OB/GYN Chief Clinical Consultant's Corner

Volume 2, No. 8, August 2004

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

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

Estrogen Therapy May Adversely Affect Global Cognitive Function

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

From Burt Attico: Making a Difference in Cambodia

From Terry Cullen: *UpToDate* Version 12.2 Now Available

**From Barbara Fine:** Call for Papers - American Indian & Alaska Native
Health Care Needs

**From Sandra Haldane:** Farewell to Barbara Fine, Women's Health
Consultant; National Alaska Native American Indian Nurses Association
Annual Summit; Nursing Education Loan Repayment Program**;** Writer\'s
Mentoring Program; Genomics and the Public Health in the 21st Century

From Steve Holve: August Indian Child Health Notes

From Rose Knox: Breastfeeding women not to use domperidone, to increase
milk production\*

**From Chuck North:** Number needed to Treat (NNT), Number needed to
Screen (NNS)

**From Ty Reidhead:** Online access to online journals that are
available at the Parklawn Library

From Lois Steel: Policy for the Group B strep in pregnancy

From Judy Thierry: Need data to help inform our legislative colleagues
about Indian Country;

How Schools Work and How to Work with Schools on Public Health Issues;
Managing Child/Adolescent Behavioral Health Problems; School based
health: How would that work in Indian Country? Knowledge path edition
about asthma in children and adolescents; American Indian Children who
receive care in the Indian Health Service have a 10% higher Immunization
rate; Psychotropic drugs in pediatric population in ITU system

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

**Obstetrics:** **page 10**

Pregnancy Rates decreased by 10% decrease in 10 years for the United
States; Intensive Management of Gestational Diabetes: Cochrane for
Clinicians; [Preterm Birth as a Social Disease; Congenital Syphilis
\-\-- United States, 2002; Dystocia and Augmentation of Labor: Practice
Guidelines](http://mdconsult.chtah.com/a/hBA3EUBAPMgn1ARsVeZAPMu5kXl/curb179)

[**Gynecology: page
11**](http://mdconsult.chtah.com/a/hBA3EUBAPMgn1ARsVeZAPMu5kXl/curb179)

[**Despite Guidelines, Pap Smears in Women Without a Cervix Very
Common;**](http://mp.medscape.com/cgi-bin1/DM/y/hhjh0G875W0Dzc0F3Zm0AC)
Have you ever tried to learn any new technique? How many till you are
competent? Clinical examination vs. dynamic magnetic resonance imaging
in vaginal vault prolapse; MRI Helpful for Deep Pelvic Endometriosis;
Asymptomatic women show pelvic floor nerve injury after uncomplicated
deliveries; Uterine myomas: an overview of development, clinical
features, and management; Significance of a negative loop
electrosurgical cone biopsy for high-grade dysplasia; The Visit Before
the Morning After; Treating Female Infertility and Improving IVF
Pregnancy Rates: Manual Physical Therapy; Increases in
Fluoroquinolone-Resistant Neisseria Gonorrhoeae: Implications for Women;
Genetic Testing for Breast and Ovarian Cancer Susceptibility: Consumer
Marketing,

**Child Health: page 13**

Educate the educators, er...providers; Ano-genital warts in children:
Sexual abuse or not? Exposure of underage girls to alcohol advertising
is substantial and increasing; What does SIDS really mean? Racial/Ethnic
Disparities in Neonatal Mortality; Violence-Related Behaviors Among High
School Students; Great Beginnings: Transform care in your hospital\'s
newborn nursery; Funding for prevention and treatment of childhood
obesity in primary care settings; Vision and school health fact sheet;
Gowning in Newborn and Special-Care Nurseries; Screening and Behavioral
Counseling Interventions in Primary Care to Reduce Alcohol Misuse;
**Alert: Paxil and Wellbutrin warnings;** Materials on Child
Maltreatment

**Chronic Illness and Disease: page 15**

Overview of the WISEWOMAN Projects: Health Promotion for Disadvantaged
Women-Featuring Alaska's Tribal Southcentral Foundation among other
recipients; Irritable Bowel Syndrome - An Evidence-Based Approach to
Diagnosis; Insulin for Type 2 Diabetes: Rescue, Augmentation, and
Replacement of Beta-Cells; HIV Counseling, Testing, and Referral

[Features:]{.underline} page 16

**AFP:** Progesterone Intrauterine System for Menorrhagia; PAPNET vs.
Manual Reading of Pap Smears; Useful Signs and Symptoms in the
Evaluation of Vaginitis; Effect of Fetal Fibronectin on Preterm Labor;
Three Days of Ciprofloxacin for UTI in Older Women; Tai Chi May Improve
Symptoms of Osteoarthritis; Exemestane vs. Tamoxifen After Breast
Cancer; No Link Between Breast Cancer and Abortion; Antihistamines for
the Common Cold? Diagnosis and Management of Galactorrhea

**ACOG:** Nonmedical Use of Obstetric Ultrasonography ; Prenatal and
Preconceptional Carrier Screening for Genetic Diseases

**AHRQ:** Bowel Prep -- AHRQ Web M + M

**Breastfeeding:** Tom Hale\'s response to FDA warning of domperidone;
Counseling for Breastfeeding: Case Study; Seeking to support
breastfeeding (breastpump procurement) at your area or service unit?

**Domestic Violence:** Funding available: OJJDP Program Announcement for
the Safe Start Program

**Elder Care News:** Women with Heart Disease; Omega-3 Fatty Acids

**Frequently asked questions:** Where can I get some funds for a
project?

**Hormone Replacement Update**: NAMS Releases Position Statement on the
Treatment of Vasomotor Symptoms Associated with Menopause: Practice
Guidelines; The Menopause Moment

**Information Technology:** HEALTHeFORCES™   Walter Reed: Women\'s
health and prevention; New web site address the health concerns of
American Indians and Alaska Natives

**International Health**; [Health Canada\'s First Nations and Inuit
Health Branch](http://www.hc-sc.gc.ca/fnihb/)**;** DHHS Afghan Family
Health Book Launch Invitation; Polio experts warn of largest epidemic in
recent years, as polio hits Darfur

**MCH Alert:** Depression among female adolescents, may be higher than
previous estimates

**Medscape**: Female Interstitial Cystitis: Chronic Pelvic Pain,
Diagnosis and Misdiagnosis

**Office of Women's Health, CDC**: Healthy Women: State Trends in Health
and Mortality

**Osteoporosis:** Longer-Term Data Confirm Raloxifene Reduces the Risk
of Breast Cancer in Older Women

**Patient Education:** Your Insulin Therapy; HIV Infection-How to Lower
Your Risk; Galactorrhea: What You Should Know About It?

**Primary Care Discussion Forum:** Violence against Native women:
November 1, 2004

##### Barbara Stillwater, Alaska Diabetes Prevention and Control: Exploratory Grant Program in Diabetes Endocrinology and Metabolism Release

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

[Gynecologic Cancer Awareness: September
2004](http://www.ihs.gov/MedicalPrograms/MCH/W/WHcancer.asp)

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

# 

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

Estrogen Therapy May Adversely Affect Global Cognitive Function

Conjugated equine estrogen (CEE) does not reduce the incidence of
dementia or mild cognitive impairment (MCI) and has an adverse effect on
global cognitive functioning, according to two reports from the Women\'s
Health Initiative Memory Study (WHIMS) published in the June issue of
*JAMA*.

#1

Shumaker SA, et al Conjugated equine estrogens and incidence of probable
dementia and mild cognitive impairment in postmenopausal women: Women\'s
Health Initiative Memory Study. JAMA. 2004 Jun 23;291(24):2947-58

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15213206>

CONTEXT: The Women\'s Health Initiative Memory Study (WHIMS) previously
found increased risk for dementia and no effect on mild cognitive
impairment (MCI) in women treated with conjugated equine estrogens (CEE)
plus medroxyprogesterone acetate (MPA). OBJECTIVE: To determine the
effects of CEE alone and CEE plus MPA on incidence of probable dementia
and MCI in older women. DESIGN, SETTING, AND PARTICIPANTS: Randomized,
double-blind, placebo-controlled clinical trials of CEE (estrogen-alone
trial) or CEE plus MPA (estrogen plus progestin trial) in
community-dwelling women aged 65 to 79 years, conducted from June 1995
to July 8, 2002 (estrogen plus progestin; n = 4532), or to February 29,
2004 (estrogen-alone; n = 2947), in 39 of the 40 WHI clinical centers.
INTERVENTIONS: In the estrogen-alone trial, 1 daily tablet containing
either 0.625 mg/d of CEE vs matching placebo; in the estrogen plus
progestin trial, 1 daily tablet containing CEE (0.625 mg/d) plus MPA
(2.5 mg/d) vs matching placebos. MAIN OUTCOME MEASURES: Probable
dementia and MCI. RESULTS: In the estrogen-alone trial, 47 participants
were diagnosed with probable dementia, of whom 28 were assigned to CEE
and 19 to placebo (hazard ratio \[HR\], 1.49; 95% confidence interval
\[CI\], 0.83-2.66). Incidence rates for probable dementia in the
estrogen-alone trial were statistically similar to those in the estrogen
plus progestin trial (45 vs 22 per 10 000 person-years for CEE plus MPA
vs placebo, respectively; P =.11). When data were pooled per the
original WHIMS protocol, the overall HR for probable dementia was 1.76
(95% CI, 1.19-2.60; P =.005). After excluding participants with baseline
Modified Mini-Mental State Examination scores at or below the screening
cut point, the HR was 1.77 (95% CI, 0.74-4.23; P =.20) in the
estrogen-alone trial and 2.19 (95% CI, 1.25-3.84; P =.006) in the pooled
trials. In the estrogen-alone trial, 76 participants were diagnosed with
MCI in the CEE group vs 58 in the placebo group (HR, 1.34; 95% CI,
0.95-1.89). In the combined trial data, the HR was similar (1.25; 95%
CI, 0.97-1.60). In the estrogen-alone trial, 93 participants receiving
CEE were diagnosed with either probable dementia or MCI vs 69 receiving
placebo (HR, 1.38; 95% CI, 1.01-1.89; P =.04).

[CONCLUSIONS:]{.underline} Estrogen therapy alone did not reduce
dementia or MCI incidence and increased the risk for both end points
combined. Pooling data for estrogen alone and estrogen plus progestin
resulted in increased risks for both end points. Use of hormone therapy
to prevent dementia or cognitive decline in women 65 years of age or
older is not recommended.

