News Flash(s) Plan now

**17th Annual IHS Research Conference and International**

**Meeting on Inuit and Native American Child Health: April 29-May 1,
2005**

**ACOG / IHS -- Total Women's Health and Neonatal Course: June 19-23,
2005**

**New Perinatology Corner Module - Should you be using the quad
screen?**

**Prenatal Genetic Screening -- Serum and Ultrasound**

New Feature:

CCC Corner Digest - A print friendly digest of the CCC Corner that can
be mailed to you, or

> your colleagues. Just send your address to <nmurphy@scf.cc>

![](media/image1.png){width="6.375in" height="1.0520833333333333in"}

OB/GYN Chief Clinical Consultant's Corner

Volume 3, No. 4, April 2005

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

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

**Human Papillomavirus - ACOG Practice Bulletin**

**NUMBER 61, APRIL 2005**

#### From your colleagues: page 5 {#from-your-colleagues-page-5 .Style-Heading-4-+-Arial-14-pt-Underline}

Burt Attico: DMPA, Bone Mineral Density, and Teens: Recent and
Reassuring Data

James Galloway: A previously under recognized disparity in CVD mortality
exists for AIAN

**Steve Holve:** April Indian Child Health Notes: Highlights

**Lori de Ravello:** Reproductive Health 2005 - Call for Abstracts

**Phil Smith:** Commodity or Public Work? Two Perspectives on Health
Care

**Judy Thierry:**

-School wellness (nutrition and PE focused) policies 

-Improve your effectiveness in home visits, family and new parent
interactions

-Fitness in Kids by State

-SAMHSA Releases Garret Lee Smith Requests for Applications

-Send me your translation of \"Make every mother and child count\" in
your tribal language

-The population you serve may be in a county represented by the National
Children's study

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

##### Obstetrics: page 8

-Gestational Diabetes Rising at Alarming Rate in U.S. Women

-Ginger: effective and safe treatment in managing nausea and vomiting in
pregnancy.

-Treatment for BV or T. vaginalis does not reduce of PTD or adverse
perinatal outcomes

\- Obstetric Anal Sphincter Injury Persists Over Long Term

\- Effects of Discontinuing Epidurals in Late Labor: Cochrane Briefs

**Gynecology: page 11**

-Antibiotics for Recurrent Urinary Tract Infections: Cochrane for
Clinicians

-Two Criteria May Be Sufficient to Diagnose Bacterial Vaginosis

-Vaginal Tape vs. Surgery for Stress Incontinence

\- Polycystic ovarian syndrome: marked differences in diagnosis and
management

\- Laparoscopic Radiofrequency Thermal Ablation Safe and Effective for
Fibroids

**Child Health: page 12**

-FASlink

\- Prevalence of Overweight Among Children and Teenagers, by Age Group

**Chronic Illness and Disease: page 12**

-Can Patients with Cancer Postpone Death for Important Events?

-Impact of Community-Based Yoga on Quality of Life

\- Antioxidant Vitamin Supplements and Cardiovascular Disease Risk
Reduction

\- Comparison of Short-Term Treatments for GERD

\- Parenteral dihydroergotamine for acute migraine headache: a
systematic review

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

##### American Family Physician

-Raloxifene Reduces the Risk of Breast Cancer

-Trial of Labor Carries Small but Real Increase in Risk

-Bariatric Surgery Effective for Long-Term Weight Loss

American College of Obstetricians and Gynecologists

-Appropriate Use of Laparoscopically Assisted Vaginal Hysterectomy

-Endometriosis in Adolescents - ACOG Committee Opinion No. 310

**Agency for Healthcare Research and Quality**

-Compare and Contrast: AHRQ Web M + M

-Use of certain antidepressants may increase risk of hip fractures among
older patients

**Ask a Librarian**

##### -Access to the NIH Library web resources availability being explored for Indian Health staff

**Breastfeeding**

#### -Decline in breastfeeding rates: 2003 Ross breastfeeding stats {#decline-in-breastfeeding-rates-2003-ross-breastfeeding-stats .Style-Heading-4-+-Arial-14-pt-Underline}

-Section on Breastfeeding: American Academy of Pediatrics

**CCC Corner Digest**

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

-Use 'Opt out' HIV screening methods during pregnancy in Indian Country

\-[Routine Population-Wide HIV Screening May Be
Cost-Effective](http://mp.medscape.com/cgi-bin1/DM/y/hmEa0G875W0Dzc0GQ3m0ET)

-Q. What is the Indian Health policy for HIV screening in pregnancy?

-Early epidural provided shorter labor and did not increase cesarean
delivery

-How many deliveries does a provider need to maintain active privileges?

-What is the significance of the latest NEJM article on trial of labor
after cesarean?

-Vaginal pH for Diagnosing Status of Menopause

-Pregnancy, Birth, and Abortion Rates Decline for Teenagers Aged 15-17
Years

\- Emergency OB Drills: The Phoenix Indian Medical Center Experience

**Domestic Violence**

###### -IHS Child Abuse Project: **Training Deadline extended**

-The Truth About Rape

**Elder Care News**

-Helping elderly drivers stay on the road: Signs of an unsafe driver

-One-time screening for abdominal aortic aneurysm: B Recommendation

**Family Planning**

-'The patch': Trouble getting it on your formulary?

-One half of women who express desire for postpartum sterilization do
not get procedure.

-Post-vasectomy semen analysis: are men following up?

**Frequently asked questions**

-In pregnancy, is a one hr. screening result \> 185 or \> 200 mg/dL
diagnostic for GDM?

-Are there alternatives to the oral glucose tolerance test? A breakfast
tolerance test?

-What is the value of biochemical markers in diagnosis or treatment of
osteoporosis?

-What are some of the issues involved with vacuum assisted deliveries?

-What are the issues involved in adoption of an American Indian or
Alaska Native child? 

**Hormone Replacement Update**

-Modifiable Lifestyle Factors That May Affect Hot Flashes

**Information Technology**

-Free Native American Continuing Education online

-EHR INTRODUCTORY COURSE ANNOUNCEMENT

-IHS Technology Conference June 27 - July 1, 2005 - Save the Dates!!

International Health

-Patients' Beliefs About Racism, Preferences for Physician Race,
Satisfaction With Care

-Spectrum of dysfunctional organizational cultures can be diagnosed and
managed

#### MCH Alert

-Ethical implications of health literacy and the steps needed to promote
it

-Suicidal behavior in the family and adolescent risk behavior

#### Medscape

**Midwives Corner**

#### -Midwifery care of poor and vulnerable women, 1925-2003 {#midwifery-care-of-poor-and-vulnerable-women-1925-2003 .Style-Heading-4-+-Arial-14-pt-Underline}

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

-Methicillin-resistant *Staphylococcus aureus* Toxic Shock Syndrome

-Host a Women's Health Fair - National Women\'s Health Week of May 9th
2005

Osteoporosis

-Osteoporosis and Fracture Prevention in the Indian Health System

-Osteoporosis: Strategies for Screening and Intervention

Patient Education

-Pregnancy: Keeping Yourself and Your Baby Healthy

\-[**What Can You Do To Make Rheumatoid Arthritis (RA) Less
Debilitating?**](http://mp.medscape.com/cgi-bin1/DM/y/hnch0G875W0Dzc0F7G10Ey)

Primary Care Discussion Forum

-Methamphetamine use in Indian Country -- still can join in

STD Corner

-Natural mentoring relationships and adolescent health: evidence from a
national study

-Syphilis Elimination Effort (SEE) Toolkit

-Outbreak of Infectious Syphilis in Alaska\--Follow-up

-HIV Infection in Alaska, 2004

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

-A Decline in Life Expectancy in the US

-Dark Chocolate Improves Insulin Sensitivity/Resistance and Blood
Pressure

-Yogurt Promotes Fat Loss

-Physical Activity Increases Insulin Sensitivity 44%

-Knowing One\'s Hgb A1c Can Improve Results

#### What's new on the ITU MCH web pages page 24

-New Perinatology Corner module -- Should you be using quad screen?

FREE CEUs, CME Prenatal Genetic Screening -- Serum and Ultrasound

\-[Osteoporosis in Indian Health - A Systems
Approach](http://www.ihs.gov/MedicalPrograms/MCH/W/WHmature.asp#OsteoAIAN)

\-[Osteoporosis: Strategies for Screening and
Prevention](http://www.ihs.gov/MedicalPrograms/MCH/W/WHmature.asp#OsteoAIAN)

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

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

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

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

**Human Papillomavirus**

ACOG Practice Bulletin NUMBER 61, APRIL 2005

**Summary of Recommendations and Conclusions**

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

-   Because HPV DNA testing is more sensitive than cervical cytology in
    detecting CIN 2 and CIN 3, women with negative concurrent test
    results can be reassured that their risk of unidentified CIN 2 and
    CIN 3 or cervical cancer is approximately 1 in 1,000.

-   Studies using combined HPV testing with cervical cytology have
    reported a negative predictive value for CIN 2 and CIN 3 of
    99--100%.

-   Human papillomavirus DNA testing is not recommended in women with
    LSIL, atypical squamous cells that cannot exclude high-grade
    squamous intraepithelial lesions, or atypical glandular cell
    cytology.

-   The triage of women with ASC-US cytology using reflex HPV DNA
    testing for high-risk types when liquid-based cytology was used at
    the time of the initial visit eliminates the need for a repeat
    office visit and is a more sensitive triage tool than repeat
    cytology while referring fewer women to colposcopy.

-   Women with high-risk HPV who have ASC-US or LSIL cytology but are
    not found to have CIN 2 or CIN 3 at their initial colposcopy have
    approximately a 10% risk of having CIN 2 or CIN 3 within 2 years.

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

-   Although evidence is lacking that condoms offer complete protection
    from HPV infection, condom use may reduce the risk of HPV-related
    disease, such as genital warts and cervical neoplasia.

-   Studies show that condoms may be effective in the clearance of HPV
    or HPV-associated lesions.

-   Use of a combination of cervical cytology and HPV DNA screening is
    appropriate for women aged 30 years and older. If this combination
    is used, women who receive negative results on both tests should be
    rescreened no more frequently than every 3 years.

-   Because of a similar risk of recurrence, no single treatment for
    external genital warts can be recommended over another.

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

-   Women older than 30 years with a negative cytology result who have
    high-risk HPV DNA positive test results should have both tests
    repeated in 6--12 months. Those with persistent high-risk HPV (on
    repeat testing) should undergo colposcopy regardless of the cytology
    result.

-   Human papillomavirus DNA testing could be used as a test of cure for
    women with CIN 2 or CIN 3 at 6--12 months following excision or
    ablation of the transformation zone. Those with high-risk HPV should
    be referred for colposcopy.

-   Treatment for genital warts should be guided by the preference of
    the patient and the experience of the heath care provider.

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

ACOG has provided a great deal of helpful information that should help
guide our screening for cervical cancer among Native women. I suggest
providers utilize the above Practice Bulletin and the American Society
for Colposcopy and Cervical Pathology Consensus Guidelines as
benchmarks. <http://www.asccp.org/consensus.shtml>

Indian Health providers and Native patients should be aware that there
are proprietary vendors aggressively marketing HPV tests directly to
patients under the guise of patient education and public health
information. Proprietary vendors can present an unrealistically
flattering portrayal of their products and may have different
motivations other than attaining the high possible health status of
Native women.

