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OB/GYN Chief Clinical Consultant's Corner

Volume 4, No. 8, August 2006

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

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

Rate of uterine rupture hasn't changed for 20 years -- Why have our
practices changed?

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

Carolyn Aoyama

-New Women's Health Work Group Forming: Looking for interested
volunteers

-AHRQ's  "Women's Health 2006: Translating Research into Practice"  

Jean Howe

# Adults with Self-Assessed Symptoms of Serious Psychological Distress, by Sex and Race 

Judy Thierry:

Providers should conduct psychosocial screening of all women in
pregnancy

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

##### Obstetrics page 10

-Update your standing post partum discharge orders: Tdap in pregnancy /
postpartum

-Repeat Cesarean Deliveries Raise Risk of Maternal Morbidity

-Membrane Sweeping at 41 Weeks Helps Prevent Post-Term Pregnancy

-Most Stillbirths Worldwide Are Preventable

-Sudden infant death syndrome and complications in other pregnancies

**Gynecology page 11**

-ACOG Releases HPV Vaccine Recommendations for Ob-Gyns

-Sensitivity of colposcopy in ASCUS / LGSIL improves with more than two
biopsies

-HPV-Based Triage May Result in Excess Colposcopies in Young Women

-Urodynamics-based detrusor overactivity diagnoses may be insufficiently
reliable

-Pessaries Helpful in Pelvic Organ Prolapse Patients

And more.....

**Child Health page 14**

-Emergency Contraception: A Primer for Pediatric Providers

-Role of subthreshold symptoms on major depressive disorder in
adolescents

**Chronic Illness and Disease page 15**

-Antidepressant Discontinuation Syndrome

-Are laxatives effective for the treatment of symptomatic hemorrhoids in
adults?

-Interventions to Facilitate Smoking Cessation

-Exercise and Older Patients: Prescribing Guidelines

#### Features page 16 {#features-page-16 .Style-Heading-4-+-Arial-14-pt-Underline}

##### American Family Physician

-Norethindrone More Effective for Menses Suppression

-Fecal Occult Blood Testing in Healthy Patients Does Not Reduce
Mortality

-Mammography Results in Overdiagnosis of Breast Cancers

-Omega-3 Fats Do Not Affect Mortality Rates

-Screening for Iron Deficiency Anemia for Children and Pregnant Women

American College of Obstetricians and Gynecologists

-Induction of Labor for Vaginal Birth After Cesarean Delivery

-Management of alloimmunization during pregnancy. ACOG Practice Bulletin

-Psychosocial Risk Factors: Perinatal Screening and Intervention

**Agency for Healthcare Research and Quality**

-More data are needed to better identify health care disparities among
AI/AN

-Increasing cervical cancer screening intervals is cost-effective for
women with three consecutive normal Pap smears

-ACE inhibitors during the first trimester of pregnancy: Increased risk
of birth defects

**Ask a Librarian**

New on Your Library Website - Daily Health Policy News Summaries

**Breastfeeding**

-Early Milk Supply Issues

-Breastfeeding Basics: Generalist to Generalist

**CCC Corner Digest**

\-[Refusals by pharmacists to dispense emergency
contraception](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_AOM.cfm)

\-[How to address health disparities? One story of
success](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Coll.cfm)\
-[Pendulum swing:  Vaginal breech delivery approved within
guidelines](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_HT.cfm#ob)

\-[CDC's Advisory Committee Recommends Human Papillomavirus Virus
Vaccination](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_HT.cfm#gyn)

\-[New Guidelines for Pediatric and Neonatal Emergency Cardiovascular
Care](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_HT.cfm#child)

\-[Driving, Other Erratic Behaviors Reported After Taking Zolpidem
(Ambien)](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_HT.cfm#chrIll)

\-[Planned Early Birth vs. Expectant Management for
PROM](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Feat.cfm#afp)

\-[William H. J. Haffner American Indian / Alaska Native Women's Health
Award](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Feat.cfm#acog)

\-[Pain is one the reasons that moms quit breastfeeding in the first 2
weeks](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Feat.cfm#breast)

\-[Injectable Contraception and Skeletal
Health](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Feat.cfm#fp)

\-[Hospital Computer Keyboards Should Be Disinfected
Daily](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Feat.cfm#it)

\-[Where There is No Doctor & A Book for
Midwives](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Feat.cfm#ih)

\-[Copious post operative mucous secretions: The rest of the
story](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Feat.cfm#mmtour)

\-[Nuchal cords, somersaults, and the value of a pulsing cord: Nuchal
Cord
Management](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Feat.cfm#MidWives)

\-[Methamphetamine abuse among women on Navajo: Part IV - The "Drop- in"
gravida](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Feat.cfm#navajo)

\-[The Association of Nurses in Aids
Care](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Feat.cfm#nurseCorner)

\-[IHS Division of Epidemiology and Disease Prevention Launches New
Website](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Feat.cfm#okie)

\-[Osteoporosis Guidelines Updated: North American Menopause
Society](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Feat.cfm#oste)

\-[Only 29% of ACOG recommendations are level A: Good and consistent
scientific
evidence](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Feat.cfm#periPicks)

\-[September 1, 2006: Palliative Medicine\'s Role in the Continuity of
Care](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Feat.cfm#pcf)

\-[Focus on adolescent sexual behavior this
month](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Feat.cfm#std)

\-[Diabetes Is The Clinical Equivalent of Aging 15
Years](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Feat.cfm#stillW)

**Domestic Violence**

-Randomized trial assesses screening for intimate partner violence in
health settings

-Physical Dating Violence Common Among Teens, Linked to Risky Behaviors

-After the Crisis - Resource Papers and Issue Briefs

-Primary care assessment of intimate partner violence and may prevent
its recurrence

**Elder Care News**

-Is 75 Years an Appropriate Upper Age Limit for Mammography?

-Performance by Elderly on 400-Meter Walk Predicts Disability and Death

-Second Annual American Indian and Alaska Native Long Term Care
Conference

**Family Planning**

Addressing Depression in Family Planning Services

**Featured Website**

Try Michigan's Health Department website. It's super!

**Frequently asked questions**

The Indian Health MCH Frequently Asked Question (FAQ) site

**Indian Child Health Notes**

\- High levels of bilirubin in newborns - more good than bad news

\- The elevated risk of jaundice in AI/AN infants

\- A round up of new vaccines for 2006 by Ros Singleton

\- Mental Health disorders in parents of AI/AN adolescents

**Information Technology**

Hospital Computer Keyboards Should Be Disinfected Daily

International Health

-HIV/AIDS in Latin America and the Caribbean

-The next influenza pandemic: what public health measures might help?

#### MCH Alert

AAP encourages implementation of new shopping cart standards to prevent
child injury

#### Medical Mystery Tour

#### First trimester screening: How would you counsel this patient? {#first-trimester-screening-how-would-you-counsel-this-patient .Style-Heading-4-+-Arial-14-pt-Underline}

#### Medscape

**Menopause Management**

-Gabapentin is an effective alternative to estrogen for the treatment of
hot flushes

-AHRQ: Menopausal hormone therapy declined after published WHI trial
results

**Midwives Corner**

VBAC: Pendulums and Ecstasy

**Navajo News**

#### Please See Abstract of the Month {#please-see-abstract-of-the-month .Style-Heading-4-+-Arial-14-pt-Underline}

**Nurses Corner**

Native Alaskan and American Indian Nurses Scholarship Opportunity

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

Final Births for 2004

**Oklahoma Perspective**

The indications for IUD use have vastly expanded

Osteoporosis

Soy Isoflavones Protect Postmenopausal Women From Bone Loss 

Patient Education

#### -Antidepressant Discontinuation Syndrome: What You Should Know {#antidepressant-discontinuation-syndrome-what-you-should-know .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Tips to Help You Quit Smoking {#tips-to-help-you-quit-smoking .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Health Care for Lesbians and Bisexual Women {#health-care-for-lesbians-and-bisexual-women .Style-Heading-4-+-Arial-14-pt-Underline}

Perinatology Picks

-Glyburide flows from fetus to mother by placental transport system

-Inappropriate Discontinuation of Asthma Medication Common in Early
Pregnancy

Primary Care Discussion Forum

September 1, 2006: Palliative Medicine\'s Role in the Continuity of Care

STD Corner

# -Condom Use and the Risk of Genital Human Papillomavirus Infection in Young Women

#### -Latest CDC STD Treatment Guidelines Just Released {#latest-cdc-std-treatment-guidelines-just-released .Style-Heading-4-+-Arial-14-pt-Underline}

-Rapid HIV Test Distribution Picks up Thousands of Infections in US

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

-Obese Girls: Threefold Risk for Early Death than Slim Counterparts\
-New Recommendations Regarding Exercise and Type 2 Diabetes Issued 

-Just how effective are diabetes management programs**?**

###### Save the Dates: Upcoming events of interest page 35

#### What's new on the ITU MCH web pages page 36

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

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

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

**Rate of uterine rupture hasn't changed for 20 years -- Why have our
practices changed?**

The rate of symptomatic uterine rupture has been quoted at 0.5% - 1.0%
for the last 20 years. The constant data has been very discordant with
the changes in practice that we have seen recently, and the increased
concentration / discussion regarding a increasing(sic) risk of rupture.