#2

Espeland MA et al Conjugated equine estrogens and global cognitive
function in postmenopausal women: Women\'s Health Initiative Memory
Study. JAMA. 2004 Jun 23;291(24):2959-68.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15213207>

CONTEXT: The Women\'s Health Initiative Memory Study (WHIMS) previously
reported that estrogen plus progestin therapy does not protect cognition
among women aged 65 years or older. The effect of estrogen-alone
therapy, also evaluated in WHIMS, on cognition has not been established
for this population. OBJECTIVES: To determine whether conjugated equine
estrogen (CEE) alters global cognitive function in older women and to
compare its effect with CEE plus medroxyprogesterone acetate (CEE plus
MPA). DESIGN, SETTING, AND PARTICIPANTS: A randomized, double-blind,
placebo-controlled ancillary study of the Women\'s Health Initiative
(WHI), WHIMS evaluated the effect of CEE on incidence of probable
dementia among community-dwelling women aged 65 to 79 years with prior
hysterectomy from 39 US academic centers that started in June 1995. Of
3200 eligible women free of probable dementia enrolled in the WHI, 2947
(92.1%) were enrolled in WHIMS. Analyses were conducted on the 2808
women (95.3%) with a baseline and at least 1 follow-up measure of global
cognitive function before the trial\'s termination on February 29, 2004.
INTERVENTIONS: Participants received 1 daily tablet containing either
0.625 mg of CEE (n = 1387) or matching placebo (n = 1421). MAIN OUTCOME
MEASURE: Global cognitive function measured annually with the Modified
Mini-Mental State Examination (3MSE). RESULTS: During a mean follow-up
of 5.4 years, mean (SE) 3MSE scores were 0.26 (0.13) units lower than
among women assigned to CEE compared with placebo (P =.04). For pooled
hormone therapy (CEE combined with CEE plus MPA), the mean (SE) decrease
was 0.21 (0.08; P =.006). Removing women with dementia, mild cognitive
impairment, or stroke from the analyses lessened these differences. The
adverse effect of hormone therapy was more pronounced among women with
lower cognitive function at baseline (all P\<.01). For women assigned to
CEE compared with placebo, the relative risk of having a 10-unit
decrease in 3MSE scores (\>2 SDs) was estimated to be 1.47 (95%
confidence interval, 1.04-2.07). [CONCLUSION:]{.underline} For women
aged 65 years or older, hormone therapy had an adverse effect on
cognition, which was greater among women with lower cognitive function
at initiation of treatment.

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

### Pearls for Practice

-   During five to seven years of follow-up, women older than 65 years
    with hysterectomy given CEE alone compared with placebo have
    slightly but significantly lower cognitive function and higher
    incidence of probable dementia.

-   CEE alone or in combination with MPA is not recommended to prevent
    cognitive impairment or dementia in women older than 65 years.

In an accompanying editorial, Lon S. Schneider, MD, from the University
of Southern California, Los Angeles, reviews remain questions regarding
estrogen therapy. These include whether short-term use of estrogen for
several years in early postmenopause might be effective in reducing
dementia two or three decades later.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15213214>

In any case, it still is the best practice to utilize life style
modifications and other therapeutic modalities as first lines choices to
control menopausal symptoms, and/or to decrease cardiovascular risks. If
hormone therapy becomes necessary, then estrogens (and progesterone)
replacement therapy should be utilized in the lowest possible dose for
the shortest duration to control menopausal symptoms. njm

## 

## From your colleagues:

#### [From Burt Attico, Phoenix]{.underline}

**Making a Difference in Cambodia**

This is interesting. During my early years in PHS, the Peace Corps was
the \"way to go,\" as well as \"Surgical Missions to Vietnam\" (where
you were actually detailed to the State Dept.). These Health Volunteers
Overseas(HVO) assignments are important ways to make a contribution in
underserved world locations.

HVO provides training in a variety of specialties in Cambodia where the
need for clinical education is acute and the opportunity to make a
difference is great. There is a particular need for volunteers in the
oral surgery (Siem Reap) and nursing (Siem Reap and Phnom Penh) programs
between now and the end of the year.

Background: Devastated by years of civil war and the brutality of the
Khmer Rouge regime, Cambodia\'s health sector was shattered in the
1970s. Many health professionals were either killed or fled the country.
Cambodia held peaceful elections in 2003 and is slowly recovering from
decades of internal strife. To learn more about Cambodia, click here

[<http://email.e-mailnetworks.com/ct/ct.php?t=655388&c=365184802&m=m&ty>pe]{.underline}

In Cambodia, HVO works with health professionals to provide teaching and
training at two facilities in the country. The Angkor Hospital for
Children (AHC) is located in the city of Siem Reap, just miles from the
celebrated ruins of Angkor Wat. The Sihanouk Hospital Center of Hope in
the capital city of Phnom Penh provides free medical care for adults.
Volunteers are needed for assignments lasting one to two weeks. For more
information about oral surgery in Cambodia. Potential volunteers should
contact the HVO Program Department

[<http://email.e-mailnetworks.com/ct/ct.php?t=655390&c=365184802&m=m&ty>pe=1]{.underline}

[From Terry Cullen, Tucson]{.underline}

*UpToDate* Version 12.2 Now Available\
We are pleased to announce that *UpToDate* version 12.2 is now
available. Here is the 12.2 Newsletter with updates on most specialties
and links to UpToDate text. Please note it is 591 KB pdf file
[**http://www.uptodate.com/img/newsletter.pdf**](http://www.uptodate.com/img/newsletter.pdf)

[From Barbara Fine, HQE]{.underline}

**Call for Papers - American Indian & Alaska Native Health Care Needs**

The American Journal of Public Health (AJPH), in collaboration with the
Henry J. Kaiser Family Foundation, is planning to publish a collection
of papers on how the United States can more effectively meet the health
care needs of American Indians and Alaska Natives (AI/ANs).

The guest editors are soliciting contributions to the \"Health Policy
and Ethics\" and \"Research and Practice\" sections of the AJPH.
Research Articles and Analytic Essays for the department \"Health Policy
and Ethics\" are encouraged that address the challenges or approaches to
eliminating health care disparities (in access, quality, or financing of
care) between AI/ANs and other population groups. DEADLINE TO SUBMIT:
September 1, 2004
[[http://submit.ajph.org/]{.underline}](http://submit.ajph.org/)**\
\
[From Sandra Haldane, HQE]{.underline}**

**Farewell to Barbara Fine, Women's Health Consultant - HQE**

We bid farewell to our IHS Public Health Nurse/Women's Health
Consultant, Barbara Fine whose retirement becomes effective September
3^rd^.  Barbara gave 26 years to the Federal Government, 22 of them with
IHS.  She worked in the following Areas: Oklahoma, Alaska, Albuquerque,
and then to HQ in a wide variety and diversity of positions. We have
appreciated Barb's hard work and dedication, her enthusiasm and
good-humor.  We had a great retirement lunch and reception for Barb
today and lots of people wished her well.  If you would like to send
written wishes to her, please send them to us here at the IHS Division
of Nursing and we will forward them to her

**National Alaska Native American Indian Nurses Association Annual
Summit**

\"Eliminating Indian Health Disparities and Preparing for 2010: Building
Partnerships in Teaching, Research and Practice\" Summit X - Sept. 16 -
19, 2004 at Salish Kootenai College in beautiful Pablo MT.
[http://www.nanaina.com](http://www.nanaina.com/)

**Nursing Education Loan Repayment Program**

As most of you know, IHS does not have nearly enough funds to provide
Loan Repayment to everyone who applies, wants, or needs it.  The Bureau
of Health Professions at HRSA offers LRP and in fact, IHS is listed as
one of the places to be employed to qualify for it.  Here is a link to
find out more about their program. 
<http://bhpr.hrsa.gov/nursing/loanrepay.htm>

**Writer\'s Mentoring Program**

The Publications Committee recently launched the Writer\'s Mentoring
Program at the N-PAC Monthly Meeting in a *brief* presentation. The
Writer\'s Mentoring Program provides an opportunity for Civil Service
and Commissioned Corps Nurses to receive guidance in the development of
documents generated for publication internally within institutions and
externally for journal or book publishers. In a personalized approach,
nurses who are new at writing a particular type of document (case study,
poster abstract, etc) is paired with a nurse who has experience in
writing that particular type of document. Self-identified nurses from CS
and the CC have volunteered to serve as Mentor/Authors. The presentation
slides are attached for reference if you are able to attend the meeting
(in person or by phone) or not able to attend this month. The Writer\'s
Mentoring Program can be accessed through our website
<http://phs-nurse.org/Publishing.htm> or directly through the email
address at: <writermentoringprogram@hotmail.com>.

**Genomics and the Public Health in the 21st Century**

The IOM is holding a conference on Genomics and the Public Health in the
21st Century on Thursday, October 7 from 9:00 AM to 5:00 PM and Friday,
October 8 from 8:30 AM to 5:00 PM in the National Academies Building,
2100 C Street NW. This conference will explore the significance of
genomics to population health and address three major topic areas: the
major scientific and policy issues related to genomics; the major
supports for and challenges to translation of genetic information into
population health benefits; and approaches to the integration of genomic
information into strategies for promoting health and preventing

disease.
[[http://www.iom.edu/event.asp?id=21464]{.underline}](http://www.iom.edu/event.asp?id=21464)
[[http://www.iom.edu/genomics]{.underline}](http://www.iom.edu/genomics)

**[From Steve Holve, Tuba City]{.underline}**

**August Indian Child Health Notes from IHS Pediatric Chief Clinical
Consultant**

Highlights include

\- Impact of the Pneumococcal Conjugate Vaccine on rates of disease in
children

\- Update from the MMWR on making the four doses of the Pneumococcal
Conjugate Vaccine available to American Indian and Alaskan Native
children at high risk

\- Review of an article that answers the question - \"are those recalled
dietary histories accurate?

