**News Flash**

**2007 Indian Health MCH and Women's Health National Conference**

-   August 15 -17, 2007 Save the Dates

![](media/image1.png){width="5.990277777777778in"
height="1.3069444444444445in"}

 

OB/GYN Chief Clinical Consultant's Corner

Volume 4, No. 5, May 2006

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

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

Maternal periodontal disease in early pregnancy:
Small-for-gestational-age infant

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

Carolyn Aoyama

-Women's Health Assessment Toolkit (WHAT)

-The Management of Eating Disorders: New Report, AHRQ

**Donald Haverkamp**

Take the provider survey on colorectal cancer screening!

Chuck North

#### The new medical \"missionaries\"\--grooming the next generation of global health workers {#the-new-medical-missionaries--grooming-the-next-generation-of-global-health-workers .Style-Heading-4-+-Arial-14-pt-Underline}

Ty Reidhead

New funding opportunity under the IHS Chronic Disease Initiative

Christine Rinki

Infant Mortality Statistics from the 2003 Period Linked Birth/Infant
Death Data Set

Judy Thierry

Gestational Diabetes best practices CALL for examples

Congratulations to Yolanda Adams, Charlotte Briggs and all!

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

##### Obstetrics:

-Counterpoint: Not Yet Time to Use the P:C Ratio by David Gahn and Eric
Manske

-New campaign materials released to help GDM patients prevent or delay
Type 2 Diabetes

-Prenatal Weight Gain Recommendations - Obesity in Pregnancy

-Preconception Care: Recommendations to Improve Health of Babies and
Moms, CDC

-Early Glucose Challenge Testing Identifies Diabetes Versus Gestational
Diabetes\
-Strategies and outcome of Infant Mortality Reviews in the Aberdeen Area
of the IHS

and more....

**Gynecology:**

-FDA: Vaccine to Prevent Cervical Cancer Is Safe, Effective

-Amenorrhea: Evaluation and Treatment

**Child Health:**

-Relationship between team sport participation and adolescent smoking

-Prevalence of diabetes and impaired fasting glucose levels among U.S.
adolescents

-Sudden, Unexplained Infant Death Initiative

#### -Tool Kit on Teaching and Assessment children with Special needs {#tool-kit-on-teaching-and-assessment-children-with-special-needs .Style-Heading-4-+-Arial-14-pt-Underline}

-SIDS/Infant Death Resource Center is looking for materials\
and more....

**Chronic Illness and Disease:**

Caring for Patients After Bariatric Surgery

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

##### American Family Physician

Immersion Exercise Reduces Leg Edema in Pregnancy

American College of Obstetricians and Gynecologists

-ACOG Recommends First Ob-Gyn Visit in Early Teens

-Vaginitis, Practice Bulletin

-Hepatitis B and Hepatitis C Virus Infections in Obstetrics--Gynecology,
Committee Opinion

-The Apgar Score, Committee Opinion

-Role of the ON/GYN in the Screening and Diagnosis of Breast Masses,
Committee Opinion

-The Initial Reproductive Health Visit, Committee Opinion

**Agency for Healthcare Research and Quality**

-Do-not-resuscitate orders for terminally ill children may not be
honored by public schools

-Ectopic pregnancy rates are declining, but the decline is slower among
black women

-Close-call reporting systems may be underutilized in identifying
potential medical errors

-Doctors still prescribe antibiotics for over half of children with sore
throats

**Ask a Librarian**

MCH Library launches redesigned web site

**Breastfeeding**

Database provides information about drugs in breastfeeding mothers

**CCC Corner Digest**

\-[Protein to Creatinine Ratio in Pre-eclampsia: Is the data preceding
the U.S.
benchmarks?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0406_AOM.cfm)

\-[RCTs: Do they have external validity for patients with multiple
co-morbidities
?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0406_Coll.cfm)

\-[Gestational Diabetes Mellitus Tracking Sheets and Case Management
PPT](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0406_Coll.cfm)

\-[Glyburide is at least as effective as insulin therapy in treating
gestational
diabetes](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0406_HT.cfm#ob)

\-[Urinary incontinence: Substantial economic costs and decrement in
quality of
life](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0406_HT.cfm#gyn)

\-[Infant Mortality Reviews in the Aberdeen Area: Strategies and
Outcomes](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0406_HT.cfm#child)

\-[Breast cancer study from
PIMC](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0406_HT.cfm#chrIll)

\-[Less Invasive Management of Cervical Cytology Abnormalities in
Adolescents](http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN0406_Feat.cfm#acog)

\-[ACOG: New Guidelines Call for Restricted Use of
Episiotomies](http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN0406_Feat.cfm#acog)

\-[Early feeding choice and
obesity](http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN0406_Feat.cfm#breast)

\-[MCH Frequently Asked Question (FAQ)
site](http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN0406_Feat.cfm#webSite)

\-[What is the common
theme?](http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN0406_Feat.cfm#mmtour)

\-[Hands off\" versus \"hands on\" for decreasing perineal lacerations:
No
difference](http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN0406_Feat.cfm#MidWives)

\-[Methamphetamine abuse among women on Navajo, Part
1](http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN0406_Feat.cfm#navajo)

\-[Journey to
Magnet](http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN0406_Feat.cfm#nurseCorner)

\-[Peripartum
Cardiomyopathy](http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN0406_Feat.cfm#okie)

\-[Vaginal breech \< 3, 500 g - No increase risk in neurodevelopment at
2 years of
age](http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN0406_Feat.cfm#periPicks)

\-[Adverse Childhood Events: Impact on chronic adult illness / Risk
taking](http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN0406_Feat.cfm#pcf)

\-[Announcing New Program Manager for the IHS National STD
Program](http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN0406_Feat.cfm#std)

\-["Clinical inertia\" - Providers not intensifying diabetes therapy
when
indicated](http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN0406_Feat.cfm#stillW)

**Domestic Violence**

Grants Alert: Domestic Violence, Cultural Competence

**Elder Care News**

Maintenance treatment of major depression in old age

**Family Planning**

-31% of Sexually Active U.S. Teenage Girls Become Pregnant

-Postpartum contraception: New Mexico Pregnancy Risk Assessment
Monitoring System

**Featured Website**

The MCH Frequently Asked Question (FAQ) site

**Frequently asked questions**

-Are there any cultural barriers among Native Americans to becoming cord
blood donors?

-Is cord blood stem cell storage a viable option in Indian Country?

**Indian Child Health Notes**

Remember when they told you in medical school that half of what they
were teaching you was wrong, they must didn\'t know which half. Now we
do\...

\- Humidification doesn\'t benefit croup

\- Fluoroquinolones can be used in children \< 12 years

However our editors Drs. Singleton and Esposito do know some things and
will share them\...

\- Which Haemophilus influenzae type b vaccine is the best for AI/AN
infants?

\- Helicobacter pylori and anemia in AI/AN children

\- Lessons from New Zealand - access to care for indigenous Maori

**Information Technology**

Annual IHS Technology Conference

International Health

Special Journal Issue Features Articles on Women, Gender, and Health
Care Disparities

MCH Alert

Dieting behavior among overweight and non-overweight adolescents

#### Medical Mystery Tour

#### What was the common theme in these 2 cases? {#what-was-the-common-theme-in-these-2-cases .Style-Heading-4-+-Arial-14-pt-Underline}

#### Medscape

**Menopause Management**

#### Effects of Conjugated Equine Estrogen on Quality of Life {#effects-of-conjugated-equine-estrogen-on-quality-of-life .Style-Heading-4-+-Arial-14-pt-Underline}

**Midwives Corner**

#### Routine use of sweeping of membranes from 38 weeks of pregnancy onwards {#routine-use-of-sweeping-of-membranes-from-38-weeks-of-pregnancy-onwards .Style-Heading-4-+-Arial-14-pt-Underline}

**Navajo News**

Methamphetamine abuse among women on Navajo (PART 2 of 4)

**Nurses Corner**

-Native American Scholarship Opportunities at the School of Nursing

-Success stories of American Indian people throughout the US needed

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

April was National Child Abuse Prevention Month. This year's theme was
Safe Children and Healthy Families are a Shared Responsibility --MMWR
article

**Oklahoma Perspective**

Female Sexual Dysfunction

Osteoporosis

Women need information about alternatives, risks, and benefits of
hormone therapy for osteoporosis to make an informed decision

Patient Education

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

Perinatology Picks

-Factors Associated With Rise in Primary Cesarean Births in the United
States, 1991-2002\
-Recurrence of hypertensive disorder in second pregnancy

-Despite \"inadequate placentation\" hypothesis, preeclampsia and IUGR
do not seem to be related as different aspects of the same disorder

Primary Care Discussion Forum

Adverse Childhood Events: Impact on chronic adult illness / Risk taking:
Ongoing now

STD Corner

-Prediction of Pelvic Inflammatory Disease Among Young, Single, Sexually
Active Women

#### -Diagnosis and Treatment of Chlamydia trachomatis Infection {#diagnosis-and-treatment-of-chlamydia-trachomatis-infection .Style-Heading-4-+-Arial-14-pt-Underline}

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

-Long-term Dietary Intervention May Reduce Risk for Insulin Resistance
in Children

-Insulin Sensitivity Measures Predict Preeclampsia

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

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

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

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

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

**Maternal periodontal disease in early pregnancy:
Small-for-gestational-age infant**\
\
OBJECTIVE: The objective of the study was to determine whether
periodontal disease is associated with delivery of a
small-for-gestational-age infant.

 STUDY DESIGN: In a prospective study of oral health, periodontal
disease was categorized as health, mild, or moderate/severe on the basis
of clinical criteria. Small for gestational age was defined as birth
weight less than the 10th percentile for gestational age. A risk ratio
(95th percentile confidence interval) for a small-for-gestational-age
infant among women with moderate or severe periodontal disease was
calculated.

RESULTS: Sixty-seven of 1017 women (6.6%) delivered a
small-for-gestational-age infant, and 143 (14.3%) had moderate or severe
periodontal disease. The small-for-gestational-age rate was higher among
women with moderate or severe periodontal disease, compared with those
with health or mild disease (13.8% versus 3.2% versus 6.5%, P \< .001).
Moderate or severe periodontal disease was associated with a
small-for-gestational-age infant, a risk ratio of 2.3 (1.1 to 4.7),
adjusted for age, smoking, drugs, marital and insurance status, and
pre-eclampsia.

CONCLUSION: Moderate or severe periodontal disease early in pregnancy is
associated with delivery of a small-for-gestational-age infant.
Understanding the mechanism of periodontal disease-associated adverse
pregnancy outcomes could lead to interventions to improve fetal growth.

[Boggess
KA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Boggess+KA"%5BAuthor%5D),
[Beck
JD](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Beck+JD"%5BAuthor%5D),
[Murtha
AP](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Murtha+AP"%5BAuthor%5D),
[Moss
K](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Moss+K"%5BAuthor%5D),
[Offenbacher
S](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Offenbacher+S"%5BAuthor%5D).
Maternal periodontal disease in early pregnancy and risk for a
small-for-gestational-age infant. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
May;194(5):1316-22.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16647916>

**[Comments:]{.underline} IHS Periodontal Consultant Todd Smith,
Phoenix**

This large prospective study supports prior research in this field; that
is, periodontitis (gum disease) is associated with increased risk for
adverse pregnancy outcomes, including preterm birth, low birth weight
infants, and preeclampsia.  The dose response relationship here is of
particular interest; the worse the periodontitis the greater the
likelihood of a small-for-gestational-age infant.  This ongoing research
is also investigating the effects of **periodontal treatment** on the
pregnancy outcome of expectant mothers. Smaller studies have found that
\"deep cleanings\" can reduce the risk of preterm and/or low birth
weight infants, probably by decreasing the chronic inflammation and
infection associated with periodontitis.  Results should be published in
2007. 

**[CCC Editorial comment:]{.underline}**

Maternal periodontal disease is a chronic exposure to oral pathogens
that may represent a treatable condition that contributes to impaired in
utero fetal growth. It appears there may be an association, but we need
to prove causation. We need an appropriately powered treatment RCT to
see if intervention makes any difference. We should be mindful of other
recent trends in preterm labor management, e.g., antibiotic therapy of
BV / vaginitis in patients in PTL or patients with prior PTB, in which
there was ultimately no difference in outcome.

For additional information on periodontitis and adverse pregnancy
outcomes, check the web link
[[www.perio.org/consumer/ftm.html]{.underline}](http://www.perio.org/consumer/ftm.html)
and click on \"Gum Disease Linked to Pregnancy Complications\" and the
Archived Press Releases \"Periodontal Disease and Overall Health.\"

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

#### Carolyn Aoymana, HQE {#carolyn-aoymana-hqe .Style-Heading-4-+-Arial-14-pt-Underline}

**Women's Health Assessment Toolkit (WHAT)**

The Women's Health Assessment Toolkit (WHAT) is a collaborative project
of the Texas Medical Center Women's Health Network and the Region VI
Office on Women's Health, U.S. DHHS. The WHAT has been developed to
guide local or regional decision-makers or community planners in
assessing women's health status and related infrastructure within a
specific designated community. The WHAT provides a series of guided
exercises that help local community planners:

-   Describe demographics about the women of their area Link to county
    level data

-   This is 2000 to 2003 data broken out by various demographics, race
    and ethnicity and the following.

-   Adopt measurable objectives based on 19 Women's Health Indicators;

-   Identify existing assets and prioritize needs from 35 community
    health status assets

    -   Health i.e. Breastfeeding support

    -   Health education and information i.e. adolescent STD

    -   Community i.e. safe recreation policies and availability

    -   Other

```{=html}
<!-- -->
```
-   Incorporate findings into a usable planning document (Part 4,
    Putting It All Together) The guided exercises can be used
    individually or collectively can be used to plan activities, raise
    funds, build collaborations, allocate resources, and influence
    public policy.

#### [**http://www.healthstatus2010.com/owh/**](http://www.healthstatus2010.com/owh/)    {#httpwww.healthstatus2010.comowh .Style-Heading-4-+-Arial-14-pt-Underline}

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

**The Management of Eating Disorders: New Report, AHRQ**

No medications are available that effectively treat patients suffering
from anorexia nervosa, but a few behavioral therapies may help prevent a
relapse and offer other limited benefits, according to a new review of
currently available research on eating disorders released today by HHS\'
Agency for Healthcare Research and Quality. The review also found
evidence that several medications and behavioral therapies can help
patients suffering from bulimia nervosa and binge eating disorder.

This review of the scientific literature published since 1980 was
conducted by AHRQ\'s Evidence-based Practice Center at RTI International
and the University of North Carolina at Chapel Hill. It did not find any
medications effective in treating anorexia nervosa but did find several
behavioral therapies that appear to offer limited help. Cognitive
behavioral therapy (CBT), a form of psychotherapy that encourages
patients to develop thinking patterns that will counteract their
unhealthy eating behavior, helped prevent relapse in adult anorexic
patients once their weight had been restored to a normal level. There
was not enough evidence to determine whether CBT works during the acute
phase of the illness, before a patient with anorexia nervosa has been
restored to a normal weight.

 

The researchers concluded that family therapy does not appear to work
with adults with longstanding anorexia nervosa. One study found that
family therapy worked better for younger patients than for older, more
chronic patients. One particular kind of family therapy, which starts by
encouraging parents to oversee a young person\'s nutrition, appeared to
help these patients gain weight and make psychological improvements.

 

Both medications and behavioral therapies were found helpful in treating
bulimia nervosa; however, there was no clear information about how to
combine medications with behavioral treatments.

 

The selective serotonin reuptake inhibitor (SSRI) fluoxetine, commonly
known as Prozac, was found helpful in treating bulimia in a short-term
clinical trial. Patients given a dose of 60 mg/day for 16 to 18 weeks
had reduced symptoms and were less likely to experience a relapse by the
end of 1 year. CBT, offered either individually or in a group, and
interpersonal psychotherapy were also helpful in reducing the core
symptoms of bulimia nervosa, binge eating and purging, and in
alleviating the psychological symptoms of this disorder. However, the
optimum length of treatment and the best strategy for maintaining these
health benefits remain unknown.

 

Several types of medications helped patients suffering from binge eating
disorder make at least short-term improvements to their health; these
medications included SSRIs, tricyclic antidepressants, an
anticonvulsant, and an appetite suppressant. CBT was also helpful in
treating binge eating disorder, reducing the number of binge days or
binge episodes patients experienced. It did not help patients with binge
eating disorder control their weight.

 

Though the numbers are difficult to establish, the National Eating
Disorders Association estimates that about 10 million girls and women
and about 1 million boys and men in the United States suffer from either
anorexia nervosa or bulimia nervosa. As many as 25 million additional
individuals may be affected by binge eating disorder. Although these
disorders most commonly affect people in their teens and twenties, they
are found in all age groups, even young children. Those who suffer from
eating disorders can experience a wide range of physical health
complications, including serious heart conditions and kidney failure.
Only about half of patients who are diagnosed with anorexia nervosa and
bulimia nervosa fully recover, and many individuals struggle for decades
with these disorders.
<http://www.ahrq.gov/downloads/pub/evidence/pdf/eatingdisorders/eatdis.pdf>

Copies of the report are available free of charge by calling the AHRQ
Publications Clearinghouse at 800-358-9295 or by sending an e-mail to
<ahrqpubs@ahrq.gov>

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

**Donald Haverkamp, Albuquerque**

**Take the provider survey on colorectal cancer screening!**

Thank you to those of you who have recently responded to our web-based
provider survey on colorectal cancer screening. If you are an MD, DO,
FNP, PA or CNM, and providing primary care to adults, we encourage you
to take this survey if you have not already done so. The following link
will take you to the survey and will remain active through June 2, 2006:

[[http://www.surveymonkey.com/s.asp?u=883861457284]{.underline}](http://www.surveymonkey.com/s.asp?u=883861457284)

The survey should take less than 10 minutes. Results will be reported in
aggregate, and will be used to inform agency efforts to provide cancer
prevention and early detection services.