Luckily, several recent publications add significant information to our
understanding of vaginal birth after cesarean (VBAC) and suggest that a
reversal of the dramatic move away from VBAC may be in order.
Nationally, the number of hospitals offering VBAC services has decreased
dramatically over the past several years. Of those facilities that do
offer VBAC, some allow a trial of labor for women in spontaneous labor
but will not offer augmentation or induction of labor. Also, some
hospitals restrict a trial of labor to women with only one prior
cesarean delivery, even for those women who have had a previous vaginal
birth. As I.H.S. facilities with full scope Ob/Gyn departments have
largely continued to offer VBAC services, it is encouraging to see VBAC
re-evaluated from a more balanced and evidence-based perspective.

[Induction of Labor]{.underline}

This month ACOG issued a new Committee Opinion addressing the safety of
induction of labor for patients who have had a prior cesarean delivery.
The abstract states:

Induction of labor in women who have had cesarean deliveries may be
necessary because of fetal or maternal indications. The potentially
increased risk of uterine rupture should be discussed with the patient
and documented in the medical record. Selecting women most likely to
give birth vaginally and avoiding the sequential use of prostaglandins
and oxytocin appear to offer the lowest risks. Misoprostol should not be
used in patients who have had cesarean deliveries or major uterine
surgery.

This Committee Opinion offers a concise review of recent studies of VBAC
and induction of labor and points out that previous studies may have
overestimated the risk of uterine rupture with induction. For example,
the study by Lydon-Rochelle et al. was a retrospective, population-based
study relying on ICD-9 codes for diagnosis of uterine rupture.
Lydon-Rochelle reported the following rupture rates: 0.16% for repeat
cesarean delivery, 0.52% for spontaneous labor, 0.77% for labor induced
without prostaglandins, and 2.4% for labor induced with prostaglandins.
The Committee Opinion notes that there was no significant difference in
the rates of uterine rupture with spontaneous labor or labor induced
without prostaglandins in this study.

More recent literature about induction is also presented. This includes
the prospective multi-center observational study by Landon, et al.,
where the outcomes experienced by 33,699 women with previous cesarean
deliveries were analyzed. Chart review confirmed 124 cases of uterine
rupture in the 17,898 women undergoing a trial of labor, with the
following rates: 0.4% for spontaneous labor, 0.9% for augmentation of
labor, and 1% for induction of labor. Additionally, this study reports a
risk of rupture of 1.1% with oxytocin alone, 0.9% with mechanical
dilation (+ oxytocin), and 1.4% when prostaglandins and oxytocin were
used in combination. The odds ratio of rupture, in comparison to the
women who labored spontaneously, was 2.42 for augmentation of labor and
2.86 for induction of labor with the highest risk associated with
prostaglandins and oxytocin used in combination (O.R. 3.95). Misoprostol
was one of the prostaglandins used in this study. Interestingly, there
were no cases of rupture in women induced only with prostaglandins,
which they suggest is due to these women going into labor "easily".

The new Committee Opinion also cites another large retrospective study
(Macones) of 25,005 women conducted by medical record data abstraction
at both tertiary and community hospitals. This study found an overall
risk of rupture of 0.98% (0.4% in women who also had a prior vaginal
delivery). The odds ratio of uterine rupture was 3 times higher in women
who underwent induction or augmentation of labor, in comparison to those
who labored spontaneously. However when specific methods were assessed
in multivariate analysis, in comparison to spontaneous labor, the odds
of uterine rupture was 1.61 with augmented labor, 0.85 induced without
oxytocin or prostaglandin, 1.46 with oxytocin alone, 1.90 with
prostaglandin alone, and 4.54 with oxytocin and prostaglandins used in
combination. Only the increased odds of rupture associated with combined
oxytocin and prostaglandin use was statistically significant.
Misoprostol was not used in this study population.

Based on this information, the Committee Opinion concludes:

Induction of labor remains a reasonable option, but the potentially
increased risk of uterine rupture associated with any induction should
be discussed with the patient and documented in the medical record.
Selecting women most likely to give birth vaginally and avoiding
sequential use of prostaglandins and oxytocin appear to offer the lowest
risks of uterine rupture. Misoprostol should not be used in patients who
have had cesarean deliveries or major uterine surgery.

This committee opinion is firm in its recommendation to avoid the use of
Misoprostol but supports the use of oxytocin augmentation and induction
in selected patients with appropriate counseling and does not mandate
the avoidance of all prostaglandins. As the most recent (2004) ACOG
Practice Bulletin on VBAC cautions against the use of any prostaglandins
in women undergoing a trial of labor, widespread use of prostaglandins
is not likely without further clarification from ACOG. Nonetheless, this
additional information about the risks associated with augmentation and
induction of labor will be helpful in counseling patients and the data
suggests that the overall increase in risk associated with augmentation
and induction of labor is less than previously stated.

[Two Prior Cesarean Deliveries]{.underline}

The two recent large studies of VBAC also offer new data about the
advisability of VBAC for woman with two prior cesarean deliveries who
desire a trial of labor. ACOG addressed this situation briefly but
emphatically in the 2004 Practice Bulletin. That recommendation was
based primarily on a study by Caughey et al. which was a retrospective
chart review of all patients undergoing a trial of labor at a single
facility over a twelve year period. The 3757 women with a single prior
scar experienced a rupture rate of 0.8% while 3.7% of women with two
prior scars experienced uterine rupture (5 of 134). They note that the
risk of uterine rupture was nearly 5 times greater for women with two
previous scars compared to one scar. In a multivariate regression
analysis they also note that the risk was of rupture with 2 scars was
only one-fourth as great if the woman had also had a prior vaginal
delivery. ACOG concluded that for women with 2 prior cesarean
deliveries, only those with a prior vaginal delivery should be
considered candidates for a trial of labor.

Macones et al. have reviewed their retrospective data from both tertiary
and community hospitals which included 20,175 women with one previous
cesarean delivery and 3,970 women with two previous cesarean deliveries.
The rates of successful VBAC were similar (75.5% and 74.6%
respectively). The risk of rupture was lower for women with one prior
cesarean delivery (0.9% vs. 1.8% for the women with two prior cesarean
deliveries). The history of a prior vaginal birth was associated with a
lower risk of rupture (0.5% vs. 2.4% with no prior vaginal delivery
history). The odds ratio of major morbidity was 2.26 for women with 2
prior cesarean deliveries who elected a trial of labor compared to a
repeat cesarean delivery. As the absolute risk of major morbidity
remains small, these investigators conclude that a VBAC attempt remains
a reasonable option for women with 2 prior cesarean deliveries.

Landon et al. have also analyzed the data from their study to address
this issue. Their prospective observational study found rates of uterine
rupture of 0.7% (115 of 16,915 women with a single prior cesarean
delivery) vs. 0.9% (9 of 975 women with a history of more than one prior
cesarean delivery) for women undergoing a trial of labor. The VBAC
success rate was 74% for those with one prior scar and 67% with two
prior scars. (The study also included 84 women with 3 prior scars and 20
women with 4 prior scars; these women experienced a 63% and 55% success
rate respectively.) The difference in the absolute rates of uterine
rupture for the subset of women with multiple prior scars who had
experienced a previous vaginal delivery (1%) and who had not had a
previous vaginal delivery (0.85%) was not statistically significant.
Prior vaginal delivery was protective in the overall analysis with an
odds ratio of uterine rupture of 0.5 compared to those women who had not
given birth vaginally in the past. The odds of major maternal morbidity
associated with a trial of labor for women with multiple prior cesarean
deliveries was 1.41.

Both studies demonstrate that the absolute risk of uterine rupture for
women with a history of two prior cesarean deliveries is small. This
information suggests that, with appropriate counseling and labor
management, women with two prior cesarean deliveries and are otherwise
acceptable VBAC candidates may be allowed to proceed with a trial of
labor. An absolute requirement for a prior vaginal delivery is not
supported by these findings, although prior vaginal delivery is an
additional predictor for success.