\- First international meeting on American Indian and Inuit Child Health
in 4/05

Please click this link for the newsletter

<http://www.ihs.gov/MedicalPrograms/MCH/C/documents/ICHN804.doc>

**[From Rose Knox, Anchorage]{.underline}**

**FDA warning: Breastfeeding women not to use domperidone, to increase
milk production\***\
MedWatch - The FDA Safety Information and Adverse Event Reporting
Program. FDA warned healthcare professionals and breastfeeding women not
to use an unapproved drug, domperidone, to increase milk production
(lactation). The agency is concerned with the potential public health
risks associated with domperidone. FDA took these actions because it has
become aware that some women are purchasing this drug from compounding
pharmacies and from foreign sources. Although domperidone is approved in
several countries outside the U.S. to treat certain gastric disorders,
it is not approved in any country, including the U.S., for enhancing
breast milk production in lactating women and is also not approved in
the U.S. for any indication.\
<http://www.fda.gov/medwatch/SAFETY/2004/safety04.htm#domperidone>

\*Please see Dr. Tom Hale's response in the Breastfeeding section below

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

**Number needed to Treat (NNT). Number needed to Screen (NNS)**

It has been suggested by some experts in clinical preventive services
that we use numbers needed to screen (NNS) to explain the value of
clinical prevention to our patients. USPSTF uses these statistics in
several of their summaries. Number needed to treat (NNT) is recommended
for RCT\'s and number needed to harm (NNT) is a companion statistic to
evaluate the downside of treatment modalities. The Bandolier website in
Oxford, England
[[www.ebandolier.com]{.underline}](../www.ebandolier.com) , (see
Knowledge Library, NNT) has an explanation and several calculation aids.
We will probably see more use of these statistics in future
recommendations from USPSTF and others

Here are some evidence based resources with good explanations of NNT and
NNH:

Number needed to treat

-Excessive vaginal bleeding: Progesterone Intrauterine System vs control

-First stage of labor pain

-Breech presentation

<http://www.cebm.utoronto.ca/glossary/nnts/og.htm#top>

Nuovo J, Melnikow J, Chang D. Reporting **number needed to treat** and
absolute risk reduction in randomized controlled trials. JAMA. 2002 Jun
5;287(21):2813-4.

[CONCLUSIONS:]{.underline} Despite CONSORT recommendations, few authors
expressed their findings in terms of NNT or ARR. Consideration should be
given to included these values in reports of RCTs.

[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12038920]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12038920)

Rembold CM. **Number needed to screen**: development of a statistic for
disease screening. BMJ. 1998 Aug 1;317(7154):307-12.

[CONCLUSION:]{.underline} These data allow the clinician to prioritise
screening strategies. Of the screening strategies evaluated, screening
for, and treatment of, dyslipidaemia and hypertension seem to produce
the largest clinical benefit.

[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9685274]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=9685274)

This is probably the **best explanation of 'framing'** that I have found

[[http://www.jr2.ox.ac.uk/bandolier/booth/glossary/framing.html]{.underline}](http://www.jr2.ox.ac.uk/bandolier/booth/glossary/framing.html)

**Screening for Breast Cancer: Case Study**

<http://www.aafp.org/afp/20021215/putting.html>

The Mammography Debate: Editorial

ALFRED O. BERG, M.D., M.P.H. *U.S. Preventive Services Task Force*

<http://www.aafp.org/afp/20021215/editorials.html>

**[From Ty Reidhead, Whiteriver]{.underline}**

**Online access to all of the online journals that are available at the
Parklawn Library**

Does everyone know that we have online access to all of the online
journals that are available at the Parklawn Library? This includes NEJM,
JAMA, Lancet and many others.

<http://np4kn9vl8d.search.serialssolutions.com/>

Also from Katy H. Ciacco Palatianos, <Katy.Ciacco-Palatianos@ihs.gov>

1\. Free emailed NEJM weekly Table of Contents. Concise summaries of
each edition\'s highlights, abstracts, and some complete articles (of
particular public health or international significance) are available to
non-subscribers.

2.  Free 8 wk trial offer to paper and online NEJM.  This might be an
especially attractive option to \"tryout use of the online Journal\"
after trying/enjoying item 1, above.

3\. Instructions for subscription to either of the options above are
described at bottom of the message.

4\. Complete full access to Parklawn Library electronically is described
in a previous email message from Rick Olson, MD, MPH. Password is
available and handy at all of your internet-accessing workstations.
<http://library.psc.gov/library>

**[From Lois Steele, Sells]{.underline}**

**Is there an actual policy for the Group B strep in pregnancy?**

We recommend use of these 2002 CDC based guidelines

<http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5111a1.htm>

Here are some frequently asked questions and clinical pearls

<http://www.ihs.gov/MedicalPrograms/MCH/M/DP46.asp#top>

Here is a free CME / CEU module from IHS on the topic

<http://www.ihs.gov/MedicalPrograms/MCH/M/DP41.asp#top>

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

**We need data to help inform our legislative colleagues about Indian
Country**

Here is one source that we can partner with: The Indian Health
Performance Evaluation System

<http://www.ihs.gov/NonMedicalPrograms/IHPES/index.cfm?module=content&option=pes>

**How Schools Work and How to Work with Schools on Public Health
Issues**

Audio conference and web seminar on How Schools Work and How to Work
with Schools on Public Health Issues. RSVP to by August 23, 2004
<webseminar@cdc.gov>

 

**Managing Child/Adolescent Behavioral Health Problems: Practical
Solutions for the Bush Primary Care Provider**.  

September 17-18th in Albuquerque Managing Child/Adolescent Behavioral
Health Problems: Practical Solutions for the Bush Primary Care
Provider.  This is in conjunction with the NM Pediatric Society\'s Fall
Business Meeting.  Conference will include small group sessions focused
on case studies and facilitated by a primary care provider and a mental
health care provider.  Each case study group will also cover
co-occurring disorders, screening and diagnostic tools for children \'s
mental health issues. See brief course excerpt attached.  Or see the
course program and registration links below:
<http://www.nmsmhi.org/news.html>

<http://www.nmsmhi.org/downloads/pcp_beh_health_conf_brochure_07-29-2004.pdf>

**School based health: How would that work in Indian Country?**

IHS MCH / Adolescent Health / school based health / primary care
providers / NM DOH Office of School Health Work Group will hold a
face2face meeting in New Mexico October 14th and 15th on strategic steps
to take to address care to school age children and adolscents these will
be broken out by (1) infrastructure; (2) data, (3) programs -
(demographics, scope of services, SBHC census), (4) training and
technical assistance, and (5) policy.  Please send me your comments and
questions - Judith K. Thierry, HQE <Judith.Thierry@ihs.gov>

**Knowledge path edition about asthma in children and adolescents**

This electronic resource guide points to a selection of recent,
high-quality resources about asthma in children and adolescents; its
management; and its impact on homes, schools, and communities. The path
also identifies tools for staying abreast of new developments in asthma
care and conducting further research. It is aimed at health
professionals, program administrators, educators, and families
<http://mchlibrary.info/KnowledgePaths/kp_asthma.html>

The following gives one a sense of some criteria for school based health
care provisions.

**The Cost of Asthma in U.S. Children**

-   Lost School Days: 14 Million Days/Year

-   Asthma Treatment: \$3.2 Billion/Year

-   Hospitalization: third leading Cause Among Children Under 15 Years
    Old

**School Health Policies and Programs Study 2000\
Data Relating to Asthma Management**^8^

Percent of schools that have:

![](media/image1.png){width="4.614583333333333in"
height="1.9895833333333333in"}

**American Indian Children who receive care in the Indian Health Service
have an Immunization rate of 80.6% compared with U.S. all races who have
a rate of 73.9%.**

![](media/image2.png){width="5.0in" height="3.75in"}

We are about 10% higher than US all races.  It is important to note
there are different methodologies in coming up with the US % and the IHS
%.  Immunization issues include vaccine shortages, tracking very mobile
child population, on going staff training and use of the immunization
software package.  One of the evidence based practices for the reduction
of Infant Mortality is immunizations. Please send me your comments and
questions - Judith K. Thierry, HQE <Judith.Thierry@ihs.gov>

**Psychotropic drugs in pediatric population in ITU system: 2
resources**

#1

CONCLUSIONS: An inverse relationship between regional change in use of
antidepressants and suicide raises the possibility of a role for using
antidepressant treatment in youth suicide prevention efforts, especially
for males, older adolescents, and adolescents who reside in lower-income
regions.

Olfson M, Relationship between antidepressant medication treatment and
suicide in adolescents. Arch Gen Psychiatry. 2003 Oct;60(10):978-82.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14557142>

**#2**

**THE USE OF PSYCHOTROPIC MEDICATION IN CHILDREN AND ADOLESCENTS**

Arizona Practice Improvement Guidelines

<http://www.hs.state.az.us/bhs/guidance/psychotropic.pdf>

**Grant opportunity in support of community and state tobacco policy
advocacy: \$12 million**

The Robert Wood Johnson Foundation (RWJF), the nation\'s largest private
foundation devoted to improving health and health care, is offering a
grant opportunity in support of community and state tobacco policy
advocacy. Approximately \$12 million will be available to support
professional staff and other infrastructure, public education, advocacy,
outreach, and technical assistance for tobacco policy change initiatives
at either the regional, state or community level

The call for proposals is posted at
[[www.rwjf.org/tobaccopolicychange]{.underline}](../www.rwjf.org/tobaccopolicychange).
There will be no printed version of the CFP. Electronic applications
will be accepted through 3:00 p.m. E.D.T. on September 1, 2004 at
[[www.rwjf.org/tobaccopolicychange]{.underline}](../www.rwjf.org/tobaccopolicychange).

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

**[Obstetrics]{.underline}**

**Pregnancy Rates decreased by 10% decrease in 10 years for the United
States**

This report presents pregnancy rates for 1990--2000, by age, race,
Hispanic origin, outcome, and by marital status. The data in this
report, together with previously published pregnancy rates for earlier
years, provide a consistent series of rates for the United States for
1976--2000. In 2000 an estimated 6,401,000 pregnancies resulted in 4.06
million live births, 1.31 million induced abortions, and 1.03 million
fetal losses. The 2000 pregnancy rate of 104.0 pregnancies per 1,000
women aged 15--44 years is 10 percent lower than the 1990 peak of 115.6.

<http://www.cdc.gov/nchs/data/nvsr/nvsr52/nvsr52_23.pdf>

#### 

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

Are your facilities delivery statistics down? Feeling some competition
for deliveries? If so, you are not alone. Obstetric delivery and
immediate newborn care can be very helpful to the bottom line of any
hospital, e.g., private, tribal, or IHS.

