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OB/GYN Chief Clinical Consultant's Corner

Volume 5, No. 10, November 2007

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

#### Abstract of the Month page 6 {#abstract-of-the-month-page-6 .Style-Heading-4-+-Arial-14-pt-Underline}

**Hospital brought rapid cesarean delivery times into range of 10.9
minutes: Can you?**

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

Kelly Acton

The the exciting launch of the NIKE Air Native N7 Shoes

Michael Berryhill

OB/GYN offering services at greatly reduced salary

Scott Giberson

USCA to Honor Native AI/AN at Opening Plenary and "Celebration of Life"
Event

**Amy Groom**

Let's clear up any confusion over the availability of the HPV vaccine

**Elaine Locke**

State Maternal Mortality Review: Accomplishments of Nine States: Now
Available

**Alan Waxman**

Mark your calendar! Ask for leave! Thnk snow! Telluride Conference -
February 8-10, 2008

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

##### Obstetrics page 10

-SBE prophylaxis not recommended for cesarean delivery or other
genitourinary tract procedures

-A preventive approach to lower the cesarean delivery rate in a rural
hospital

-1 of every 6 women studied had filled a class D or X prescription

-Risk of uterine rupture with a prior cesarean delivery much lower than
expected: 0.3%

-Women who quit smoking before pregnancy benefit from reduced risk of
abruption

....and more

**Gynecology page 13**

-2006 ASCCP consensus guidelines for abnormal cervical cancer screening,
CIN, AIS

-Effectiveness of two tinidazole regimens in treatment of bacterial
vaginosis: RCT

-Minimally invasive strategy for large cysts: Laparoscopically guided
minilaparotomy

-Tailored mesh significantly reduced the rate of recurrence of anterior
vaginal wall prolapse

-Botulinum toxin injections for adults with overactive bladder syndrome

....and more

**Child Health page 17**

-Traumatic events and alcohol use disorders among American Indian
adolescents

-Viracept Use Should Be Limited in Children and Pregnant Women

-Statement Updated for Screening and Treatment of Teens at Risk for
Suicide 

-Medication errors made during half of care for children seen at
emergency departments

# -Maternal Weight Tied to Child\'s Body Composition at Age 9

**Chronic Illness and Disease page 18**

-Aging and prevalence of CVD risk factors in American Indians: the
Strong Heart Study

-Both coping and communication-enhancing and supportive counseling work
after cancer

-Opioid Analgesia During Evaluation of Acute Abdominal Pain

#### -Does Screening Mammography Benefit Women in Their 40s? {#does-screening-mammography-benefit-women-in-their-40s .Style-Heading-4-+-Arial-14-pt-Underline}

-CDC Updates Guidelines for Use of Influenza Vaccine and Antiviral
Agents

....and more

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

American College of Obstetricians and Gynecologists page 21

-Viral Hepatitis in Pregnancy

-Disclosure and Discussion of Adverse Events

-Routine Thyroid Screening Not Recommended for Pregnant Women

-Fetal Monitoring Prior to Scheduled Cesarean Delivery

-Evaluation of Stillbirths and Neonatal Deaths

##### American Family Physician

-Repeat Cesarean Delivery vs. Planned Induction of Labor: Cochrane
Briefs

-Hyperthyroidism

-Bell\'s Palsy: Diagnosis and Management

-Peptic Ulcer Disease

-Respiratory Distress in the Newborn

**Agency for Healthcare Research and Quality**

-Childbirth preferences after prior cesarean delivery: Information
affects future choices

-Colorectal cancer screening is not just for symptoms: Primary care
providers should clarify

-Three characteristics double risk of hysterectomy for women with common
pelvic conditions

-Three-fourths of low-income women dissatisfied with their body size 6
months after giving birth

-Women receive worse care than men for cardiovascular disease and
diabetes

**Ask a Librarian**

In Search of a Research Article?

**Breastfeeding**

-Breastfeeding Promotion: Good Public Health Policy

-Early skin-to-skin contact for mothers and their newborn infants
improves outcomes

-Breast milk: Greater mental development and fewer re-hospitalizations

**CCC Corner Digest**

\-[Group Prenatal Care Improves Pregnancy Outcomes at No Additional
Cost](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_AOM.cfm)

\-[Rebuilding Iraq one patient at a time: You can be part of the
solution](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Coll.cfm)

\-[Do Unsutured Second-Degree Perineal Lacerations Affect Postpartum
Outcomes?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_HT.cfm#ob)

\-[Cervical cancer differences disappear in rural women after
controlling for poverty and
race](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_HT.cfm#gyn)

\-[How to improve psychosocial problems at well child care
visits?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_HT.cfm#child)

\-[Why Hasn\'t This Patient Been Screened for Colon
Cancer?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_HT.cfm#chrIll)

\-[Management of Delivery of a Newborn With Meconium-Stained Amniotic
Fluid](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#acog)

\-[In Search of a Research
Article?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#AskLib)

\-[A pacifier by any other
name....](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#breast)

\-[October is Domestic Violence Awareness
Month](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#dv):
Materials available

\-[Advance Provision for Emergency Oral Contraception Reduces Post
Coital
Interval](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#fp)

\-[What\'s the first course of action for this couple that\'s trying to
conceive?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#faq)

\-[Bar code medication administration changes nurses\'
work](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#it)

\-[Prevention of Mother-to-Child HIV Transmission: An Innovative Program
in
Cameroon](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#ih)

\-[AI / AN researchers on perinatal depression requesting names of
interested
individuals](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#headlines)

\-[Endometriosis: Where is the real
truth?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#mmtour)

\-[Estrogen Protects Women's Brains Prior to
Menopause](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#menopause)

\-[Piercing the veil: the marginalization of midwives in the United
States](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#MidWives)

\-[Evaluation of the pregnant patient for non-obstetric
surgery](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0907_Feat.cfm#navajo)

\-[Memories, As a Public Health Nurse on the
Navajo](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#nurseCorner)\*

\-[Common Questions about HPV and Cervical Cancer: For Women Who Have
HPV](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#owh)

\-[Fracture Outcomes in Women Discontinuing
Alendronate](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#oste)

\-[Procedure-related complications of amniocentesis and CVS are
small](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#periPicks)

\-[Chronic Renal Disease is Part of Primary
Care](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0907_Feat.cfm#pcfhttp://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm)

\-[Call for re-evaluation of gestational diabetes diagnosis and
treatment
criteria](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#stillW)

\- [Ovarian Cancer: Pinn Point on Women's
Health](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#wheadlines)

**Domestic Violence**

-Coaching Boys into Men, AI/AN poster

-Aberdeen requesting DV and sexual assault pamphlets or CD-ROM resources

-Patient Self-Administered Report Effective to Screen for Domestic
Violence 

-DV victims have higher health care use and costs, even long after the
abuse has ended

**Elder Care News**

-Moderate- and High-Intensity Resistance Training Improves Cognitive
Function in Elderly

-Fall Injury Episodes Among Non-institutionalized Older Adults: United
States, 2001--2003

-Maintenance Antidepressant Treatment Improves Well-Being in Late-Life
Depression

\-[The Last Hours of Living: Practical Advice for
Clinicians](http://www.medscape.com/viewprogram/5808)

\-[Principles of Effective Pain Management at the End of
Life](http://www.medscape.com/viewprogram/6079)

**Family Planning**

-Transdermal hormonal contraception: benefits and risks

#### -Oral Contraceptive Use Linked to Cancer Risk {#oral-contraceptive-use-linked-to-cancer-risk .Style-Heading-4-+-Arial-14-pt-Underline}

**Featured Website**

It was low hanging fruit before: Now it is even easier - Perinatology
Corner

**Frequently asked questions**

How can we best manage Jehovah's Witnesses during pregnancy?

**Indian Child Health Notes**

-Challenges in Pediatric Rheumatic Disease: Special Issues with Native
Children

-Study of Virus Etiologies of Respiratory Hospitalizations in Alaska
Native children

-Native American genetic resources and the concept of cultural harm

-Widening socioeconomic disparities in US childhood mortality, 1969-2000

**Information Technology**

-National Release - RPMS Electronic Health Record, Version 1.1

-National Release - BI Immunization System, Version 8.2

International Health

-Treating schizophrenia in poorer countries: Old dilemmas and new
directions

#### MCH Alert

-Having more family meals during adolescence is associated with improved
diet quality

-Telemedicine Meeting the Health Care Needs of Children

-Challenges in the prevention of mother to child HIV transmission

-Supplement examines influences on obesity and healthy adolescent
behavior

#### MCH Headlines

-Child passengers are exposed to secondhand smoke

-26th Annual "Protecting Our Children"

-Child Poverty in Nonmetropolitan Areas by State including New Mexico 

-Substance Use Treatment Among Women of Childrearing Age

-Number one killer of youth: MVAs - Great set of slides to pick and
choose from

....and more

#### Medical Mystery Tour

#### Endometriosis: Where is the real truth? (Answers to last month's quiz) {#endometriosis-where-is-the-real-truth-answers-to-last-months-quiz .Style-Heading-4-+-Arial-14-pt-Underline}

#### Medscape

#### -Prevention of Influenza in a Family Setting to Reduce Transmission to Individuals at Risk {#prevention-of-influenza-in-a-family-setting-to-reduce-transmission-to-individuals-at-risk .Style-Heading-4-+-Arial-14-pt-Underline}

#### -78-year-old woman, is seen in consultation for chronic neck pain {#year-old-woman-is-seen-in-consultation-for-chronic-neck-pain .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Epidemiology and Prevalence of Breast Cancer in the US {#epidemiology-and-prevalence-of-breast-cancer-in-the-us .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Important Considerations for Treating Epilepsy in a Woman of Middle Age  {#important-considerations-for-treating-epilepsy-in-a-woman-of-middle-age .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Individualized Preventive Management of Hereditary Breast Ovarian Cancer Syndrome {#individualized-preventive-management-of-hereditary-breast-ovarian-cancer-syndrome .Style-Heading-4-+-Arial-14-pt-Underline}

....and more

**Menopause Management**

-Hormone therapy has no effect on memory but increases sexual interest

-Continuous HRT combined therapy vs sequential therapy and endometrial
cancer risk

#### -There are benefits to the introduction of hormone therapy on exercise {#there-are-benefits-to-the-introduction-of-hormone-therapy-on-exercise .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Strength Training Helps Prevent Fat Gain in Overweight, Obese Premenopausal Women {#strength-training-helps-prevent-fat-gain-in-overweight-obese-premenopausal-women .Style-Heading-4-+-Arial-14-pt-Underline}

**Midwives Corner**

-If you gotta use something, nitrous oxide might be better than
narcotics and epidurals

-Repeat HIV testing in pregnancy identifies opportunities for
antiretroviral prophylaxis

-Nei-Guan point acupressure is a useful treatment for relieving
hyperemesis gravidarum

-One in Seven Women are Depressed Before, During, or After Pregnancy

**Navajo News**

Acute Appendicitis and Pregnancy

**Nurses Corner**

Nurses and physicians have different perspectives in medical decisions

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

Church-Based Breast Cancer Screening Education: Impact of Two Approaches

**Oklahoma Perspective**

Training for Shoulder Dystocia

Osteoporosis

-Ordinary Doses of Vitamin D Linked to Lower Mortality

-Home health care following hip fracture limits osteoporosis progression

Patient Education

-Unsafe drugs during pregnancy: Frequency of birth control services with
prescriptions

-Improved health literacy should address literacy, language, and
cultural barriers

-Health literacy is not associated with how minorities perceive their
physical or mental health

#### -Bell\'s Palsy: What You Should Know {#bells-palsy-what-you-should-know .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Peptic Ulcers: What You Should Know {#peptic-ulcers-what-you-should-know .Style-Heading-4-+-Arial-14-pt-Underline}

Perinatology Picks

-The Dating Game (No, I don't mean TV show the Dating Game)

-Prevention is the most effective evidence-based management to avoid
recurrence of FGR

-3 criteria of oligohydramnios in identifying peripartum complications

-Oxytocin agonists for preventing postpartum haemorrhage

-Features of metabolic syndrome increase risk of a child with a NTD

....and more

Primary Care Discussion Forum

Chronic Kidney Disease: CKD is Part of Primary Care!

STD Corner

-American Indian women, HIV/AIDS, and health disparity

# -Adolescents' Discussions About Contraception Or STDs with Partners Before First Sex 

-Using clinical classifcation trees to identify risk of STDs during
pregnancy

-Exam room reminders / provider feedback can improve screening for
chlamydia in young women

#### -Genital Herpes: Framing the Problem, Diagnosing the Disease {#genital-herpes-framing-the-problem-diagnosing-the-disease .Style-Heading-4-+-Arial-14-pt-Underline}

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

-Magic Pill Improves Glycemic Control and Decreases Death by 25% for
Type 2\'s

-Laugh Your Way to Normal Blood Sugars

-Maternal Weight Gain Series (Six articles)

-True or False:  The largest at-risk group for sleep-related crashes is
commercial drivers

-PRESENT Diabetes, an Online Clinical Conference any time day or night

....and more

**Women's Health Headlines**

-Planning Group - conference on midwifery models of care

-Are women being scared away from math, science, and engineering fields?

###### Save the Dates: Upcoming events of interest page 63

#### What's new on the ITU MCH web pages page 64

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

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

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

**Hospital brought rapid cesarean delivery times into range of 10.9
minutes: Can you?**

It\'s every provider\'s nightmare: Everything is going smoothly during
labor, with normal progress, a reassuring fetal heart rate (FHR)
tracing, and a dilated cervix. Suddenly there\'s profound bradycardia,
with deceleration of the FHR to the 60s. The bedside nurse administers
oxygen and IV fluids, but bradycardia persists.

A pelvic exam is performed; the cervix is unchanged, the baby is in
vertex presentation and cord prolapse is ruled out. A fetal scalp
electrode is placed; the monitor is picking up fetal, not maternal heart
rate, and the baby has been \"down\" for over 5 minutes.

The charge nurse calls to the ob\'s answering service and the ward clerk
\"beeps\" her as well. The ob calls back within 5 minutes, and the
patient is moved to the operating room. The in-house ob physician, the
OR team, and the ob anesthesiologist are paged \"Stat\" to the OR, and
the baby is delivered by cesarean section, about 8 minutes after the
move to the operating room---and 20 to 25 minutes after the onset of
bradycardia. The placenta shows a partial abruption. The baby has
depressed Apgar scores and cord blood gas studies show metabolic
acidosis with pH less than 7.00.

Everything was done \"right.\" The nurses took appropriate measures to
try to resuscitate the baby in utero, the in-house physicians and OR
team responded promptly, and the baby was delivered well within the
American College of Obstetricians and Gynecologists standard of 30
minutes from \"decision to incision.\"1 But the baby may or may not do
well. Can we do better?

Sharp Mary Birch hospital in San Diego utilized an innovative approach
to ob emergencies can make these unnerving episodes seem less like an
avalanche and more like downhill skiing. One of the keys is replacing
sequential with simultaneous activation of the ob team.

[\'Simultaneous team activation\' as a paradigm shift]{.underline}

Post-hoc analysis of the time to delivery in cases of unexpected
profound fetal bradycardia shows that at our institution, the nursing
interventions typically require 3 to 10 minutes. Reaching the attending
obstetrician by pager or phone typically requires at least 3 to 5
minutes and there may not be a response for up to 10 or 15 minutes. Even
when the obstetrician is in house and decides to proceed immediately
with C/S, it is unlikely that the patient and anesthesiologist will be
in the OR within 10 minutes of the onset of fetal bradycardia. At our
institution, delivery for intrapartum emergencies like cord prolapse and
profound fetal bradycardia was historically nearly always well within 30
minutes of decision for C/S, but seldom within 15 minutes of onset of
bradycardia.

First, it\'s necessary to activate the entire response team rapidly and
simultaneously.

Even awaiting arrival of an \"in-house\" obstetrician prior to
activation would make it virtually impossible to reach the 15-minute
goal. Similarly, it\'s essential to empower the front-line team
member---namely the L&D nurse---to make the activation decision---to
pull the trigger,

-Second, the response must proceed in a coordinated, virtually
choreographed fashion.

-Next, bring in the rapid response team

-Next, test your team concept

(see full article for details)

[Can their program improve response times for every
hospital?]{.underline}

Certainly, for hospitals with an in-house OR team, obstetrician, and ob
anesthesiologist, a system similar to ours should be practical, and we
believe it will likely have a positive impact. For hospitals without
in-house teams, it may still be possible to improve response times by
analyzing the timing of responses, assessing the possibility of using
simultaneous rather than sequential activation, and building a feedback
mechanism into the emergency response concept from the start.

As they have watched Ob Team Stat evolve, thier \"choreography\" has
steadily improved; responding to ob emergencies feels less like being
caught in an avalanche and more like downhill skiing. Many of the early
skeptics have become ardent proponents of the concept. We believe that
this approach has also improved unit morale and \"word of mouth\"
dissemination to other hospitals in our area. Most importantly, it seems
that every week, in the lounge \"the morning after,\" we are hearing not
about \"the disaster last night\" but about the \"great save.\"

Catanzarite, V et al OB Team STAT: Developing a better L/D rapid
response team.Contemporary OB/GYN, Sep 1, 2007
<http://www.contemporaryobgyn.net/obgyn/article/articleDetail.jsp?id=455751>

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

**Improve your facility's response to emergencies through improved
teamwork**

As was discussed at the 2007 Women's Health and MCH Conference in August
there are simple practical steps to remove error and delay in your
response to all emergencies.

We heard from speakers from Sharp Mary Birch hospital in San Diego
(article above) the Institiute for Healthcare Improvement,and from your
colleagues, e. g., PIMC, Zuni, ANMC, and many others...about do-able
methods to improve the system to improve the outcome.

This article highlights these concepts...

-Empowering all staff to 'pull the trigger' on a rapid response

-Simultaneous team activation as a paradigm shift

-Testing the new system

...but there are many other methods.

The lecture notes and presentations from the 2007 Women's Health and MCH
Conference will be available here soon:
<http://www.ihs.gov/MedicalPrograms/MCH/F/lecNotes.cfm>

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

**Kelly Acton, National Diabetes Program**

**NIKE Air Native N7 Shoes**

I have received many emails and inquiries since the exciting launch of
the NIKE Air Native N7 shoe at the National Indian Health Board Consumer
Conference earlier this week, a shoe designed specifically for the
Native American foot. The IHS Division of Diabetes is proud and excited
to have been part of the team that conceived of, designed and tested
this shoe. As you have probably heard in the news reports, the NIKE Air
Native N7 is designed with a larger fit for the distinct foot shape of
Native Americans (as determined by field testing with Native people from
70 different tribes), and has a culturally specific look. It will be
distributed solely to American Indians and Alaska Natives; tribal
diabetes and diabetes prevention programs, tribal wellness programs and
tribal schools nationwide will be able to purchase the shoe at wholesale
price (\$42.80) and then distribute it to community members. And yes,
the rumor you heard is true: Nike plans to pour every penny from the
proceeds of this shoe back into our communities to promote health and
fitness!

If you would like to see a picture of the shoe and read about its
features, please follow this link:
<http://mont.images.worldnow.com/images/incoming/ktvq/documents/Native_Air.pdf>
(or copy it and paste into the window of your internet browser).

Many of you have asked for information about how to order the shoe. My
understanding is that Nike will not have the shoes actually available
until mid- to late October. Shoes will be available through the tribal
programs I mentioned above. We are working with Nike's Native American
Business Incentive Program to create a way for federal programs (such as
IHS service units) to be able to purchase the shoes as well.  For more
information on how to become a part of Nike's Native American Business
Incentive Program to order the shoes, contact Mr. Sam McCracken, Native
American Business Manager at <Sam.Mccracken@nike.com> or call
1-503-671-3281.

One very important feature of this product: because this shoe is sized
specifically for the Native American foot it is sized differently than
other Nike shoes. It is very important to measure the wearer's foot
according to the directions on the Nike website so that the proper shoe
size can be determined. In many cases, the purchaser will wear one half
to one full size smaller in this shoe compared to what he/she is used to
purchasing. But a reminder: not every person will fit into these shoes,
especially if he or she has a more narrow foot. So fit is extremely
important to avoid the problems one can encounter with an ill-fitting
shoe (especially if that person has diabetes). Over the next few months
our office will be developing an educational pamphlet that explains more
about fitting the shoe, and we will make it available on our website as
well as through the Area Diabetes Consultants.

As more information becomes available we will be sure to send it out to
all of you. Please share this email with your colleagues so that we can
spread the word about this exciting development.

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

#### Michael Berryhill, HQE {#michael-berryhill-hqe .Style-Heading-4-+-Arial-14-pt-Underline}

**OB/GYN offering services at greatly reduced salary**

A provider contacted the IHS Health Professional Recruiters with the
following information: I would like to provide a total of twelve months
appointment with IHS with a salary of \$1500.00 per month with room and
board. I am quite current in outpatient procedures and clinical acumen
since I have been doing that actively as well as write books and
magazine articles on OB and GYN topics. I am quoted in about fifty
publications yearly. Contact <Michael.Berryhill@ihs.gov>

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

#### Scott Giberson, HQE {#scott-giberson-hqe .Style-Heading-4-+-Arial-14-pt-Underline}

**USCA to Honor Native American, Alaska Native, and Native Hawaiian
Communities at Opening Plenary and "Celebration of Life" Event**

The [National Minority AIDS Council](http://ga1.org/ct/m7NtzWp1vQlp/)
(NMAC) hosts the annual [2007 United States Conference on
AIDS](http://ga1.org/ct/m1NtzWp1vQll/) (USCA), One Family, One Voice,
One Spirit set for November 7-10 at the Palm Springs Convention Center
in Palm Springs, California and focuses on communities in the United
States heavily impacted by, and at high risk for, HIV/AIDS.

"In recognition of the importance and value of Native American, Alaska
Native and Native Hawaiian communities in the fight against HIV/AIDS,
USCA partners with tribes in the local area to enhance the conference
experience and invites tribal leaders to address participants at the
Opening Plenary. This November, we feel particularly honored to be
holding USCA in Palm Springs, on the land of the Agua Caliente Band of
Cahuilla Indians," says Paul Kawata, NMAC Executive Director. Mr. Kawata
explains, "The Grand Entry planned for the Opening Plenary will alert
our participants to the rich traditions of Native peoples, and the need
for increased HIV/AIDS awareness in Native American, Alaska Native, and
Native Hawaiian communities."

"This Opening Plenary is an opportunity to celebrate our rich diversity
as well as to increase awareness of this critical issue in our
community," says Warren Jimenez, member of the Chumash Tribe, Coastal
Band and the Executive Director of the [National Native American AIDS
Prevention Center](http://ga1.org/ct/mpNtzWp1vQlP/) (NNAAPC). "We are
excited to partner with NMAC, the [Red Circle Project at AIDS Project
Los Angeles](http://ga1.org/ct/mdNtzWp1vQl0/) (APLA), and the local host
committee to be part of this celebration."

The USCA Opening Plenary, planned in partnership with NNAAPC, the Red
Circle Project at APLA, and the local host committee, will take place on
Wednesday, November 7, 2007 at 8:30 am. It will honor Native and
indigenous communities with a Grand Entry procession. Native and
indigenous peoples are respectfully invited to join us in opening the
conference in traditional and/or cultural regalia/attire during the
Grand Entry. Participants can meet prior to the procession in the "Green
Room" at the convention center. Arrangements to participate may be made
by contacting Elton Naswood at 213-201-1311 or by email:
[[NativeUSCA2007@gmail.com]{.underline}](mailto:NativeUSCA2007@gmail.com)

**Amy Groom, IHS Immunization Program Manager**

**Let's clear up any confusion over the availability of the HPV
vaccine**

There has been confusion over the availability of the HPV vaccine to all
eligible AI/AN females. When the vaccine was first released some states
placed age restrictions on usage. Apparently those restrictions have now
been removed in all states with significant AI/AN populations.
Unfortunately many clinics within the Indian Health Service and tribal
health system still have out of date information that the HPV vaccine is
restricted to certain age groups.

Please read Ms. Groom's e-mail below. All AI/AN females up through age
18 years are eligible for free vaccine from the Vaccines for Children
program in your state. If you have any questions about your ability to
receive HPV vaccine for all AI/AN females between ages 11-18 years
please contact your state immunization coordinator from the link that
Ms. Groom has supplied. If there is any state that is limiting the HPV
vaccine for AI/AN females please let me know.

Steve Holve, MD

Chief Clinical Consultant in Pediatrics

HI Steve --The programs that are restricting are offering it to 11 -- 18
only, not 9 -- 18, so while a restriction, it isn't as restrictive as it
had been. And of those, 2 of the 3 programs with restrictions are
actually cities, and not cities with a significant AI/AN population (and
no urban Indian facility). The other is a state (PA) with no federally
or state recognized tribe and no IHS or tribal facility, so I doubt that
is an issue for the folks you are talking with. Every other state, per
AIM and per CDC, is offering the HPV vaccine to all VFC eligible females
(which would include all AI/AN)  in accordance with the ACIP
recommendation -- that is to say, to  all 9 -- 18 year olds.

There may be some lingering confusion or communication issues related to
the earlier restrictions that some states placed when the vaccine first
came out, so I would encourage people to contact their VFC program
directly and ask for the specific guidance related to HPV. If there are
in fact states that are still restricting the vaccine we can look into
it to see what the situation is.

If people need assistance identifying the appropriate contact person at
the state, I am happy to help -- a list of all the VFC and Immunization
Program Mangers for each state is also available at:
<http://www.immunize.org/coordinators/>

**Flu Season**

Flu season is considered Sept -- March. Vaccination begins around
October and although typically vaccination slows down after
Thanksgiving, the CDC and partners are actively promoting vaccinating
through out the flu season, even into January and Feb 2008.

This year CDC and partners are promoting "National Influenza Vaccination
Week" November 26 -- December 2nd to get that message out.

Hawaii has already reported flu cases, so it may be an earlier flu
season than last year (last year peaked quite late, around February).
Also, the southern hemisphere (Australia, New Zealand) had a very heavy
flu season this year, so there are some that predict we may be in for an
earlier and more sever flu season than last year. See the IHS Provider
notes about this and stats on coverage for 6 -- 23 months as well.

Amy V. Groom, MPH

IHS Immunization Program Manager/CDC Field Assignee

IHS Division of Epidemiology

5300 Homestead RD., NE

Albuquerque, NM  87110

Phone: (505) 248 -- 4374

<Amy.Groom@ihs.gov>

**Elaine Locke, ACOG**

**State Maternal Mortality Review: Accomplishments of Nine States: Now
Available**

The Centers for Disease Control Division of Reproductive Health is
please to announce the availability of a new publication; \"State
Maternal and Morality:  Accomplishments of Nine States.\" 

 

The CDC would be happy to provide you copies of that publication. 
Please e-mail a complete mailing address. All publications are
complimentary, however, we do limit our quantities.  Allow 2-3 week for
Domestic shipping and 6-8 weeks for International shipping. 770-488-5200

 

Thank you for your interest, and we\'ll look forward to completing your
request.

 

Public Inquiries Group CDC/DRH\
Division of Reproductive Health 4770 Buford Hwy, NE\
Centers for Disease Control and Prevention MS K-20\
<http://www.cdc.gov/reproductivehealth/index.htm> Atlanta, GA 30341-3717

**Alan Waxman, University of New Mexico (Retired IHS OB/GYN CCC)**

![](media/image2.wmf){width="2.192361111111111in"
height="2.2604166666666665in"}The TELLURIDE Conference

February 8-10, 2008

Mark your calendar! Ask for leave! Think snow!

It's time to make plans to attend the annual Indian Health Midwinter
Conference on Women's and Children's Healthcare.

This conference will bring together healthcare providers and nurses from
Navajo Area and throughout Indian country for three days of continuing
education, networking and winter recreation. Topics will include a wide
range of timely issues important for ob/gyns, pediatricians, family
physicians, NPs, CNMs, PAs, and RNs who care for Native American women
and children.

It will be a fun and educational weekend if you ski, snowboard or like
to sit by the fire.

As always, no advance registration is needed. Details regarding times
and location will be mailed later in the fall. If you need additional
information in the meantime, please contact Alan Waxman, MD at
[**awaxman@salud.unm.edu**](mailto:awaxman@salud.unm.edu)

Share this announcement with a friend. See you there!

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

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

**SBE prophylaxis not recommended for genitourinary or gastrointestinal
tract procedures**

BACKGROUND: The purpose of this statement is to update the
recommendations by the American Heart Association (AHA) for the
prevention of infective endocarditis that were last published in 1997.

METHODS AND RESULTS: The American College of Cardiology/AHA
classification of recommendations and levels of evidence for practice
guidelines were used. The paper was subsequently reviewed by outside
experts not affiliated with the writing group and by the AHA Science
Advisory and Coordinating Committee.