[Resources for VBAC]{.underline}

All Navajo Area facilities with full-scope Ob/Gyn services continue to
offer VBAC, as do a number of other I.H.S. sites. For more information
about strategies to optimize safety for women undergoing a trial of
labor, the work of the Northern New England Perinatal Quality
Improvement Network remains an excellent reference. NNEPQIN has put
forth guidelines for risk stratification and resource development on
their web site. These guidelines classify as low risk women with one
prior uterine scar presenting with spontaneous labor and without FHR
abnormalities. Medium risk women are those undergoing induction or
augmentation, with 2 or more previous scars, or with a \<18 month
inter-delivery interval. High risk women are defined as those with
repetitive non-reassuring FHR abnormalities, bleeding suggestive of
abruption, or 2 hours without cervical change in active labor despite
adequate contractions. They then describe appropriate resources needed
to manage each risk group. The NNEPQIN site also has model consent forms
and patient information as well as suggestions about conducting drills.
Dr. Lauria, one of the leaders of the ACOG-award winning NNEPQIN VBAC
project, will be returning to speak at the triennial I.H.S. Ob/Gyn
meeting in Albuquerque in August 2007.

From Jean Howe, Chinle

#### 

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

**The VBAC pendulum is beginning to swing back toward a more reasonable
approach**

Clearly the national benchmark recommendations that women with 2
previous cesarean deliveries and no vaginal delivery should have a
repeat cesarean delivery should be reexamined in light of this new
information.

Likewise, cervical ripening and induction of labor with oxytocin and
foley bulbs can be considered as the data suggests that the overall
increase in risk associated with augmentation and induction of labor is
less than previously stated.

In addition, as we counsel our patients we should not just speak in
terms of odds ratios or relative risks, but in terms of attributable
risk or marginal risks - above the baseline risk. For instance, the
Network data in the Landon study demonstrated that the rate of hypoxic
ischemic encephalopathy was actually quite small at approximately 1 /
2,000 trials of labor.

I encourage you to take advantage of unique opportunity available to
staff who provide care for Indian Health women and children. One of the
foremost experts on this issue and how implement reality obstetric based
drills, Dr. Lauria, will be one of the Key Note Speakers at the next
National Women's Health and MCH Meeting August 15-17, 2007. There will
also be presentations on successful implementation of emergency
obstetric drills from the staff of Phoenix Indian Medical Center.

Special thanks to Jean Howe from Chinle for this month's Abstract(s) of
the Month.

**Resources**

ACOG, Induction of Labor for Vaginal Birth after Cesarean Delivery, ACOG
Committee Opinion #342, August 2006.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16880321>

Lydon-Rochelle M, et al. Risk of uterine rupture during labor among
women with a prior cesarean delivery. N Engl J Med 2001;345:3-8.
<http://content.nejm.org/cgi/reprint/345/1/3.pdf>

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=11439945>

Landon MB, et al. Maternal and perinatal outcomes associated with a
trial of labor after prior cesarean delivery. N Engl J Med
2004;351:2581-9. <http://content.nejm.org/cgi/reprint/351/25/2581.pdf>

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

[Macones
GA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Macones+GA"%5BAuthor%5D),
et al Maternal complications with vaginal birth after cesarean delivery:
a multicenter study. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');)
2005;193:1656-62.

[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=Abstract&list_uids=16260206]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=Abstract&list_uids=16260206)

ACOG, Vaginal Birth after Previous Cesarean Delivery, ACOG Practice
Bulletin #54, July 2004.
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=15229039>

[Caughey
AB](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Caughey+AB"%5BAuthor%5D),
et al Rate of uterine rupture during a trial of labor in women with one
or two prior cesarean deliveries. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');)
1999;181:872-6.

[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=Abstract&list_uids=10521745]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=Abstract&list_uids=10521745)

[Macones
GA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Macones+GA"%5BAuthor%5D),
et al. Obstetric outcomes in women with two prior cesarean deliveries:
is vaginal birth after cesarean delivery a viable option? [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');)
2005;192:1223-9.

[[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=Abstract&list_uids=15846208]{.underline}](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=Abstract&list_uids=15846208)

Landon, et al. Risk of uterine rupture with a trial of labor in women
with multiple and single prior cesarean delivery. Obstet Gynecol
2006;108:12-20.
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16816050>

Northern New England Perinatal Quality Improvement Network

<http://www.nnepqin.org/nneob/servlet/ViewPage?id=3>

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

**Carolyn Aoyama, HQE**

**New Women's Health Work Group Forming: Looking for interested
volunteers**

I want people for whom women's health is their true calling -- people
who are passionate about some part of women's health care - to join me
in forming an IHS Workgroup on Women's Health.  There are people out
there who are local experts on mobilizing women to come in for their PAP
smears, or their mammograms.  There are others who care about access to
high quality behavioral health services for women.  Maternal/Child
Health advocates who are especially interested in the "M" in MCH would
be invaluable.  How about chronic disease, or other health issues?

I am interested in forming a Women's Health Workgroup with people who
would be willing to serve in an advisory capacity to me.  I value the
advice of IHS staff that are passionately interested in expanding
services that will improve access, quality and health outcomes of AI/AN
women.   One of the first things I want to work on is an IHS Women's
Health Strategic Plan.  Please email me if you would be interested in
serving in this advisory capacity.  I need your perspective, experience,
and ideas. <Carolyn.Aoyama@ihs.gov>

**AHRQ's  "Women's Health 2006: Translating Research into Practice"  **

Lecture presentations from "Women's Health 2006: Translating Research
into Practice" are supported by a grant from the U.S. Department of
Health & Human Services Agency for Healthcare Research & Quality (AHRQ).
Their support in this dissemination effort is gratefully acknowledged.
<http://www.womenshealth.vcu.edu/wh2006lectures/>

#### Jean Howe, Chinle {#jean-howe-chinle .Style-Heading-4-+-Arial-14-pt-Underline}

# QuickStats: Percentage of Adults with Self-Assessed Symptoms of Serious Psychological Distress,\* by Sex and Race \-\-- United States, 2000\--2004^†^

![](media/image2.png){width="6.500694444444444in"
height="3.3958333333333335in"}

\* Six psychological distress questions were included in the adult
component of the National Health Interview Survey. These questions
asked: \"During the past 30 days, how often did you feel 1) so sad that
nothing could cheer you up, 2) nervous, 3) restless or fidgety, 4)
hopeless, 5) that everything was an effort, or 6) worthless?\" Response
codes (0\--4) for the six items for each person were summed to yield a
point value on a 0\--24 point scale. A value of 13 or more was used to
define serious psychological distress.

† Estimates are age adjusted to the 2000 projected U.S. standard
population aged \>18 years using four age groups: 18\--24 years, 25\--44
years, 45\--64 years, and \>65 years. Estimates are based on household
interviews of a sample of the civilian, noninstitutionalized U.S.
population.

§ 95% confidence interval.

¶ Persons who indicated a single racial group.

During 2000\--2004, American Indian/Alaska Native (AI/AN) adults were
most likely to have self-assessed symptoms of serious psychological
distress, and Asian adults were least likely. Overall, the percentage
was highest for AI/AN women, who were at least twice as likely as white
women and black women and nearly four times as likely as Asian women to
have self-assessed symptoms of serious psychological distress. AI/AN men
were more than three times as likely as Asian men to have symptoms.

**SOURCES:**

National Health Interview Surveys, 2000\--2004. Available at
<http://www.cdc.gov/nchs/nhis.htm>

Barnes PM, Adams PF, Powell-Griner E. Health characteristics of the
American Indian and Alaska Native adult population: United States
1999\--2003. Advance data from vital and health statistics; no. 356.
Hyattsville, MD: US Department of Health and Human Services, CDC; 2005.
Available at <http://www.cdc.gov/nchs/data/ad/ad356.pdf>

Kessler RC, Barker PR, Colpe LJ, et al. Screening for serious mental
illness in the general population. Arch Gen Psychiatry 2003;60:184\--9

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

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

**Providers should conduct psychosocial screening of all women in
pregnancy**\
or prenatal care, according to a new Committee Opinion, Psychosocial
Risk Factors: Perinatal Screening and Intervention. The document,
published in the August issue of Obstetrics & Gynecology, was developed
by the ACOG Committee on Health Care for Underserved Women. The document
advises that "because problems may arise during the pregnancy that were
not present at the initial visit, it is best to perform psychosocial
screening at least once each trimester to increase the likelihood of
identifying important issues and reducing poor birth outcomes. The
document includes a well-regarded screening tool developed by the
Healthy Start Program of the Florida Department of Health. Questions
from the tool are included in ACOG's Obstetric Medical History Form.
From the ACOG newsletter, ACOG Today

<http://www.acog.org/publications/acog_newsletters/acogToday0806.pdf>

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

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

**Update your standing post partum discharge orders: Tdap in pregnancy /
postpartum**

ACIP just came out with new provisional recommendations among Pregnant
women. The ACIP recommends that Tdap be given routinely in the
postpartum period before discharge if 2 or more years have elapsed since
the last Td. The reason for these recommendation is that mothers are the
source of 32% of pertussis that occurs in infants.

[Other recommendations:]{.underline}

-Health Care Workers the ACIP also recommends Tdap if it\'s been 2 or
more years since last Td.