This significant decline in delivery numbers in US, all races, is
reflected in the Indian Health System statistics as well. Our patients
have many excellent options. For patient autonomy, and perhaps the
ultimate financial well being of our own facility, you should be
brainstorming with your colleagues on how you can provide the most
user-friendly and highest quality obstetric delivery care in your area.

In next month's CCC Corner, and on the MCH web page, I will post just
how far our Indian Health delivery numbers are down, as just presented
at the August 2004 Biennial Indian Women's Health Meeting in
Albuquerque. njm

Intensive Management of Gestational Diabetes: Cochrane for Clinicians

Putting Evidence into Practice - Clinical Question

Does intensive management of gestational diabetes improve outcomes?

**Evidence-Based Answer**

There is not enough evidence to support dietary or drug treatment in
patients with gestational diabetes.

**Practice Pointers**

Gestational diabetes and impaired glucose tolerance are associated with
macrosomia and may be associated with increased risk for cesarean
delivery, shoulder dystocia, and birth trauma. Although preexisting
diabetes has been shown to increase the risk of poor perinatal outcomes,
it is not clear that data relating to preexisting diabetes can be
extrapolated to patients with gestational diabetes.

Overall, evidence is insufficient to support therapy for gestational
diabetes. However, universal screening is the standard of care in most
communities. When faced with abnormal results, most family physicians
will opt to follow the consensus opinion of our specialist colleagues.

<http://www.aafp.org/afp/20040701/cochrane.html>

[**Smokeless tobacco use during pregnancy linked to low birth weight,
prematurity**](http://mdconsult.chtah.com/a/hBA3EUBAPMgn1ARsVeZAPMu5kXl/curb179)

CONCLUSIONS: Consumption of smokeless tobacco during pregnancy decreases
gestational age at birth and birth weight independent of gestational
age. It should receive specific attention as a part of routine prenatal
care.

Gupta PC, Sreevidya S. Smokeless tobacco use, birth weight, and
gestational age: population based, prospective cohort study of 1217
women in Mumbai, India. BMJ. 2004 Jun 26;328(7455):1538\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15198947&dopt=Abstract>

**Preterm Birth as a Social Disease**

Spontaneous preterm birth is a common outcome of a broad combination of
medical and social factors. In fact, it may be said to be a social
disease: it happens much more frequently when the mother is poor, has a
low educational level, is isolated, single or too young\...National data
are unequivocal on this major point: preterm birth is closely related to
social class\...

<http://www.medscape.com/viewarticle/481732?src=search>

**Congenital Syphilis \-\-- United States, 2002**

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5331a4.htm>

**Dystocia and Augmentation of Labor: Practice Guidelines**

<http://www.aafp.org/afp/20040715/practice.html#c>

**[Gynecology]{.underline}**

[**Despite Guidelines, Pap Smears in Women Without a Cervix Very
Common**](http://mp.medscape.com/cgi-bin1/DM/y/hhjh0G875W0Dzc0F3Zm0AC)

CONCLUSIONS: Many US women are undergoing Pap smear screening even
though they are not at risk of cervical cancer. The US Preventive
Services Task Force recommendations either have not been heard or have
been ignored.

Sirovich BE, Welch HG. Cervical cancer screening among women without a
cervix. JAMA. 2004 Jun 23;291(24):2990-3.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15213211>

**Have you ever tried to learn any new technique? How many till you are
competent?**

[CONCLUSION:]{.underline} A learning experience of 30
laparoscopic-assisted vaginal hysterectomies was necessary in our
institution to reach a low level of complications. Duration of the
surgical procedure was not an adequate study endpoint to assess a
learning effect. LEVEL OF EVIDENCE: II-3 Altgassen C, Michels W,
Schneider A. Learning laparoscopic-assisted hysterectomy. Obstet
Gynecol. 2004 Aug;104(2):308-13.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15292004&dopt=Abstract>

**Clinical examination vs. dynamic magnetic resonance imaging in vaginal
vault prolapse**

[CONCLUSION]{.underline}: There is poor correlation between clinical and
MRI findings when assessing vaginal apex prolapse. Magnetic resonance
imaging allows the identification of other prolapsing compartments and
may be a complementary diagnostic tool for the diagnosis of complex
vaginal apex prolapse

Cortes E, Reid WM, Singh K, Berger L. Clinical examination and dynamic
magnetic resonance imaging in vaginal vault prolapse. Obstet Gynecol.
2004 Jan;103(1):41-6\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14704242>

**MRI Helpful for Deep Pelvic Endometriosis**

[CONCLUSION:]{.underline} MR imaging demonstrates high accuracy in
prediction of deep pelvic endometriosis in specific locations

Bazot M, et al Deep Pelvic Endometriosis: MR Imaging for Diagnosis and
Prediction of Extension of Disease. Radiology. 2004 Aug;232(2):379-89.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15205479>

**Asymptomatic women show pelvic floor nerve injury after uncomplicated
deliveries**\
[CONCLUSION]{.underline}: Quantitative EMG using multiple motor unit
action potential analysis can detect the presence after vaginal
childbirth of subtle nerve injury not demonstrable by pudendal nerve
terminal motor latency. Even asymptomatic women show evidence of pelvic
floor nerve injury after uncomplicated deliveries. LEVEL OF EVIDENCE:
II-2\
Gregory WT, Lou JS, Stuyvesant A, Clark AL. Quantitative
electromyography of the anal sphincter after uncomplicated vaginal
delivery**.** Obstet Gynecol. 2004 Aug;104(2):327-35\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15292007&dopt=Abstract>

**Uterine myomas: an overview of development, clinical features, and
management**

[CONCLUSION:]{.underline} The past century has witnessed development of
highly sophisticated diagnostic and therapeutic technology for myomas.
The tools currently at our disposal permit greater management
flexibility with safe options, which must be tailored to the individual
clinical situation.

Wallach EE, Vlahos NF. Uterine myomas: an overview of development,
clinical features, and management. Obstet Gynecol. 2004
Aug;104(2):393-406.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15292018&dopt=Abstract>

**Significance of a negative loop electrosurgical cone biopsy for
high-grade dysplasia**

[CONCLUSION:]{.underline} A negative LEEP is not an uncommon finding,
occurring in 14% (95% confidence interval 11-17%) of specimens at our
institution. Negative LEEPs are more likely to contain histologic
features that limit pathology interpretation. A negative LEEP is not a
reassuring finding and was associated with a recurrence rate similar to
those of a positive LEEP. Both negative and positive populations should
be carefully followed. LEVEL OF EVIDENCE: II-3

Livasy CA, Moore DT, Van Le L. The clinical significance of a negative
loop electrosurgical cone biopsy for high-grade dysplasia. Obstet
Gynecol. 2004 Aug;104(2):250-4.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15291995&dopt=Abstract>

**The Visit Before the Morning After**

CONCLUSION Findings suggest that even when attitudes towards EC are
generally favorable, some physicians and patients have substantial
reservations about advance prescription. Education and dialogue are
needed to overcome these reservations.

Karasz, Alison et al The Visit Before the Morning After: Barriers to
Preprescribing Emergency Contraception Annals of Family Medicine
2:345-350 (2004)

<http://www.annfammed.org/cgi/content/abstract/2/4/345>

**Treating Female Infertility and Improving IVF Pregnancy Rates: Manual
Physical Therapy**\
[Conclusions:]{.underline} The data trend across these studies suggests
that this innovative site-specific protocol of manual soft-tissue
therapy facilitates fertility in women with a wide array of
adhesion-related infertility and biomechanical reproductive organ
dysfunction. The therapy, designed to improve function by restoring
visceral, osseous, and soft-tissue mobility, is a nonsurgical,
noninvasive manual technique with no risks and few, if any, adverse side
effects or complications. As such, it should be considered a new adjunct
to existing medical infertility treatments.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15266276>

Increases in Fluoroquinolone-Resistant Neisseria Gonorrhoeae:
Implications for Women

Given the apparent low prevalence of QRNG among heterosexuals, a
national change in treatment in that group is [not recommended at this
time]{.underline}. However, QRNG prevalence among heterosexuals is
likely to increase over time and already might be high enough in some
areas to warrant new local treatment recommendations. For example,
increased prevalence of QRNG among heterosexuals has been identified in
several counties in Michigan, where recommendations have been made to
avoid using fluoroquinolones among all persons infected with gonorrhea.
Because gonococcal infections, especially in women, frequently are
asymptomatic, monitoring for symptomatic treatment failures alone does
not provide a reliable indication of emerging antimicrobial resistance.
If prevalence increases nationally among heterosexuals, guidance from
the CDC will be forthcoming. Local and state treatment recommendations,
technical information, surveillance data, references, and other links
related to gonococcal resistance are available at
<http://www.cdc.gov/std/gisp>.

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5316a1.htm>

**Genetic Testing for Breast and Ovarian Cancer Susceptibility: Consumer
Marketing, CDC**

The findings from the provider survey indicate that DTC advertisements
might have motivated women interested in learning more about BRCA1/2
testing to talk to their physicians and request testing. Findings from
the consumer survey suggest that women in the pilot cities were more
aware of BRCA1/2 testing than those in the comparison cities. No
evidence suggested an increased interest in the test among women most
suited for BRCA1/2 testing (i.e., those having a first-degree relative
with BOC). The demonstrated lack of provider knowledge underscores the
need for additional education; providers in certain specialties were
unprepared to address the complexities surrounding genetic testing for
susceptibility to BOC.

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5327a1.htm>

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

**Educate the educators, er...providers**

Education that focuses on improving the delivery of adolescent
preventive services needs to focus not only on increasing knowledge and
skill but also on increasing clinicians\' competence that they can
effectively use the skills

Ozer EM, et al Provider self-efficacy and the screening of adolescents
for risky health behaviors. J Adolesc Health. 2004 Aug;35(2):101-7.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15261638>

**Ano-genital warts in children: Sexual abuse or not?**

Child sexual abuse is a problem that affects many Americans. The
diagnosis of sexual abuse is typically made on the basis of the child\'s
history. Objective evidence of sexual abuse, including abnormal physical
findings noted on physical examination or the presence of a sexually
transmitted disease, are rare. Ano-genital warts are one of the most
common sexually transmitted diseases found in adults. However, is the
presence of ano-genital warts in children evidence of sexual abuse? The
link between ano-genital warts and child sexual abuse requires an
understanding of wart transmission and incubation period to properly
interpret their significance. Ano-genital warts in children have serious
medical, social, and legal implications. It is important that primary
care providers have an understanding of the appearance, mode of
transmission, and incubation period of human papilloma virus in
children. Implications for practice will provide guidelines for
diagnosing, evaluating, and properly managing ano-genital warts in
children.