CONCLUSIONS: The major changes in the updated recommendations include
the following: (1) The Committee concluded that only an extremely small
number of cases of infective endocarditis might be prevented by
antibiotic prophylaxis for dental procedures even if such prophylactic
therapy were 100% effective. (2) Infective endocarditis prophylaxis for
dental procedures should be recommended only for patients with
underlying cardiac conditions associated with the highest risk of
adverse outcome from infective endocarditis. (3) For patients with these
underlying cardiac conditions, prophylaxis is recommended for all dental
procedures that involve manipulation of gingival tissue or the
periapical region of teeth or perforation of the oral mucosa. (4)
Prophylaxis is not recommended based solely on an increased lifetime
risk of acquisition of infective endocarditis. (5) Administration of
antibiotics solely to prevent endocarditis is not recommended for
patients who undergo a genitourinary or gastrointestinal tract
procedure. These changes are intended to define more clearly when
infective endocarditis prophylaxis is or is not recommended and to
provide more uniform and consistent global recommendations.

[Wilson
W](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Wilson W"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Prevention of Infective Endocarditis. Guidelines From the American
Heart Association. A Guideline From the American Heart Association
Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council
on Cardiovascular Disease in the Young, and the Council on Clinical
Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the
Quality of Care and Outcomes Research Interdisciplinary Working Group.
[Circulation.](javascript:AL_get(this, 'jour', 'Circulation.');) 2007
Apr 19
<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17446442>

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

**Please change all your SBE prophylaxis guidelines**

The 2007 SBE prophylaxis guidelines are remarkable because they use
levels of evidence for practice guidelines and classifications of
recommendations.

Uncomplicated vaginal or cesarean delivery is not a routine indication
for antibiotic prophylaxis because the rate of bacteremia is low with
these procedures. However, women with the highest risk cardiac
conditions described above who are undergoing uncomplicated vaginal
delivery can be given the option of antibiotic prophylaxis. If
bacteremia is suspected during vaginal or cesarean delivery, antibiotic
prophylaxis should be administered to these patients with the highest
risk cardiac conditions.

If antibiotic prophylaxis is given, the recommended drugs noted above
are all safe at the time of delivery.

**Indications for prophylaxis** --- Prophylaxis was recommended only in
those settings associated with the highest risk of developing an adverse
outcome if infective endocarditis (IE) were to occur. The following
cardiac conditions were considered to meet this criterion:

-Prosthetic heart valves, including bioprosthetic and homograft valves.

-A prior history of IE.

-Unrepaired cyanotic congenital heart disease, including palliative
shunts and conduits.

-Completely repaired congenital heart defects with prosthetic material
or device, whether placed by surgery or by catheter intervention, during
the first six months after the procedure.

-Repaired congenital heart disease with residual defects at the site or
adjacent to the site of the prosthetic device.

-Cardiac valvulopathy in a transplanted heart.

**No longer indicated** --- Common valvular lesions for which
antimicrobial prophylaxis is no longer recommended include bicuspid
aortic valve, acquired aortic or mitral valve disease (including mitral
valve prolapse with regurgitation and those who have undergone prior
valve repair), and hypertrophic cardiomyopathy with latent or resting
obstruction.

**Procedures that may result in transient bacteremia** --- The 2007 AHA
guidelines recommend that antimicrobial prophylaxis be given to patients
with the cardiac lesions cited above when they undergo procedures likely
to result in bacteremia with a microorganism that has the potential
ability to cause endocarditis

The risk of IE is generally considered to be the highest for all dental
procedures that involve manipulation of either gingival tissue or the
periapical region of teeth or perforation of the oral mucosa.

The risk of bacteremia is significantly lower for invasive genitourinary
(GU) procedures such as dilation of strictures, insertions of catheters,
and prostatectomy. Invasive gastrointestinal (GI) procedures, such as
lower bowel endoscopy with biopsy or endoscopic retrograde
cholangiopancreatography have an even lower risk of IE since bacteremia
due to organisms capable of causing endocarditis occurs in less than 5
to 10 percent of cases.

The AHA guidelines no longer considers any GI (including diagnostic
colonoscopy or esophagogastroduodenoscopy ) or GU procedures high risk
and therefore do not recommend routine use of IE prophylaxis even in
patients with the highest risk cardiac conditions defined above.

Some patients with established infections of the GI or GU tract may have
enterococcal bacteremia. For patients with the highest risk cardiac
conditions who have ongoing GI or GU tract infection or who are
undergoing a procedure for which antibiotic therapy to prevent wound
infection or sepsis is indicated, the AHA suggests an antibiotic regimen
that includes an agent active against enterococci.

Patients with infected skin, skin structure, or musculoskeletal tissue
generally have polymicrobial infections. When such patients undergo a
surgical procedure, only bacteremia with staphylococci or beta-hemolytic
streptococci are likely to cause IE. The appropriate antibiotic regimen
is discussed in the UpToDate link below.

**Resources**

**Full text article**

<http://www.circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.106.183095v1>

**Antimicrobial prophylaxis for bacterial endocarditis, UpToDate**

<http://www.uptodateonline.com/utd/content/topic.do?topicKey=endocard/7638&selectedTitle=6~2776&source=search_result>

**Other**

**A preventive approach to lower the cesarean delivery rate in a rural
hospital**

[Results:]{.underline} The exposed group (n = 794), as compared with the
nonexposed group (n = 1,075), had a higher labor induction rate (31.4%
vs 20.4%, P\<.001), a greater use of prostaglandin E2 (23.3% vs 15.7%, P
\<.001), and a lower cesarean delivery rate (5.3% vs 11.8%, P \<.001).
Adjustment for cluster effects, patient characteristics, and the use of
epidural analgesia did not eliminate the significant association between
exposure to this preventive method of care and a lower cesarean delivery
rate. Rates of other adverse birth outcomes were either unchanged or
reduced in the exposed group.\
[Conclusions:]{.underline} A preventive approach to reducing cesarean
deliveries may be possible. This study found that practitioners who
often used risk-guided, prostaglandin-assisted labor induction had a
lower cesarean delivery rate without increases in rates of other adverse
birth outcomes. Randomized controlled trials of this method of care are
warranted.

[Nicholson
JM](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Nicholson JM"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al A preventive approach to obstetric care in a rural hospital:
association between higher rates of preventive labor induction and lower
rates of cesarean delivery.\
Ann Fam Med. 2007 Jul-Aug;5(4):310-9.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17664497>

**1 of every 6 women studied had filled a class D or X prescription**

More Counseling Needed for Women of Childbearing Age Prescribed
Teratogenic Drugs

CONCLUSION: Prescriptions for potentially teratogenic medications are
frequently filled by women of childbearing age without documentation of
contraceptive counseling

[Schwarz
EB](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Schwarz EB"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Documentation of contraception and pregnancy when prescribing
potentially teratogenic medications for reproductive-age women.Ann
Intern Med. 2007 Sep 18;147(6):370-6

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17876020>

and

**Summaries for patients. Frequency of birth control services with
prescriptions for unsafe drugs during pregnancy.**

Summaries for patients. Frequency of birth control services with
prescriptions for unsafe drugs during pregnancy.Ann Intern Med. 2007 Sep
18;147(6):I38.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17876016>

**Risk of uterine rupture with a prior cesarean delivery is 0.3% but
ranges from 0% to 0.74%**

CONCLUSION: At term, the risk of uterine rupture and adverse perinatal
outcome for women with a singleton and prior cesarean delivery is low
regardless of mode of delivery, occurring in 3 per 1,000 women. Maternal
complications occurred in 3-8% of women within the five delivery groups.
LEVEL OF EVIDENCE: II.

[Spong
CY](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Spong CY"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Risk of Uterine Rupture and Adverse Perinatal Outcome at Term
After Cesarean Delivery. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007
Oct;110(4):801-807

<http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=17906012&dopt=AbstractPlus>

**Women who quit smoking before pregnancy benefit from reduced risk of
abruption**

These findings suggest that women who quit smoking before pregnancy may
benefit from reduced risk of abruption. The observation that the
recurrence of abruption is substantially increased regardless of changes
in smoking habits suggests that factors other than smoking may influence
the recurrence of placental abruption.

[Ananth
CV](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Ananth CV"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Influence of maternal smoking on placental abruption in successive
pregnancies: a population-based prospective cohort study in Sweden. Am J
Epidemiol. 2007 Aug 1;166(3):289-95.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17548787>

**Intrapartum cardiotocography in low obstetric risk increases the risk
of caesarean delivery** CONCLUSION: Intrapartum admission
cardiotocography in women at low obstetric risk increases the risk of
caesarean and instrumental delivery. In addition, there is no evidence
for neonatal benefit in terms of Apgar score at 5 min after delivery. A
larger sample size would be needed in order to answer this important
question.

[Gourounti
K](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Gourounti K"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
[Sandall
J](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Sandall J"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus).
Admission cardiotocography versus intermittent auscultation of fetal
heart rate: effects on neonatal Apgar score, on the rate of caesarean
sections and on the rate of instrumental delivery\--a systematic review.
[Int J Nurs Stud.](javascript:AL_get(this, 'jour', 'Int J Nurs Stud.');)
2007 Aug;44(6):1029-35

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=16919279>

**Uterine rupture risks: induction, birthweight, gestational age, and
maternal characteristics**

Study suggests prudent management of women with a history of caesarean
delivery after finding that the risk of uterine rupture during
subsequent birth is significantly increased following a previous
caesarean.

CONCLUSION: The risk of uterine rupture in subsequent deliveries is not
only markedly increased among women with a previous caesarean delivery
but also influenced by induction of labour, birthweight, gestational
age, and maternal characteristics.

[Kaczmarczyk
M](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Kaczmarczyk M"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Risk factors for uterine rupture and neonatal consequences of
uterine rupture: a population-based study of successive pregnancies in
Sweden. BJOG. 2007 Oct;114(10):1208-14.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17877673>

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

**2006 consensus guidelines for the management of abnormal cervical
cancer screening**

A group of 146 experts representing 29 organizations and professional
societies met September 18-19, 2006, in Bethesda, MD, to develop revised
evidence-based, consensus guidelines for managing women with abnormal
cervical cancer screening tests. Recommendations for managing atypical
squamous cells of undetermined significance and low-grade squamous
intraepithelial lesion (LSIL) are essentially unchanged. Changes were
made for managing these conditions in adolescents for whom cytological
follow-up for 2 years was approved. Recommendations for managing
high-grade squamous intraepithelial lesion (HSIL) and atypical glandular
cells (AGC) also underwent only minor modifications. More emphasis is
placed on immediate screen-and-treat approaches for HSIL. Human
papillomavirus (HPV) testing is incorporated into the management of AGC
after their initial evaluation with colposcopy and endometrial sampling.
The 2004 Interim Guidance for HPV testing as an adjunct to cervical
cytology for screening in women 30 years of age and older was formally
adopted with only very minor modifications.

[Wright TC
Jr](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Wright TC Jr"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al 2006 consensus guidelines for the management of women with
abnormal cervical cancer screening tests [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2007
Oct;197(4):346-55

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17904957>

**2006 consensus guidelines for the management CIN or adenocarcinoma in
situ**

A group of 146 experts representing 29 organizations and professional
societies met Sept. 18-19, 2006, in Bethesda, MD, to develop revised
evidence-based, consensus guidelines for managing women with abnormal
cervical cancer screening tests. The management of low-grade cervical
intraepithelial neoplasia (CIN) grade 1 has been modified significantly.
Previously, management depended on whether colposcopy was satisfactory
and treatment using ablative or excisional was acceptable for all women
with CIN 1. In the new guidelines, cytological follow-up is the only
recommended management option for women with CIN 1 who have low-grade
referral cervical cytology, regardless of whether the colposcopic
examination is satisfactory. Treatment is particularly discouraged in
adolescents. The basic management of women in the general population
with CIN 2,3 underwent only minor modifications, but options for the
conservative management of adolescents with CIN 2,3 have been expanded.
Moreover, management recommendations for women with biopsy-confirmed
adenocarcinoma in situ are now included.

[Wright TC
Jr](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Wright TC Jr"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al 2006 consensus guidelines for the management of women with
cervical intraepithelial neoplasia or adenocarcinoma in situ. [Am J
Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2007
Oct;197(4):340-5

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17904956>

**Editorial: The evolution of cost-effective screening and prevention of
cervical carcinoma: implications of the 2006 consensus guidelines and
human papillomavirus vaccination**

Cervical cancer accounts for more gynecology-related deaths worldwide
than any other malady, thus making it the most important preventable
disease in woman's health today. Although likely an underestimate,
Parkin et al reported that cervical cancer affected 493,243 women
worldwide in 2002, which makes it the second most common female cancer
and the third most common cause of female cancer death, with 273,505
deaths reported. Another way to analyze the importance of cervical
cancer to society is to evaluate the years of life lost by young and
middle-aged women (25-64 years old). On a global basis, cancer of the
cervix is responsible for approximately 2% of the total (weighted) years
of life lost. However, it is the most important cause of years of life
lost in Latin America and the Caribbean. Cervical cancer also
contributes the largest portion to years of life lost from cancer in the
populous regions of Sub-Saharan Africa and South-Central Asia, where the
actual risk of loss of life from this cause is even higher, although it
is somewhat overshadowed by deaths from noncancerous causes, such as
acquired immunodeficiency disease and tuberculosis.

Further study of alternative screening models is needed to develop a
system that can realize the cost savings in screening that is necessary
to offset the added cost of universal HPV vaccination. The current
guidelines are a short step toward this end; unfortunately, their net
effect will likely not realize this necessary and worthy goal. Finally,
although universal vaccination of teenagers and young women is a
desirable policy, ethical and cultural barriers must be conquered before
HPV vaccination is adopted widely across all sectors.

[Monk
BJ](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Monk BJ"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
[Herzog
TJ](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Herzog TJ"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus).
The evolution of cost-effective screening and prevention of cervical
carcinoma: implications of the 2006 consensus guidelines and human
papillomavirus vaccination. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2007
Oct;197(4):337-9

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17904955>

**[Editorial comment]{.underline}: Alan Waxman, Univ. of New Mexico
(Retired IHS OB/GYN CCC)**

**Putting the 2006 Consensus Guidelines into perspective**

In 2001, the American Society for Colposcopy and Cervical Pathology
(ASCCP) responded to the "new" 2001 revision of the Bethesda
nomenclature for abnormal Pap tests by convening a conference of experts
to evaluate available scientific evidence and recommend management
options. The big news in 2001 was the recommendations regarding use of
HPV DNA testing as a triage for the ASCUS Pap. This has become widely
implemented as "Reflex HPV" testing. In the years since 2001, numerous
studies have been published on the natural history of HPV and cervical
dysplasia and on the effects of treatment on subsequent pregnancy. In
addition, HPV DNA testing received FDA approval for use as an adjunct to
the Pap test, and data from HPV vaccine trials has become available. So
it seemed a good time to review and revise the ASCCP Guidelines.

The Consensus Conference process was similar to that employed 5 years
earlier. Diagnosis-specific workgroups composed of physicians, expert in
cervical disease, were assigned to review the literature since 2000.
Preliminary recommendations were posted on a web bulletin board for
comment from interested parties worldwide. By the time the consensus
conference was convened in mid-September, 2001, a set of fairly mature
recommendations had been developed. At the conference, each
recommendation was debated by 146 representatives of 29 professional
organizations and government agencies. Each recommendation was voted up
or down, revised and voted on again as needed. The resulting 2006
Guidelines were published this month in the American Journal of
Obstetrics and Gynecology and are available free to the public at
[www.asccp.org](http://www.asccp.org/).

The new guidelines include a number of major changes that will affect
the way we care for women with abnormal Pap tests. Without question, the
most radical of these is in the recommended management of adolescents
with LSIL or ASC-US. This is a logical progression of American Cancer
Society's 2002 recommendation to delay the first Pap test in adolescent
women until about three years after the onset of sexual activity or age
21. The 2006 ASCCP Guidelines acknowledge the high prevalence of HPV
infection in women under age 21, but also the high probability of
spontaneous resolution of SIL and very low incidence of invasive cancer
in this age group. In addition several studies have shown that treatment
of dysplasia is associated with an increase in premature births with
subsequent pregnancy. As a result, the 2006 Guidelines recommend
deferring colposcopy for adolescent women with LSIL or ASC-US for two
years, while monitoring with cytology annually, and defaulting to
colposcopy only if a follow-up Pap test progresses to HSIL or if it
remains ASC-US or worse at two years. This approach should identify
those few young women at risk of developing cancer and prevent cost,
discomfort, anxiety, and potential perinatal morbidity for the large
number with minimally abnormal Pap results.

The field of cervical cancer screening and HPV continues to produce a
large body of innovative research. With the approval and widespread
implementation of the HPV Vaccine we are likely to see the "new" 2006
Guidelines revised and improved upon in the future. In the meantime,
they offer those of us caring for women a well thought out approach to
the abnormal Pap test that's based on today's most current evidence.

**Other Cervical Cancer Screening resources this month**

**Less intervention for CIN 2 may be acceptable in adolescents**

CONCLUSION: CIN \> or = 2 is present in 35% of our cohort. Most had CIN
2, and most experienced regression. Our observation supports continued
vigilance in the evaluation of adolescents but suggests that less
intervention for CIN 2 may be acceptable.

[Moore
K](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Moore K"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Adolescent cervical dysplasia: histologic evaluation, treatment,
and outcomes.\
Am J Obstet Gynecol. 2007 Aug;197(2):141.e1-6.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17689626>

**Use of routine prophylactic topical antibiotics not recommended after
LLETZ**

CONCLUSIONS: An antimicrobial vaginal pessary containing tetracycline
and amphotericin B did not provide any significant benefit after LLETZ,
except for a subgroup of women with positive vaginal or endocervical
swabs. Given that this group of women cannot be identified before the
procedure since swabs are not routinely taken, the use of routine
prophylactic topical antibiotics cannot be recommended for the general
population

[Chan
KK](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Chan KK"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al The use of vaginal antimicrobial after large loop excision of
transformation zone: a prospective randomised trial. BJOG. 2007
Aug;114(8):970-6.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17635487>

**Other**

**Effectiveness of two tinidazole regimens in treatment of bacterial
vaginosis: RCT**

CONCLUSION: Both tinidazole regimens studied provided effective
treatment for bacterial vaginosis

[Livengood CH
3rd](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Livengood CH 3rd"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Effectiveness of two tinidazole regimens in treatment of bacterial
vaginosis: a randomized controlled trial. Obstet Gynecol. 2007 Aug;110(2
Pt 1):302-9.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17666604>

**Minimally invasive strategy for large cysts: Laparoscopically guided
minilaparotomy** CONCLUSION: Laparoscopically guided minilaparotomy,
when compared with laparoscopy, is able to reduce intraperitoneal
spillage in patients with presumably benign large adnexal masses, with
minimal increase in patient short- and long-term discomfort. Because
data regarding the importance of intraperitoneal spillage during surgery
for benign and malignant pathologies, as well as rupture rates during
traditional laparotomy, are scarce, traditional laparotomy still
represents the standard treatment. In women desiring a minimally
invasive strategy for large cysts, laparoscopically guided
minilaparotomy should be considered

[Panici
PB](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Panici PB"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Laparoscopy compared with laparoscopically guided minilaparotomy
for large adnexal masses: a randomized controlled trial. Obstet Gynecol.
2007 Aug;110(2 Pt 1):241-8.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17666596>

**Tailored mesh significantly reduced the rate of recurrence of anterior
vaginal wall prolapse**

CONCLUSION: Anterior colporrhaphy, reinforced with, tailored mesh
significantly reduced the rate of recurrence of anterior vaginal wall
prolapse compared with the traditional operation, but was associated
more often with stress urinary incontinence.

[Hiltunen
R](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Hiltunen R"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Low-weight polypropylene mesh for anterior vaginal wall prolapse:
a randomized controlled trial. Obstet Gynecol. 2007 Aug;110(2 Pt
2):455-62.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17666627>

**Botulinum toxin injections for adults with overactive bladder
syndrome**

CONCLUSIONS: Intravesical botulinum toxin shows promise as a therapy for
overactive bladder symptoms, but as yet too little controlled trial data
exist on benefits and safety compared with other interventions, or with
placebo. Practitioners should be aware that at present there is little
more than anecdotal evidence, in the form of case reports to support the
efficacy of intravesical botulinum toxin; there is not much in the way
of substantial, robust safety data. Furthermore, the optimal dose of
botulinum toxin for efficacy and safety has not yet been demonstrated.

[Duthie
J](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Duthie J"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Botulinum toxin injections for adults with overactive bladder
syndrome. [Cochrane Database Syst
Rev.](javascript:AL_get(this, 'jour', 'Cochrane Database Syst Rev.');)
2007 Jul 18;(3):CD005493

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17636801>

**Early-stage ovarian cancer No difference in adjuvant chemotherapy and
radiotherapy**

RESULTS: Twenty-two prospective randomized studies were analyzed, which
included 4,626 patients. No difference between adjuvant chemotherapy
(AC) and radiotherapy was found. There is agreement on that patients
with stage IA, grade 1 tumors have excellent survival and do not need
postsurgical therapy. The International Collaborative Ovarian Neoplasm
1/Adjuvant Chemotherapy in Ovarian Neoplasm trials were the first to
show an effect on survival of AC, but in patients with adequate surgical
staging, there was no additional effect of AC. For patients who are
staged incompletely at the time of initial surgery, completion of the
staging procedure with either laparoscopy or laparotomy is a reasonable
approach before a final decision is made regarding the need for AC.

CONCLUSION: Future randomized studies in EOC will include the
investigation of new targeted therapies and new prognostic factors in
adequately staged patients.

Tropé C; Kaern J Adjuvant chemotherapy for early-stage ovarian cancer:
review of the literature. [J Clin Oncol.  2007;
25(20):2909-20](http://www.medscape.com/medline/publicationbrowser/123?pmid=17617522) 

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17617522>

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

**Traumatic events and alcohol use disorders among American Indian
adolescents\
**Researchers analyzed interviews with 432 American Indian adolescents
and young adults between the ages of 15 and 24. The participants were
enrolled tribal members living on or near two closely related Northern
Plains Indian reservations. As part of a larger survey on mental health,
interviewers asked the participants if they had experienced any of 16
types of traumatic events and about their use of alcohol.

The traumatic events were categorized as noninterpersonal trauma
(disaster, life-threatening accidents); interpersonal trauma (combat,
rape, sexual abuse, physical assault/ abuse); witnessed trauma (seeing
violence perpetrated upon others or observing a serious accident or
disaster that resulted in harm or death of others); hearing traumatic
news about a close other (life-threatening illness, rape, suicide, of a
family member or friend), and other trauma.

Over one-fourth (26 percent) of those interviewed were diagnosed with
alcohol use disorders. Overall, 21 percent had experienced one severe
traumatic event, 10 percent had experienced two, and 16 percent had
experienced three or more. Young adults (aged 20-24) experienced more
traumatic events than adolescents (aged 15-19), as did participants in
both age groups who reported that their parents used alcohol while they
were growing up.

The odds for alcohol use disorders increased from nearly twofold for one
trauma to somewhat less than fourfold for three or more traumas compared
with no trauma. These results held after adjusting for age, gender, and
parental alcohol use, suggesting a dose-response effect of trauma on
alcohol disorders among American Indians living on or near reservations.

[Boyd-Ball
AJ](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Boyd-Ball AJ"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Traumatic events and alcohol use disorders among American Indian
adolescents and young adults. J Trauma Stress. 2006 Dec;19(6):937-47.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17195969>

**Viracept Use Should Be Limited in Children and Pregnant Women**

Interim specifications for use of nelfinavir mesylate (Viracept, Pfizer,
Inc) preclude initiation of therapy in children and pregnant women, the
US Food and Drug Administration warned healthcare professionals.

These measures are based on the risk for high levels of ethyl
methanesulfonate (EMS), a process-related impurity. Although no human
data exist, animal studies indicate that EMS is teratogenic, mutagenic,
and carcinogenic.

For pediatric patients who are stable on nelfinavir-containing regimens
and pregnant women with no other therapeutic options, the benefit-risk
ratio remains favorable, and nelfinavir therapy may be continued,
according to an alert sent from MedWatch, the FDA\'s safety information
and adverse event reporting program.

Although other patients are not currently affected by these measures, a
temporary interruption of drug supply in the future may require
switching to alternative products.

Earlier this year, excess levels of EMS prompted a recall of nelfinavir
in the European Union; subsequent testing revealed levels to be
substantially lower in the US product and within final acceptable
limits.

Toxicology experts generally agree that the lifetime risk associated
with exposure to a carcinogen is about 3-fold greater among pediatric
patients aged 2 to 16 years and is even higher for those aged younger
than 2 years, the company said in a letter to doctors. These data were
used to determine acceptable levels of EMS in pediatric formulations of
nelfinavir.

Action is currently being taken to ensure that EMS levels meet final
acceptable limits. Interim specifications agreed on by the company and
the FDA limit the theoretical lifetime increased cancer risk in adults
to fewer than 17 cases per 100,000 exposed; long-term specifications
limit the risk to less than 1 case per 100,000 exposed. The background
incidence in the HIV population is currently estimated to be 20 to 30
cases per 1000 patient-years.

Nelfinavir is a protease inhibitor indicated with other antiretroviral
agents for the treatment of HIV infection.

Healthcare professionals should report nelfinavir-related adverse events
to the FDA by phone at 1-800-FDA-1088, by fax at 1-800-FDA-0178, online
at <http://www.fda.gov/medwatch>, or by mail to 5600 Fishers Lane,
Rockville, MD 20852-9787.

**Statement Updated for Screening and Treatment of Teens at Risk for
Suicide **

Suicide is the third-leading cause of death for adolescents 15 to 19
years old. Pediatricians can take steps to help reduce the incidence of
adolescent suicide by screening for depression and suicidal ideation and
behavior. This report updates the previous statement of the American
Academy of Pediatrics and is intended to assist the pediatrician in the
identification and management of the adolescent at risk of suicide. The
extent to which pediatricians provide appropriate care for suicidal
adolescents depends on their knowledge, skill, comfort with the topic,
and ready access to appropriate community resources. All teenagers with
suicidal thoughts or behaviors should know that their pleas for
assistance are heard and that pediatricians are willing to serve as
advocates to help resolve the crisis.

[Shain
BN](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Shain BN"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus);
[American Academy of Pediatrics Committee on
Adolescence](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="American Academy of Pediatrics Committee on Adolescence"%5BCorporate Author%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus).
Suicide and suicide attempts in adolescents.
[Pediatrics.](javascript:AL_get(this, 'jour', 'Pediatrics.');) 2007
Sep;120(3):669-76

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17766542>

**Medication errors are made during care for half of the children seen
at rural California emergency departments**

<http://www.ahrq.gov/research/sep07/0907RA3.htm>

# Maternal Weight Tied to Child\'s Body Composition at Age 9

Conclusions: Mothers with a higher pre-pregnant body mass index or a
larger mid-upper arm circumference during pregnancy tend to have
children with greater adiposity at age nine. The extent to which this is
attributable to genetic factors, the influence of maternal lifestyle on
that of her child, or maternal adiposity acting specifically during
pregnancy on the child\'s fat mass cannot be determined in this study.

[Gale
CR](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Gale CR"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Maternal Size in Pregnancy and Body Composition in Children. J
Clin Endocrinol Metab. 2007 Aug 7

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17684051>

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

**Aging and prevalence of CVD risk factors in American Indians: the
Strong Heart Study**\
Although mortality rates from CVD in the United States continue to
decrease, rates are rising among Native American Indians and are now
likely exceed those of the general population. Also, CVD is the leading
cause of death in American Indians beginning at age 45 compared with age
65 for the U.S. general population. As older American Indians age, more
of them develop hypertension, diabetes, and low levels of high density
lipoprotein cholesterol (HDL-C), all risk factors for developing
cardiovascular disease, according to this study.

The researchers examined the development of major CVD risk factors among
a rural group of 4,549 American Indians aged 45 to 74 during initial
examination in 1989 to 1991 and 8 years later. Their work was part of
the Strong Heart Study of 13 predominantly poor tribes of American
Indians. This aging group had decreased prevalence of smoking and no
consistent changes in adverse HDL-C and low-density
lipoprotein-cholesterol (LDL-C) profiles. However, the group had
substantial increases in the prevalence of hypertension and diabetes,
two of the most important CVD risk factors.

For example, prevalence of hypertension increased from 42.2 percent at
the initial examination to 61.3 percent among men 8 years later and from
36.4 percent to 60.3 percent among women. The prevalence of hypertension
in this group (aged 40-59) was comparable with the 65 percent
hypertension rate among an older group (60 years and older) that
participated in the National Health and Nutrition Examination Survey
(NHANES).

