokane September 30, 2004 - Seattle 

For more information.
[www.childprofile.org](http://www.childprofile.org/)

**[From Sandra Haldane, HQE]{.underline}**

**NANAINA Summit 2004 Call for Abstracts**

 The National Alaska Native American Indian Nurses Association\'s Summit
X is September 17 - 19, 2004 at the KwaTaqNuk Resort in Polson, MT and
Salish Kootenai College in Pablo, Montana.  The conference theme is
\"Eliminating Indian Health Disparities and Preparing for 2010: Building
Partnerships in Teaching, Research, and Practice.\"

 Please consider and encouraged abstracts for oral and poster
presentations.  Topics need to relate to American Indian/Alaska Native
health and health care issues.  The deadline for submission is September
1, 2004.  For more information on the NANAINA Summit X, please visit
NANAINA online at <http://www.nanaina.com/annual_summit/main.html>

**[From Yolanda Meza, Anchorage]{.underline}**

**Centering or group prenatal visits: Exciting prenatal management
program**

Centering is an exciting model of care that we have started utilizing
at ANMC and SCF\'s Women\'s Clinic within the last year, but had been
utilized at Phoenix Indian Medical Center for quite a while before we
started.  It is called \"Centering\" or group prenatal care.  There is a
national / international organization created and run by Sharon Rising
CNM, MSN.  If you care to look at the great resources and support
offered to providers using the model.  <http://centeringpregnancy.org/>

**[From Chuck North, Albuquerque]{.underline}**

**Making Evidence-base Medicine Doable in Everyday Practice, by Brandi
White\
**This article is very readable and has excellent references and live
links.

[[http://www.aafp.org/fpm/20040200/51maki.html]{.underline}](http://www.aafp.org/fpm/20040200/51maki.html)

**Understanding the Risks of Medical Interventions**

You are reviewing a recent lipid panel on John, a 50-year-old man who
has been following an exercise and diet program since you discovered a
high cholesterol level at his wellness physical six months ago. John\'s
total cholesterol has gone from 315 to 280, his HDL from 40 to 45 and
his LDL from 205 to 185. John\'s wife read an ad in a magazine about a
cholesterol-lowering medication that will reduce the risk of heart
attack by 30 percent, so he asks you about taking it. What will you tell
him?

To start, you will certainly evaluate John\'s other heart attack risk
factors ­ smoking status, hypertension, family history and diabetes \--
but it will also help if you can explain to John and his wife what this
30 percent risk reduction actually means. To do that, you need to
understand how risks are calculated. Here are 3 simple methods:

<http://www.aafp.org/fpm/20000500/59unde.html>

**Evidence-based Obstetrics & Gynecology**  

*Evidence-based Obstetrics & Gynecology* helps clinicians to combine the
best external evidence from systematic research with individual clinical
expertise to make effective decisions about patient treatment and care.
For each issue key articles are selected from the literature and
reviewed in the form of a structured abstract and expert commentary. It
is in a concise and easy to read format. Most reviews are 1-2 pages
long, not unlike a Cochrane Database Abstract.

A sample Issue is available online. Go to this link:
<http://www.harcourt-international.com/journals/ebog/>

From the journal's Home Page above, click on area along the left border
that says: 'Latest issue, contents and abstracts now available' on with
the Science Direct logo. On the right-hand side of the page that opens,
click on: **sample issue online** located below the picture of the
journal. On that page click on **Volume 6 Issue one.** You will have
full-text access to all the articles in that issue. Navigation
directions thanks to Anne Girling, ANMC Librarian, <agirling@anmc.org>

**[From Richard Olson, HQE]{.underline}**

**American Indian & Alaska Native Health Care Needs: Papers sought**\
The American Journal of Public Health (AJPH), in collaboration with the
Henry J. Kaiser Family Foundation, is planning to publish a collection
of papers on how the United States can more effectively meet the health
care needs of American Indians and Alaska Natives (AIANs).

DEADLINE TO SUBMIT:  September 1, 2004 Apply at
<http://submit.ajph.org/>

**[From Judy Thierry, HQE]{.underline}**

**Prenatal classes : What are you doing?**

Dr. Thierry is interested in learning what you are doing for prenatal
classes. What works well and what doesn't work well? Dr. Thierry will
collate all the great ideas she hears and get the best practices back to
you. Please contact: <Judith.Thierry@ihs.gov>

**Helping Pregnant Women Quit Smoking: Progress and Directions**

Tobacco research and pregnancy - entire issue devoted to perinatal
tobacco exposure.

<http://www.ntrjournal.org/pregnancy.html>

**Interested in SIDS / IMR? Consider attending this....**

National Symposium on Child Fatalities

2004 A Decade of Experience - A Future of Promise

8/1/04 to 8/3/04 St. Louis, Missouri

<http://www.mimh.edu/ceconfs/info/info.asp?value=05001>

**[Hot Topics:]{.underline}**

**[Obstetrics]{.underline}**

**New Perinatology Corner Module available: Syphilis in Pregnancy**

Free CME /CEUs available that address the recent increase in syphilis in
Indian Country

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

**Glucose challenge thresholds \> than 180 mg/dL are NOT DIAGNOSTIC FOR
GDM**

**Predictive value for GDM only 50%.** [CONCLUSION:]{.underline} Data
suggests that an elevated glucose challenge test level cannot be used as
a single diagnostic tool for gestational diabetes mellitus (GDM) even in
high test thresholds. An elevated glucose challenge test value increases
the risk of GDM, but even in high glucose challenge test thresholds
(more than 180 mg/dL), the predictive value for GDM was only 50%. A
threshold of 130 mg/dL may be recommended as a screening threshold for
GDM in Mexican-American women. LEVEL OF EVIDENCE: II-3 Yogev Y, Langer
O, Xenakis EM, Rosenn B. Glucose Screening in Mexican-American Women.
Obstet Gynecol. 2004 Jun;103(6):1241-1245.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15172859&dopt=Abstract>

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

A small number of centers have developed practices whereby pregnant
patients with glucose challenge levels \> 185 - 200 mg/dL are
automatically diagnosed and managed as if they actually had GDM without
a 3 hour 100gm OGTT. This process of automatically converting a
[screening]{.underline} test result into a [diagnostic]{.underline} test
result has not been borne out well in the evidence. It can lead to many
incorrect diagnoses, as pointed out by Yogev above, and is akin to
starting radiation therapy for the presumed [diagnosis]{.underline} of
cervical cancer based solely on a single Pap smear [screen.]{.underline}

[Please note:]{.underline} We iatrogenically expose our patients with
gestational diabetes to higher rates of cesarean delivery testing,
regardless of birth weight and obstetric outcome, simply based on the
diagnosis GDM alone. (Naylor) If that GDM diagnosis was systematically
incorrect from the outset, there is also the needless discomfort of
frequent ongoing daily capillary blood glucose determinations and
numerous other interventions. njm
<http://www.ihs.gov/MedicalPrograms/MCH/M/DP04.asp#top>

**(**scroll down to: What about screening glucose levels of \>185 mg/dL
or \> 200 mg/dL?**)\
**

Atilano LC, Lee-Parritz A, Lieberman E, Cohen AP, Barbieri RL
Alternative methods of diagnosing gestational diabetes mellitus. Am J
Obstet Gynecol 1999 Nov;181(5 Pt 1):1158-61

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10561637&dopt=Abstract>

Landy HJ, Gomez-Marin O, O\'Sullivan MJ Diagnosing gestational diabetes
mellitus: use of a glucose screen without administering the glucose
tolerance test. Obstet Gynecol 1996 Mar;87(3):395-400

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8598962&dopt=Abstract>

Naylor CD, Sermer M, Chen E, Sykora K Cesarean delivery in relation to
birth weight and gestational glucose tolerance: pathophysiology or
practice style? Toronto Trihospital Gestational Diabetes Investigators.
JAMA 1996 Apr 17;275(15):1165-70

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8609683&dopt=Abstract>

Shivvers SA, Lucas MJ Gestational diabetes. Is a 50-g screening result
\> or = 200 mg/dL diagnostic? J Reprod Med 1999 Aug;44(8):685-8

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10483538&dopt=Abstract>

**Noninvasive Prenatal Testing Cuts Amniocentesis Use**

[CONCLUSION:]{.underline} Advances in maternal serum screening and
second-trimester ultrasonography have resulted in more judicious use of
amniocentesis and chorionic villus sampling. LEVEL OF EVIDENCE: II-2
Benn PA et al Changes in the Utilization of Prenatal Diagnosis. Obstet
Gynecol. 2004 Jun;103(6):1255-1260.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15172861>

**Vitamin C Reduces Risk of Gestational Diabetes**

[CONCLUSION:]{.underline} Low maternal dietary vitamin C intake and low
plasma AA concentrations are associated with an increased risk of GDM.
Large, prospective, cohort studies are needed to further evaluate the
potential beneficial role of vitamin C and other antioxidants in the
prevention of impaired glucose tolerance in pregnancy.