Hornor G. Ano-genital warts in children: Sexual abuse or not? J Pediatr
Health Care. 2004 Jul-Aug;18(4):165-70.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15224040>

**Exposure of underage girls to alcohol advertising is substantial and
increasing**

[CONCLUSION:]{.underline} Exposure of underage girls to alcohol
advertising is substantial and increasing, pointing to the failure of
industry self-regulation and the need for further action.

Jernigan DH, et al Sex differences in adolescent exposure to alcohol
advertising in magazines. Arch Pediatr Adolesc Med. 2004
Jul;158(7):629-34.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15237061>

**What does SIDS really mean?**

The definition of sudden infant death syndrome (SIDS) originally
appeared in 1969 and was modified 2 decades later. During the following
15 years, an enormous amount of additional information has emerged,
justifying additional refinement of the definition of SIDS to
incorporate epidemiologic features, risk factors, pathologic features,
and ancillary test findings. An expert panel of pediatric and forensic
pathologists and pediatricians considered these issues and developed a
new general definition of SIDS for administrative and vital statistics
purposes.

Krous HF et al Sudden infant death syndrome and unclassified sudden
infant deaths: a definitional and diagnostic approach. Pediatrics. 2004
Jul;114(1):234-8.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15231934>

**Racial/Ethnic Disparities in Neonatal Mortality \-\-- United States,
1989\--2001**

Although greater declines in mortality were found among AI/ANs, the
number of infants in this population is small, and trends should be
interpreted with caution. Second, NMRs for AI/ANs might be
underestimated because of underreporting of very low birthweight infants
born on reservations (*10*). Third, gestational age reporting on birth
certificate data might be misclassified; however, exclusion of
implausible birthweight/gestational age combinations reduces the impact
of this limitation. Finally, NMRs during 1995\--2001 might vary from
reported U.S. vital statistics rates during 1995\--2001, which used
weighted data to adjust for unlinked infant deaths. To be consistent
with data during 1989\--1991, unweighted data were used for this trend
analysis.

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5329a2.htm>

**Violence-Related Behaviors Among High School Students \-\--
1991---2003, CDC**

<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5329a1.htm>

**Great Beginnings: Transform care in your hospital\'s newborn nursery**

The National Initiative for Children\'s Healthcare Quality, NICHQ, is
pleased to announce \"Great Beginnings,\" an Internet based improvement
collaborative, conducted in partnership with the Vermont Oxford Network,
designed to help multidisciplinary clinical teams transform the care
they provide to newborn infants and their families during the birth
hospitalization. In seven interactive action-oriented web conferences
guided by a faculty of national experts, organizations will receive
tools, training and materials fostering collaboration, measurement, and
improvement. Please join us! Who should join?

-   All hospitals providing maternal and newborn care

-   Obstetricians, nurse managers, neonatalogists, pediatricians, family
    practitioners, nurses

-   State hospital associations

-   Public health professionals

-   State programs with nursery oversight

Contents areas: Jaundice and hyperbilirubinemia, Breastfeeding, Group B
Strep disease screening and assessment, Sleep position, Screening for
domestic violence and maternal depression, Real-time quality
improvement, Family-centered care, Risk based discharge follow-up
planning, Newborn Metabolic screening, Sleep position/SIDS prevention.\
August 11, 12:00-1 PM ET or September 8, 12:00-1 PM ET\
From the US: (800) 860-2442 From Canada: (866) 519-5086\
Ask for the NICHQ Great Beginnings call with leader Chuck Mercier, MD.

Program and registration form go to:
[http://www.nichq.org/events/greatbeginnings](http://webmail.anthc.org/exchweb/bin/redir.asp?URL=http://www.nichq.org/events/greatbeginnings)\
For more information, [www.nichq.org](http://www.nichq.org/) or contact
Lisa Horvitz
[lhorvitz@nichq.org](mailto:lhorvitz@nichq.org?subject=Great Beginnings Question).

**Funding for prevention and treatment of childhood obesity in primary
care settings**

Research projects responsive to this solicitation would test
intervention programs delivered in primary care practices, including
dental practices, to improve dietary and physical activity behaviors of
pediatric patients in order to prevent excessive weight gain in children

at risk for obesity and/or to prevent further weight gain or to promote
weight loss in children who are already obese. APPLICATION RECEIPT
DATE:  November 23, 2004

RFA-HD-04-020
<http://grants1.nih.gov/grants/guide/rfa-files/RFA-HD-04-020.html>

**Vision and school health fact sheet**

A new fact sheet on Childhood Vision issues has been posted on the
Center for Health and Health Care in School\'s web site. This research
summary includes prevalence data, vision problem warning signs, a
comparison of vision exams and vision screenings, as well as
recommendations on how schools, parents and communities might respond.

<http://www.healthinschools.org/sh/visionfs.asp> 

**Gowning in Newborn and Special-Care Nurseries**

**Clinical Question**

Does gowning attendants and visitors in newborn and special-care
nurseries improve outcomes?

**Evidence-Based Answer**

There is no evidence that gowning in newborn nurseries and neonatal
intensive care units (NICUs) improves clinically important outcomes.

**Practice Pointers**

Gowns are an uncomfortable and not very fashionable fact of life at many
newborn nurseries. It is thought that they reduce transmission of
infection from clinicians to infants and limit the introduction of
infectious agents by visitors from outside the nursery. Webster and
Pritchard reviewed the literature and identified 12 relevant studies,
four of which were excluded because they were not randomized or used
historical controls (i.e., outcomes before and after a gowning
requirement was begun or stopped were compared).

<http://www.aafp.org/afp/20040701/cochrane.html>

**Screening and Behavioral Counseling Interventions in Primary Care to
Reduce Alcohol Misuse: U.S. Preventive Services Task Force**
<http://www.aafp.org/afp/20040715/us.html>

**Alert: Paxil and Wellbutrin warnings**

FDA and GlaxoSmithKline notified healthcare professionals of revisions
to the WARNINGS and PRECAUTIONS sections of Wellbutrin (bupropion
hydrochloride) labeling to alert healthcare professionals that patients
with major depressive disorder, both [adult and pediatric]{.underline},
may experience worsening of their depression and/or the emergence of
suicidal ideation and\
behavior (suicidality), whether or not they are taking antidepressant
medications. The warning recommends patients being treated with
antidepressants be observed closely for clinical worsening and
suicidality, especially at the beginning of a course of drug therapy, or
at the time of dose changes, either increases or decreases.

<http://www.fda.gov/medwatch/SAFETY/2004/safety04.htm#wellbutrin>

FDA and GlaxoSmithKline notified healthcare professionals of revisions
to the WARNINGS and PRECAUTIONS sections of Paxil (paroxetine
hydrochloride) labeling to alert healthcare professionals that patients
with major depressive disorder, both adult and pediatric, may experience
worsening of their depression and/or the emergence of suicidal ideation
and behavior\
(suicidality), whether or not they are taking antidepressant
medications. The warning recommends patients being treated with
antidepressants be observed closely for clinical worsening and
suicidality, especially at the beginning of a course of drug therapy, or
at the time of dose changes, either increases or decreases.

<http://www.fda.gov/medwatch/SAFETY/2004/safety04.htm#paxil>

**Materials on Child Maltreatment**

These books child abuse are for doctors, nurses, healthcare workers,
legal services, social services, educators, law enforcement, parents,
teachers, and those responsible for training mandated reporters,  you
now have the power to help defend the innocent in ways you never had
before: The power to properly identify and diagnose all types of
suspected child maltreatment cases. The power to ask the right questions
of the adolescent and caregivers. The power to uphold your
responsibilities as a mandated reporter. This process may give a voice
to those who may find it impossible to speak themselves.
<http://www.gwmedical.com/>

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

**Overview of the WISEWOMAN Projects: Health Promotion for Disadvantaged
Women**

**-Features Alaska's Tribal Southcentral Foundation among other
recipients**

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15257848>

The Supplement contains 15 scientific articles written by more than 50
CDC and collaborating scientists. The articles offer valuable insights
into the WISEWOMAN projects, health disparities issues, \"lessons
learned,\" and how-to guidance on programmatic issues such as cultural
adaptation of materials, cost-effectiveness evaluations, staff morale,
and partnering.

[CONCLUSIONS]{.underline}: The WISEWOMAN demonstration projects have
been successful at reaching financially disadvantaged and minority women
who are at high risk for chronic diseases. These projects face
challenges because they are generally implemented by safety net
providers who have limited resources and staff to conduct research and
evaluation. On the other hand, the findings from these projects will be
especially informative in reducing health disparities because they are
conducted in those settings where the most socially and medically
vulnerable women receive care.

Will JC, et al Health promotion interventions for disadvantaged women:
overview of the WISEWOMAN projects. J Womens Health (Larchmt). 2004
Jun;13(5):484-502.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15257842>

**Irritable Bowel Syndrome - An Evidence-Based Approach to Diagnosis**

Irritable bowel syndrome (IBS) represents one of the most common reasons
for primary care visits and consultation with a gastroenterologist. It
is characterized by abdominal discomfort, bloating and disturbed
defecation in the absence of any identifiable physical, radiologic or
laboratory abnormalities indicative of organic gastrointestinal disease.
IBS is a costly disorder, responsible for significant direct and
indirect costs to patients and society. Much of the cost attributed to
IBS arises from the time and resources used to establish the diagnosis.
Historically IBS has been viewed by many as a diagnosis of exclusion
rather than as a primary diagnosis, and many patients with typical
symptoms will undergo an extensive array of diagnostic tests and
procedures prior to the eventual diagnosis of IBS. Recent reviews
addressing the management of such patients have cast doubt on the
necessity for this degree of testing.

Current best evidence [does not support]{.underline} the routine use of
blood tests, stool studies, breath tests, abdominal imaging or lower
endoscopy in order to exclude organic gastrointestinal disease in
patients with typical IBS symptoms without alarm features. Serological
testing for celiac sprue in this population may eventually prove useful
but validation of studies indicating an increased prevalence of this
disease in patients with suspected IBS is needed.