Diabetes remained markedly and disproportionately high in this age group
of Native American Indians. Prevalence increased from 41.4 to 47.4
percent among men and from 48.4 to 55.8 percent among women during the
study period---three times higher than the 16.4 percent of people with
diabetes among a similar age group in the 1994 NHANES. Men had a
nonsignificant decrease in LDL-C and men and women initially had rapid
increases in the prevalence of low HDL-C, which may have been affected
by factors such as diabetes or insulin resistance that were also
associated with this group.

[Rhoades
DA](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Rhoades DA"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
[Welty
TK](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Welty TK"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Aging and the prevalence of cardiovascular disease risk factors in
older American Indians: the Strong Heart Study.\
J Am Geriatr Soc. 2007 Jan;55(1):87-94.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17233690>

**Both coping and communication-enhancing and supportive counseling work
after cancer**

Women with greater than average increases in physician-rated physical
symptoms and/or women who were more expressive of positive emotions
benefited more from SC than women with lower than average increases in
symptom scores and/or women who were less expressive of positive
emotions. These findings suggest that both interventions may be
effective in treating depressive symptoms among patients with
gynecological cancer. Future research should evaluate whether bolstering
both psychological interventions with additional intervention sessions
and topics in the disease trajectory will result in persistent long-term
effects.

[Manne
SL](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Manne SL"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Coping and communication-enhancing intervention versus supportive
counseling for women diagnosed with gynecological cancers.\
J Consult Clin Psychol. 2007 Aug;75(4):615-28.

[**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17663615**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17663615)

Opioid Analgesia During Evaluation of Acute Abdominal Pain

[Clinical Question]{.underline}

Does providing early opioid analgesia during evaluation of acute
abdominal pain improve patient comfort or outcomes?

[Evidence-Based Answer]{.underline}

Providing early opioid analgesia to patients presenting with acute
abdominal pain does not affect or delay management decisions, but it
lessens pain intensity as rated by the patient.

[Practice Pointers]{.underline}

The differential diagnosis of acute abdominal pain includes many causes
that may require urgent surgical treatment or hospitalization such as
appendicitis, cholecystitis, bowel obstruction, kidney stones,
perforated peptic ulcer, pancreatitis, diverticulitis, pelvic abscesses,
and ectopic pregnancy. Most acute abdominal pain is visceral pain, which
is characterized by generalized aching, pressure, or sharp pain.
Visceral pain generally responds best to intraspinal local anesthetic or
nonsteroidal anti-inflammatory drugs or opioids administered via any
route.1 It is common practice to withhold opioid analgesia in patients
with acute abdominal pain. This practice is based on the theory that
opioids might mask symptoms, causing inaccurate or delayed diagnostic
and treatment decisions.

To evaluate the accuracy of this theory, the authors of this Cochrane
review searched for randomized controlled trials comparing opioid
analgesia with no analgesia in adults with abdominal pain. Six trials,
including 699 total patients, were identified. Most of the trials
compared 5 to 15 mg of morphine (Duramorph) with an equivalent amount of
saline. There were no significant differences between groups in changes
in the physical examination, errors in treatment decisions, inaccurate
diagnoses, nausea and vomiting, or length of hospitalization. The two
studies that reported patient comfort found significant improvement with
opioids. There was not enough information to determine if opioid use
causes a delay in the decision to operate, affects costs, or affects
morbidity. There was also insufficient evidence to suggest an optimal
treatment regimen.

Manterola C, Astudillo P, Losada H, Pineda V, Sanhueza A, Vial M.
Analgesia in patients with acute abdominal pain. Cochrane Database Syst
Rev 2007;(3):CD005660.

Cochrane Briefs <http://www.aafp.org/afp/20071001/cochrane.html>

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

#### Does Screening Mammography Benefit Women in Their 40s? {#does-screening-mammography-benefit-women-in-their-40s-1 .Style-Heading-4-+-Arial-14-pt-Underline}

Conclusion: The authors conclude that although women in their 40s who
undergo screening mammography have a lower risk of breast cancer-related
death, screening also results in harms that may be clinically
significant for some women. The authors suggest that an individualized
risk assessment, taking into account patient factors such as family
history and the value attached to a false-positive test result, may be
appropriate to guide decisions about breast cancer screening in this age
group.

Echoing the conclusions of the systematic review by Armstrong and
colleagues, an accompanying American College of Physicians clinical
practice guideline recommends individualized risk assessment and shared
decision making for women in their 40s who are considering breast cancer
screening.1 This guideline differs from recommendations of other
organizations. For example, the U.S. Preventive Services Task Force
(USPSTF) recommends screening mammography every one to two years for
women 40 years and older.2 The USPSTF is currently updating its
recommendation.

Armstrong K, et al. Screening mammography in women 40 to 49 years of
age: a systematic review for the American College of Physicians. Ann
Intern Med April 3, 2007;146:516-26

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17404354>

**CDC Updates Guidelines for Use of Influenza Vaccine and Antiviral
Agents**

This report updates the 2006 recommendations by CDC\'s Advisory
Committee on Immunization Practices (ACIP) regarding the use of
influenza vaccine and antiviral agents (CDC. Prevention and control of
influenza: recommendations of the Advisory Committee on Immunization
Practices \[ACIP\]. MMWR 2006;55\[No. RR-10\]). The groups of persons
for whom vaccination is recommended and the antiviral medications
recommended for chemoprophylaxis or treatment (oseltamivir or zanamivir)
have not changed. Estimated vaccination coverage remains \<50% among
certain groups for whom routine annual vaccination is recommended,
including young children and adults with risk factors for influenza
complications, health-care personnel (HCP), and pregnant women.
Strategies to improve vaccination coverage, including use of
reminder/recall systems and standing orders programs, should be
implemented or expanded. The 2007 recommendations include new and
updated information. Principal updates and changes include 1)
reemphasizing the importance of administering 2 doses of vaccine to all
children aged 6 months\--8 years if they have not been vaccinated
previously at any time with either live, attenuated influenza vaccine
(doses separated by \> or =6 weeks) or trivalent inactivated influenza
vaccine (doses separated by \> or =4 weeks), with single annual doses in
subsequent years; 2) recommending that children aged 6 months\--8 years
who received only 1 dose in their first year of vaccination receive 2
doses the following year, with single annual doses in subsequent years;
3) highlighting a previous recommendation that all persons, including
school-aged children, who want to reduce the risk of becoming ill with
influenza or of transmitting influenza to others should be vaccinated;
4) emphasizing that immunization providers should offer influenza
vaccine and schedule immunization clinics throughout the influenza
season; 5) recommending that health-care facilities consider the level
of vaccination coverage among HCP to be one measure of a patient safety
quality program and implement policies to encourage HCP vaccination
(e.g., obtaining signed statements from HCP who decline influenza
vaccination); and 6) using the 2007\--2008 trivalent vaccine virus
strains A/Solomon Islands/3/2006 (H1N1)-like (new for this season),
A/Wisconsin/67/2005 (H3N2)-like, and B/Malaysia/2506/2004-like antigens.

[Fiore
AE](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Fiore AE"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Prevention and control of influenza. Recommendations of the
Advisory Committee on Immunization Practices (ACIP), 2007. [MMWR Recomm
Rep.](javascript:AL_get(this, 'jour', 'MMWR Recomm Rep.');) 2007 Jul
13;56(RR-6):1-54

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17625497>

Effectiveness of Treatments for Type 2 Diabetes

[Background]{.underline}**:** About 90 percent of the 20 million persons
with diabetes in the United States have type 2 disease. The prevalence
of diabetes increases with age from 1.4 percent in persons younger than
45 years to 16.7 percent in persons 65 to 74 years of age. Patients with
type 2 diabetes have insulin resistance, increased hepatic glucose
production, reduced glucose clearance, and impaired beta cell insulin
secretion. Visceral fat increases insulin resistance. In the disease
course, postprandial glucose levels probably increase before fasting
glucose levels increase. Several studies have shown that tight glucose
control is associated with a decrease in the development and progression
of microvascular complications. The Diabetes Control and Complications
Trial, which evaluated patients with type 1 diabetes, found that a 2
percent reduction in A1C level was associated with a delay in the onset
and progression of retinopathy and nephropathy. Similar results were
found in trials evaluating patients with type 2 diabetes, but no trial
has specifically evaluated patients older than 60 years.

[Recommendations]{.underline}**:** Based on these trials, it is
recommended that patients achieve an A1C goal of less than 7 percent.
Modest weight loss can lower A1C levels by 1 percent, and moderate
exercise can lower A1C levels by 0.5 percent. Treatments include
medications that increase insulin secretion. Two new secretagogue
medications are available: exenatide injection (Byetta); and sitagliptin
(Januvia), a dipeptidyl peptidase type IV inhibitor. More established
treatment options include metformin (Glucophage) and thiazolidinediones,
which decrease insulin resistance; and alpha-glucosidase inhibitors,
which delay absorption of carbohydrates from the gastrointestinal tract.
Individually, antihyperglycemic medications reduce A1C levels by 0.5 to
2 percent. Combinations of medications with different mechanisms of
action have additive effects.

If patients do not achieve A1C goals with oral medications, insulin is
initiated. Other indications for insulin therapy include severe
symptoms, ketoacidosis, and preconception planning. When the fasting
glucose level is elevated, 10 units (or 0.1 units per kg) of nighttime
basal insulin is titrated upward until fasting blood glucose is at the
desired level. At lower A1C levels, postprandial blood glucose is likely
to contribute more to overall glucose control. When postprandial glucose
is elevated, patients should use short-acting insulins before meals and
should stop using insulin secretagogues while continuing insulin
sensitizers

Abrahamson MJ. A 74-year-old woman with diabetes. JAMA January 10,
2007;297:196-204.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17213403>

**The Critical Role of Pathology in Multidisciplinary Treatment of
Breast Cancer**

<http://www.medscape.com/viewprogram/7862?src=nlcmealert>

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

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

**Viral Hepatitis in Pregnancy**

**Summary of Recommendations and Conclusions**

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

-   Routine prenatal screening of all pregnant women by HBsAg testing is
    recommended.

-   Newborns born to hepatitis B carriers should receive combined
    immunoprophylaxis consisting of HBIG and hepatitis B vaccine within
    12 hours of birth.

-   Hepatitis B infection is a preventable disease, and all at-risk
    individuals, particularly health care workers, should be vaccinated.
    All infants should receive the hepatitis B vaccine series as part of
    the recommended childhood immunization schedule.

-   Breastfeeding is not contraindicated in women with HAV infection
    with appropriate hygienic precautions, in those chronically infected
    with hepatitis B if the infant receives HBIG passive prophylaxis and
    vaccine active prophylaxis, or in women with HCV infection.

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

-   Routine prenatal HCV screening is not recommended; however, women
    with significant risk factors for infection should be offered
    antibody screening.

-   Route of delivery has not been shown to influence the risk of
    vertical HCV transmission, and cesarean delivery should be reserved
    for obstetric indications in women with HCV infection.

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

-   The risk of transmission of hepatitis B associated with
    amniocentesis is low.

-   Susceptible pregnant women who are at risk for hepatitis B
    infections should be specifically targeted for vaccination.

Viral Hepatitis in Pregnancy. ACOG Practice Bulletin No. 86. American
College of Obstetricians and Gynecologists. Obstet Gynecol
2007;110:941--55.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17906043>

**Disclosure and Discussion of Adverse Events**

ABSTRACT: Disclosure and discussion of adverse events in health care is
desired by patients and championed by safety experts and policy makers.
Improving the disclosure process through policies, programmatic
training, and accessible resources will enhance patient satisfaction,
strengthen the physician--patient relationship, and most importantly,
promote a higher quality of health care.

Disclosure and Discussion of Adverse Events. ACOG Committee Opinion No.
380. American College of Obstetricians and Gynecologists. Obstet Gynecol
2007;110:957--8

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17906044>

**Routine Thyroid Screening Not Recommended for Pregnant Women**

ABSTRACT: Subclinical hypothyroidism is diagnosed in asymptomatic women
when the thyroid-stimulating hormone level is elevated and the free
thyroxine level is within the reference range. Thyroid hormones,
specifically thyroxine, are essential for normal fetal brain
development. However, data indicating fetal benefit from thyroxine
supplementation in pregnant women with subclinical hypothyroidism
currently are not available. Based on current literature, thyroid
testing in pregnancy should be performed on symptomatic women and those
with a personal history of thyroid disease or other medical conditions
associated with thyroid disease (eg, diabetes mellitus). Without
evidence that identification and treatment of pregnant women with
subclinical hypothyroidism improves maternal or infant outcomes, routine
screening for subclinical hypothyroidism currently is not recommended.

Subclinical Hypothyroidism in Pregnancy. ACOG Committee Opinion No. 381.
American College of Obstetricians and Gynecologists. Obstet Gynecol
2007;110:959--60.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17906045>

**Fetal Monitoring Prior to Scheduled Cesarean Delivery**

ABSTRACT: There are insufficient data to determine the value of fetal
monitoring prior to scheduled cesarean delivery in patients without risk
factors.

With the increasing rate of scheduled cesarean deliveries in the United
States, clinicians and hospitals must decide whether there is need to
determine fetal status prior to scheduled cesarean delivery. At the
present time there are insufficient data to determine the value of fetal
monitoring, either by electronic fetal heart rate monitoring or by
ultrasound, prior to scheduled cesarean delivery in patients without
risk factors. The decision to monitor the fetus prior to scheduled
cesarean delivery should be individualized. Presence of fetal heart
tones prior to surgery should be documented.

Fetal Monitoring Prior to Scheduled Cesarean Delivery. ACOG Committee
Opinion No. 382. American College of Obstetricians and Gynecologists.
Obstet Gynecol 2007;110:961.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17906046>

**Evaluation of Stillbirths and Neonatal Deaths**

ABSTRACT: A complete evaluation of a stillbirth or neonatal death may
explain the cause of death, direct further investigation of the family,
and be particularly valuable in counseling parents about recurrence
risks in future pregnancies. The results of the autopsy, placental
examination, laboratory tests, and cytogenetic studies should be
communicated to the involved clinicians and to the family of the
deceased infant in a timely manner.

Evaluation of Stillbirths and Neonatal Deaths. ACOG Committee Opinion
No. 383. American College of Obstetricians and Gynecologists. Obstet
Gynecol 2007;110:963--6.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17906047>

## AFP, American Family Physician {#afp-american-family-physician .Style-Heading-2-+-14-pt}

Repeat Cesarean Delivery vs. Planned Induction of Labor: Cochrane Briefs

Clinical Question

Should women who have had a previous low-transverse cesarean delivery
and who require **induction of labor be offered a trial of labor?**

Evidence-Based Answer

There are no randomized controlled trials (RCTs) of labor induction in
women with a low-transverse uterine scar. Observational studies indicate
that there is a small increased risk of uterine rupture and adverse
fetal outcomes, especially in women induced with prostaglandins.
Although induction in these patients is common practice in other
countries, based on these data, the American College of Obstetricians
and Gynecologists (ACOG) recommends that patients be discouraged from
induction of labor after a single previous low-transverse cesarean
delivery.

Practice Pointers

Based on retrospective cohort studies, most women with one previous
low-transverse cesarean delivery are candidates for vaginal birth and
should be counseled and offered a trial of labor.1,2 In a retrospective,
population-based review (including more than 20,000 total women), the
overall rate of uterine rupture after a previous low-transverse cesarean
delivery was 4.5 per 1,000; the rate was 1.6 per 1,000 with repeat
cesarean delivery and no labor, 5.2 per 1,000 with spontaneous labor,
7.7 per 1,000 with nonprostaglandin induction, and 24.5 per 1,000 with
prostaglandin induction.3

Another study showed that using oxytocin (Pitocin) to augment labor in
women with a previous low-transverse cesearan delivery increases the
risk of uterine rupture compared with spontaneous labor (8.7 versus 3.6
per 1,000); using oxytocin alone to induce labor increases the risk to
10.7 per 1,000. In women undergoing a trial of labor, the overall
uterine rupture-related perinatal death was 0.11 per 1,000. The rate of
perinatal hypoxic brain injury was 0.46 per 1,000 trials of labor
compared with zero in women who had a repeat cesarean delivery.4

In Australia, New Zealand, and Canada, it is common practice to offer a
trial of labor to women with a previous low-transverse cesarean delivery
who require induction. Most physicians prefer oxytocin induction rather
than cervical ripening with prostaglandins.

The authors of this Cochrane review found no RCTs to help further
determine the safety of labor induction after previous cesarean
delivery. In particular, it is not clear if prostaglandin use causes
adverse outcomes in women attempting vaginal birth or if having an
unfavorable cervix is simply a marker for complications.

The ACOG recommends that women who have had one previous low-transverse
cesarean delivery be counseled and offered a trial of labor. However,
because of limited and inconsistent evidence showing an increased risk
of uterine rupture, the ACOG recommends that women who require cervical
ripening or induction be discouraged from attempting a vaginal delivery.
If a woman attempts a vaginal delivery after a previous low-transverse
cesarean delivery, the ACOG recommends that her labor be managed in a
hospital with immediate access to emergency obstetric care.

Because data are limited, the individual patient and her physician
should make the ultimate decision. Vaginal birth after cesarean delivery
should not be attempted in a woman with a classic uterine incision or
history of transfundal surgery.2

Dodd JM, Crowther CA. Elective repeat caesarean section versus induction
of labour for women with a previous caesarean birth. Cochrane Database
Syst Rev 2006;(4):CD004906.

[**http://www.aafp.org/afp/20071001/cochrane.html**](http://www.aafp.org/afp/20071001/cochrane.html)

Hyperthyroidism

What are the effects of drug treatments for primary hyperthyroidism?

likely to be beneficial

**Antithyroid Drugs (Carbimazole, Propylthiouracil, and Thiamazole).**
We found no randomized controlled trials (RCTs) comparing antithyroid
drug treatment with placebo in persons with hyperthyroidism, although
there is consensus that treatment is beneficial. We found no RCTs
comparing antithyroid drugs (carbimazole, propylthiouracil, or
thiamazole) with each other. One systematic review found that fewer
persons relapsed with 18 months of higher-dose antithyroid drug
treatments than with six months; however, it found no significant
difference for more than 18 months compared with 12 to 18 months of
lower-dose treatment. One systematic review found that a similar number
of persons relapsed to hyperthyroidism with antithyroid drugs alone
(titration) and antithyroid drugs plus thyroxine (block replace). One
RCT found a similar proportion of persons who relapsed and who became
euthyroid between high- and low-dose thiamazole. However, it found that
adverse effects were lower with titration regimens. There have been
concerns about bone marrow suppression, neutropenia, and agranulocytosis
with antithyroid drugs. The doses of antithyroid drugs reported in the
studies are higher than are generally used in practice. (Based on
consensus because RCTs would be considered unethical.)

**Radioactive Iodine (in Persons Without Ophthalmopathy; May Increase
Ophthalmopathy in Persons with Graves\' Disease)**. We found no RCTs
comparing radioiodine with placebo in persons with hyperthyroidism,
although there is consensus that treatment is beneficial. Cohort studies
found that radioiodine can increase some thyroid and extrathyroid
cancers but not overall incidence of cancer. RCTs found that radioiodine
can worsen ophthalmopathy in persons with Graves\' disease compared with
other treatments. (Based on consensus because RCTs would be considered
unethical.)

unlikely to be beneficial

**Adding Thyroxine to Antithyroid Drugs (Carbimazole, Propylthiouracil,
and Thiamazole).** One systematic review found that a similar number of
persons relapsed to hyperthyroidism between antithyroid drugs plus
thyroxine (block replace) and antithyroid drugs alone (titration).
However, it found that adverse effects were higher with block replace
regimens. Another systematic review found no significant difference in
relapse between thyroxine and no treatment after antithyroid treatment.

What are the effects of surgical treatments for primary hyperthyroidism?

likely to be beneficial

**Thyroidectomy.** We found no RCTs comparing surgery with placebo in
persons with hyperthyroidism, although there is consensus that treatment
is beneficial. One systematic review and subsequent RCT found that total
thyroidectomy decreased hyperthyroidism and increased euthyroidism and
hypothyroidism compared with subtotal thyroidectomy. However, another
subsequent RCT found no significant difference among bilateral subtotal,
unilateral total, and contralateral subtotal, and total thyroidectomy in
improvement in Graves\' ophthalmopathy. The systematic review and RCTs
did not find sufficient evidence that adverse effects were worse with
total or subtotal thyroidectomy. (Based on consensus because RCTs would
be considered unethical.)

What are the effects of treatments for subclinical hyperthyroidism?

likely to be beneficial

**Any Antithyroid Treatment.** One controlled clinical trial found that
thyroid-stimulating hormone (TSH; also known as thyrotropin) and bone
mineral density were higher in women given radioiodine compared with no
treatment in women with no compression symptoms from a nodular goiter.

[Definition]{.underline}

Hyperthyroidism is characterized by high levels of serum thyroxine (T4),
high levels of serum triiodothyronine (T3), or both, and low levels of
TSH. Subclinical hyperthyroidism is characterized by decreased levels of
TSH (less than 0.1 mIU per L) but with levels of T4 and T3 within the
normal range (total T4: 5 to 11 mcg per dL \[64 to 142 nmol per L\];
total T3: 65.19 to 162.97 ng per dL \[1.0 to 2.5 nmol per L\], depending
on assay type). The terms hyperthyroidism and thyrotoxicosis are often
used synonymously; however, they refer to slightly different conditions.
Hyperthyroidism refers to overactivity of the thyroid gland leading to
excessive production of thyroid hormones. Thyrotoxicosis refers to the
clinical effects of unbound thyroid hormones, whether or not the thyroid
gland is the primary source.

Secondary hyperthyroidism owing to pituitary adenomas, thyroiditis,
iodine-induced hyperthyroiditis, and treatment of children and pregnant
or lactating women are not covered in this review. Hyperthyroidism can
be caused by Graves\' disease (diffusely enlarged thyroid gland on
palpation, ophthalmopathy, and dermopathy), toxic multinodular goiter
(thyrotoxicosis and increased radioiodine uptake with multinodular
goiter on palpation), or toxic adenoma (benign hyperfunctioning thyroid
neoplasm presenting as a solitary thyroid nodule). We have not included
treatment of Graves\' ophthalmopathy in this review, although we do
report on worsening of Graves\' ophthalmopathy with radioiodine. We also
have not included euthyroid sick syndrome (a condition occurring in
persons with, for example, pneumonia, acute myocardial infarction,
cancer, and depression; it is characterized by low levels of TSH and
T3).

[Diagnosis]{.underline}

The diagnosis of hyperthyroidism is established by a raised serum total
or free T4 or T3 hormone levels, reduced TSH level, and high radioiodine
uptake in the thyroid gland with features of thyrotoxicosis. The usual
symptoms are irritability, heat intolerance and excessive sweating,
palpitations, weight loss with increased appetite, increased bowel
frequency, and oligomenorrhea. Persons with hyperthyroidism also often
have tachycardia, fine tremors, warm and moist skin, muscle weakness,
and eyelid retraction or lag.

[Incidence and Prevalence]{.underline}

Hyperthyroidism is more common in women than in men. One study (2,779
persons in the United Kingdom; median age 58 years; 20 years\'
follow-up) found an incidence of clinical hyperthyroidism of 0.8 per
1,000 women a year (95% confidence interval \[CI\], 0.5 to 1.4 per 1,000
women a year). The study reported that the incidence was negligible in
men.

In areas with low iodine intake, the incidence of hyperthyroidism is
higher than in areas with high iodine intake because suboptimal iodine
intake induces nodular goiter, and by the time the nodules become
autonomic, hyperthyroidism develops. In Denmark, with moderate iodine
insufficiency, the overall incidence of hyperthyroidism (defined as low
levels of TSH) is 9.7 percent compared with 1.0 percent in Iceland with
high iodine intake. The prevalence in the Danish study was 38.7 per
100,000 women a year and two per 100,000 men a year.

[Etiology]{.underline}

Smoking is a risk factor, with an increased risk of Graves\' disease
(odds ratio \[OR\] = 2.5; 95% CI, 1.8 to 3.5) and toxic nodular goiter
(OR = 1.7; 95% CI, 1.1 to 2.5). In areas with high iodine intake, the
major cause is Graves\' disease, whereas nodular goiter is the major
cause in areas with low iodine intake. A correlation between diabetes
mellitus and thyroid dysfunction has been described. In a Scottish
population with diabetes, the overall prevalence of thyroid disease was
13 percent; the prevalence was highest in women with type 1 diabetes (31
percent). As a result of screening, new thyroid disease was diagnosed in
7 percent of persons with diabetes (hyperthyroidism in 1 percent).

[Prognosis]{.underline}

Clinical hyperthyroidism can be complicated by severe cardiovascular or
neuropsychiatry manifestations requiring hospital admission or urgent
treatment.

[Mortality]{.underline}

One population-based 10-year cohort study of 1,191 persons at least 60
years of age found a higher mortality among persons who had a low
initial TSH level. The excess in mortality was attributable to
cardiovascular diseases. However, the persons in this study who had a
low TSH level may have had a higher prevalence of other illnesses, and
adjustment was done only for age and sex, not for comorbidity. We found
another population-based study evaluating 3,888 persons with
hyperthyroidism. No increase was found in all-cause mortality or serious
vascular events in persons whose hyperthyroidism was treated and
stabilized, but an increased risk of dysrhythmias was found in persons
treated for hyperthyroidism compared with the standard population
(standardized incidence ratio = 2.71; 95% CI, 1.63 to 4.24).

[Atrial fibrillation in persons with overt hyperthyroidism]{.underline}

We found one cohort study evaluating the incidence of atrial
fibrillation in persons older than 60 years with low serum TSH
concentrations (0.1 mIU per L or less). It found that low serum TSH
concentrations were associated with an increased risk of atrial
fibrillation (diagnosed by electrocardiography) at 10 years (61 persons
with low TSH and 1,576 persons with normal TSH; incidence of atrial
fibrillation was 28 per 1,000 person-years with low TSH values versus 11
per 1,000 person-years with normal TSH values; 13 out of 61 \[21
percent\] persons with low TSH values versus 133 out of 1,576 \[8
percent\] persons with normal TSH values; relative risk \[as calculated
by Clinical Evidence\] = 2.53; 95% CI, 1.52 to 4.20). A population-based
study including 40,628 persons diagnosed with hyperthyroidism in Denmark
from 1977 to 1999 found that 8.3 percent were diagnosed with atrial
fibrillation or flutter within 30 days from the date of diagnosis of
hyperthyroidism.

[Quality of life]{.underline}

The quality of life of persons with thyroid problems can be reduced in
many ways if left untreated, and this can continue in the long term. In
a long-term follow-up (179 persons, treated for 14 to 21 years before
investigation), persons with Graves\' disease had diminished vital and
mental quality-of-life aspects even after years of treatment compared
with a large Swedish reference population.

[Fracture rate and bone mineral density]{.underline}

Hip and spine bone mineral density levels can decrease if
hyperthyroidism is untreated. However, when treated, bone mineral
density can increase to normal levels. The risk of hip fracture is also
higher in persons with hyperthyroidism. Progression from subclinical to
overt hyperthyroidism occurs in persons with nodular goiter but not in
persons found by screening without other signs of thyroid disease. A
meta-analysis (search date 1996), based on data from screening studies,
estimated that each year 1.5 percent of women and 1.0 percent of men who
had a low TSH level and normal free T4 and T3 levels developed an
elevated free T4 or T3 level. Ophthalmopathy is a complication of
Graves\' hyperthyroidism. Treatment can be problematic and usually
involves topical corticosteroids and external radiation of the eye
muscles.

[Thyroid volume and the nodularity of the gland influence the cure rate
of hyperthyroidism]{.underline}

In a controlled study of 124 persons with newly diagnosed
hyperthyroidism, remission rates were calculated after treatment with a
combined antithyroid drug plus T4 for about two years. Persons with
Graves\' disease who did not have a goiter or had a small goiter had a
significantly better outcome compared with persons with Graves\' disease
who had a medium- or large-sized goiter. Most persons with multinodular
goiter had a relapse within the first year after stopping medication.
<http://www.aafp.org/afp/20071001/bmj.html>

Clinical Evidence Concise,A Publication of BMJ Publishing Group

**Bell\'s Palsy: Diagnosis and Management (See also Patient Education)**

Bell\'s palsy is a peripheral palsy of the facial nerve that results in
muscle weakness on one side of the face. Affected patients develop
unilateral facial paralysis over one to three days with forehead
involvement and no other neurologic abnormalities. Symptoms typically
peak in the first week and then gradually resolve over three weeks to
three months. Bell\'s palsy is more common in patients with diabetes,
and although it can affect persons of any age, incidence peaks in the
40s. Bell\'s palsy has been traditionally defined as idiopathic;
however, one possible etiology is infection with herpes simplex virus
type 1. Laboratory evaluation, when indicated by history or risk
factors, may include testing for diabetes mellitus and Lyme disease. A
common short-term complication of Bell\'s palsy is incomplete eyelid
closure with resultant dry eye. A less common long-term complication is
permanent facial weakness with muscle contractures. Approximately 70 to
80 percent of patients will recover spontaneously; however, treatment
with a seven-day course of acyclovir or valacyclovir and a tapering
course of prednisone, initiated within three days of the onset of
symptoms, is recommended to reduce the time to full recovery and
increase the likelihood of complete recuperation. Am Fam Physician
2007;76:997-1002, 1004.