Zhang C, et al Vitamin C and the risk of gestational diabetes mellitus:
a case-control study. J Reprod Med. 2004 Apr;49(4):257-66.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15134150>

**Oral Misoprostol an Inexpensive Alternative for Induction of Labor**

[CONCLUSIONS:]{.underline} Oral misoprostol (100 microg) has similar
efficacy to vaginal PGE2 tablets, and may be an option to consider for
term labour induction

Shetty A, A randomised comparison of oral misoprostol and vaginal
prostaglandin E2 tablets in labour induction at term. BJOG. 2004
May;111(5):436-40.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15104606>

**Physician characteristics are a major** **determinant of cesarean
delivery**

[CONCLUSION]{.underline}: This study documents a heretofore unrecognized
clinical entity: intrapartum elective cesarean delivery. Physician
characteristics, as opposed to patient characteristics or intrapartum
factors, are a major determinant of whether laboring patients are being
offered cesarean delivery. LEVEL OF EVIDENCE: III

Robin B. Kalish, et al Intrapartum Elective Cesarean Delivery: A
Previously Unrecognized Clinical Entity *Obstetrics & Gynecology*
2004;103:1137-1141

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15172844&dopt=Abstract>

**Closure of subcutaneous fat during cesarean delivery decreases wound
disruption**

[CONCLUSION:]{.underline} Suture closure of subcutaneous fat during
cesarean delivery results in a 34% decrease in risk of wound disruption
in women with fat thickness greater than 2 cm

disruption after cesarean delivery: a meta-analysis. Obstet Gynecol.
2004 May;103(5):974-80.

[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15121573]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15121573)

**Fetal Alcohol Syndrome \-\-- Alaska, Arizona, and Colorado**

[[http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5120a2.htm]{.underline}](http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5120a2.htm)

**Cervical cerclage shown not to reduce preterm delivery**

[INTERPRETATION:]{.underline} The insertion of a Shirodkar suture in
women with a short cervix does not substantially reduce the risk of
early preterm delivery. Routine sonographic measurement of cervical
length at 22-24 weeks identifies a group at high risk of early preterm
birth.

Fetal Medicine Foundation Second Trimester Screening Group. Et al
Cervical cerclage for prevention of preterm delivery in women with short
cervix: randomised controlled trial. Lancet. 2004 Jun
5;363(9424):1849-53.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15183621>

**Genetic variation linked to gestational diabetes**

[CONCLUSION:]{.underline} Our results indicate that the haplotype
121/221 of the calpain-10 gene may be associated with disturbances of
glucose metabolism during pregnancyLEVEL OF EVIDENCE: II-1

Leipold H et al Calpain-10 haplotype combination and association with
gestational diabetes mellitus. Obstet Gynecol. 2004 Jun;103(6):1235-40.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15172858>

**12 suggestions for practice for all personnel in an
obstetric--neonatal unit**

In January 2003, the American College of Obstetricians and Gynecologists
(ACOG) and The American Academy of Pediatrics (AAP) published *Neonatal
Encephalopathy and Cerebral Palsy: Defining the Pathogenesis and
Pathophysiology*.

Two years in development, this publication has received wide
endorsements. Specific goals of the Task Force in preparing the document
included broadening the understanding of neonatal encephalopathy and
developing recommendations for evaluation of the newborn with
encephalopathy in defining both the cause and the timing of the
encephalopathy.

Although it is clear that applying the evidence presented in the
publication to clinical practice has important potential in risk
management, we felt that the document did not make specific suggestions
for obstetric practice. (These suggestions are part of a lecture slide
set we developed with the sponsorship of COPIC, a physician liability
insurance company in Colorado, to summarize and illustrate the key
points in the document.) Accordingly, we propose the following 12
suggestions, drawing on *Neonatal Encephalopathy and Cerebral Palsy:
Defining the Pathogenesis and Pathophysiology* as well as other
documents and our clinical judgment. These suggestions have not been
developed by members of the ACOG Task Force, nor have they been
submitted for endorsement.

1.  Based on the ACOG/AAP publication, neonatal encephalopathy or
    cerebral palsy should *not* be attributed to an intrapartum event in
    the medical record unless all 4 essential criteria are met.

```{=html}
<!-- -->
```
1.  Accordingly, after delivery of an infant with risk factors for
    neonatal encephalopathy, obtaining an umbilical artery pH, Pco~2~,
    and base deficit may help determine timing of the insult. Such risk
    factors may include an infant with low Apgar scores, severe
    intrauterine growth restriction (IUGR), nonreassuring heart rate
    tracings, or a sentinel event (such as cord prolapse, uterine
    rupture, or abruption). Cord gases may also be helpful in cases with
    thick meconium in which the disease process of meconium aspiration
    syndrome may not be evident until a few hours after birth. Here,
    gases are most likely to show the absence of acidosis. As noted in a
    current ACOG Committee Opinion, \"a clamped segment of cord is
    stable for pH and blood gas assessment for at least 60 minutes, and
    a cord blood sample in a syringe flushed with heparin is stable for
    up to 60
    minutes.\"[^2^](http://www.greenjournal.org/cgi/content/full/103/4/778#R2-27%23R2-27)
    Umbilical artery blood (coming from fetus to placenta) is the basis
    of fetal acidosis. Umbilical vein blood (coming from placenta to
    fetus) may be helpful also, such as when there is a uteroplacental
    problem (eg, abruption or maternal asthma).

2.  For uncomplicated pregnancies with normal labor and resulting in
    delivery of a vigorous infant with normal Apgar scores at 1 and 5
    minutes, the likelihood of severe metabolic acidosis and of neonatal
    encephalopathy or cerebral palsy resulting from an intrapartum event
    is so remote that the routine sending of umbilical cord blood gases
    is not needed.

3.  After delivery of an infant with risk factors for neonatal
    encephalopathy, a detailed note should address as many of the 4
    essential criteria and the 5 suggestive criteria as possible. For
    example, the obstetric note should include cord blood values,
    sentinel events, antepartum information (eg, IUGR), fetal heart rate
    (FHR) patterns, and Apgar scores. For example, the pediatric note
    should include the above, plus neurologic examination, presence of
    other organ dysfunction, relevant exclusion evaluations, and imaging
    studies, if done.

4.  The term *perinatal asphyxia* should *not* be based on
    meconium-stained amniotic fluid, low Apgar scores, or nonreassuring
    FHR patterns because these are nonspecific markers.

5.  In maternal and neonatal charts, avoid the term *fetal distress*,
    which is often inaccurate. Rather use the more descriptive term
    *nonreassuring fetal heart rate pattern*, and amplify this entry by
    describing the type, frequency, intensity, and duration of the FHR
    pattern. In clinical parlance, do not use *fetal distress*.

6.  Gross and microscopic placental examination may show pathology,
    establishing that there were other potential causes of neonatal
    encephalopathy/cerebral palsy (besides hypoxia) and that they may
    have predated the labor. Examples of conditions that suggest the
    need for placental examination are shown in the box.

7.  In cases of neonatal encephalopathy, a thorough investigation of
    causes should be carried out, including a detailed family history, a
    detailed maternal history, a placental examination (if the specimen
    is available), and where appropriate, an assessment of maternal
    thyroid disease, maternal or fetal thrombophilias, family genetic or
    metabolic conditions, and cerebral or cerebrovascular anomalies.
    Bear in mind that intrauterine exposure to infection is a common
    cause of term or near-term infants doing poorly in the delivery room
    despite reassuring obstetric assessments. In these unexpectedly
    \"flat\" infants, evaluation for infection is critical.

8.  The type of cerebral palsy (such as spastic quadriplegia) should be
    carefully documented by a pediatric neurologist.

9.  All fetal heart rate tracings should be labeled and archived.

10. Although instrumental vaginal delivery is associated with a
    increased relative risk for neonatal encephalopathy, it is unclear
    whether the increased risk is caused by the indication for the
    operative vaginal delivery or by the procedure itself. Nevertheless,
    it is helpful to have a detailed written note or dictation in the
    chart giving a description of the operative procedure that includes
    the indication, the instrument used, ease or difficulty of the
    application, duration of the procedure, number of pulls, attendants
    at delivery, etc.

11. Keep the pediatrician in the loop. Communicate specific risk factors
    (eg, maternal medical conditions and antepartum or intrapartum
    complications) with those taking care of the newborn. When the
    placenta is sent for examination, also communicate risk factors to
    the pathologist.

Familiarity with the publication and implementation of these suggestions
for practice---by all personnel in an obstetric--neonatal unit---are
important risk management techniques.

Gibbs RS, et al Suggestions for practice to accompany neonatal
encephalopathy and cerebral palsy. Obstet Gynecol. 2004
Apr;103(4):778-9.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15051573&dopt=Abstract>

**[Gynecology]{.underline}**

**Test your women\'s health IQ\...**\
**Questions: \*answers below\
**1.  Do you know the number one killer of women?\
2.  Do you know the leading cause of cancer death for women? \
3.  What is the greatest health epidemic currently facing our nation?\
4.  True or False? Teenage boys are more likely to smoke than teenage
girls.