Thanks for your time. Colon and rectal cancer is an important problem
and we are committed to making a difference! Contact:
<donald.haverkamp@ihs.gov>

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

#### Chuck North, Albuquerque {#chuck-north-albuquerque .Style-Heading-4-+-Arial-14-pt-Underline}

#### The new medical \"missionaries\"\--grooming the next generation of global health workers {#the-new-medical-missionaries--grooming-the-next-generation-of-global-health-workers-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### In addition to a discussion of the Indian Health system, there is an OB/GYN residency where the residents all rotate to Eritrea and do pelvic reconstruction. {#in-addition-to-a-discussion-of-the-indian-health-system-there-is-an-obgyn-residency-where-the-residents-all-rotate-to-eritrea-and-do-pelvic-reconstruction. .Style-Heading-4-+-Arial-14-pt-Underline}

#### Other examples include: Noelle Benzekri is a first-year medical student with a mission. Even before the 27-year-old New York native spent a year as a clinic assistant and polio vaccinateur in Senegal, she knew that global health was her calling. \"It\'s the reason I decided to go to medical school,\" the former philosophy major acknowledged at a recent meeting of our journal club on global health at the University of California, Los Angeles (UCLA). Spurred by memories of her African patients, Benzekri intends to return to Africa someday to train local health workers to deliver care to the poorest of the poor.....go to NEJM link below for further text... {#other-examples-include-noelle-benzekri-is-a-first-year-medical-student-with-a-mission.-even-before-the-27-year-old-new-york-native-spent-a-year-as-a-clinic-assistant-and-polio-vaccinateur-in-senegal-she-knew-that-global-health-was-her-calling.-its-the-reason-i-decided-to-go-to-medical-school-the-former-philosophy-major-acknowledged-at-a-recent-meeting-of-our-journal-club-on-global-health-at-the-university-of-california-los-angeles-ucla.-spurred-by-memories-of-her-african-patients-benzekri-intends-to-return-to-africa-someday-to-train-local-health-workers-to-deliver-care-to-the-poorest-of-the-poor..go-to-nejm-link-below-for-further-text .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Panosian C](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Panosian+C"%5BAuthor%5D), [Coates TJ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Coates+TJ"%5BAuthor%5D). The new medical \"missionaries\"\--grooming the next generation of global health workers. [N Engl J Med.](javascript:AL_get(this, 'jour', 'N Engl J Med.');) 2006 Apr 27;354(17):1771-3. {#panosian-c-coates-tj.-the-new-medical-missionaries--grooming-the-next-generation-of-global-health-workers.-n-engl-j-med.-2006-apr-27354171771-3. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Display&dopt=pubmed_pubmed&from_uid=16641393**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Display&dopt=pubmed_pubmed&from_uid=16641393) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgidbpubmedcmddisplaydoptpubmed_pubmedfrom_uid16641393 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### [**http://content.nejm.org/cgi/content/extract/354/17/1771**](http://content.nejm.org/cgi/content/extract/354/17/1771) {#httpcontent.nejm.orgcgicontentextract354171771 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Ty Reidhead, Whiteriver {#ty-reidhead-whiteriver .Style-Heading-4-+-Arial-14-pt-Underline}

**New funding opportunity under the IHS Chronic Disease Initiative**

The Indian Health Service (IHS) is pleased to announce a new funding
opportunity under the IHS Chronic Disease Initiative.  During Year 1 of
the initiative, funding will support a small group of selected
applicants (from a pool of federal IHS sites) who will work together
through a collaborative process to develop an innovative approach to
chronic disease management in the Indian health system.  It is
anticipated that in Initiative Year 2, non-federal sites will have the
opportunity to apply for funding to participate in the collaborative.

 

Pilot sites will receive one year of funding to pay for travel to one
in-person training meeting, as well as the supplies and equipment
required to participate in Chronic Disease Collaborative web-based
activities. Pilot sites will also receive a small amount of funding to
ensure dedicated time for a local pilot site coordinator who will
provide day-to-day leadership.  

Questions can be directed to:

Pat Lundgren Phone:  (928) 338-4911 x3707 <pat.lundgren@ihs.gov>

Charles Ty Reidhead, MD Phone:  (928) 338-4911
<charles.reidhead@ihs.gov>

**Christine Rinki, Northern Plains Tribal Epidemiology Center**

Infant Mortality Statistics from the 2003 Period Linked Birth/Infant
Death Data Set

T.J. Mathews, M.S. and Marian F. MacDorman, Ph.D., Division of Vital
Statistics![](media/image2.png){width="7.177083333333333in"
height="2.6458333333333335in"}<http://www.cdc.gov/nchs>

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

#### Judy Thierry, HQE {#judy-thierry-hqe .Style-Heading-4-+-Arial-14-pt-Underline}

**Gestational Diabetes best practices CALL for examples**

The Best Practices work group on Gestational Diabetes (GDM) is looking
for examples to include in the "long version" of the best practices
document.  Tell us about your program that other sites may know about
it.  WE would like to hear from you.  [We are following up on a request
made in late 2005]{.underline} for GDM best practice examples from
basic, intermediate and comprehensive programs.  While we have a sense
of the "criteria" for a basic, intermediate, etc we want to hear from
you.  Please share with us how your program may be engaged with any and
or all of the following six elements:

1.  Organization of the healthcare delivery system (commitment from
    organizational leadership i.e. resources for personnel, data
    collection and development, health education, referral and
    management; organizational wide goals and strategies for improvement
    i.e. customer focused system, DM audit that includes GDM and
    prenatals)

```{=html}
<!-- -->
```
1.  Community resources and linkages ( defined CHS referral methods for
    consultation and management of GDM women, use of case managers,
    community health reps, PHN, Healthy Start, WIC, early head start,
    mch committee's

2.  Self-management support (i.e. Documenting and assessing
    self-management needs and activities, family support, routine
    patient follow-up, behavior change interventions)

3.  Delivery system design (i.e. coordinator, known and expected lines
    of communication, client centered appointment system, application of
    evidence based guidelines, informed primary care providers, informed
    patients, and informed community)

4.  Decision support (i.e. application of evidence-based guidelines,
    informed primary care providers, informed patients, and informed
    community)

5.  Clinical information systems design and support (ie. information
    technology support, clinical reporting tool, clinical scheduling and
    reminder tools)

You can send your information as detailed as possible in a narrative
e-mail, or in an attachment and if you have slides feel free to include
those as well.  Also! Please let us know if your are interested in
presenting on your program at the July Regional Meeting in San
Francisco.

<Judith.Thierry@IHS.GOV>

**Congratulations to Yolanda Adams, Charlotte Briggs and all!**

The New Mexico Immunization Coalition honored Mescalero PHS Indian
Hospital at the 2006

Provider Awards Dinner as part of the events and activities for National
Infant Immunization Week/Vaccination Week in the Americas.

<http://www.cdc.gov/nip/events/niiw/2006/docs/sample_proclamation.rtf>

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

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

**Point / Counterpoint: Not Yet Time to Use the P:C Ratio**

The P:C ratio would at first glance seem to be an excellent short cut in
the diagnosis and management of pre-eclampsia, but we have several
concerns:

1\) Because of the many physiologic changes that occur in pregnancy and
the unique pathophysiology of pre-eclampsia, comparing the usefulness of
the P:C ratio in pre-eclampsia to the management of chronic renal
disease is, we feel, inappropriate.

2\) The literature in pregnant women is incomplete and inconsistent but
seems to indicate that P:C ratio can be used to rule OUT significant
proteinuria, but is not reliable in quantifying the level of proteinuria
in pregnant women with pre-eclampsia.

3\) In regards to the pathophysiology of proteinuria in pre-eclampsia,
we cannot assume that protein excretion from the glomerular
endotheliosis is as constant as the creatinine excretion. Meaning that
the excretion of protein can increase and decrease significantly over
short periods of time, independent of the GFR, where the excretion of
creatinine will not.

4\) Despite all this, we would still endorse the use of the P:C ratio in
certain clinical situations for ruling out pre-eclampsia if the cut-off
is low enough to keep the sensitivity high. We might consider using the
P:C ratio to make a transfer decision, but not to diagnose/treat a
patient in house.(Can you imagine trying to transfer a 30 week EGA woman
to a wary physician 200 miles away solely because of an elevated P:C
ratio?) We suspect there would be enough other clinical information
available to make the transfer decision.

5\) Medico-legally, we are rolling the dice if ACOG hasn\'t endorsed the
use of P:C ratios in diagnosing and managing pre-eclampsia.

6\) In the article, we appreciated the comment about looking at the
entire clinical picture. Pre-eclampsia is a sneaky disease and the
appropriate treatment is typically based on the "weight of evidence". We
often hear ourselves and our colleagues after a lengthy discussion of a
patient in whom we are trying to r/o pre-eclampsia say, \"Does she look
like she has pre-eclampsia?\" It is often the most important piece of
data when the diagnosis is questionable.

Overall, we are not convinced we can predict the 24-hour urine protein
excretion reliably with the P:C ratio in both the 120 kg 40 y/o diabetic
woman and the 45 kg 16 y/o woman. Also, the pursuit seems academic. We
haven\'t seen a patient go from questionable pre-eclampsia to a disease
state that doesn\'t allow for transfer while waiting for a 24-hour
urine. We know that pre-eclampsia can progress rapidly and all of us
have seen people go from mild to severe to seizures over a short period
of time, but we are usually not surprised by the rapid progression. It
would seem that the major reason for promoting the use of P:C ratio in
pregnancy is simply to avoid the hassle (for patient and clinician) of
collecting and waiting for the results of the venerable 24-hour urine
protein quantification. Unfortunately, for the reasons outlined above,
we do not believe that this is clinically appropriate or supported by
the current data.

David Gahn, Hastings Indian Medical Center

Eric Manske, Gallup Indian Medical Center

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

I want to thank David Gahn and Eric Mankse for this thoughtful
counterpoint to the April CCCC Abstract of the Month, 'Protein to
Creatinine Ratio in Pre-eclampsia: Is the data preceding the U.S.
benchmarks? ' with Comments by Jonathan Steinhart and Jean Howe.

[**http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0406_AOM.cfm**](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0406_AOM.cfm)

I would like to clarify two other points that were raised in the wake of
that Abstract of the Month.

First, the original systematic review by Price et al, suggested that the
P:C had it greatest value in the P:C's ability to 'rule out' significant
proteinuria, i.e. one were emphasizing the negative predictive value.
"Most importantly, we have shown that the protein: creatinine ration for
a random urine sample (particularly with adjustment of the test
threshold to a lower value) might be used to rule out the presence of
significant proteinuria as defined by a quantitative measure of the 24-h
protein excretion. Use of the ration negates the uncertainty associated
with the use of dilute or concentrated urine\...When results above the
cutoff value for the protein:creatinine ration are obtained, a full 24-h
urine collection and quantification are indicated.\"

From a logistics viewpoint, there is enough evidence to use the P:C to
rule out the disease. That way one can let the patient go home without
the delay of being admitted and doing the collection, which as we agree
gives very variable results. If the P:C value is over 0.2, then they
should probably have further evaluation. Also, as Sibai has demonstrated
in several papers, while the *presence* of proteinuria is what enables
us to make the diagnosis, the *amount* of proteinuria is not associated
with either maternal or infant outcome.

Secondly, here was another important comment from one of our readers....

"You state in passing that "as we currently recommend the use of daily
aspirin therapy in patients with previous severe pre-eclampsia"; I am
unaware that this is a currently endorsed strategy for prevention of
preeclampsia in this country, given the large multicenter trials
disproving this intervention (e.g., NEJM 1998; 338:701-05. Caritis et al
"low-dose aspirin to prevent preeclampsia in women at high risk").
Though the Cochrane review of 42 trials does show a small benefit.

What source(s) do you have? "

Yes, we have been recommending low dose ASA on our Indian Health
national guidelines website for a small group of high risk patients for
a while now.

-Chronic HTN

-Past severe pre-eclampsia

-Renal disease

-Pre-existing Diabetes

IHS Guidelines page

<http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-clinguid.cfm>

Hypertension in Pregnancy Guidelines

<http://www.ihs.gov/NonMedicalPrograms/nc4/Documents/HYPERT12004.doc>

Yes, it is based on the Cochrane Review below, though the content was
actually brought to our attention by the IHS Nephrology Chief Clinical
Consultant prior to that

.

Knight M, Duley L, Henderson-Smart DJ, King JF. Antiplatelet agents for
preventing and treating pre-eclampsia. The Cochrane Database of
Systematic Reviews 2000, Issue 2. Art. No.: CD000492. DOI:
10.1002/14651858.CD000492.

[**http://www.update-software.com/publications/cochrane/**](http://www.update-software.com/publications/cochrane/)

**New campaign materials released to help GDM patients prevent or delay
Type 2 Diabetes**

It\'s Never Too Early to Prevent Diabetes, the latest diabetes
prevention campaign message by the National Diabetes Education Program,
is spreading the word about the risk of type 2 diabetes faced by women
with a history of gestational diabetes mellitus (GDM) and their
children.

The message is part of Small Steps. Big Rewards. Prevent type 2
Diabetes, the nation\'s first comprehensive multicultural type 2
diabetes prevention campaign. The campaign offers materials that can
help women with a history of GDM take steps to prevent or delay type 2
diabetes and help their children lower their risk for the disease.

Available campaign materials include a tip sheet in English and Spanish
for women who have had GDM, a tip sheet in English and Spanish for
children at risk for type 2 diabetes, and a booklet for adults to help
women and their families make healthy food choices and be more
physically active to prevent or delay type 2 diabetes. These materials
are available at
[[http://www.ndep.nih.gov/campaigns/SmallSteps/SmallSteps_nevertooearly.htm]{.underline}](http://www.ndep.nih.gov/campaigns/SmallSteps/SmallSteps_nevertooearly.htm)

Prenatal Weight Gain Recommendations - Obesity in Pregnancy

One third of adult women in the United States are obese. During
pregnancy, obese women are at increased risk for several adverse
perinatal outcomes, including anesthetic, perioperative, and other
maternal and fetal complications. Obstetricians should provide
preconception counselling and education about the possible complications
and should encourage obese patients to undertake a weight reduction
program before attempting pregnancy. Obstetricians also should address
prenatal and peripartum care considerations that may be especially
relevant for obese patients, including those who have undergone
bariatric surgery.

Women who are obese (i.e., those with a body mass index \[BMI\] of 30 kg
per m2 or greater) are at increased risk of complications of pregnancy
such as gestational hypertension and diabetes, preeclampsia, fetal
macrosomia, spontaneous abortion, cesarean delivery, neural tube defects
in the fetus, and stillbirth. Estimation of fetal weight and
interpretation of external fetal heart rate and patterns of uterine
contraction also may be problematic in women who are obese. Infants who
are large for their gestational age are more common in mothers who are
obese, and these infants subsequently are at increased risk of childhood
obesity. In addition, operative and postoperative complications such as
excessive blood loss, longer operative time, wound infection,
endometritis, and anesthetic challenges are more common in obese
patients.

ACOG strongly encourages preconception assessment and counseling of
women who are obese, with provision of education about the risks and
potential complications for mother and fetus. Nutrition advice should be
provided, and patients should be encouraged to make changes in diet and
exercise before pregnancy is attempted. Weight loss also should be
encouraged before initiation of infertility treatment because of the
increased risk of spontaneous abortion in obese women who undergo this
therapy. Counseling and exercise programs should continue after
delivery.

Women who have had bariatric surgery should be counseled to avoid
pregnancy during the postsurgery phase of rapid weight loss. Pregnant
women who have had bariatric surgery should have levels of vitamin B12,
folate, iron, and calcium assessed to determine whether supplementation
is necessary.

Prenatal weight gain recommendations should correspond to the Institute
of Medicine guidelines: BMI below 25 kg per m^2^ 25 to 35 lb (11.4 to
15.9 kg)

BMI of 25 to 29 kg per m^2^ 15 to 25 lb (6.8 to 11.4 kg)

BMI of 30 or greater kg per m^2^ 15 lb (6.8 kg)

In pregnant women who are obese, screening for gestational diabetes
should be considered at presentation or in the first trimester, with
screenings repeated throughout pregnancy if the results are negative.

Because of the increased likelihood of cesarean delivery and
complications of surgery, ACOG recommends that pregnant women who are
obese have an anesthesiology consultation before delivery. Because of
the increased risk of wound breakdowns and infections in obese patients,
antibiotic prophylaxis should be given if cesarean delivery is required.
The use of graduated compression stockings, hydration, and early
mobilization may be helpful during and after cesarean delivery.
<http://www.aafp.org/afp/20060415/practice.html>

ACOG Committee Opinion number 315, September 2005. Obesity in pregnancy.
[Obstet Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');)
2005 Sep;106(3):671-5.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16135613>

**Preconception Care: Recommendations to Improve Health of Babies and
Moms, CDC**

The Centers for Disease Control and Prevention (CDC), in collaboration
with more than 35 federal, public and private partners, today released
national recommendations designed to encourage women to take steps
toward good health before becoming pregnant.

<http://www.cdc.gov/od/oc/media/pressrel/r060420b.htm>

The preparers of this report analyzed the National Ambulatory Medical
Care Survey and demonstrated that diabetes affects approximately 1.85
million (21 per 1,000) women in the United States aged 18\--44 years,
and that

-   Preconceptional diabetes management has the potential to reduce the
    risk for pregnancy loss and congenital malformation for
    approximately 113,000 births per year.

-   Anti-epileptic/antiseizure drugs are prescribed for approximately 1
    million women (19 per 1,000), potentially affecting an estimated
    75,000 pregnancies.

-   Approximately 7 million (125 per 1,000) women of childbearing age
    are frequent drinkers, and without preconception interventions,
    alcohol misuse might affect approximately 577,000 births per year.

-   Women with chronic medical conditions and their specialty providers
    should take advantage of every opportunity to discuss preconception
    health and risks.

These conditions and risk factors affect substantial proportions of the
approximately 4 million pregnancies that occur in the United States each
year. (J Thierry Note: 42,000 AIAN)

**Four goals   **                       

1\) improve the knowledge and attitudes and behaviors of men and women
related to preconception
health                                                                    

2\) assure that all women of childbearing age in the United States
receive preconception care services (i.e., evidence-based risk
screening, health promotion, and interventions) that will enable them to
enter pregnancy in optimal
health                                            

3\) reduce risks indicated by a previous adverse pregnancy outcome
through interventions during the interconception period, which can
prevent or minimize health problems for a mother and her future
children; and
                                                                                                             

4\) reduce the disparities in adverse pregnancy outcomes.

Patients are exposed to chronic conditions and or consume substances
that can have an adverse effect on pregnancy outcomes, leading to
pregnancy loss, infant death, birth defects, or other complications for
mothers and infants. For example, in 2002, approximately 6% of adult
women aged 18\--44 years had asthma, 50% were overweight or obese, 3%
had cardiac disease, 3% were hypertensive, 9% had diabetes, and 1% had
thyroid disorder (44). Dental caries and other oral diseases also are
common (\>80% of women aged 20\--39 years) and associated with
complications for women and infants. .....Social determinants of
women\'s health also play a role in pregnancy outcomes. The health
status of minority women with low incomes contributes to persistent, and
sometimes increasing, disparities in birth outcomes. In one study, the
reduced overall health status (including poorer physical and emotional
health) of women with low income during the month before pregnancy was
associated with an increased risk for preterm labor. Socioeconomic
status directly and indirectly influences three major determinants of
health: health-care access, environmental exposure, and health behavior.
Racial inequalities in access to effective treatment also influence
these determinants of pregnancy outcomes for women and infants Existing
clinical practice guidelines (e.g., AAP and ACOG).

-   Isotretinoins. Use of isotretinoins (e.g., Accutane®) in pregnancy
    to treat acne can result in miscarriage and birth defects. Effective
    pregnancy prevention should be implemented to avoid unintended
    pregnancies among women with childbearing potential who use this
    medication.

-   Alcohol misuse. No time during pregnancy is safe to drink alcohol,
    and harm can occur early, before a woman has realized that she is or
    might be pregnant. Fetal alcohol syndrome and other alcohol-related
    birth defects can be prevented if women cease intake of alcohol
    before conception.

-   Anti-epileptic drugs. Certain anti-epileptic drugs are known
    teratogens (e.g., valproic acid). Recommendations suggest that
    before conception, women who are on a regimen of these drugs and who
    are contemplating pregnancy should be prescribed a lower dosage of
    these drugs.