<http://lyris.aafp.org/t/1935903/16249464/520268/0/>

**Peptic Ulcer Disease (See also Patient Education)**

Peptic ulcer disease usually occurs in the stomach and proximal
duodenum. The predominant causes in the United States are infection with
*Helicobacter pylori* and use of nonsteroidal anti-inflammatory drugs.
Symptoms of peptic ulcer disease include epigastric discomfort
(specifically, pain relieved by food intake or antacids and pain that
causes awakening at night or that occurs between meals), loss of
appetite, and weight loss. Older patients and patients with alarm
symptoms indicating a complication or malignancy should have prompt
endoscopy. Patients taking nonsteroidal anti-inflammatory drugs should
discontinue their use. For younger patients with no alarm symptoms, a
test-and-treat strategy based on the results of *H. pylori* testing is
recommended. If *H. pylori* infection is diagnosed, the infection should
be eradicated and antisecretory therapy (preferably with a proton pump
inhibitor) given for four weeks. Patients with persistent symptoms
should be referred for endoscopy. Surgery is indicated if complications
develop or if the ulcer is unresponsive to medications. Bleeding is the
most common indication for surgery. Administration of proton pump
inhibitors and endoscopic therapy control most bleeds. Perforation and
gastric outlet obstruction are rare but serious complications.
Peritonitis is a surgical emergency requiring patient resuscitation;
laparotomy and peritoneal toilet; omental patch placement; and, in
selected patients, surgery for ulcer control. (Am Fam Physician
2007;76:1005-12, 1013 <http://www.aafp.org/afp/20071001/1005.html>

**Respiratory Distress in the Newborn**

The most common etiology of neonatal respiratory distress is transient
tachypnea of the newborn; this is triggered by excessive lung fluid, and
symptoms usually resolve spontaneously. Respiratory distress syndrome
can occur in premature infants as a result of surfactant deficiency and
underdeveloped lung anatomy. Intervention with oxygenation, ventilation,
and surfactant replacement is often necessary. Prenatal administration
of corticosteroids between 24 and 34 weeks\' gestation reduces the risk
of respiratory distress syndrome of the newborn when the risk of preterm
delivery is high. Meconium aspiration syndrome is thought to occur in
utero as a result of fetal distress by hypoxia. The incidence is not
reduced by use of amnioinfusion before delivery nor by suctioning of the
infant during delivery. Treatment options are resuscitation,
oxygenation, surfactant replacement, and ventilation. Other etiologies
of respiratory distress include pneumonia, sepsis, pneumothorax,
persistent pulmonary hypertension, and congenital malformations;
treatment is disease specific. Initial evaluation for persistent or
severe respiratory distress may include complete blood count with
differential, chest radiography, and pulse oximetry. Am Fam Physician
2007;76:987-94 <http://www.aafp.org/afp/20071001/987.html>

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

**Information women receive in pregnancy affects their childbirth
preferences after prior cesarean delivery**

<http://www.ahrq.gov/research/oct07/1007RA15.htm>

**Primary care doctors should encourage colorectal cancer screening and
clarify that screening is not just for those with symptoms**

<http://www.ahrq.gov/research/oct07/1007RA5.htm>

**Three clinical characteristics double the likelihood of hysterectomy
for women with common noncancerous pelvic conditions**

<http://www.ahrq.gov/research/sep07/0907RA13.htm>

**Three-fourths of low-income women are dissatisfied with their body
size 6 months after giving birth**

<http://www.ahrq.gov/research/oct07/1007RA14.htm>

**Women in Medicare and private managed care plans receive worse care
than men for cardiovascular disease and diabetes**

<http://www.ahrq.gov/research/sep07/0907RA7.htm>

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

**In Search of a Research Article?**

**The HSR Library- a branch of the NIH Library Provides Access to Many
Online Journals**

The HSR Library\'s online journal collection continues to expand. Select
from these options to access one of the titles now available:

-   Click on the ![](media/image3.png){width="1.0416666666666667in"
    height="0.2604166666666667in"} button that appears when searching
    *PubMed*®, *Scopus*™, *Web of Science*®, and other HSR Library
    databases.

> OR

-   Go to the [HSR Library](http://hsrl.nihlibrary.nih.gov/) website and
    select [Online
    Journals](http://hsrl.nihlibrary.nih.gov/ResearchTools/default.htm?srchType=OnlineJournals)
    under Quick Links.

-   OR

-   Search the HSR Library [Online
    Catalog](http://hsrl.nihlibrary.nih.gov/ResearchTools/Online+Catalog.htm)
    for a journal title.

If the Library does not subscribe to the journal you need, you may use
the [Order a
Document](http://hsrl.nihlibrary.nih.gov/LibraryServices/Order+a+Document.htm)
form to request electronic copies of articles.\
Links:

HSR Library <http://hsrl.nihlibrary.nih.gov/>

Online Journals
<http://hsrl.nihlibrary.nih.gov/ResearchTools/default.htm?srchType=OnlineJournals>

Online Catalog
<http://hsrl.nihlibrary.nih.gov/ResearchTools/Online+Catalog.htm>

Order a Document
<http://hsrl.nihlibrary.nih.gov/LibraryServices/Order+a+Document.htm>

For more information or help using your online library resources,
contact me at <cooperd@mail.nih.gov>

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

#### Breastfeeding, Amy Patterson, California Area\* {#breastfeeding-amy-patterson-california-area .Style-Heading-4-+-Arial-14-pt-Underline}

**Breastfeeding Promotion: Good Public Health Policy**

Why do we care about breastfeeding?

Babies, mothers, and society at large all benefit from breastfeeding.
Breast milk is a complete form of nutrition for infants. Breast milk has
just the right amount of fat, sugar, water, and protein needed for a
baby\'s growth and development, and is easier to digest than formula. As
a result, breastfed infants tend to gain less unnecessary weight. This
may carry over into adulthood. A number of studies have shown that
children and adults who were breastfed are less likely to be overweight
compared to those who were never breastfed. Breastfeeding has the
potential to help stem the epidemic of childhood and adult obesity in
the United States.

Breastfeeding also promotes good health. Breast milk contains antibodies
that can protect infants from bacterial and viral infections; formula
does not contain these antibodies. Breastfed babies are less likely to
be hospitalized for illness than formula-fed babies. 1 Breastfed infants
also have lower rates of asthma and diabetes later in life. Research
suggests that exclusive breastfeeding for at least the first 4 months is
preventive for asthma and other allergies in children. 2 Breastfeeding
has also been correlated with a lower prevalence of type 2 diabe­tes in
adult American Indians. 3,4

By contrast, babies who are not breastfed are sick more often and have
more doctor visits. They are more likely to develop a wide range of
infectious diseases including ear infections, diarrhea, and respiratory
illnesses. The difference in health status is stark: infants who are not
breastfed are 21% more likely to die within their first year than
breastfed babies in the in the U.S. 5 A few studies suggest that infants
who are not breastfed have higher rates of sudden infant death syndrome
(SIDS) in the first year of life. 6,7 The health disparities continue
even after the first year; people who were not breastfed have higher
rates of type 1 and type 2 diabetes, lymphoma, leukemia, Hodgkin\'s
disease, overweight and obesity, high cholesterol and asthma. 8

The benefits of breastfeeding extend to nursing mothers as well. Nursing
uses up extra calories, making it easier to lose weight gained during
pregnancy. Breastfeeding lowers the long-term risk of breast and ovarian
cancers, and possibly the risk of hip fractures and osteoporosis after
menopause. Breastfeeding has also been linked with a reduced risk of
type 2 diabetes, and the protective effect increases with exclusivity
and duration. 9 Exclusive breastfeeding (meaning no supplementing with
formula) also delays the return of normal ovulation and menstrual
cycles, though it should not be relied upon as a fail-safe form of birth
control.

Breastfeeding also makes a nursing mother's life easier; it saves time
and money, and is more convenient than bottle feeding. There are no
bottles and nipples to sterilize, and no risk of contamination, as there
is with formula. A mother can give her baby immediate satisfaction by
providing breast milk when her baby is hungry. Breastfeeding requires a
mother to take some quiet time for herself and her baby, and helps them
bond. Physical contact is important to newborns and can help them feel
more secure, warm and comforted.

1.  Ball TM, Wright AL. Health care costs of formula feeding in the
    first year of life. Pediatrics. 1999 Apr;103(4 Pt 2)870-6.

2.  Kull I, Wickman M, Lilja G, Nordvall SL, Pershagen G. Breastfeeding
    and allergic diseases in infnats - a prospective birth cohort study.
    Arch Dis Child. 2002 Dce;87(6):478-81.

3.  Pettitt DJ, Forman MR, Hanson RL, Knowler WC, Bennett PH.
    Breastfeeding and incidence of non-insulin-dependent diabetes
    mellitus in Pima Indians. Lancet. 1997Jul 19;350(9072):166-8.

4.  Young TK, Martens PJ, Taback SP, Sellers EA, Dean HG, Cheang M,
    Flatt B.Type 2 Diabetes mellitus in children:prenatal and early
    infancy risk factors among Native Canadians. Arch Pediatr Adolesc
    Med. 2002 Jul;156(7):651-5.

5.  Chen A, Rogan WJ. Breastfeeding and the risk of postneonatal death
    in the United States.Pediatrics. 2004 May;113(5):e435-9.

6.  Ford RP, Taylor BJ, Mitchell EA, Enright SA, Stewart AW, Becroft DM,
    Scraff R, Hassall IB, Barry DM, Allen EM, et al. Breastfeeding and
    the risk of sudden infant death syndrome. int J Epidemiol. 1993
    Oct;22(5):885-90.

7.  Mitchell EA, Tuohy PG, Brunt JM, Thompson JM, Clements MS, Stewart
    AW,

> Ford RP, Taylor BJ. Risk factos for sudden infant death syndrome
> following the prevention campaign in New Zealand. Pediatrics. 1997
> Nov;100(5):835-40.

8.  Gartner LM, Morton J, Lawrence RA, Naylor AJ, O\'Hare D, Schanler
    RJ, Eidelman AI; American Academy of Pediatrics Section on
    Breastfeeding. Breastfeeding and the use of human milk. Pediatrics.
    2005 Feb;115(2):496-506.

9.  Stuebe AM, Rich-Edwards JW, Willett WC, Manson JE, Michels KB.
    Duration of lactation and incidence of type 2 diabetes. JAMA. 2005
    Nov 23;294(20):2601-10.

Note: Tune in next month for the next installment "Getting it Right"

If you would like more information and prefer to use one comprehensive
article,

please consider:

> Ips, Chung M. Raman G. Chew P, Magula N. De Vine D, Trikalinos T, Lau
> J. Breastfeeding and Maternal and Infant Health Outcomes in Developed
> Countries. Evidence Report/Technology Assessment . 2007 Apr
> (153):1-186.

\*by Amy Patterson (PhD, Public Health Analyst, California Area Indian
Health Service)

<Suzan.Murphy@ihs.gov>

**Other**

**Early skin-to-skin contact for mothers and their newborn infants
improves outcomes**

BACKGROUND: Mother-infant separation postbirth is common in Western
culture. Early skin-to-skin contact (SSC) begins ideally at birth and
involves placing the naked baby, covered across the back with a warm
blanket, prone on the mother\'s bare chest. According to mammalian
neuroscience, the intimate contact inherent in this place (habitat)
evokes neurobehaviors ensuring fulfillment of basic biological needs.
This time may represent a psychophysiologically \'sensitive period\' for
programming future behavior.

CONCLUSIONS: The intervention may benefit breastfeeding outcomes, early
mother-infant attachment, infant crying and cardio-respiratory
stability, and has no apparent short or long-term negative effects.

[Moore
ER](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Moore ER"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et a; Early skin-to-skin contact for mothers and their healthy newborn
infants. [Cochrane Database Syst
Rev.](javascript:AL_get(this, 'jour', 'Cochrane Database Syst Rev.');)
2007 Jul 18;(3):CD003519

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17636727>

**Breast milk: Greater mental development and fewer
re-hospitalizations**

Extremely low birth weight premature infants who received breast milk
shortly after birth, while still in intensive care units, had greater
mental development scores at 30 months than did infants who were not fed
breast milk, reported researchers in an NIH network. Moreover, infants
fed breast milk were less likely to have been re-hospitalized after
their initial discharge than were the infants not fed breast milk.

CONCLUSIONS: Beneficial effects of ingestion of breast milk in the NICU
persist at 30 months\' corrected age in this vulnerable extremely low
birth weight population. Continued efforts must be made to offer breast
milk to all extremely low birth weight infants both in the NICU and
after discharge.

[Vohr
BR](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Vohr BR"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Persistent beneficial effects of breast milk ingested in the
neonatal intensive care unit on outcomes of extremely low birth weight
infants at 30 months of age. Pediatrics. 2007 Oct;120(4):e953-9.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17908750>

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

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

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

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

\-[Group Prenatal Care Improves Pregnancy Outcomes at No Additional
Cost](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_AOM.cfm)

\-[Rebuilding Iraq one patient at a time: You can be part of the
solution](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Coll.cfm)

\-[Do Unsutured Second-Degree Perineal Lacerations Affect Postpartum
Outcomes?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_HT.cfm#ob)

\-[Cervical cancer differences disappear in rural women after
controlling for poverty and
race](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_HT.cfm#gyn)

\-[How to improve psychosocial problems at well child care
visits?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_HT.cfm#child)

\-[Why Hasn\'t This Patient Been Screened for Colon
Cancer?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_HT.cfm#chrIll)

\-[Management of Delivery of a Newborn With Meconium-Stained Amniotic
Fluid](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#acog)

\-[In Search of a Research
Article?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#AskLib)

\-[A pacifier by any other
name....](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#breast)

\-[October is Domestic Violence Awareness
Month](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#dv):
Materials available

\-[Advance Provision for Emergency Oral Contraception Reduces Post
Coital
Interval](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#fp)

\-[What\'s the first course of action for this couple that\'s trying to
conceive?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#faq)

\-[Bar code medication administration changes nurses\'
work](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#it)

\-[Prevention of Mother-to-Child HIV Transmission: An Innovative Program
in
Cameroon](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#ih)

\-[AI / AN researchers on perinatal depression requesting names of
interested
individuals](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#headlines)

\-[Endometriosis: Where is the real
truth?](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#mmtour)

\-[Estrogen Protects Women's Brains Prior to
Menopause](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#menopause)

\-[Piercing the veil: the marginalization of midwives in the United
States](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#MidWives)

\-[Evaluation of the pregnant patient for non-obstetric
surgery](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0907_Feat.cfm#navajo)

\-[Memories, As a Public Health Nurse on the
Navajo](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#nurseCorner)\*

\-[Common Questions about HPV and Cervical Cancer: For Women Who Have
HPV](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#owh)

\-[Fracture Outcomes in Women Discontinuing
Alendronate](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#oste)

\-[Procedure-related complications of amniocentesis and CVS are
small](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#periPicks)

\-[Chronic Renal Disease is Part of Primary
Care](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0907_Feat.cfm#pcfhttp://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_Feat.cfm)

\-[Call for re-evaluation of gestational diabetes diagnosis and
treatment
criteria](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#stillW)

\- [Ovarian Cancer: Pinn Point on Women's
Health](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1007_Feat.cfm#wheadlines)

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/CCCC_v5_09.pdf>

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

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

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

#### ![](media/image4.png){width="4.655555555555556in" height="0.1763888888888889in"}  {#section-7 .Style-Heading-4-+-Arial-14-pt-Underline}

![](media/image5.png){width="1.667361111111111in"
height="2.498611111111111in"}\
The FVPF launches two new posters for use in American Indian/Alaska
Native (AI/AN) communities! The posters, part of two current FVPF
campaigns: Coaching Boys into Men and Fathering After Violence, may be
used in any community setting frequented by men and boys. This may
include tribal offices, schools, gyms, batter's intervention programs,
health care facilities and visitation centers.\
\
About the Coaching Boys Into Men Campaign\
\
Men -- as fathers, brothers, coaches, teachers, uncles and mentors --
are in a unique position to prevent domestic violence through action and
conversation. Over the past five years, the Family Violence Prevention
Fund (FVPF) has refined its public education strategy to focus on men
and boys as a critical part of the national movement to end violence
against women and girls. Coaching Boys into Men (CBIM) is the result of
this shift - helping stop violence before it starts. The campaign's core
goal is to inspire men to teach boys to respect women and that violence
never equals strength. Learn more about the [Coaching Boys Into Men
Campaign](http://www.endabuse.org/cbim/). Alternate poster versions are
available for diverse communities.\
\
The AI/AN CBIM poster was developed by a committee of leaders working in
AI/AN communities and on violence prevention and is co-sponsored by
[Mending the Sacred Hoop Technical Assistance
Project](http://msh-ta.org/).\
\
[Download and print this CBIM AI/AN
poster](http://endabuse.org/programs/publiceducation/files/CBIM-AIAN.pdf)

<http://endabuse.org/programs/publiceducation/files/CBIM-AIAN.pdf>

**Resources**

<http://fvpfstore.stores.yahoo.net/coaching-boys-into-men-aian-poster.html>

and

<http://www.endabuse.org/programs/healthcare/>

**Aberdeen requesting DV and sexual assault pamphlets or CD-ROM
resources**

Willeen Druley MCH / WH coordinator at Aberdeen Area is requesting your
assistance if you happen to have access to any DV and sexual assault
pamphlets or CD-ROM resources.

<Willeen.Druley@ihs.gov>

**Patient Self-Administered Report Effective to Screen for Domestic
Violence **

CONCLUSIONS: Domestic violence is common, and we found that most
patients and clinicians are comfortable with domestic violence screening
in urban family medicine settings. Patient self-administered domestic
violence screening is as effective as clinician interview in terms of
disclosure, comfort, and time spent screening.

[Chen
PH](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Chen PH"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Randomized comparison of 3 methods to screen for domestic violence
in family practice. [Ann Fam
Med.](javascript:AL_get(this, 'jour', 'Ann Fam Med.');) 2007
Sep-Oct;5(5):430-5.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17893385>

**Domestic violence victims have higher health care use and costs than
other women, even long after the abuse has ended**

<http://www.ahrq.gov/research/sep07/0907RA11.htm>

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

**Moderate- and High-Intensity Resistance Training Improves Cognitive
Function in Elderly**

CONCLUSIONS: Moderate- and high-intensity resistance exercise programs
had equally beneficial effects on cognitive functioning.

[Cassilhas
RC](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Cassilhas RC"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al The impact of resistance exercise on the cognitive function of the
elderly.\
Med Sci Sports Exerc. 2007 Aug;39(8):1401-7.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17762374>

**Fall Injury Episodes Among Noninstitutionalized Older Adults: United
States, 2001--2003**

The annualized rate of fall injury episodes for noninstitutionalized
adults aged 65 years and over in 2001--2003 was 51 episodes per 1,000
population. Rates of fall injuries increased with age, and were higher
for women compared with men. The most common cause of fall injuries
among older adults was slipping, tripping, or stumbling, and most fall
injuries occurred inside or around the outside of the home. Nearly 60
percent of older adults who experienced a fall injury visited an
emergency room for treatment or advice. Nearly one-third of older adults
experiencing a fall injury needed help with activities of daily living
as a result, and over one-half of these persons expected to need this
help for at least 6 months. A similar percentage experienced limitation
in instrumental activities of daily living as a result of fall injuries.
<http://www.cdc.gov/nchs/data/ad/ad392.pdf>

**Maintenance Antidepressant Treatment Improves Well-Being in Late-Life
Depression**

CONCLUSION: Maintenance antidepressant pharmacotherapy is superior to
placebo in preserving improvements in overall well-being achieved with
treatment response in late-life depression. No such benefit was seen
with interpersonal psychotherapy.

[Dombrovski
AY](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Dombrovski AY"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Maintenance treatment for old-age depression preserves
health-related quality of life: a randomized, controlled trial of
paroxetine and interpersonal psychotherapy.\
J Am Geriatr Soc. 2007 Sep;55(9):1325-32.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17767673>

**[The Last Hours of Living: Practical Advice for
Clinicians](http://www.medscape.com/viewprogram/5808) (Medscape)**

Preparing for the Last Hours of Life\
Physiologic Changes and Symptom Management\
Two Roads to Death\
When Death Occurs\
Notifying Others of the Death\
Pronouncing Death

<http://www.medscape.com/viewarticle/542262>

[**Principles of Effective Pain Management at the End of
Life**](http://www.medscape.com/viewprogram/6079)

Case based CME module, Medscape

<http://www.medscape.com/viewarticle/545562>

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

**Transdermal hormonal contraception: benefits and risks**

Transdermal drug delivery systems have been available in the United
States for \>20 years. Since the introduction of the first transdermal
patch (scopolamine) for the treatment of motion sickness, \>35
transdermal patch products have been approved by the US Food and Drug
Administration for a variety of indications that include hormone
replacement therapy, nicotine replacement therapy, chronic pain
(fentanyl), angina (nitroglycerin), hypertension (clonidine), and more
recently, overactive bladder (oxybutynin), and contraception (ethinyl
estradiol/norelgestromin). Clinical data demonstrated the efficacy and
safety of the contraceptive patch; however, concerns regarding estrogen
levels and reports of venous thromboembolism led to the development of 2
epidemiologic studies and, subsequently, revised product labeling.
Despite this, the contraceptive patch may be an appropriate option for
some patients

[Burkman
RT](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Burkman RT"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus).
Transdermal hormonal contraception: benefits and risks. Am J Obstet
Gynecol. 2007 Aug;197(2):134.e1-6.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17689623>

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

#### Oral Contraceptive Use Linked to Cancer Risk {#oral-contraceptive-use-linked-to-cancer-risk-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### The evidence suggests that current users of combined oral contraceptives have an increased risk of cancer of the breast, cervix, and liver compared with non-users. The risks of breast and cervical cancer decline after stopping oral contraception, returning to that of non-users within about 10 years. Current users of combined oral contraceptives, however, have a reduced risk of cancer of the endometrium, ovaries, and, possibly, colorectum {#the-evidence-suggests-that-current-users-of-combined-oral-contraceptives-have-an-increased-risk-of-cancer-of-the-breast-cervix-and-liver-compared-with-non-users.-the-risks-of-breast-and-cervical-cancer-decline-after-stopping-oral-contraception-returning-to-that-of-non-users-within-about-10-years.-current-users-of-combined-oral-contraceptives-however-have-a-reduced-risk-of-cancer-of-the-endometrium-ovaries-and-possibly-colorectum .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: In this UK cohort, oral contraception was not associated with an overall increased risk of cancer; indeed it may even produce a net public health gain. The balance of cancer risks and benefits, however, may vary internationally, depending on patterns of oral contraception usage and the incidence of different cancers. {#conclusion-in-this-uk-cohort-oral-contraception-was-not-associated-with-an-overall-increased-risk-of-cancer-indeed-it-may-even-produce-a-net-public-health-gain.-the-balance-of-cancer-risks-and-benefits-however-may-vary-internationally-depending-on-patterns-of-oral-contraception-usage-and-the-incidence-of-different-cancers. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Hannaford PC](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Hannaford PC"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus) et al Cancer risk among users of oral contraceptives: cohort data from the Royal College of General Practitioner\'s oral contraception study. BMJ. 2007 Sep 29;335(7621):651. {#hannaford-pc-et-al-cancer-risk-among-users-of-oral-contraceptives-cohort-data-from-the-royal-college-of-general-practitioners-oral-contraception-study.-bmj.-2007-sep-293357621651. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17855280**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17855280) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch17855280 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Featured Website David Gahn, IHS MCH Portal Web Site Content
Coordinator**

**It was low hanging fruit before: Now it is even easier - Perinatology
Corner**

#### The Perinatology Corner, a great Indian Health resource on many obstetric topics, plus free CME, has just gotten easier to use. Once you create an IHS login username and password (which takes about 30 seconds) the system will remember you and make it easier each time you want to take another module.

#### [Submitting a Posttest]{.underline}

To take a posttest, log in with an IHS login now

The link to log in is in the leftside menu of each module\'s posttest
page. (You will only need to log in once to any page that provides the
link in the IHS site.) Once you fill in the registration information on
the posttest page of one module, the demographics will self populate all
future modules, thereby saving you time and effort.

You can take and retake any posttest. Any time you take a posttest, an
email will sent to you with answers. You only get credit for the first
time you take a module\'s posttest.

You can change your contact information (except their email address,
through this system) in the form of any module\'s posttest once you\'ve
submitted your contact information in the first posttest you take.

You can update your contact information on the form when you\'re
submitting a new posttest, when retaking a test with or without retaking
the posttest.

Here is how to complete the Posttest and Evaluation\
It is easy. Ptease log in and the Posttest page will become available

> -If you have logged into the to the Indian Health registration before,
> then go directly to Login (choose the \"Login\" link):
>
> Hit Login or Register
>
> -If haven\'t completed the Registration process before, it is easy,
> secure, and relatively quick.\
> -It will also allow you to take future modules without having to
> repeat your contact information each time.\
> Choose the \"Register\" link:

Once you have successfully logged into your web account, then hit the
Return button on the\
Successful Login page and it will take you to the Posttest and
Evaluation

**Perinatology Corner**

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

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

**Q.  How can we best manage Jehovah's Witnesses during pregnancy?**

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

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

**November 2007 -- Highlights**

-Challenges in Pediatric Rheumatic Disease: Special Issues with Native
Children

-Study of Virus Etiologies of Respiratory Hospitalizations in Alaska
Native children

-Cultural challenges to biotechnology: Native American genetic resources
and the concept of cultural harm

\- Widening socioeconomic disparities in US childhood mortality,
1969-2000

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

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

**National Release - RPMS Electronic Health Record, Version 1.1**

OIT is VERY pleased to announce the certification of the RPMS Electronic
Health Record (EHR) graphical user interface (GUI) application, version
1.1.

The RPMS EHR GUI functionality was tested at the following alpha and
beta test sites:  Wind River Service Unit, Cherokee Indian Hospital,
Carl Albert Indian Hospital, Warm Springs Health and Wellness Center,
Fort Defiance Indian Hospital, Whiteriver Indian Hospital, and Phoenix
Indian Medical Center.  Each facility has endorsed the certification and
release of EHR v1.1. 

EHR v1.1 routines and documentation adhere to the 2006 RPMS Programming
Standards and Conventions.  A number of minor functional issues have
been identified by users at test sites, and these will be addressed in
upcoming application patches. 

Release Criteria

EHR v1.1 should be installed ONLY at sites that are already running the
RPMS EHR v1.0.  Although v1.0 is not a technical prerequisite for v1.1,
certain EHR infrastructure applications including Order Entry v3 and
Outpatient Pharmacy v7, among others, are prerequisites.  These
applications continue to be released in a controlled manner by OIT to
sites that have met specific preparation criteria. 

 

It is very strongly recommended that all installations of EHR v1.1 be
coordinated and scheduled with the Information Systems Coordinator (ISC)
and other technical and support staff at your Area Office.  This is to
ensure availability of support at the Area level should issues be
encountered during installation and configuration of the application. 
OIT has asked the ISCs to provide a schedule of planned installations so
that OIT may anticipate v1.1 support calls. 

Functionality

EHR v1.1 includes a wide variety of enhancements to the Electronic
Health Record interface.  The EHR configuration menus have been
consolidated and greatly simplified to make EHR management easier for
Clinical Application Coordinators.  Functional enhancements include
numerous changes to the medication management component, enhancements to
the documentation of patient education, improvements in documenting
refusals, and the ability to configure Web links to speed access to
information and decision support, among many others.  Errors and bugs
identified since the release of v1.0 and not addressed in prior patches
have been corrected, and previous exceptions to the Standards and
Conventions have been resolved.  A new EHR Technical Manual has been
delivered and all prior guides and manuals have been updated.

 

The new release of this software is available from the IHS Website,
<http://www.ihs.gov/Cio/RPMS/index.cfm?module=home&option=software>

**National Release - BI Immunization System, Version 8.2**

OIT is pleased to announce the release of a new version of the
immunization package. Please contact your site manager for further
information.