-Adolescents up to 18 ACIP recommends Tdap if it\'s been 5 or more years
since last Td.

-Other adults \<65 Tdap is recommended if it\'s been 10 years since last
Td.

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

At some point soon it would be worthwhile considering update your
standing orders for Tdap before postpartum discharge. The new
provisional recommendations for pregnant women and the recommendations
for Tdap in adults are at the link below and they will become official
when published in [CDC\'s Morbidity and Mortality Weekly
Report](http://www.cdc.gov/mmwr/) (MMWR).
<http://www.cdc.gov/nip/recs/provisional_recs/tdap-preg.pdf>

**Repeat Cesarean Deliveries** **Raise Risk of Maternal Morbidity**

As the number of repeat cesarean deliveries increases, so does the risk
of bowel injury, ICU admission, and other maternal complications,

CONCLUSION: Because serious maternal morbidity increases progressively
with increasing number of cesarean deliveries, the number of intended
pregnancies should be considered during counseling regarding elective
repeat cesarean operation versus a trial of labor and when debating the
merits of elective primary cesarean delivery. LEVEL OF EVIDENCE: II-2.

[Silver
RM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Silver+RM"%5BAuthor%5D),
et al Maternal morbidity associated with multiple repeat cesarean
deliveries. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Jun;107(6):1226-32.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16738145>

**Membrane Sweeping at 41 Weeks Helps Prevent Post-Term Pregnancy**

CONCLUSIONS: Membrane sweeping at 41 weeks can substantially reduce the
proportion of women with post-term pregnancy.

[de Miranda
E](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="de+Miranda+E"%5BAuthor%5D),
et al Membrane sweeping and prevention of post-term pregnancy in
low-risk pregnancies: a randomised controlled trial.
[BJOG.](javascript:AL_get(this, 'jour', 'BJOG.');) 2006
Apr;113(4):402-8.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16489935>

**Most Stillbirths Worldwide Are Preventable**

INTERPRETATION: The numbers of stillbirths are high and there is a
dearth of usable data in countries and regions in which most stillbirths
occur, with under-reporting being a major challenge. Although our
estimates are probably underestimates, they represent a rigorous attempt
to measure the numbers of babies dying during the last trimester of
pregnancy. Improving stillbirth data is the first step towards making
stillbirths count in public-health action.

[Stanton
C](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Stanton+C"%5BAuthor%5D),
et al Stillbirth rates: delivering estimates in 190 countries.
[Lancet.](javascript:AL_get(this, 'jour', 'Lancet.');) 2006 May
6;367(9521):1487-94

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16679161>

**Sudden infant death syndrome and complications in other pregnancies**

INTERPRETATION: Women whose infants die from SIDS are more likely to
have complications in their other pregnancies. Recurrence of pregnancy
complications predisposing to SIDS could partly explain why some women
have recurrent SIDS.

[Smith
GC](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Smith+GC"%5BAuthor%5D),
et al Sudden infant death syndrome and complications in other
pregnancies. [Lancet.](javascript:AL_get(this, 'jour', 'Lancet.');) 2005
Dec 17;366(9503):2107-11.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16360787>

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

**ACOG Releases HPV Vaccine Recommendations for Ob-Gyns**

***Washington, DC*** \-- The American College of Obstetricians and
Gynecologists (ACOG) today released clinical recommendations for females
ages 9 to 26 for the human papillomavirus (HPV) vaccine in advance of
their publication in the September 2006 issue of *Obstetrics &
Gynecology*. A new committee opinion offers general information about
the vaccine and addresses proper administration, precautions, and
contraindications.

\"The approval of this vaccine represents a significant development in
women\'s health and the fight against cancer. Obstetrician-gynecologists
should be proactive in educating our patients about the vaccine so that
as many women as possible are able to take advantage of this medical
milestone,\" said ACOG President Douglas W. Laube, MD, MEd. \"We must be
prepared both to administer the vaccine and to answer patient and parent
questions that will arise,\" Dr. Laube added.

\"Ob-gyns will play a critical role in the vaccine\'s widespread use in
girls and women and we should discuss vaccination with our patients.
Additionally, ob-gyns should stress the importance of continued cervical
cytology screening regardless of vaccination status,\" Dr. Laube added.

Despite the protection the vaccine offers, ACOG emphasizes that the
recommendations for cervical cytology screening remain unchanged. Pap
screening should begin within three years of sexual intercourse (or by
age 21) and then annually until age 30. After age 30, most women can
continue annual testing or can choose to be tested every two to three
years after three consecutive negative Pap tests. While the vaccine
protects against HPV types 6, 11, 16, and 18, there are additional HPV
strains that can cause cervical cancer. Pap testing can detect abnormal
cervical cells caused by other HPV strains not covered by the vaccine.

The HPV vaccine is most effective when administered to girls and women
before the onset of sexual activity. While the US Food and Drug
Administration has approved the vaccine for girls and women ages 9 to
26, the federal Advisory Committee on Immunization Practices recommends
that girls routinely receive the vaccine between the ages of 11 and 12.
Although most ob-gyns are not likely to see many girls in this age
group, ACOG recommends that teens first visit an ob-gyn between the ages
of 13 and 15. This initial reproductive health visit is an ideal time to
discuss the benefits of the vaccine and to offer it to teens.

Vaccination is also recommended for women up to age 26, regardless of
sexual activity. Ob-gyns are encouraged to talk about the vaccine any
time they see a patient within the target population and offer it to
those who have not yet received it. However, women who are already
sexually active should be counseled that the vaccine may be less
effective if there has been prior HPV exposure.

Women who previously have had abnormal cervical cytology, genital warts,
or precancerous lesions can be vaccinated. Those with suppressed immune
systems also can be vaccinated, although the protection may be less than
that of patients with normal immune function. The HPV vaccine is not a
treatment for current HPV infection or genital warts. Patients
undergoing treatment for HPV-related symptoms (cervical cytology
abnormalities, genital warts) should continue with their prescribed
medication and therapy.

While the vaccine has not been shown to have a harmful effect on
pregnancy, it is not recommended that pregnant women be vaccinated. If a
woman discovers she is pregnant during the vaccine schedule, she should
delay finishing the series until after she gives birth. Women who are
breastfeeding can receive the vaccine.

The recently approved vaccine shows great promise for controlling the
spread of the main types of HPV that cause cervical cancer and genital
warts. Given in a series of three shots over six months, the vaccine
protects against four strains of HPV responsible for 70% of cervical
cancers and 90% of genital warts cases. With widespread use, HPV
vaccination has the potential to lower the occurrence of cervical cancer
in future generations. Worldwide, cervical cancer is the second leading
cause of cancer death in women with nearly half a million new cases and
275,000 deaths annually. An increase in routine Pap testing has led to a
decrease in new cases and death (9,710 and 3,700 respectively) from
cervical cancer in the US, but there is still a significant population
of women who are not regularly screened.

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

**Will widespread human papillomavirus prophylactic vaccination change
sexual practices of adolescent and young adult women in America?**

Two virus-like particle human papillomavirus (HPV) vaccines have been
shown to be nearly 100% effective in preventing type-specific persistent
HPV infections and associated type-specific high-grade cervical
intraepithelial neoplasia (CIN). Recently, it has been hypothesized that
the administration of this vaccine to young girls in the United States
might increase sexual promiscuity among adolescent women and/or young
adults. Thus, it has been suggested that focused vaccine strategies
either based on the risk of CIN or gender might be more rational or
cost-effective. However, such strategies are unlikely to completely
eradicate the burden of this disease and decrease the cost of cervical
cancer screening.

The same misguided rationale above was used during implementation of the
hepatitis B vaccine.

The suggestion that widespread vaccination will alter sexual practices
is refuted and the rationale for the vaccination of all girls and boys
is outlined in the Monk and Wiley Commentary below. Here is part of that
commentary:

"Seat belts do not cause reckless driving, tetanus shots do not cause
children to seek out rusty nails, and hepatitis B vaccination has not
altered sexual practices or increased injection-drug abuse in any
population. Preventive measures do not always lead to high-risk
behavior. It is naïve to think that abstinence and monogamy will
eradicate the morbidity and mortality of cervical cancer as suggested by
some conservative organizations. Society needs to emphasize the benefits
of HPV vaccination and find ways to increase its adoption and not create
ill-founded barriers. Support and approval of HPV vaccination is not
synonymous with support and approval of promiscuity rather a cry to
rally together to eradicate cervical cancer worldwide."

**Resources:**

Committee Opinion #344, \"Human Papillomavirus Vaccination,\" to be
published in the September 2006 issue of Obstetrics & Gynecology, also
addresses research recommendations, educational outreach, consent, and
advocacy concerns.