**Does Hysterectomy Have an Impact on Sexuality?**

[CONCLUSION:]{.underline} Sexual pleasure improves after vaginal
hysterectomy, subtotal abdominal hysterectomy, and total abdominal
hysterectomy. The persistence and development of bothersome problems
during sexual activity were similar for all three

Roovers JP, et al Hysterectomy and sexual wellbeing: prospective
observational study of vaginal hysterectomy, subtotal abdominal
hysterectomy, and total abdominal hysterectomy. BMJ. 2003 Oct
4;327(7418):774-8.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14525872>

**Self testing for HPV DNA may be sufficiently sensitive for the
detection of high-risk HPV**

[CONCLUSION:]{.underline} Self testing for HPV DNA may be sufficiently
sensitive for the detection of high-risk HPV DNA among adolescent and
young adult women in clinical settings.

Kahn JA, Slap GB, Huang B, Rosenthal SL, Wanchick AM, Kollar LM, Hillard
PA, Witte D, Groen P, Bernstein DI. Comparison of Adolescent and Young
Adult Self-Collected and Clinician-Collected Samples for Human
Papillomavirus. Obstet Gynecol. 2004 May;103(5):952-959.\
[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15121570&dopt=Abstract]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15121570&dopt=Abstract)

**Evidence for the management of mastalgia**

Mastalgia is the commonest breast symptom presenting to general
practitioners and breast surgeons alike. To make a full assessment of
the cause, all patients require a full history, examination and,
sometimes, investigations. Diary cards are often helpful. The commonest
cause is cyclical mastalgia. Most women require reassurance only and the
pain often settles spontaneously after a few months. For the remainder,
simple lifestyle changes should be suggested initially, such as wearing
a well-fitted sports bra, weight reduction, regular exercise and a
reduction in caffeine intake. Unfortunately, there is a paucity of
evidence for the usefulness of these measures. If pain is persistent or
severe, a variety of pharmacological agents exist. The most effective
with least side effects is a 3-6-month course of low-dose tamoxifen
(10mg). Other proven agents include danazol and bromocriptine, but these
have a higher side-effect profile and are rarely indicated nowadays.
Newer treatments include lisuride maleate and topical non-steroidal
anti-inflammatory preparations. Gumm R, et al Evidence for the
management of mastalgia. Curr Med Res Opin. 2004 May;20(5):681-4.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15140333>

**Mifepristone for the Treatment of Uterine Leiomyomata: Systematic
Review**

[CONCLUSION:]{.underline} Published trials of mifepristone showed
reduction in leiomyoma size and improvement in symptoms. A notable
adverse effect of mifepristone was development of endometrial
hyperplasia.

Jody Steinauer et al Systematic Review of Mifepristone for the Treatment
of Uterine Leiomyomata *Obstetrics & Gynecology* 2004;103:1331-1336

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15172874&dopt=Abstract>

**U.S. Preventive Services Task Force (USPSTF)** **recommends against
routine screening for ovarian cancer: D recommendation.**

The USPSTF found fair evidence that screening with serum CA-125 level or
transvaginal ultrasound can detect ovarian cancer at an earlier stage
than it can be detected in the absence of screening; however, the USPSTF
found fair evidence that earlier detection would likely have a small
effect, at best, on mortality from ovarian cancer. Because of the low
prevalence of ovarian cancer and the invasive nature of diagnostic
testing after a positive screening test, there is fair evidence that
screening could likely lead to important harms. The USPSTF concluded
that the potential harms outweigh the potential benefits.

**CLINICAL CONSIDERATIONS**

• There is no existing evidence that any screening test, including
CA-125, ultrasound, or pelvic examination, reduces mortality from
ovarian cancer. Furthermore, existing evidence that screening can detect
early-stage ovarian cancer is insufficient to indicate that this earlier
diagnosis will reduce mortality.

• Because there is a low incidence of ovarian cancer in the general
population (age-adjusted incidence of 17 per 100,000 women), screening
for ovarian cancer is likely to have a relatively low yield. The great
majority of women with a positive screening test will not have ovarian
cancer (ie, they will have a false-positive result). In women at average
risk, the positive predictive value of an abnormal screening test is, at
best, approximately 2% (ie, 98% of women with positive test results will
not have ovarian cancer).

• The positive predictive value of an initially positive screening test
would be more favorable for women at higher risk. For example, the
lifetime probability of ovarian cancer increases from about 1.6% in a
35-year-old woman without a family history of ovarian cancer to about 5%
if she has one relative and 7% if she has two relatives with ovarian
cancer. If ongoing clinical trials show that screening has a beneficial
effect on mortality rates, then women at higher risk are likely to
experience the greatest benefit.

<http://www.ahrq.gov/clinic/uspstf/uspsovar.htm>

**Study finds that symptoms precede diagnosis of ovarian cancer**

[CONCLUSIONS]{.underline}: Symptoms that are more severe or frequent
than expected and of recent onset warrant further diagnostic
investigation because they are more likely to be associated with both
benign and malignant ovarian masses.

Goff BA, et al Frequency of symptoms of ovarian cancer in women
presenting to primary care clinics. JAMA. 2004 Jun 9;291(22):2705-12.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15187051>

**Need some data on the health of women?**

CDC just recently released 12 new tables in the Healthy Women Project
data warehouse. 

Binge Drinking\
Blood Stool Testing\
Body Mass Index\
Cholesterol Screening\
Health Care Coverage\
Hypertension\
Mammogram Screening\
Pap Smear Screening\
Physical Activity\
Routine Checkups\
Smoking Status

Daily Servings of Fruits and Vegetables

From CDC Healthy Women Project website:
<http://www.cdc.gov/nchs/healthywomen.htm>

**\*Quiz Answers from above:\
1.  Heart disease.**  The condition accounted for almost 54 percent of
all women\'s deaths in 2001.  According to a recent issue of Newsweek,
which contained several articles on women\'s health, a survey by the
American Heart Association found that only 13 percent of women consider
heart disease their greatest health risk and just over one third say
they have spoken with their doctor about heart disease.\
**2.  Lung cancer** is the leading cause of cancer death for all women,
although breast cancer kills more women ages 35 to 44.\
**3.  Obesity** has reached epidemic proportions, as the majority of
Americans are either overweight or obese. Obesity is the second leading
cause of preventable death in the U.S.  For women, being overw eight is
associated with a greater risk of developing heart disease, certain
cancers and a number of chronic conditions including diabetes. According
to the CDC, physical inactivity - a major contributing factor to
obesity - is more common among women than men.\
**4.  False.**  Girls and boys smoke at about the same rate, and one in
four high school girls are current smokers.  However, girls are more
likely to report that they have tried to quit than boys and are more
likely to be successful at quitting when their smoking cessation
programs include social support from family and peers.

National Women\'s Law Center\'s  E-Update
<http://www.nwlc.org/details.cfm?id=1752&section=infocenter>

**[Child Health]{.underline}**

**Adolescent Risk Taking Behavior: Discussion Summary**

On May 1, 2004, Donna Perry in Chinle, began moderating a discussion of
Adolescent Risk Taking Behavior on the Primary Care Discussion Forum.
This will be a combined listserv Discussion with the Special Interest
Group -- Indian Health of the AAP.

The Discussion is captured online:
<http://www.ihs.gov/medicalprograms/MCH/M/documents/ADODisc6904.doc>

The complete Summary is here:
<http://www.ihs.gov/medicalprograms/MCH/M/documents/ADOSumm6904.doc>

An excerpt of the **Summary** is presented here:

".......We have some challenges. I would suggest we consider more
adolescent topics at our local, regional and national meetings. This
would be a place for dialog, increasing our skills, and planning more
standardized approaches given our restraints on resources. We need to
share programs that work in our communities. We can develop outcomes
measures that will help us plan for improving care in our communities. A
recent supplement to the journal Pediatrics discussed how to measure
effectiveness of adolescent health care. How can we apply that to our
communities? For those who have school based or school linked clinics,
IHS headquarters is developing a discussion and work group in which we
can participate. We can also commiserate in our struggle to provide
increasingly accessible teen health care."

**Adolescent Risk references are presented under Primary Care Discussion
group below**

**Four causes of death account for 70 percent of deaths among persons
aged 10-24 years**

70.8% of all deaths among persons aged 10-24 years result from only four
causes: motor-vehicle crashes, other unintentional injuries, homicide,
and suicide. during the 30 days preceding the survey, numerous high
school students engaged in behaviors that increased their likelihood of
death from these four causes.

<http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5302a1.htm>

**Ways to measure the quality of health services for children and
adolescents**

Extensive quality problems have been documented across all sectors of
health services for children and adolescents. Problems persist in asthma
care, well-child and adolescent care, childhood immunization rates, and
sexually transmitted disease screening for adolescents. Many other
problems in children\'s health care delivery are not being adequately
measured and monitored. A January 2004 supplement to the journal
*Pediatric*s 113(1) is focused on measuring the quality of children\'s
health care as a key step in quality improvement.

[[http://www.ahrq.gov/research/apr04/0404RA15.htm#head1]{.underline}](http://www.ahrq.gov/research/apr04/0404RA15.htm#head1)

**Bicycle Helmet Use by National Safe Kids Campaign and Bell Sports**

This study (\"Headed for injury: An observational survey of helmet use
among children ages 5 to 14 participating in wheeled sports\")
indicates, that fewer than half (41 percent) of children ages 5 to 14
wear helmets when participating in wheeled activities, and more than a
third (35 percent) of those who use helmets wear them improperly.\
<http://www.safekids.org/content_documents/ACFC7.pdf>

**New recommendations for health workers and children aged 6-23 months:
Flu vaccine**

ACIP recommendations include information on influenza vaccine for
children aged 6-23 months; vaccination of health-care workers with live,
attenuated influenza vaccine (LAIV); personnel who may administer LAIV;
the 2004-05 trivalent inactivated vaccine virus strains; and assessment
of the vaccine supply and timing of influenza vaccination.