Human papillomavirus. ACOG Practice Bulletin No. 61. American College of
Obstetricians and Gynecologists. Obstet Gynecol 2005; 105:905--18.

**ACOG non-Members**

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15802436>

**ACOG Member**

<http://www.acog.org/publications/educational_bulletins/pb061.cfm>

**Helpful Human Papillomavirus (HPV) Infection Patient Education
available:**

**HPV Testing- Is it for me? ASCCP Patient Education brochure**

<http://asccp.org/pdfs/patient_edu/hpv_testing.pdf>

**ASCCP Patient Education site**

<http://asccp.org/patient_edu.shtml>

**CDC Human Papillomavirus (HPV) Infection** **resources**

<http://www.cdc.gov/std/hpv/default.htm>

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

#### Burt Attico, Phoenix {#burt-attico-phoenix .Style-Heading-4-+-Arial-14-pt-Underline}

**DMPA, Bone Mineral Density, and Teens: Recent and Reassuring Data:
Andrew M. Kaunitz**

**Question**

With recent studies showing that there is 3% to 6% bone density loss per
year when a patient is using depot medroxyprogesterone acetate (DMPA,
*Depo Provera* ), is there a length of time after which alternative
contraception should be used? Is there any role for \"add-back
therapy\"? Bone density does not always correlate with bone strength,
but a lot of our younger generations do not take in much calcium and we
may have lower bone masses aggravated by DMPA.

**Answer**

Depot medroxyprogesterone acetate (*Depo-Provera* , DMPA) injectable
contraception is widely used in the United States, particularly by
teens. Use of DMPA not only suppresses ovulation (resulting in highly
effective long-acting birth control), but it also reduces ovarian
production of estradiol. Recognition that bone mineral density (BMD)
declines during DMPA use and given the dearth of BMD data related to
DMPA use in young women, concerns have been raised regarding DMPA\'s
skeletal safety in teens. The US Food and Drug Administration recently
placed a black-box warning on DMPA package labeling indicating that
women who use DMP may lose significant BMD and that the loss may not be
completely reversible. It also notes that it is unknown whether DMPA use
during adolescence or early adulthood will reduce peak bone mass and
increase the risk for osteoporotic fracture in later life.

However, DMPA use has not been linked to menopausal osteoporosis or
fractures. In addition, reassuring evidence of complete recovery of
subsequent BMD in former DMPA users has come from cross-sectional data.

The good news is that 2 recent publications should allow clinicians to
offer DMPA to their adolescent patients with confidence that they are
not putting them at risk for osteoporosis later in life. In a 2-year,
double-blinded, randomized controlled trial of 123 adolescents, Cromer
and her colleagues in Cleveland, Ohio, found that when estradiol
supplementation was added to DMPA, the BMD did not drop. Similar
observations that DMPA + estrogen result in stable BMD in adult women
have been made by Cundy and his colleagues in New Zealand.

Reassurance regarding recovery of BMD following use of DMPA in teens can
be derived from the results found in a cohort study by Scholes and her
colleagues in Seattle, Washington. A cohort of 170 adolescents
(including 80 who used DMPA at baseline) found that recovery of BMD is
complete within 12 months post DMPA discontinuation: \"Adjusted mean BMD
values for discontinuers were at least as high as those of nonusers for
all anatomic sites at 12 months and at all subsequent follow-up
intervals.\" Duration of DMPA use was not observed to affect speed of
BMD recovery after DMPA discontinuation. These observations led to the
authors\' concluding sentence: \" .. these results in teens and those
from our previous cohort provide reassurance that bone loss is regained,
even in younger users.\"

The Cromer study emphasizes that in teens, as in adult women, the
transient loss of BMD associated with DMPA use can be attributed
entirely to reduced ovarian estradiol production with use of this
injectable contraceptive. Although \'add-back\' estrogen supplementation
indeed prevents BMD loss in teen and adult DMPA users, the recovery of
BMD that occurs after DMPA discontinuation in both teens and adults
means that the need for such \'add-back\' would be unusual. As both
Cromer and Scholes point out in their respective publications, the
transient impact of DMPA on endogenous estradiol levels and BMD is
similar to trends noted with lactation, which has not been found to have
a long-term impact on skeletal health. Although calcium supplementation
is appropriate for North American teens, such a recommendation should
apply regardless of contraceptive use. **References available:**
<http://www.medscape.com/viewarticle/499653>

#### James Galloway, IHS Cardiology Program {#james-galloway-ihs-cardiology-program .Style-Heading-4-+-Arial-14-pt-Underline}

**A previously under recognized disparity in CVD mortality exists for
AIAN**

I would like to share with you an important article published this month
in Circulation revealing something I believe we have all been aware of
but not previously published in a highly respected, peer reviewed
journal. This article reveals that incorrect CVD death rates have been
reported previously due to racial misclassification of AI/AN and shows
that the CVD death rates are not only substantially higher than the
general population (and higher than previously recognized in the
national medical literature) but continue to increase (at least up to
1998)\... This also provides for further discussion of the REACH data
from the CDC MMWR below revealing that, at least by phone survey, the
rates of CVD and its risk factors are even higher in AI/AN than in other
ethnic and minority populations

#### Clearly, our major efforts focused on the prevention of CVD, DM, obesity and all chronic disease, by the I/T/U system alone or through partnerships and collaborations with academic and service organizations are vital. I am honored to continue to work with each of you in our prevention efforts and initiatives and I look forward to our future successes in the reduction of the rates of chronic disease and their associated suffering and morbidity. {#clearly-our-major-efforts-focused-on-the-prevention-of-cvd-dm-obesity-and-all-chronic-disease-by-the-itu-system-alone-or-through-partnerships-and-collaborations-with-academic-and-service-organizations-are-vital.-i-am-honored-to-continue-to-work-with-each-of-you-in-our-prevention-efforts-and-initiatives-and-i-look-forward-to-our-future-successes-in-the-reduction-of-the-rates-of-chronic-disease-and-their-associated-suffering-and-morbidity. .Style-Heading-4-+-Arial-14-pt-Underline}

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

CONCLUSIONS: A previously under recognized disparity in CVD mortality
exists for AIAN, particularly among middle-aged adults. Moreover, these
disparities are increasing. Efforts to reduce CVD mortality in AIAN must
begin before the onset of middle age

#### Rhoades DA. Racial misclassification and disparities in cardiovascular disease among American Indians and Alaska Natives. Circulation. 2005 Mar 15;111(10):1250-6. [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15769765**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15769765) {#rhoades-da.-racial-misclassification-and-disparities-in-cardiovascular-disease-among-american-indians-and-alaska-natives.-circulation.-2005-mar-15111101250-6.-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids15769765 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Health Status of American Indians Compared with Other Racial/Ethnic Minority Populations MMWR, Vol 52, Number 47, Nov. 28, 2003. p 1148-1152 {#health-status-of-american-indians-compared-with-other-racialethnic-minority-populations-mmwr-vol-52-number-47-nov.-28-2003.-p-1148-1152 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5247a3.htm**](http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5247a3.htm) {#httpwww.cdc.govmmwrpreviewmmwrhtmlmm5247a3.htm .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Steve Holve, Tuba City  {#steve-holve-tuba-city .Style-Heading-4-+-Arial-14-pt-Underline}

**April Indian Child Health Notes: Highlights**

\- A review of the new AAP/AAFP guidelines on jaundice\
- Documented increased risk of physiologic jaundice in Native American
infants\
- A paper on jaundice and vigintiphobia (look that up)\
- A recent report on health care contacts and risk of fatal injury in
Native Americans

<http://www.ihs.gov/MedicalPrograms/MCH/C/documents/childhealthNotesApril05.doc>

**Lori de Ravello, Albuquerque**

**Call for Abstracts: Reproductive Health 2005**

Submit your abstract online for the Association of Reproductive Health
Professionals' 42^nd^ annual meeting, *Reproductive Health 2005*,
co-sponsored by the Society of Family Planning and Planned Parenthood^®^
Federation of America (PPFA), September 7 -- 10, 2005 in Tampa/St.
Petersburg. All abstracts will be peer reviewed; those of highest
quality and relevance will be accepted for oral or poster presentation
and will be published in ARHP's journal, *Contraception: An
International Reproductive Health Journal*. Awards will be presented to
the authors of the best oral abstracts. Deadline April 25, 2005 at 5pm
EDT.
[www.arhp.org/2005callforabstracts](http://www.arhp.org/2005callforabstracts)
or

[www.arhp.org/rh2005](http://www.arhp.org/rh2005) Call ARHP at (202)
466-3825 or <conferences@arhp.org>.

# Phil Smith, HQE

**Commodity or Public Work? Two Perspectives on Health Care**

Untreated disease, uncompensated disability, and untended suffering in a
community diminishes (sic) not only the individuals who suffer, but the
community as a whole. According to this view, health is a state of
individual and communal wellness and well-being, a state attained both
through actions one takes in life and through relationships, structures,
and communal fabric that connect people. Unlike the commodity
conception, the public work conception makes it impossible to be healthy
(or sick) all by yourself. We can only be healthy or sick together.\" 
Jennings B & Hanson MJ. \"Commodity or Public Work? Two Perspectives on
Health Care.\" Bioethics Forum, Fall 1995, pp. 3-11
[http://www.cpn.org/topics/health/commodity.html](https://mail.southcentralfoundation.com/exchweb/bin/redir.asp?URL=http://www.cpn.org/topics/health/commodity.html)

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

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

**School wellness (nutrition and PE focused) policies **

Model policies individual sample policies are where the rubber meets the
playground!   

I.  [School Health
    Councils](http://www.schoolwellnesspolicies.org/WellnessPolicies.html#councils)

II. [Nutritional Quality of Foods and Beverages Sold and Served on
    Campus](http://www.schoolwellnesspolicies.org/WellnessPolicies.html#quality)

III. [Nutrition and Physical Activity Promotion and Food
     Marketing](http://www.schoolwellnesspolicies.org/WellnessPolicies.html#promotion)

IV. [Physical Activity Opportunities and Physical
    Education](http://www.schoolwellnesspolicies.org/WellnessPolicies.html#opportunities)

V.  [Monitoring and Policy
    Review](http://www.schoolwellnesspolicies.org/WellnessPolicies.html#monitoring)

Sample Policies   
 <http://www.fns.usda.gov/tn/Healthy/wellness_samplepolicies.html>

Use the Index as a self-assessment and planning tool to improve the
effectiveness of health and safety policies and programs.      
[[http://apps.nccd.cdc.gov/shi/HealthTopics.aspx?GradeID=1]{.underline}](http://apps.nccd.cdc.gov/shi/HealthTopics.aspx?GradeID=1)  
Order the complete booklet by emailing <HealthyYouth@cdc.gov>  

**Improve your effectiveness in home visits, family and new parent
interactions**

The University of Washington Nursing Research group has extraordinary
training opportunities

If you want to improve your effectiveness in home visits, family and new
parent interactions and education check them out.  The August 5 and 6,
2005 course in Seattle will be great.  I just heard two of the speakers
today at the Surgeon General's Child Maltreatment Conference here in
Bethesda.  The Maternal Mental Health is another outstanding course
designed to address issues fundamental to mothering and being mothered.
[www.ncast.org](http://www.ncast.org/)

**Fitness in Kids by State**

<http://www.child.com/kids/health_nutrition/fittest_states.jsp?page=9>

**SAMHSA Releases Garret Lee Smith Requests for Applications**

Categories are:

1.  STATE/TRIBAL YOUTH SUICIDE PREVENTION GRANT PROGRAM    

```{=html}
<!-- -->
```
1.  CAMPUS SUICIDE PREVENTION GRANT PROGRAM   

2.  LINKING ADOLESCENTS AT RISK TO MENTAL HEALTH SERVICES

Contact <Judith.Thierry@ihs.gov>

**Send me your translation of \"Make every mother and child count\" in
your tribal language**

World Health Day: The theme is **Make every mother and child count**

I am preparing a poster that includes tribal languages.