-   Diabetes (preconception). The three-fold increase in the prevalence
    of birth defects among infants of women with type 1 and type 2
    diabetes is substantially reduced through proper management of
    diabetes.

-   Folic acid deficiency. Daily use of vitamin supplements containing
    folic acid has been demonstrated to reduce the occurrence of neural
    tube defects by two thirds
    ([83](http://www.cdc.gov/mmwr/preview/mmwrhtml/00019479.htm)\--88).

-   Hepatitis B. Vaccination is recommended for men and women who are at
    risk for acquiring hepatitis B virus (HBV) infection. Preventing HBV
    infection in women of childbearing age prevents transmission of
    infection to infants and eliminates risk to the woman of HBV
    infection and sequelae, including hepatic failure, liver carcinoma,
    cirrhosis, and death.

-   HIV/AIDS. If HIV infection is identified before conception, timely
    antiretroviral treatment can be administered, and women (or couples)
    can be given additional information that can help prevent
    mother-to-child transmission.

-   Hypothyroidism. The dosages of Levothyroxine® required for treatment
    of hypothyroidism increase during early pregnancy. Levothyroxine®
    dosage needs to be adjusted for proper neurologic development of the
    fetus.

-   Maternal phenylketonurea (PKU). Women diagnosed with PKU as infants
    have an increased risk for delivering neonates/infants with mental
    retardation. However, this adverse outcome can be prevented when
    mothers adhere to a low phenylalanine diet before conception and
    continue it throughout their pregnancy.

-   Rubella seronegativity. Rubella vaccination provides protective
    seropositivity and prevents congenital rubella syndrome.

-   Obesity. Adverse perinatal outcomes associated with maternal obesity
    include neural tube defects, preterm delivery, diabetes, cesarean
    section, and hypertensive and thromboembolic disease. Weight loss
    before pregnancy reduces these risks). Appropriate weight loss and
    nutritional intake before pregnancy reduces these risks.

-   Oral anticoagulant. Warfarin, which is used for the control of blood
    clotting, has been demonstrated to be a teratogen. To avoid exposure
    to warfarin during early pregnancy, medications can be changed to a
    nonteratogenic anticoagulant before the onset of pregnancy.

-   STD. Chlamydia trachomatis and Neisseria gonorrhoeae have been
    strongly associated with ectopic pregnancy, infertility, and chronic
    pelvic pain. STDs during pregnancy might result in fetal death or
    substantial physical and developmental disabilities, including
    mental retardation and blindness. Early screening and treatment
    prevents these adverse outcomes.

-   Smoking. Preterm birth, low birthweight, and other adverse perinatal
    outcomes associated with maternal smoking in pregnancy can be
    prevented if women stop smoking before or during early pregnancy.
    Because only 20% of women successfully control tobacco dependence
    during pregnancy, cessation of smoking is recommended before
    pregnancy. <http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5506a1.htm>

Preconception care - Patient and provider education CDC website

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

**Strategies and outcome of Infant Mortality Reviews in the Aberdeen
Area of the IHS**

The authors set out to determine the cause and manner of deaths in the
Aberdeen Area of the Indian Health Service from 1998 to 2002 and
identify risk markers for infant mortality. They found that Sudden
Infant Death Syndrome was the leading cause of infant death and
accounted for 33% of infant deaths. Prematurity was the second leading
cause and accounted for 22% of infants. The authors also found that
infant mortality was recurrent; 32% of mothers of a deceased infant had
another infant death.

The authors note that participation of tribal team members provides an
important cultural and community perspective. The authors conclude that
the reviews have been very helpful in public education. They say that
quality improvement actions are underway on substance abuse, mental
health/bereavement issues and reviews of fetal deaths.

Eaglestaff, ML et al. Infant Mortality Reviews in the Aberdeen Area of
the Indian Health Service: Strategies and Outcomes. Public Health
Reports. Volume 121 (March/April 2006) pp 140 - 148.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16528946>

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

Kudos to the Aberdeen Area Perinatal and Infant Mortality Review (PIMR)
Team!

Above is another article published in a national peer review journal
that illustrates the excellent work the PIMR team is accomplishing. All
Indian Health Areas and tribes should use the success of the Aberdeen
Area as benchmark for best practice.

An important outcome of the PIMR has been the routine examination of
infant deaths and the realization that patterns of risk factors are
present,\" conclude the authors, adding that \"additional research is
urgently needed to determine why the rate of SIDS remains high in the
AAIHS.\"

\"By examining the data by cause of and age at death, we found
significant differences that may be useful to other groups who are
considering development of an infant death review committee,\" state the
authors of an article published in the March-April 2006 issue of Public
Health Reports. The Aberdeen Area Indian Health Service (AAIHS) has
higher rates of infant mortality, especially of post-neonatal infant
mortality, when compared to the overall U.S. rate and the overall Indian
Health Service (IHS) rate. To improve the classification of the cause
and manner of infant death and to identify preventable causes of infant
death, the Aberdeen Area Perinatal and Infant Mortality Review (PIMR)
was established. The article reports data on 5 consecutive years of
infant death reviews from the AAIHS PIMR. A discussion of the benefits
of a systematic infant mortality review in communities with high infant
mortality rates is also included.

Data for the review were drawn from death certificates sent by the four
states in the AAIHS and from information that IHS service units and
committee members identified by reviewing obituaries from multiple
regional newspapers, death certificates by race, and reports from
regional referral centers. Case reviews for 148 consecutive infant
deaths from 1998 to 2002 were examined as summary data for the total
group, by mortality category, and by three age-of-death categories.

The authors found that

\* Nearly two-thirds of the infants who died were males (ratio: 1.8 to
1).

\* Nearly one-third of the infants (32%) had a previous sibling death.

\* The PIMR attributed 22% of the deaths to prematurity and 33% to SIDS.

\* Infants who died from prematurity had significantly lower
birthweights, shorter gestation, and younger age at death than infants
who died from SIDS or other causes. Mothers of infants who died from
prematurity had significantly fewer prenatal visits than mothers of
infants who died from SIDS or other causes.

\* Mothers of infants who died from SIDS were more likely to have begun
prenatal care after the first trimester than mothers of infants who died
from prematurity or other causes.

\* Birthweights were significantly lower and gestation significantly
shorter for infants who died in the first 3 weeks of life, compared with
infants who died at older ages. Mothers of infants who died in the first
3 weeks of life had significantly fewer prenatal visits.

\* Autopsies and death scene investigations were more likely to have
been completed for older infants.

Eaglestaff ML, Klug MG, Burd L. 2006. Infant mortality reviews in the
AAIHS. Public Health Reports (121(2):140-147.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16528946>

Full text available to subscribers at
[[http://www.publichealthreports.org/userfiles/121_2/121140.pdf]{.underline}](http://www.publichealthreports.org/userfiles/121_2/121140.pdf)

**Early Glucose Challenge Testing Identifies Diabetes Versus Gestational
Diabetes\
**In women in whom prenatal care is the first medical care they receive,
screening for gestational diabetes before they are 24 weeks pregnant
could help identify those with pre-gestational diabetes mellitus.

A 1-hour glucose challenge test was performed at the first visit in
women obtaining prenatal and delivery care. If the test was positive,
further appropriate testing was undertaken, then subsequent testing at
24 to 28 gestational weeks, if necessary.

Data collected included age, parity, ethnicity, body mass index,
gestational age at delivery, fetal weight and mode of delivery.

A total of 756 patients were eligible for enrollment, and average
gestational age at first visit was 14 2/7 weeks. Subjects were
predominantly Hispanic or South Asian.

Gestational diabetes was diagnosed in 6.7%. Of these patients, 64.7% had
an abnormal first visit test (P \<.05) and 45% were diagnosed with
gestational diabetes based on their early screening test alone.

Maternal ages were significantly higher and birth weights lower in women
with abnormal first-visit glucose challenge tests than screen-negative
controls (P \<.04). Almost 50% of gestational diabetics were South
Asian, and more South Asians were diagnosed with gestational diabetes
based on early screening tests alone.

Certain populations are at increased risk of pre-gestational diabetes
mellitus. In pregnancy, it\'s important to know whether this is the case
because the mothers are at higher risk of preterm labor, and newborns
\[are at risk\] of fetal demise or congenital abnormalities. Gestational
diabetes does not carry such a serious risk profile.\"

Venkatachalam S. Utility of the 1-Hour Glucose Challenge Test at the
First Prenatal Visit to Screen for Pregestational Diabetes. Abstract p.
37S, 54th Annual Clinical Meeting of the American College of
Obstetricians and Gynecologists (ACOG).

<http://www.acog.com/acm/program/welcome.cfm>

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

These results from a retrospective review performed at an inner-city
public hospital confirm the Indian Health procedure that recommends that
certain high risk groups may benefit from earlier screening. As part of
the 1993 ACOG Consultation\* it was discussed that AI/AN women be
screened at their first visit and again at 24- 28 weeks. Another aspect
is that in certain high risk AI/AN populations, e.g., over 7 % diabetes
in pregnancy, may consider one step screening / diagnostic test with a 3
hour OGTT.

**\*GDM: Can we proceed directly to one step screening / diagnosis in AI
/ AN women?**

<http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_HT.cfm#ob>

**Vitamins C and E does not reduce preeclampsia, IUGR, restriction, or
death**

CONCLUSIONS: Supplementation with vitamins C and E during pregnancy does
not reduce the risk of preeclampsia in nulliparous women, the risk of
intrauterine growth restriction, or the risk of death or other serious
outcomes in their infants.

[Rumbold
AR](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Rumbold+AR"%5BAuthor%5D),
et al Vitamins C and E and the risks of preeclampsia and perinatal
complications. [N Engl J
Med.](javascript:AL_get(this, 'jour', 'N Engl J Med.');) 2006 Apr
27;354(17):1796-806.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16641396>

Editorial

Antioxidants and the prevention of preeclampsia\--unresolved issues.
[Jeyabalan
A](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Jeyabalan+A"%5BAuthor%5D)

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16641402>

**Grants Being Distributed: Methamphetamine Pregnancy/Postpartum**

See grant announcement. For additional information and to apply, you may
access

[[http://www.grants.gov/]{.underline}](http://www.grants.gov/)

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

**FDA: Vaccine to Prevent Cervical Cancer Is Safe, Effective**\
The U.S. Food and Drug Administration Advisory Panel endorsed Merck\'s
Gardasil vaccine against the four strains of human papillomavirus (HPV)
responsible for 70 percent of cervical cancer cases. Questions remain as
to whether the vaccine\'s effectiveness could be \"offset\" by the fact
that it does not protect against all cervical cancer-causing HPV strains
and congenital anomalies found in some infants born to women who
received the vaccine near the time of conception. If approved as
expected, the vaccine will be the first to protect against cervical
cancer.

The American Cancer Society predicts that about 9,710 new cases of
invasive cervical cancer will occur in the United States in 2006 and
calculate that about 3,700 women will die from this disease this year.
Globally, HPV causes about 470,000 cases of cervical cancer per year,
according to the World Health Organization. Many adolescents, adults and
health care providers have a limited understanding of HPV infections,
particularly those that are sexually transmitted. Individuals must
understand these issues to make informed decisions about the new
vaccines. The media will play an exceptionally important role in the
public\'s understanding of the issues surrounding HPV and the vaccines.

National Network for Immunization Information

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

**CDC Facts HPV accine**

<http://www.cdc.gov/std/hpv/STDFact-HPV-vaccine.htm>

**Amenorrhea: Evaluation and Treatment (also see Patient Education)**

A thorough history and physical examination as well as laboratory
testing can help narrow the differential diagnosis of amenorrhea. In
patients with primary amenorrhea, the presence or absence of sexual
development should direct the evaluation. Constitutional delay of growth
and puberty commonly causes primary amenorrhea in patients with no
sexual development. If the patient has normal pubertal development and a
uterus, the most common etiology is congenital outflow tract obstruction
with a transverse vaginal septum or imperforate hymen. If the patient
has abnormal uterine development, müllerian agenesis is the likely cause
and a karyotype analysis should confirm that the patient is 46,XX. If a
patient has secondary amenorrhea, pregnancy should be ruled out. The
treatment of primary and secondary amenorrhea is based on the causative
factor. Treatment goals include prevention of complications such as
osteoporosis, endometrial hyperplasia, and heart disease; preservation
of fertility; and, in primary amenorrhea, progression of normal pubertal
development. Am Fam Physician 2006;73:1374-82, 1387

<http://www.aafp.org/afp/20060415/1374.html>

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

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

**Relationship between team sport participation and adolescent smoking**

The present study provides the first evidence of interacting effects of
environmental influences with specific genetic variants on adolescent
smoking progression. Experimentation with cigarette smoking usually
begins in adolescence. Some, although not all, adolescents who
experiment with cigarettes progress to a regular smoking habit.
Environmental or behavioral factors, such as physical activity, seem to
account for some of the variability in adolescent smoking progression.

\* Physical activity had a significant negative effect on smoking, but
only for adolescents with team sport participation. The between-group
difference in the effect of physical activity on smoking was
significant.

\*For adolescents participating in at least one team sport, having one
and two risk genotypes had a positive effect on physical activity.

\* For adolescents with no team sport participation, neither risk
genotype had a significant effect on physical activity.

\* The difference in the effect of smoking risk genotype on physical
activity between the groups was significant for one and two risk
genotypes.

\* For adolescents involved in at least one team sport, neither smoking
risk genotype had a significant direct effect on smoking; the effect was
indirect through physical activity. The indirect effect of one and two
smoking risk genotypes on smoking progression through physical activity
was significant.

\* There was not a significant indirect effect of one and two smoking
risk genotypes on smoking progression through physical activity for
adolescents without team sport participation, although a direct effect
approached significance, indicating an increased risk of smoking
progression by the end of 12th grade for adolescents with one and two
risk genotypes.

....because adolescent smoking often results in long-term smoking in
adulthood, the medical and economic impact of preventing and reducing
youth smoking could be significant.

Audrain-McGovern J, Rodriguez D, Wileyto EP, et al. 2006. Effect of team
sport participation on genetic predisposition to adolescent smoking
progression. Archives of General Psychiatry 63(4):433-441.
[[http://archpsyc.ama-assn.org/cgi/content/abstract/63/4/433]{.underline}](http://archpsyc.ama-assn.org/cgi/content/abstract/63/4/433)

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

**Prevalence of diabetes and impaired fasting glucose levels among U.S.
adolescents**

This study does provide evidence that the prevalence of type 2 diabetes
and impaired fasting glucose level is substantial among U.S.
adolescents. Nationally representative data to monitor diabetes trends
among adolescents (ages 12-19) are not available.

\* In the full sample, 18 adolescents (0.5%) reported having diabetes,
equivalent to a population-based weighted sample of 134,071 adolescents.

\* Among adolescents who reported having diabetes, approximately 8 (29%)
were categorized as having type 2 diabetes, equivalent to a
population-based weighted sample of 39,005 adolescents.

\* In the subsample (adolescents without self-reported diabetes who had
fasted for at least 8 hours), approximately 178 adolescents (11%) were
categorized as having impaired fasting glucose levels, equivalent to a
population-based weighted sample of 2,769,736 adolescents.

These findings have important implications for public health because of
the high rate of conversion from impaired fasting glucose level to type
2 diabetes in adults, and the increased risk of cardiovascular disease
among adults with type 2 diabetes,\" states the author. The author
concludes that \"these data provide a compelling rationale for
prevention of diabetes and impaired fasting glucose levels among
adolescents in the U.S. population.\"

#### Duncan GE. 2006. Prevalence of diabetes and impaired fasting glucose levels among U.S. adolescents: National Health and Nutrition Examination Survey, 1999-2002. Archives of Pediatrics and Adolescent Medicine 160(5):523-528 [[http://archpedi.ama-assn.org/cgi/content/abstract/160/5/523]{.underline}](http://archpedi.ama-assn.org/cgi/content/abstract/160/5/523) {#duncan-ge.-2006.-prevalence-of-diabetes-and-impaired-fasting-glucose-levels-among-u.s.-adolescents-national-health-and-nutrition-examination-survey-1999-2002.-archives-of-pediatrics-and-adolescent-medicine-1605523-528-httparchpedi.ama-assn.orgcgicontentabstract1605523 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Sudden, Unexplained Infant Death Initiative**

# Summary

-   Rates of SIDS among American Indian infants are almost three times
    higher than SIDS rates among white infants.

-   CDC's Division of Reproductive Health, in collaboration with
    partners, launched the Sudden, Unexplained Infant Death Initiative
    in 2004 to address these problems and to **improve and standardize
    infant death scene investigations** and cause-of-death reporting.
    Its objectives are to revise the 1996 Sudden, Unexplained Infant
    Death Investigation Reporting Form (SUIDIRF) and to develop a
    **standard training curriculum and materials** for those who
    investigate and determine causes of death.

-   Revision of the 1996 SUIDIRF: In 2004, a work group that included
    medical examiners, coroners, death scene investigators, researchers,
    and groups of SIDS parents worked with CDC to revise the 1996
    SUIDIRF. Two key members of this team \-- a forensic pathologist and
    a Federal Bureau of Investigation (FBI) agent who coordinates infant
    death investigations -- have experience working in AI/AN
    communities.

-   At the October 2005 NIHB Tribal Public Health Workshop in Phoenix,
    Arizona, Dr. Terry Davis of CDC provided information to attendees
    about CDC's SUID Initiative and plans to offer training for infant
    death scene investigators in AI/AN communities.

-   Plan is to develop training vignettes that address issues specific
    to infant death scene investigations in AI/AN communities. CDC is
    seeking assistance and input on these from the AI/AN community.
    <http://www.cdc.gov/SIDS/SUIDactivites.htm>

-   (if you submit any vignettes to Terry -- please cc
    <jthierry@ihs.gov> )

Dr. Terry Davis at email: <ddu8@cdc.gov> or phone:770-488-6259 directly

Terry can answer any and all questions on the logistics of the regional
training for state teams and approaches being considered for AIAN Tribes
and communities and their jurisdictions.

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

#### Tool Kit on Teaching and Assessment children with Special needs {#tool-kit-on-teaching-and-assessment-children-with-special-needs-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### This Tool Kit ... current and relevant information about practices that will improve and enhance education opportunities for students with disabilities throughout the nation. Office of Special Education and Rehabilitative Services (OSERS), U.S. Department of Education {#this-tool-kit-current-and-relevant-information-about-practices-that-will-improve-and-enhance-education-opportunities-for-students-with-disabilities-throughout-the-nation.-office-of-special-education-and-rehabilitative-services-osers-u.s.-department-of-education .Style-Heading-4-+-Arial-14-pt-Underline}

<http://www.osepideasthatwork.org/toolkit/ovr_intro.asp>

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

**SIDS/Infant Death Resource Center is looking for materials**\
The Health Resources and Services Administration (HRSA), Maternal and
Child Health Bureau (MCHB), National SIDS/Infant Death Resource Center
is developing a searchable electronic resource compendium where
professionals and consumers can access information on sudden infant
death syndrome (SIDS), other infant death, miscarriage, and stillbirth,
in the areas of risk reduction and bereavement support. The resource
compendium will be available on the NSIDRC Web site at
[[www.sidscenter.org]{.underline}](blocked::http://www.sidscenter.org/).
The compendium includes links to electronic versions of publications
such as fact sheets, brochures, booklets, posters, order forms, and
electronic materials in CD/DVD/video format (including foreign-language
materials). The Resource Compendium offers professionals and consumers a
topical index that is sorted and searchable by keyword and by
organization.