<http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5306a1.htm>

**[Chronic disease and Illness]{.underline}**

**Disparities in Tobacco Use -- Alaska Natives:** Part 3 of a 5-Part
Series

Alaska Native High School students and pregnant women smoke and use
smokeless tobacco more than their non-Native peers. These trends do not
seem to be diminishing over time

<http://epi.alaska.gov/bulletins/docs/rr2004_05.pdf>

**The series on Tobacco Use by the State of Alaska Section on
Epidemiology**

<http://epi.alaska.gov/bulletins/catlist.jsp?cattype=Smoking/Tobacco>

**Aspirin and other NSAID effective chemopreventive agents for breast
cancer**

[CONCLUSION:]{.underline} These data add to the growing evidence that
supports the regular use of aspirin and other NSAIDs (which may operate
through inhibition of estrogen biosynthesis) as effective
chemopreventive agents for breast cancer.

Terry MB et al Association of frequency and duration of aspirin use and
hormone receptor status with breast cancer risk.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15161893>

**Increased body weight was associated with increased cancer death
rates**

[CONCLUSIONS:]{.underline} Increased body weight was associated with
increased death rates for all cancers combined and for cancers at
multiple specific sites.

Calle EE, Rodriguez C, Walker-Thurmond K, Thun MJ Overweight, obesity,
and mortality from cancer in a prospectively studied cohort of U.S.
adults. N Engl J Med. 2003 Apr 24;348(17):1625-38
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12711737>

**Cigarette Smoking Among Adults: Related to socioeconomic status**

1\) The socioeconomic status of U.S. adults is inversely related to
their likelihood of smoking and 2) During 1983\--2002, the gap in
smoking prevalence by socioeconomic status did not narrow and might have
widened. These findings underscore the need for targeted interventions
that can better reach persons of lower socioeconomic status

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5320a2.htm>

**Influencing Attitudes Toward Mammography Screening**

[CONCLUSIONS:]{.underline} Women improved the accuracy of their
responses to questions about the benefits and harms of mammography after
seeing the videos, but this change was not affected by the framing of
information. Women strongly perceived that the benefits of mammography
outweighed the harms, and providing accurate information had no effect
on these perceptions, regardless of how it was framed.

Lewis CL, et al A randomized trial of three videos that differ in the
framing of information about mammography in women 40 to 49 years old. J
Gen Intern Med. 2003 Nov;18(11):875-83.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14687272>

# Suicide and Attempted Suicide: Entire MMWR dedicated to topic 

Suicide is the 13th leading cause of death worldwide, the 11th in the
United States, and the third among U.S. residents aged 10\--24 years,
accounting for 4,243 (11.7%) of all deaths in this age group. Suicide
attempts and other acts of self harm that result in nonfatal injuries
take a heavy toll on the health of younger persons. In 2002, an
estimated 124,409 visits to U.S. emergency departments were made after
attempted suicides or other self-harm incidents among persons aged
10\--24 years.

To provide insights that might lead to successful prevention programs,
this week\'s *MMWR* includes reports on 1) trends in suicide by persons
aged 10\--19 years, 2) suicide attempts and physical fighting among high
school students, 3) school-associated suicides, 4) suicide among
Hispanics, and 5) suicidal behavior in China.

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5322a1.htm>

Reducing the overall suicide rate and the number of suicide attempts
reported by adolescents are among the 2010 national health objectives
(objective nos. 18-1 and 18-2) (*2*). Integrated prevention strategies
that address multiple associated factors (e.g., substance abuse
prevention, family and peer support, and access to health services) are
likely to be more effective in reducing suicidal behavior than programs
that focus on a single risk factor (*3*). Additional information about
suicide prevention is available at
<http://www.cdc.gov/ncipc/factsheets/suifacts.htm>.

**Surgeon General Updates Report on Health Effects of Smoking**

The Health Consequences of Smoking: A Report of the Surgeon General
updates the 1964 report on the health effects of active smoking was
prepared by the Centers for Disease Control and Prevention\'s Office on
Smoking and Health

The U.S. Department of Health and Human Services has also released a
companion database containing more than 1,600 articles cited in the
report. The database can be used to find detailed information on the
specific effects of smoking as well as to develop customized analyses,
tables, and figures. The database will be updated as new studies are
published. An animated Web site for the public has also been launched to
show the hazards of smoking and the benefits of quitting. The printed
report, a full-color summary, the companion database, and the public Web
site are available at
[[http://www.surgeongeneral.gov/library/smokingconsequences]{.underline}](http://www.surgeongeneral.gov/library/smokingconsequences)

##### Features

## American Family Physician\*\*

###### Patient-Oriented Evidence that Matters (POEMS)\*

**Breast Augmentation Unlikely to Affect Cancer Identification**

[Bottom Line:]{.underline} Breast augmentation decreases the sensitivity
of screening mammography in asymptomatic women but does not increase the
false-positive rate. The prognostic characteristics of tumors at the
time of diagnosis and treatment in these women are not influenced by
augmentation, suggesting but not proving that there is no effect on
long-term morbidity or mortality rates. Among symptomatic women with
augmentation, the accuracy of mammography appears to be unaffected and
the prognostic characteristics of tumors are slightly more favorable. As
with other women, those with breast augmentation should be encouraged to
undergo routine screening mammography at recommended intervals. (Level
of Evidence: 2b)

<http://www.aafp.org/afp/20040601/tips/13.html>

###### 

**Labor in Water Is Effective Treatment for Slow Labor**

[Bottom Line:]{.underline} Labor in water is as effective as oxytocin
augmentation in the management of slow labor progress in the first stage
in terms of time to delivery and mode of delivery. Women in the group
randomized to labor in water had less pain and less frequent use of
epidural analgesia. (Level of Evidence: 1b)

<http://www.aafp.org/afp/20040601/tips/14.html>

**Use Single Course of Corticosteroids for PPROM**

[Bottom Line:]{.underline} A single course of antenatal corticosteroids
is recommended for women with PPROM. Weekly courses do not improve
neonatal outcomes and are associated with increased risk of
chorioamnionitis. (Level of Evidence: 1b)

<http://www.aafp.org/afp/20040601/tips/15.html>

**\*POEM Rating system**: <http://www.infopoems.com/levels.html> **POEM
Definition:** <http://www.aafp.org/x19976.xml>

**Ethinyl Estradiol/Drospirenone (Yasmin): A Newer Oral Contraceptive**

<http://www.aafp.org/afp/20040515/steps.html>

**Over-the-Counter Medications in Pregnancy**

<http://www.aafp.org/afp/20030615/2517.html>

**Editorial: Information on Medication Use in Pregnancy**

<http://www.aafp.org/afp/20030615/editorials.html>

**Diethylstilbestrol Exposure**

Women who took diethylstilbestrol during pregnancy have a slightly
increased risk of breast cancer. Their offspring have a higher incidence
of structural reproductive tract anomalies and an increased risk for
some types of cancer.

<http://www.aafp.org/afp/20040515/2395.html>

**Patient Education: DES Exposure**

<http://www.aafp.org/afp/20040515/2401ph.html>

**Depression in Later Life: A Diagnostic and Therapeutic Challenge**

<http://www.aafp.org/afp/20040515/2375.html>

**Prevention and Treatment of Overweight in Children and Adolescents**

<http://www.aafp.org/afp/20040601/2591.html>

\*\* The AFP sites will ask for a username and password. Instead, just
hit 'cancel' the pop up password screen, and the page you are requesting
will come up without having to enter a username and password.

##### ACOG

**Diagnosis and Treatment of Gestational Trophoblastic Disease**

**ACOG Practice Bulletin No. 53**.

**Summary of Recommendations**

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

-   In women of reproductive age with abnormal bleeding or symptoms that
    could be caused by a malignancy, ß-hCG levels should be evaluated to
    facilitate early diagnosis and treatment of gestational
    trophoblastic disease.

-   In patients with molar pregnancy, the preferred method of evacuation
    is suction D&C. After molar evacuation, all patients should be
    monitored with serial hCG determinations to diagnose and treat
    malignant sequelae promptly.

-   Oral contraceptives have been demonstrated to be safe and effective
    during posttreatment monitoring based on randomized controlled
    trials.

-   Women with nonmetastatic gestational trophoblastic disease should be
    treated with single-agent chemotherapy.

-   For women with nonmetastatic gestational trophoblastic disease,
    weekly doses of 30--50 mg/m^2^ of intramuscular methotrexate has
    been found to be the most cost-effective treatment when taking
    efficacy, toxicity, and cost into consideration.

-   Women with metastatic gestational trophoblastic disease should be
    referred to specialists with experience treating this disease.