The BI Immunization Version 8.2 has the following new features.

[Human Papillomavirus (HPV) vaccine Forecasting]{.underline}

Version 8.2 provides two forecasting options for HPV vaccine. Providers
can choose to forecast HPV vaccine for 11 to 18-year-old or 11 to
26-year-old females.

[New Adolescent Report]{.underline}

There is a new adolescent immunization report which provides
immunization coverage rates for single vaccines (HepB, HepA, Td/Tdap,
MMR, Varicella, MeningCV4,Influenza and HPV vaccines) and combinations
(e.g., 3HepB, 2MMR, 1Var, 1Td/Tdap) for adolescents 11 to 17-years-old
with 2 visits in the past 3 years. This report follows the logic and age
groups that the Centers for Disease Control (CDC) is using for the new
Adolescent National Immunization Survey.

[New Lot Number Inventory Tracking]{.underline}

Version 8.2 contains a new Vaccine Inventory system that monitors
vaccine stock by lot number. When the pharmacist/manager enters a new
lot number, they will input the expiration date, source (VFC, non-VFC),
starting number of doses, and unused doses. The "doses unused" decreases
each time an immunization of that lot number is entered into RPMS. The
provider will get an alert notice if they enter an expired vaccine lot,
or if the supply is low.

[Forecasting for Rotavirus (v8.1\*1 patch]{.underline})

There is a new rotavirus forecasting option that forecasts rotavirus
(rota-pent, RotaTeq®) vaccine for all infants at 2 months (or 6 weeks),
4 months, and 6 months.

Influenza vaccine routinely forecast for children 6 - 59 months (v8.1\*1
patch)

The routine influenza forecasting for children was changed from 6 - 23
months to 6 - 59 months to match recommendations from the Advisory
Committee on  Immunization Practices.

[Second dose of Varicella Forecast at 4 - 18 Years (v8.1\*1
patch)]{.underline}

A second dose of Varicella vaccine is forecast starting at age 4 years 0
months. The minimal interval between the first and second doses is 3
months; however, a second dose is valid if there are at least 4 weeks
between the first and second doses.

[MMR maximum age 18 years (v8.1\*1 patch)]{.underline}

No forecasting option will forecast MMR vaccine after 18 years 364 days,
regardless of previous vaccine history. <Theresa.Cullen@ihs.gov>

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

**Treating schizophrenia in poorer countries: Old dilemmas and new
directions**

Although for many years the conventional wisdom in international
psychiatry held that schizophrenia had a better prognosis in the Third
World than in the First, this belief has recently been called into
question. Evidence suggests that conditions for the chronically mentally
ill may be changing for the worse, in part because rapid social and
economic change are undermining the family-based care that has
traditionally provided for people with schizophrenia. (Interestingly,
income inequality and urbanization are linked with poor outcomes even
more strongly than poverty per se). Mental health has sometimes been
called the Cinderella of international public health, and with good
reason. Developing countries typically devote less than 1% of their
already limited health budgets to mental health, and have on average one
to two qualified mental health providers for every million population --
a population that should include three to five thousand schizophrenics,
as rates of schizophrenia appear to vary little among societies. Little
or no community-based care for the chronically mentally ill exists, and
psychiatric hospitals are few, large, and undersupplied with staff and
therapies. Some evidence suggests that human rights abuses of the
mentally ill are on the rise.

In a recent PLoS Medicine article, three psychiatrists with experience
in India and Pakistan propose new models for treating schizophrenics.
The director of a schizophrenia research foundation, R. Thara, argues
that simply treating more people with antipsychotics will reduce stigma
by pushing communities to accept medical (rather than magical or
religious) explanations for psychotic disorders. National mental health
programs can follow up with campaigns intended to destigmatize
schizophrenia the way previous campaigns worked to destigmatize leprosy.
Saeed Farooq, a psychiatrist from Pakistan, takes a similar approach,
but one built on the model of tuberculosis. Farooq proposes that
patients with schizophrenia be given free antipsychotic drugs under
supervision for two years, echoing the "Directly Observed Therapy,
Short-Course" (DOTS) used more-or-less successfully in many countries to
control tuberculosis. Families already provide the most expensive care
for these patients, Farooq argues; surely the state can shoulder a small
part of the burden by paying for the drugs. Like Thara, he believes
effective treatment will reduce stigma and insure that more sufferers
will seek help. Vikram Patel proposes a more integrated model in which
minimally trained community health workers act as case finders,
referring patients to health practitioners who can make the diagnosis
and initiate drug treatment. The patients are then referred back to the
community health worker, who will follow up for medication adherence,
refer to social welfare organizations, and help to strengthen employment
options.

All three models use antipsychotics as a lever to change community
perceptions of schizophrenia. All three are hazy on issues of cost and
the possibility of coercion. At least one of these strategies (the DOTS
analogue) is being tested in an RCT now. We should soon have better
information on methods that work -- or don't work -- for this serious
problem in international health.

Patel V, Farooq S, Thara R. What is the best approach to treating
schizophrenia in developing countries? PLoS Medicine 4(6):e159, June
2007

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17579508>

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

**Having more family meals during adolescence is associated with
improved diet quality**

The article describes meal patterns of young adults and examines
relationships between family meals during adolescence and dietary
quality and meal patterns during early young adulthood. Results of this
study indicate that having more family meals during adolescence is
associated with improved diet quality during young adulthood.

The authors found that

\* The frequency of family meals at Time 1 was as follows: 1-2 times per
week for 22.1% of adolescents, 3-6 times per week for 41.9% of
adolescents, and 7 or more times per week for 18.6% of adolescents. The
prevalence of never having family meals was 17.4%.

\* Time 1 family meal frequency was positively associated with Time 2
dietary intake as follows: among females, intakes of vegetables,
magnesium, potassium, and fiber were directly associated and soft drinks
inversely associated with Time 1 family meals; among males, intakes of
fruit, vegetables, dark-green and orange vegetables, and potassium were
directly associated with Time 1 family meals.

\* Associations between Time 1 family meals and Time 2 meal patterns
were significant only for dinner frequency among males. Among males,
higher family meal frequency at Time 1 predicted a higher priority for
social eating and meal structure at Time 2.

\* Stratified analyses conducted according to residence showed few
differences between young adults living with their parents or away from
their parents, and differences did not follow a consistent pattern.

Based on the study findings, the authors conclude that food and
nutrition professionals should encourage families to share meals as
often as practically possible.

Larson NI, Neumark-Sztainer D, Hannan PJ, et al. 2007. Family meals
during adolescence are associated with higher diet quality and healthful
meal patterns during young adulthood. Journal of the American Dietetic
Association 107(9):1502-1510. Abstract available at

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17761227>

**Telemedicine Meeting the Health Care Needs of Children**

Telemedicine, when applied appropriately, can address the health care
needs of children in California, particularly children from families
with low incomes who live in medically underserved areas. The issue
brief is the third in the Digital Opportunity for Youth series produced
by The Children\'s Partnership. Content includes (1) an overview of the
benefits of telemedicine for children and families, health systems, and
communities;

\(2\) the challenges associated with the successful adoption of
telemedicine; and (3) recommendations for ensuring that telemedicine
reaches its full potential in meeting the health care needs of
California\'s most vulnerable children. The use of telemedicine is
specifically illustrated in the following areas: emergency and critical
care, oral health, vision screening, mental health, children with
special health care needs, home health care, telepharmacy, child abuse
evaluations, educating families, supporting families, supporting rural
health professionals, providing medical education, disease management,
caring for children where they are located, and language translation.
Information on the history of telemedicine and additional resources from
the Children\'s Partnership are included.

<http://www.childrenspartnership.org/AM/Template.cfm?Section=Home&Template=/CM/ContentDisplay.cfm&ContentID=11343>

**Challenges in the prevention of mother to child HIV transmission**

Much progress has been made in PMTCT \[prevention of mother-to-child
transmission\] of HIV both in the United States and internationally.

However, the challenges of complete elimination of new perinatal HIV
infections will depend on not only PMTCT interventions worldwide but
also effective primary HIV prevention interventions among adolescents
and young adults. PMTCT in the United States and Europe has been a major
success story. However, translation of findings from research studies
into successful national PMTCT programs and health policies has not been
optimal. The supplement focuses on achievements, issues, and challenges
in PMTCT in the United States and in settings where resources are
limited. The article presents information on the experience and on
remaining gaps and challenges in perinatal HIV prevention efforts in the
United States, international experience in PMTCT, international trials
aimed at reducing transmission among women with HIV who breastfeed, and
current challenges and program gaps internationally. A table of the
chronology of events in perinatal HIV prevention in the United States
and PMTCT in international settings and future directions for PMTCT in
the United States and internationally are also presented.

Future directions include the following:

\* Efforts that led to the declines in perinatal HIV transmission need
to continue, and ongoing surveillance of the scope and breadth of
perinatal transmission in the United States needs to be strengthened.

\* All women should be offered testing early in prenatal care for every
pregnancy.

\* Ongoing and expanded education and resources for obstetric clinicians
are needed, especially as rapid HIV testing for women in labor with
unknown HIV status becomes the standard of care.

\[Note: The Health Resources and Services Administration and CDC jointly
support the National Perinatal HIV Consultation and Referral Service\'s
Perinatal Hotline at (888) 448-8765\].

\* In international settings, there is an urgent need for effective
strategies to make breastfeeding safer for HIV-exposed infants through
the first year of life. The authors assert that an infant HIV vaccine,
if proven efficacious, would be an optimal approach to both reducing the
risk of HIV transmission during the first year of life and providing the
infant with adequate nutrition and the continued protection breastmilk
provides against other infectious causes of morbidity and mortality.

Fowler MG, Lampe MA, Jamieson DJ, et al. 2007. Reducing the risk of
mother-to-child human immunodeficiency virus transmission: Past
successes, current progress and challenges, and future directions.

American Journal of Obstetrics and Gynecology 197(3, suppl. 1):S3-S9.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17825648>

\[Note: The Centers for Disease Control and Prevention (CDC) recently
expanded recommendations for routine HIV testing to include all adults
and adolescents in health care facilities as well as pregnant women in
all antenatal settings and those women at labor and

delivery with unknown HIV status.
[[http://www.cdc.gov/mmwR/preview/mmwrhtml/rr5514a1.htm]{.underline}](http://www.cdc.gov/mmwR/preview/mmwrhtml/rr5514a1.htm)
\]

\[Note: The CDC is launching the One Test, Two Lives campaign in the
United States to encourage obstetrical professionals in all settings to
offer early HIV testing as a routine, opt-out practice for their
pregnant clients and to counsel clients who decline testing to accept an
HIV test. More information is available at
[[http://www.cdc.gov/1test2lives]{.underline}](http://www.cdc.gov/1test2lives)
\]

**Supplement examines influences on obesity and healthy adolescent
behavior**

The October 2007 supplement to the American Journal of Preventive
Medicine examines the impact of the policies, programs, practices, and
other environmental influences on obesity among adolescents. The
supplement includes an introduction and 11 papers containing some of the
first findings from research supported by the Robert Wood Johnson
Foundation (RWJF) on the environmental determinants of obesity among
adolescents and on the physical inactivity and poor dietary practices
that contribute to the problem. The introduction to the supplement
briefly describes RWJF\'s Bridging the Gap (BTG) initiative and the
surveys and other data sets from which it has drawn its data; highlights
some of the initiative\'s research on adolescent substance abuse to
illustrate its potential for parallel contributions to the childhood
obesity issue; and discusses the conceptual framework that underlies
BTG\'s more recent work on youth physical activity, healthy eating, and
obesity. The papers that follow emphasize the disparities that exist in
these factors and outcomes among different racial and ethnic and
socioeconomic groups. Two papers from the National Cancer Institute\'s
related efforts to identify, rate, and track state policies potentially
affecting these behaviors are also included.

Bridging the Gap. Chaloupka FJ et al (eds) American Journal of
Preventive Medicine Volume 33, Issue 4, Supplement S (October 2007)

[[http://www.ajpm-online.net/issues/contents?issue_key=S0749-3797(07)X0129-6]{.underline}](http://www.ajpm-online.net/issues/contents?issue_key=S0749-3797(07)X0129-6)

**MCH Headlines Judy Thierry HQE**

**Child passengers are exposed to secondhand smoke**

Similar to injuries to children from improperly installed car seats,
childhood illness from [secondhand
smoke](http://www.epa.gov/smokefree/healtheffects.html#What is Secondhand Smoke)
exposure in cars is preventable. The National Highway Traffic Safety
Administration ([NHTSA](http://www.nhtsa.gov/)) and the U.S.
Environmental Protection Agency ([EPA](http://www.epa.gov/)) [Indoor
Environments Division](http://www.epa.gov/iaq/) are dedicated to
protecting children from the heightened risk of injury and illness in
cars. With your help, parents and caregivers can learn how to prevent
child passengers from being injured and becoming ill from secondhand
smoke in cars.   

The [U.S. Surgeon General has
reported](http://www.surgeongeneral.gov/library/secondhandsmoke/) that
secondhand smoke is a known cause of respiratory problems, ear
infections, asthma attacks, and even sudden infant death syndrome in
infants and children. While many smokers open a window or increase the
ventilation in their cars, the child passenger is still exposed to
secondhand smoke.  When you are educating families about car seat
safety, you may also want to give them written information, such as
EPA's [Smoke-free Homes & Cars](http://www.epa.gov/smokefree/)
educational materials which are free and available for downloading and
distribution.

What you can do to help:

-   Share this information with your affiliates, colleagues, and others
    in the child passenger safety community.

-   Download materials from EPA to give to parents and caregivers during
    car seat safety inspections or other car safety events.

-   Talk to organizations in your community that reach parents and
    caregivers of young children about the effects of secondhand smoke.

>  

To download, print and/or order Smoke free Homes and Cars materials, see
[www.epa.gov/smokefree/publications.html](http://www.epa.gov/smokefree/publications.html)

For more information on EPA's Smoke-free Homes and Cars Program, see
[www.epa.gov/smokefree](http://www.epa.gov/smokefree)

or call Alexander Sinclair, U.S. Department of Transportation/NHTSA
(202) 366-2723

**26th Annual "Protecting Our Children"**

-   April 20-23, 2008

-   Minneapolis, MN

-   National American Indian Conference on Child Abuse and Neglect

-   <http://www.nicwa.org/>

**Child Poverty in Nonmetropolitan Areas by State including New
Mexico **

Key results include:

\# The rural child poverty rate in 2006 ranges from a low of 9.1 percent
in Connecticut to a high of nearly 34.7 percent in Mississippi.\
\# Rural child poverty rates increased between 2000 and 2006 in 37 of
the 47 states where rural data was available (data were unavailable in 3
states and the District of Columbia).\
\# In 19 states, the increase in the rural child poverty rate was higher
than the increase in the overall U.S. child poverty rate (3.0 percent)
between 2000 and 2006.\
\# The state with the biggest percentage point increase in rural child
poverty between 2000 and 2006 was Ohio (+6.8 percentage points),
followed by Indiana (+6.4 percentage points), and Maine (+5.5 percentage
points).\
\# Ten states showed a decrease in the rural child poverty rate, led by
Maryland with a 4.0 percentage point decrease.\
\# Five states (Ohio, Indiana, Maine, Tennessee, and South Carolina)
experienced increases of 5 percentage points or more in rural child
poverty between 2000 and 2006.

\# Three states ( Mississippi, Louisiana, and New Mexico) all had rural
child poverty rates above 30 percent in 2006, which reflects the
pervasive child poverty problem in the rural South as well as areas with
high percentages of minority populations.

<http://carseyinstitute.unh.edu/FS_ruralchildpoverty_07.htm>

**Substance Use Treatment Among Women of Childrearing Age**

A 3 page short report, based on SAMHSA\'s National Survey on Drug Use
and Health (NSDUH), provides national data on the rates of substance use
treatment needed and received as well as rates of unmet need and reasons
for not receiving treatment among women aged 18 to 49.

**Highlights:** Combined data from SAMHSA\'s National Surveys on Drug
Use & Health conducted from 2004 to 2006 indicate that an annual average
of 6.3 million women (9.4%) aged 18 to 49 needed treatment for a
substance use problem. 

Of the women aged 18 to 49 who met criteria for needing substance use
treatment in the past year, 84.2% neither received it nor perceived the
need for substance use treatment. Only 5.5% of women in this age group
had a perceived unmet treatment need (i.e., did not receive substance
use treatment even though they thought they needed it).

The reasons for not receiving substance use treatment among the women
with an unmet treatment need were as follows: 36.1% were not ready to
stop using alcohol or illicit drugs, 34.4% could not cover their
treatment costs because of no or inadequate health insurance coverage,
and 28.9% did not seek substance use treatment because of social stigma.

To find OAS data on a specific topic, go to SAMHSA\'s Office of Applied
Studies\' topics website at <http://www.oas.samhsa.gov/topics.cfm>  You
can always get to the topics website by clicking on \"Topics\" on the
OAS banner at the top of most OAS web pages.  You can also get data on
specific drugs by clicking on \"Drugs\" on the OAS banner.   You can get
to the treatment topics at the Topics page or by clicking on
\"Treatment\" on the footer of most OAS web pages.

[[http://oas.samhsa.gov/2k7/womenTX/womenTX.cfm]{.underline}](http://oas.samhsa.gov/2k7/womenTX/womenTX.cfm)

 

For single or bulk orders of free copies of these reports or any OAS
report for meetings, contact SAMHSA's National Clearinghouse for Alcohol
and Drug Information (NCADI) either on the web or by phone.  Please
allow sufficient time to process your request. NCADI:  
<http://ncadi.samhsa.gov/>

**For children of all ages: Driving Safety Statistics, tips, and good
slide (4 items)**

#1

**Number one killer of youth: MVAs - Great set of slides to pick and
choose from**

One hundred and forty nine slides for your information and use from
NHTSA

![](media/image6.png){width="2.53125in" height="0.8854166666666666in"}

![](media/image7.png){width="2.5416666666666665in" height="1.6875in"}

**Blood alcohol unchanged**

![](media/image8.png){width="2.4270833333333335in"
height="0.6354166666666666in"}

Young drivers

![](media/image9.png){width="2.4375in" height="0.71875in"}

**Fatalities of passengers and drivers**

![](media/image10.png){width="2.4895833333333335in"
height="1.2916666666666667in"}

**Changes by month**

![](media/image11.png){width="1.9270833333333333in"
height="2.2395833333333335in"}

Contact Judith Thierry at <Judith.Thierry@ihs.gov>

**#2**

**Primary Enforcement Laws Reach Groups Least Likely to Use Safety
Belts**

A recent study by researchers from CDC\'s Injury Center highlights
primary enforcement safety belt laws as an effective strategy to
increase overall safety belt use and to reduce disparities among
subpopulations.

Primary vs. Secondary Enforcement Laws

Primary enforcement safety belt laws allow police to stop and ticket
motorists solely for being unbelted. Secondary laws only allow police to
issue a safety belt citation if the vehicle has been stopped for another
reason (e.g., speeding). Primary laws more effectively increase safety
belt use and reduce traffic fatalities and serious injuries than
secondary laws.

Study Findings

Primary enforcement safety belt laws may have the greatest impact on
groups least likely to wear safety belts. According to Injury Center
researchers, these groups include males, young adults, those with
limited education, Native Americans/Alaska Natives, the obese, and
impaired drivers. For each of these groups, safety belt use was at least
13 percentage points higher in states with primary enforcement laws than
those with secondary enforcement laws. Overall, safety belt use was 85%
in primary enforcement states and 74% in secondary enforcement states.

Safety belt use is the single most effective way to prevent
crash-related deaths. The study supports primary enforcement laws as an
effective population-based strategy to increase overall safety belt use
and to reduce disparities among subpopulations.

Beck LF, Shults RA, Mack KA, Ryan GW. Associations between
sociodemographics and safety belt use in states with and without primary
enforcement laws. American Journal of Public Health 2007;
97(9):1619-1624.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17666699>

**#3**

**NHTSA crash data for 2006**

NHTSA has made available on its website the crash data files for 2006.
Included in this release are the 2006 Fatality Analysis Reporting System
(FARS) file, the final 2005 Fatality Analysis Reporting System file, the
full 2006 Annual Assessment Report, the 2006 Traffic Safety Annual
Assessment, the updated State Traffic Safety Information (STSI) and the
2006 National Automotive Sampling System General Estimates System (NASS
GES) file.

The FARS files are a census of all motor vehicle crashes that resulted
in a fatality within 30 days of the crash. The NASS GES is a nationally
representative sample of the police-reported crashes of all severities,
including those that result in a death, injury, or property damage.
Click here for more information:

![](media/image12.png){width="5.729166666666667in"
height="2.1458333333333335in"}

<http://www.nhtsa.gov/portal/site/nhtsa/menuitem.6a6eaf83cf719ad24ec86e10dba046a0/>

**#4**

**NHTSA booster seat data**

Probability-based surveys of 1) booster seat use in the United States
based on the observation of children in vehicles; 2) use of seat belts
and child restraints by racial and ethnic groups; and 3) whether
children in the United States are utilizing restraints appropriate for
their height and weight.

![](media/image13.png){width="1.53125in" height="1.7604166666666667in"}

<http://www.nhtsa.gov/portal/site/nhtsa/menuitem.6a6eaf83cf719ad24ec86e10dba046a0/>

**Do you know is it 1 in 5, 7, 10, or 12 Americans that are living with
a disability?**

October is Disability Awareness Month. 

Learn more about what CDC is doing to promote the health and well-being
among people of all ages with disabilities.

Today, about 50 million Americans, or one in five people, are living
with at least one disability, and most Americans will experience a
disability at some time during the course of their lives. Some
disabilities are easy to see, such as when a person uses a wheelchair or
when someone has lost an arm. Other disabilities, like a developmental
disability such as autism or a chronic condition like arthritis, may not
be as easy to see. Some people may live with a disability all their
lives. Others may have a disability when they are young or as an older
adult. Different kinds of disabilities affect people in different ways.
And the same disability can affect each person differently. Send a
Health-e card - <http://www2a.cdc.gov/ecards/>

**CDC Health-e-Card from Judith Thierry to school based health care
programs**

Materna l and Child Health Program has sent you a CDC Health- e- Card.

<http://www2a.cdc.gov/ecards/viewcard.asp?gid=A1dfC9DF367e17D79A5a102320200>

**FAS Prevention: Request for Proposals Released**

Fetal Alcohol Spectrum Disorders Prevention or Diagnosis and
Intervention

Juvenile Court Proposals Are Due November 1, 2007

Local Community Proposals Are Due November 8, 2007

State Proposals Are Due November 15, 2007

Questions Are Due October 11, 2007

Proposals are requested from State agencies; juvenile courts; and local
public, private, or tribal non-profit organizations. There will be a
full and open competition in each of these three categories -- States,
juvenile courts, and local communities. Please consider submitting a
proposal and forward this to others who may be interested in the RFP's.

Organizations are asked to organize, implement, and evaluate programs
that will either:

·       Decrease the incidence of FASD by implementing evidence-based
programs to eliminate alcohol consumption by pregnant women. (The target
audience will be pregnant women who drink or women of childbearing age
in alcohol or substance abuse treatment.) Or

·       Improve the functioning and quality of life of people with an
FASD and their families by diagnosing those with an FASD and providing
interventions based on the diagnosis.

Types of organizations invited to submit proposals:

·       WIC programs serving pregnant women, maternity or prenatal care
programs, and alcohol and substance abuse programs serving women.
Additional organizations that provide services to women likely to drink
during pregnancy may also submit proposals. 

·       Developmental disabilities, mental health, child welfare,
juvenile justice, adult substance abuse, and vocational rehabilitation.
Other organizations serving a population that likely has a higher
prevalence of FASD than the general population may also submit
proposals.

·       Juvenile courts or those legally authorized to provide services
to adjudicated youth on probation or dependent youth.

Those submitting proposals should have the authority to change the
relevant policies and procedures of the service delivery organization(s)
of interest.

Funded organizations will receive technical assistance to organize and
conduct their FASD prevention or FASD intervention program.  This
request for proposals is an opportunity for those interested in
preventing or addressing fetal alcohol spectrum disorders in the
population they serve.

Northrop Grumman, Inc. will be funding and managing the FASD
subcontractors.  Northrop Grumman is the prime contractor with the
Substance Abuse and Mental Health Service Administration (SAMHSA). 
SAMHSA is an agency of the U.S. Department of Health and Human Services.
The RFP's are posted on
[www.fasdcenter.com](http://www.fasdcenter.com/).

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

#### Endometriosis: Where is the real truth? {#endometriosis-where-is-the-real-truth .Style-Heading-4-+-Arial-14-pt-Underline}

#### Here are the answers with discussions and references to last month's questions {#here-are-the-answers-with-discussions-and-references-to-last-months-questions .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### 1.) Endometriosis virtually always progresses in severity without treatment {#endometriosis-virtually-always-progresses-in-severity-without-treatment .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

#### It appears that endometriosis is a dynamic process of chronic and constant remodeling, not one of linear growth, which was confirmed in studies with African monkeys. As such, determining where along the course, or continuum, any individual patient might be at any one time will better let us tailor treatment to the status of that woman. {#it-appears-that-endometriosis-is-a-dynamic-process-of-chronic-and-constant-remodeling-not-one-of-linear-growth-which-was-confirmed-in-studies-with-african-monkeys.-as-such-determining-where-along-the-course-or-continuum-any-individual-patient-might-be-at-any-one-time-will-better-let-us-tailor-treatment-to-the-status-of-that-woman. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### [D\'Hooghe TM](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="D'Hooghe TM"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus), et al Serial laparoscopies over 30 months show that endometriosis in captive baboons (Papio anubis, Papio cynocephalus) is a progressive disease. [Fertil Steril.](javascript:AL_get(this, 'jour', 'Fertil Steril.');) 1996 Mar;65(3):645-9 {#dhooghe-tm-et-al-serial-laparoscopies-over-30-months-show-that-endometriosis-in-captive-baboons-papio-anubis-papio-cynocephalus-is-a-progressive-disease.-fertil-steril.-1996-mar653645-9 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=8774301**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=8774301) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch8774301 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Having said that.... {#having-said-that. .Style-Heading-4-+-Arial-14-pt-Underline}

#### The degree of response to laparoscopy is parallel to the extent of the disease. {#the-degree-of-response-to-laparoscopy-is-parallel-to-the-extent-of-the-disease. .Style-Heading-4-+-Arial-14-pt-Underline}

#### In the first trial (Sutton 1994), women with stage I disease (a large proportion of study participants) were less likely to improve after their surgical procedure, whereas 74 percent of stage II-IV disease patients achieved pain relief. Most of the women in the second trial (Abbott 2004) had stage II-IV disease, which may account, at least in part, for the higher surgical success rate reported in this study. {#in-the-first-trial-sutton-1994-women-with-stage-i-disease-a-large-proportion-of-study-participants-were-less-likely-to-improve-after-their-surgical-procedure-whereas-74-percent-of-stage-ii-iv-disease-patients-achieved-pain-relief.-most-of-the-women-in-the-second-trial-abbott-2004-had-stage-ii-iv-disease-which-may-account-at-least-in-part-for-the-higher-surgical-success-rate-reported-in-this-study. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### [Sutton CJ](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Sutton CJ"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus), et al Prospective, randomized, double-blind, controlled trial of laser laparoscopy in the treatment of pelvic pain associated with minimal, mild, and moderate endometriosis. [Fertil Steril.](javascript:AL_get(this, 'jour', 'Fertil Steril.');) 1994 Oct;62(4):696-700 {#sutton-cj-et-al-prospective-randomized-double-blind-controlled-trial-of-laser-laparoscopy-in-the-treatment-of-pelvic-pain-associated-with-minimal-mild-and-moderate-endometriosis.-fertil-steril.-1994-oct624696-700 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=7926075**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=7926075) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch7926075 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### [Abbott J](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Abbott J"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus), et al Laparoscopic excision of endometriosis: a randomized, placebo-controlled trial. [Fertil Steril.](javascript:AL_get(this, 'jour', 'Fertil Steril.');) 2004 Oct;82(4):878-84 {#abbott-j-et-al-laparoscopic-excision-of-endometriosis-a-randomized-placebo-controlled-trial.-fertil-steril.-2004-oct824878-84 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=15482763**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=15482763) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch15482763 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### 2.) Postoperative medical therapy has been shown to produce significant benefit in reducing pain in women who have treated for endometriosis laparscopically {#postoperative-medical-therapy-has-been-shown-to-produce-significant-benefit-in-reducing-pain-in-women-who-have-treated-for-endometriosis-laparscopically .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

#### REVIEWERS\' CONCLUSIONS: There is insufficient evidence from the studies identified to conclude that hormonal suppression in association with surgery for endometriosis is associated with a significant benefit with regard to any of the outcomes identified.  {#reviewers-conclusions-there-is-insufficient-evidence-from-the-studies-identified-to-conclude-that-hormonal-suppression-in-association-with-surgery-for-endometriosis-is-associated-with-a-significant-benefit-with-regard-to-any-of-the-outcomes-identified. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### [Yap C](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Yap C"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus), et al Pre and post operative medical therapy for endometriosis surgery. [Cochrane Database Syst Rev.](javascript:AL_get(this, 'jour', 'Cochrane Database Syst Rev.');) 2004;(3):CD003678 {#yap-c-et-al-pre-and-post-operative-medical-therapy-for-endometriosis-surgery.-cochrane-database-syst-rev.-20043cd003678 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=15266496**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=15266496) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch15266496 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### 3.) Appoximately 40% of women with endometriosis and pain will derive symptomatic benefit from treatment with placebo {#appoximately-40-of-women-with-endometriosis-and-pain-will-derive-symptomatic-benefit-from-treatment-with-placebo .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

#### The placebo response to any treatment in chronic pelvic pain is roughly 40% for a period of at least 3 months. {#the-placebo-response-to-any-treatment-in-chronic-pelvic-pain-is-roughly-40-for-a-period-of-at-least-3-months. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### [Abbott J](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Abbott J"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus), et al Laparoscopic excision of endometriosis: a randomized, placebo-controlled trial. [Fertil Steril.](javascript:AL_get(this, 'jour', 'Fertil Steril.');) 2004 Oct;82(4):878-84 {#abbott-j-et-al-laparoscopic-excision-of-endometriosis-a-randomized-placebo-controlled-trial.-fertil-steril.-2004-oct824878-84-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=15482763**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=15482763) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch15482763-1 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### [Dlugi AM](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Dlugi AM"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus), et al Lupron depot (leuprolide acetate for depot suspension) in the treatment of endometriosis: a randomized, placebo-controlled, double-blind study. Lupron Study Group. [Fertil Steril.](javascript:AL_get(this, 'jour', 'Fertil Steril.');) 1990 Sep;54(3):419-27 {#dlugi-am-et-al-lupron-depot-leuprolide-acetate-for-depot-suspension-in-the-treatment-of-endometriosis-a-randomized-placebo-controlled-double-blind-study.-lupron-study-group.-fertil-steril.-1990-sep543419-27 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=2118858**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=2118858) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch2118858 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### [Sutton CJ](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Sutton CJ"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus), et al Prospective, randomized, double-blind, controlled trial of laser laparoscopy in the treatment of pelvic pain associated with minimal, mild, and moderate endometriosis. [Fertil Steril.](javascript:AL_get(this, 'jour', 'Fertil Steril.');) 1994 Oct;62(4):696-700 {#sutton-cj-et-al-prospective-randomized-double-blind-controlled-trial-of-laser-laparoscopy-in-the-treatment-of-pelvic-pain-associated-with-minimal-mild-and-moderate-endometriosis.-fertil-steril.-1994-oct624696-700-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=7926075**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=7926075) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch7926075-1 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### 4.) Surgical modalities, such as electrocautery, laser, or harmonic scalpel appear to be equally effective in treating endometriosis {#surgical-modalities-such-as-electrocautery-laser-or-harmonic-scalpel-appear-to-be-equally-effective-in-treating-endometriosis .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

Conservative surgery is typically accomplished by laparoscopy. Adequate
treatment of endometriosis is usually possible, and desirable, at the
initial diagnostic procedure. This offers the advantage of ablating the
implants and adhesions while avoiding possible disease or symptom
progression. The currently available methods of ablation appear to be
equally effective and the choice of modality is dependent on the
experience of the surgeon.