<http://www.acog.com/from_home/publications/press_releases/nr08-08-06.cfm>

[Monk
BJ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Monk+BJ"%5BAuthor%5D),
[Wiley
DJ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Wiley+DJ"%5BAuthor%5D).
Will widespread human papillomavirus prophylactic vaccination change
sexual practices of adolescent and young adult women in America? [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Aug;108(2):420-4.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16880314>

**New Vaccine for Cervical Cancer Virus Raises Access Questions: Vaccine
Approved**

<http://www.medscape.com/viewarticle/541349?src=mp>

**Other:**

**Sensitivity of colposcopy in ASCUS / LGSIL improves with more than two
biopsy samples**

CONCLUSION: Colposcopy with guided biopsy or biopsies detects
approximately two thirds of CIN 3+. Although the sensitivity of the
procedure does not differ significantly by type of medical training, it
is greater when two or more biopsies are taken. LEVEL OF EVIDENCE: II-2.

[Gage
JC](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Gage+JC"%5BAuthor%5D),
et al Number of Cervical Biopsies and Sensitivity of Colposcopy. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Aug;108(2):264-272.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16880294>

**HPV-Based Triage May Result in Excess Colposcopies in Young Women**

Although women 25 years old or younger have a high prevalence of human
papillomavirus (HPV) infection and low-grade cytologic abnormalities,
high-grade dysplasia in this age group is relatively uncommon,
researchers have found.

CONCLUSION: Given the high prevalence of human papillomavirus and low
occurrence of high-grade lesions in young women with atypical squamous
cells of undetermined significance, a human papillomavirus-based triage
strategy will result in the referral of a large number of women for
colposcopy and may limit its cost-effectiveness. LEVEL OF EVIDENCE: III.

[Wright
JD](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Wright+JD"%5BAuthor%5D),
et al Human papillomavirus triage for young women with atypical squamous
cells of undetermined significance. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Apr;107(4):822-9

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16582118>

**Urodynamics-based detrusor overactivity diagnoses may be
insufficiently reliable**

CONCLUSION: In our group, lower urinary tract diagnoses of stress
urinary incontinence from both clinical and urodynamic data demonstrated
substantial reliability and interobserver agreement. However, by
conventional interpretation of kappa-statistics, reliability of
diagnoses of detrusor overactivity or voiding dysfunction was only
moderate, and interobserver agreement on these diagnoses was no better
than fair. Urodynamic interpretations may not be satisfactorily
reproducible for these diagnoses. LEVEL OF EVIDENCE: II-2.

[Whiteside
JL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Whiteside+JL"%5BAuthor%5D),Reliability
and agreement of urodynamics interpretations in a female pelvic medicine
center. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Aug;108(2):315-23

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16880301>

**Pessaries Helpful in Pelvic Organ Prolapse Patients**

CONCLUSION: A vaginal pessary is an effective and simple method of
alleviating symptoms of pelvic organ prolapse and associated pelvic
floor dysfunction. Failure to retain the pessary is associated with
increasing parity and previous hysterectomy. LEVEL OF EVIDENCE: II-3.

[Fernando
RJ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Fernando+RJ"%5BAuthor%5D),
et al Effect of vaginal pessaries on symptoms associated with pelvic
organ prolapse. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Jul;108(1):93-9

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16816061>

**SUI during first pregnancy is associated with a high risk of symptoms
12 years later**

CONCLUSION: Onset of stress urinary incontinence during first pregnancy
or puerperal period carries an increased risk of long-lasting symptoms.
LEVEL OF EVIDENCE: II-2\
[Viktrup
L](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Viktrup+L"%5BAuthor%5D)
et al Risk of stress urinary incontinence twelve years after the first
pregnancy and delivery. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Aug;108(2):248-54.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=1688029>

**Uterosacral ligament vaginal vault fixation durable for vaginal repair
of apical prolapse**

CONCLUSION: Uterosacral ligament vaginal vault fixation seems to be a
durable procedure for vaginal repair of enterocele and vaginal vault
prolapse. Lower urinary tract, bowel, and sexual function may be
maintained or improved. LEVEL OF EVIDENCE: II-3.

[Silva
WA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Silva+WA"%5BAuthor%5D),
et al Uterosacral ligament vault suspension: five-year outcomes. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Aug;108(2):255-63.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16880293>

**Primary dysmenorrhea: advances in pathogenesis and management**\
Primary dysmenorrhea is painful menstrual cramps without any evident
pathology to account for them, and it occurs in up to 50% of
menstruating females and causes significant disruption in quality of
life and absenteeism. Current understanding implicates an excessive or
imbalanced amount of prostanoids and possibly eicosanoids released from
the endometrium during menstruation. The uterus is induced to contract
frequently and dysrhythmically, with increased basal tone and increased
active pressure. Uterine hypercontractility, reduced uterine blood flow,
and increased peripheral nerve hypersensitivity induce pain. Diagnosis
rests on a good history with negative pelvic evaluation findings.
Evidence-based data support the efficacy of cyclooxygenase inhibitors,
such as ibuprofen, naproxen sodium, and ketoprofen, and
estrogen-progestin oral contraceptive pills (OCPs). Cyclooxygenase
inhibitors reduce the amount of menstrual prostanoids released, with
concomitant reduction in uterine hypercontractility, while OCPs inhibit
endometrial development and decrease menstrual prostanoids. An algorithm
is provided for a simple approach to the management of primary
dysmenorrhea.

[Dawood
MY](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Dawood+MY"%5BAuthor%5D).
Primary dysmenorrhea: advances in pathogenesis and management. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Aug;108(2):428-41.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16880317>

**Primary Care for Lesbians and Bisexual Women**

For the most part, lesbians and bisexual women face the same health
issues as heterosexual women, but they often have difficulty accessing
appropriate care. Physicians can improve care for lesbians and bisexual
women by acknowledging the potential barriers to care (e.g., hesitancy
of physicians to inquire about sexual orientation and of patients to
disclose their sexual behavior) and working to create a therapeutic
physician-patient relationship. Taking an inclusive and nonjudgmental
history and being aware of the range of health-related behaviors and
medicolegal issues pertinent to these patients enables physicians to
perform relevant screening tests and make appropriate referrals. Some
recommendations, such as those for screening for cervical cancer and
intimate partner violence, should not be altered for lesbians and
bisexual women. Considerations unique to lesbians and bisexual women
concern fertility and medicolegal issues to protect familial
relationships during life changes and illness. The risks of suicidal
ideation, self-harm, and depression may be higher in lesbians and
bisexual women, especially those who are not open about their sexual
orientation, are not in satisfying relationships, or lack social
support. Because of increased rates of nulliparity, the risks of
conditions such as breast and ovarian cancers also may be higher. The
comparative rates of alcohol and drug use are controversial. Smoking and
obesity rates are higher in lesbians and bisexual women, but there is no
evidence of an increased risk of cardiovascular disease. Am Fam
Physician 2006;74:279-86, 287-8

<http://www.aafp.org/afp/20060715/279.html>

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

**Emergency Contraception: A Primer for Pediatric Providers**

Emergency contraception (EC) is a contraceptive method used safely and
successfully by women for more than 30 years to prevent pregnancy.
Nurses at all levels are often the first point of contact for a woman
who is requesting EC, thus it is particularly important for them to stay
abreast of both the facts regarding the use of this product and the
current political controversies. It is particularly important for Nurse
Practitioners (NPs) working in primary care with adolescents to remain
cognizant of the significant barriers that remain for many women of all
ages trying to access this important contraceptive tool.

[Clements
AL](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Clements+AL"%5BAuthor%5D),
[Daley
AM](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Daley+AM"%5BAuthor%5D).
Emergency contraception: a primer for pediatric providers. [Pediatr
Nurs.](javascript:AL_get(this, 'jour', 'Pediatr Nurs.');) 2006
Mar-Apr;32(2):147-53

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16719425>

**Role of subthreshold symptoms on major depressive disorder in
adolescents**

Results indicate that the presence of subthreshhold symptoms increases
risk for onset of MDD \[major depressive disorder\], with disturbances
in mood contributing unique variance over and above all of the other
symptoms of depression.

The authors found that

\* After controlling for gender and history of depression, seven of the
nine DSM-III-R symptoms (depressed mood, anhedonia, weight/appetite
disturbance, sleep disturbance, motor disturbance, loss of
energy/fatigue, worthlessness/guilt, thinking difficulties, and thoughts
of death/suicide) contributed significantly to the prediction of MDD
when tested in separate models.

\* Endorsement of each symptom increased the likelihood of MDD onset
over a 1-year interval.

\* In a summary model that included all of the significant symptoms
identified in the separate models and that controlled for gender,
history of depression, and all significant symptoms, sad mood was the
only symptom that contributed unique variance to the prediction of MDD
onset.

A symptom-level approach to research on adolescent depression may help
guide the identification of adolescents at risk by focusing on the
endorsement of particular subthreshold symptoms . . . either before or
after an episode of depression or subsequent to an episode in the form
of residual symptomology. Such an approach may also help clarify some of
the underlying causal mechanisms involved in the development of this
disorder and have implications for etiologic models of depression.