-   Women with high-risk metastatic disease should be treated with
    multiagent chemotherapy. This includes triple therapy with
    methotrexate, dactinomycin, and either chlorambucil or
    cyclophosphamide. More recent regimens further incorporate etoposide
    with or without cisplatin into combination chemotherapy

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

-   False-positive test results should be suspected if hCG values
    plateau at relatively low levels and do not respond to therapeutic
    maneuvers, such as methotrexate given for a presumed persistent mole
    or ectopic pregnancy.

-   Serial quantitative serum hCG determinations should be performed
    using a commercially available assay capable of detecting ß-hCG to
    baseline values (\<5 mIU/mL). Ideally, serum hCG levels should be
    obtained within 48 hours of evacuation, every 1--2 weeks while
    elevated, and then at 1--2 month intervals for an additional 6--12
    months.

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

-   Abnormal bleeding for more than 6 weeks following any pregnancy
    should be evaluated with hCG testing to exclude a new pregnancy or
    gestational trophoblastic disease.

-   In compliant patients, the low morbidity and mortality achieved by
    monitoring patients with serial hCG determinations and instituting
    chemotherapy only in patients with postmolar gestational
    trophoblastic disease outweighs the potential risk and small benefit
    of routine prophylactic chemotherapy after evacuation of a molar
    pregnancy.

-   Serious complications are not uncommon in women with a uterus size
    greater than a 16-week gestation, so they should be managed by
    physicians experienced in the prevention and management of
    complications.

-   Patients for whom initial therapy for nonmetastatic or low-risk
    metastatic disease fails and those with high-risk malignant
    gestational trophoblastic disease should be managed in consultation
    with individuals or facilities with expertise in the complex,
    multimodality treatment of these patients.

Diagnosis and treatment of gestational trophoblastic disease. ACOG
Practice Bulletin No. 53. American College of Obstetricians and
Gynecologists. Obstet Gynecol 2004;103:1365--77.

Non-ACOG members

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15172880>

ACOG members

<http://www.acog.org/publications/educational_bulletins/pb053.cfm>

**At-Risk Drinking and Illicit Drug Use: Ethical Issues in Obstetric and
Gynecologic Practice**

Committee Opinion #294

ABSTRACT: Abuse of alcohol and drugs is a major health problem for
American women across differences in socioeconomic status, race,
ethnicity, and age, and it is costly to individuals and to society.
Obstetrician--gynecologists have an ethical obligation to learn and use
a protocol for universal screening questions, brief intervention, and
referral to treatment in order to provide patients and their families
with medical care that is state-of-the-art, comprehensive, and
effective. In this Committee Opinion, the American College of
Obstetricians and Gynecologists\' Committee on Ethics proposes an
ethical rationale for this protocol in both obstetric and gynecologic
practice and provides guidelines for resolving common ethical dilemmas
related to drug and alcohol use that arise in the clinical setting.

ACOG Committee Opinion #294: At-Risk Drinking and Illicit Drug Use:
Ethical Issues in Obstetric and Gynecologic Practice. Obstet Gynecol.
2004 May;103(5):1021-1031.

For non-members

[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15121596]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15121596)

For ACOG members

[[http://www.acog.org/publications/committee_opinions/co294.cfm]{.underline}](http://www.acog.org/publications/committee_opinions/co294.cfm)

**Pregnancy, Airline Travel and Radiation Exposure**

Occasional airline travel by pregnant women generally poses little risk
of radiation exposure to developing fetuses, but pregnant pilots, flight
attendants, air marshals, couriers, and frequent business travelers can
receive radiation exposures that exceed current recommendations if they
do not modify their work schedules, according to a current commentary in
*Obstetrics & Gynecology*

<https://www.acog.com/from_home/publications/press_releases/nr05-31-04-2.cfm>

Current commentary in *Obstetrics & Gynecology*

<https://www.acog.com/from_home/publications/green_journal/2004/v103n6p1326.pdf>

##### AHRQ

**Hysterectomy results in better outcomes than medicine with abnormal
uterine bleeding**

[[http://www.ahrq.gov/research/apr04/0404RA1.htm]{.underline}](http://www.ahrq.gov/research/apr04/0404RA1.htm)

**Cervical cancer screening every 3 yrs after three or more normal Pap
tests is a safe option**

[[http://www.ahrq.gov/research/apr04/0404RA8.htm#head3]{.underline}](http://www.ahrq.gov/research/apr04/0404RA8.htm#head3)

**USPSTF: Primary care clinicians should screen / counsel adults to
prevent ETOH misuse**

[[http://www.ahrq.gov/research/apr04/0404RA22.htm#head1]{.underline}](http://www.ahrq.gov/research/apr04/0404RA22.htm#head1)

**Telecolposcopy reduces barriers to diagnosis of cervical cancer among
rural women**

[[http://www.ahrq.gov/research/may02/0502RA23.htm#head2]{.underline}](http://www.ahrq.gov/research/may02/0502RA23.htm#head2)

**Mammography increases likelihood of breast-conserving surgery among
older women**

[[http://www.ahrq.gov/research/may02/0502RA22.htm#head1]{.underline}](http://www.ahrq.gov/research/may02/0502RA22.htm#head1)

**Findings discount link between estrogen deficiency and cognitive
decline in older women**

[[http://www.ahrq.gov/research/may02/0502RA24.htm#head3]{.underline}](http://www.ahrq.gov/research/may02/0502RA24.htm#head3)

##### Breastfeeding

**Breastfeeding may reduce heart disease risk later in life**

[INTERPRETATION:]{.underline} Our data provide experimental evidence for
the long-term benefits of breastmilk feeding on the risk of
atherosclerosis.

Singhal A, Cole TJ, Fewtrell M, Lucas A.Breastmilk feeding and
lipoprotein profile in adolescents born preterm: follow-up of a
prospective randomised study. Lancet. 2004 May 15;363(9421):1571-8.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15145629>

**Diabetes prevention and breastfeeding**

<http://www.amysbabycompany.com/newsletter/marchapril2004.html>

**[Domestic Violence]{.underline}**

**Pregnancy-associated assault hospitalizations**

[CONCLUSION:]{.underline} While pregnant women were more likely to be
hospitalized for assaults, most of the increase is associated with their
lower hospital admission threshold and increased rates of both pregnancy
and assaults among young and nonwhite women. Practitioners should
perhaps think of pregnant women more as a \"sensitive\" rather than a
\"high-risk\" group.

Weiss HB, Lawrence BA, Miller TR. Pregnancy-associated assault
hospitalizations. Obstet Gynecol. 2002 Oct;100(4):773-80.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12383548>

**Health care and contraception among adolescents reporting unwanted
sexual intercourse**

[CONCLUSIONS:]{.underline} Many adolescents have been forced or
pressured to have sexual intercourse. Although many have never told
anyone about the incident, most have visited a primary care physician or
clinician. Physicians and other clinicians should screen for a history
of unwanted intercourse and provide needed referrals for counseling
and/or contraceptive information.

Wilson KM, Klein JD. Opportunities for appropriate care: health care and
contraceptive use among adolescents reporting unwanted sexual
intercourse. Arch Pediatr Adolesc Med. 2002 Apr;156(4):341-4

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11929367>

**Patterns of intimate partner violence among adolescent mothers in the
postpartum period**\
[CONCLUSIONS:]{.underline} Adolescents are at high risk for experiencing
IPV during the postpartum period. Frequent screening for IPV by health
care practitioners is critical to maximize detection.\
Harrykissoon SD, Rickert VI, Wiemann CM.Prevalence and patterns of
intimate partner violence among adolescent mothers during the postpartum
period. Arch Pediatr Adolesc Med. 2002 Apr;156(4):325-30

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11929364>

**Domestic violence screening behaviors among pediatricians and family
physicians**

[CONCLUSIONS:]{.underline} Only a minority of Connecticut pediatric care
physicians routinely screen mothers for DV. Primary care physicians with
education and training about DV are screening at higher rates than
physicians with no education and training. Pediatric physicians need
training, protocols, and best-practice models on how to identify /
intervene with families experiencing DV.

Lapidus G, Cooke MB, Gelven E, Sherman K, Duncan M, Banco L. A statewide
survey of domestic violence screening behaviors among pediatricians and
family physicians. Arch Pediatr Adolesc Med. 2002 Apr;156(4):332-6.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11929365>

**Domestic violence: an education program for hospital staff**\
An assistant director of nursing in an acute hospital describes how she
identified a need for staff education about domestic violence and set up
an awareness programme. Nominated nurses from the clinical areas most
affected\--Accident & Emergency, maternity, gynaecology and
paediatrics\--attended and disseminated information to colleagues. The
content of the course is described. Evaluation showed that
participants\' knowledge base increased by an estimated 25%. Junior
medical staff now receive one hour\'s education in domestic violence
during their A&E rotation. Links were forged with community agencies
specialising in domestic violence, resulting in a more effective
referral system.

Wallace A. Domestic violence: an education programme for hospital staff.
J Fam Health Care. 2002;12(3):65-7.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12415764>

**Violence-inflicted injuries: reporting laws in the fifty states**

[CONCLUSION:]{.underline} Forty-five states have laws that mandate
physician reports of injuries caused by weapons, crimes, or domestic
violence. Physicians need to be aware of the existence of these laws and
of their state\'s specific requirements.