The Resource Compendium can assist you to increase the visibility of
your publications. As a result, participating organizations may see an
opportunity for collaboration with the author of a certain publication
of interest. 

If you would like to contribute your organization's publications to the
compendium, please follow the instructions
below:**  **[www.sidescenter.org/biblio/](http://www.sidescenter.org/biblio/)
** **Webpage where you can enter specific information for each
publication to be submitted.

Material must currently be online in either HTML, PDF, or Word format.

#### 8280 Greensboro Drive, Suite 300 McLean, VA 22102 866.866.7437 (toll-free) Fax: 703.821.2098 703.902.1249 [**http://www.sidscenter.org**](http://www.sidscenter.org/) {#greensboro-drive-suite-300-mclean-va-22102-866.866.7437-toll-free-fax-703.821.2098-703.902.1249-httpwww.sidscenter.org .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### National Asthma Education and Prevention Program recommend inhaled corticosteroids {#national-asthma-education-and-prevention-program-recommend-inhaled-corticosteroids .Style-Heading-4-+-Arial-14-pt-Underline}

#### Guidelines from the National Asthma Education and Prevention Program recommend inhaled corticosteroids or another daily long-term control medication in older children and adults with persistent asthma to prevent symptoms and quick-relief medication such as inhaled bronchodilator to treat acute asthma symptoms if they occur. The results of the PEAK study provide strong support for extending the use of inhaled corticosteroids, for the same reasons, to pre-school children at high risk for asthma. {#guidelines-from-the-national-asthma-education-and-prevention-program-recommend-inhaled-corticosteroids-or-another-daily-long-term-control-medication-in-older-children-and-adults-with-persistent-asthma-to-prevent-symptoms-and-quick-relief-medication-such-as-inhaled-bronchodilator-to-treat-acute-asthma-symptoms-if-they-occur.-the-results-of-the-peak-study-provide-strong-support-for-extending-the-use-of-inhaled-corticosteroids-for-the-same-reasons-to-pre-school-children-at-high-risk-for-asthma. .Style-Heading-4-+-Arial-14-pt-Underline}

**Resources**

Guidelines for the Diagnosis and Management of Asthma \-- Update on
Selected Topics 2002,

<http://www.nhlbi.nih.gov/guidelines/asthma/index.htm>

National Asthma Education and Prevention Program

<http://www.nhlbi.nih.gov/about/naepp/index.htm>

Asthma Information for Patients and the General Public

<http://www.nhlbi.nih.gov/health/public/lung/index.htm>

Prevention of Early Asthma in Kids

<http://www.asthma-carenet.org/clinicaltrials/peak.html>

Inhaled Steroids Safe and Effective for Children with Asthma, NHLBI

<http://www.nhlbi.nih.gov/new/press/oct11-00.htm>

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

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

**Caring for Patients After Bariatric Surgery**

Bariatric surgery leads to sustainable long-term weight loss and may be
curative for such obesity-related comorbidities as diabetes and
obstructive sleep apnea in severely obese patients. The Roux-en-Y
gastric bypass has become the most common procedure for patients
undergoing bariatric surgery. The procedure carries a mortality risk of
up to 1 percent and a serious complication risk of up to 10 percent.
Indications include body mass index of 40 kg per m2 or greater, or 35 kg
per m2 or greater with serious obesity-related comorbidities (e.g.,
diabetes, obstructive sleep apnea, coronary artery disease, debilitating
arthritis). Pulmonary emboli, anastomotic leaks, and respiratory failure
account for 80 percent of all deaths 30 days after bariatric surgery;
therefore, appropriate prophylaxis for venous thromboembolism
(including, in most cases, low-molecular-weight heparin) and awareness
of the symptoms of common complications are important. Some of the
common short-term complications of bariatric surgery are wound
infection, stomal stenosis, marginal ulceration, and constipation.
Symptomatic cholelithiasis, dumping syndrome, persistent vomiting, and
nutritional deficiencies may present as long-term complications. Am Fam
Physician 2006;73:1403-8 <http://www.aafp.org/afp/20060415/1403.html>

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

## American Family Physician\*\* {#american-family-physician-1 .Style-Heading-2-+-14-pt}

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

Immersion Exercise Reduces Leg Edema in Pregnancy

**Clinical Question:** Does immersion exercise reduce dependent edema in
pregnant women?

**Study Design:** Cohort (prospective)

**Synopsis:** Dependent edema is common in pregnancy. In this study,
nine women with marked edema and otherwise uncomplicated pregnancies
participated in a 45-minute exercise session while immersed in water.
Lower leg volumes were measured before and after the session, including
the foot and 4 in (10 cm) of the lower leg. Mean volume decreased by 112
mL on the left leg and 84 mL on the right leg (*P* = .007). The women
also had a subjective impression of reduction in edema. The authors did
not report the duration of the effect or other patient-oriented
outcomes.

**Bottom Line:** Water immersion exercise is an option for managing leg
edema in otherwise uncomplicated pregnancies. (Level of Evidence: 2b)

Hartmann S, Huch R. Response of pregnancy leg edema to a single
immersion exercise session. Acta Obstet Gynecol Scand December
2005;84:1150-3 <http://www.aafp.org/afp/20060415/tips/11.html>

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

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

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

**ACOG Recommends First Ob-Gyn Visit in Early Teens**

***Washington, DC*** \-- The American College of Obstetricians and
Gynecologists (ACOG) reaffirms its recommendation that teenage girls
first visit an ob-gyn between the ages of 13 and 15 in a new committee
opinion published in the May 2006 issue of *Obstetrics & Gynecology*.
This initial reproductive health visit will help teens develop a
relationship with their ob-gyn before they need to seek care for a
specific health issue. The committee opinion details ACOG
recommendations for the scope of the visit, discussion topics, and ways
to address confidentiality concerns.

The early teen years are an ideal time for an initial ob-gyn office
visit that focuses on screening and preventive health care. \"During
these years, young teens face new issues regarding sexual and
reproductive health and development on a daily basis. It\'s important
that they develop a relationship with their ob-gyn,\" says Marc Laufer,
MD, chair of ACOG\'s Committee on Adolescent Health Care. \"Interaction
with an ob-gyn they trust allows teens to get answers to questions that
they may be too embarrassed or afraid to raise with parents and friends.
Ob-gyns also can encourage teens to adopt healthy lifestyle habits that
they can carry into adulthood.\"

Physicians can discuss normal development, menstruation, sexuality,
healthy eating habits, safety and injury prevention, and date rape
prevention with teens. It also gives ob-gyns an opportunity to address
problems that may require early intervention such as eating disorders
and weight issues, blood pressure problems, and mental health issues
such as anxiety, depression, and physical, sexual, and emotional abuse.

\"Teens who are nervous about receiving a pelvic exam can rest easy. A
pelvic exam is rarely necessary during the initial visit, unless
indicated by medical history,\" Dr. Laufer adds. Because ACOG recommends
that young women have their first Pap test approximately three years
after vaginal intercourse but before age 21, teens may visit the ob-gyn
several times before a speculum or pelvic exam is needed. However,
ob-gyns may recommend a pelvic exam if the teen has had an abnormal
puberty (pubertal aberrancy), abnormal bleeding, or abdominal or pelvic
pain.

\"The first reproductive health visit is an excellent time to discuss
pregnancy prevention and sexually transmitted infections,\" says Lesley
Breech, MD, vice chair of the Committee on Adolescent Health Care.
Today, more than 85% of adolescents become sexually active during the
teen years - nearly one-third of ninth graders and more than 60% of 12th
graders report having had sexual intercourse, and the US has the highest
teen pregnancy rate of any industrialized nation. \"Physicians can use
the visit as an opportunity to provide teens with early and accurate
information about sex. We can talk about how to use condoms correctly
and the various types of contraception that are available, such as
emergency contraception, before they start having sex,\" Dr. Breech
adds. If a teen is already sexually active at the time of her first
visit, she can be screened for certain sexually transmitted infections
through a urine sample.

Parents are encouraged to get involved. The first visit provides an
opportunity for parents or guardians to meet the physician, alleviate
fears, and develop trust. Parents also can encourage a positive
relationship between their daughter and her ob-gyn. Ob-gyns can greet
parents and teens together to give a thorough explanation of the visit
and confidentiality issues. The exam and discussion should then continue
between physician and teen alone to ensure privacy.

<http://www.acog.org/from_home/publications/press_releases/nr05-09-06-2.cfm>

**Vaginitis**

**ACOG Practice Bulletin No. 72**

Summary of Recommendations and Conclusions

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

-   Women with complicated vulvovaginal candidiasis should receive more
    aggressive treatment than women with an uncomplicated episode.

-   To prevent reinfection, women with trichomoniasis should avoid
    intercourse until they and their partner have received treatment.

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

-   Microscopy is the first line for diagnosing vulvovaginal candidiasis
    and trichomoniasis. In selected patients, culture for yeast and T
    vaginalis should be obtained in addition to standard office-based
    testing.

-   Douching is not recommended for the prevention or treatment of
    vaginitis.

-   Self-diagnosis of vaginitis is unreliable.

The following recommendation is based primarily on consensus and expert
opinion (Level C):

-   Clinical evaluation of women with vaginal symptoms should be
    encouraged, particularly for women who fail to respond to
    self-treatment with a nonprescription antifungal.

Vaginitis. ACOG Practice Bulletin No. 72. American College of
Obstetricians and Gynecologists. Obstet Gynecol 2006;107:1195--206.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16648432>

**Hepatitis B and Hepatitis C Virus Infections in
Obstetrics--Gynecology**

**ACOG Committee Opinion No. 332**

ABSTRACT: Hepatitis B and hepatitis C may be transmitted from patients
to health care workers and from health care workers to patients. To
reduce the risk, all obstetrician--gynecologists who provide clinical
care should receive hepatitis B virus vaccine.
Obstetrician--gynecologists who are hepatitis B surface antigen positive
and e antigen positive should not perform exposure prone procedures
until they have sought counsel from an expert review panel. Because the
risk of hepatitis C virus transmission is lower than that of hepatitis B
virus transmission, routine testing of health care workers is not
recommended, and hepatitis C virus-positive health care workers are not
required to restrict professional activities.

Hepatitis B and Hepatitis C Virus Infections in
Obstetrician--Gynecologists. ACOG Committee Opinion No. 332. American
College of Obstetricians and Gynecologists. Obstet Gynecol
2005;106:1141--2.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Display&dopt=pubmed_pubmed&from_uid=16648433>

**The Apgar Score**

**ACOG Committee Opinion No. 333**

ABSTRACT: The Apgar score provides a convenient shorthand for reporting
the status of the newborn infant and the response to resuscitation. The
Apgar score has been used inappropriately to predict specific neurologic
outcome in the term infant. There are no consistent data on the
significance of the Apgar score in preterm infants. The Apgar score has
limitations, and it is inappropriate to use it alone to establish the
diagnosis of asphyxia. An Apgar score assigned during resuscitation is
not equivalent to a score assigned to a spontaneously breathing infant.
An expanded Apgar score reporting form will account for concurrent
resuscitative interventions and provide information to improve systems
of perinatal and neonatal care.

The Apgar Score. ACOG Committee Opinion No. 333. American College of
Obstetricians and Gynecologists. Obstet Gynecol 2005;106:1141--2.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16648434>

**Role of the Obstetrician--Gynecologist in the Screening and Diagnosis
of Breast Masses**

**ACOG Committee Opinion No. 334**

ABSTRACT: Obstetrician--gynecologists are in a favorable position to
diagnose breast disease in their patients. Obstetrician--gynecologists
are more likely to encounter a patient with breast cancer than a patient
with any gynecologic cancer. The American College of Obstetricians and
Gynecologists (ACOG) has adopted the goals of assisting in educating
obstetrician--gynecologists in the diagnosis and treatment of breast
cancer and in reducing mortality from breast cancer. To help meet these
goals, ACOG has developed recommendations for the early diagnosis of
breast disease

Role of the Obstetrician--Gynecologist in the Screening and Diagnosis of
Breast Masses. ACOG Committee Opinion No. 334. American College of
Obstetricians and Gynecologists. Obstet Gynecol 2005;106:1141--2.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Display&dopt=pubmed_pubmed&from_uid=16648435>

**The Initial Reproductive Health Visit**

**ACOG Committee Opinion No. 335**

ABSTRACT: The American College of Obstetricians and Gynecologists (ACOG)
recommends that the first visit to the obstetrician--gynecologist take
place between the ages of 13 and 15 years (1). This visit will provide
health guidance, screening, and preventive health care services and
provide an excellent opportunity for the obstetrician--gynecologist to
start a physician--patient relationship. This visit generally does not
include an internal pelvic examination.

The Initial Reproductive Health Visit. ACOG Committee Opinion No. 335.
American College of Obstetricians and Gynecologists. Obstet Gynecol
2006;107:745-7.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Display&dopt=pubmed_pubmed&from_uid=16648436>

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

**Do-not-resuscitate orders for terminally ill children may not be
honored by public schools**

[http://www.ahrq.gov/research/mar06/0306RA12.htm](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ahrq.gov/research/mar06/0306RA12.htm)

**Ectopic pregnancy rates are declining, but the decline is slower among
black women**

[http://www.ahrq.gov/research/mar06/0306RA17.htm](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ahrq.gov/research/mar06/0306RA17.htm)

**Close-call reporting systems may be underutilized in identifying
potential medical errors**

[http://www.ahrq.gov/research/mar06/0306RA3.htm](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ahrq.gov/research/mar06/0306RA3.htm)

**Doctors still prescribe antibiotics for over half of children with
sore throats**

[http://www.ahrq.gov/research/mar06/0306RA13.htm](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ahrq.gov/research/mar06/0306RA13.htm)

 

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

**MCH Library launches redesigned web site**

The MCH Library has launched a redesigned Web site that provides
accurate, reliable, and timely information and resources for the
maternal and child health (MCH) community. The Web site contains the MCH
Alert weekly e-newsletter, resource guides, full text publications,
databases, and links to quality MCH Web sites.

A search box, an A-Z topic index, and frequently asked questions are
featured on the Web site home page. The home page also includes links to
the MCH thesaurus, final reports produced by Maternal and Child Health
Bureau grantees, an index to non-English-language materials and
resources, and resources for families. The Healthy People 2010 Web page
provides information related to MCH goals and objectives and library
products related to leading health indicators. The Web site, intended
for use by health professionals, policymakers, family advocates,
community service professionals, MCH/public health faculty and students,
and families:
[[http://www.mchlibrary.info]{.underline}](http://www.mchlibrary.info/)

##### 

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

**Database provides information about drugs in breastfeeding mothers\
**The Drugs and Lactation Database (LactMed) is a peer-reviewed and
fully referenced database of drugs to which breastfeeding mothers may be
exposed. The database was produced by the National Library of Medicine
as part of the Toxicology Data Network. Among the data included are
maternal and infant levels of drugs, possible effects on breastfed
infants and on lactation, and alternate drugs to consider. The database
is searchable by drug name\
[http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT)

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

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

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

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

\-[Protein to Creatinine Ratio in Pre-eclampsia: Is the data preceding
the U.S.
benchmarks?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0406_AOM.cfm)

\-[RCTs: Do they have external validity for patients with multiple
co-morbidities
?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0406_Coll.cfm)

\-[Gestational Diabetes Mellitus Tracking Sheets and Case Management
PPT](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0406_Coll.cfm)

\-[Glyburide is at least as effective as insulin therapy in treating
gestational
diabetes](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0406_HT.cfm#ob)

\-[Urinary incontinence: Substantial economic costs and decrement in
quality of
life](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0406_HT.cfm#gyn)

\-[Infant Mortality Reviews in the Aberdeen Area: Strategies and
Outcomes](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0406_HT.cfm#child)

\-[Breast cancer study from
PIMC](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0406_HT.cfm#chrIll)

\-[Less Invasive Management of Cervical Cytology Abnormalities in
Adolescents](http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN0406_Feat.cfm#acog)

\-[ACOG: New Guidelines Call for Restricted Use of
Episiotomies](http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN0406_Feat.cfm#acog)

\-[Early feeding choice and
obesity](http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN0406_Feat.cfm#breast)

\-[MCH Frequently Asked Question (FAQ)
site](http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN0406_Feat.cfm#webSite)

\-[What is the common
theme?](http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN0406_Feat.cfm#mmtour)

\-[Hands off\" versus \"hands on\" for decreasing perineal lacerations:
No
difference](http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN0406_Feat.cfm#MidWives)

\-[Methamphetamine abuse among women on Navajo, Part
1](http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN0406_Feat.cfm#navajo)

\-[Journey to
Magnet](http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN0406_Feat.cfm#nurseCorner)

\-[Peripartum
Cardiomyopathy](http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN0406_Feat.cfm#okie)

\-[Vaginal breech \< 3, 500 g - No increase risk in neurodevelopment at
2 years of
age](http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN0406_Feat.cfm#periPicks)

\-[Adverse Childhood Events: Impact on chronic adult illness / Risk
taking](http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN0406_Feat.cfm#pcf)

\-[Announcing New Program Manager for the IHS National STD
Program](http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN0406_Feat.cfm#std)

\-["Clinical inertia\" - Providers not intensifying diabetes therapy
when
indicated](http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN0406_Feat.cfm#stillW)

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/documents/06AprOL.pdf**](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/06AprOL.pdf) {#httpwww.ihs.govmedicalprogramsmchmdocuments06aprol.pdf .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

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

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

**Grants Alert: Domestic Violence, Cultural Competence**\
Purpose:  To provide for the distribution of credible and persuasive\
information by community organizations to help break the cycle of
family\
violence. Support for these efforts will help ensure that individuals\
are aware of available resources and alternative responses for the\
intervention and prevention of violence.\
Administration for Children and Families Community Awareness and
Outreach Campaign Projects for the Prevention of Family Violence,
Department of Health & Human Services

Application Deadline: 06/11/2006.

Estimated Available Funds: \$750,000.\
Maximum Award Size: \$75,000 per project period.\
Estimated Number of Awards: 5 to 10.\
CFDA No.: 93.592.

For more information, contact: William D. Riley, Director\
Email: <wriley@acf.hhs.gov> or go to: <http://tinyurl.com/zkmjj>

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

**Maintenance treatment of major depression in old age**

Depression is common in the elderly, and places them at increased risk
of death and disability.  Elders treated successfully for depression
tend to have recurrences over time.  This study evaluated whether long
term antidepressant treatment with either medication or psychotherapy
reduced the rate of recurrence in patients 70 and older with major
depression who have responded to initial treatment with paroxetine (an
SSRI antidepressant) and psychotherapy.  Over a two year period those
patients receiving maintenance medication, with or without
psychotherapy, were roughly half as likely as those who did not receive
medication to have recurrence of their depression.  This study was not
supported by the pharmaceutical industry. 