Early surgical therapy also avoids the expense and side effects of
medical therapy. Potential disadvantages include inadvertent damage to
adjacent organs (eg, bowel and bladder), infection, and mechanical
trauma to pelvic structures that may result in greater adhesion
formation.

Conservative surgery involves excision, fulguration, or laser
vaporization of endometriotic implants and removal of associated
adhesions. Its goal is restoration of normal pelvic anatomy.
Laparoscopic treatment offers advantages over laparotomy, including
shorter hospitalization, anesthetic, and recuperation times.

Laparotomy may be more advisable, however, when dealing with extensive
adhesions or invasive endometriosis located near structures such as the
uterine arteries, ureter, bladder, and bowel. Ancillary procedures to
laparotomy may include presacral neurectomy, uterosacral interruption of
sensory nerves innervating the pelvis, and uterine suspension to avoid
adhesion formation from the cul-de-sac to the posterior surface of the
uterus, tube, and ovaries.

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

#### Kennedy S et al ESHRE guideline for the diagnosis and treatment of endometriosis. Hum Reprod 2005 Oct;20(10):2698-704. Epub 2005 Jun 24. {#kennedy-s-et-al-eshre-guideline-for-the-diagnosis-and-treatment-of-endometriosis.-hum-reprod-2005-oct20102698-704.-epub-2005-jun-24. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=15980014**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=15980014) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch15980014 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### 5.) Surgical aspiration is the preferred treatment method for women with ovarian endometrioma {#surgical-aspiration-is-the-preferred-treatment-method-for-women-with-ovarian-endometrioma .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

#### CONCLUSION(S): Laparoscopic cystectomy of endometriomas is a better choice than fenestration and coagulation because the former technique leads to a lower recurrence of signs and symptoms and a lower rate of reoperation and a higher cumulative pregnancy rate than the latter. {#conclusions-laparoscopic-cystectomy-of-endometriomas-is-a-better-choice-than-fenestration-and-coagulation-because-the-former-technique-leads-to-a-lower-recurrence-of-signs-and-symptoms-and-a-lower-rate-of-reoperation-and-a-higher-cumulative-pregnancy-rate-than-the-latter. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### [Alborzi S](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Alborzi S"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus), et al A prospective, randomized study comparing laparoscopic ovarian cystectomy versus fenestration and coagulation in patients with endometriomas. [Fertil Steril.](javascript:AL_get(this, 'jour', 'Fertil Steril.');) 2004 Dec;82(6):1633-7 {#alborzi-s-et-al-a-prospective-randomized-study-comparing-laparoscopic-ovarian-cystectomy-versus-fenestration-and-coagulation-in-patients-with-endometriomas.-fertil-steril.-2004-dec8261633-7 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=15589870**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=15589870) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch15589870 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### 6.) Treatment with a GnRH analog for 6 months is associated with an increased fracture risk in women with endometriosis {#treatment-with-a-gnrh-analog-for-6-months-is-associated-with-an-increased-fracture-risk-in-women-with-endometriosis .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

#### This study examined the effect of a low-dose E and pulsed progestogen hormone therapy (HT) regimen for add-back during long-term GnRH-agonist therapy on bone mineral density (BMD) in five patients with stage IV endometriosis. Bone mineral density was stable after initiation of HT for the entire follow-up period (up to 10 years). One patient stopped her treatment on two occasions to conceive and was successful each time with delivery of a normal baby. No patient had return of pelvic pain after HT add-back.  {#this-study-examined-the-effect-of-a-low-dose-e-and-pulsed-progestogen-hormone-therapy-ht-regimen-for-add-back-during-long-term-gnrh-agonist-therapy-on-bone-mineral-density-bmd-in-five-patients-with-stage-iv-endometriosis.-bone-mineral-density-was-stable-after-initiation-of-ht-for-the-entire-follow-up-period-up-to-10-years.-one-patient-stopped-her-treatment-on-two-occasions-to-conceive-and-was-successful-each-time-with-delivery-of-a-normal-baby.-no-patient-had-return-of-pelvic-pain-after-ht-add-back. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### [Bedaiwy MA](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Bedaiwy MA"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus), [Casper RF](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Casper RF"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus).Treatment with leuprolide acetate and hormonal add-back for up to 10 years in stage IV endometriosis patients with chronic pelvic pain. Fertil Steril. 2006 Jul;86(1):220-2. Epub 2006 May 23. {#bedaiwy-ma-casper-rf.treatment-with-leuprolide-acetate-and-hormonal-add-back-for-up-to-10-years-in-stage-iv-endometriosis-patients-with-chronic-pelvic-pain.-fertil-steril.-2006-jul861220-2.-epub-2006-may-23. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=16716325**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=16716325) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch16716325 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### [Zupi E](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Zupi E"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus) et al Add-back therapy in the treatment of endometriosis-associated pain. Fertil Steril. 2004 Nov;82(5):1303-8.  {#zupi-e-et-al-add-back-therapy-in-the-treatment-of-endometriosis-associated-pain.-fertil-steril.-2004-nov8251303-8. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=15533351**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=15533351) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch15533351 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### 7.) Interstitial cystitis coexists with endometriosis in approximately 10 percent of cases {#interstitial-cystitis-coexists-with-endometriosis-in-approximately-10-percent-of-cases .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

#### CONCLUSIONS: Results of this prospective study show that interstitial cystitis and endometriosis may frequently coexist in patients with chronic pelvic pain. A positive Potassium Sensitivity Test accurately predicted the presence of interstitial cystitis in 96% of these patients with chronic pelvic pain, as confirmed by cystoscopic hydrodistention. It is necessary to consider the diagnosis of endometriosis and interstitial cystitis concurrently in the evaluation of patients with chronic pelvic pain to avoid unnecessary delay in identifying either condition. {#conclusions-results-of-this-prospective-study-show-that-interstitial-cystitis-and-endometriosis-may-frequently-coexist-in-patients-with-chronic-pelvic-pain.-a-positive-potassium-sensitivity-test-accurately-predicted-the-presence-of-interstitial-cystitis-in-96-of-these-patients-with-chronic-pelvic-pain-as-confirmed-by-cystoscopic-hydrodistention.-it-is-necessary-to-consider-the-diagnosis-of-endometriosis-and-interstitial-cystitis-concurrently-in-the-evaluation-of-patients-with-chronic-pelvic-pain-to-avoid-unnecessary-delay-in-identifying-either-condition. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### [Chung MK](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Chung MK"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus) et al Interstitial cystitis and endometriosis in patients with chronic pelvic pain: The \"Evil Twins\" syndrome. JSLS. 2005 Jan-Mar;9(1):25-9. {#chung-mk-et-al-interstitial-cystitis-and-endometriosis-in-patients-with-chronic-pelvic-pain-the-evil-twins-syndrome.-jsls.-2005-jan-mar9125-9. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=15791965**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=15791965) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch15791965 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Extra credit {#extra-credit .Style-Heading-4-+-Arial-14-pt-Underline}

#### Promising therapies for endometriosis include: {#promising-therapies-for-endometriosis-include .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Aromatase inhibitors {#aromatase-inhibitors .Style-Heading-4-+-Arial-14-pt-Underline}

#### -RU-486 {#ru-486 .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Levonorgestrel containing IUDs {#levonorgestrel-containing-iuds .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Antiangiogenic cancer therapy {#antiangiogenic-cancer-therapy .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Answer: All of the above {#answer-all-of-the-above .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### -Aromatase inhibitors {#aromatase-inhibitors-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION(S): Fourteen of 15 patients with refractory endometriosis achieved significant pain relief using anastrazole and 20 microg ethinyl estradiol/0.1 mg levonorgestrel with minimal side effects. This treatment for endometriosis is a promising new modality that warrants further investigation. {#conclusions-fourteen-of-15-patients-with-refractory-endometriosis-achieved-significant-pain-relief-using-anastrazole-and-20-microg-ethinyl-estradiol0.1-mg-levonorgestrel-with-minimal-side-effects.-this-treatment-for-endometriosis-is-a-promising-new-modality-that-warrants-further-investigation. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Amsterdam LL](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Amsterdam LL"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus) et al Anastrazole and oral contraceptives: a novel treatment for endometriosis. Fertil Steril. 2005 Aug;84(2):300-4. {#amsterdam-ll-et-al-anastrazole-and-oral-contraceptives-a-novel-treatment-for-endometriosis.-fertil-steril.-2005-aug842300-4. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=16084868**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=16084868) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch16084868 .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

#### -RU-486, Mifepristone, an antiprogestogen {#ru-486-mifepristone-an-antiprogestogen .Style-Heading-4-+-Arial-14-pt-Underline}

#### Medical treatment of endometriosis relies on drugs that suppress ovarian steroids and induce an hypoestrogenic state that causes atrophy of ectopic endometrium. Gonadotrophin-releasing hormone (GnRH) analogues, danazol, progestogens and oestrogen-progestin combinations have all proven effective in relieving pain and reducing the extent of endometriotic implants. However, symptoms often recur after discontinuation of therapy and hypoestrogenism-related side effects limit the long-term use of most medications. Furthermore, these therapies are of limited value in patients with a desire to become pregnant because they inhibit ovulation. An important target for current research is to identify effective therapies that can be safely administered in the long term. GnRH analogues with add-back therapy, progestogens and continuous oral contraceptive are options available for a medium or long-term systemic treatment. Mifepristone, an antiprogestogen, may constitute an alternative if encouraging preliminary data on its effectiveness and tolerability are confirmed. A very appealing area of interest is the possibility of treating {#medical-treatment-of-endometriosis-relies-on-drugs-that-suppress-ovarian-steroids-and-induce-an-hypoestrogenic-state-that-causes-atrophy-of-ectopic-endometrium.-gonadotrophin-releasing-hormone-gnrh-analogues-danazol-progestogens-and-oestrogen-progestin-combinations-have-all-proven-effective-in-relieving-pain-and-reducing-the-extent-of-endometriotic-implants.-however-symptoms-often-recur-after-discontinuation-of-therapy-and-hypoestrogenism-related-side-effects-limit-the-long-term-use-of-most-medications.-furthermore-these-therapies-are-of-limited-value-in-patients-with-a-desire-to-become-pregnant-because-they-inhibit-ovulation.-an-important-target-for-current-research-is-to-identify-effective-therapies-that-can-be-safely-administered-in-the-long-term.-gnrh-analogues-with-add-back-therapy-progestogens-and-continuous-oral-contraceptive-are-options-available-for-a-medium-or-long-term-systemic-treatment.-mifepristone-an-antiprogestogen-may-constitute-an-alternative-if-encouraging-preliminary-data-on-its-effectiveness-and-tolerability-are-confirmed.-a-very-appealing-area-of-interest-is-the-possibility-of-treating .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### [Fedele L](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Fedele L"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus), [Berlanda N](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Berlanda N"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus). Emerging drugs for endometriosis. [Expert Opin Emerg Drugs.](javascript:AL_get(this, 'jour', 'Expert Opin Emerg Drugs.');) 2004 May;9(1):167-77 {#fedele-l-berlanda-n.-emerging-drugs-for-endometriosis.-expert-opin-emerg-drugs.-2004-may91167-77 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=15155142**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=15155142) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch15155142 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### -Levonorgestrel containing IUDs {#levonorgestrel-containing-iuds-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSIONS: One small study has shown that postoperative use of the LNG-IUS reduces the recurrence of painful periods in women who have had surgery for endometriosis. There is a need for further well-designed RCTs of this approach. {#conclusions-one-small-study-has-shown-that-postoperative-use-of-the-lng-ius-reduces-the-recurrence-of-painful-periods-in-women-who-have-had-surgery-for-endometriosis.-there-is-a-need-for-further-well-designed-rcts-of-this-approach. .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-44 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Abou-Setta AM](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Abou-Setta AM"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus) et al Levonorgestrel-releasing intrauterine device (LNG-IUD) for symptomatic endometriosis following surgery. Cochrane Database Syst Rev. 2006 Oct 18;(4):CD005072. Review. {#abou-setta-am-et-al-levonorgestrel-releasing-intrauterine-device-lng-iud-for-symptomatic-endometriosis-following-surgery.-cochrane-database-syst-rev.-2006-oct-184cd005072.-review. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17054236**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17054236) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch17054236 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### -Antiangiogenic cancer therapy {#antiangiogenic-cancer-therapy-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### In summary, antiangiogenic agents inhibited the growth of explants in an in vivo model of endometriosis by disrupting the vascular supply, and this effect is likely to apply to the human disease. These findings suggest that antiangiogenic agents may provide a novel therapeutic approach for the treatment of endometriosis. {#in-summary-antiangiogenic-agents-inhibited-the-growth-of-explants-in-an-in-vivo-model-of-endometriosis-by-disrupting-the-vascular-supply-and-this-effect-is-likely-to-apply-to-the-human-disease.-these-findings-suggest-that-antiangiogenic-agents-may-provide-a-novel-therapeutic-approach-for-the-treatment-of-endometriosis. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Hull ML](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Hull ML"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus), et al Antiangiogenic agents are effective inhibitors of endometriosis. J Clin Endocrinol Metab. 2003 Jun;88(6):2889-99. {#hull-ml-et-al-antiangiogenic-agents-are-effective-inhibitors-of-endometriosis.-j-clin-endocrinol-metab.-2003-jun8862889-99. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=12788903**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=12788903) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch12788903 .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

#### Prevention and Management of Influenza in a Family Setting to Reduce Transmission to Individuals at Risk {#prevention-and-management-of-influenza-in-a-family-setting-to-reduce-transmission-to-individuals-at-risk .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.medscape.com/viewprogram/7693?src=mp**](http://www.medscape.com/viewprogram/7693?src=mp) {#httpwww.medscape.comviewprogram7693srcmp .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Mrs. Wilson, a 78-year-old woman, is seen in consultation for chronic neck pain {#mrs.-wilson-a-78-year-old-woman-is-seen-in-consultation-for-chronic-neck-pain .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.medscape.com/viewarticle/562117**](http://www.medscape.com/viewarticle/562117) {#httpwww.medscape.comviewarticle562117 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Epidemiology and Prevalence of Breast Cancer in the US {#epidemiology-and-prevalence-of-breast-cancer-in-the-us-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.medscape.com/infosite/brcc/article-1?src=0_nl_sm_0**](http://www.medscape.com/infosite/brcc/article-1?src=0_nl_sm_0) {#httpwww.medscape.cominfositebrccarticle-1src0_nl_sm_0 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Important Considerations for Treating Epilepsy in a Woman of Middle Age  {#important-considerations-for-treating-epilepsy-in-a-woman-of-middle-age-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### <http://medsitecme.com/(e024vi55quyrrmuk0axhf4ud)/IDetail/Default_Campaign/Default_Program//261//sponsor.aspx> {#httpmedsitecme.come024vi55quyrrmuk0axhf4udidetaildefault_campaigndefault_program261sponsor.aspx .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Individualized Preventive and Therapeutic Management of Hereditary Breast Ovarian Cancer Syndrome {#individualized-preventive-and-therapeutic-management-of-hereditary-breast-ovarian-cancer-syndrome .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.medscape.com/viewprogram/7811?src=nlcmealert**](http://www.medscape.com/viewprogram/7811?src=nlcmealert) {#httpwww.medscape.comviewprogram7811srcnlcmealert .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Hereditary Link to PMDD Identified {#hereditary-link-to-pmdd-identified .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.medscape.com/resource/pmdd?src=rcupdate#1**](http://www.medscape.com/resource/pmdd?src=rcupdate#1) {#httpwww.medscape.comresourcepmddsrcrcupdate1 .Style-Heading-4-+-Arial-14-pt-Underline}

######### 

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

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

######### 

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

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

**Clinical Discussion Board Index, Medscape**

Hundreds of ongoing clinical discussions available

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

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

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

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

**Menopause Management**

**Hormone therapy has no effect on memory but increases sexual
interest**

Hormone therapy taken in the first few years after menopause does not
appear to affect a woman's memory, but may lead to increased sexual
interest. The study also found an increase in sexual interest and
thoughts in the women taking hormone therapy. The level of sexual
interest reported by women on hormone therapy increased 44 percent and
their number of sexual thoughts increased 32 percent compared to the
placebo group

#### CONCLUSIONS: With the power to detect an effect size of \>/=0.45, this study suggests potential modest negative effects on verbal memory that are consistent with previous hormone therapy trials in older women {#conclusions-with-the-power-to-detect-an-effect-size-of-0.45-this-study-suggests-potential-modest-negative-effects-on-verbal-memory-that-are-consistent-with-previous-hormone-therapy-trials-in-older-women .Style-Heading-4-+-Arial-14-pt-Underline}

[Maki
PM](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Maki PM"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Hormone therapy in menopausal women with cognitive complaints: A
randomized, double-blind trial.
[Neurology.](javascript:AL_get(this, 'jour', 'Neurology.');) 2007 Sep
25;69(13):1322-30

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17893293>

**Continuous HRT combined therapy vs sequential therapy and endometrial
cancer risk**

CONCLUSION: These results support the hypotheses that continuous
combined therapy does not increase (and may decrease) endometrial cancer
risk and that long-term sequential therapy can lead to a modest
increased risk. However, the collective results of all studies of these
questions and their clinical implications remain unclear.

[Doherty
JA](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Doherty JA"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Long-term use of postmenopausal estrogen and progestin hormone
therapies and the risk of endometrial cancer. Am J Obstet Gynecol. 2007
Aug;197(2):139.e1-7.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17689625>

####  {#section-54 .Style-Heading-4-+-Arial-14-pt-Underline}

#### There are benefits to the introduction of hormone therapy on exercise {#there-are-benefits-to-the-introduction-of-hormone-therapy-on-exercise-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: The peripheral circulation is the limiting system in postmenopausal women experiencing exercise intolerance, and there are benefits in introducing HT. LEVEL OF EVIDENCE: II. {#conclusion-the-peripheral-circulation-is-the-limiting-system-in-postmenopausal-women-experiencing-exercise-intolerance-and-there-are-benefits-in-introducing-ht.-level-of-evidence-ii. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Mercuro G](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Mercuro G"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus), et al Effect of hormone therapy on exercise capacity in early postmenopausal women. [Obstet Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007 Oct;110(4):780-7 {#mercuro-g-et-al-effect-of-hormone-therapy-on-exercise-capacity-in-early-postmenopausal-women.-obstet-gynecol.-2007-oct1104780-7 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=17906009&dopt=AbstractPlus**](http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=17906009&dopt=AbstractPlus) {#httpwww.ncbi.nlm.nih.govsitesentrezcmdretrievedbpubmedlist_uids17906009doptabstractplus .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-55 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Strength Training Helps Prevent Fat Gain in Overweight, Obese Premenopausal Women {#strength-training-helps-prevent-fat-gain-in-overweight-obese-premenopausal-women-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: This study suggests that strength training is an efficacious intervention for preventing percentage body fat increases and attenuating intraabdominal fat increases in overweight and obese premenopausal women. This is relevant to public health efforts for obesity prevention because most weight gain can be assumed to be fat, including abdominal fat. {#conclusion-this-study-suggests-that-strength-training-is-an-efficacious-intervention-for-preventing-percentage-body-fat-increases-and-attenuating-intraabdominal-fat-increases-in-overweight-and-obese-premenopausal-women.-this-is-relevant-to-public-health-efforts-for-obesity-prevention-because-most-weight-gain-can-be-assumed-to-be-fat-including-abdominal-fat. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Schmitz KH](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Schmitz KH"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus) et al Strength training and adiposity in premenopausal women: Strong, Healthy, and Empowered study. Am J Clin Nutr. 2007 Sep;86(3):566-72. {#schmitz-kh-et-al-strength-training-and-adiposity-in-premenopausal-women-strong-healthy-and-empowered-study.-am-j-clin-nutr.-2007-sep863566-72. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17823418**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17823418) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch17823418 .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-56 .Style-Heading-4-+-Arial-14-pt-Underline}

**Midwives Corner**, **Lisa Allee, CNM, Chinle**

**If you gotta use something, nitrous oxide might be better than
narcotics and epidurals**

Judith Rooks and Judith Bishop, two well known midwives in the United
States, present information about nitrous oxide---a labor pain
medication available to women in many countries, but used very little in
the US. Rooks presents the evidence that self administered nitrous oxide
is safe and effective. It is safe for mother and baby because it is
eliminated by the lungs rather than the liver, so it has transient
effects rather than cumulative. It is more effective than opioids and
does not have the negative effects on babies that narcotics are well
known for nor the maternal side effects of epidurals. She stresses that
self administration is crucial for safety and efficacy and has the added
benefit of giving women the real sense of control over their pain
management. Rooks also covers the occupational and environmental
concerns about nitrous oxide that are largely unfounded. Bishop shares
the standardized procedure for nitrous oxide administration by CNMs at
University of California San Francisco.

As I am sure you all have realized I am a staunch supporter of natural,
non-medicated birth. I really think it is the gold standard. So, when I
saw this article my initial reaction was "oh no, not another drug." But
I am also fully grounded in reality and have been with enough women in
labor to know that medication for pain is needed and/or desired by some
women. As I read on about nitrous oxide for labor, I could see that it
is superior in many ways to the narcotics we usually use. The speed at
which it takes effect (a minute or less) and wears off (also really
quick), the lack of sleepiness in the babies, the self administration
giving women complete control, and the fact that it does not slow labor
and that continuous EFM nor IV fluids are needed are all huge pluses for
nitrous. I was also fascinated that Rooks' description of the experience
of nitrous oxide---"diminished pain, or a continued awareness of pain
without feeling bothered by it...a kind of strange sensation of feeling
the pain while feeling a sense of bliss...so the pain may still exist
for some women, but the gas may create a feeling of: "Painful
contraction? Who cares?!""---was exactly my experience when I was
trained in hypnobirthing. When deeply relaxed (hypnotized) I didn't care
that someone was squeezing my ankle as hard as they could, but when I
was no longer in that alpha state I rapidly pulled my ankle away yelling
"Ow!" I have guided laboring women to that state and seen it have
wonderful results. One young woman said "That wasn't so bad" right after
she had her first baby! So, I can see nitrous as a great tool in our bag
of tricks if, for whatever reason, deep relaxation is not happening for
a laboring woman. Unfortunately, however, most women in the US do not
have, or even know about, this option. This is something that the
midwifery community needs to explore and change. If you have experience
with nitrous, are working to bring nitrous oxide to your practice, or
are interested in doing so, please email me and the listserve with your
observations and thoughts.

Rooks, JP Use of nitrous oxide in midwifery practice\--complementary,
synergistic, and needed in the United States. Journal of Midwifery &
Women's Health 2007 May-Jun;52(3):186-9

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17467584>

Bishop, JT Administration of nitrous oxide in labor: expanding the
options for women. Journal of Midwifery & Women's Health 2007
May-Jun;52(3):308-9

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17467598>

**Other**

**Repeat HIV testing in pregnancy identifies opportunities for
antiretroviral prophylaxis**

RESULTS: Fifty-four HIV-infected women were identified. Four primary HIV
infections were recognized, with median estimated seroconversion at 22
weeks of gestation. All 4 women denied new sex partners, alcohol, and
illegal drug use during pregnancy. Three of the 4 mother-infant pairs
received antiretroviral medications. One infant was infected
perinatally, with positive HIV DNA polymerase chain reaction at birth.
Questionnaire data identified 2 additional women with HIV that was
likely acquired during pregnancy (identified by rapid testing at labor
and delivery), which suggests that 6 of 54 HIV-infected women (11%) in
the MIRIAD study had primary infection during pregnancy.

CONCLUSION: Repeat HIV testing in pregnancy can identify opportunities
for antiretroviral prophylaxis and should be used in areas of high HIV
prevalence.

[Nesheim
S](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Nesheim S"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Primary human immunodeficiency virus infection during pregnancy
detected by repeat testing. Am J Obstet Gynecol. 2007
Aug;197(2):149.e1-5.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17689629>

**Nei-Guan point acupressure is a useful treatment for relieving
hyperemesis gravidarum**

RESULTS: The degree of nausea and vomiting was statistically
significantly lower in the Nei-Guan point acupressure group in
comparison with the placebo and control groups. Ketonuria levels were
reduced over time and, on days three and four of hospitalization, levels
in the treatment group were statistically significantly lower than in
the placebo or control groups (P \< 0.05).

CONCLUSION: Nei-Guan point acupressure is a useful treatment for
relieving symptoms experienced by women with hyperemesis gravidarum

[Shin
HS](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Shin HS"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Effect of Nei-Guan point (P6) acupressure on ketonuria levels,
nausea and vomiting in women with hyperemesis gravidarum. J Adv Nurs.
2007 Sep;59(5):510-9. Epub 2007 Jul 20

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17645494>

**One in Seven Women are Depressed Before, During, or After Pregnancy**

The first integrated survey of maternal depression, shows that more than
one in seven women are depressed at some time during the nine months
before becoming pregnant, during pregnancy, or in the nine months after
childbirth.

CONCLUSIONS: Approximately one in seven women was identified with and
treated for depression during 39 weeks before through 39 weeks after
pregnancy, and more than half of these women had recurring indicators
for depression.