Violence-inflicted injuries: reporting laws in the fifty states Houry D,
Sachs CJ, Feldhaus KM, Linden J. Ann Emerg Med. 2002 Jan;39(1):56-60.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11782731>

**Measuring the quality of hospital-based domestic violence programs**

[CONCLUSIONS:]{.underline} A number of measures have been identified as
useful for evaluating hospital-based DV programs. Use of these measures
should assist researchers, program planners, and administrators in
assessing the quality of hospital-based DV programs.

Coben JH. Measuring the quality of hospital-based domestic violence
programs. Acad Emerg Med. 2002 Nov;9(11):1176-83.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12414467>

**[Elder Care News]{.underline}**

**Ultrasound bone assessment is a reliable predictor of fracture risk**

A large (15,000) cohort of men and women recruited from primary care
practices as part of a cancer epidemiology study had heel ultrasound
measurements with a mean follow-up of 1.9 years. Fractures were
ascertained from admission data (missing less serious fractures and many
vertebral fractures). Men and women in the lowest 10% of the cohort (as
measured by broadband ultrasound attenuation -- BUA) had over 4 times
the risk of fracture over the study period as men and women in the
highest 30% (RR 4.44, 95% CI 2·24--8·89). The lowest 10% BUA was roughly
equivalent to 2.0 SD below the mean at age 45 in men and 1.5% below the
mean at age 45 in women. Ultrasound prediction of fracture risk was
independent of clinical risk factors and had the same power of
prediction in older and younger persons and in men and women. Bone
density as measured by heel ultrasound is a continuous variable. Every
1SD decrease in BUA (broadband ultrasound attenuation) was associated
with a doubling of the risk of fracture (RR 1.95, 95% CI 1·50--2·52).

This study adds to the evidence (Siris, et al) that ultrasound bone
assessment is a reliable predictor of fracture risk. Ultrasound is an
accessible modality for many Indian health facilities, but treatment
trials have all been based on the more expensive and less accessible
DEXA modality. It is also one of the few large studies to look
prospective bone health data and fracture risk in men. The authors point
out that a population-based approach to bone health (through ensuring
adequate calcium and vitamin D intake and regular physical activity) has
the potential to increase bone density (as measured by heel ultrasound
or DEXA) and thus reduce the rate of fracture.

Khaw K-T et al. Prediction of total and hip fracture risk in men and
women by quantitative ultrasound of the calcaneous: EPPIC-Norfolk
prospective population study. Lancet 2004 Jan17; 363:197-202.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14738792>

[Siris ES, et al. Identification and fracture outcomes of undiagnosed
low bone mineral density in postmenopausal women; results from the
National Osteoporosis Risk Assessment. JAMA 2001. 286(22):
2815-2822.](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11735756)

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11735756>

**[Frequently asked questions]{.underline}**

**Q. Should Active Management of the Third Stage of Labor Be Routine?**

**A.** Yes, AFP presents a review of the Cochrane Library

<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHfaq.asp#activeman>

**Q. How can my department tell if we providing effective urinary
incontinence procedures?**

A. Two good benchmark times to re-evaluate are at 1 and 5 years post
operatively.

<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHfaq.asp#incontSuc>

**Q. Is membrane stripping associated with abruption placenta?**

A. No, in addition, there was no increased risk of maternal or neonatal
infection, but minor maternal discomforts were common.

<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHfaq.asp#memStr>

**Q. Is percutaneous drainage of tubo-ovarian abscess standard of
care?**

A. Yes, especially in women who have not completed their child-bearing

<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHfaq.asp#tubo>

**[Hormone Replacement Update]{.underline}**

**Regular soy intake may protect against endometrial cancer**

[CONCLUSION:]{.underline} Regular intake of soya foods is associated
with a reduced risk of endometrial cancer.

Xu WH, et al Soya food intake and risk of endometrial cancer among
Chinese women in Shanghai: population based case-control study. BMJ.
2004 May 29;328(7451):1285

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15136343>

# [Information Technology]{.underline}

**Q Man, Collecting Data for the CMS Initiatives**

Terry Cullen has passed along the following information to the IHS
hospitals about running Q Man queries on your RPMS databases to assist
you in your new reporting requirements to CMS (for hospitals only).

A detailed User Manual \"QMan, Collecting Data for the CMS Initiatives\"
may be downloaded directly for the RPMS Documentation web site, at the
following link:
<http://www.ihs.gov/Cio/RPMS/PackageDocs/bgp/otherbgpdocs.asp>

The document is available in both PDF and HTML formats.\
Additional questions about reporting to CMS should be referred to Elmer
Brewster.

**2004 Technology Conference**

DIR is planning to host the 2004 Technology Conference the week of
August 23^rd^, 2004 in Scottsdale, Az. Contact Terry Cullen for
questions <Theresa.Cullen@IHS.GOV>

# [International Health Update]{.underline}

**Eating Dirt**\
This article explores what appears to be nonpathological dirt eating in
pregnant women (especially in sub-Saharan Africa), migrants from
sub-Saharan cultures to other parts of the world (notably the United
States), and children worldwide.

<http://www.cdc.gov/ncidod/EID/vol9no8/03-0033.htm>

#### [MCH Alert]{.underline}

**Blood pressure has increased substantially among children and
adolescents**

CONCLUSIONS: Blood pressure has increased over the past decade among
children and adolescents. This increase is partially attributable to an
increased prevalence of overweight.

Muntner P, et al Trends in blood pressure among children and
adolescents. JAMA. 2004 May 5;291(17):2107-13\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15126439>

#### [Medscape\*]{.underline}

######### Patient Education: Understanding Sleep Problems - The Basics

<http://www.medscape.com/viewarticle/474122>

######### 

######### 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.

**[Office of Women's Health, CDC]{.underline}**

**Spina Bifida and Anencephaly decreased by 25% After Folic Acid
Mandate**

Neural tube defects (NTD) affected pregnancies in the United States
declined from 4,000 in 1995-1996 to 3,000 in 1999-2000. This decline in
NTD-affected pregnancies highlights the partial success of the U.S.
folic acid fortification program as a public health strategy. To reduce
further the number of NTD-affected pregnancies, all women capable of
becoming pregnant should follow the USPHS recommendation and consume 400
*µ*g of folic acid every day. 

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5317a3.htm>

**Few Women Regret Sterilization Procedures**

The proportion of women who experience regret was essentially the same -
about 6 to 7% - five years after their husbands\' vasectomy or their own
tubal sterilization. Substantial conflict between a woman and her
husband increases the risk of regret after either vasectomy or tubal
sterilization

[[http://www.nih.gov/news/pr/jun2002/nichd-17.htm]{.underline}](http://www.nih.gov/news/pr/jun2002/nichd-17.htm)

**[Osteoporosis]{.underline}**

**Childbearing reduces hip fracture risk by means that may be
independent of hip BMD**

Conclusion: childbearing reduces hip fracture risk by means that may be
independent of hip bone mineral density.

Hillier TA, Rizzo JH, Pedula KL, Stone KL, Cauley JA, Bauer DC, Cummings
SR Nulliparity and fracture risk in older women: the study of
osteoporotic fractures. J Bone Miner Res. 2003 May;18(5):893-9\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12733729>

**Depot Medroxyprogesterone Acetate Use Associated With Bone Mineral
Density Loss**

Results of a study suggest that the loss of bone mineral density
associated with the use of depot medroxyprogesterone acetate is linear
during the first 2 years of use. Women who used the medication for 24
months had an average loss in bone mineral density of 5.7%.

Berenson AB et al Effects of hormonal contraception on bone mineral
density after 24 months of use. Obstet Gynecol. 2004 May;103(5 Pt
1):899-906.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15121563>

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

**Consumer Health Journal**

"We read the studies for you, and translate them into readable English.
But we tell you where to find them, too, in case you want to read them
for yourself. We also provide background biology and end-of-article
reporter\'s notes, as well as mid-article links to our sources."

Recent articles include:
<http://www.consumerhealthjournal.com/index.html>

[Regulated Medical School Admissions Protect Doctor
Salaries](http://www.consumerhealthjournal.com/articles/regulated-doctor-shortage.html)\
[Study Analysis: Prenatal Alcohol; Studies Show Harm, but Ignore
Smoking](http://www.consumerhealthjournal.com/articles/prenatal-alcohol.html)\
[Health Rankings: Buyer
Beware](http://www.consumerhealthjournal.com/articles/health-rankings.html)\
[Cancer\'s Geography in the
USA](http://www.consumerhealthjournal.com/articles/cancer-deaths-graph.htm)\
[Medical Studies: Types and
Limitations](http://www.consumerhealthjournal.com/articles/medical-studies.html)\
[Study Analysis: Milk Is Linked to
Cancer](http://www.consumerhealthjournal.com/articles/milk-and-cancer.html)\
[Doctors Avoid the Weight
Issue](http://www.consumerhealthjournal.com/articles/doctors-avoid-weight-issue.html)\
[Overview: Health Insurance for
Fido:](http://www.consumerhealthjournal.com/articles/dog-health-insurance.html)\
[Chocolate Is Shown to Combat
Aging](http://www.consumerhealthjournal.com/articles/chocolate.htm)\
[Study Analysis: More Meals May Mean Better
Health](http://www.consumerhealthjournal.com/articles/meal-frequency.html)\
[Media Bombards Women with Mixed Weight
Messages](http://www.consumerhealthjournal.com/articles/women-and-weight.html)\
[Q&A: Pregnancy and
Alcohol](http://www.consumerhealthjournal.com/articles/prenatal-alcohol-QA.html)

**[Primary Care Discussion Forum]{.underline}**

**Next topic: Adult Asthma**

On August 1, 2004, thanks to Charles (Ty) Reidhead, Whiteriver, we will
start an Adult Asthma Discussion. This topic is a special request from
the Council of Clinical Directors.