I would so appreciate hearing from you!

Include: [Language         translation]{.underline}

English   Make every mother and child count <Judith.Thierry@ihs.gov>

**The population you serve may be in a county represented by the
National Children's study**

[http://nationalchildrensstudy.gov](http://www.nationalchildrensstudy.gov/news/e-updates/e_update_032005.cfm)

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

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

**Gestational Diabetes Rising at Alarming Rate in U.S. Women**

OBJECTIVE: The prevalence of gestational diabetes mellitus (GDM) varies
in direct proportion with the prevalence of type 2 diabetes in a given
population or ethnic group. Given that the number of people with
diabetes worldwide is expected to increase at record levels through
2030, we examined temporal trends in GDM among diverse ethnic groups.
RESEARCH DESIGN AND METHODS: Kaiser Permanente of Colorado (KPCO) has
used a standard protocol to universally screen for GDM since 1994. This
report is based on 36,403 KPCO singleton pregnancies occurring between
1994 and 2002 and examines trends in GDM prevalence among women with
diverse ethnic backgrounds.

RESULTS: The prevalence of GDM among KPCO members doubled from 1994 to
2002 (2.1-4.1%, P \< 0.001), with significant increases in all
racial/ethnic groups. In logistic regression, year of diagnosis (odds
ratio \[OR\] and 95% CI per 1 year = 1.12 \[1.09-1.14\]), mother\'s age
(OR per 5 years = 1.7 \[1.6-1.8\]) and ethnicity other than non-Hispanic
white (OR = 2.1 \[1.9-2.4\]) were all significantly associated with GDM.
Birth year remained significant (OR = 1.06, P = 0.006), even after
adjusting for prior GDM history.

CONCLUSIONS: This study shows that the prevalence of GDM is increasing
in a universally screened multiethnic population. The increasing GDM
prevalence suggests that the vicious cycle of diabetes in pregnancy
initially described among Pima Indians may also be occurring among other
U.S. ethnic groups.

Dabelea D, et al Increasing prevalence of gestational diabetes mellitus
(GDM) over time and by birth cohort: Kaiser Permanente of Colorado GDM
Screening Program**.** Diabetes Care. 2005 Mar;28(3):579-84.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15735191>

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

The increasing GDM prevalence suggests that the vicious cycle of
diabetes in pregnancy initially described among Pima Indians and then in
other AI/AN groups, is now occurring among other U.S. ethnic groups.

The prevalence of GDM has been increasing over the past 8 years by 12%
per year. The prevalence of gestational diabetes mellitus (GDM) appears
to be increasing in U.S. women, which may be a reflection of the
well-documented obesity epidemic.\
Dr. Dana Dabelea from the University of Colorado Health Sciences Center
and colleagues examined temporal trends in GDM in more than 36,000
ethnically diverse women who were members of the Kaiser Permanente of
Colorado health plan. All gave birth to a single infant between 1994 and
2002.\
The prevalence of GDM among these women doubled over that period. The
prevalence of GDM has been increasing over the past 8 years \-- by about
12% per year.\
The increase, she said, was \"present and similar\" among all racial and
ethnic groups studied. These included non-Hispanic whites, Hispanics,
African Americans and Asians.\
\"Moreover, women born more recently were at increased risk for GDM
compared with women born earlier, probably reflecting an increased
exposure to risk factors operating before childbearing years, such as
obesity,\" she said.\
Dr. Dabelea pointed out that like type 2 diabetes mellitus and obesity,
GDM is also increasing, \"Future studies,\" she added, \"need to explore
reasons for this increase as well as the effects of this increase on the
future generations.\"

Unfortunately, this is not news to the Indian Health system. Our goal
should be to slow down the increasing trend toward glucose intolerance
and overweight in our female Native patients.

**Ginger may be an effective and safe treatment in managing nausea and
vomiting symptoms in pregnancy**.

CONCLUSION: Ginger may be an effective treatment for nausea and vomiting
in pregnancy. However, more observational studies, with a larger sample
size, are needed to confirm the encouraging preliminary data on ginger
safety LEVEL OF EVIDENCE: I.

Borrelli F et al Effectiveness and safety of ginger in the treatment of
pregnancy-induced nausea and vomiting. Obstet Gynecol. 2005
Apr;105(4):849-56.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15802416&dopt=Abstract>

**Antibiotic treatment for bacterial vaginosis or Trichomonas vaginalis
during pregnancy does not reduce the risk of preterm birth or other
adverse perinatal or maternal outcomes.**

CONCLUSION: Contrary to the conclusions of 3 recent systematic reviews,
we found no evidence to support the use of antibiotic treatment for
bacterial vaginosis or Trichomonas vaginalis in pregnancy to reduce the
risk of preterm birth or its associated morbidities in low- or high-risk
women.

Okun N, et al Antibiotics for Bacterial Vaginosis or Trichomonas
vaginalis in Pregnancy: A Systematic Review. Obstet Gynecol. 2005
Apr;105(4):857-868.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15802417&dopt=Abstract>

**Obstetric Anal Sphincter Injury Persists Over Long Term**

CONCLUSIONS: Subjective and objective anal function after anal sphincter
injury deteriorates further over time and with subsequent vaginal
deliveries. Thin perineal body and internal sphincter injury seem to be
important for continence and anal pressure.\
Fornell EU et al Obstetric anal sphincter injury ten years after:
subjective and objective long term effects**.** BJOG. 2005
Mar;112(3):312-6.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15713145>

Effects of Discontinuing Epidurals in Late Labor: Cochrane Briefs

Clinical Question

Does discontinuing epidural analgesia in the second stage of labor
reduce rates of instrumented delivery or change patient satisfaction
with labor?

Evidence-Based Answer

Based on three good studies of 462 patients, discontinuing epidural
analgesia in the second stage of labor does not significantly change
rates of instrumented delivery or other delivery outcomes, but it
increases rates of inadequate pain relief.

Practice Pointers

The American College of Obstetricians and Gynecologists^1^ supports the
use of epidural analgesia during labor. The policy states that epidurals
should not be denied because of the patient\'s insurance and that nurses
should not be restricted from managing regional anesthesia. Because
epidural analgesia provides the highest level of pain relief, the
physician and patient should decide when it should be used. However,
there are concerns that epidural analgesia increases rates of
instrumented deliveries. To reduce this risk, physicians sometimes
discontinue epidural analgesia during the second stage of labor.
Torvaldsen and colleagues reviewed the literature to determine if this
practice improves outcomes.

The authors found five studies, three of which were good quality. They
did not find a statistically significant difference in rates of
instrumented delivery or cesarean delivery, duration of the second stage
of labor, low Apgar scores, or fetal malposition at delivery. The only
statistically significant difference was an increased rate of inadequate
pain relief during the second stage of labor.

Some women may be willing to accept discomfort in the second stage of
labor even if the risk of poor outcomes is small. A larger study is
needed to determine if there is a difference in outcomes. There is
inadequate data to support the practice of discontinuing epidural
analgesia in the second stage of labor.

Torvaldsen S, et al. Discontinuation of epidural analgesia late in
labour for reducing the adverse delivery outcomes associated with
epidural analgesia. Cochrane Database Syst Rev 2004;(4):CD004457.
<http://www.aafp.org/afp/20050401/cochrane.html>

**The risk of cesarean delivery after both medical and elective
induction of labor in nulliparous women is related to an unfavorable
Bishop score**

CONCLUSION: Compared with spontaneous onset of labor, medical and
elective induction of labor in nulliparous women at term with a single
fetus in cephalic presentation is associated with an increased risk of
cesarean delivery, predominantly related to an unfavorable Bishop score
at admission.

Vrouenraets FP et al Bishop score and risk of cesarean delivery after
induction of labor in nulliparous women. Obstet Gynecol. 2005
Apr;105(4):690-7.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15802392&dopt=Abstract>

**Early Epidural Analgesia and Labor Progression**

CONCLUSION: Our data support recent American College of Obstetricians
and Gynecologists guidelines that the restraining use of epidural
analgesia at \<4 cm of cervical dilation is unnecessary.

Vahratian A, et al. The effect of early epidural versus early
intravenous analgesia use on labor progression: a natural experiment. Am
J Obstet Gynecol July 2004;191:259-65.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15295376>

#### The correct methods to measure blood pressure: Pregnant Women

The detection of elevated BP during pregnancy is one of the major
aspects of optimal antenatal care, and thus accurate measurement of BP
is essential Mercury sphygmomanometry continues to be the recommended
method for BP measurement during pregnancy. BP should be obtained in the
seated position, but the left lateral recumbency position is a
reasonable alternative, particularly during labor. The 5th Korotkoff
sound should be used for diastolic pressure, but when sounds are audible
with the cuff deflated Korotkoff 4 should be used.

It is recognized that alternatives to mercury devices may be necessary
in the future, and a small number of automated BP recorders have been
validated for use in pregnancy.^\[41\]^ Self-monitoring may be useful in
evaluating BP changes during pregnancy.

Pickering TG et al Recommendations for blood pressure measurement in
humans: an AHA scientific statement from the council on high blood
pressure research professional and public education subcommittee. J Clin
Hypertens (Greenwich). 2005 Feb;7(2):102-9.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15722655>

**Pre-eclampsia Community Guidelines: National Clinical Excellence
Recommendations**

The strengths of the PRECOG guideline are its simplicity, its evidence
base for risk assessment, its reliance only on clinical features for
assessment, and its straightforward management plan,\" Dr. Greer writes.
\"These features make it relevant not only in the United Kingdom but
also in other countries. The weakness is that the available evidence to
support intervention with more frequent assessment or by different
healthcare professionals is limited in quantity and quality.\"

### **Pearls for Practice**

-   Risk factors for preeclampsia include maternal age older than 35
    years, nulliparity, interval of more than 10 years between
    pregnancies, previous preeclampsia, family history, multiple
    pregnancy, raised blood pressure at booking, and medical conditions
    including preexisting hypertension, renal disease, increased body
    mass index, and autoimmune disease.

-   PRECOG recommendations include routine assessment for signs and
    symptoms of preeclampsia throughout antenatal care, consultation for
    specialist care, and referral to a hospital-day assessment unit for
    women with a positive screening for risk and immediate hospital
    admission for women diagnosed as having preeclampsia.

Milne F et al The pre-eclampsia community guideline (PRECOG): how to
screen for and detect onset of pre-eclampsia in the community. BMJ. 2005
Mar 12;330(7491):576-80.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15760998>

**Evidence-Based Prenatal Care: Part I. General Prenatal Care and
Counseling Issues**

<http://www.aafp.org/afp/20050401/1307.html> (see also Patient
Education)

**Editorial: Prenatal Care: Examining the Evidence for an Evolving
Paradigm**

<http://www.aafp.org/afp/20050401/editorials.html>

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

Antibiotics for Recurrent Urinary Tract Infections: Cochrane for
Clinicians

A 26-year-old woman visits your clinic with dysuria. She is diagnosed
with her fourth urinary tract infection (UTI) of the year.