Georgiades K, Lewinsohn PM, Monroe SM, et al. 2006. Major depressive
disorder in adolescence: The role of subthreshold symptoms. Journal of
the American Academy of Child and Adolescent Psychology 45(8):936-944.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16865036>

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

**Antidepressant Discontinuation Syndrome (See Patient Education)**

Antidepressant discontinuation syndrome occurs in approximately 20
percent of patients after abrupt discontinuation of an antidepressant
medication that was taken for at least six weeks. Typical symptoms of
antidepressant discontinuation syndrome include flu-like symptoms,
insomnia, nausea, imbalance, sensory disturbances, and hyperarousal.
These symptoms usually are mild, last one to two weeks, and are rapidly
extinguished with reinstitution of antidepressant medication.
Antidepressant discontinuation syndrome is more likely with a longer
duration of treatment and a shorter half-life of the treatment drug. A
high index of suspicion should be maintained for the emergence of
discontinuation symptoms, which should prompt close questioning
regarding accidental or purposeful self-discontinuation of medication.
Before antidepressants are prescribed, patient education should include
warnings about the potential problems associated with abrupt
discontinuation. Education about this common and likely underrecognized
clinical phenomenon will help prevent future episodes and minimize the
risk of misdiagnosis. Am Fam Physician 2006;74:449-56, 457

<http://www.aafp.org/afp/20060801/449.html>

**Are laxatives effective for the treatment of symptomatic hemorrhoids
in adults?**

Evidence-Based Answer

Fiber has a consistent beneficial effect in the treatment of symptomatic
hemorrhoids for up to three months\' follow-up as measured by overall
symptoms and bleeding.

Practice Pointers

Hemorrhoid treatment options include medical management, rubber-band
ligation, sclerotherapy, coagulation, and surgical hemorrhoidectomy
depending on the type of hemorrhoid and the frequency and severity of
symptoms. The goal of first-line medical management is to minimize
constipation and associated straining. Clinical practice guidelines
recommend the use of fiber despite inconclusive evidence about its
effectiveness in improving symptoms.

Alonso-Coello and colleagues reviewed the literature and identified
seven randomized controlled trials comparing the effectiveness of fiber
versus placebo in adults 23 to 71 years of age with symptomatic
hemorrhoids. The trials studied several types of fiber including
ispaghula husk, Plantago ovata or psyllium, sterculia, and unprocessed
bran for a treatment duration of one to 18 months. Study size ranged
between 28 and 92 participants with a mean of 50. Six of the seven
trials assessed the degree of improvement of individual symptoms (e.g.,
bleeding, pain, itching, prolapse) or overall symptoms measured at six
weeks\' and three months\' follow-up. One study examined rubber-band
ligation plus fiber versus rubber-band ligation alone for third-degree
hemorrhoids (defined as hemorrhoids that prolapse with straining but are
reducible) and measured recurrence rate and the need for repeat
procedures at 18 months.

The results of five studies reporting overall symptoms were pooled and
showed a 53 percent reduction in the risk of persistent symptoms or lack
of improvement. Of those taking fiber, 16 to 40 percent did not improve
compared with 23 to 61 percent of those taking placebo. The four studies
that reported bleeding as an individual outcome found a trend or a
significant difference in favor of the fiber group. Pooled analysis of
the two studies evaluating pain or discomfort showed a nonsignificant
trend in favor of fiber. Likewise, the pooled analysis of three studies
showed a nonsignificant difference between fiber and placebo for
persistent prolapse. The two studies that evaluated itching did not find
a significant difference between the groups. The one study examining
rubber-band ligation plus fiber versus rubber-band ligation alone
reported that the number of long-term recurrences was fewer overall in
the group that received fiber (15 versus 45 percent, respectively) at 18
months\' follow-up.

The most common side effects with fiber were gastrointestinal symptoms,
typically starting at the study onset, and these generally were not
severe enough for participants to discontinue fiber. The rate of side
effects varied considerably among studies, with some studies reporting
no side effects and others reporting up to a 50 percent incidence of
gastrointestinal bloating.

The American Gastroenterological Association recommends adequate water
and fiber intake as the mainstay of medical management and suggests that
topical steroids and analgesics also may be useful in relieving
hemorrhoidal symptoms.1

**Source:** Alonso-Coello P, et al. Laxatives for the treatment of
hemorrhoids. Cochrane Database Syst Rev 2005;(4):CD004649.

Laxatives for Hemorrhoids? Cochrane Briefs - Clinical Question

REFERENCE

1\. American Gastroenterological Association medical position statement:
diagnosis and treatment of hemorrhoids. Gastroenterology
2004;126:1461-2.

<http://www.aafp.org/afp/20060801/cochrane.html#c2>

**Interventions to Facilitate Smoking Cessation (see Patient
Education)**

Tobacco use, primarily cigarette smoking, is the leading cause of
preventable morbidity and mortality in the United States, and nearly one
third of those who try a cigarette become addicted to nicotine. Family
physicians, who see most of these patients in their offices every year,
have an important opportunity to decrease smoking rates with
office-based interventions. The U.S. Public Health Service recommends
that primary care physicians use the five A\'s (Ask, Advise, Assess,
Assist, and Arrange) model when treating patients with nicotine
addiction. Physicians can improve screening and increase cessation rates
by asking patients about tobacco use at every office visit. Behavior
modification can improve long-term smoking cessation success; even brief
(five minutes or less) advice on smoking cessation during an office
visit can increase cessation rates. The effectiveness of
nonpharmacologic treatments generally is lower; therefore,
pharmacotherapy is recommended for smokers who are willing to attempt
cessation, unless medical contraindications exist. The pharmacologic
agents approved by the U.S. Food and Drug Administration for treatment
of tobacco dependence include bupropion (a non-nicotine therapy) and
nicotine replacement therapies in the form of a gum, patch, nasal spray,
inhaler, and lozenge. These agents have similar long-term success rates.
Am Fam Physician 2006;74:262-71, 276.
<http://www.aafp.org/afp/20060715/262.html>

**Exercise and Older Patients: Prescribing Guidelines**

A combination of aerobic activity, strength training, and flexibility
exercises, plus increased general daily activity can reduce medication
dependence and health care costs while maintaining functional
independence and improving quality of life in older adults. However,
patients often do not benefit fully from exercise prescriptions because
they receive vague or inappropriate instructions. Effective exercise
prescriptions include recommendations on frequency, intensity, type,
time, and progression of exercise that follow disease-specific
guidelines. Changes in physical activity require multiple motivational
strategies including exercise instruction as well as goal-setting,
self-monitoring, and problem-solving education. Helping patients
identify emotionally rewarding and physically appropriate activities,
contingencies, and social support will increase exercise continuation
rates and facilitate desirable health outcomes. Through patient contact
and community advocacy, physicians can promote lifestyle patterns that
are essential for healthy aging. Am Fam Physician 2006;74:437-44.
<http://www.aafp.org/afp/20060801/437.html>

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

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

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

###### 

Norethindrone More Effective for Menses Suppression

**Clinical Question:** Do oral contraceptives containing norethindrone
acetate or levonorgestrel differ in their effect on suppression of
menses with continuous use?

**Synopsis:** There were 139 women enrolled in this double-blind,
four-arm trial of oral contraceptives used continuously for 180 days for
the purpose of suppressing menstrual periods. The estrogen used in all
study arms was ethinyl estradiol (E2), which could be at a dose of 20
mcg or 30 mcg. The progestin was 1 mg norethindrone acetate (Loestrin)
or 100 mcg levonorgestrel (Seasonale). The four study arms included: (1)
norethindrone acetate plus 20 mcg ethinyl E2; (2) norethindrone acetate
plus 30 mcg ethinyl E2; (3) levonorgestrel plus 20 mcg ethinyl E2; and
(4) levonorgestrel plus 30 mcg ethinyl E2.

All study participants had used cyclic oral contraceptives for at least
three months before randomization. This study had an overall drop-out
rate of 45 percent. More days of amenorrhea were recorded in the
norethindrone acetate groups, with no difference between the lower
versus higher estrogen dosing (mean days of amenorrhea during 180 days\'
use: norethindrone acetate plus 20 mcg ethinyl E2 = 164, levonorgestrel
plus 20 mcg ethinyl E2 = 151; *P* = .02).

**Bottom Line:** In continuous dosing regimens, more days of amenorrhea
can be achieved with oral contraceptives containing 1 mg norethindrone
acetate than with oral contraceptives containing 100 mcg levonorgestrel.
(Level of Evidence: 2b)

<http://www.aafp.org/afp/20060715/tips/6.html>

Fecal Occult Blood Testing in Healthy Patients Does Not Reduce Mortality

**Clinical Question:** Does fecal occult blood testing (FOBT) reduce
all-cause mortality?

**Synopsis:** The idea behind screening tests is that they may detect
something in otherwise healthy persons that will help them live longer,
making all-cause mortality the most important outcome measure of any
screening. This study tried to determine if FOBT reduces all-cause
mortality. The authors combined data from three large published
randomized trials of FOBT: one Danish, one British, and one American.
All studies compared FOBT, performed every two years, with no screening.