Ty is the IHS Internal Medicine Chief Clinical Consultant and will
moderate a discussion that uses evidence based practice to improve
patient outcomes in Indian Country for this common problem.

Also see the summary of the AAP, Indian Health - Special Interest Group
Discussion of
<http://www.ihs.gov/generalweb/webapps/sitelink/site.asp?link=http://www.aap.org/nach/asthmasummary.htm>

Contact Steve Holve, Tuba City, for questions about the AAP Indian
Health Special Interest Group, 928 283 2679.

**Other coming topics:**

**November 1, 2004: Violence against Native women**

Moderator: Terry Cullen

This discussion will include the scope of violence against Native women,
tools for patient evaluation, best practice policies and procedures,
plus ideas about available resources.

**Just wrapping up**

**Adolescent Risk Taking Behavior**

On May 1, 2004, Donna Perry in Chinle, began moderating a discussion of
Adolescent Risk Taking Behavior on the Primary Care Discussion Forum.
This will be a combined listserv Discussion with the Special Interest
Group -- Indian Health of the AAP.

The Discussion is captured online:
<http://www.ihs.gov/medicalprograms/MCH/M/documents/ADODisc6904.doc>

The Summary is presented here:
<http://www.ihs.gov/medicalprograms/MCH/M/documents/ADOSumm6904.doc>

An excerpt of the **Summary** and **References** are presented here:

.......We have some challenges. I would suggest we consider more
adolescent topics at our local, regional and national meetings. This
would be a place for dialog, increasing our skills, and planning more
standardized approaches given our restraints on resources. We need to
share programs that work in our communities. We can develop outcomes
measures that will help us plan for improving care in our communities. A
recent supplement to the journal Pediatrics discussed how to measure
effectiveness of adolescent health care. How can we apply that to our
communities? For those who have school based or school linked clinics,
IHS headquarters is developing a discussion and work group in which we
can participate. We can also commiserate in our struggle to provide
increasingly accessible teen health care.

**References**

A January 2004 supplement to the journal *Pediatric*s 113(1) is focused
on measuring the quality of children\'s health care as a key step in
quality improvement.

Extensive quality problems have been documented across all sectors of
health services for children and adolescents. For example, problems
persist in asthma care, well-child and adolescent care, childhood
immunization rates, and sexually transmitted disease screening for
adolescents. Many other problems in children\'s health care delivery are
not being adequately measured and monitored.

[[http://www.ahrq.gov/research/apr04/0404RA15.htm#head1]{.underline}](http://www.ahrq.gov/research/apr04/0404RA15.htm#head1)

Patient Education handouts on Reproductive Health

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

Updated consent and confidentiality and other adolescent health care
related policy

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

School based health care and good evaluation of care suggestions and
outcomes options

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

To subscribe to the Primary Care Discussion Forum, please go the site
below and click the word 'subscribe' in the first paragraph, or contact
me, <nmurphy@anmc.org>

[[www.ihs.gov/MedicalPrograms/MCH/M/MCHdiscuss.asp]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdiscuss.asp)

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

**Pediatric Obesity and Type 2 Diabetes, Cardiovascular Disease**\
The Diabetes Prevention & Control Program (DPCP) is hosting a
teleconference titled, \"Pediatric Obesity and Type 2 Diabetes,
Cardiovascular Disease\" on Wednesday, June 23, 2004, from 12:30 - 2:00
PM EST. Michael Goran, M.D., and Francine Kaufman, M.D., Keck School of
Medicine, University of Southern California, will discuss the
progression of childhood obesity to type 2 diabetes and the implications
for adult chronic disease-specifically cardiovascular disease.

Contact <Barbara_Stillwater@health.state.ak.us>

**DID YOU KNOW?**\
\"In a study of 72488 women, those 20% who walked the most - 10 miles
per week or more (about 3500 steps per day), had 1/3 lower risk of
coronary heart disease compared with those in the bottom 20% of
activity.\" [CONCLUSIONS]{.underline}: These prospective data indicate
that brisk walking and vigorous exercise are associated with substantial
and similar reductions in the incidence of coronary events among women.

Manson JE, et al A prospective study of walking as compared with
vigorous exercise in the prevention of coronary heart disease in women.
N Engl J Med. 1999 Aug 26;341(9):650-8\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10460816>

**Dark Chocolate Improves Endothelial Function in Healthy Adults**

[CONCLUSION:]{.underline} Flavonoid-rich dark chocolate improves
endothelial function and is associated with an increase in plasma
epicatechin concentrations in healthy adults. No changes in oxidative
stress measures, lipid profiles, blood pressure, body weight or BMI were
seen.

Engler MB, et al Flavonoid-rich dark chocolate improves endothelial
function and increases plasma epicatechin concentrations in healthy
adults. J Am Coll Nutr. 2004 Jun;23(3):197-204.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15190043>

**Two New RCTs: Low Carb Diet More Beneficial Than Low Fat Diet**

[CONCLUSIONS:]{.underline} Compared with a low-fat diet, a
low-carbohydrate diet program had better participant retention and
greater weight loss. During active weight loss, serum triglyceride
levels decreased more and high-density lipoprotein cholesterol level
increased more with the low-carbohydrate diet than with the low-fat
diet.

Yancy WS et al A low-carbohydrate, ketogenic diet versus a low-fat diet
to treat obesity and hyperlipidemia: a randomized, controlled trial. Ann
Intern Med. 2004 May 18;140(10):769-77.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15148063>

[CONCLUSION:]{.underline} Participants on a low-carbohydrate diet had
more favorable overall outcomes at 1 year than did those on a
conventional diet. Weight loss was similar between groups, but effects
on atherogenic dyslipidemia and glycemic control were still more
favorable with a low-carbohydrate diet after adjustment for differences
in weight loss

Stern L et al The effects of low-carbohydrate versus conventional weight
loss diets in severely obese adults: one-year follow-up of a randomized
trial. Ann Intern Med. 2004 May 18;140(10):778-85.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15148064>

**Acarbose Curbs Atherosclerosis in Pre-Diabetes**

[CONCLUSIONS:]{.underline} Acarbose slows progression of IMT in IGT
subjects, a high-risk population for diabetes and atherosclerosis. This
is the first placebo-controlled prospective subgroup analysis,
demonstrating that counterbalancing of postprandial hyperglycemia may be
vasoprotective.

Hanefeld M et al Acarbose slows progression of intima-media thickness of
the carotid arteries in subjects with impaired glucose tolerance.
Stroke. 2004 May;35(5):1073-8. Epub 2004 Apr 08.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15073402>

**41 MILLION ADULTS NOW REPORTED TO HAVE PRE-DIABETES: 40% of US
Adults**

The Department of Health and Human Services announced that about 40
percent of U.S. adults ages 40 to 74 - or 41 million people - currently
have pre-diabetes, a condition that raises a person\'s risk of
developing type 2 diabetes, heart disease, and stroke. Many don\'t know
they are at risk or that they have pre-diabetes.

Tailored diabetes prevention materials are now available for these high
risk audiences: African Americans, Hispanic and Latino Americans,
American Indians and Alaska Natives, Asian Americans and Pacific
Islanders, and older adults. Materials available at
[[www.ndep.nih.gov]{.underline}](../www.ndep.nih.gov).

**Walking \... A Step in the Right Direction**

The CDC has partnered with NIDDK to make agencies aware of a terrific
walking program already available, \"Walking \... A Step in the Right
Direction\" created by the Weight-control Information Network (WIN) of
NIDDK.   It is simple and easy to follow.   When used with a pedometer
to get accurate data and a weekly log to record that data, the program
provides measurable physical activity in a usable and useful format. 

\"Walking \... A Step in the Right Direction\"\
<http://www.niddk.nih.gov/health/nutrit/walking/walkingbro/walking.htm>

\"Weight Loss for Life\"\
<http://www.niddk.nih.gov/health/nutrit/pubs/wtloss/wtloss.htm>

\"Choosing a Safe and Successful Weight Loss Program\"\
<http://www.niddk.nih.gov/health/nutrit/pubs/choose.htm>

**How many children are likely to get type 2 diabetes and why it
develops?**

SEARCH is a 5-year multi-center study funded by the CDC (Center for
Disease Control and Prevention) and NIDDK (National Institute of
Diabetes and Digestive and Kidney Diseases). The study focuses on
children and youth in the U.S. who have diabetes. It is expected that
the six clinical centers located in California, Colorado, Hawaii, Ohio,
South Carolina, and Washington will invite approximately 9000 children
and youth who have been diagnosed with diabetes to participate in this
study. Data from these children and youth will provide more information
and help us better understand diabetes. Contact for questions

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

**What are the best ways to treat type 2 diabetes in children and
teens?**

The TODAY (Treatment Options for type 2 Diabetes in Adolescents and
Youth) study, which seeks to identify the best treatment of type 2
diabetes in children and teens, has begun in 12 medical centers and
affiliated sites around the country.