 

The accompanying editorial points out that mild-moderate depression can
often be treated by exercise and increased social activities.  The
author also suggests that elderly individuals who have had a significant
depressive episode should have lifelong periodic reevaluation.

 Elder Care Director Comments

I would now consider continuing treatment of an the older individual
 with depression who has responded to antidepressant therapy for up to
two years and would plan to incorporate  periodic reevaluation for
depression into their plan of care..  We are reminded that depression in
the elderly should be considered a chronic condition.

[Reynolds CF III, et
al.](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16540613&query_hl=1&itool=pubmed_docsum) 
Maintenance treatment of major depression in old age.\
N Engl J Med. 2006 Mar 16; 354(11):1130-8.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16540613>

[Reifler
BV.](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16540621&query_hl=4&itool=pubmed_docsum)
Play it again, Sam\--depression is recurring.  N Engl J Med. 2006 Mar
16;354(11):1189-90.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16540621>

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

**31% of Sexually Active U.S. Teenage Girls Become Pregnant**

Based on the National Survey of Family growth from the National Center
for Health Statistics, CDC, and HHS, nearly 31% of girls ages 15 to 19
who have had sexual intercourse at least once become pregnant. In
addition, more than 13% of sexually active teenage boys say they have
been involved in a pregnancy. The analysis shows that more than
one-third of sexually active girls who have had three or more sexual
partners have been pregnant, compared with one in four who have had one
or two partners. In addition, the report finds that 27% of girls who
used a form of contraception when having sex for the first time said
they became pregnant, compared with 43% of girls who did not use
contraception during sexual debut.\
<http://www.teenpregnancy.org/press/pdf/ScienceSays23.pdf>

**Postpartum contraception: New Mexico Pregnancy Risk Assessment
Monitoring System**

OBJECTIVE: To examine factors associated with postpartum contraception,
including the relationship between ethnicity and postpartum
contraceptive use.

METHODS: We used data from the New Mexico Pregnancy Risk Assessment
Monitoring System, which monitors selected maternal events occurring
before, during and after pregnancy.

RESULTS: Our findings in 4096 women revealed that women who are aged
\>or=35 years, unmarried and lacking a postpartum visit have increased
risk of no postpartum contraception. The odds of postpartum
contraception were over three times greater in women with a postpartum
visit \[adjusted odds ratio (OR)=3.06, 95% confidence interval (CI):
2.17-4.31) and over 50% greater in married women(adjusted OR=1.57, 95%
CI: 1.16-2.11). Hispanic women were more likely than were Native
Americans to use postpartum contraception (OR=1.25, 95% CI: 0.95-1.64).

CONCLUSION: Focused contraception counseling, especially in the
postpartum setting, is important to help ensure the well-being of women
and children.

Depineres T, Blumenthal PD, Diener-West M. Postpartum contraception: the
New Mexico Pregnancy Risk Assessment Monitoring System. Contraception.
72(6):422-5, 2005 Dec

<http://www.contraceptionjournal.org/issues/contents>

**Featured Website David Gahn, IHS Women's Health Web Site Content
Coordinator**

**The MCH Frequently Asked Question (FAQ) site**

This site offers over 425 answers to common questions about the care of
women and children in the unique settings found in Indian Country.
Answers include both a quick answer and then significant background and
multiple resources and links.

The site is maintained frequently (see section below) with 11 new FAQs
this month and numerous existing FAQs being updated. There are 15
answers to questions on bilateral tubal ligation alone.

Go here to explore the frequently asked question page

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

Finally, if the particular question you have is not already posted, then
please contact the OB/GYN Chief Clinical Consultant directly. You can
get an answer at <nmurphy@scf.cc>

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

**Q. Are there any cultural barriers/among Native Americans to becoming
cord blood donors?**

A. Yes, there are issues of the cost for long term cord blood storage,
as well as cultural issues. Below are five resources about various
aspects of cord blood and tissue donation. The MCH web page also has a
Frequently Asked Question with a sample cord blood donation disclaimer
and many other resources.

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/CordStem4206.doc>

1.) Why should minorities be concerned about organ donation?

Some diseases of the kidney, heart, lung, pancreas, and liver are found
more frequently in racial and ethnic minority populations than in the
general population. For example, African Americans, Asian and Pacific
Islanders, and Hispanics are three times more likely to suffer from
end-stage renal disease than Caucasians. Native Americans are four times
more likely than Caucasians to suffer from diabetes. Some of these
diseases are best treated through transplantation; others can only be
treated through transplantation.

Successful transplantation often is enhanced by the matching of organs
between members of the same ethnic and racial group. For example, any
patient is less likely to reject a kidney if it is donated by an
individual who is genetically similar. Generally, people are genetically
more similar to people of their own ethnicity or race than to people of
other races. Therefore, a shortage of organs donated by minorities can
contribute to death and longer waiting periods for transplants for
minorities. <http://www.unos.org/qa.asp>

2.) Q: Why is there a need for women from all racial and ethnic groups
to donate their baby\'s cord blood?

## A: Because the tissue traits that are used to match a cord blood unit with a patient are inherited, a patient\'s most likely match will be cord blood donated by someone of the same heritage. American Indian and Alaska Native, Asian, Black and African American, Hispanic and Latino, Native Hawaiian and Other Pacific Islander, and multiple-race patients face a greater challenge in finding a match than White patients. 

NMDP cord blood banks are working in local communities to increase the
racial and ethnic diversity of NMDP cord blood listings. From 2001 to
2003, the likelihood of finding a matched cord blood unit has grown at
least twofold for patients from all racial and ethnic groups. Still,
some patients are unable to find a match because of the rarity of their
tissue traits. Some tissue traits are more likely to be found among
people of a particular racial or ethnic heritage. That is why a pressing
need remains for more cord blood donations from American Indian and
Alaska Native, Asian, Black and African American, Hispanic and Latino,
Native Hawaiian and Other Pacific Islander, and multiple-race donors.
<http://www.marrow.org/DONOR/cord_blood_faqs.html#minority>

National Marrow Donor Program
<http://www.marrow.org/DONOR/cord_blood_faqs.html>

3.) Native Village: Youth and Education News: Umbilical Cord Blood
Donation

Cryobanks International is a facility accepting umbilical cord blood
donations throughout the United States. Umbilical cord blood is rich in
stem cells used in place of bone marrow for transplants.  Cryobanks is
now working with Dave Jackson, a Native American Advocate and high-risk
OB physician, to sponsor an umbilical cord blood donation program. 
Umbilical Cord Blood Donation is a painless, non-invasive process that
utilizes cord blood that would otherwise be discarded as medical waste. 
Currently, Native Americans in life and death searches have little
chance to find a stem cell match. Donations are accepted from anywhere
in the Continental United States.

There is no charge to donate, but be sure to ask about storage charges.
[[ipressler@cryo-intl.com]{.underline}](mailto:ipressler@cryo-intl.com)

Native Village: Youth and Education News December 10, 2003 Issue 124,
Volume 3

[http://www.nativevillage.org/Archives/2003/Dec%2010%20NEWS/Native%20Village%20News%20,%20Dec%2010%202003%20I%20124%20V3.htm](http://www.nativevillage.org/Archives/2003/Dec 10 NEWS/Native Village News , Dec 10 2003 I 124 V3.htm)

Learn more about Cryobanks: <http://www.cryo-intl.com/>

4.) Sacred symbolic value associated with the placenta, umbilical cord,
and umbilical cord blood

Excerpt:

Yet, in many indigenous cultures, including Native American, the
placenta, umbilical cord, and umbilical cord blood have sacred symbolic
value associated \...

Abstract:. Religious discussion of human organs and tissues has
concentrated largely on donation for therapeutic purposes. The retrieval
and use of human tissue samples in diagnostic, research, and education
contexts have, by contrast, received very little direct theological
attention. Initially undertaken at the behest of the National Bioethics
Advisory Commission, this essay seeks to explore the theological and
religious questions embedded in nontherapeutic use of human tissue. It
finds that the \"donation paradigm\" typically invoked in religious
discourse to justify uses of the body for therapeutic reasons is
inadequate in the context of nontherapeutic research, while the
\"resource paradigm\" implicit in scientific discourse presumes a
reductionist account of the body that runs contrary to important
religious values about embodiment. The essay proposes a \"contribution
paradigm\" that provides a religious perspective within which research
on human tissue can be both justified and limited.
<http://muse.jhu.edu/>

Campbell, Courtney S. 1956- \"Religion and the Body in Medical
Research\"\
Kennedy Institute of Ethics Journal - Volume 8, Number 3, September
1998, pp. 275-305\
The Johns Hopkins University Press

<http://muse.jhu.edu/cgi-bin/access.cgi?uri=/journals/kennedy_institute_of_ethics_journal/v008/8.3campbell.html>

5.) Ethical bases for the draft Indian Health Service\'s (IHS)
Guidelines about the collection and use of research specimens

"34. People in some Tribes have traditional beliefs that the placenta,
umbilical cord, and umbilical cord blood are sacred and must be handled
in a special manner. IHS hospitals give such tissues back to the patient
or family upon request. "

This paper presents the ethical bases for the DRAFT Indian Health
Service\'s (IHS) Guidelines about the collection and use of research
specimens (Appendix A). The Guidelines were designed to be a working
document for American Indian and Alaska Native (AI/AN)(3) Tribal
communities and people; its ethical rationale was not discussed. The
Guidelines are relevant to most U.S. people, researchers, and policy
makers; if researchers and ethicists are to them as relevant, however,
that ethical rationale must be clarified and convincing...

For the proper perspective please view the entire paper at link below.

<http://scholar.google.com/scholar?hl=en&lr=&q=cache:lN-Ni_NcrDoJ:www.unm.edu/~hsethics/pubfreeman.htm+The+role+of+Community+in+research+with+stored+tissue+samples>

This was published in Weir R (ed.). Stored tissue samples: Ethical,
legal, and public policy implications. U. Iowa Press; Iowa City, IA.
1998: 267-301. This file is the pre-edited next-to-final version. For
the final, printed, version, please see the book.

This paper does not necessarily represent the views of the Indian Health
Service

Frequently Asked Question: MCH website

**Q. Is cord blood stem cell storage a viable option in Indian
Country?**

A. Cord blood stem cell storage can offer patients both advantages and
disadvantages.

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/CordStem4206.doc>

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

**Highlights of May 2006**

Remember when they told you in medical school that half of what they
were teaching you was wrong, they must didn\'t know which half. Now we
do\...

\- Humidification doesn\'t benefit croup

\- Fluoroquinolones can be used in children \< 12 years

However our editors Drs. Singleton and Esposito do know some things and
will share them\...

\- Which Haemophilus influenzae type b vaccine is the best for AI/AN
infants?

\- Helicobacter pylori and anemia in AI/AN children

\- Lessons from New Zealand - access to care for indigenous Maori
[[http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ICHN5706.doc]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ICHN5706.doc)

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

**Annual IHS Technology Conference**

We are pleased to announce the IHS Technology Conference, June 19-23,
2006, to be held in the Albuquerque Convention Center, Albuquerque, New
Mexico.  The theme is \"Native Communities Sharing Information through
Technology\". Please register for the conference using the website, and
refer to the site for conference tracks, agenda, and presentations.

[[http://www.ihs.gov/AdminMngrResources/techconf/index.cfm]{.underline}](http://www.ihs.gov/AdminMngrResources/techconf/index.cfm)

Please contact: 
[[tech.conf@ihs.gov]{.underline}](mailto:tech.conf@ihs.gov) for detailed
information or questions.

#### International Health Update {#international-health-update .Style-Heading-4-+-Arial-14-pt-Underline}

**Special Journal Issue Features Articles on Women, Gender, and Health
Care Disparities**

The March-April issue of the *Journal of Women\'s Health* features seven
articles on women, gender, and health care disparities coauthored by
AHRQ\'s Director of Women\'s Health and Gender-Based Research, Rosaly
Correa-de-Araujo, M.D. The articles are as follows:

1.  Introduction to the theme issue: Women, gender, and health care
    disparities, by Correa-de-Araujo R.

```{=html}
<!-- -->
```
1.  Commentary: Catalyzing quality of care improvements for women, by
    Correa-de-Araujo R and Clancy C.

2.  Gender differences across racial and ethnic groups in the quality of
    care for acute myocardial infarction and heart failure associated
    with comorbidities, by Correa-de-Araujo R, Stevens B, Moy E,
    Nilasena D, Chesley F, and McDermott K.

3.  Gender differences across racial and ethnic groups in the quality of
    care for diabetes, by Correa-de-Araujo R, McDermott K , and Moy E.

4.  Women\'s health care utilization and expenditures, by Taylor AT,
    Larson S, and Correa-de-Araujo R.

5.  Preventive health examinations: A comparison along the rural-urban
    continuum, by Larson S and Correa-de-Araujo R.

6.  Quality of health care for older women: What do we know,? by Kosiak
    B, Sangl J, and Correa-de-Araujo R.

A copy is available by sending an e-mail to <ahrqpubs@ahrq.hhs.gov>.
Limited copies are available. *Journal of Women\'s Health*
<http://www.liebertpub.com/publication.aspx?pub_id=42>

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

**Dieting behavior among overweight and non-overweight adolescents**

Findings from the present study show that the risks associated with
dieting appear similar for overweight and non-overweight teens. Dieting
behavior has been shown to co-occur with a variety of negative
correlates in adolescents. Dieting could be a reasonable,
health-promoting behavior for adolescents who are overweight, while
simultaneously carrying health risks for those not overweight.
Alternatively, dieting could carry similar risks for all adolescents,
regardless of their weight status

The authors found that

\* The majority (68.2%) of the students were classified as
non-overweight, with 31.8% classified as overweight.

\* Student report of dieting was common (55.2% of girls and 25.9% of
boys).

\* Students classified as overweight were roughly 1.5 to 3 times as
likely as students classified as non-overweight to report dieting,
EWCBs, and body dissatisfaction.

\* Girls who reported dieting had elevated odds ratios for EWCBs, low
self-esteem, body dissatisfaction, and depressive symptoms, and tobacco
use and alcohol use; boys who reported dieting had elevated odds for
EWCBs, low self-esteem, body dissatisfaction, and depressive symptoms.

\* Increased risks associated with dieting were similar for overweight
and non-overweight students, with the exception of body dissatisfaction
in non-overweight girls (5.26) vs. overweight girls (3.19).

\"The psychosocial and behavioral risks of dieting . . . may outweigh
the potential benefits, even for overweight teens,\" conclude the
authors.

Crow S, Eisenberg ME, Story M, et al. 2006. Psychosocial and behavioral
correlates of dieting among overweight and non-overweight adolescents.

Journal of Adolescent Health 38(5):569-574.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16635769>

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

#### What was the common theme in these 2 cases? {#what-was-the-common-theme-in-these-2-cases-1 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Let's recap what we learned last month {#lets-recap-what-we-learned-last-month .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### This 35 year old G 2 P1001 was originally scheduled for elective repeat cesarean delivery at 36 2/7 pending results of fetal lung maturity studies. The patient's prenatal course was significant for a first visit at 8 weeks. The gestational age was confirmed by a 10 week ultrasound. The patient was offered a quad screen and /or amniocentesis and declined both. The patient had gastroesophageal reflux disease and received omeprazole 20 mg per day orally. {#this-35-year-old-g-2-p1001-was-originally-scheduled-for-elective-repeat-cesarean-delivery-at-36-27-pending-results-of-fetal-lung-maturity-studies.-the-patients-prenatal-course-was-significant-for-a-first-visit-at-8-weeks.-the-gestational-age-was-confirmed-by-a-10-week-ultrasound.-the-patient-was-offered-a-quad-screen-and-or-amniocentesis-and-declined-both.-the-patient-had-gastroesophageal-reflux-disease-and-received-omeprazole-20-mg-per-day-orally. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### The patient's previous delivery was significant for a low transverse cesarean delivery for an abruption placenta at term. The infant did well and she had an unremarkable course. She otherwise had a history of mild endometriosis and laparoscopy for an ovarian cystectomy. {#the-patients-previous-delivery-was-significant-for-a-low-transverse-cesarean-delivery-for-an-abruption-placenta-at-term.-the-infant-did-well-and-she-had-an-unremarkable-course.-she-otherwise-had-a-history-of-mild-endometriosis-and-laparoscopy-for-an-ovarian-cystectomy. .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

#### This 20 year old G 3 P 0020 at 40 2/7 presented with good early dating for an outpatient cervical ripening regimen. The patient had uncomplicated Class A~1~ gestational diabetes mellitus. The patient weighed 193 lbs and her fetus was in a cephalic presentation. Her cervical exam was 50% effaced, 1 cm dilation at the external os, firm, and posterior with the presenting part at -3 station. {#this-20-year-old-g-3-p-0020-at-40-27-presented-with-good-early-dating-for-an-outpatient-cervical-ripening-regimen.-the-patient-had-uncomplicated-class-a1-gestational-diabetes-mellitus.-the-patient-weighed-193-lbs-and-her-fetus-was-in-a-cephalic-presentation.-her-cervical-exam-was-50-effaced-1-cm-dilation-at-the-external-os-firm-and-posterior-with-the-presenting-part-at--3-station. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### The question was: What do these two patients have in common? {#the-question-was-what-do-these-two-patients-have-in-common .Style-Heading-4-+-Arial-14-pt-Underline}

#### First, let me tell you a little more about our patients {#first-let-me-tell-you-a-little-more-about-our-patients .Style-Heading-4-+-Arial-14-pt-Underline}

#### Patient #1 received an amniocentesis that revealed a fluorescence polarization (FP) of 30 mg / g, which is immature. One reference laboratory's FP ranges include {#patient-1-received-an-amniocentesis-that-revealed-a-fluorescence-polarization-fp-of-30-mg-g-which-is-immature.-one-reference-laboratorys-fp-ranges-include .Style-Heading-4-+-Arial-14-pt-Underline}

#### IMMATURE \<= 39 MG/G {#immature-39-mgg .Style-Heading-4-+-Arial-14-pt-Underline}

#### MATURE \>= 55 MG/G {#mature-55-mgg .Style-Heading-4-+-Arial-14-pt-Underline}

#### Results between 40-54 mg/G cannot be declared \"Mature\" or \"Immature with the same level of confidence and should be considered \"Inconclusive\". {#results-between-40-54-mgg-cannot-be-declared-mature-or-immature-with-the-same-level-of-confidence-and-should-be-considered-inconclusive. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### The reflex follow up test was a phosphatidyglyscerol (PG) {#the-reflex-follow-up-test-was-a-phosphatidyglyscerol-pg .Style-Heading-4-+-Arial-14-pt-Underline}