Clinical Question

Should we use prophylactic antibiotics in patients with recurrent UTIs?
If so, which antibiotic and schedule are best?

Evidence-Based Answer

Prophylactic antibiotics can reduce the number of recurrent UTIs in
nonpregnant women while they are taking the medication (relative risk
\[RR\], 0.21; number needed to treat \[NNT\], 2). No antibiotic was
significantly better than others at decreasing the number of UTIs, and
all antibiotics caused side effects such as candidiasis, rash, and
nausea in some patients. Postcoital prophylaxis was as effective as
daily prophylaxis in young women. Limited evidence suggests that weekly
prophylaxis is better than monthly prophylaxis, but the former has not
been compared with daily or postcoital prophylaxis.
<http://www.aafp.org/afp/20050401/cochrane.html>

The practice recommendations in this activity are available online at
<http://www.cochrane.org/cochrane/revabstr/AB001209.htm>.

**Two Criteria May Be Sufficient to Diagnose Bacterial Vaginosis**

CONCLUSION: The clinical criteria for diagnosing bacterial vaginosis can
be simplified to 2 clinical criteria without loss of sensitivity and
specificity.

Gutman RE et al Evaluation of clinical methods for diagnosing bacterial
vaginosis. Obstet Gynecol. 2005 Mar;105(3):551-6.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15738023>

**Vaginal Tape vs. Surgery for Stress Incontinence**

TVT surgery provides a higher rate of cure in women with urinary
incontinence. It also is associated with better patient-related outcomes
than laparoscopic mesh colposuspension.

Valpas A, et al. Tension-free vaginal tape and laparoscopic mesh
colposuspension for stress urinary incontinence. Obstet Gynecol July
2004;104:42-9.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15228999>

**Polycystic ovarian syndrome: marked differences between
endocrinologists and gynaecologists in diagnosis and management**

CONCLUSIONS: There is a lack of consensus between endocrinologists and
gynaecologists in the definition, diagnosis and treatment of PCOS. As a
consequence, women may receive a different diagnosis or treatment
depending on the type of specialist consulted

Cussons AJ et al Polycystic ovarian syndrome: marked differences between
endocrinologists and gynaecologists in diagnosis and management. Clin
Endocrinol (Oxf). 2005 Mar;62(3):289-95.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15730409>

**Laparoscopic Radiofrequency Thermal Ablation Safe and Effective for
Fibroids**

CONCLUSION: In this pilot study, laparoscopic radiofrequency ablation
successfully reduced fibroid symptoms and fibroid volume in short-term
follow-up. Additional studies are needed before its efficacy and safety
can be confirmed.

Bergamini V et al. Laparoscopic radiofrequency thermal ablation: a new
approach to symptomatic uterine myomas. Am J Obstet Gynecol. 2005
Mar;192(3):768-73.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15746670>

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

**FASlink**

The approach is directed at maternal drinking behavior and dose. The
content itself grabs you right off about in the first sentence. Canadian
data could be extrapolated to US data. The physiology and effects remain
the same. The depth and scope and the various media allows you to access
a basic and user friendly resource kit <http://www.faslink.org/>
[jthierry@hqe.ihs.gov]{.underline}

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

**QuickStats: Prevalence of Overweight Among Children and Teenagers, by
Age Group**

Overweight among children and teenagers more than tripled between the
1960s and 2002.

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5408a6.htm>

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

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

Can Patients with Cancer Postpone Death for Important Events? POEM

**Clinical Question:** In patients with cancer, can \"death take a
holiday\"?

**Bottom Line:** Patients with cancer are equally likely to die in the
week before or after a significant holiday or personal event. This study
found no evidence to support the common belief that patients can
temporarily postpone death to survive a holiday or other meaningful
event. (Level of Evidence: 1b)

**Bottom Line:** Patients with cancer are equally likely to die in the
week before or after a significant holiday or personal event. This study
found no evidence to support the common belief that patients can
temporarily postpone death to survive a holiday or other meaningful
event. (Level of Evidence: 1b)
<http://www.aafp.org/afp/20050401/tips/15.html>

**Study Reference:** Young DC, Hade EM. Holidays, birthdays, and
postponement of cancer death. JAMA December 22, 2004;292:3012-6.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15613670>

**Impact of Community-Based Yoga on Quality of Life**

Quality of life related to physical, emotional, and social functioning
and mental health can be improved for some persons after three months of
a community-based mind-body training program. While the study
participants initially reported more anxiety and depression than
community norms, their higher self-efficacy scores indicate that persons
who choose alternative medicine tend to regard health as subject to
individual control. Stress reduction and social support may be mediators
of the improvements observed.

Lee SW, et al. Prospective study of new participants in a
community-based mind-body training program. J Gen Intern Med July
2004;19:760-5.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15209590>

Antioxidant Vitamin Supplements and Cardiovascular Disease Risk
Reduction

The American Heart Association (AHA) has released a science advisory on
the effects of antioxidant vitamin supplements on reducing the risk of
cardiovascular disease.

The authors found that clinical trials generally have failed to
demonstrate a beneficial effect of antioxidant supplements on
cardiovascular morbidity and mortality. This lack of efficacy was
demonstrated consistently for different doses of various antioxidants in
diverse populations. Some smaller studies did show benefits from
a-tocopherol, a-tocopherol plus slow-release vitamin C, and vitamin C
plus vitamin E on cardiovascular end points.

There is some evidence that antioxidant supplements may have adverse
effects on cardiovascular end points. Some study results showed that
antioxidant supplements may have interfered with the efficacy of
statin-plus-niacin therapy, and that the addition of antioxidant
vitamins blunted the expected rise in the protective high-density
lipoprotein (HDL)-2 cholesterol and apolipoprotein A1 subfractions of
HDL.

Kris-Etherton PM et all Antioxidant vitamin supplements and
cardiovascular disease. Circulation. 2004 Aug 3;110(5):637-41.\
<http://circ.ahajournals.org/cgi/content/full/110/5/637> or

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15289389&dopt=Abstract>

Comparison of Short-Term Treatments for GERD: Cochrane Brief

Clinical Question

Which medications improve outcomes in patients with symptoms of
gastroesophageal reflux disease (GERD) who are treated empirically and
in those with symptoms but a normal endoscopy?

Evidence-Based Answer

For empiric treatment of GERD or endoscopy-negative reflux disease, a
short trial of a proton pump inhibitor increases the chance of
remission. Histamine H~2~-receptor antagonists are less expensive and
work well in many patients, particularly those with less severe symptoms
or endoscopy-negative reflux disease.

Practice Pointers

GERD is extremely common, and most patients are treated empirically.
Endoscopy can diagnose esophagitis, ulcers, bleeding, strictures,
Barrett\'s esophagus, and carcinoma. Urgent upper endoscopy should be
performed in patients with melena, hematemesis, persistent vomiting,
anemia, acute onset of total dysphagia, or involuntary weight loss of
more than 5 percent of total body weight. Patients older than 45 to 50
years should receive nonurgent endoscopy. Younger patients should be
considered for endoscopy if they are at risk for gastric cancer.^1,2^
Pinxeren and colleagues reviewed the literature to determine which
treatments benefit patients with symptoms of GERD who are treated
empirically, and which options are effective in patients with GERD
symptoms but a normal endoscopy.

The authors found 27 trials with 8,402 participants ranging from 18 to
79 years of age (mean age, 48 years); 45 percent of participants were
men. Most of the trials were of adequate quality. Patients who were
treated empirically had a remission in heartburn when they received
proton pump inhibitors (relative risk \[RR\], 0.37; 95 percent
confidence interval \[CI\], 0.32 to 0.44) and histamine H~2~-receptor
antagonists (RR, 0.77; 95 percent CI, 0.60 to 0.99). In direct
comparisons, proton pump inhibitors were significantly more effective
than histamine H~2~-receptor antagonists and prokinetics in achieving
remission. No significant differences were noted between proton pump
inhibitors and histamine H~2~-receptor antagonists in patients with
endoscopy-negative reflux disease.

The results of this study did not identify differences between proton
pump inhibitors (such studies are lacking). Because many patients do
well with a histamine H~2~-receptor antagonist at much lower cost, these
drugs still should be considered viable treatment options for many
patients. The cost difference between the newest proton pump inhibitor
(rabeprazole; \$4.50 per day) and generic omeprazole (less than \$1 per
day) or ranitidine (less than \$0.50 per day) is substantial.

Pinxteren B, et al. Short-term treatment with proton pump inhibitors,
H~2~-receptor antagonists and prokinetics for gastro-oesophageal reflux
disease-like symptoms and endoscopy negative reflux disease. Cochrane
Database Syst Rev 2004;(4):CD002095.

<http://www.aafp.org/afp/20050401/cochrane.html>

**Parenteral dihydroergotamine for acute migraine headache: a systematic
review**

CONCLUSION: This evidence suggests that dihydroergotamine is not as
effective as sumatriptan or phenothiazines as a single agent for
treatment of acute migraine headache; however, when administered with an
antiemetic, dihydroergotamine appears to be as effective as opiates,
ketorolac, or valproate. Given its nonnarcotic properties, parenteral
dihydroergotamine combined with an antiemetic should be considered as
effective initial therapy in clinical practice

Colman I Parenteral dihydroergotamine for acute migraine headache: a
systematic review of the literature. *Ann Emerg Med* - 01-APR-2005;
45(4): 393-401

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15795718>

**Risk factors identified for substance abuse relapse among doctors**

CONCLUSIONS: The risk of relapse with substance use was increased in
health care professionals who used a major opioid or had a coexisting
psychiatric illness or a family history of a substance use disorder. The
presence of more than 1 of these risk factors and previous relapse
further increased the likelihood of relapse. These observations should
be considered in monitoring the recovery of health care professionals.\
Domino KB et al Risk factors for relapse in health care professionals
with substance use disorders. JAMA. 2005 Mar 23;293(12):1453-60.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15784868>

**Lupus Research Institute (LRI) National Coalition: *Get into the
Loop***

Lupus---it can start with something as simple as fever, fatigue or even
joint pain, but can lead to heart attack, kidney failure or even be
fatal.  This hard-hitting wake-up call, targeted at young women who are
most at risk, is the theme of the new national public service
advertising campaign launched by the Lupus Research Institute (LRI)
National Coalition. 

Actor James Garner says in the TV spot, "lupus has scarred my youngest
daughter's life," and urges women to protect themselves, get the facts
and *Get into the Loop*. The *Get into the Loop* slogan reinforces the
bright orange loop as the visible symbol for lupus. 

The LRI is asking for your organization's help in promoting this
campaign within your newsletters and websites to help women understand
what lupus is and what signs and symptoms to look for. 