The British and Danish studies used unrehydrated FOBT in adults 45 to 75
years of age; the American study used rehydrated FOBT in adults 50 to 80
years of age. All three studies monitored patients for a mean of 12
years; which means that 245,217 persons were followed up for more than 3
million patient years. Overall, there was a 13 percent relative
reduction in colorectal cancer mortality. In absolute terms, dividing
the total colorectal cancer deaths by total participants, that is 0.82
versus 0.94 percent (*P* = .002; number needed to treat = 833 for 12
years).

There was a 1.9 percent relative increase in noncolorectal cancer deaths
in the nonscreened group, and no overall difference between groups in
all-cause mortality (26.51 for screened and 26.46 for nonscreened
patients). Potential explanations for this paradox include unintended
consequences of screening (e.g., failure of the patient to adopt a
healthier lifestyle because he or she has been screened, mortality from
follow-up colonoscopy) and better identification of colorectal cancer as
a cause of death in screened patients.

**Bottom Line:** Screening for colorectal cancer using FOBT does not
reduce all-cause mortality. This is important when considering whether
to screen healthy patients. (Level of Evidence: 1a)

<http://www.aafp.org/afp/20060715/tips/1.html>

Mammography Results in Overdiagnosis of Breast Cancers

**Clinical Question:** Does screening mammography result in the
identification and treatment of breast cancers that would never be
apparent clinically?

**Synopsis:** There are two possible harmful outcomes of screening for
breast cancer. The first is a false-positive result, telling a woman she
may have breast cancer only to find out on biopsy that she does not. A
more subtle negative outcome is the risk of overdiagnosis, in which
breast cancer is detected by mammography in a woman who would otherwise
have lived her life never knowing that she had breast cancer. The
authors conducting this analysis used the results of the Malmo
mammographic screening trial. Over 10 years, 42,283 women were enrolled
in the trial and randomized to receive mammography or no mammography.
Follow-up continued for another 15 years.

As would be expected, significantly more women receiving mammography
were identified as having breast cancer than were nonscreened women.
However, there continued to be more diagnoses of breast cancer in the
screened group than in the nonscreened group, even though during
follow-up women in both groups had regular mammography. Because any
woman diagnosed with breast cancer was no longer part of the screening
group, the initially unscreened women should have caught up and had more
breast cancers identified when they started regular mammography. That
they did not indicates that overdiagnosis occurred in the women
initially assigned to the screening group.

Overall, about 10 percent (95% confidence interval, 1 to 18 percent) of
the women who had mammography and were diagnosed with breast cancer were
overdiagnosed, meaning they would never have known they had breast
cancer-or have received treatment-except for the screening program.

**Bottom Line:** In addition to the possibility of having a
false-positive result on mammography sometime in her life, one in 10
women who has a real diagnosis of breast cancer undergoes treatment
that, although seemingly curative, ultimately has no beneficial effect
on her because she would never have developed clinically apparent breast
cancer. (Level of Evidence: 2b)

<http://www.aafp.org/afp/20060801/tips/6.html>

Omega-3 Fats Do Not Affect Mortality Rates

**Clinical Question:** Does supplementation with omega-3 fatty acids
decrease mortality, cardiovascular disease, or cancer in adults?

**Setting:** Various (meta-analysis)

**Study Design:** Systematic review

**Synopsis:** In this update of a previous Cochrane review, authors
identified 48 randomized controlled trials and 41 cohort studies
evaluating the effect of fish oil supplementation on overall mortality,
cardiovascular disease, and cancer in adults. The authors identified
these studies through the usual Cochrane methodology and analyzed the
results from randomized trials separately from cohort data. The studies
included patients with or without preexisting coronary heart disease. As
a result, the authors combined primary and secondary prevention
research.

Omega-3 fatty acids were given as supplements or a recommendation was
made to eat more oily fish. In randomized trials enrolling more than
30,000 patients, omega-3 supplementation did not significantly reduce
mortality (relative risk \[RR\] = 0.87; 95% confidence interval \[CI\],
0.73 to 1.03) or the likelihood of a cardiovascular event (RR = 1.09;
CI, 0.87 to 1.37). Long-chain omega-3 fatty acids did not produce
results different from short-chain fats. Cancer was neither increased
nor decreased in clinical trials or cohort studies. The lack of benefit
demonstrated in this study conflicts with the results of an earlier
meta-analysis of the effect in patients with coronary heart disease
(Bucher HC, et al. N-3 polyunsaturated fatty acids in coronary heart
disease: a meta-analysis of randomized controlled trials. Am J Med
2002;112:298-304). However, this is the second study published after the
meta-analysis that did not find a benefit overall.

Bottom Line: Overall, omega-3 fatty acid supplementation does not
decrease mortality or cardiovascular disease compared with placebo. This
study combined primary and secondary prevention; that is, it included
persons with or without coronary heart disease.

(Level of Evidence: 1a) <http://www.aafp.org/afp/20060801/tips/1.html>

Screening for Iron Deficiency Anemia, Including Iron Supplementations
for Children and Pregnant Women

U.S. Preventive Services Task Force Recommendation Statement

The USPSTF concludes that evidence is insufficient to recommend for or
against routine screening for iron deficiency anemia in asymptomatic
children six to 12 months of age.

**I recommendation.**

The USPSTF recommends routine screening for iron deficiency anemia in
asymptomatic pregnant women.

**B recommendation.**

<http://www.aafp.org/afp/20060801/us.html>

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

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

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

**Induction of Labor for Vaginal Birth After Cesarean Delivery (see
Abstract of the Month)**

ABSTRACT: Induction of labor in women who have had cesarean deliveries
may be necessary because of fetal or maternal indications. The
potentially increased risk of uterine rupture should be discussed with
the patient and documented in the medical record. Selecting women most
likely to give birth vaginally and avoiding the sequential use of
prostaglandins and oxytocin appear to offer the lowest risks.
Misoprostol should not be used in patients who have had cesarean
deliveries or major uterine surgery.

Induction of labor for vaginal birth after cesarean delivery. ACOG
Committee Opinion No. 342. American College of Obstetricians and
Gynecologists. Obstet Gynecol 2006;108:465--67.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16880321>

**Management of alloimmunization during pregnancy. ACOG Practice
Bulletin**

[Recommendations and Conclusions]{.underline}

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

-   In a center with trained personnel and when the fetus is at an
    appropriate gestational age, Doppler measurement of peak systolic
    velocity in the fetal middle cerebral artery is an appropriate
    noninvasive means to monitor pregnancies complicated by red cell
    alloimmunization.

-   The initial management of a pregnancy involving an alloimmunized
    patient is determination of the paternal erythrocyte antigen status.

-   Serial titers are not useful for monitoring fetal status when the
    mother has had a previously affected fetus or neonate.

-   Antibody titers are not appropriate for monitoring Kell-sensitized
    patients because Kell antibodies do not correlate with fetal status.

-   Anti-D immune globulin is indicated only in Rh-negative women who
    are not previously sensitized to D.

Management of alloimmunization during pregnancy. ACOG Practice Bulletin
No. 75. American College of Obstetricians and Gynecologists. Obstet
Gynecol 2006;108:457--64.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=10458556>

**Psychosocial Risk Factors: Perinatal Screening and Intervention**

ABSTRACT: The American College of Obstetricians and Gynecologists
advocates assessing for psychosocial risk factors and helping women
manage psychosocial stressors as part of comprehensive care for women.
Psychosocial screening of all women seeking pregnancy evaluation or
prenatal care should be performed regardless of social status,
educational level, or race and ethnicity. Because problems may arise
during the pregnancy that were not present at the initial visit, it is
best to perform psychosocial screening at least once each trimester to
increase the likelihood of identifying important issues and reducing
poor birth outcomes. When screening is completed, every effort should be
made to identify areas of concern, validate major issues with the
patient, provide information, and, if indicated, make suggestions for
possible changes. When necessary, the health care provider should refer
the patient for further evaluation or intervention. Psychosocial risk
factors also should be considered in discharge planning after delivery.
Many of the psychosocial issues that increase the risk for poor
pregnancy outcome also can affect the health and welfare of the newborn.
Screening should include assessment of barriers to care, unstable
housing, unintended pregnancy, communication barriers, nutrition,
tobacco use, substance use, depression, safety, intimate partner
violence, and stress.