####  %PGL Trace  {#pgl-trace .Style-Heading-4-+-Arial-14-pt-Underline}

####  %Ppt.Lec. 65  {#ppt.lec.-65 .Style-Heading-4-+-Arial-14-pt-Underline}

####  %PI 27.0  {#pi-27.0 .Style-Heading-4-+-Arial-14-pt-Underline}

####  LS ratio 2.4  {#ls-ratio-2.4 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Comment: Interpretation: Lungs are - Mature with caution if not Diabetic or 36 weeks  {#comment-interpretation-lungs-are---mature-with-caution-if-not-diabetic-or-36-weeks .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Soon after the PG level result returned (NB: the patient had been 36 2/7 when the amniocentesis was performed) the patient underwent a cesarean delivery for what was termed 'extreme maternal anxiety'.  {#soon-after-the-pg-level-result-returned-nb-the-patient-had-been-36-27-when-the-amniocentesis-was-performed-the-patient-underwent-a-cesarean-delivery-for-what-was-termed-extreme-maternal-anxiety. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### The patient delivered a 7 lb. 5 oz. with Apgars of 8 and 9. The infant developed respiratory distress and required additional respiratory support and was transferred to the neonatal intensive care unit. The mother did well and was discharged on the third post-operative day. The infant remained hospitalized in the special care nursery and was discharged on the 5^th^ hospital day. {#the-patient-delivered-a-7-lb.-5-oz.-with-apgars-of-8-and-9.-the-infant-developed-respiratory-distress-and-required-additional-respiratory-support-and-was-transferred-to-the-neonatal-intensive-care-unit.-the-mother-did-well-and-was-discharged-on-the-third-post-operative-day.-the-infant-remained-hospitalized-in-the-special-care-nursery-and-was-discharged-on-the-5th-hospital-day. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Patient #2 was functional a primipara who received a 3 day cervical ripening process followed by a prolonged 2 day induction of labor. This process culminated in a cesarean delivery for prolonged 1^st^ stage of labor as the patient did not progress beyond 8-9 cm despite adequate contractions with oxytocin augmentation. The patient delivered a 6 lb. 15 oz. infant with Apgars of 7/8. The mother and infant initially had an unremarkable post-operative course and were both discharged afebrile on post-operative day 2.  {#patient-2-was-functional-a-primipara-who-received-a-3-day-cervical-ripening-process-followed-by-a-prolonged-2-day-induction-of-labor.-this-process-culminated-in-a-cesarean-delivery-for-prolonged-1st-stage-of-labor-as-the-patient-did-not-progress-beyond-8-9-cm-despite-adequate-contractions-with-oxytocin-augmentation.-the-patient-delivered-a-6-lb.-15-oz.-infant-with-apgars-of-78.-the-mother-and-infant-initially-had-an-unremarkable-post-operative-course-and-were-both-discharged-afebrile-on-post-operative-day-2. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### The mother had to be re-admitted for wound care on post-operative day #6 for wound cellulitus. The patient was started on ampicillin, clindamycin, and gentamicin intravenously and spontaneously began draining purulent material from her wound. The patient remained hospitalized until post-operative day #10. At the time of this review the patient was still being followed in outpatient clinic for continued wound care 5 weeks after her surgery.  {#the-mother-had-to-be-re-admitted-for-wound-care-on-post-operative-day-6-for-wound-cellulitus.-the-patient-was-started-on-ampicillin-clindamycin-and-gentamicin-intravenously-and-spontaneously-began-draining-purulent-material-from-her-wound.-the-patient-remained-hospitalized-until-post-operative-day-10.-at-the-time-of-this-review-the-patient-was-still-being-followed-in-outpatient-clinic-for-continued-wound-care-5-weeks-after-her-surgery. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Let me summarize the clinical scenarios:  {#let-me-summarize-the-clinical-scenarios .Style-Heading-4-+-Arial-14-pt-Underline}

#### The first patient received an elective cesarean delivery for 'extreme maternal anxiety' with an immature lung profile at 36 weeks. (Please recall it was reported a 'Mature with caution if not Diabetic or 36 weeks and the patient had been 36 2/7 at the time of amniocentesis) Her infant developed respiratory distress and required neonatal intensive care. The infant remained hospitalized after the mother was discharged. {#the-first-patient-received-an-elective-cesarean-delivery-for-extreme-maternal-anxiety-with-an-immature-lung-profile-at-36-weeks.-please-recall-it-was-reported-a-mature-with-caution-if-not-diabetic-or-36-weeks-and-the-patient-had-been-36-27-at-the-time-of-amniocentesis-her-infant-developed-respiratory-distress-and-required-neonatal-intensive-care.-the-infant-remained-hospitalized-after-the-mother-was-discharged. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### The second patient underwent a cervical ripening and subsequent prolonged induction of labor with an unripe cervix. The patient ultimately received a cesarean delivery with a less than 7 lb. infant for a prolonged 1^st^ stage of labor. The patient developed a wound infection and required re-admission to the hospital. The patient required prolonged outpatient wound care that was not complete at the time of this review. {#the-second-patient-underwent-a-cervical-ripening-and-subsequent-prolonged-induction-of-labor-with-an-unripe-cervix.-the-patient-ultimately-received-a-cesarean-delivery-with-a-less-than-7-lb.-infant-for-a-prolonged-1st-stage-of-labor.-the-patient-developed-a-wound-infection-and-required-re-admission-to-the-hospital.-the-patient-required-prolonged-outpatient-wound-care-that-was-not-complete-at-the-time-of-this-review. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### So, back to the question: What do these cases have in common? {#so-back-to-the-question-what-do-these-cases-have-in-common .Style-Heading-4-+-Arial-14-pt-Underline}

#### The cases have two things in common: {#the-cases-have-two-things-in-common .Style-Heading-4-+-Arial-14-pt-Underline}

#### First, the patients developed common complications of common procedures {#first-the-patients-developed-common-complications-of-common-procedures .Style-Heading-4-+-Arial-14-pt-Underline}

#### -prolonged neonatal intensive care after premature delivery {#prolonged-neonatal-intensive-care-after-premature-delivery .Style-Heading-4-+-Arial-14-pt-Underline}

#### (though in this case, iatrogenic prematurity) {#though-in-this-case-iatrogenic-prematurity .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### -prolonged wound care after a cesarean delivery for a failed induction {#prolonged-wound-care-after-a-cesarean-delivery-for-a-failed-induction .Style-Heading-4-+-Arial-14-pt-Underline}

#### (though in this case, for a non-acute indication with an unripe cervix) {#though-in-this-case-for-a-non-acute-indication-with-an-unripe-cervix .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Second, these both happened the during the same holiday week.  {#second-these-both-happened-the-during-the-same-holiday-week. .Style-Heading-4-+-Arial-14-pt-Underline}

#### The first patient received her amniocentesis on Christmas day and second patient had the decision to begin cervical ripening made on the day before Christmas Eve. {#the-first-patient-received-her-amniocentesis-on-christmas-day-and-second-patient-had-the-decision-to-begin-cervical-ripening-made-on-the-day-before-christmas-eve. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### A couple thoughts come to mind. As some move toward cesarean delivery on demand and increasingly patient directed care, we may want to reflect that at one point that our predecessors followed this dictum, in Greek \"First, do no harm\" becomes \"Primum non nocere\" in Latin.\*  {#a-couple-thoughts-come-to-mind.-as-some-move-toward-cesarean-delivery-on-demand-and-increasingly-patient-directed-care-we-may-want-to-reflect-that-at-one-point-that-our-predecessors-followed-this-dictum-in-greek-first-do-no-harm-becomes-primum-non-nocere-in-latin. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### One could argue that in an effort to comply with these patient's wishes to be at home with their family for the holidays, that our health system may have failed to uphold the spirit of one of its most basic principles. {#one-could-argue-that-in-an-effort-to-comply-with-these-patients-wishes-to-be-at-home-with-their-family-for-the-holidays-that-our-health-system-may-have-failed-to-uphold-the-spirit-of-one-of-its-most-basic-principles. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Is it 'poor datism' or post datism, and other issues {#is-it-poor-datism-or-post-datism-and-other-issues .Style-Heading-4-+-Arial-14-pt-Underline}

#### Considering the 2 cases above, let's muse about elective induction of labor. In 2002, the last year for which full natality statistics were available, the labor induction rate was 20.6%. This reflects a 64% increase since 1989. Demographics reveal that induction of labor is more common in insured patients, but is rising in all groups. As more than 60% of women are in the formal work force, some degree of scheduling is desirable on economic grounds alone. The challenge is to balance patient autonomy with resource utilization and health care concerns as illustrated above. {#considering-the-2-cases-above-lets-muse-about-elective-induction-of-labor.-in-2002-the-last-year-for-which-full-natality-statistics-were-available-the-labor-induction-rate-was-20.6.-this-reflects-a-64-increase-since-1989.-demographics-reveal-that-induction-of-labor-is-more-common-in-insured-patients-but-is-rising-in-all-groups.-as-more-than-60-of-women-are-in-the-formal-work-force-some-degree-of-scheduling-is-desirable-on-economic-grounds-alone.-the-challenge-is-to-balance-patient-autonomy-with-resource-utilization-and-health-care-concerns-as-illustrated-above. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Other positive aspects of labor induction is that is allows us to smooth the L/D work flow and as increasing number of indications for induction of labor are developing rapidly, e.g., post term vs post datism. The key calibrate our patients expectations and not to allow ourselves to misguide patients about their chance of timely delivery with an unfavorable cervix. Or put another way, to what extent do we need to allow our patient's mother in law's frequent flyer ticket affect our clinical practice. We should also be aware that in many cases we are inducing patients for what amounts to 'poor datism', rather than true post datism.  {#other-positive-aspects-of-labor-induction-is-that-is-allows-us-to-smooth-the-ld-work-flow-and-as-increasing-number-of-indications-for-induction-of-labor-are-developing-rapidly-e.g.-post-term-vs-post-datism.-the-key-calibrate-our-patients-expectations-and-not-to-allow-ourselves-to-misguide-patients-about-their-chance-of-timely-delivery-with-an-unfavorable-cervix.-or-put-another-way-to-what-extent-do-we-need-to-allow-our-patients-mother-in-laws-frequent-flyer-ticket-affect-our-clinical-practice.-we-should-also-be-aware-that-in-many-cases-we-are-inducing-patients-for-what-amounts-to-poor-datism-rather-than-true-post-datism. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Throughout this increase in induction of labor, ACOG has not changed its criteria for elective delivery, e.g., 39 weeks by good dating parameters.\*\* {#throughout-this-increase-in-induction-of-labor-acog-has-not-changed-its-criteria-for-elective-delivery-e.g.-39-weeks-by-good-dating-parameters. .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

**Elective induction: an analysis of economic and health consequences**

Kaufman et al concluded: Elective induction of labor at term is not cost
saving and results in a large excess of cesarean deliveries. Costs are
significantly altered by the timing of the induction, parity, and
cervical ripeness.

Specifically, Kaufman showed that induction of primiparas with
unfavorable cervices at 39 weeks would result in an additional annual
health expenditure of \$ 84,000,000 and lead to another 11,000 cesarean
deliveries. Depending on that primipara's desired ultimate family size,
many issues arise about future uterine rupture, scar dehiscence, and
neonatal compromise. In addition, depending on the patient's physical
location, she may or may not be offered a vaginal birth after cesarean
with her next pregnancy. This may have the effect of increasing her
chances of subsequent placenta accreta, plus other operative
complications that could lead to cesarean hysterectomy.

#### Routine use of sweeping of membranes from 38 weeks of pregnancy onwards {#routine-use-of-sweeping-of-membranes-from-38-weeks-of-pregnancy-onwards-1 .Style-Heading-4-+-Arial-14-pt-Underline}

(See Midwives Corner below)

**Resources:**

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

**Q. When should we change the estimated date of delivery (EDD) based on
ultrasound?**

A. There are various criteria, but once you determine an EDD, stick with
it. See these helpful tips

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/documents/USdating4606.doc**](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/USdating4606.doc) {#httpwww.ihs.govmedicalprogramsmchmdocumentsusdating4606.doc .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Perinatology Corner CME/CEU Modules (also just full of good resources) {#perinatology-corner-cmeceu-modules-also-just-full-of-good-resources .Style-Heading-4-+-Arial-14-pt-Underline}

#### Post-term Pregnancy and Induction of Labor {#post-term-pregnancy-and-induction-of-labor .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/DP61.cfm#top**](http://www.ihs.gov/MedicalPrograms/MCH/M/DP61.cfm#top) {#httpwww.ihs.govmedicalprogramsmchmdp61.cfmtop .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Vaginal Birth After Cesarean {#vaginal-birth-after-cesarean .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/VB01.cfm**](http://www.ihs.gov/MedicalPrograms/MCH/M/VB01.cfm) {#httpwww.ihs.govmedicalprogramsmchmvb01.cfm .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### \*\*Confirmation of Term Gestation, ACOG Practice Bulletin, No. 10 {#confirmation-of-term-gestation-acog-practice-bulletin-no.-10 .Style-Heading-4-+-Arial-14-pt-Underline}

-   Fetal heart tones have been documented for 20 weeks by nonelectronic
    fetoscope or for 30 weeks by Doppler.

-   It has been 36 weeks since a positive serum or urine human chorionic
    gonadotropin pregnancy test was performed by a reliable laboratory.

-   An ultrasound measurement of the crown. rump length, obtained at
    6-12 weeks, supports a gestational age of at least 39 weeks.

-   An ultrasound obtained at 13-20 weeks confirms the gestational age
    of at least 39 weeks determined by clinical history and physical
    examination.

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

#### Induction of Labor ACOG Practice Bulletin NUMBER 10, NOVEMBER 1999. American College of Obstetricians and Gynecologists, Washington, D.C.  {#induction-of-labor-acog-practice-bulletin-number-10-november-1999.-american-college-of-obstetricians-and-gynecologists-washington-d.c. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### American College of Obstetricians and Gynecologists. Assessment of fetal lung maturity. ACOG Educational Bulletin 230. Washington DC: ACOG, 1996 {#american-college-of-obstetricians-and-gynecologists.-assessment-of-fetal-lung-maturity.-acog-educational-bulletin-230.-washington-dc-acog-1996 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9061400**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9061400) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids9061400 .Style-Heading-4-+-Arial-14-pt-Underline}

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

[Kaufman
KE](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Kaufman+KE"%5BAuthor%5D),
[Bailit
JL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Bailit+JL"%5BAuthor%5D),
[Grobman
W](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Grobman+W"%5BAuthor%5D).
Elective induction: an analysis of economic and health consequences. [Am
J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2002
Oct;187(4):858-63.

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12388964**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12388964) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids12388964 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-42 .Style-Heading-4-+-Arial-14-pt-Underline}

#### \*A translation of the original perhaps, but some sources attribute \"Primum non nocere\" to the Roman physician, Galen. [**http://www.geocities.com/everwild7/noharm.html**](http://www.geocities.com/everwild7/noharm.html) {#a-translation-of-the-original-perhaps-but-some-sources-attribute-primum-non-nocere-to-the-roman-physician-galen.-httpwww.geocities.comeverwild7noharm.html .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-43 .Style-Heading-4-+-Arial-14-pt-Underline}

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

######### Ask the Experts topics in Women\'s Health and OB/GYN Index, by specialty, Medscape

######### [**http://www.medscape.com/pages/editorial/public/ate/index-womenshealth**](http://www.medscape.com/pages/editorial/public/ate/index-womenshealth)

######### 

######### OB GYN & Women\'s Health Clinical Discussion Board Index, Medscape

<http://boards.medscape.com/forums?14@@.ee6e57b>

**Clinical Discussion Board Index, Medscape**

Hundreds of ongoing clinical discussions available

<http://boards.medscape.com/forums?14@@.ee6e57b>

**Free CME: MedScape CME Index by specialty**

<http://www.medscape.com/cmecenterdirectory/Default>

\*NB: Medscape is free to all, but registration is required. It can be
accessed from anywhere with Internet access. You just need to create a
personal username and password.

**Menopause Management**

#### Effects of Conjugated Equine Estrogen on Quality of Life {#effects-of-conjugated-equine-estrogen-on-quality-of-life-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### The authors conclude that oral conjugated equine estrogen does not have a clinically significant effect on health-related quality of life in women who have had a hysterectomy. They add that in the WHI study, the risks and benefits of conjugated equine estrogen use were relatively balanced at six years. They note that vasomotor symptoms will improve in some women, but this is offset by the adverse effects of hormone therapy. [**http://www.aafp.org/afp/20060415/tips/12.html**](http://www.aafp.org/afp/20060415/tips/12.html) {#the-authors-conclude-that-oral-conjugated-equine-estrogen-does-not-have-a-clinically-significant-effect-on-health-related-quality-of-life-in-women-who-have-had-a-hysterectomy.-they-add-that-in-the-whi-study-the-risks-and-benefits-of-conjugated-equine-estrogen-use-were-relatively-balanced-at-six-years.-they-note-that-vasomotor-symptoms-will-improve-in-some-women-but-this-is-offset-by-the-adverse-effects-of-hormone-therapy.-httpwww.aafp.orgafp20060415tips12.html .Style-Heading-4-+-Arial-14-pt-Underline}

#### Brunner RL, et al. Effects of conjugated equine estrogen on health-related quality of life in postmenopausal women with hysterectomy. Arch Intern Med September 26, 2005;165:1976-86 {#brunner-rl-et-al.-effects-of-conjugated-equine-estrogen-on-health-related-quality-of-life-in-postmenopausal-women-with-hysterectomy.-arch-intern-med-september-26-20051651976-86 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16186467**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16186467) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids16186467 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-45 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Midwives Corner {#midwives-corner .Style-Heading-4-+-Arial-14-pt-Underline}

#### Routine use of sweeping of membranes from 38 weeks of pregnancy onwards {#routine-use-of-sweeping-of-membranes-from-38-weeks-of-pregnancy-onwards-2 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Cochrane Database of Systematic Review  {#cochrane-database-of-systematic-review .Style-Heading-4-+-Arial-14-pt-Underline}

#### Risk of caesarean section was similar between groups (relative risk (RR) 0.90, 95% confidence interval (CI) 0.70 to 1.15). Sweeping of the membranes, performed as a general policy in women at term, was associated with reduced duration of pregnancy and reduced frequency of pregnancy continuing beyond 41 weeks (RR 0.59, 95% CI 0.46 to 0.74) and 42 weeks (RR 0.28, 95% CI 0.15 to 0.50). To avoid one formal induction of labour, sweeping of membranes must be performed in eight women (NNT = 8). There was no evidence of a difference in the risk of maternal or neonatal infection. Discomfort during vaginal examination and other adverse effects (bleeding, irregular contractions) were more frequently reported by women allocated to sweeping. Studies comparing sweeping with prostaglandin administration are of limited sample size and do not provide evidence of benefit. {#risk-of-caesarean-section-was-similar-between-groups-relative-risk-rr-0.90-95-confidence-interval-ci-0.70-to-1.15.-sweeping-of-the-membranes-performed-as-a-general-policy-in-women-at-term-was-associated-with-reduced-duration-of-pregnancy-and-reduced-frequency-of-pregnancy-continuing-beyond-41-weeks-rr-0.59-95-ci-0.46-to-0.74-and-42-weeks-rr-0.28-95-ci-0.15-to-0.50.-to-avoid-one-formal-induction-of-labour-sweeping-of-membranes-must-be-performed-in-eight-women-nnt-8.-there-was-no-evidence-of-a-difference-in-the-risk-of-maternal-or-neonatal-infection.-discomfort-during-vaginal-examination-and-other-adverse-effects-bleeding-irregular-contractions-were-more-frequently-reported-by-women-allocated-to-sweeping.-studies-comparing-sweeping-with-prostaglandin-administration-are-of-limited-sample-size-and-do-not-provide-evidence-of-benefit. .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-46 .Style-Heading-4-+-Arial-14-pt-Underline}

[Authors\' conclusions]{.underline}: Routine use of sweeping of
membranes from 38 weeks of pregnancy onwards does not seem to produce
clinically important benefits. When used as a means for induction of
labour, the reduction in the use of more formal methods of induction
needs to be balanced against women\'s discomfort and other adverse
effects.