[Dietz
PM](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Dietz PM"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Clinically identified maternal depression before, during, and
after pregnancies ending in live births. Am J Psychiatry. 2007
Oct;164(10):1515-20.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17898342>

**Advice on fish intake during pregnancy sparks controversy**

For Pregnant Women, Benefits of Eating Ocean Fish Outweigh Concerns from
Trace Levels of Mercury: Experts in Obstetrics and Nutrition Unveil
Seafood Consumption Recommendations During Pregnancy

A coalition that advocates for healthy pregnancies came under criticism
after issuing an advisory urging pregnant women to eat more fish, based
on an evidence review that received financial support from the fisheries
industry. In its advisory, however, the National Healthy Mothers,
Healthy Babies (HMHB) Coalition stated that "consumption of ocean fish
rather than ingestion of fish oil supplements is the best public health
approach," and added that "whole fish itself rather than fish oil
supplements has been linked to reductions in preterm labor."

<http://www.hmhb.org/oceanfishpr.html>

**Navajo News, John Balintona, Shiprock**

**Acute Appendicitis and Pregnancy**

Appendicitis occurs in about 1 in 5000 pregnancies making it the most
common nonobstetric surgical event during pregnancy. This condition can
occur in any trimester but seems to be more common in the second
trimester. Obstetric providers should have high clinical suspicion and
be prepared to start a treatment regimen for the patient.

Acute appendicitis during pregnancy is a potentially life-threatening
condition for the mother and could possibly affect the well being of the
fetus. Delay in making the diagnosis and initiating intervention
contributes to increased morbidity and mortality.

Because the uterus displaces the omentum into the upper abdomen, the
infectious process may not be confined and disseminate more rapidly. The
increase in vasculatrity during pregnancy may make the inflammatory
response more intense. The acuity of this response tends to increase as
gestation increases and therefore maternal morbidity and mortality is
highest in the third trimester. Effects on the fetus are mainly due to
premature delivery and if there is peritonitis present. Fetal loss rates
in uncomplicated appendicitis are about 1%, rising to about 30% if
peritonitis occurs.

### [Diagnosis]{.underline}

The diagnosis of appendicitis during pregnancy can be difficult for
several reasons: including the anatomic changes that naturally occur and
the similarity of many signs and symptoms of appendicitis and normal
pregnancy. The most common clinical signs of acute appendicitis are
right lower quadrant abdominal tenderness and vague abdominal pain. Due
to the migration of the appendix in the second and third trimester, the
pain may be found in the right upper quadrant or right flank. Rebound
tenderness and guarding may not be effective diagnostic tools during
pregnancy due to the laxity of the abdominal muscles. Anorexia with
nausea and vomiting are common, especially in the first and early second
trimester, but nevertheless should be evaluated. An elevated leukocyte
count associated with appendicitis ranges from 5 -- 25,000, which
incorporates the normal mild leukocytosis seen in pregnancy. Studies
have shown that there is no known distinguishing temperature that
separates appendicitis from those that turned out to be falsely positive
and therefore fever is only of limited benefit. The use of imaging
techniques has proven to be a valuable diagnostic tool in the diagnosis
of appendicitis during pregnancy and should be considered in the
evaluation of these patients. Both ultrasound and CT have been shown to
have acceptable sensitivity and specificity in the diagnosis of
appendicitis. Many sources do suggest that due to radiation exposure,
ultrasound should be the first imaging modality that is attempted with
CT reserved for unsure findings on ultrasound.

Obstetric providers should be cognizant of other medical conditions that
may mimic the signs and symptoms of appendicitis. Ectopic pregnancy can
present with unilateral lower quadrant pain. Ovarian cysts and torsion
can also cause pain and an inflammatory response. Degenerating fibroids
have been found in patients with suspected appendicitis, as well as,
gall bladder disease and hepatitis. The most common misdiagnosis is
pyelonephritis.

### [Treatment]{.underline}

Many surgeons accept a 15% false positive rate for surgical intervention
for suspected appendicitis in nonpregnant patients. Due to the
difficulty in diagnosis and the issues related to delay in diagnosis
some suggest that a 30% false positive rate is appropriate for pregnant
patients. The treatment of appendicitis is surgical. Laparotomy is
viewed as the most common mode, but laparoscopy may be considered
especially in the first trimester. Perioperative prophylactic
antibiotics may be considered in cases of suspected appendicitis, but
appropriate broad-spectrum antibiotics are indicated in cases of
gangrene, perforation, or peritonitis. Surgeons should also consider
placement of operative site drains especially in scenarios involving
perforation and peritonitis. Prophylactic tocolysis may be considered if
preterm contractions occur, however, there is no conclusive evidence
that this intervention is effective.

Morbidity and mortality from appendicitis during pregnancy occurs with
uncertainty in diagnosis and delay in treatment. Obstetric providers
have a responsibility in providing an expeditious evaluation and
treatment plan for patients with suspected appendicitis.

### [References]{.underline}

1.  Williams Obstetrics. 22nd Edition. 2002. Chapter 50.
    Gastrointestinal Disorders.

2.  Erilmaz R, et al. Acute Appendicitis During Pregnancy. Digestive
    Surgery. 2002. Vol 19. 40-44

3.  Mourad J, et al. Appendicitis in Pregnancy. American Journal of
    Obstetrics and Gynecology. 2000. Vol. 182. 1027-9

4.  Williams R and Shaw, J. Ultrasound Scanning in the Diagnosis of
    Acute Appendicitis in Pregnancy. Emergency Medicine Journal. 2007.
    Vol 24. 359-360

#### Contact [**John.Balintona@ihs.gov**](mailto:John.Balintona@ihs.gov) for questions {#contact-john.balintonaihs.gov-for-questions .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-57 .Style-Heading-4-+-Arial-14-pt-Underline}

**Nurses Corner, Sandra Haldane, HQE**

**Nurses and physicians have different perspectives in medical
decisions**

Nurses and physicians are both very involved in the care of nursing home
residents. However, their roles in and perspectives on medical
decisionmaking for residents can be very different, concludes a new
study. Jiska Cohen-Mansfield, Ph.D., A.B.P.P., and colleagues
interviewed nurses and physicians involved in the care of 28 cognitively
impaired nursing home residents who were unable to communicate their own
wishes. In these cases, the resident either had a change in health
status, change in a nonchronic condition that required medical followup
by a doctor, or died from a nonchronic illness.

Five male physicians and two female nurse practitioners answered the
medical staff questionnaire. The nurses who answered the nursing staff
questionnaire included 1 nurse manager and 17 primary charge nurses (3
RNs and 15 LPNs).

Compared with physicians, nurses reported a greater degree of
familiarity with the family\'s and resident\'s wishes. Physicians
reported considering more treatment options and choosing more treatments
for residents than nurses, probably because nurses did not see this as
part of their role in some of the cases. In 65 percent of cases, doctors
estimated that the condition was likely to improve with the treatment,
while the nurses predicted improvement in only 48 percent of cases.

Both physicians and nurses agreed that physicians had a major role in
decisionmaking that nurses did not. However, the gap in reported roles
was greater based on physicians\' reports compared with nurses\'
reports. Both physicians and nurses were generally comfortable with
their medical decisions and had similar perceptions of the families\'
reactions to the decisions. However, the involvement of the nurse as a
partner in these decisions was reported to be minor. In a third of the
reported cases, physicians and nurses disagreed about whether advance
directives had been followed.

Medical decision-making in the nursing home: A comparison of physician
and nurse perspectives,\" by Dr. Cohen-Mansfield, Steven Lipson, M.D.,
and Debra Horton, R.N., in the December 2006 *Journal of Gerontological
Nursing* 32(12), pp. 14-21

<http://www.ahrq.gov/research/sep07/0907RA15.htm>

####  {#section-58 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Church-Based Breast Cancer Screening Education: Impact of Two
Approaches**

The Tepeyac Project is a church-based health promotion project that was
conducted from 1999 through 2005 to increase breast cancer screening
rates in Colorado. In this report, an evaluation is done on the program
among enrollees in the state's five major insurance plans. The mammogram
rate for Latinas in the Printed Intervention remained the same from
baseline to follow-up. In the Promotora Intervention, the rate was 59%
at baseline and 61% at follow-up. Rates increased modestly over time and
varied widely by insurance type. After adjusting for age, income, urban
versus rural location, disability, and insurance type, women exposed to
the Promotora Intervention had a significantly higher increase in
biennial mammograms than did women exposed to the Printed Intervention.
<http://www.cdc.gov/pcd/issues/2007/oct/06_0150.htm>

####  {#section-59 .Style-Heading-4-+-Arial-14-pt-Underline}

**Oklahoma Perspective** **Nathan Tillotson, DO, Hastings Indian Medical
Center**

**Training for Shoulder Dystocia**

Shoulder dystocia is an obstetric emergency with serious potential risks
for both mother and fetus. The reported incidence ranges from 0.6% to
1.4% among vaginal deliveries. It is an unpredictable event with no
cost-effective means of prevention for the large majority of women at
higher risk. A study of 236 shoulder dystocia cases reported an 11% rate
of postpartum hemorrhage and a 3.8% rate of fourth-degree lacerations.
Neonates can experience brachial plexus injuries and fractures of the
clavicle and humerus with shoulder dystocia. Fortunately, fewer than 10%
of all cases of shoulder dystocia result in a persistent brachial plexus
injury.

Training for shoulder dystocia among midwives and obstetricians using
low and high-fidelity mannequins has been shown to improve performance:
use of basic maneuvers 114 of 140 (81.4%) to 125 of 132 (94.7%),
successful deliveries 60 of 140 (42.9%) to 110 of 132 (83.3%), good
communication with the patient 79 of 139 (56.8%) to 109 of 132 (82.6%),
pre- and posttraining, respectively. Training with the high-fidelity
mannequin was associated with a higher successful delivery rate than
training with traditional devices: 94% compared with 72% (odds ratio
6.53, P=.002). A delivery was considered successful if performed within
5 minutes.

ACOG Practice Bulletin Number 40, Shoulder Dystocia: November 2002.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17138783>

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

**Ordinary Doses of Vitamin D Linked to Lower Mortality**

CONCLUSIONS: Intake of ordinary doses of vitamin D supplements seems to
be associated with decreases in total mortality rates. The relationship
between baseline vitamin D status, dose of vitamin D supplements, and
total mortality rates remains to be investigated. Population-based,
placebo-controlled randomized trials with total mortality as the main
end point should be organized for confirming these findings.

[Autier
P](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Autier P"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
[Gandini
S](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Gandini S"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus).
Vitamin D Supplementation and Total Mortality: A Meta-analysis of
Randomized Controlled Trials. [Arch Intern
Med.](javascript:AL_get(this, 'jour', 'Arch Intern Med.');) 2007 Sep
10;167(16):1730-7

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17846391>

**Home health care following hospitalization for hip fracture may
provide an opportunity to limit osteoporosis progression**

<http://www.ahrq.gov/research/sep07/0907RA14.htm>

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

**Unsafe drugs during pregnancy: Frequency of birth control services
with prescriptions**

Summaries for patients. Frequency of birth control services with
prescriptions for unsafe drugs during pregnancy.Ann Intern Med. 2007 Sep
18;147(6):I38.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17876016>

**Strategies to improve health literacy for diverse populations should
address literacy, language, and cultural barriers**

<http://www.ahrq.gov/research/oct07/1007RA6.htm>

**Health literacy is not associated with how minorities perceive their
physical or mental health status**

<http://www.ahrq.gov/research/oct07/1007RA7.htm>

####  {#section-60 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Bell\'s Palsy: What You Should Know {#bells-palsy-what-you-should-know-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20071001/1004ph.html**](http://www.aafp.org/afp/20071001/1004ph.html) {#httpwww.aafp.orgafp200710011004ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-61 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Peptic Ulcers: What You Should Know {#peptic-ulcers-what-you-should-know-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20071001/1013ph.html**](http://www.aafp.org/afp/20071001/1013ph.html) {#httpwww.aafp.orgafp200710011013ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-62 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**No, I don't mean THAT Dating Game**

"....THE DATING GAME was and still is by all accounts, the premiere game
show for singles. It was the forerunner for many imitators such as
\"Love Connection\", MTV\'s \"Singled Out\" and numerous others. But
they all have the same influence: Chuck Barris, the creator of the one
that started it all! \"THE DATING GAME\" first premiered on December
20-24, 1965 on ABC-TV and remained a fixture on the\..."

No, I don't mean the above Dating Game.

I mean Ultrasound Dating - Update 2007

We continuously play "the dating game" in obstetrics. A reliable
estimation of when a woman is at term is critically important
information for us to have in order to be able to plan for delivery,
especially if complications of pregnancy develop later. Women and their
families also want to be able to plan for the birth by having a reliable
date. We often argue about the importance of "listening to women"
(menstrual dates) versus "technology" (ultrasound dates) in making our
decisions about when due dates will fall, but, considering the following
information, this really should not be an issue.

Women who undergo ovulation induction and/or artificial insemination may
have gestational age estimates of +3 days. However, for the vast
majority of women, a major problem in using menstrual dates to determine
fetal age is the biologic variability in the length of the follicular
phase, which is not a normally distributed variable. A higher number of
women ovulate late in the cycle (after day 21) than early in the cycle
(earlier than day 11). In a large recent study, 3% of the gestational
ages by ultrasound evaluation were greater than expected from an optimal
menstrual history (indicating early ovulation), and 17% were less
(indicating late ovulation). The "pregnancy wheels" we all carry in our
pockets (or PalmPilots!) are not able to predict the exact due date
because they are set up only for those women (about 52%) who ovulate on
cycle day 14.

Early ultrasound therefore has an advantage over even "good" dates. The
accuracy of first trimester (6-12 weeks) ultrasounds is also critically
influenced by the caliber of the machine and the expertise of the
ultrasonographer. These are variables that are usually not uniform from
service unit to service unit, and it is important to know your unit's
capabilities in order to be able to trust the results they generate.
That said, with current equipment, and a capable sonographer, the
accuracy of first trimester scans should be +3 days, not the +7 days
values generated from data accrued with the older instrumentation. This
result takes precedence over menstrual dates, and over first trimester
pelvic exams (which are only accurate to +2 weeks). At this stage of
pregnancy there is minimal biologic size variability as estimated from
crown-rump length (CRL), and it remains the most reliable biometric
parameter for estimation of the due date.

Measurement of crown-rump length is generally considerably more accurate
than measurement of gestational sac dimensions, so, if no fetal pole is
identified (\<6 weeks), the exam should ideally be repeated in 1-2 weeks
to document both dates, viability, and the location of the pregnancy.
The gestational age established by the CRL in the first trimester should
be used for the due date, and not changed based on biometric
measurements made later in pregnancy.

In the first half of the second trimester (13-20 weeks), fetal biometry
remains quite accurate. The composite parameters used (BPD, HC, AC, FL)
to derive the average ultrasound age (AUA) should be accurate to within
+7 days at this stage of pregnancy. The machine's computational software
uses a regression equation to derive a predicted gestational age from
the combined measurements, so one shouldn't just add up the values
obtained and divide by 4. Later in the second trimester (21-28 weeks),
because of the more pronounced biologic variability in fetal growth, the
most recent evidence seems to indicate that the standard deviation of
the composite measurements is +14 days. This difference becomes even
more pronounced in the third trimester (29-42 weeks) when the accuracy
is now reduced to +21 days. These latter values are unfortunately no
different from those obtained in the early 1980's with the older
equipment, again because of the biologic variability in fetal size as
term approaches.

What can you do with the patient who presents late for prenatal care in
the early third trimester, with no or "poor" dates? If her fundal height
is not congruent with the dates she gives, the question arises whether
she is growth restricted, or just premature, or if she is actually
farther along than suspected. In a recent WHO study in developing
nations, measurement of fundal height proved to be the best screening
tool for intrauterine growth restriction, but it was just that, a
screening, not a diagnostic, test. Third trimester physical exam has
been found to be as inaccurate as +6 weeks, again because of the "bell
curve" of fetal size, as normal term infants can weigh 5 ½ pounds or 9
pounds, and everything in between. Ethnicity and parental size are also
important variables to take into consideration.

The best strategy here, time permitting, is to do serial ultrasounds 3
weeks apart. The normal fetus should follow a normal growth curve. Thus,
if the first ultrasound gave a gestational age of 29+3 weeks, the
subsequent scan in 3 weeks should demonstrate a gestational age of 32+3
weeks. The two estimated dates of delivery (EDD) generated should be
comparable, and can then be used to set the anticipated due date, again
with the known standard deviations. Scans obtained sooner than 3 weeks
apart may be misleading, because of that +3 week standard deviation.

Another "quick and dirty" practical point for patients who present close
to term with unknown, or unclear, dates, and who are not diabetic, but
in whom an expeditious decision about gestational age needs to be made,
is to rely on the biparietal diameter. This assumes the fetal head is
not engaged, and a satisfactory BPD can be obtained. As a rough "rule of
thumb", if the BPD is \>92 mm, the infant is most likely at term.
Sonographic estimated fetal weights obtained in the late trimester are
no more reliable than clinical estimates however, with a margin of error
of at least 20% in either direction (that could be almost 2 pounds for a
suspected macrosomic fetus\...).

**Summary**

In order to optimize our care, it would be ideal if all our service
units were to use the same standards. This is especially important for
regional centers and the individual outlying sites that refer women for
delivery to them. From the best available evidence I have found, I would
like to recommend that CRL obtained between 6-12 weeks is the most
accurate parameter for establishing a due date, and supersedes menstrual
dates.

In order to make this a reality, the following assumptions need to be
true:

there is a capable sonographer available on a stable basis, as well up
to date equipment that is well maintained with an ongoing quality
assurance program. If those assumptions are the case, then our service
units should use the same standards, listed below.

Average Ultrasound Age Accuracy

6-12 weeks +3 days

13-20 weeks +7 days

21-28 weeks +14 days

29-42 weeks +21 days

References

1.  Callen PW. Ultrasonography in Obstetrics and Gynecology. (5th
    ed.) 2007. W. B. Saunders Co., Philadelphia, PA.

2.  Goldberg BB, McGahan JP. Atlas of Ultrasound Measurements. (2nd
    ed.) 2006. Mosby, Inc., Philadelphia, PA.

3.  Altman DG, Chitty LS. New charts for ultrasound dating of pregnancy.
    Ultrasound Obstet Gynecol 1997; 10:174-9.

4.  Royston P, Wright EM. How to construct 'normal ranges' for fetal
    variables. Ultrasound Obstet Gynecol 1998; 11:30-8.

5.  ACOG. Ultrasonography in pregnancy. ACOG Practice Bulletin #58,
    December 2004.

**Others**

**Prevention is the most effective evidence-based management to avoid
recurrence of FGR**

Fetal growth restriction is associated with multiple short- and
long-term consequences for the infant. A woman with a prior gestation
complicated by fetal growth restriction has nearly a 20% risk of
recurrence. Strategies to predict and prevent the recurrence are
critical in obstetric management. Effective interventions for prevention
of recurrent fetal growth restriction include the following: a
reproductive plan because spacing of pregnancies impacts their outcome,
optimization of maternal medical conditions, smoking cessation, accurate
dating by first-trimester sonography and monitoring of fetal growth with
serial sonograms, and low-dose aspirin (80--160 mg) started before 20
weeks. In women with nutritional deficiencies, optimizing caloric intake
with low-protein (less than 25%) supplementation of 500--1,000 calories
may prevent recurrent fetal growth restriction. In women living in areas
endemic for malaria, antimalarial prophylaxis diminishes risk of
recurrent fetal growth restriction.

[Berghella
V](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Berghella V"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus).
Prevention of recurrent fetal growth restriction. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007
Oct;110(4):904-12

<http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=17906027&dopt=AbstractPlus>

**3 criteria of oligohydramnios in identifying peripartum
complications**

[Study Design]{.underline} The 3 definitions of oligohydramnios were
amniotic fluid index (AFI) 5.0 cm or less and AFI \<5% for gestational
age (GA) using nomograms by Moore and Cayle or Magann et al. Likelihood
ratio (LR) and guidelines by the Evidence-Based Medicine Working Group
were used in the secondary analysis of previously published reports. AFI
obtained during antepartum and intrapartum periods were analyzed
separately.

[Results]{.underline} The 95% confidence intervals for the prevalence of
oligohydramnios using the 3 criteria are significantly different in the
antepartum or intrapartum analysis. The LR was \<6 for ante- and
intrapartum AFI to identify cesarean delivery for nonreassuring fetal
heart rate tracing, Apgar score 3 or less at 5 minutes, umbilical
arterial pH \<7.00, and newborns' weight 5% or less for GA.

[Conclusion]{.underline} The 3 criteria for determining the adequacy of
amniotic fluid are not fungible, and they are not useful diagnostic
tests for identifying peripartum complications because LR is \<10.

[Johnson
JM](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Johnson JM"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al A comparison of 3 criteria of oligohydramnios in identifying
peripartum complications: a secondary analysis. Am J Obstet Gynecol.
2007 Aug;197(2):207.e1-7; discussion 207.e7-8.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17689653>

**Oxytocin agonists for preventing postpartum haemorrhage**

AUTHORS\' CONCLUSIONS: There is insufficient evidence that 100
micrograms of intravenous carbetocin is as effective as oxytocin to
prevent PPH. In comparison to oxytocin, carbetocin was associated with
reduced need for additional uterotonic agents, and uterine massage.
There was limited comparative evidence on adverse events.

[Su
L](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Su L"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Oxytocin agonists for preventing postpartum haemorrhage. [Cochrane
Database Syst
Rev.](javascript:AL_get(this, 'jour', 'Cochrane Database Syst Rev.');)
2007 Jul 18;(3):CD005457

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17636798>

**Features of metabolic syndrome increase risk of a child with a NTD**

CONCLUSIONS: We found about 2-fold and 6-fold higher risk for NTD in the
presence 1, and 2 or more features, of the metabolic syndrome,
respectively. It is not clear whether this risk is altered by the
presence of a high serum hsCRP concentration.

[Ray
JG](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Ray JG"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Metabolic Syndrome features and risk of neural tube defects.\
BMC Pregnancy Childbirth. 2007 Sep 19;7(1):21

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17880716>

**Pregnant women who have very low cholesterol may face a greater risk
of preterm delivery**

Pregnant women who have very low cholesterol may face a greater risk of
delivering their babies prematurely than women with more moderate
cholesterol levels

CONCLUSIONS: Total serum cholesterol \<10th population percentile was
strongly associated with preterm delivery among otherwise low-risk white
mothers in this pilot study population. Term infants of mothers with low
total cholesterol weighed less than control infants among both racial
groups.

[Edison
RJ](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Edison RJ"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Adverse birth outcome among mothers with low serum cholesterol.\
Pediatrics. 2007 Oct;120(4):723-33.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17908758>

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

**Chronic Kidney Disease: CKD is Part of Primary Care**!

Moderator: Andrew Narva, MD

Ongoing now

-   What is the burden of CKD in AI/AN?

-   How should CKD patients be identified and followed?

-   What should we be doing for CKD patients in the primary setting?

-   When should patients be referred?

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

Subscribe to the Primary Care listserv

<http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=26>

Unsubscribe from the Primary Care listserv

<http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=26>

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

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

**American Indian women, HIV/AIDS, and health disparity**

Data are presented regarding the prevalence of HIV/AIDS among American
Indian women. Health disparities found among American Indians are
discussed and biological, economic, social, and behavioral risk factors
associated with HIV are detailed. Recommendations are suggested to
alleviate the spread of HIV among American Indian women and, in the
process, to diminish a culture of treatment malpractice and a weakening
of treatment ethics, racism, and genderism.

[Vernon
IS](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Vernon IS"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus).
American Indian women, HIV/AIDS, and health disparity. [Subst Use
Misuse.](javascript:AL_get(this, 'jour', 'Subst Use Misuse.');)
2007;42(4):741-52

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17558961**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17558961) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch17558961 .Style-Heading-4-+-Arial-14-pt-Underline}

# Adolescents' Discussions About Contraception Or STDs with Partners Before First Sex 

RESULTS: Fifty-three percent of females and 45% of males discussed
contraception or STDs before having first sex. The greater respondents'
perceived condom knowledge and the greater their communication with
their parents about everyday life, the higher their odds of discussing
contraception or STDs before first sex (odds ratio, 1.2 for each). Being
black was positively associated with sexual communication before first
sex (1.9); as the number of dating activities and score on a test of
verbal ability increased, so did the odds of such communication (1.6 and
1.02, respectively). The predictors of discussions about contraception
or STDs did not differ by gender.

CONCLUSIONS: By increasing teenagers' knowledge about condoms and other
methods of contraception, pregnancy and STD prevention programs can help
to encourage communication among teenage partners before the initiation
of sexual intercourse. Programs should also encourage conversations
between parents and teenagers, even when not about sex.

# Ryan S et al Adolescents' Discussions About Contraception Or STDs with Partners Before First Sex Perspectives on Sexual and Reproductive Health, Volume 39 Issue 3 Page 149-157, September 2007 

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17845526>

**Using clinical classifcation trees to identify risk of STDs during
pregnancy**

RESULTS: Nineteen percent of women had an incident STD during pregnancy.
Classification tree analysis identified three subgroups with a high STD
incidence (33--61%), one with a moderate incidence (16%) and three with
a low incidence (6--11%).Women in subgroups with high STD incidence
included those not living with the partner with whom they conceived and
those who had a moderate or a high level of depression, a history of
STDs and a low level of social support. A logistic regression model
using groups defined by the classification tree analysis had better
predictive ability than one using common demographic and sexual risk
predictors.

CONCLUSION: This classification tree identified risk factors not
captured by traditional risk screenings, and could be used to guide STD
treatment, care and prevention within the prenatal care setting.

Kershaw TS et al Using Clinical Classification Trees to Identify
Individuals at Risk of STDs During PregnancyPerspectives on Sexual and
Reproductive Health,   Volume 39, Number 3, September 2007, p.  141--148

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17845525>

**Exam room reminders and physician feedback can improve screening for
chlamydia in young women during preventive care visits**

<http://www.ahrq.gov/research/sep07/0907RA12.htm>

#### Genital Herpes: Framing the Problem, Diagnosing the Disease {#genital-herpes-framing-the-problem-diagnosing-the-disease-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.medscape.com/viewprogram/7905?src=nlcmealert**](http://www.medscape.com/viewprogram/7905?src=nlcmealert) {#httpwww.medscape.comviewprogram7905srcnlcmealert .Style-Heading-4-+-Arial-14-pt-Underline}

# Sexual Behaviors of Opposite-Sex Couples Through Emerging Adulthood 

RESULTS: Eighty percent of respondents had engaged in cunnilingus and
fellatio as well as vaginal intercourse in their current relationship;
this group included 22% who also had engaged in anal sex. Compared with
their peers who reported that they and their partner did not love each
other a lot, both males and females who reported mutually loving
relationships had significantly higher odds of having given oral sex
(odds ratios, 3.9 and 2.6, respectively) and having received oral sex
(1.8 and 3.3); males in mutually loving relationships also had elevated
odds of having had anal sex (3.1).

CONCLUSIONS: Most young adult couples in long-term relationships engage
in a variety of sexual practices with loving partners; the direction of
causality in this association and its implications for relationship
building require exploration. Furthermore, programs and interventions
that address health and well-being during emerging adulthood should
cover issues relevant to a broad range of sexual activities, including
oral and anal sex.

# Kaestle CE, Halpern TC What's Love Got to Do with It? Sexual Behaviors of Opposite-Sex Couples Through Emerging Adulthood Perspectives on Sexual and Reproductive Health  Volume 39 Issue 3 Page 134-140, September 2007 

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17845524>

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

**Magic Pill Improves Glycemic Control and Decreases Death by 25% for
Type 2\'s**

Imagine an inexpensive pill that could decrease the hemoglobin A1c value
by 1 percentage point, reduce cardiovascular death by 25%, and
substantially improve functional capacity (strength, endurance, and bone
density). Diabetes experts would be quick to incorporate this pill into
practice guidelines and performance measures for diabetes.

Aerobic and resistance training each improve glycemic control for
patients with type 2 diabetes, but the improvement is greatest when both
forms of exercise are combined,

CONCLUSION: Either aerobic or resistance training alone improves
glycemic control in type 2 diabetes, but the improvements are greatest
with combined aerobic and resistance training.