The development and refinement of symptom-based criteria defining the
clinical syndrome of IBS has greatly facilitated the diagnosis of this
condition, which can be confidently diagnosed through the identification
of typical symptoms, normal physical examination and the exclusion of
alarm features.

The presence of alarm features or persistent non-response to
symptom-directed therapies should prompt a more detailed diagnostic
evaluation dictated by the patient\'s predominant symptoms.

Cash BD, Chey WD. Irritable bowel syndrome - an evidence-based approach
to diagnosis. Aliment Pharmacol Ther. 2004 Jun 15;19(12):1235-45.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15191504>

**Insulin for Type 2 Diabetes: Rescue, Augmentation, and Replacement of
Beta-Cells**

Type 2 diabetes is characterized by progressive beta-cell failure.
Indications for exogenous insulin therapy in patients with this
condition include acute illness or surgery, pregnancy, glucose toxicity,
contraindications to or failure to achieve goals with oral antidiabetic
medications, and a need for flexible therapy. Augmentation therapy with
basal insulin is useful if some beta-cell function remains. Replacement
therapy with basal-bolus insulin is required for beta-cell exhaustion.
Rescue therapy using replacement regimens for several weeks may reverse
glucose toxicity. Replacement insulin therapy should mimic normal
release patterns.

Am Fam Physician 2004;70:489-500,511-2. American Academy of Family
Physicians.
[**http://www.aafp.org/afp/20040801/489.html**](http://www.aafp.org/afp/20040801/489.html)

\*Also see Patient Education section for a posting on insulin therapy
below

**HIV Counseling, Testing, and Referral (also see Patient Education,
below)**

<http://www.aafp.org/afp/20040715/295.html>

##### Features

## American Family Physician\*\*

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

**Progesterone Intrauterine System for Menorrhagia**

**Clinical Question:** Which is preferred in the treatment of
menorrhagia: hysterectomy or the levonorgestrel-releasing intrauterine
system?

###### Bottom Line: Women with menorrhagia frequently require hysterectomy for symptom relief and health satisfaction. Placement of the levonorgestrel-releasing intrauterine system results in similar outcomes for many women and is more cost-effective as an initial treatment. (Level of Evidence: 1b-) [**http://www.aafp.org/afp/20040715/tips/16.htm**](http://www.aafp.org/afp/20040715/tips/16.htm)

PAPNET vs. Manual Reading of Pap Smears

**Clinical Question:** Are PAPNET readings of conventional Papanicolaou
(Pap) tests better than manual readings by cytologists?

**Bottom Line:** PAPNET is as accurate as manual readings by cytologists
for abnormal diagnoses. The choice of using PAPNET or a manual reading
by a cytologist should be based on cost. (Level of Evidence: 1b)

<http://www.aafp.org/afp/20040715/tips/17.html>

**Useful Signs and Symptoms in the Evaluation of Vaginitis**

**Clinical Question:** How useful are the history, physical examination,
and routine office-based laboratory studies in the diagnosis of
vaginitis?

**Bottom Line:** In the diagnosis of vaginitis, useful symptoms include
information about odor and itching. Useful signs include odor and the
presence of inflammatory changes. Office microscopy is the most accurate
laboratory test. (Level of Evidence: 3a)

<http://www.aafp.org/afp/20040701/tips/15.html>

**Effect of Fetal Fibronectin on Preterm Labor**

**Clinical Question:** Does the use of fetal fibronectin in the
management of preterm labor affect age at delivery or rate of
interventions?

**Bottom Line:** Use of fetal fibronectin in the assessment of women
presenting to labor and delivery units with symptoms of preterm labor
does not affect the gestational age at delivery, frequency of use of
medical interventions, length of time in labor and delivery, or rate of
inpatient admissions. (Level of Evidence: 1b)

<http://www.aafp.org/afp/20040715/tips/13.html>

Three Days of Ciprofloxacin for UTI in Older Women

**Clinical Question:** Is three days of ciprofloxacin therapy as
effective as seven to 10 days of the same drug in older women with
urinary tract infection (UTI)?

**Bottom Line:** This reasonably large study found that treatment with
three days of ciprofloxacin twice daily is as effective and better
tolerated than seven days of treatment in healthy older women with UTI.
Although a much larger study might find a small difference in outcomes,
it is unlikely to be clinically meaningful; this study was powered to
detect a modest 10 percent difference in outcomes. (Level of Evidence:
1b)

<http://www.aafp.org/afp/20040715/tips/15.html>

Tai Chi May Improve Symptoms of Osteoarthritis

**Clinical Question:** Can a specifically designed tai chi exercise
program improve symptoms and physical function in women with
osteoarthritis?

**Bottom Line:** A specifically designed tai chi program for older women
with osteoarthritis decreases pain and joint stiffness, and improves
physical function, balance, and abdominal muscle strength in women who
continue the exercises. The results may be a bit inflated because the
researchers evaluating the outcomes may have known which patients had
received treatment. (Level of Evidence: 1c)
<http://www.aafp.org/afp/20040801/tips/13.html>

**Exemestane vs. Tamoxifen After Breast Cancer**

**Clinical Question:** Does exemestane therapy improve outcomes in
patients who have breast cancer when begun two to three years after
diagnosis?

Setting: Outpatient (specialty)

Study Design: Randomized controlled trial (double-blinded)

**Bottom Line**: Exemestane improves outcomes for postmenopausal women
with estrogen-receptor-positive breast cancer when given for two to
three years after a two- to three-year course of treatment with
tamoxifen. (Level of Evidence: 1b)

<http://www.aafp.org/afp/20040715/tips/14.html>

###### No Link Between Breast Cancer and Abortion

**Clinical Question:** Is there a link between abortion, induced or
spontaneous, and breast cancer?

**Bottom Line:** No association exists between induced or spontaneous
abortions and the development of breast cancer. (Level of Evidence: 1a)

<http://www.aafp.org/afp/20040801/tips/12.html>

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

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

Antihistamines for the Common Cold? Cochrane Briefs

Clinical Question

How effective are antihistamines for treatment of the common cold?

Evidence-Based Answer

Antihistamines are of minimal to no benefit as monotherapy for the
common cold, and first-generation antihistamines may increase sedation
in patients with a cold. Antihistamine-decongestant combinations reduce
nasal symptoms and improve the recovery rate in older children and
adults, but these combinations are not effective in younger children.

Practice Pointers

Although antihistamines are widely used in the treatment of the common
cold, particularly as part of decongestant-antihistamine combinations,
there is little evidence of benefit. De Sutter and colleagues reviewed
22 randomized, controlled trials (RCTs) of antihistamines as monotherapy
and 13 RCTs of antihistamines combined with another medication, usually
a decongestant. Most studies excluded patients with allergic rhinitis.

There was some evidence of a small beneficial effect of first-generation
antihistamines as monotherapy for rhinorrhea and sneezing and a small
short-term benefit in terms of overall recovery (number needed to treat,
14). However, more patients taking a first-generation antihistamine
experienced sedation (7.9 versus 4.4 percent; absolute risk increase,
3.5 percent; number needed to harm, 29). No studies found a benefit for
second-generation, nonsedating antihistamines.

Antihistamine-decongestant combinations were not effective in younger
children but did improve general recovery and nasal symptoms in older
children and adults. However, the latter studies did not report the
magnitude of benefit, so it was difficult to tell if the benefit was
clinically and not just statistically significant. Of course, the
benefit may have been largely due to the decongestant alone. De Sutter
AI, et al. Antihistamines for the common cold. Cochrane Database Syst
Rev 2003;3:CD001267
<http://www.update-software.com/cochrane/abstract.htm>

**Diagnosis and Management of Galactorrhea\***

<http://www.aafp.org/afp/20040801/543.html>

\*Also see Patient Education section for a posting on galactorrhea below

##### ACOG

**Nonmedical Use of Obstetric Ultrasonography**

ACOG Committee Opinion Number 297, August 2004

ABSTRACT: The American College of Obstetricians and Gynecologists (ACOG)
has endorsed the \"Prudent Use\" statement from the American Institute
of Ultrasound in Medicine (AIUM) discouraging the use of obstetric
ultrasonography for nonmedical purposes (eg, solely to create keepsake
photographs or videos). The ACOG Committee on Ethics provides reasons in
addition to those offered by AIUM for discouraging this practice.

ACOG members
<http://www.acog.org/publications/committee_opinions/co297.cfm>

**Prenatal and Preconceptional Carrier Screening for Genetic Diseases in
Individuals of Eastern European Jewish Descent**

ACOG Committee Opinion Number 298, August 2004

ABSTRACT: Certain autosomal recessive disease conditions are more
prevalent in individuals of Eastern European Jewish (Ashkenazi) descent.
Previously, the American College of Obstetricians and Gynecologists
recommended that individuals of Eastern European Jewish ancestry be
offered carrier screening for Tay--Sachs disease, Canavan disease, and
cystic fibrosis as part of routine obstetric care. Based on the criteria
used to justify offering carrier screening for Tay--Sachs disease,
Canavan disease, and cystic fibrosis, the American College of
Obstetricians and Gynecologists\' Committee on Genetics recommends that
couples of Ashkenazi Jewish ancestry also should be offered carrier
screening for familial dysautonomia. Individuals of Ashkenazi Jewish
descent may inquire about the availability of carrier screening for
other disorders. Carrier screening is available for mucolipidosis IV,
Niemann-Pick disease type A, Fanconi anemia group C, Bloom syndrome, and
Gaucher\'s disease.

ACOG members
<http://www.acog.org/publications/committee_opinions/co298.cfm>

##### AHRQ

**Bowel Prep -- AHRQ Web M + M\
**[Prior to colonoscopy, a woman is found unresponsive after completing
her bowel prep regimen.](http://www.webmm.ahrq.gov/cases.aspx?ic=67)

[http://www.webmm.ahrq.gov](http://www.webmm.ahrq.gov/)

**Sigmoidoscopy may be less effective for detecting colorectal cancer in
women and elders**

[http://www.ahrq.gov/research/jun04/0604RA11.htm#head1](http://webmail.anthc.org/exchweb/bin/redir.asp?URL=http://www.ahrq.gov/research/jun04/0604RA11.htm%23head1)

 

**Review illuminates women\'s childbirth preferences following a
previous cesarean delivery**

[http://www.ahrq.gov/research/jun04/0604RA12.htm#head2](http://webmail.anthc.org/exchweb/bin/redir.asp?URL=http://www.ahrq.gov/research/jun04/0604RA12.htm%23head2)

 

**Findings suggest invasive prenatal diagnostic testing should be
offered to all women**

[http://www.ahrq.gov/research/jun04/0604RA13.htm#head3](http://webmail.anthc.org/exchweb/bin/redir.asp?URL=http://www.ahrq.gov/research/jun04/0604RA13.htm%23head3)

**USPSTF Recommends Against Routine Screening for Ovarian Cancer**

Rating: [D
Recommendation](http://www.ahrq.gov/clinic/3rduspstf/ratings.htm#drec).