#### Boulvain M, Stan C, Irion O. Membrane sweeping for induction of labour. The Cochrane Database of Systematic Reviews 2005, Issue 1. Art. No.: CD000451.pub2. DOI: 10.1002/14651858.CD000451.pub2 {#boulvain-m-stan-c-irion-o.-membrane-sweeping-for-induction-of-labour.-the-cochrane-database-of-systematic-reviews-2005-issue-1.-art.-no.-cd000451.pub2.-doi-10.100214651858.cd000451.pub2 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.update-software.com/publications/cochrane/**](http://www.update-software.com/publications/cochrane/) {#httpwww.update-software.compublicationscochrane .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-47 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Navajo Corner, Kathleen Harner, Tuba City {#navajo-corner-kathleen-harner-tuba-city .Style-Heading-4-+-Arial-14-pt-Underline}

**Methamphetamine abuse among women on Navajo**

**PART II**

Recognizing methamphetamine (MA) abuse is not always simple. A few weeks
ago, I saw a lovely multigravid woman in the ER, at TCRHCC, bleeding
with an incomplete abortion. Her husband was with her and she was
clearly grieving about the pregnancy loss. He was appropriately
concerned about her and attentive to her grief. When he left the ER to
check on their children at home, she confided to me that he had been
"doing meth" and it was affecting their marriage. She asked me if I
would talk to him and urge him, for the sake of their family, to stop.
Although I routinely ask patients about illicit drug use, I would never
have guessed that this family had a problem. The first challenge for the
practitioner is identifying the patients with a problem. Once this is
done, how best to help the Gravida and her family?

One of the best opportunities to approach and intervene with the
substance abusing woman is when she is pregnant. The pregnancy or the
child's birth may give her a powerful motive to seek treatment for her
addiction. Early intervention efforts during the prenatal period
increase the likelihood that she will successfully recover from drug
abuse. It is equally important to provide the pregnant, substance
abusing woman with optimal, comprehensive obstetrical care to avoid the
complications of pregnancy that can occur in the abusing gravida. A
continuum of follow up services is a critical element for an improved
quality of life for the substance abusing woman and her family. She
often lives in a stressful environment that may include physical and
sexual abuse, single parenthood, and limited financial and social
support. Interventions during the postnatal period are needed to help
her successfully parent her child, abstain from the use of drugs, and
address complex social needs.

It is a good assumption, that if a pregnant MA abuser seeks prenatal
care, she is interested in ending her drug use. Health care providers
have a unique opportunity during pregnancy to identify drug abusers and
help them stop abusing. For a treatment program to effectively meet the
needs of MA abusers, it is essential to understand the perspective of
the \"customer\" as she approaches, enters, and participates in
treatment. There are a number of entry points in the system for women
who might not present directly for treatment, including:

Pediatricians (mothers will take children to the doctor even when they
will not go for their own problems)

Child protective agencies

Social service agencies

Primary care providers

Criminal justice system

Two types of barriers must often be addressed concerning outreach to
women who use MA. First, internal barriers to seeking treatment for
substance use disorders that include guilt, depression, fear of children
being taken away, and fear of partners who are using or dealing drugs
must be identified and mitigated. Second, external barriers to be
examined include lack of accessibility to treatment programs, need for
childcare, or lack of community-based programs that prevent women from
seeking treatment. Often, reducing just one barrier is enough to bring a
woman into treatment. For example, treatment programs that provide
childcare may have higher participation levels than those that do not.
Treatment for women should involve a holistic approach.

According to the National Institute on Drug Abuse the most effective
treatments for MA addiction are cognitive behavioral interventions.
These approaches are designed to help modify the patient's thinking,
expectations and behaviors and to increase skill in coping with life
stressors. Methamphetimine support groups are also effective adjuncts to
behavioral interventions. There are no pharmacological treatments for MA
abuse although antidepressant medications can be helpful in combating
the depressive symptoms seen in the first few months of abstinence from
the drug.

Incentives, contingent on drug abstinence are a powerful intervention
tool for facilitating abstinence in cocaine and methadone maintained
cocaine abusers. There is evidence that MA dependent individuals respond
similarly. The aim is to decrease behaviors maintained by drug
reinforcers and increase behaviors maintained by nondrug enforcers by
presenting rewards.

Although some traditional drug abuse treatment elements are appropriate
for MA abusers, many treatment staff feels ill prepared to address the
challenges presented by MA abusers. Poor treatment engagement rates,
high drop out rates, severe paranoia, high relapse rates, ongoing
episodes of psychosis severe craving and anhydonia are clinical
challenges that are frequently more problematic than seen with standard
treatment populations. In small communities, it is often only law
enforcement which has the proper skills to deal with the needs of MA
abusers. Several of the clinical problems encountered by the staff
working with MA abusers occur because the staff has primarily been
trained in alcoholism treatment and the severe psychiatric
symptomatology of MA abusers is simply beyond their scope of practice.
Providing extra training to this staff is part of the solution.
Involving mental health experts also helps to meet these clinical
challenges.

Pregnant women pose additional challenges; in addition to intensive
outpatient treatment attention must be given to providing prenatal care.
It is important that the clinical staff working with pregnant women is
capable of dealing with their relapses. Often there is a lack of empathy
to pregnant women who are using drugs. Additionally, women with small
children require an increased level of support while in treatment. The
combined burdens of work, home care, childcare and family
responsibilities in addition to attending treatment frequently can lead
to a fatigue so profound the MA abuse may reoccur in an effort to combat
exhaustion.

Stimulant users, which include MA abusers, respond well to contingency
procedures and this includes drug court strategies. Drug courts are
based upon the rapid and certain application of contingent consequences
based upon the behavior of the drug user. Drug court participants who
successfully exhibit desired behaviors can earn their way to
progressively less demanding treatment regimens. Those unable to
maintain a contract of desired behaviors move to more intensive levels
of care or incarceration. The National Institute of Drug Abuse has
demonstrated that once women enter a treatment program, the motivation
to stay drug free is their children.

**Next Month:** The Phoenix Indian Medical Center's approach to the
substance abusing gravida

**References:**

The DASIS Report. Pregnant Women in Substance Abuse Treatment:2002.
September 3 2004. <http://www.oas.samhsa.gov/2k4/pregTX/pregTX.htm>

HSTAT. SAMHSA/CSAT Treatment Improvement Protocols.
<http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.chapter.22442#top>

Milne, D.January 2003. Experts Desperately Seeking Meth Abuse
Prevention, Treatment. Psychiatric News. Vol 38 number 1.
<http://pn.psychiatryonline.org/cgi/content/full/psychnews;38/1/12>

National Institute on Drug Abuse Research Report Series. Methamphetamine
Abuse and Addiction.
<http://www.nida.nih.gov/ResearchReports/Methamph/Methamph.html>

Principles of Drug Addiction Treatment A Research-Based Guide. NIH
Publication Umber 99-4180 Printed October 1999.
<http://www.nida.nih.gov/PODAT/PODATindex.html>

Rawson RA, Anglin MD, Ling W. Will the Methamphetamine Problem Go Away?.
Journal of Addictive Diseases, Vol 21 (1) 2002.

Rawson RA, Gonzales R, Brethen P. Treatment of methamphetamine use
disorders: an update. Journal of Substance Abuse Treatment 23 (2002)
145-50.

####  {#section-48 .Style-Heading-4-+-Arial-14-pt-Underline}

**Nurses Corner Sandra Haldane, HQE**

**Native American Scholarship Opportunities at the School of Nursing**

Dear Colleagues:

 We wished to share this important information about expanded
scholarship activities for Native American nurses wishing to further
their nursing education at The Catholic University of America (CUA).\
Scholarship opportunities are available for BSN, MSN, RN to BSN, RN to
MSN and PhD studies. The attached announcement may be circulated and
reproduced on web-sites. Our goal is to have this information
distributed as widely as possible so that qualified individuals may
apply. 

\"CUA Receives \$420K for Native American Scholarships

 

The Catholic University of America has been awarded \$420,000 to use for
scholarships for Catholic Native Americans who are studying nursing at
the graduate level.The grant was made by the Bureau of Catholic Indian
Missions, a Washington, D.C.-based Roman Catholic organization founded
in 1874 for the protection and promotion of Catholic Indian missions in
the United States. The money will be added to previous funds donated by
the group for \"The Cardinal Terence Cooke/ Bureau of Catholic Indian
Missions Scholarship Fund,\" an endowed fund that provides tuition
scholarships for academically qualified Catholic Native American
applicants who belong to a tribe or have a formal association with one.

 

\"I am grateful to the Bureau of Catholic Indian Missions and to its
executive director, Monsignor Paul Lenz, for this generous grant and for
the important graduate and undergraduate scholarship support it has
provided to Catholic University in the past,\" said the Very Rev. David
M. O\'Connell, C.M., university president. \"We share the bureau\'s
commitment to providing an excellent university education to deserving
Native American students,\" he added. \"We\'re very pleased to be able
to offer more scholarship money to CUA where we hope it will be used for
the education of Native Americans, and Catholic Native Americans in
particular,\" Monsignor Lenz said. \"We\'ve looked forward to this and
are delighted we were able to make it happen.\" The Bureau of Catholic
Indian Missions\' board of directors includes Cardinal William Keeler of
Baltimore, president; Cardinal Edward Egan of New York and Cardinal
Justin Rigali of Philadelphia.  In 1985 the Bureau of Catholic Indian
Missions first began giving annual grants of \$25,000 or \$50,000 to
Catholic University. In 2003, the Bureau gave a \$1 million scholarship
grant to CUA to support qualified undergraduates. With the most current
donation, the bureau is now funding two \$1 million scholarships at
Catholic University - one for graduate students and the other for
undergraduates.\"

Nalini Jairath RN PhD\
Dean, School of Nursing\
The Catholic University of America

202-319-5403 <jairath@cua.edu>

**Success stories of American Indian people throughout the US needed**

I would like to feature success stories on each of the handout
\"backs\".  It seems that there are many doom and gloom health stories
and we\'re likely to  capture attention and generate behavior change by
featuring positive stories of success that make people feel good and
inspire them to change. 

 If you agree with this approach, perhaps we can talk about ways to find
success stories of American Indian people throughout the US. 

I will call and interview people you select, probing to get the \"good
stuff\" for a powerful testimony.  After writing their story, I always
call back and read the entire story to them to confirm the facts and
make sure they are comfortable with what will be said about them.  I
also arrange to have their picture taken for the handout back, often
with their family, if appropriate.  Here the type of people I would like
to talk to:

 1.  Person who lived on soda, drinking many a day.  Something happened
to make him/her switch to fresh, natural, cool and inviting water.  They
now prefer the taste of water and enjoy saving money previously wasted
on soda.  (Of course, there won\'t be anyone with this exact
story\--just someone who switched from soda to water.)

2.  Someone who lost weight simply by eating less food.  Not dramatic
changes in the type of food, but the amount. 

3.  Mother (or anyone) who deliberately chooses to give her family fruit
rather than candy.  This change could be spurred by anything\--family
illness, awareness, etc. 

4.  Someone who was raised on meat and potatoes and rarely ate
vegetables but now loves them.  She/he may have influenced his/her
family or co-workers

to eat more veggies too.  Now they crave veggies and use meat only as a
compliment to the rest of the meal rather than the main plate filler.

5.  Someone who used too eat super sized meals (or served super sized
food to his/her children) but found that they didn\'t like that too full
feeling.  Perhaps they have a way of knowing when to stop eating and use
how they feel as the gauge of when to stop eating rather than what\'s on
the plate. 

6.  Someone who previously ate candy, cookies, and other extras as main
fare.  Veggies and fruit were eaten only occasionally.  They \"saw the
light\" and now choose to eat \"treats\" only occasionally, much
preferring how they feel when the focus on the \"good stuff\" first. 

Thanks.  Pam McCarthy <pammccarthy2@comcast.net>

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

**April was National Child Abuse Prevention Month --MMWR article**

This year\'s theme was Safe Children and Healthy Families are a Shared
Responsibility. Communities throughout the United States held **blue
ribbon campaigns** to promote healthy families, organizing educational
fairs, and honoring parenting heroes.   

Many cases of child maltreatment go unreported to authorities. However,
approximately:

-   906,000 children in the United States were confirmed by child
    protective services as being abused or neglected in 2003, a rate of
    12.4 per 1,000 children.

-   Of the reported cases,

    -   5% involved emotional or psychological abuse,

    -   10% involved sexual abuse,

    -   9% involved physical abuse, and

    -   61% involved neglect

```{=html}
<!-- -->
```
-   Persistent stress ... impairs development of the nervous and immune
    response systems

-   Adverse health effects throughout their lives (e.g., suicide,
    obesity, smoking, alcoholism, drug abuse, depression, eating
    disorders, sexual promiscuity, and certain chronic diseases)

-   In addition, persons who are abused as children are twice as likely
    to be assaulted as adults

NCAPM is an opportunity to raise awareness about child maltreatment and
its devastating effects.
<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5513a6.htm>

Information about child maltreatment is available online from CDC at
<http://www.cdc.gov/injury>.

NCAPM materials are available online from the U.S. Department of Health
and Human Services, Administration for Children and Families, at:
 [http://nccanch.acf.hhs.gov](http://nccanch.acf.hhs.gov/)

IHS National Child Abuse Project <http://www.ovccap.ihs.gov/>

Karen Cook <Karen.cook@ihs.gov> ** **505-368-6818 contact info

####  {#section-49 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Female Sexual Dysfunction**

Female sexual dysfunction is a common problem affecting an estimated
50-80% of postmenopausal women as well as a significant number or
premenopausal women. Sexual dysfunction can take on several variations
from an absence of sexual fantasies and desire for sexual activity
(hypoactive sexual desire disorder) to an absence of orgasm after normal
sexual excitement phase (female orgasmic disorder). As with many topics
in our specialty, this taboo subject is often only discussed when asked
about. Getting a good history and providing the patient with information
can often alleviate some of the problems. Medications such as
testosterone and hormone replacement therapy can be used but, there is
limited evidence supporting widespread use of these medications. Here
are a few articles that will make you more comfortable approaching this
topic with your patients.

Reference:

[Basson
R](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Basson+R"%5BAuthor%5D).
Clinical practice. Sexual desire and arousal disorders in women. [N Engl
J Med.](javascript:AL_get(this, 'jour', 'N Engl J Med.');) 2006 Apr
6;354(14):1497-506.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16598046&dopt=Abstract>

[Modelska
K](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Modelska+K"%5BAuthor%5D),
[Cummings
S](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Cummings+S"%5BAuthor%5D).
Female sexual dysfunction in postmenopausal women: systematic review of
placebo-controlled trials. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2003
Jan;188(1):286-93.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12548231>

[Sarrel
PM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Sarrel+PM"%5BAuthor%5D).
Sexual dysfunction: treat or refer. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2005
Oct;106(4):834-9.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16199644>

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

**Women need information about alternatives, risks, and benefits of
hormone therapy for osteoporosis to make an informed decision, AHRQ**

[http://www.ahrq.gov/research/mar06/0306RA16.htm](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.ahrq.gov/research/mar06/0306RA16.htm)

 

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

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

#### [**http://www.aafp.org/afp/20060415/1387ph.html**](http://www.aafp.org/afp/20060415/1387ph.html) {#httpwww.aafp.orgafp200604151387ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-50 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Factors Associated With Rise in Primary Cesarean Births in the United
States, 1991-2002**\
Objectives: We examined factors contributing to shifts in primary
cesarean rates in the United States between 1991 and 2002.\
Methods: US national birth certificate data were used to assess changes
in primary cesarean rates stratified according to maternal age, parity,
and race/ethnicity. Trends in the occurrence of medical risk factors or
complications of labor or delivery listed on birth certificates and the
corresponding primary cesarean rates for such conditions were examined.\
Results: More than half (53%) of the recent increase in overall cesarean
rates resulted from rising primary cesarean rates. There was a steady
decrease in the primary cesarean rate from 1991 to 1996, followed by a
rapid increase from 1996 to 2002. In 2002, more than one fourth of
first-time mothers delivered their infants via cesarean. Changing
primary cesarean rates were not related to general shifts in mothers'
medical risk profiles. However, rates for virtually every condition
listed on birth certificates shifted in the same pattern as with the
overall rates.\
Conclusions: Our results showed that shifts in primary cesarean rates
during the study period were not related to shifts in maternal risk
profiles.

Declercq E, Menacker F, MacDorman M. Factors Associated With the Rise in
Primary Cesarean Births in the United States, 1991-2002 Am. J Public
Health. 2006; 96(5):867-872)

<http://www.medscape.com/viewarticle/530786>

**Recurrence of hypertensive disorder in second pregnancy**

CONCLUSION: Recurrence of hypertensive disorders in pregnancy is common,
but not specified by type of disorder in first pregnancy. Overweight and
weight gain between pregnancies are associated with recurrent
hypertensive disorders in pregnancy in women with gestational
hypertension. Early onset of hypertension is a risk factor, independent
of body weight.

[Hjartardottir
S](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Hjartardottir+S"%5BAuthor%5D),
et al Recurrence of hypertensive disorder in second pregnancy. [Am J
Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Apr;194(4):916-20.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16580276>

**Despite \"inadequate placentation\" hypothesis, preeclampsia and IUGR
do not seem to be related as different aspects of the same disorder**

Preeclampsia and gestational hypertension shared many risk factors,
although there are differences that need further evaluation. Both
conditions significantly increased morbidity and mortality. Conversely,
preeclampsia and unexplained intrauterine growth restriction, often
assumed to be related to placental insufficiency, seem to be independent
biologic entities.

Preeclampsia, gestational hypertension and intrauterine growth
restriction, related or independent conditions? [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Apr;194(4):921-31

<http://www.ajog.org/article/PIIS0002937805024361/abstract>

#### Primary Care Discussion Forum {#primary-care-discussion-forum .Style-Heading-4-+-Arial-14-pt-Underline}

**Adverse Childhood Events: Impact on chronic adult illness / Risk
taking**

**Moderator:       Andrew Hsi, M.D, University of New Mexico**

**Ongoing right now**

Have you ever wondered where some untoward adult behaviors and chronic
illness(s) come from?....perhaps they have roots in childhood?

We are lucky to have Andrew Hsi M.D., University of New Mexico, moderate
a discussion on:

-Parental obesity and inactivity: Impact on childhood obesity

-Past sexual abuse: Effect on adult obesity

-Many other examples will be discussed

We will also be joined by the Indian Health Special Interest Group, AAP
for this discussion

Go here:

<http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForumMod.cfm#adverseEvents>

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

Subscribe to the Primary Care listserv

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

Unsubscribe from the Primary Care listserv

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

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

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

**Prediction of Pelvic Inflammatory Disease Among Young, Single,
Sexually Active Women**

Objectives: To assess prediction strategies for pelvic inflammatory
disease (PID).