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

**Bextra Withdrawn From Market**

<http://www.fda.gov/cder/drug/infopage/cox2/default.htm>

# Features {#features .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)\*

Raloxifene Reduces the Risk of Breast Cancer

**Clinical Question:** Does raloxifene prevent breast cancer?

###### Bottom Line: Previous research has shown that raloxifene can protect against breast cancer after four years of use. In this four-year extension of the original study, this level of protection continued. (Level of Evidence: 1b) [**http://www.aafp.org/afp/20050401/tips/21.html**](http://www.aafp.org/afp/20050401/tips/21.html)

**Study Reference:** Martino S, et al. Continuing outcomes relevant to
Evista: breast cancer incidence in postmenopausal osteoporotic women in
a randomized trial of raloxifene. J Natl Cancer Inst December 1,
2004;96:1751-61.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15572757>

Trial of Labor Carries Small but Real Increase in Risk

**Clinical Question:** What are the risks associated with trial of labor
following cesarean delivery?

**Bottom Line:** The risks of trial of labor after cesarean delivery are
small but cannot be ignored. The most important is an increase in the
risk of neonatal death, stillbirth, or encephalopathy (NNH = 398), which
is higher than that occurring in other research

*(Guise JM, et al. Systematic review of the incidence and consequences
of uterine rupture in women with previous caesarean section. BMJ July 3,
2004;329:19-25).* This article provides some additional guidance for
physicians and patients who must make this decision. (Level of Evidence:
2b) <http://www.aafp.org/afp/20050401/tips/20.html>

**Study Reference:** Landon MB, et al. Maternal and perinatal outcomes
associated with a trial of labor after prior cesarean delivery. N Engl J
Med December 16, 2004;351:2581-9

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15598960&dopt=Abstract>

Editorial

Greene MF. Vaginal birth after cesarean revisited. N Engl J Med. 2004
Dec 16;351(25):2647-9\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15598961&dopt=Abstract>

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

**"Risk, like beauty, is in the eye of the beholder"**

This article is significant both what is says, and what it doesn't say.

This is a large observational 4 year prospective at 19 academic
institutions. It showed a small increased risk of hypoxic-ischemic
encephalopathy, endometritis, and blood transfusion among the vaginal
delivery group. As the Editorial points out it would take approximately
588 cesarean deliveries to prevent a single adverse perinatal outcome.

Due to the timing of this study and its observational nature,
approximately ½ of the symptomatic uterine ruptures were involved with
prostaglandin administration, so even the 1/588 risk number may be
overstated a large factor.

As this is not a RCT we can't know with certainty the exact risk, but
this study confirms previous studies that the risk of adverse outcome is
very small.

It is reasonable to use the tenets described at the August 2004 Indian
Women's Health Conference:

-minimize risk by assuring the entire L/D unit functions as a cohesive
team

-perform periodic emergency delivery drills on L/D as a team

-carefully triage TOLAC patients: low, medium, and high risk

-be especially mindful of a lack of timely intrapartum labor progress

See the lecture notes from Michelle Lauria for more details

<http://www.ihs.gov/MedicalPrograms/MCH/M/PROG01.cfm#MeetingLecNotes>

See 3/05 Midwives Corner for related topics

<http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN0305_Feat.cfm#MidWives>

Bariatric Surgery Effective for Long-Term Weight Loss

**Clinical Question:** How effective is bariatric surgery in the long
term?

**Bottom Line:** Bariatric surgery helps patients lose weight and
reverse diabetes, hypertension, and some hyperlipidemias. It is still
unknown whether it affects all-cause mortality. (Level of Evidence: 2c)
<http://www.aafp.org/afp/20050401/tips/19.html>

**Study Reference:** Sjostrom L, et al. Lifestyle, diabetes, and
cardiovascular risk factors 10 years after bariatric surgery. N Engl J
Med December 23, 2004;351:2683-93.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15616203>

**\*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}

**Appropriate Use of Laparoscopically Assisted Vaginal Hysterectomy**

ABSTRACT: The technique used for hysterectomy should be dictated by the
indication for the surgery, patient characteristics, and patient
preference. Most patients requiring hysterectomy should be offered the
vaginal approach when technically feasible and medically appropriate. If
specific additional procedures that can be completed laparoscopically
are anticipated before surgery, laparoscopically assisted vaginal
hysterectomy may be an appropriate alternative to abdominal
hysterectomy. The benefits of laparoscopically assisted vaginal
hysterectomy must be weighed against the potentially increased risk and
expense of two distinct operative procedures, laparoscopy and vaginal
hysterectomy.

Appropriate use of laparoscopically assisted vaginal hysterectomy. ACOG
Committee Opinion No. 311. American College of Obstetricians and
Gynecologists. Obstet Gynecol 2005;105:929--30.

**ACOG non-Members**

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15802439>

**ACOG Members**

<http://www.acog.org/publications/committee_opinions/co311.cfm>

**Endometriosis in Adolescents - ACOG Committee Opinion No. 310.**

ABSTRACT: Historically thought of as a disease that affects adult women,
endometriosis increasingly is being diagnosed in the adolescent
population. This disorder, which was originally described more than a
century ago, still represents a vague and perplexing entity that
frequently results in chronic pelvic pain, adhesive disease, and
infertility. The purpose of this Committee Opinion is to highlight the
differences in adolescent and adult types of endometriosis. Early
diagnosis and treatment during adolescence may decrease disease
progression and prevent subsequent infertility.

Endometriosis in adolescents. ACOG Committee Opinion No. 310. American
College of Obstetricians and Gynecologists. Obstet Gynecol
2005;105:921--7.

**ACOG non-Members**

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15802438>

**ACOG Members**

<http://www.acog.org/publications/committee_opinions/co310.cfm>

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

**Compare and Contrast: AHRQ Web M + M**

[A 76 y.o. female patient with presumed small bowel obstruction
undergoes a contrast-enhanced CT scan. She develops contrast nephropathy
requiring dialysis.](http://www.webmm.ahrq.gov/case.aspx?caseID=92)

<http://www.webmm.ahrq.gov/>

**Use of certain antidepressants may increase risk of hip fractures
among older patients**

<http://www.ahrq.gov/research/mar05/0305RA9.htm#head9>

#### 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}

##### Access to the NIH Library web resources availability being explored for Indian Health staff

There has been some initial confusion about Indian Health staff's access
to the NIH Library webpage. At this time, current \'federal\' employees
of IHS have access to the website below through our wide area network
(WAN). The NIH is exploring access issues for tribal employees.

<http://hsrl.nihlibrary.nih.gov/> Questions? Diane Cooper
<cooperd@ors.od.nih.gov>

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

#### Decline in breastfeeding rates: 2003 Ross breastfeeding stats {#decline-in-breastfeeding-rates-2003-ross-breastfeeding-stats-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Mail out survey results it conducts on breastfeeding rates {#mail-out-survey-results-it-conducts-on-breastfeeding-rates .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

#### Section on Breastfeeding: American Academy of Pediatrics {#section-on-breastfeeding-american-academy-of-pediatrics .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aap.org/advocacy/bf/brsection.htm**](http://www.aap.org/advocacy/bf/brsection.htm) {#httpwww.aap.orgadvocacybfbrsection.htm .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

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

#### Highlights include {#highlights-include-1 .Style-Heading-4-+-Arial-14-pt-Underline}

-Use 'Opt out' HIV screening methods during pregnancy in Indian Country

\-[Routine Population-Wide HIV Screening May Be
Cost-Effective](http://mp.medscape.com/cgi-bin1/DM/y/hmEa0G875W0Dzc0GQ3m0ET)

-Q. What is the Indian Health policy for HIV screening in pregnancy?

-Early epidural provided shorter labor and did not increase cesarean
delivery

-How many deliveries does a provider need to maintain active privileges?

-What is the significance of the latest NEJM article on trial of labor
after cesarean?

-Vaginal pH for Diagnosing Status of Menopause

-Pregnancy, Birth, and Abortion Rates Decline for Teenagers Aged 15-17
Years

\- Emergency OB Drills: The Phoenix Indian Medical Center Experience

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/documents/05MarOL.pdf**](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/05MarOL.pdf) {#httpwww.ihs.govmedicalprogramsmchmdocuments05marol.pdf .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-9 .Style-Heading-4-+-Arial-14-pt-Underline}

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

###### IHS CHILD ABUSE PROJECT: Training Deadline extended

The deadline for applications to be submitted by physicians, nurse
practitioners, and physician assistants to attend the IHS Child Abuse
Project has been extended !!  Attendance is open to both Tribal and IHS
physicians, nurse practitioners, and physician assistants.  It is a two
year program that requires a commitment on the part of the participant
and the employing agency. 
[www.ovccap.ihs.gov](http://www.ovccap.ihs.gov/) Jane Powers
<Jane.Powers@mail.ihs.gov> (435) 725-6839

  

**The Truth About Rape**

This two pager lists eight myths and truths about rape.

[http://www.cdc.gov/ncipc/dvp/The%20Truth%20About%20Rape%20Final.pdf](http://www.cdc.gov/ncipc/dvp/The Truth About Rape Final.pdf)

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

**Helping elderly drivers stay on the road: Skill levels and
deterioration vary**

**Signs of an unsafe driver**

-   Severe medical problems like dementia, vision loss or other physical
    impairments that could jeopardize driving ability or decisions
    behind the wheel.

-   Becoming lost in familiar areas.

-   Driving too fast or too slow.

-   Making poor judgments when driving.

-   Failure to notice street signs.

-   Having more accidents.

-   People honking or gesturing at them.

-   Miscalculating speed.

-   Misinterpreting traffic signals, such as turning left on a green
    yield, without the green left turn arrow.

-   Fresh scrapes and dings in the car.

-   Slower reaction time.

-   Tunnel vision --- not being in tune with the driving environment ---
    because driving has become too complicated to watch out for other
    drivers.

<http://home.mdconsult.com/das/stat/view/462211932/mnfp?nid=159265&sid=0&pos=1&date=week>

**(from MD Consult: Free with a password --** Contact Diane Cooper
<cooperd@ors.od.nih.gov> )

**One-time screening for abdominal aortic aneurysm: B Recommendation**

Ask your patients to pass the following along to the male family members
and friends

**The USPSTF recommends one-time screening for abdominal aortic aneurysm
(AAA) by ultrasonography in men aged 65 to 75 who have ever smoked.
Rating: [B
Recommendation](http://www.ahrq.gov/clinic/3rduspstf/ratings.htm#brec).**

U.S. Preventive Services Task Force. Screening for abdominal aortic
aneurysm: Recommendation statement. Ann Intern Med 205 Feb1;
142:198-202.

Fleming C et al. Screening for abdominal aortic aneurysm: A
best-evidence systematic review for the U.S. Preventive Services Task
Force. Ann Intern Med 2005 Feb 1; 142:203-11.

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

Does this recommendation apply to our patients? 

**Dr. James Galloway, IHS Cardiologist and Director of the Native
American Cardiology Program** says:  *" I cannot think of any reasons
why this should not apply for our folks and with the evidence of
increased CVD and atherosclerosis in our population over other
populations, I would feel strongly that this recommendation be
maintained in our system as well\....".*

This recommendation has been added to the IHS Preventive Care Guidelines
for the Elderly, recently updated and available at
<http://www.ihs.gov/MedicalPrograms/ElderCare/index.asp>

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

**'The patch': Trouble getting it on your formulary?**

The cost of a pregnancy for a 14 year old far exceeds in dollars and
human cost the cost of effective contraception. You may have only one
opportunity to provide birth control in this age group. The have been
about 129 separate expenditures for 'the patch' have been made from the
IHS expenditures. The average cost is \$ 93.56 each with a range of \$
86 to \$ 116. Overall the expenditure is over 0.5 million dollars ITU
wide for 'the patch' alone.