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

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

##### Breastfeeding

**Tom Hale\'s response to FDA warning of domperidone (see FDA Warning
above)**\
The Food and Drug Administration called yesterday to inform me of their
decision to issue a warning on the use of domperidone in breastfeeding
mothers. They stated that they became concerned after the publication of
several case reports of domperidone toxicity following high dose
\"intravenous\" domperidone in some patients.  Unfortunately, the
correlation of intravenous administration with oral administration of
domperidone is simply ludicrous.  Domperidone is only 13-17%
bioavailable orally. Peak plasma levels in recipients following 20 mg
orally are only 15-18 ng/ml.  Peak plasma levels following a 10 mg
intravenous dose is reported to be 1200 ng/ml, almost 80-150 fold more
than oral administration.  I don\'t really see how high doses
intravenously even correlate with the use of low to moderate doses
orally in breastfeeding mothers...\
...This warning from the FDA has nothing to do with its safety, its all
about the importation of drugs from Canada and control by this federal
agency. They simply want to stop the importation of all drugs,
particularly those used by the elderly, and now the breastfeeding
mother.\
The reality is that I still believe domperidone is the safest product we
can use for stimulating milk production in some women. It is still true
that in many mothers it offers the only hope for maintaining a milk
supply for their infants and preventing the untoward effects of
formula.\
When I asked them if they had consulted with anyone in the field of
human lactation about the consequences of this action, they had not.
When I asked them what breastfeeding mothers were to do, they answered
contact their physician for options, or switch to formula. I do not
propose to advise you as to what you should do, but as for me, I simply
choose to ignore them, and their advice. Contact for questions Rose Knox
<RDKnox@ANMC.ORG>

**Counseling for Breastfeeding: Case Study**

**Putting Prevention into Practice**: **An Evidence-Based Approach**

BS, a 26-year-old woman in her second trimester of pregnancy, comes to
your office for routine prenatal care. She expresses concern because one
of her relatives has told her that she should not breastfeed. You want
to recommend breastfeeding and wonder how to counsel her.

**Case Study Questions** <http://www.aafp.org/afp/20040701/putting.html>

**Seeking to support breastfeeding (breastpump procurement) at your area
or service unit?**

From Liz Flight at National Naval medical center a Grant Proposal:

You could cut and paste from the Executive Summary - if you are seeking
to support breastfeeding (breastpump procurement) at your area or
service unit.   Pass this on or discuss with your MCH groups.  Good for
either contract or grant. If you have other questions could email Judith
Thierry, (HQE) <Judith.Thierry@ihs.gov> or directly to Liz Flight at
NNMC <EIFlight@Bethesda.med.navy.mil> 

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

Funding available: OJJDP Program Announcement for the Safe Start
Program.\
The Office of Juvenile Justice and Delinquency Prevention (OJJDP) has
issued a Program Announcement for the Safe Start: Promising Approaches
for Children Exposed to Violence Program.\
OJJDP will select up to 14 applicants to receive up to \$210,000 in
funding through cooperative agreements for up to a 4-year period to
implement the most promising approaches, based on current research, for
reducing the impacts of children\'s exposure to violence. These funds\
must be allocated proportionally to provide up to \$200,000 for
intervention activities related to practice and policy strategies and up
to \$10,000 for data collection activities.\
Interested applicants may download the Program Announcement online via
OJJDP\'s Web site at
[**http://ojjdp.ncjrs.org/funding/FundingDetail.asp?fi=16**](http://webmail.anthc.org/exchweb/bin/redir.asp?URL=http://ojjdp.ncjrs.org/funding/FundingDetail.asp?fi=16).
For additional information, call OJJDP, 202-307-1341. Applications must
be received by 8:00 p.m. ET on September 10, 2004.

**See also Primary Care Discussion Forum of Domestic Violence, below**

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

**Women with Heart Disease**

SCIENCE AND LEADERSHIP SYMPOSIUM: MAYO CLINIC, OCTOBER 9-13, 2004\
WHAT? A four-day science and leadership training course for women heart
patients who want to:

-   Learn the basic science and language of heart disease

-   Know which diagnostic tests and treatments work best for women

-   Learn new ways to heal mind and body

-   Educate other women and community groups about heart disease risks
    in women

-   Give effective interviews to the media

-   Work to improve how women with heart disease are treated within the
    healthcare system

-   Serve as an official WomenHeart spokeswoman

This comprehensive course will contain lectures, interactive
presentations and breakout sessions, along with opportunities to meet
with faculty and fellow patients. Presenters include Mayo Clinic
cardiology staff and invited health educators, women\'s health
advocates, and professional media trainers.\
WHERE? Mayo Clinic in Rochester, MN

**[Several travel scholarships are available for women with low incomes
who cannot afford travel expenses.]{.underline}** Contact Barbara Fine
<Barbara.Fine@ihs.gov>

**Omega-3 Fatty Acids**

Omega-3 fatty acids have been shown to significantly reduce the risk for
sudden death caused by cardiac arrhythmias and all-cause mortality in
patients with known coronary heart disease. Fatty fish, such as salmon
and tuna, and fish oil are rich sources of the omega-3 fatty acids
eicosapentaenoic acid and docosahexaenoic acid. Flaxseed, canola oil,
and walnuts also are good dietary sources of omega-3 fatty acids. In
addition to being antiarrhythmic, the omega-3 fatty acids are
antithrombotic and anti-inflammatory. Am Fam Physician 2004;70:133-40.
<http://www.aafp.org/afp/20040701/133.html>

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

**Where can I get some funds for a project?**

Try the Community Health Leadership Program (CHLP): The Robert Wood
Johnson Foundation provides an award to ten outstanding individuals who
overcome daunting odds to expand access to health care and social
services to underserved and isolated populations in communities across
the United States. Awards are \$120,000 each.

Deadline(s): 09/22/2004 e-mail: <website@communityhealthleaders.org>

Or contact:
[http://www.communityhealthleaders.org/index1.cfm](http://webmail.anthc.org/exchweb/bin/redir.asp?URL=http://www.communityhealthleaders.org/index1.cfm)

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

**NAMS Releases Position Statement on the Treatment of Vasomotor
Symptoms Associated with Menopause: Practice Guidelines**

<http://www.aafp.org/afp/20040715/practice.html#a>

**The Menopause Moment**

An email newsletter
[www.TheMenopauseExpert.com](http://webmail.anthc.org/exchweb/bin/redir.asp?URL=http://www.themenopauseexpert.com/)

Entry forwarded by Yolanda Meza, CNM, Anchorage.

# [Information Technology]{.underline}

HEALTHeFORCES™   Walter Reed: Women\'s health, prevention, etc

This is a great resource that DoD has shared with us njm

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

[For a demo:]{.underline}

\*HEALTHeFORCES™  Instructions

-   Go to demo, Log in as default

-   Go to My patients (in left margin, first box), Select a patient

-   Go to HEALTHeCARDS (in left margin HEALTHeFORCES box)

-   You will find a list HEALTHeCARDs and HEALTHeCARD Most Recent Date
    Entered, e.g., Breast Cancer Unknown, CHF Unknown , COPD Unknown,
    CVRR Unknown, Childhood Asthma Unknown, Diabetes Unknown, Pharmacy
    Unknown, Stroke Unknown, Wellness Unknown, or Women\'s Health
    Unknown

-   If you touch the Question marks, they will open up specific a short
    paragraph of best practice advice for that variable

-   Click on any one of the cards and you will get multiple guidelines,
    eductional pieces etc

**National Release - Referred Care Information System, Version 3.0**

ITSC is pleased to announce the release of the latest version of the
referred care information system. Please ask your site manager for
further information about this updated software application. The
referral status will now display on the health summary if you are using
RCIS

Contact for questions. Theresa Cullen <Theresa.Cullen@IHS.GOV>

**New web site address the health concerns of American Indians and
Alaska Natives**

American Indian Health, a new National Library of Medicine Web site,
presents information on issues affecting the health and well-being of
American Indians and Alaska Natives. The Web site is designed to bring
together health and medical resources, including policies, consumer
health information, and research. Information on traditional healing
resources and links to an assortment of documents, Web sites, databases,
and other resources is also provided. The Web site is available at
[[http://americanindianhealth.nlm.nih.gov]{.underline}](http://americanindianhealth.nlm.nih.gov/).

# [International Health Update]{.underline}

[**Health Canada\'s First Nations and Inuit Health
Branch**](http://www.hc-sc.gc.ca/fnihb/)

The [Health Canada\'s First Nations and Inuit Health
Branch](http://www.hc-sc.gc.ca/fnihb/) is interested in partnering with
US Indian Health and Tribal groups to improve the care of Native
peoples.. For more information, go here: <http://www.hc-sc.gc.ca/fnihb/>
Below are some of the programs they are highlighting

[FAS Program details, Community Projects, funding, and
publications](http://www.hc-sc.gc.ca/fnihb/cp/fas_fae/index.htm)

<http://www.hc-sc.gc.ca/fnihb/cp/fas_fae/index.htm>

[National Aboriginal Health Organization](http://www.naho.ca/)

<http://www.naho.ca/english/>

[Aboriginal Healing Foundation: Residential Schools and issues of
abuse](http://www.ahf.ca/)

<http://www.ahf.ca/>

[Aboriginal Peoples Television Network](http://www.aptn.ca/)

<http://www.aptn.ca/>

**DHHS Afghan Family Health Book Launch Invitation**

The U.S. Department of Health and Human Services (HHS) is committed to
assisting the Government of Afghanistan in ensuring the health and well
being of the Afghan people. As part of this commitment, HHS has worked
with Leapfrog Enterprises Inc., a leading developer, designer and
manufacturer of technology-based educational products, to create a
unique health education\
program for use in Afghan health clinics and communities throughout the
country. The first product is the Afghan Family Health Book dealing with
women and children\'s health issues.