Study Design: One thousand one hundred seventy women were enrolled based
on a high chlamydial risk score. Incident PID over a median of 3 years
was diagnosed by either histologic endometritis or Centers for Disease
Control and Prevention criteria. A multivariable prediction model for
PID was assessed.

Results: Women enrolled using the risk score were young, single,
sexually active, and often had prior sexually transmitted infections.
Incident PID was common (8.6%). From 24 potential predictors,
significant factors included age at first sex, gonococcal/chlamydial
cervicitis, history of PID, family income, smoking, medroxyprogesterone
acetate use, and sex with menses. The model correctly predicted 74% of
incident PID; in validation models, correct prediction was only 69%.

Conclusions: Our data validate a modified chlamydial risk factor scoring
system for prediction of PID. Additional multivariable modeling
contributed little to prediction. Women identified by a threshold value
on the chlamydial risk score should undergo intensive education and
screening.

Ness RB et al. Prediction of Pelvic Inflammatory Disease Among Young,
Single, Sexually Active Women. Sexually Transmitted Diseases.
33(3):137-142, March 2006.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16505735>

#### Diagnosis and Treatment of Chlamydia trachomatis Infection {#diagnosis-and-treatment-of-chlamydia-trachomatis-infection-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### *Chlamydia trachomatis* infection most commonly affects the urogenital tract. In men, the infection usually is symptomatic, with dysuria and a discharge from the penis. Untreated chlamydial infection in men can spread to the epididymis. Most women with chlamydial infection have minimal or no symptoms, but some develop pelvic inflammatory disease. Chlamydial infection in newborns can cause ophthalmia neonatorum. Chlamydial pneumonia can occur at one to three months of age, manifesting as a protracted onset of staccato cough, usually without wheezing or fever. Treatment options for uncomplicated urogenital infections include a single 1-g dose of azithromycin orally, or doxycycline at a dosage of 100 mg orally twice per day for seven days. The recommended treatment during pregnancy is erythromycin base or amoxicillin. The Centers for Disease Control and Prevention and the U.S. Preventive Services Task Force recommend screening for chlamydial infection in women at increased risk of infection and in all women younger than 25 years. Am Fam Physician 2006;73:1411-6 [**http://www.aafp.org/afp/20060415/1411.html**](http://www.aafp.org/afp/20060415/1411.html) {#chlamydia-trachomatis-infection-most-commonly-affects-the-urogenital-tract.-in-men-the-infection-usually-is-symptomatic-with-dysuria-and-a-discharge-from-the-penis.-untreated-chlamydial-infection-in-men-can-spread-to-the-epididymis.-most-women-with-chlamydial-infection-have-minimal-or-no-symptoms-but-some-develop-pelvic-inflammatory-disease.-chlamydial-infection-in-newborns-can-cause-ophthalmia-neonatorum.-chlamydial-pneumonia-can-occur-at-one-to-three-months-of-age-manifesting-as-a-protracted-onset-of-staccato-cough-usually-without-wheezing-or-fever.-treatment-options-for-uncomplicated-urogenital-infections-include-a-single-1-g-dose-of-azithromycin-orally-or-doxycycline-at-a-dosage-of-100-mg-orally-twice-per-day-for-seven-days.-the-recommended-treatment-during-pregnancy-is-erythromycin-base-or-amoxicillin.-the-centers-for-disease-control-and-prevention-and-the-u.s.-preventive-services-task-force-recommend-screening-for-chlamydial-infection-in-women-at-increased-risk-of-infection-and-in-all-women-younger-than-25-years.-am-fam-physician-2006731411-6-httpwww.aafp.orgafp200604151411.html .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-51 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Long-term Dietary Intervention May Reduce Risk for Insulin Resistance
in Children**

Long-term, biannual dietary intervention reduces risk for insulin
resistance in children, according to the results of a randomized study.

CONCLUSIONS: The long-term biannual dietary intervention decreases the
intake of total and saturated fat and has a positive effect on insulin
resistance index in 9-year-old children.

[Kaitosaari
T](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Kaitosaari+T"%5BAuthor%5D),
et al Low-saturated fat dietary counseling starting in infancy improves
insulin sensitivity in 9-year-old healthy children: the Special Turku
Coronary Risk Factor Intervention Project for Children (STRIP) study.
[Diabetes Care.](javascript:AL_get(this, 'jour', 'Diabetes Care.');)
2006 Apr;29(4):781-5.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16567815>

**Insulin Sensitivity Measures Predict Preeclampsia**

Conclusions: Judging from our findings, insulin sensitivity indexes
(fasting homeostasis model assessment and quantitative insulin
sensitivity check index are simple tests that can pinpoint impaired
insulin sensitivity early in the pregnancy. Given their high sensitivity
and specificity, these indexes could be useful in predicting the
development of preeclampsia in early pregnancy, before the disease
become clinically evident.

[Parretti
E](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Parretti+E"%5BAuthor%5D),
et al Preeclampsia in lean normotensive normotolerant pregnant women can
be predicted by simple insulin sensitivity indexes.
[Hypertension.](javascript:AL_get(this, 'jour', 'Hypertension.');) 2006
Mar;47(3):449-53.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16446386>

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

**PUBLIC'S HEALTH & THE LAW IN THE 21^ST^ CENTURY**

-   June 12-14, 2006

-   Atlanta, Georgia

<http://www2a.cdc.gov/phlp/conference2006.asp>

**I.H.S. / A.C.O.G. Obstetric, Neonatal, and Gynecologic Care Course**

-   September 17 -- 21, 2006

-   Denver, CO

-   Contact <YMalloy@acog.org> or call Yvonne Malloy at 202-863-2580

-   Neonatal Resuscitation Program available

-   Brochure

> <http://www.ihs.gov/MedicalPrograms/MCH/F/documents/ACOG_06brochR1_1.pdf>

**2007 Indian Health MCH and Women's Health National Conference**

-   August 15 -17, 2007

-   Albuquerque, NM

-   THE place to be for anyone involved in care of women, children

-   Internationally recognized speakers

-   Save the dates. Details to follow

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

**Is a fetal ultrasound survey indicated for all patients routinely?**

<http://www.ihs.gov/MedicalPrograms/MCH/F/documents/USsurvey42406.doc>

There are several upcoming **Conferences**

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

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

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

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

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

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

#### The April 2006 OB/GYN CCC Corner is available at: {#the-april-2006-obgyn-ccc-corner-is-available-at .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0406.cfm**](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0406.cfm) {#httpwww.ihs.govmedicalprogramsmchmobgyn0406.cfm .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Protein to Creatinine Ratio in Pre-eclampsia: Is the data preceding
the U.S. benchmarks?**

#### From your colleagues: page 8 {#from-your-colleagues-page-8 .Style-Heading-4-+-Arial-14-pt-Underline}

Carolyn Aoyama:

-Pap screening: Great review of various types of interventions

-Breast Cancer Research Program Releases Program Announcements, 2006

#### -Emergency guide for older adults and their caregivers {#emergency-guide-for-older-adults-and-their-caregivers .Style-Heading-4-+-Arial-14-pt-Underline}

Terry Cullen:

-All-or-None Measurement Raises the Bar on Performance: April 19, 2006

#### -Suicide Prevention Grants Available for Tribes and States {#suicide-prevention-grants-available-for-tribes-and-states .Style-Heading-4-+-Arial-14-pt-Underline}

Chuck North:

RCTs: do they have external validity for patients with multiple
co-morbidities

Judy Thierry:

-Child and Youth Projects (CYP) Cooperative Agreement Grant Announcement

-Failure Mode Analysis (FMA) - Improving Perinatal Care

-Looking Ahead -- Institute for Healthcare Improvement: Phase II

-CDC release: Sudden Unexplained Infant Death Investigation (SUIDI)
Reporting Form

-National Women's Health Indicators Data Base

and more...

**Shelley Thorkelson:**

-Gestational Diabetes Mellitus [Tracking
Sheet](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/GDMtrackingsheete.doc) 

-Program Review and Case Management - Diabetes in Pregnancy

**Alan Waxman:**

FDA Approves New Imaging System to Help Detect Cervical Pre-Cancer

**Judy Whitecrane:**

-2006 Physician Assistant/Advanced Practice Nurse CE Seminar

-Exposure to Mumps During Air Travel \-\-- United States, April 2006

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

##### Obstetrics: page 13

-Glyburide is at least as effective as insulin therapy in treating
gestational diabetes

-Use the 'talk but not sing' rule: Physical activity predicts GDM risk\
-Calcium reduced severity, maternal morbidity, and neonatal mortality in
preeclampsia

-Increasing Angle of Episiotomy Reduces Third-Degree Tear Risk

-Bed Rest Not Be Helpful for Threatened Miscarriage

and more...

**Gynecology: page 18**

-Extensive condyloma acuminata treated with imiquimod 5% cream

-Urinary incontinence: Substantial economic costs and decrement in
quality of life

-Sexual activity and function in middle-aged and older women

-Connection Between Obesity and Pelvic Organ Dysfunction

-LLETZ and cold knife conization: Similar effects on pregnancy-related
morbidity

and more...

**Child Health: page 19**

-New article from Aberdeen Area - Infant Mortality Reviews

-Adverse Childhood Events: Impact on chronic adult illness / Risk taking

#### -Anti-tobacco Advertising Has Positive Effect on Adolescents {#anti-tobacco-advertising-has-positive-effect-on-adolescents .Style-Heading-4-+-Arial-14-pt-Underline}

-Shifts in the sexual behavior of adolescent males: It's a Guy Thing

-Too Much TV Put Extra Pounds on Your Preschooler

and more...

**Chronic Illness and Disease: page 23**

-Breast cancer study from PIMC

-Estrogen use after menopause does not increase breast cancer risk

-Newly identified risk factor for death, MI: Pregnancy complications

-Differences Between Painless and Painful Constipation Among Community
Women

-Women and Heart Disease Fact Sheet

#### Features: page 27 {#features-page-27 .Style-Heading-4-+-Arial-14-pt-Underline}

##### American Family Physician 

## -Active Treatment for Partial Small Bowel Obstruction {#active-treatment-for-partial-small-bowel-obstruction .Style-Heading-2-+-14-pt}

-Sequential Testing Best Detects Down Syndrome

-Effect of Caffeine Intake on Risk of Hypertension

-Embolization Usually Successful to Treat Fibroids

American College of Obstetricians and Gynecologists

-Less Invasive Management of Cervical Cytology Abnormalities in
Adolescents

-New Guidelines Call for Restricted Use of Episiotomies

-Safe Use of Medication

**Agency for Healthcare Research and Quality**

-Estimates of cervical cancers that may be missed by extending screening
time

-Noninvasive tests may miss breast cancer

-Hospital type and location influence discharge of adolescents
hospitalized for suicide

-Light therapy: Improves sleep, mood, and energy in women with
non-seasonal depression

-Changes in the delivery of care needed to reduce the burden of diabetes
among minorities

**Ask a Librarian**

Great Resource: Library Services for the Indian Health Service via NIH

**Breastfeeding**

-Early feeding choice and obesity

-Racial and Socioeconomic Disparities in Breastfeeding - United States,
2004

-New Quarterly Medical Journal on Breastfeeding Launched

**CCC Corner Digest**

#### -March 2006 Highlights include {#march-2006-highlights-include .Style-Heading-4-+-Arial-14-pt-Underline}

\-[Tired of hearing only bad news from the WHI? Here is some good
news](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_AOM.cfm)

\-[Sample templates for guidelines: IUDs, Manual Vacuum Aspiration (MVA)
for SAB,
etc...](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Coll.cfm)

\-[GDM: Can we proceed directly to one step screening / diagnosis in AI
/ AN
women?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_HT.cfm#ob)

\-[Diet and Exercise Reduce Incontinence in Women at Risk of
Diabetes](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_HT.cfm#gyn)

\-[FDA Warns Parents About Contaminated Teething
Rings](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_HT.cfm#child)

\-[Colon cancer rates: Increased in AI/AN women -- March is Colon Cancer
Month](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_HT.cfm#chrIll)

\-[Are you aware of the vast amount of Library Services available to the
Indian Health
System?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Feat.cfm#AskLib)

\-[Results raise doubts about the value of the bimanual pelvic exam in
routine
screening](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Feat.cfm#ahrq)

\-[Breastfeeding as a Pain
Reliever](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Feat.cfm#breast)

\-[Fatal infection without fever: Sepsis and Medical Abortion - FDA
Public Health
Advisory](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Feat.cfm#fp)

\-[Two New Perinatology Corner
Modules](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Feat.cfm#webSite)

[-Twins: Antepartum assessment and Intrapartum management: Double
Trouble?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Feat.cfm#webSite)

[-Antibody Screen Positive:
Rh](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Feat.cfm#webSite)
/ Other Antibodies:  Kell kills, Duffy dies, and Lewis lives?

\-[The case of the wandering spleen - Desperate Housewives - 'As seen on
TV'](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Feat.cfm#mmtour)

\-[Should we continue to draw Rubella titers as part of the prenatal
panel?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Feat.cfm#MidWives)

\-[Do Birth Certificate Data Reflect the Number of CNM-Attended
Births?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Feat.cfm#MidWives)

\-[VZIG No Longer Available: Protect non-immune women against
Chickenpox](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Feat.cfm#navajo)

\-[Nurse Education Loan Repayment Program: Deadline March
30](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Feat.cfm#nurseCorner)

\-[Metformin and Polycystic Ovarian
Syndrome](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Feat.cfm#okie)

\-[Move beyond 'integrated' screening to 'contingency'
screening](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Feat.cfm#periPicks)

\-[Incorrect use of condoms, not product failure may account for lack of
effectiveness](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Feat.cfm#std)

\-[Statin Therapy for Type 2\'s Regardless of LDL Levels and
CVD](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_Feat.cfm#stillW)

**Domestic Violence**

-Native women, violence, substance abuse and HIV risk

-Safety, permanency, and well-being of AI/AN children: New publication

-Child Maltreatment Institute

-Sexual Violence Prevention: Beginning the Dialogue

-April 2006 is National Child Abuse and Prevention month

**Elder Care News**

-Can you read your patients\' palms and predict their health?

-Older Adult Drivers with Cognitive Impairment

**Family Planning**

#### -Depo Provera Increase Diabetes Risk in Women {#depo-provera-increase-diabetes-risk-in-women .Style-Heading-4-+-Arial-14-pt-Underline}

-Low educational status 2+ times risk of unintended pregnancy 1 year
after delivery

**Featured Website**

The MCH Frequently Asked Question (FAQ) site

**Frequently asked questions**

-Can we use a protein to creatinine ratio instead of a 24 urine protein
in preeclampsia?

-Is cord blood stem cell storage a viable option in Indian Country?

-Ever had problems with a stenotic cervix? E.G., for an IUD placement or
EmBx?

-When should we change the estimated date of delivery (EDD) based on
ultrasound?

-Is my first trimester patient always hyperthyroid if her labs are
abnormal?

and more...

**Indian Child Health Notes**

-In medical school that 50% of what you will learn will turn out to be
wrong\
-Ventilating tubes for Otitis Media with effusion turned out to be in
the bad 50%\
-Dr. Esposito says Indian Health deserves more money and here is how to
get it.\
-Helicobacter pylori is everywhere, especially in AI/AN children. What
should we do - or not do

**Information Technology**

National Release Graphical User Interface Clinical Scheduling System,
Version 1.0

International Health

-Global Warming May Be a Graver Public Health Threat Than Nuclear War

-Prenatal Care Has Not Lowered Perinatal Mortality in Minorities

#### MCH Alert

Injury Reporting: Cautiously interpret injury data, esp. with stressful
life circumstances

#### Medical Mystery Tour

#### What is the common theme? {#what-is-the-common-theme .Style-Heading-4-+-Arial-14-pt-Underline}

#### Medscape

######### Do You Know The AHA Guidelines for CVD Prevention in Women?

**Menopause Management**

Gabapentin Reduces Hot Flashes in Breast Cancer Survivors

**Midwives Corner**

-Liability in triage: management of EMTALA regulations and common
obstetric risks

-All-fours maneuver effective for reducing shoulder dystocia during
labor

-\"Hands off\" versus \"hands on\" for decreasing perineal lacerations:
No difference

-Does Vaginal Birth Increase the Risk for Incontinence?

-Diagnosis and Management of Candida of the Nipple and Breast

and more...

**Navajo News**

Methamphetamine abuse among women on Navajo: Part 1

**Nurses Corner**

-Journey to Magnet

#### -Nominations: \"Integrating Cultural Competency into Nursing Education and Practice\"  {#nominations-integrating-cultural-competency-into-nursing-education-and-practice .Style-Heading-4-+-Arial-14-pt-Underline}

#### -For commissioned officers or those considering switching\... {#for-commissioned-officers-or-those-considering-switching... .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Improving Perinatal Care: Nurses encouraged to attend, IHI {#improving-perinatal-care-nurses-encouraged-to-attend-ihi .Style-Heading-4-+-Arial-14-pt-Underline}

-Scholarship Opportunity for American Indian Commission Corps Officers

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

Cigarette smoking among those who have spent \>24 hours on the streets,
in a shelter

**Oklahoma Perspective**

Peripartum Cardiomyopathy

Osteoporosis

Role and Importance of Calcium in Preventing and Managing Osteoporosis

Patient Education

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

#### -What You Should Know About Worrying Too Much {#what-you-should-know-about-worrying-too-much .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Driving and Dementia: What You Should Know {#driving-and-dementia-what-you-should-know .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-52 .Style-Heading-4-+-Arial-14-pt-Underline}

Perinatology Picks

-No increase risk in neurodevelopment at 2 years of age: Vaginal breech
\< 3, 500 g

-Valacyclovir at 36 weeks reduced the number of women with clinical HSV
recurrences

-3 manuscripts that examine the timing and cesarean rate with epidural
analgesia

\-[Is clinical research
overrated?](http://www.contemporaryobgyn.net/obgyn/article/articleDetail.jsp?id=312700)

Primary Care Discussion Forum

Adverse Childhood Events: Impact on chronic adult illness / Risk taking

STD Corner

-New CDC Fact Sheet on HPV in Men

-Announcing New Program Manager for the IHS National STD Program

-Funding opportunities announced. Applications due May 19th

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

-"Clinical inertia\" - Providers not intensifying diabetes therapy when
indicated

-Eating Potatoes May Increase Risk for Type 2 Diabetes

-Cutting Calories Helps You Live Longer

-Join for the WOMAN Challenge

###### Save the Dates: Upcoming events of interest page 50

#### What's new on the ITU MCH web pages page 50

The past CCC Corners are archived at:

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

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

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

or 907 729 3154 (with voicemail)

\*The opinions expressed in the OB/GYN CCC Corner are strictly those of
the authors, and not necessarily those of the Indian Health System, or
the author of this newsletter. If you have any comments, please share
them by joining the Primary Care Discussion Forum where this topic was
recently discussed. To join the Primary Care Listserv, click on
'Subscribe' here

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

5/21/06njm