A link from the company
[[http://www.orthoevra.com/]{.underline}](http://www.orthoevra.com/) and

for balance, the Alan Guttmacher Institute
[[http://www.agi-usa.org/pubs/fb_contr_use.html]{.underline}](http://www.agi-usa.org/pubs/fb_contr_use.html)

Given IHS purchasing numbers, the patch by cost alone is about 20% of
the total costs - of course condoms (included in this list) are a
fraction of the cost and are apples to oranges as far as effective
contraception but contribute to the over all total cost. Here are
several web sites that one could use to make a case for your local P&T
should you be one of the sites that does not have access to the patch or
it is limited in some fashion because of \"trial\" and \"error\" before
going to the patch as a second line contraceptive. The patch may be the
first line choice in an IHS high risk population - tobacco use, positive
family history of clotting disorders etc not with standing. This Power
Point is helpful
<http://www.jointcenter.org/healthpolicy/docs/presentations/WL-NOAPPP-2003.ppt>

Information: Wilhelmina A. Leigh, Ph.D. Senior Research Associate Joint
Center for Political and Economic Studies 1090 Vermont Avenue, NW Suite
1100 Washington, DC 20005-4928 Phone: 202-789-3529 FAX: 202-789-6390
e-mail: <wleigh@jointcenter.org> or
[[http://www.jointcenter.org]{.underline}](http://www.jointcenter.org/)
From Baylor, a series of slides with slide \# 10 containing comparison
of the use of the
patch.[<http://www.contraceptiononline.org/slides/slide01.cfm?q=unintended+pr>egnancy&dpg=1]{.underline}
any of these can be down loaded and use for a presentation. From
[jthierry@hqe.ihs.gov]{.underline}

**Almost half of women who express a desire for postpartum sterilization
will not undergo the procedure.**

CONCLUSION: Despite their initial request, only 54% of women in our
sample underwent sterilization. Young age, African-American race,
request in the second trimester, and vaginal delivery were significantly
associated with not undergoing sterilization. Our data suggest that
providers should counsel all women who desire postpartum sterilization
about the wide array of contraceptive methods available, with the
understanding that approximately half of all women may not undergo the
sterilization procedure. LEVEL OF EVIDENCE: II-2.

Zite N, Wuellner S, Gilliam M. Failure to obtain desired postpartum
sterilization: risk and predictors. Obstet Gynecol. 2005
Apr;105(4):794-9.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15802407&dopt=Abstract>

**Post-vasectomy semen analysis: are men following up?**

CONCLUSIONS: Compliance with instructions to men undergoing vasectomy to
return for PVSA is low both from the perspective of this study, as well
as other studies evaluated. Older men are more likely to return for
PVSA. Christensen RE, Maples DC Jr. Postvasectomy semen analysis: are
men following up? J Am Board Fam Pract. 2005 Jan-Feb;18(1):44-7.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15709063>

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

**Q. In pregnancy, is a one hr. screening result \> 185 or \> 200 mg/dL
diagnostic for GDM?**

A. No, one of five of these patients has a normal 3 hr. OGTT. See
details.

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/elevGDMScre4605.doc>

**Q. Are there alternatives to the oral glucose tolerance test? A
breakfast tolerance test?**

A. Yes, there are several alternatives. Polycose is best. Mixed meals
are not a reliable.

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/AltGlu4505.doc>

**Q. What is the value of biochemical markers in diagnosis or treatment
of osteoporosis?**

A. Biochemical markers reflect bone turnover, but their clinical utility
is limited.

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/NTX4405.doc>

**Q. What are some of the issues involved with vacuum assisted
deliveries?**

A. The mechanics are one issue, larger issues are when to use and when
not.

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/vacuum4205.doc>

**Q. What are the issues involved in adoption of an American Indian or
Alaska Native child? **

A. One would need to contact the ICWA worker at each specific tribe.
Here are some details

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/Adopt32905.doc>

#### Hormone Replacement Update {#hormone-replacement-update .Style-Heading-4-+-Arial-14-pt-Underline}

**Modifiable Lifestyle Factors That May Affect Hot Flashes**

CONCLUSION: Although study respondents were from similar
sociodemographic groups and received their health care in the same
health maintenance organization, modifiable factors associated with hot
flashes were different for perimenopausal and postmenopausal women.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15209587>

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

**Free Native American Continuing Education online**

From the Center for Native American TeleHealth and TeleEducation at the
University of Colorado Health Sciences Center in Aurora Colorado

<http://www.ihs.gov/MedicalPrograms/MCH/m/mchabout.asp#ctrNATele>

**EHR INTRODUCTORY COURSE ANNOUNCEMENT**

Introductory course for sites who are considering the IHS Electronic
Health Record\
This will be a one day activity designed to introduce site and service
units to the EHR for the first time. The course will provide a
demonstration on how the EHR is used in the   clinical setting and how
other departments, (pharmacy, lab, radiology, medical records,
information technology), use or are affected by the EHR. This class is
not intended to provide user training or training on setting up the EHR.
This course provides a general overview of what you can expect from the
 EHR and some guidelines on how to get ready for  it. CME credits are
available. Registration is mandatory an can be done online:\
<http://www.ihs.gov/Cio/RPMS/index.cfm>
  [\<http://www.ihs.gov/Cio/RPMS/index.cfm\>](http://www.ihs.gov/Cio/RPMS/index.cfm)
  \
Select RPMS training in the left hand column. Choose the  link  entitled
\"OIT Albuquerque\"\
Find a training for one of the  above dates  and press the \"register\"
button.\
Carolyn Johnson <cjohnson@wsp.portland.ihs.gov> or Chris Lamer
<chris.lamer@ihs.gov>

**Save the Dates!!** **IHS Technology Conference June 27 - July 1,
2005**

The annual IHS Office of Information Technology (OIT) Technical
Conference has been officially scheduled for the week of June 27, 2005
in Scottsdale AZ.  The theme of this year's conference is Raising Indian
Health Through Information Technology. <Theresa.Cullen@ihs.gov>

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

**Patients' Beliefs About Racism, Preferences for Physician Race,
Satisfaction With Care**

CONCLUSIONS Many African Americans and Latinos perceive racism in the
health care system, and those who do are more likely to prefer a
physician of their own race or ethnicity. African Americans who have
preferences are more often satisfied with their care when their own
physicians match their preferences.

## **Frederick M. Chen, et al** Patients' Beliefs About Racism, Preferences for Physician Race, and Satisfaction With Care ***Annals of Family Medicine*** 3:138-143 (2005)

<http://www.annfammed.org/cgi/content/full/3/2/138> or

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15798040&dopt=Abstract>

**There is a spectrum of dysfunctional organizational cultures that can
be diagnosed and responsibly managed by physicians committed to
maintaining professional integrity.**

This paper presents an ethically justified approach to the diagnosis and
management of progressive dysfunction of health care organizational
cultures. We explain the concept of professional integrity in terms of
the ethical concept of the co-fiduciary responsibility of physicians and
health care organizations. We identify the ethical features of a healthy
health care organization and the spectrum of progressive dysfunction of
organizational cultures from cynical through wonderland and Kafkaesque
to postmodern. Physicians should respond to cynical health care
organizations by creating moral enclaves of professional integrity for
the main purpose of confrontation and reform, to wonderland
organizations by strengthening moral enclaves for the main purpose of
resisting self-deception, to Kafkaesque organizations by strengthening
moral enclaves still further for the main purpose of defending
professional integrity (adopting a Machiavellian appearance of virtue as
necessary), and to postmodern organizations by creating moral fortresses
and, should these fail, quitting.

Chervenak FA, McCullough LB The diagnosis and management of progressive
dysfunction of health care organizations. Obstet Gynecol. 2005
Apr;105(4):882-7.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15802422&dopt=Abstract>

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

**Ethical implications of health literacy and the steps needed to
promote it**

Progress in public health literacy will yield an informed, motivated
public with the skills and resources to make positive choices that
enhance individual and community health. We cannot ignore Americans who
do not manage their health nor improve their quality of life because
they do not understand how to do so. We must build a society where
people can understand and act on health information. Gazmarian J, Curran
J, Parker RM, et al. 2005. Public health literacy in America: An ethical
imperative. American Journal of Preventive Medicine 28(3):317-322.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15766622>

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

**Suicidal behavior in the family and adolescent risk behavior**

Adolescents who have been exposed to suicide attempts and suicide deaths
by family members are likely to be engaged in behaviors that put them at
risk for future problems including marijuana use, binge drinking,
suicidal ideation and attempt, and violence toward others

-Exposure to a family member\'s suicide attempt in the past year was
reported by 3.9% of the adolescents, and exposure to a family member\'s
death by suicide in the past year was reported by 1.2% of the
adolescents.

-Adolescents who had experienced a family member\'s suicide attempt were
more likely than their counterparts who had no such experience to report
the following: smoking, marijuana use, binge drinking, suicidal
ideation, suicide attempt, serious physical fighting, inflicting serious
injury, decreased life expectancy, emotional distress, and poor
parent-child and family connectedness.

-Adolescents who had experienced a family member\'s suicide death were
more likely than their counterparts who had no such experience to report
the following: marijuana use, binge drinking, suicidal ideation, suicide
attempt, inflicting serious injury, decreased life expectancy, and
emotional distress.

-Neither a family member\'s suicide attempt nor suicide death had a
significant independent effect on the adolescent\'s GPA (grade point

average) or parental reports of parent-child connectedness.

#### -A suicide attempt in the family \"must now be considered a risk that can be the focus of intervention. {#a-suicide-attempt-in-the-family-must-now-be-considered-a-risk-that-can-be-the-focus-of-intervention. .Style-Heading-4-+-Arial-14-pt-Underline}

#### Cerel J, Roberts A. 2005. Suicidal behavior in the family and adolescent risk behavior. Journal of Adolescent Health 36(4):e9-e15 {#cerel-j-roberts-a.-2005.-suicidal-behavior-in-the-family-and-adolescent-risk-behavior.-journal-of-adolescent-health-364e9-e15 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15780792**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15780792) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids15780792 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-11 .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.

#### Midwives Corner: Marsha Tahquechi, CNM, GIMC {#midwives-corner-marsha-tahquechi-cnm-gimc .Style-Heading-4-+-Arial-14-pt-Underline}

#### Midwifery care of poor and vulnerable women, 1925-2003 {#midwifery-care-of-poor-and-vulnerable-women-1925-2003-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### A systematic literature review of midwifery care of poor and vulnerable women from 1925 to 2003, was performed; 44 studies published between 1955 and 2003 were identified. Outcomes examined included prenatal care visits, vaginal versus operative births, labor interventions, maternal and neonatal mortality and morbidity, birth weight, and cost-effectiveness. Studies showed that midwives predominantly serve vulnerable women who are young, poor, immigrants, or members of racial and ethnic minorities. Preterm birth prevention is emerging as a midwifery research focus. Health system changes are making it more difficult to provide effective care and counseling to disadvantaged women, especially in managed care settings. Extensive evidence documents excellent outcomes of midwifery care for the poor in urban and rural settings. Raisler J, Kennedy H. Midwifery care of poor and vulnerable women, 1925-2003. J Midwifery Womens Health. 2005 Mar-Apr;50(2):113-21. [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15749297**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15749297) {#a-systematic-literature-review-of-midwifery-care-of-poor-and-vulnerable-women-from-1925-to-2003-was-performed-44-studies-published-between-1955-and-2003-were-identified.-outcomes-examined-included-prenatal-care-visits-vaginal-versus-operative-births-labor-interventions-maternal-and-neonatal-mortality-and-morbidity-birth-weight-and-cost-effectiveness.-studies-showed-that-midwives-predominantly-serve-vulnerable-women-who-are-young-poor-immigrants-or-members-of-racial-and-ethnic-minorities.-preterm-birth-prevention-is-emerging-as-a-midwifery-research-focus.-health-system-changes-are-making-it-more-difficult-to-provide-effective-care-and-counseling-to-disadvantaged-women-especially-in-managed-care-settings.-extensive-evidence-documents-excellent-outcomes-of-midwifery-care-for-the-poor-in-urban-and-rural-settings.-raisler-j-kennedy-h.-midwifery-care-of-poor-and-vulnerable-women-1925-2003.-j-midwifery-womens-health.-2005-mar-apr502113-21.-httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmeddoptabstractlist_uids15749297 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Methicillin-resistant *Staphylococcus aureus* Toxic Shock Syndrome**

This is a report of a case of toxic shock syndrome (TSS) due to a
methicillin-resistant *S. aureus* strain that produced a TSS toxin 1. A
54-year-old woman was admitted to the emergency ward of Brugmann
University Hospital, Brussels, with a 2-day history of myalgia,
diarrhea, and vomiting. She had undergone surgery for a palate neoplasia
2 months earlier, and again 2 weeks earlier, in another hospital. After
the second operation, she had been treated for a local scar infection
with amoxicillin--clavulanic acid for 1 week. TSS caused by MRSA strains
has been found extensively in Japan, rarely in the United States, and,
thus far, not in Europe.