<http://www.niddk.nih.gov/patient/today/today.htm>

**Fat Distribution In Women Tied To Heart Disease Risks**

<http://www.diabetesincontrol.com/issue210/item6.shtml>

**Physical Activity Does More Than Burn Calories & Improve Diabetes
Control**

<http://www.diabetesincontrol.com/issue210/item2.shtml>

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

**New Perinatology Corner Module available: Syphilis in Pregnancy**

Free CME /CEUs available that address the recent increase in syphilis in
Indian Country

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

**FDA Estrogen and Estrogen with Progestin Therapies: Good patient
handouts**

<http://www.ihs.gov/MedicalPrograms/MCH/W/WHmature.asp#FDAEstrogen>

**Women\'s Health Information - National Institutes of Health**

<http://www.ihs.gov/MedicalPrograms/MCH/M/Mchpated.asp#natInst>

There are several upcoming **Conferences**

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

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

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

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

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

...or just take a look at the **What's New** page

<http://www.ihs.gov/MedicalPrograms/MCH/W/WN00.asp#top>

### **[Save the dates]{.underline}**

**2004 Native Maternity Care and Women's Health meeting: Prevention in
Women's Health**

August 4-6, 2004

Albuquerque, New Mexico

Great CEU /CME, plus good networking for leaders of Women's Health / MCH

Contact Neil Murphy for questions <nmurphy@anmc.org>

<http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#August2004>

**Indian Health Service Health Summit**

**"Healthier Indian Communities through Partnership and Prevention"**

September 22-24, 2004

Washington, D.C.

Sponsor: Health Promotion/Disease Prevention (HP/DP)

<http://www.ihs.gov/HPDP/Documents/IHS_Indian_Health_Summit.doc>

**20th Annual Midwinter Conference**

-   For providers caring for Native women and children

-   February 25 - 27, 2005 **Final dates**

-   Telluride, CO
    <http://www.ihs.gov/MedicalPrograms/MCH/M/ConfDnlds/Tellurideagenda10-2004.doc>

-   Contact Alan Waxman <awaxman@salud.unm.edu>

Did you miss something in the last OB/GYN Chief Clinical Consultant
Corner?

The **May 2004 OB/GYN CCC Corner** is available at:\
<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/4C51904.doc>

**[Contents:]{.underline}**

**[Abstract of the Month]{.underline}: page 2**

ACOG Recognizes Vermont and New Hampshire Ob-Gyns for Vaginal Birth
after Cesarean (VBAC) Project: What is the trend in VBAC?

[From your colleagues:]{.underline} page 4

**From Barbara Fine:** Impaired Fasting Glucose now starts a 100 mg/dL:
Millions More Have Pre-Diabetes; Native Women with Heart Disease; HRSA
Announces Perinatal Mental Wellness Grant; Scholarships for Native
Health leaders, practitioners, and other individuals committed to
promoting public health for Native American tribes.

**From Bill Green:** Aggressive Lipid Lowering With Statins Better Than
Moderate Lowering** **

From Steve Holve: May Child Health Notes, IHS, Steve Holve:
Bronchiolitis, etc...

From Elaine Locke: Free Job Postings for Indian Facilities Only on ACOG
Career Connection

From Barbara Orcutt: Post-Coital Contraception: Differing opinions and
options discussed

**From Jane Powers:** New Website from IHS / Office for Victims of
Crimes: Child Abuse Training

**From Laura Shelby:** Prevalence of chlamydial and gonococcal
infections among young adults

**From Barbara Stillwater:** Short Women Are At Greater Risk for
Gestational Diabetes; Diabetes doubled after gestational diabetes

**From Judy Thierry:** Breastfeeding and the Risk of Postneonatal Death
in the United States; Patient education for prenatals: I specifically
would like to know what.....; Please tell me how and if genetics clinics
are being run in your area?

**From Mary Wachacha:** Prenatal Patient Education Available in one
click

**[Hot Topics:]{.underline}**

**Obstetrics: page 8**

Skin-to-Skin Contact Beneficial in Healthy Term Newborns: Kangaroo care;
Some treatments for cervical intraepithelial neoplasia increase risk of
PROM; Prenatal exposure to fluoxetine \[Sarafem, Prozac\] results in
poor neonatal adaptation; Maternal Physical Activity May Reduce
Gestational Diabetes Risk; Potential Risk Factors for Gestational
Hypertension Identified; Does Asthma Adversely Affect Pregnancy
Outcomes? Multigene Association Study With Pregnancy Hypertension;
Dental care use and self-reported dental problems in relation to
pregnancy; Maternal dental x-rays linked to increased risk of infant low
birth weight

**Gynecology:** **page 10**

Aromatase and Leiomyoma of the Uterus; Sacral nerve stimulation
effective for fecal incontinence; In vitro-fertilization outcomes
improving in U.S.; Emergency Contraception: Effectiveness of a telephone
prescription service; Metformin Helps Patients with Polycystic Ovary
Syndrome; Benefits and Risks of OCPs Beyond Contraception

###### Child Health: page 11

###### Adolescent Health Issues in Indian Health; Schools: Finding they can raise funds without undermining children\'s diets and health

**Chronic Illness and Disease:** **page 12**

Glucosamine Has a Disease-Modifying Effect on Osteoarthritis; ACS
Guidelines Updated for Detection of Cancer: Cervical, breast,
colorectal, endometrial; Reduce alcohol misuse by adults, including
pregnant women - USPSTF; Pain-free efficacy with sumatriptan in the mild
pain of menstrually associated migraine; Optimal Exercise Duration and
Intensity in Women; Aromatase inhibitors - Use of Letrozole After
Tamoxifen for Breast Cancer; Sibutramine Treatment for Binge-Eating
Disorder

[Features:]{.underline} page 13

**AFP:** Annual Proteinuria Screening Is Not Cost-Effective -- POEM;
Cochrane for Clinicians

Vaginal Estrogen Preparations for Relief of Atrophic Vaginitis; Abnormal
Uterine Bleeding; Impaired Glucose Tolerance and Impaired Fasting
Glucose; Diagnosis and Treatment of Acne;

**ACOG:** Failure of the FDA To Approve OTC Status for Plan B® :Question
of decision's motivation; ACOG Recognizes Vermont and New Hampshire
Ob-Gyns for VBAC Project; Ginger Supplement Helps Relieve
Pregnancy-Related Nausea and Vomiting

**AHRQ:** Do Me a Favor -- Web Morbidity and Mortality

**Breastfeeding:** Is Varicella Vaccination Safe During Lactation?

**Domestic Violence:** Domestic Violence Track at Indian Health
Conference on Women's Issues: August 4-6, 2004, Albuquerque; Intimate
partner violence (IPV) high: Female caregivers of children reported to
CPS

**Elder Care News:** Ultrasound bone assessment is a reliable predictor
of fracture risk

**Frequently asked questions:** What should I do about a pregnant
patient's varicella like rash?

**Hormone Replacement Update**: Estrogen Does Not Prevent Chronic
Disease in Postmenopausal Women With Hysterectomy -- Medscape CME

**Information Technology:** 2004 Technology Conference, Scottsdale, AZ

**International Health:** Guidelines Can Save Lives -- Royal College of
Obstetricians and Gynaecologists (RCOG); Confidential Enquiry into
Stillbirths and Deaths in Infancy (CESDI) and the Confidential Enquiry
into Maternal Deaths (CEMD); National Institute for Clinical Excellence

**MCH Alert:** Oral Health and Health in Women: A Two-Way Relationship

######### Medscape: Emergency Contraceptive Pills and Adolescents (Web Conference) CME

#### Office of Women's Health, CDC: Venous Thromboembolism after Air Travel: Thrombophilia and Oral Contraceptives

**Osteoporosis:** Higher Calcium Intake May Decrease Risk of Kidney
Stones in Younger Women; Vitamin D Use Reduces Risk of Falls in Elderly

**Patient Education:** What Every Pregnant Woman Needs to Know About
Cesarean Delivery; Vaginal Yeast Infections; Vaginal Discharge;
Bacterial Vaginosis

**Primary Care Discussion Forum**: Adolescent Risk Taking Behavior with
Donna Perry is the current discussion; Adult Asthma will begin on August
1, 2004 with Ty Reidhead

The past CCC Corners are archived at:

<http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN01.cfm#top>

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

Let me know if you want to add something to next month's CCC Corner at
<nmurphy@anmc.org>

or 907 729 3154 (with voicemail)

\*The opinions expressed in the OB/GYN CCC Corner are strictly those of
the authors, and not necessarily those of the Indian Health System, or
the author of this newsletter. If you have any comments, please share
them by joining the Primary Care Discussion Forum where this topic was
recently discussed. To join the Primary Care Listserv, contact Jason
Crim at: [jason.crim@mail.ihs.gov](mailto:jason.crim@mail.his.gov)

6/14/04njm