[Sigal
RJ](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Sigal RJ"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Effects of aerobic training, resistance training, or both on
glycemic control in type 2 diabetes: a randomized trial. [Ann Intern
Med.](javascript:AL_get(this, 'jour', 'Ann Intern Med.');) 2007 Sep
18;147(6):357-69

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17876019>

**Laugh Your Way to Normal Blood Sugars**

People with type 2 diabetes may be better able to process sugar from
meals if they laugh, according to a small study. Researchers found that
diabetics who watched a comedy show had a smaller rise in post-meal
blood sugar than when they listed to a non-humorous lecture. The effect
occurred in people without diabetes as well. Stress is known to raise
the risk of elevated blood sugar, and poorly controlled blood sugar can
increase the risk of diabetes complications such as heart disease,
kidney failure and blindness. Past studies have found that positive
emotions such as laughter may lower blood pressure, release endorphins,
improve circulation, stimulate the nervous system, heighten the immune
system and strengthen the heart. Researchers are not certain why
laughter appears to reduce blood sugar, but suggested that it might
increase the consumption of energy by using the abdominal muscles, or
might affect the neuroendocrine system, which controls glucose levels in
the blood.

[Hayashi
K](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Hayashi K"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Laughter lowered the increase in postprandial blood
glucose.[Diabetes
Care](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12716853&dopt=Abstract)
May 2003;26:1651-1652

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=12716853>

**Maternal Weight Gain Series (Six articles)**

**Fat mum hastens path to childhood obesity**

An overweight mother, watching TV and being a girl increase your odds of
being an obese child.

CONCLUSIONS: Many primary school aged children start on the trajectory
of obesity in the preschool years, which suggests interventions need to
start early. Maternal overweight/obesity, television watching, sedentary
activity time and rapid weight gain in infancy, early and middle
childhood are risk factors for childhood obesity, and are all
potentially modifiable.

Blair NJ et al Risk factors for obesity in 7-year-old European children:
the Auckland Birthweight Collaborative Study. Arch Dis Child. 2007
Oct;92(10):866-71.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17855436>

**Optimal gestational weight gain for BMI categories: Outcome based**

CONCLUSION: The gestational weight gain limits for BMI categories
determined in this large population-based cohort study from Swedish
Medical Registers showed that a decreased risk of adverse obstetric and
neonatal outcomes was associated with lower gestational weight gain
limits than was earlier recommended, especially among obese women. LEVEL
OF EVIDENCE: II.

[Cedergren
MI](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Cedergren MI"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus).
Optimal gestational weight gain for body mass index categories. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007
Oct;110(4):759-64

<http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=17906006&dopt=AbstractPlus>

**Editorial**

[Catalano
PM](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Catalano PM"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus).
Increasing maternal obesity and weight gain during pregnancy: the
obstetric problems of plentitude. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007
Oct;110(4):743-4

<http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=17906003&dopt=AbstractPlus>

[**Diet or exercise, or both, for weight reduction in women after
childbirth.**](http://mp.medscape.com/cgi-bin1/DM/y/hBYKq0Ou5N60Juv0IyaW0E1)

CONCLUSIONS: Preliminary evidence from this review suggests that dieting
and exercise together appear to be more effective than diet alone at
helping women to lose weight after childbirth, because the former
improves maternal cardiorespiratory fitness level and preserves fat-free
mass, while diet alone reduces fat-free mass. For women who are
breastfeeding, more evidence is required to confirm whether diet or
exercise, or both, is not detrimental for either mother or baby. Due to
insufficient available data, additional research, with larger sample
size, is needed to confirm the results.

[Diet or exercise, or both, for weight reduction in women after
childbirth.](http://mp.medscape.com/cgi-bin1/DM/y/hBYKq0Ou5N60Juv0IyaW0E1)
Cochrane Database Syst Rev. 2007 Jul 18;(3):CD005627.

<http://www.medscape.com/medline/abstract/17636810?cid=med&src=nlbest>

**Obese Pregnant Women Should Limit Weight Gain**

Severely obese women should lose weight during pregnancy, while obese
women who are pregnant should gain less weight than currently
recommended

RESULTS: Gestational weight gain incidence for overweight or obese
pregnant women, less than the currently recommended 15 lb, was
associated with a significantly lower risk of preeclampsia, cesarean
delivery, and large for gestational age birth and higher risk of small
for gestational age birth. These results were similar for each National
Institutes of Health obesity class (30-34.9, 35-35.9, and 40.0 kg/m(2)),
but at different amounts of gestational weight gain. CONCLUSION: Limited
or no weight gain in obese pregnant women has favorable pregnancy
outcomes. LEVEL OF EVIDENCE: II.

[Kiel
DW](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Kiel DW"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Gestational weight gain and pregnancy outcomes in obese women: how
much is enough? Obstet Gynecol. 2007 Oct;110(4):752-8.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17906005>

**Normal pre-pregnancy BMI and weight gain: Low risk of adverse outcomes
if full-term**

CONCLUSION: Our study shows that adherence to the current Institute of
Medicine guidelines results in lower risks for adverse pregnancy, labor,
and delivery outcomes when comparing all outcomes collectively.

[Devader
SR](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Devader SR"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Evaluation of gestational weight gain guidelines for women with
normal prepregnancy body mass index. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2007
Oct;110(4):745-51.
<http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=17906004&dopt=AbstractPlus>

# 

# Maternal Weight Tied to Child\'s Body Composition at Age 9

Conclusions: Mothers with a higher pre-pregnant body mass index or a
larger mid-upper arm circumference during pregnancy tend to have
children with greater adiposity at age nine. The extent to which this is
attributable to genetic factors, the influence of maternal lifestyle on
that of her child, or maternal adiposity acting specifically during
pregnancy on the child\'s fat mass cannot be determined in this study.

[Gale
CR](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Gale CR"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus)
et al Maternal Size in Pregnancy and Body Composition in Children. J
Clin Endocrinol Metab. 2007 Aug 7

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17684051>

**Other**

**Sleep Deprivation Series: (3 articles)**

True or False:  The largest at-risk group for sleep-related crashes is
commercial drivers.  

November 5-11, 2007 in your state and with local health departments.
Teen drowsy driving is an emerging issue. Consider the following annual
facts:

-   Drowsiness impairs judgment, vision, hand-eye coordination, and
    reaction times just like alcohol and other drugs. Being awake for 17
    hours is equivalent to someone with a blood alcohol concentration
    (BAC) of 0.05.

-   The National Highway Traffic Safety Administration estimates that
    100,000 police-reported crashes are caused by fatigued drivers,
    resulting in more than 1,550 deaths and 71,000 injuries annually.

-   According to National Sleep Foundation surveys half of Americans
    consistently report that they have driven drowsy and approximately
    20% admit that they have fallen asleep at the wheel in the past
    year.

The CSN and National Center for Child Death Review Policy and Practice
are proud co-sponsors with the National Sleep Foundation (NSF) of the
Drowsy Driving Prevention Week campaign. The campaign is designed to
educate young drivers (and everyone on the road!) about the dangers of
driving while sleepy.  This Toolkit provides resources about healthy
sleep and drowsy driving prevention during DDPW and beyond for states
and communities.

NSF\'s Drowsy Driving Prevention Week campaign includes:

-   The newly redesigned Web site offers extensive resources about
    drowsy driving toolkit that include public policy, fact sheets,
    human interest stories, and news features.
    [http://www.drowsydriving.org](http://www.drowsydriving.org/)

-   Presentations and online educational tools

-   Parent/Teen Safe Driver Contract

-   Resources to support drowsy driving advocates in their communities

-   A \"State of the States\" survey to be released later this month

ANSWER   Not commercial drivers -- it is the kids! - Sleep-related
crashes are most common in young people who tend to stay up late - sleep
too little and drive at night.

**Sleepy young drivers? Elevate your sleep IQ**

Check out the Doze family [dynamic 3-D animations of the Doze family
members](http://www.resisoftip.com/resisoft/nsf/flash_content/preloader.htm)
depicting effects of age and sleep and alertness influencers such as
shift work, caffeine, alcohol, stress and \"Monday morning blues.\" 

A must see web site -- 20 minutes with the doze will have you awake.

Young, elderly, teen, night shift, stressed worker what is your sleep
pattern and what lifestyle adjustments CAN you make!

National Sleep Foundation is a real find Take the Quiz. Elevate your
sleep IQ

<http://www.sleepfoundation.org/site/c.huIXKjM0IxF/b.2418861/k.B1A8/Tools_and_Quizzes.htm>

Sleep for all ages -- section on children -- "sleep deprived...
obstructive sleep apnea... Sleeping should be refreshing... Teachers
should look for children who are frequently yawning or falling asleep in
class... behavior/mood problems... in clinical history taking sleep is
often overlooked" \[Spring 2004, Volume 6, Issue 2 of sleepmatters.\]

<http://www.resisoftip.com/resisoft/nsf/flash_content/preloader.htm>

#### Losing Sleep Triggers Abnormal Glucose Metabolism {#losing-sleep-triggers-abnormal-glucose-metabolism .Style-Heading-4-+-Arial-14-pt-Underline}

According to a new study, Even a small amount of sleep loss can cause
changes in hormonal glucose regulation, with a strong effect on
pancreatic islet secretion, a decrease in glucagon levels and a slight
reduction in C-peptide levels.

#### CONCLUSION: Short-term SD distinctly alters hormonal glucose regulation, affecting especially pancreatic islet secretion, and also increases hunger. Immediate perturbations in the dynamic regulation of energy metabolism caused by acute sleep curtailment may contribute to the association between chronic sleep loss and metabolic disorders. {#conclusion-short-term-sd-distinctly-alters-hormonal-glucose-regulation-affecting-especially-pancreatic-islet-secretion-and-also-increases-hunger.-immediate-perturbations-in-the-dynamic-regulation-of-energy-metabolism-caused-by-acute-sleep-curtailment-may-contribute-to-the-association-between-chronic-sleep-loss-and-metabolic-disorders. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Schmid SM](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Schmid SM"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus), et al Sleep loss alters basal metabolic hormone secretion and modulates the dynamic counterregulatory response to hypoglycemia. [J Clin Endocrinol Metab.](javascript:AL_get(this, 'jour', 'J Clin Endocrinol Metab.');) 2007 Aug;92(8):3044-51 {#schmid-sm-et-al-sleep-loss-alters-basal-metabolic-hormone-secretion-and-modulates-the-dynamic-counterregulatory-response-to-hypoglycemia.-j-clin-endocrinol-metab.-2007-aug9283044-51 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17519315**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17519315) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch17519315 .Style-Heading-4-+-Arial-14-pt-Underline}

**Women's Health Much More at Risk from Sleep Deprivation**

New research led by researchers at Warwick Medical School at the
University of Warwick reveals that women's health is much more at risk
from sleep deprivation than men's. Professor Francesco Cappuccio from
the University of Warwick's Warwick Medical School led the research he
declared that women sleeping les than 5 hours a night should try to get
more sleep as:

\"Sustained sleep curtailment, ensuing excessive daytime sleepiness, and
the higher cardiovascular risk are causes for concern. Emerging evidence
also suggests a potential role for sleep deprivation as a predictor or
risk factor for conditions like obesity and diabetes.\"

[Cappuccio
FP](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Cappuccio FP"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Gender-specific associations of short sleep duration with
prevalent and incident hypertension: the Whitehall II Study.
Hypertension. 2007 Oct;50(4):693-700.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17785629>

**Other**

**PRESENT Diabetes, an Online Clinical Conference any time day or
night**

On this web site, we will provide you with a quick look at PRESENT
Diabetes, revealing it\'s innovative features and showing your how it
will connect you to diabetes care givers around the world and provide an
unparalleled opportunity to improve your knowledge and skills.

[An Online Clinical Conference]{.underline}\
Imagine a robust clinical conference, with cutting edge lectures with
FREE CME, focus groups, break out sessions and other forms of
professional networking - all available to you online 24/7/365 for free.
<http://presentdiabetes.com/#top>

**Women less likely than men to change habits that increase
heart-disease risk**

Smoking, eating fattening foods and not getting enough exercise are all
lifestyle habits that can lead to poor health and cardiovascular disease
-- more so if you have a family history. But researchers at UT
Southwestern Medical Center have found that women don't change these
habits as often as men, even when they have relatives with heart
disease.

#### CONCLUSIONS: Despite a stronger association with CVD risk factors and atherosclerosis prevalence with FHMI among young women compared with men, young women with FHMI demonstrated less CVD risk awareness and worse lifestyle choices. Family history of premature MI may be an especially useful risk assessment tool in young women, and greater efforts are needed to promote CVD risk awareness among young women with FHMI. {#conclusions-despite-a-stronger-association-with-cvd-risk-factors-and-atherosclerosis-prevalence-with-fhmi-among-young-women-compared-with-men-young-women-with-fhmi-demonstrated-less-cvd-risk-awareness-and-worse-lifestyle-choices.-family-history-of-premature-mi-may-be-an-especially-useful-risk-assessment-tool-in-young-women-and-greater-efforts-are-needed-to-promote-cvd-risk-awareness-among-young-women-with-fhmi. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [Patel MJ](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Patel MJ"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus) et al Implications of family history of myocardial infarction in young women [Am Heart J.](javascript:AL_get(this, 'jour', 'Am Heart J.');) 2007 Sep;154(3):454-60 {#patel-mj-et-al-implications-of-family-history-of-myocardial-infarction-in-young-women-am-heart-j.-2007-sep1543454-60 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17719289**](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17719289) {#httpwww.ncbi.nlm.nih.govsitesentrezdbpubmedcmdshowdetailviewtermtosearch17719289 .Style-Heading-4-+-Arial-14-pt-Underline}

**Strong link between a mother\'s hip size and the risk of breast cancer
in her daughters**

We conclude that the intercristal width, and the roundness of the iliac
crests, are markers of mothers\' sex hormones, and postulate that high
concentrations cause genetic instability in differentiating breast cells
in their daughters in utero

[Barker
DJ](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Barker DJ"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al A possible link between the pubertal growth of girls and breast
cancer in their daughters. Am J Hum Biol. 2007 Oct 5;

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17922483>

[**Cholesterol-Related Compound Can Block Estrogen From Helping To
Prevent Heart Disease in Some
Women**](http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=47533)

New research suggests that higher risk may be partially explained by the
presence of a naturally occurring chemical that blocks estrogen\'s
protective effects on the heart.

A molecule related to cholesterol can block the hormone estrogen from
performing functions in blood vessels that keep them healthy and
protected against heart disease

The researchers theorize that women taking hormone replacement therapy
may be at greater risk of developing heart disease because the chemical
27-hydroxycholesterol (27HC) inhibits the activity of estrogens
circulating in the blood. 27-hydroxycholesterol is produced when the
body breaks down cholesterol. Decreased estrogen, when combined with
high cholesterol, atherosclerosis, or both, could lead to an increased
risk of cardiovascular disease.

Before this work, it was well known that estrogen may be
cardioprotective. But the evidence was nil that there might be some
endogenous antagonist to this protective system

#### Umetani M et al 27-Hydroxycholesterol is an endogenous SERM that inhibits the cardiovascular effects of estrogen Nature Medicine Published online: 16 September 2007 {#umetani-m-et-al-27-hydroxycholesterol-is-an-endogenous-serm-that-inhibits-the-cardiovascular-effects-of-estrogen-nature-medicine-published-online-16-september-2007 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.nature.com/nm/journal/vaop/ncurrent/abs/nm1641.html**](http://www.nature.com/nm/journal/vaop/ncurrent/abs/nm1641.html) {#httpwww.nature.comnmjournalvaopncurrentabsnm1641.html .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-64 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Planning Group - conference on midwifery models of care**

Over the next 5 years, Indian Health Service and Health Canada, First
Nations Inuit Health Branch (FNIHB) will be collaborating on various
maternal and child health issues.  The first topic to be explored will
be midwifery care of AI/AN and First National/Inuit people. 

A group has been formed and planning has begun.  We have begun our
discussions with differences in midwifery education, credentialing and
licensure and the health care delivery systems between the US and
Canada.  We've had three calls over three months and more frequent
follow-up conversations in between. 

The planning group needs to be expanded.  Please email me if you are an
AI/AN midwife working in a IHS, Tribal, or Urban site.  I would also
like to hear from midwives who have developed one or more models of care
to address a specific health disparity, or to improve cultural
acceptability.  And I would also like to hear from midwives who have
significant midwifery experience in I/T/U settings.

Please remember that this activity requires time and commitment.  We may
not be able to add everyone who expresses an interest, but the idea is
to be as inclusive as possible.  Please contact me.

M. Carolyn Aoyama, CNM, MPH

Senior Consultant Women\'s Health & Advanced Practice Nursing

301-443-1028 <Carolyn.Aoyama@ihs.gov>

**Are women being scared away from math, science, and engineering
fields?**

Female academic performance lies in the (gender) balance

This study examined the cues hypothesis, which holds that situational
cues, such as a setting\'s features and organization, can make potential
targets vulnerable to social identity threat. Objective and subjective
measures of identity threat were collected from male and female math,
science, and engineering (MSE) majors who watched an MSE conference
video depicting either an unbalanced ratio of men to women or a balanced
ratio. Women who viewed the unbalanced video exhibited more cognitive
and physiological vigilance, and reported a lower sense of belonging and
less desire to participate in the conference, than did women who viewed
the gender-balanced video. Men were unaffected by this situational cue.
The implications for understanding vulnerability to social identity
threat, particularly among women in MSE settings, are discussed.

[Murphy
MC](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Murphy MC"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
et al Signaling threat: how situational cues affect women in math,
science, and engineering settings. Psychol Sci. 2007 Oct;18(10):879-85.

<http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17894605>

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

**2007 National HIV Prevention Conference**

-   December 2-5, 2007

-   Atlanta, Georgia

-   Center for Disease Control and Prevention

-   <http://www.2007nhpc.org/conferenceinfo.asp>

**23nd Annual Midwinter Indian Health OB/PEDS Conference**

-   February 8 - 10, 2008

-   For providers caring for Native women and children

-   Telluride, CO

-   Contact <AWaxman@salud.unm.edu>

**26th Annual "Protecting Our Children"**

-   April 20-23, 2008

-   Minneapolis, MN

-   National American Indian Conference on Child Abuse and Neglect

-   <http://www.nicwa.org/>

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

**How can we best manage Jehovah's Witnesses during pregnancy?**

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

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>

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

#### The October 2007 OB/GYN CCC Corner is available at: {#the-october-2007-obgyn-ccc-corner-is-available-at .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN01.cfm**](http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN01.cfm) {#httpwww.ihs.govmedicalprogramsmchmobgyn01.cfm .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Group Prenatal Care Improves Pregnancy Outcomes at No Additional
Cost**

#### From your colleagues page 6 {#from-your-colleagues-page-6 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Michael Berryhill {#michael-berryhill .Style-Heading-4-+-Arial-14-pt-Underline}

#### Interested in a subinternship / externship / observership {#interested-in-a-subinternship-externship-observership .Style-Heading-4-+-Arial-14-pt-Underline}

Scott Giberson

New items on IHS HIV website

**Amy Groom**

2007-2008 Influenza Vaccine

**Craig Vanderwagen**

Rebuilding Iraq one step at a time: You can be part of the solution

**Roberta Ward**

First trimester screening for Down Syndrome

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

#### Obstetrics page 9 {#obstetrics-page-9 .Style-Heading-4-+-Arial-14-pt-Underline}

## -Do Unsutured Second-Degree Perineal Lacerations Affect Postpartum Outcomes?

-Treating Gestational Diabetes May Reduce Childhood Obesity

-Increased still birth among obese mothers

-Neonatal sepsis increases linearly with membrane rupture up to 36 hours

-Extraabdominal uterine repair at cesarean: Increased patient
discomfort, nausea, vomiting

and more......

**Gynecology page 12**

-Cervical cancer differences disappear in rural women after controling
for poverty and race

-Improvements in outcome with subtotal hysterectomy not confirmed

-Cost effectiveness of home based population screening for Chlamydia
trachomatis

**Child Health page 12**

-How to improve psychosocial problems at well child care visits?

-Is Ibuprofen Appropriate for Pain Control in Children?

-School based intervention to lower incidence of disordered weight
control behavior

-Management of Type 2 Diabetes in Youth: An Update

-Are babies born to short, primiparous, or thin mothers \"normally\" or
\"abnormally\" small?

**Chronic Illness and Disease page 14**

## -Why Hasn\'t This Patient Been Screened for Colon Cancer? 

-Migraine With Aura Increases Risk for Ischemic Stroke

-US Dietary Guidelines Effectively Limit Insulin Resistance in Women

-The Choice of a Metabolic Syndrome Generation: Soft Drinks

-ACIP Recommends the Use of Tdap in Adults

and more......

#### Features page 17 {#features-page-17 .Style-Heading-4-+-Arial-14-pt-Underline}

American College of Obstetricians and Gynecologists

-Pelvic Organ Prolapse

-Management of Delivery of a Newborn With Meconium-Stained Amniotic
Fluid

-ACOG Advises Against Cosmetic Vaginal Procedures: Safety and Efficacy
Data

-Research Involving Women

##### American Family Physician

Counseling Women About Mammography: Benefits vs. Harms

###### Guidelines on Screening for Fetal Chromosomal Abnormalities

**Agency for Healthcare Research and Quality**

-Maternal and fetal labor and delivery complications increase beyond 39
weeks

-Midwife practices vary greatly in compensation and employment
structures

-Pediatricians recognize most overweight or obese children without using
weight curves

-Gender of both the child and parent affect a child\'s participation
during visits to the doctor

-Pertussis vaccination in adults can be cost-effective depending on
incidence rates

**Ask a Librarian**

In Search of a Research Article?

**Breastfeeding**

A pacifier by any other name....\*

Medications: Information for Pregnant and Breastfeeding Women

Breastfeeding Trends and National Health Objectives for Exclusive
Breastfeeding

**CCC Corner Digest**

-Women\'s greater risk of dying after surgery: Transfusion-related
immunosuppression

-Ann Bullock is the new Chief Clinical Consultant for Family Medicine

-Low-dose aspirin has benefits when used for prevention of pre-eclampsia

-Human papillomavirus, vaccines and women\'s health: questions and
cautions

-Educate parents about new pre-adolescent vaccine recommendations

-Exposing the Great Bottled Water Scam

-Prevention of Deep Vein Thrombosis and Pulmonary Embolism  Practice
Bulletin

-Prevent Fetal Alcohol Spectrum Disorders: A Toolkit

-Various Implantable Contraceptives Equally Effective in Preventing
Pregnancy

-Moderate morning sickness only partially responding to doxylamine and
pyridoxine

-Don't use Google, use Blackle instead and save 750 mega watts/hour per
year

-Sex, Soap & Social Change - The Sabido Methodology

-Motor vehicle restraint use in American Indian children: Meaningful
interventions

-Nausea and Vomiting in Pregnancy

-Study Supports HRT Use for Short Term, but Little Benefit in Older
Women

-Group prenatal care reduces preterm births and increases breastfeeding
initiation: RCT

-Evaluation of the pregnant patient for non-obstetric surgery

-Nursing education scholarship opportunities

-Decision Rules Useful for Selecting Women for Bone Mineral Density
Testing

-Nausea and Vomiting of Pregnancy

-Chronic Renal Disease is Part of Primary Care

-Culture, context, and sexual risk among Northern Plains American Indian
Youth

-Within eight years, 75% of adults will be obese or overweight

-APN scope of practice: colonoscopy?

**Domestic Violence**

-Domestic Violence Awareness Month: October

-Health Cares About Domestic Violence Day: October 10, 2007

-Victim Advocates And Tribal Law Enforcement: October 17-18, 2007

-Location of shelters impacts the incidence of violence against homeless
women

**Elder Care News**

-Daily Back Pain May Have Adverse Health Effects in Elderly Women 

# -Estrogens May Modify Course of Parkinson\'s Disease in Women

**Family Planning**

Advance Provision for Emergency Oral Contraception

**Featured Website**

State trends on uninsured children

**Frequently asked questions**

What\'s the first course of action for this couple that\'s trying to
conceive?

**Indian Child Health Notes**

-Superhero related injuries in pediatrics

-Unpublicized nuclear releases in American Indian communities

-Removable brace versus casting in children with low-risk ankle
fractures.

-Influenza Vaccination for 2007-8

-The tail end of guinea worm -- global eradication without a drug or a
vaccine

**Information Technology**

-Changes in workflow and tasks with bar code medication administration
into nurses\' work

-Commonwealth Fund/Harvard University Fellowship in Minority Health
Policy

International Health

Prevention of Mother-to-Child HIV Transmission: An Innovative Program in
Cameroon

#### 

#### MCH Alert

-Infant Mortality Awareness Month Toolkit

-New Edition of Child Health USA Released

-MCH Library expands availability and access to historical documents

#### MCH Headlines

-AIAN researchers on perinatal depression requesting names of interested
individuals

-Protecting America's Future

-Alliance for a Healthier Generation Webinar

#### Medical Mystery Tour

#### Endometriosis: Where is the real truth? {#endometriosis-where-is-the-real-truth-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Medscape

#### -Hereditary Link to PMDD Identified {#hereditary-link-to-pmdd-identified-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### -The Reproductive Phenotype in Polycystic Ovary Syndrome {#the-reproductive-phenotype-in-polycystic-ovary-syndrome .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Passive Smoking Increases Risk for Sleep Disturbance During Pregnancy {#passive-smoking-increases-risk-for-sleep-disturbance-during-pregnancy .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Management of Valvular Heart Disease in Pregnancy {#management-of-valvular-heart-disease-in-pregnancy .Style-Heading-4-+-Arial-14-pt-Underline}

**Menopause Management**

#### -Estrogen Protects Women's Brains Prior to Menopause {#estrogen-protects-womens-brains-prior-to-menopause .Style-Heading-4-+-Arial-14-pt-Underline}

-Atrophic Vaginitis and Estrogen Treatment - Medscape CME

\-[Cholesterol-Related Compound Can Block Estrogen To Prevent Heart
Disease](http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=47533)

**Midwives Corner**

-Nurse Midwife Week October 7-13, 2007

-Piercing the veil: the marginalization of midwives in the United States

-Impact of written information on women\'s use of postpartum services

**Navajo News**

Evaluation of the pregnant patient for non-obstetric surgery: Part Two

**Nurses Corner**

Memories, As a Public Health Nurse on the Navajo

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

-Common Questions about HPV and Cervical Cancer: For Women Who Have HPV

# -Prevalence of HPV Infection Among Sexually Active Females 

-Pre-Teen Vaccine Campaign

**Oklahoma Perspective**

Preconception Health of Women Delivering Live-Born Infants --- Oklahoma,
2000--2003

Osteoporosis

-Fracture Outcomes in Women Discontinuing Alendronate

-Childhood, Teen Restriction of Dairy Foods Lowers Spinal Bone Mineral
Content

-Pharmacologic Treatment of Osteopenia Not Usually Indicated

Patient Education

Type 2 Diabetes in Youth: What You Should Know

Perinatology Picks

-Procedure-related complications of amniocentesis and CVS are small

-Positive association between hyperemesis gravidarum and Helicobacter
pylori infection

-HgbA1C and GHb for risk of congenital anomaly in women with diabetes

-Crohn\'s disease: Preterm birth etc greater with azathioprine
/6-mercaptopurine

-Magnesium sulphate for women at risk of preterm birth for
neuroprotection of the fetus

and more......

Primary Care Discussion Forum

Chronic Kidney Disease: CKD is Part of Primary Care!

STD Corner

-Culture, context, and sexual risk among Northern Plains American Indian
Youth

-Sexual Assertiveness among Adolescent Girls: Initiation, Refusal, and
Protective Behaviors

-Sexually Transmitted Infections in Preadolescent Children

#### -Screening for Chlamydial Infection: USPSTF Recommendation Statements {#screening-for-chlamydial-infection-uspstf-recommendation-statements .Style-Heading-4-+-Arial-14-pt-Underline}

# -Home screening for sexually transmitted diseases in high-risk young women: RCT

...and more

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

-HAPO: Call for re-evaluation of gestational diabetes diagnosis and
treatment criteria

#### -Children whose mothers are overweight: Higher levels of body fat themselves at age nine {#children-whose-mothers-are-overweight-higher-levels-of-body-fat-themselves-at-age-nine .Style-Heading-4-+-Arial-14-pt-Underline}

-Women less likely than men to change habits that increase heart-disease
risk

#### -Maternal Diabetes Depletes Fetal Iron Stores {#maternal-diabetes-depletes-fetal-iron-stores .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Gestational diabetes mellitus may increase risk of developing pancreatic cancer {#gestational-diabetes-mellitus-may-increase-risk-of-developing-pancreatic-cancer .Style-Heading-4-+-Arial-14-pt-Underline}

**Women's Health Headlines**

Ovarian Cancer: Pinn Point on Women's Health

###### Save the Dates: Upcoming events of interest page 44

#### What's new on the ITU MCH web pages page 45

New Breastfeeding Headlines Box: The Latest in Breastfeeding Updates

The past CCC Corners are archived at:

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

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

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

or 907 729 3154 (with voicemail)

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

10/14/07