<http://www.cdc.gov/ncidod/eid/vol11no04/04-0893.htm>

**Host a Women's Health Fair - National Women\'s Health Week of May 9th
2005**

How to Coordinate a Health Fair: CDC
<http://www.cdc.gov/od/spotlight/nwhw/planning/plan1.htm>

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

**Osteoporosis and Fracture Prevention in the Indian Health System**

Toward a Public Health Approach, p 230-4: Steven Brown and Bruce Finke

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

**Osteoporosis: Strategies for Screening and Intervention**

Steven Brown and Roy Teramoto

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

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

**Pregnancy: Keeping Yourself and Your Baby Healthy**

<http://www.aafp.org/afp/20050401/1321ph.html>

[**What Can You Do To Make Rheumatoid Arthritis (RA) Less
Debilitating?**](http://mp.medscape.com/cgi-bin1/DM/y/hnch0G875W0Dzc0F7G10Ey)\
Rheumatoid arthritis is a chronic, debilitating disease that affects
about 2 million people. Read about research that may reveal new targets
for treatment as well as other clinically useful information in the
Rheumatoid Arthritis Resource Center.

<http://www.medscape.com/pages/editorial/resourcecenters/public/rheumarthritis/rc-rheumarthritis.ov>

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

**April 1, 2005: Methamphetamine use in Indian Country -- still can join
in**

Moderator: Steve Holve

-How common is Methamphetamine use in your area?

-Should all mothers be screened at delivery for Methamphetamine use or
only if medically indicated?

-What resources are available in your community if a pregnant mother is
found to be using Methamphetamine?

-What resources are available for teenagers and adults who are
Methamphetamine users?

-What programs have shown success in treating Methamphetamine addiction?

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

Subscribe to the Primary Care listserv

<http://www.ihs.gov/generalweb/helpcenter/helpdesk/index.cfm?module=listserv&option=subscribe&newquery=1>

Unsubscribe from the Primary Care listserv

<http://www.ihs.gov/generalweb/helpcenter/helpdesk/index.cfm?module=listserv&option=unsubscribe&newquery=1>

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

**STD Corner - Laura** **Shelby, STD Director, IHS**

**Natural mentoring relationships and adolescent health: evidence from a
national study**

This article analyzes the mentoring database of the National
Longitudinal Study of Adolescent Health.  According to the authors,
mentoring relationships (with non parent adults) had some positive
effect on health and related outcomes but individual and environmental
factors had a greater impact on these outcomes, outweighing the impact
of mentors.

DuBois DL, Silverthorn N. Natural mentoring relationships and adolescent
health: evidence from a national study. Am J Public Health. 2005
Mar;95(3):518-24\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15727987&dopt=Abstract>

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

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

**Syphilis Elimination Effort (SEE) Toolkit**

This SEE Tool Kit is for public health practitioners responsible for
planning, managing, and developing community coalitions to increase the
awareness of and garner support for their syphilis elimination or
prevention effort. The toolkit includes: a guide that provides advice
and instructions on how to mobilize a community; camera-ready print ads;
brochures, posters, banners, educational materials specifically
developed for health care providers, leaders of the community-based and
faith-based organizations, and for elected officials;
sexual-history-taking guide; Syphilis - A Physicians Pocket Guide; form
letters; radio PSAs; resource guides; tip sheets; and a CD-ROM
containing all of the kit materials.

<http://www.cdc.gov/std/SEE/default.htm>

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

**Outbreak of Infectious Syphilis in Alaska\--Follow-up**

#### [**http://www.epi.hss.state.ak.us/bulletins/docs/b2005_14.pdf**](http://www.epi.hss.state.ak.us/bulletins/docs/b2005_14.pdf) {#httpwww.epi.hss.state.ak.usbulletinsdocsb2005_14.pdf .Style-Heading-4-+-Arial-14-pt-Underline}

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

**HIV Infection in Alaska, 2004**

[[http://www.epi.hss.state.ak.us/bulletins/docs/b2005_13.pdf]{.underline}](http://www.epi.hss.state.ak.us/bulletins/docs/b2005_13.pdf)

####   {#section-16 .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}

**A Decline In Life Expectancy in the US**

A nine-month fall in life span would be greater than the negative effect
of all deaths from accidents, murder and suicide. The magnitude of that
effect may sound trivial to some, but in fact it\'s greater than the
negative effect of all accidental mortality, such as car accidents,
suicides and homicides combined.

[Conclusion]{.underline} Forecasts of life expectancy are an important
component of public policy that influence age-based entitlement programs
such as Social Security and Medicare. Although the Social Security
Administration recently raised its estimates of how long Americans are
going to live in the 21st century, current trends in obesity in the
United States suggest that these estimates may not be accurate. From our
analysis of the effect of obesity on longevity, we conclude that the
steady rise in life expectancy during the past two centuries may soon
come to an end.

Olshansky SJ, et al A potential decline in life expectancy in the United
States in the 21st century. N Engl J Med. 2005 Mar 17;352(11):1138-45.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15784668>

**Dark Chocolate Improves Insulin Sensitivity/Resistance and Blood
Pressure**

It is probably the flavanols and procyanidins contained in the dark
chocolate and not white chocolate that is associated with the observed
health effects.

[CONCLUSION]{.underline}: Dark, but not white, chocolate decreases blood
pressure and improves insulin sensitivity in healthy people. Grassi et
al. Short-term administration of dark chocolate followed by a
significant increase in insulin sensitivity and a decrease in blood
pressure in healthy persons.

Am J Clin Nutr. 2005;81:541-542, 611-614

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15755830>

**Yogurt Promotes Fat Loss**

CONCLUSION: Isocaloric substitution of yogurt for other foods
significantly augments fat loss and reduces central adiposity during
energy restriction

Zemel MB et al. Dairy (yogurt) augmentation of total and central fat
loss in obese subjects. Int J Obes. 2005;29:388-390, 391-397

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15672113>

**Physical Activity Increases Insulin Sensitivity 44%**

Physical Activity in women with type 2 diabetes may not only reduce
waist size, but can also reduce the amount of visceral fat surrounding
organs in the abdomen - the type of fat known to be associated with
insulin resistance, even without diet, a study shows. Physical Activity
needs to be part of the prescription for controlling type II diabetes.
One wants to reduce that visceral fat because you want all the health
benefits that come with it.

[In conclusion]{.underline}, modest weight loss, through either D or
D+E, resulted in similar improvements in total abdominal fat, SAT, and
glycemic status in postmenopausal women with type 2 diabetes; however,
the addition of exercise to diet is necessary for VAT loss. These data
demonstrate the importance of exercise in the treatment of women with
type 2 diabetes.

Giannopoulou I et al Exercise is required for visceral fat loss in
postmenopausal women with type 2 diabetes. J Clin Endocrinol Metab. 2005
Mar;90(3):1511-8\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15598677>

**Knowing One\'s Hgb A1c Can Improve Results**

CONCLUSIONS: Respondents who knew their HbA(1c) values reported better
diabetes care understanding and assessment of their glycemic control
than those who did not. Knowledge of one\'s HbA(1c) level alone,
however, was not sufficient to translate increased understanding of
diabetes care into the increased confidence and motivation necessary to
improve patients\' diabetes self-management. Strategies to provide
information to patients must be combined with other behavioral
strategies to motivate and help patients effectively manage their
diabetes

Heisler M, et al The Relationship Between Knowledge of Recent HbA1c
Values and Diabetes Care Understanding and Self-Management. Diabetes
Care. 2005 Apr;28(4):816-22.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15793179&dopt=Abstract>

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

**New Perinatology Corner Module Should you be using the quad screen?**

**Prenatal Genetic Screening -- Serum and Ultrasound**

<http://www.ihs.gov/MedicalPrograms/MCH/m/TM01.cfm>

[**Osteoporosis in Indian Health - A Systems
Approach**](http://www.ihs.gov/MedicalPrograms/MCH/W/WHmature.asp#OsteoAIAN)

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

[**Osteoporosis: Strategies for Screening and
Prevention**](http://www.ihs.gov/MedicalPrograms/MCH/W/WHmature.asp#OsteoAIAN)

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

There are several upcoming **Conferences**

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

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

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

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

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

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

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

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

**17th Annual IHS Research Conference: International Meeting on Inuit
and Native American Child Health: Innovations in clinical care and
research**

-   April 29-May 1, 2005, Seattle, WA

-   <http://www.aap.org/nach/InternationalMeeting.htm>

**3rd Western MCH Epidemiology**

-   May 12-13, 2005

-   Portland, OR

-   <http://sphcm.washington.edu/mchepi2005/>

**American College of Obstetricians and Gynecologists Annual Clinical
Meeting**

-   May 7-11, 2005

-   San Francisco , California

-   53rd Annual ACOG ACM <http://www.acog.org/ACM2005/>

**Advances in Indian Health**

-   May 11-13, 2005

-   Albuquerque, NM

-   2004 Brochure (2005 pending)

-   [http://hsc.unm.edu/cme/2004%20Web%20Info/AIH2004/AIHIndex.shtml](http://hsc.unm.edu/cme/2004 Web Info/AIH2004/AIHIndex.shtml)

-   Contact <CNorth@abq.ihs.gov>

**Prevention of Cardiovascular Disease & Diabetes Among** **AI / AN**

-   May 16 - 19, 2005

-   Denver, CO

-   Co-sponsored by IHS, Joslin, ADA, NIH

-   <http://professionaled.joslin.org/CourseListing/CourseDesc.asp?intCourseTypeId=4&intCourseID=1269&strFullInd=Y>

**Native American Women's Health: Leadership for Change Conference**

-   May 19 -20, 2005

-   Denver, CO

-   Office on Women's Health, DHHS

-   Invitation for Dialogue, Planning, and Commitment to Health

-   <http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#May05>

**2005 U.S. Public Health Conference/Global Health Summit**

-   June 5-9, 2005

-   Philadelphia, PA, Development of the Report on Global Health

-   40^th^ Annual U.S. Public Health Professional Conference, June 6-9,
    2005

-   [www.coausphsconference.org](../../../../../../../../exchweb/bin/redir.asp%3FURL=http://www.coausphsconference.org/)