A team of HHS multidisciplinary health care professionals developed the
content of the book, which is culturally and linguistically appropriate
and has been field tested in Afghanistan. Focusing on health promotion
and disease prevention, the book contains useful and practical
information for the people of Afghanistan. The Afghan Family Health Book
expands personal\
knowledge about the ability to practice healthy behaviors to ensure
wellness and reduce risk of disease. HHS plans to distribute the books
across Afghanistan via hospitals, clinics, women\'s health centers, and
individual homes beginning in mid-August.  To receive further
information, call Maria-Stella Gatzoulis at 202-691-4188 or send an
email to Jillian Frumkin at <mep@wwic.si.edu> FOR MORE INFORMATION ABOUT
THE WEBCAST\...CLICK HERE:\
[http://wwics.si.edu/index.cfm?fuseaction=events.event&event_id=87159](http://webmail.anthc.org/exchweb/bin/redir.asp?URL=http://wwics.si.edu/index.cfm?fuseaction=events.event%26event_id=87159) 

**Polio experts warn of largest epidemic in recent years, as polio hits
Darfur - WHO**

Epidemiologists \'alarmed\' by continuing spread of virus - warn
thousands of children could be paralyzed across west and central Africa.
Epidemiologists of the Global Polio Eradication Initiative today issued
a stark warning that west and central Africa is on the brink of the
largest polio epidemic in recent years. The warning follows confirmation
today that a child was paralyzed on 20 May 2004 by polio in the Darfur
region of the Sudan, a country which had not seen the disease in more
than 3 years.

[[http://www.who.int/mediacentre/releases/2004/pr45/en/]{.underline}](http://www.who.int/mediacentre/releases/2004/pr45/en/)

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

**Depression among female adolescents, may be higher than previous
estimates**

As... depressive symptoms are likely to coexist with other adolescent
problem behaviors, such as bullying and substance use, young adolescents
who are involved in such behaviors might be depressed as well,\" state
the authors. They suggest that \"practitioners who work with youths who
have such symptoms/behaviors should consider screening them for
depression.....

Saluja G, et al Prevalence of and risk factors for depressive symptoms
among young adolescents. Arch Pediatr Adolesc Med. 2004
Aug;158(8):760-5.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15289248>

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

######### Female Interstitial Cystitis: Chronic Pelvic Pain, Diagnosis and Misdiagnosis: CME

######### <http://www.medscape.com/viewarticle/474706_1>

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

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

######### 

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

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

**Clinical Discussion Board Index, Medscape**

Hundreds of ongoing clinical discussions available

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

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

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

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

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

**Healthy Women: State Trends in Health and Mortality**

Five tables using birth certificate data were recently updated and
released in the Healthy Women Project data warehouse. These tables
include: birthweight, preterm birth, cesarean deliveries, prenatal care,
and smoking during pregnancy.

<http://www.cdc.gov/nchs/healthywomen.htm>

**[Osteoporosis]{.underline}**

**Longer-Term Data Confirm Raloxifene Reduces the Risk of Breast Cancer
in Older Women**

This SERM, Raloxifene, also has an effect on osteoporosis related
fractures.

<http://www.cancer.gov/clinicaltrials/results/raloxifene0604>

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

**Your Insulin Therapy**

<http://www.aafp.org/afp/20040801/511ph.html>

**HIV Infection-How to Lower Your Risk**

<http://www.aafp.org/afp/20040715/307ph.html>

**Galactorrhea: What You Should Know About It?**

<http://www.aafp.org/afp/20040801/553ph.html>

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

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

Moderator: Terry Cullen

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

NB: To subscribe to the **Primary Care Discussion Forum**, please go the
site below and click the word 'subscribe' in the first paragraph,
[[www.ihs.gov/MedicalPrograms/MCH/M/MCHdiscuss.asp]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdiscuss.asp)

or contact me, <nmurphy@anmc.org>

**[Barbara Stillwater, Alaska Diabetes Prevention and
Control]{.underline}**

##### Exploratory Grant Program in Diabetes Endocrinology and Metabolism Release

##### The Division of Diabetes, Endocrinology, and Metabolic Disease of the National Institute of Diabetes and Digestive and Kidney Diseases invites applications for the exploratory/developmental (R21) grant mechanism in selected areas of opportunity within our mission. The intent of this initiative is to encourage researchers to apply novel technologies, develop new tools, biomarkers and model systems, and test innovative concepts of potential diagnostic and therapeutic relevance to diseases within our mission including diabetes and its complications, obesity, endocrine disorders including osteoporosis, cystic fibrosis and inborn errors of metabolism. The R21 mechanism is intended to encourage exploratory research projects by providing support at the conceptual stages of these projects. This initiative represents a reissue of the original PA-02-008 [**http://grants.NIH.gov/grants/guide/pa-files/PA-02-008.html**](http://grants.NIH.gov/grants/guide/pa-files/PA-02-008.html)

#####  

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

[**Gynecologic Cancer Awareness Month September 2004 (Scroll to the
'General'
section)**](http://www.ihs.gov/MedicalPrograms/MCH/W/WHcancer.asp)

<http://www.ihs.gov/MedicalPrograms/MCH/W/WHcancer.asp>

There are several upcoming **Conferences**

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

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

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

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

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

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

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

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

**Indian Health Service Health Summit**

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

September 22-24, 2004

Washington, D.C.

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

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

**20th Annual Midwinter Conference**

-   For providers caring for Native women and children

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

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

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

**\
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>

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

The **July 2004 OB/GYN CCC Corner** is available at:\
<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/4C7104.doc>

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

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

Lidocaine Plus Naproxen for Endometrial Sampling Pain: POEM

[From your colleagues:]{.underline} page 3

From George Gilson: 80% of patients with gestational diabetes can be
treated effectively with glyburide.

**From Anne Girling**: Stomach upset instead of crushing substernal
chest pain: Women's cardiovascular Sx

**From Steve Holve:** IHS Child Health Notes -- June, July

**From Jennifer Retsinas:** Do you use e-mail with your patients? If so,
you may want a few style points for caution

**From Ros Singleton:** 17th Annual IHS Research Conference April 29-May
1, 2005

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

**Obstetrics:** **page 4**

Aberdeen Area Infant Mortality Study (AAIMS) now available on the MCH
web page; Can mandatory second opinions lower cesarean section rates?
Metformin, Diet/Exercise Comparable at Cutting Diabetes Risk in Women
With GDM; Hypoglycemic events are common during treatment in gestational
diabetic pregnancies; AFI may cause more interventions by labeling twice
as many at-risk pregnancies as having oligohydramnios than with the
single deepest pocket technique; Racial/Ethnic Trends in Fetal Mortality
\-\-- United States, 1990---2000, CDC; Acyclovir Can Reduce Genital
Herpes Recurrence at Delivery; Vertical Incisions for Cesarean Delivery
in Obese Patients; Diminishing Racial Disparities in Neonatal Group B
Streptococcal Disease, 2003, CDC

**Gynecology**: **page 7**

Polycystic Ovary Syndrome More Prevalent in US Than Had Been Thought

**Child Health: page 8**

Emergency Contraception to Adolescents; Motivational Counseling improves
dental caries in children; Cigarette Use Among High School Students
\-\-- United States, 1991---2003, CDC

**Chronic Illness and Disease**: **page 8**

Continue Breast Cancer Screening After Age 65? Liposuction: Removing 20%
of total body fat with liposuction does not improve the metabolic
abnormalities seen in obese women with and without impaired glucose
tolerance; Eliminating H. pylori doesn\'t reduce heartburn or reflux
symptoms; DVT and Pulmonary Embolism: Part I. Diagnosis; DVT and
Pulmonary Embolism: Part II. Treatment and Prevention;
Spondyloarthropathies; Metabolic Syndrome: Time for Action

[Features:]{.underline} page 9

**AFP: POEMS -** see #1 Abstract of the Month, #2 Osteoporosis**;**
Screening for Coronary Heart Disease: Recommendation Statement U.S.
PREVENTIVE SERVICES TASK FORCE

ACOG: Vaginal Birth After Previous Cesarean Delivery First-Trimester
Screening for Fetal Aneuploidy; Pain Relief During Labor

**AHRQ:** Less than half of older women who have suffered fractures due
to osteoporosis are treated properly to prevent further fractures;
Jaundice and feeding problems are not associated with short hospital
stay, as long as newborns are evaluated at 3 or 4 days of life; Studies
examine hospital mortality rates and long-term outcomes of very low
birth weight babies; Preventive Services Task Force issues 3 new
recommendations

**Breastfeeding:** The National Breastfeeding Campaign \-- Babies Were
Born to Be

**Domestic Violence:** New York City is largest American Indian Village:
Physical, sexual trauma, and HIV risk; Therapeutic Foster Care for the
Prevention of Violence

**Elder Care News:** Ten years\' experience with alendronate for
osteoporosis in postmenopausal women** **

**Frequently asked questions:** HIV - What are the latest screening and
treatment guidelines from the CDC ?

**Hormone Replacement Update**: Reducing Cardiovascular Risk Factors in
Postmenopausal Women through a Lifestyle Change Intervention

**Information Technology:** Behavioral health applications available:
All IHS-direct, tribal, and urban (I/T/U)

**International Health:** Adolescent related behaviors across five
countries

#### MCH Alert: Parents to help their daughters develop bone healthy habits

#### Medscape: Female Interstitial Cystitis: Chronic Pelvic Pain, Diagnosis and Misdiagnosis: CME

#### Office of Women's Health, CDC: Disparities in Maternal Health-Related Behaviors

Osteoporosis: Calcium Supplementation in Postmenopausal Women: Cochrane
Abstract; Strontium Reduces Risk of Vertebral Fracture: POEM

Patient Education: Metabolic Syndrome: What Is It and What Can I Do
About It?

Primary Care Discussion Forum: August 1, 2004 - **Adult Asthma;**
November 1, 2004: Violence against Native women

#### Barbara Stillwater, Alaska Diabetes Prevention and Control: Administration of Insulin Lispro Effective Alternative

#### What's new on the ITU MCH web pages: page 17

#### Mammography Screening Among Low-Income Women

The past CCC Corners are archived at:

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

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

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

or 907 729 3154 (with voicemail)

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

8/21/04