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

-   June 19 - 23, 2005

-   Denver, CO

-   Contact [Yvonne Malloy](mailto:YMalloy@acog.org) <YMalloy@acog.org>
    202-863-2580

-   Save the date info
    <http://www.ihs.gov/MedicalPrograms/MCH/M/documents/pgcoursesavethedate.doc>

-   2005 Brochure

```{=html}
<!-- -->
```
-   <http://www.ihs.gov/MedicalPrograms/MCH/M/Documents/Brochure2005EL.doc>

-   June 19th at 8:00 am: NEONATAL RESUSCITATION PROGRAM

```{=html}
<!-- -->
```
-   NRP Class size limited. Sign up now
    <http://www.ihs.gov/MedicalPrograms/MCH/M/documents/NeonatalResuscitationProvider2.doc>

```{=html}
<!-- -->
```
-   Meeting Website
    <http://www.ihs.gov/MedicalPrograms/MCH/M/CN01.cfm#June05>

**National Summit on Preconception Care**

-   JUNE 21-22, 2005

-   Atlanta, Georgia

-   Catalyst for national recommendations for preconception care, CDC

-   <http://www.signup4.net/Public/ap.aspx?EID=NATI14E>

# 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 **March 2005 OB/GYN CCC Corner** is available at:\
<http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0305.cfm>

#### Abstract(s) of the Month: page 3 {#abstracts-of-the-month-page-3 .Style-Heading-4-+-Arial-14-pt-Underline}

**#1 Use 'Opt out' HIV screening methods during pregnancy in Indian
Country**

[**Routine Population-Wide HIV Screening May Be
Cost-Effective**](http://mp.medscape.com/cgi-bin1/DM/y/hmEa0G875W0Dzc0GQ3m0ET)

**Q. What is the Indian Health policy for HIV screening in pregnancy?**

**#2** **Early epidural provided shorter labor and did not increase
cesarean delivery page 5**

#### From your colleagues: page 7 {#from-your-colleagues-page-7 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Burt Attico: 3 items on Pre-eclampsia from BMJ; Physicians May Be Ignoring Guidelines for Gestational Weight Gain {#burt-attico-3-items-on-pre-eclampsia-from-bmj-physicians-may-be-ignoring-guidelines-for-gestational-weight-gain .Style-Heading-4-+-Arial-14-pt-Underline}

#### Katy Ciacco-Palatianos: Health Literacy Fellowship {#katy-ciacco-palatianos-health-literacy-fellowship .Style-Heading-4-+-Arial-14-pt-Underline}

### **Terry Cullen:** IHS Domestic Violence Prevention / Intentional Injuries Course

#### Sandra Dodge: How many deliveries does a provider need to maintain active privileges? {#sandra-dodge-how-many-deliveries-does-a-provider-need-to-maintain-active-privileges .Style-Heading-4-+-Arial-14-pt-Underline}

#### Mara Fusfield: What are some good resources to develop guidelines from?  {#mara-fusfield-what-are-some-good-resources-to-develop-guidelines-from .Style-Heading-4-+-Arial-14-pt-Underline}

#### Jim Galloway: Women's Health Cardiology Resources Available {#jim-galloway-womens-health-cardiology-resources-available .Style-Heading-4-+-Arial-14-pt-Underline}

**Steve Holve:** What are some of the issues in adoption of an American
Indian child?

March Indian Child Health Notes

**Elaine Locke:** Job Postings on ACOG Career Connection

**Kathleen Masis:** U.S. Surgeon General Releases Advisory on Alcohol
Use in Pregnancy

#### Kate McCarthy: The Public's Health and the Law in the 21^st^ Century: 4^th^ Annual Partnership  {#kate-mccarthy-the-publics-health-and-the-law-in-the-21st-century-4th-annual-partnership .Style-Heading-4-+-Arial-14-pt-Underline}

**Neil Murphy:** Take two Clomid and call me in the morning: A true
story

#### Jane Powers: IHS Child Abuse Project Website has just been updated {#jane-powers-ihs-child-abuse-project-website-has-just-been-updated .Style-Heading-4-+-Arial-14-pt-Underline}

#### Robert Stockburger: Locum tenens availability {#robert-stockburger-locum-tenens-availability .Style-Heading-4-+-Arial-14-pt-Underline}

**Scott Sunde:** What is the significance of the latest NEJM article on
trial of labor after cesarean?

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

#### -How would you like to be the Czarina of Women's Health in Indian Country? {#how-would-you-like-to-be-the-czarina-of-womens-health-in-indian-country .Style-Heading-4-+-Arial-14-pt-Underline}

-Good FAS web site

-U.S. Surgeon General Releases Advisory on Alcohol Use in Pregnancy

-Potential Economic Benefits of the National Children\'s Study

-How does your state rank in fitness in Children?

**Judy Whitecrane**: Native American Women\'s Health: Leadership for
Change Conference

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

##### Obstetrics: page 12

-Misoprostol decreases oxytocin use largely due to labor within the
ripening period

-Overweight and obese women with single cephalic term pregnancies have
increased risk

-Fast-Absorbing Sutures Better for Postpartum Perineal Repair

-Severe Preeclampsia and Eclampsia: Systolic Hypertension Is Also
Important

#### -[**Perinatal HIV Transmission Now Most Likely to Occur in Utero**](http://mp.medscape.com/cgi-bin1/DM/y/hl4V0G875W0Dzc0GQdM0EH)  {#perinatal-hiv-transmission-now-most-likely-to-occur-in-utero .Style-Heading-4-+-Arial-14-pt-Underline}

-And more

**Gynecology:** **page 15**

-Vaginal pH for Diagnosing Status of Menopause

-Surgical or Medical Treatment for Refractory Menorrhagia?

-Symptom Experiences of Chronically Constipated Women With Pelvic Floor
Disorders

**Child Health:** **page 16**

-Pregnancy, Birth, and Abortion Rates Decline for Teenagers Aged 15-17
Years

-Are children born after assisted reproductive technology at increased
risk for adverse health outcomes?

**Chronic Illness and Disease:** **page 16**

**-Low-dose aspirin can prevent cardiovascular disease in older women**

-Antiplatelet Therapy and Anticoagulation in Patients with Hypertension

-Cardiovascular risk higher among patients with migraine

-Control of Cardiovascular Risk Factors - Diabetic Women Compared to Men

-Insulin Monotherapy vs. Combination Therapy

-And more

#### Features: page 18 {#features-page-18 .Style-Heading-4-+-Arial-14-pt-Underline}

##### AFP

-Does Melatonin Improve Sleep in Asthmatic Women?

ACOG

\- Pregestational diabetes mellitus, ACOG Practice Bulletin No. 60

**AHRQ**

-Follow-up of newborns after hospital discharge: Critical to
preventjaundice and other problems

**Ask a Librarian**

\- Salmonella from Pet Turtles-Again

**Breastfeeding**

-Resurgence of kernicterus attributed primarily to early discharge of
newborns

**CCC Corner Digest**

#### -LEEP Treatment Increases Risk of Preterm Delivery in Future Pregnancies  {#leep-treatment-increases-risk-of-preterm-delivery-in-future-pregnancies .Style-Heading-4-+-Arial-14-pt-Underline}

#### -New OB/GYN Deputy Chief Clinical Consultant IHS {#new-obgyn-deputy-chief-clinical-consultant-ihs .Style-Heading-4-+-Arial-14-pt-Underline}

-Progesterone Treatment Decreases Preterm Birth Rate

-Radio-Frequency Endometrial Ablation for Menorrhagia

#### -Hormonal Contraceptives and Weight Gain {#hormonal-contraceptives-and-weight-gain .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Walk 2000 More Steps a Day and Never Gain Another Pound {#walk-2000-more-steps-a-day-and-never-gain-another-pound .Style-Heading-4-+-Arial-14-pt-Underline}

**Domestic Violence**

-Intimate Partner Violence During Pregnancy

-Homicide is the 2nd leading cause of injury-related deaths among
pregnant and women

-An easy palm-based downloadable domestic violence assessment tool

**Elder Care News**

-Palliative care and hospice training in Anchorage, Alaska - May 10-12,
2005

**Family Planning**

-Women continue to die from unintended pregnancy

-Effects of Contraception on Bone Mineral Density

**Frequently asked questions**

-What is the Indian Health policy for HIV screening in pregnancy?

-Should I prescribe Depo Provera as a long term agent for more than 2
years?

-What preventive therapy is recommended for patients at high risk for
pre-eclampsia?

-My patient is not doing too well with her hormone replacement therapy.
Options?

-What are some of the opportunities to provide care in Indian women's
health?

**Hormone Replacement Update**

-Estrogen with or without progestin should not be prescribed for relief
of incontinence

**Information Technology**

-Computerized order entry system may increase risk of medication errors

-Intranet-based prenatal record improves communication

-UpToDate Version 13.1 Now Available; Includes Pediatrics

-Tribal Connections

-Native Web.org: Resource Database / Health

International Health

-Women, inequality, and the burden of HIV

-Physician Missions With Doctors Without Borders:

-UN Predicts Global Population of 9.1 Billion by 2050

#### MCH Alert

-Task Force presents recommendations for reducing violence

#### Medscape

-Genital Herpes and Pregnancy: Preventing Neonatal Transmission

**Midwives Corner**

\- Emergency OB Drills: The Phoenix Indian Medical Center Experience

-Concern over rising cesarean delivery rate: ACNM approaches Congress

-Alternative Medicines\' Popularity Prompts Concern

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

-Spread the Word - National Women\'s Health Week, May 8-14, 2005

Osteoporosis

-How best to start good bone health?

-Clinical Rules Don\'t Predict Osteoporosis in Women

Patient Education

-Consumer Health: Indian Health

-What Should I Know About Cholesterol?

-Vertigo-A Type of Dizziness

Primary Care Discussion Forum

-April 1, 2005: Methamphetamine use in Indian

STD Corner

-Women\'s Sexual Health and Sexually Transmitted Diseases -- May 13,
2005

#### -Expedited treatment of sex partners on persistent gonorrhea or chlamydial infection {#expedited-treatment-of-sex-partners-on-persistent-gonorrhea-or-chlamydial-infection .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### -Postmenopausal Women and Visceral Fat Loss through Exercise {#postmenopausal-women-and-visceral-fat-loss-through-exercise .Style-Heading-4-+-Arial-14-pt-Underline}

## -Minding the gender gap: The divergence between men\'s and women\'s health research

-Omitting breakfast on insulin sensitivity and fasting lipid:
Deleterious effects

#### -Beginning Exercise Routine Later in Life Still Reduces Heart Disease, Diabetes risk {#beginning-exercise-routine-later-in-life-still-reduces-heart-disease-diabetes-risk .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Blood Pressure, Insulin Sensitivity Linked to Waist Circumference {#blood-pressure-insulin-sensitivity-linked-to-waist-circumference .Style-Heading-4-+-Arial-14-pt-Underline}

#### What's new on the ITU MCH web pages page 28

The past CCC Corners are archived at:

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

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

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

or 907 729 3154 (with voicemail)

\*The opinions expressed in the OB/GYN CCC Corner are strictly those of
the authors, and not necessarily those of the Indian Health System, or
the author of this newsletter. If you have any comments, please share
them by joining the Primary Care Discussion Forum where this topic was
recently discussed. To join the Primary Care Listserv, click on
'Subscribe' here
<http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdiscuss.asp>

4/9/05njm