Psychosocial risk factors: perinatal screening and intervention. ACOG
Committee Opinion No. 343. American College of Obstetricians and
Gynecologists. Obstet Gynecol 2006;108:469--77.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16880322>

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

**More data are needed to better identify health care disparities among
American Indians and Alaska Natives**

<http://www.ahrq.gov/research/jun06/0606RA5.htm>

**Increasing cervical cancer screening intervals is cost-effective for
women with three consecutive normal Pap smears**

<http://www.ahrq.gov/research/jun06/0606RA13.htm>

**Use of ACE inhibitors during the first trimester of pregnancy is
related to an increased risk of birth defects**

<http://www.ahrq.gov/research/jun06/0606RA1.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}

**New on Your Library Website**

**Daily Health Policy News Summaries**

You might notice something different when you go to your HSR Library
website. Headlines now appear at the top of the Features Panel. Click on
the headline links and you will go to news summaries on the latest in
women's health policy, health policy in general, and HIV/AIDS news.
These summaries provide further links to the actual full-text articles
and papers on the subject.

These news summaries are called the Kaiser Daily Health Reports, and are
written and published by a for-profit organization, The Advisory Board
Company, for the Henry J. Kaiser Family Foundation. The Reports are free
and we have a trial subscription. Take a look and give some feedback on
rather this service is useful or not to you.

Filter Preferences in PubMed

When you conduct a literature search in PubMed, you can use LIMITS to
limit your subject search to humans, English language only, publication
years, age groups and other limits. After you enter GO, your retrieval
page will now show two default tabs above the results, "All" and
"Review". The "All" tab includes all citations found on the subject you
typed into the search box; the "Review" tab will show you only those
citations in the "All" group that are review articles.

What's new is this: Now you can group your search results further by
areas of interest using Filter Preferences. To get to the Filter
Preference page, click on the tiny hammer/wrench icon located next to
the "Review" tab. You will now be in My NCBI (formerly "My Cubby"),
where you will need to login using your user name and password. If you
haven't registered, you will need to create your user name and password.

On the Filter Preference page, you can click on Browse to further select
areas of interest. For example in the Properties Group under Clinical
Queries you may select "diagnosis" or "therapy" among many
possibilities. Another example in the Properties Group under the
category, Health Services Research Queries is "Outcomes Assessment."

Here's an example. Let's look for articles on vitamin D and diet using
the "Outcomes Assessment" filter. When you hit the Go, your search
retrieval will now show 3 tabs:

"All" tab; "Review" tab; and "Outcomes Assessment" tab.

Tip: If you want to see citations that fit two or more categories (e.g.,
aged and outcomes assessment), use LIMIT to select "aged" and then go on
to the FILTER PREFERENCE page and select the filter "Outcomes
Assessment." Using the LIMIT selection for "aged" will guarantee that
the citations in the "Outcomes Assessment" tab are only "aged." On the
other hand, if you were to select "aged" in the FILTER PREFERENCE page,
then you would see "aged" as a tab and all articles key-worded to "aged"
are in this group of search results. Under the "Outcomes Assessment" tab
will be "aged" and "not aged" in the citations.

Another Tip: Through the magic of cookies and central memory, your tab
selections will stay with you for your next search. You can always
delete a tab selection by checking on "My Selections."

If you need help using this feature or any of the electronic resources
available to you through the HSR Library, please email me at
<cooperd@mail.nih.gov>

##### 

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

**Early Milk Supply Issues**

Providers who work with new families usually hear lots of versions about
"not enough milk" concerns. Phrases like:

-   I don't think that I have enough milk

-   I don't think I have any milk because I didn't leak while I was
    pregnant

-   My breasts are flat

-   There is nothing coming out

-   The baby is hungry all the time

usually mean that the mom/family is worried, scared, and unaware of how
to know if their baby is getting enough to eat. The following are ways
to assess adequate intake and help guide families in the first weeks.

Reasonable expectations for intake and feeding behavior in a normal,
healthy baby are:

-   Birth -- 24 hours

    -   Effective latch at birth, lots of sleep, and sleepy feeds. 2-3
        feedings (including latch at birth) in the first 24 hours is
        success.

-   24 hours and until the white (\"mature\") milk comes in

    -   The first milk, colostrum is thick (like honey), hard to suck
        out, and harder to see. The average amount consumed at each
        feeding is 5 cc (1 tsp). The baby\'s stomach size is 5-10cc at
        birth, expanding to about 60 cc (2 oz) at 1 week. The mother\'s
        colostrum and white milk production increases as the baby\'s
        stomach expands.

    -   Feedings averaging every 2-3 hours -- 8-12 times in 24 hours are
        important - they help insure adequate intake and stimulate the
        mom\'s milk supply. Wake the baby as needed.

    -   Frequent feedings are normal. Babies often get fussy at
        feedings, perhaps because their mouths are tired from learning
        how to suck. They get stronger quickly. It will be easier once
        the white milk comes in.

    -   Expect one diaper change for every day of life. For example if
        the baby is 3 days old, 3 diaper changes tells the mom that the
        baby is getting enough.

-   By 2-5 days, the white milk is in.

    -   Encourage the mom to feed every 2-3 hours to help prevent
        engorgement and insure adequate intake for the baby.

    -   Watch for one diaper change for every day of life -- up to 6 or
        more in 24 hours -- this tells that mom that the baby is getting
        enough.

    -   Once the baby is waking to eat, and diaper changes are 6 or more
        in 24 hours, the mom can relax a little and feed the baby on
        demand.

-   Watch for:

    -   \< 7% weight loss in the first several days.

    -   Birth weight re-gained by 2 weeks.

    -   Weight gain of ½ oz to 1 oz per day in the first 3-6 months to
        double birth weight at 4-6 months and triple by one year.

-   Growth spurts happen every couple weeks. The baby will suddenly want
    to eat more, all the time. The feeding frenzy will last 1-2 days,
    the mom\'s milk supply will increase to meet the need, and things
    will be fine.

-   If the family wants to supplement, encourage them to use caution.
    Supplementing in the first weeks can undermine the mom\'s body\'s
    ability to maintain her supply.

-   By 6-8 weeks, the baby\' stomach is bigger, and the suck is much
    more efficient. Also the mom\'s body has become accustomed to the
    milk being there. The feedings are much shorter and less frequent,
    the mom\'s breasts are softer, and the leaking is almost gone.
    Breastfeeding is much easier.

Schanler R et al. Breastfeeding Handbook for Physicians, American
Academy of Pediatrics and American college of Obstetricians and
Gynecologists. 2006

Biancuzzo M. Breastfeeding the Newborn: Clinical Strategies for Nurses,
Mosby Publishing, 2003.

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

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

**Breastfeeding Basics: Generalist to Generalist**

Date: August 31, 2006

Time: 1:00 pm Eastern, 12:00 pm Central, 11:00 am Mountain, 10:00 am
Pacific

American Academy of Pediatrics Breastfeeding Promotion in Physicians'
Office Practices Program Phase III (BPPOP III) Teleconference

 

The BPPOP III Program is delighted to bring you a teleconference
concerning breastfeeding support and management in your office setting.
As physicians who have made breastfeeding support and management a
priority in their practices, Sharon Mass, MD, FACOG, Liaison to the
Section on Breastfeeding from the American College of Obstetricians and
Gynecologists, Jenny Thomas, MD, IBCLC, FAAP, Wisconsin Chapter
Breastfeeding Coordinator, and Margreete Johnston, MD, FAAP, Tennessee
Chapter Breastfeeding Coordinator, will walk you through breastfeeding
basics, generalist to generalist. These are busy practitioners making it
work in their practice. If they can do it, so can you!

 

During this teleconference, participants will learn how to:

 

> ü      encourage and support breastfeeding before and during pregnancy
>
> ü      fit breastfeeding assessment and management into your office
> visits
>
> ü      weave a web of breastfeeding support and resources in your
> community

 

Because the BPPOP III program is dedicated to serving
racially/ethnically diverse populations, we would like to recruit
participants to these teleconferences that serve these populations,
however all health care providers are encouraged to sign-up if there is
an interest. One week prior to the call you will receive call-in
information and call materials.

 

If you are interested in participating in the teleconference please
email Becky Ramsey, Breastfeeding Initiatives Program Coordinator, at
<bramsey@aap.org>

 

#### 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}

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

\-[Refusals by pharmacists to dispense emergency
contraception](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_AOM.cfm)

\-[How to address health disparities? One story of
success](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Coll.cfm)\
-[Pendulum swing:  Vaginal breech delivery approved within
guidelines](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_HT.cfm#ob)

\-[CDC's Advisory Committee Recommends Human Papillomavirus Virus
Vaccination](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_HT.cfm#gyn)

\-[New Guidelines for Pediatric and Neonatal Emergency Cardiovascular
Care](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_HT.cfm#child)

\-[Driving, Other Erratic Behaviors Reported After Taking Zolpidem
(Ambien)](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_HT.cfm#chrIll)

\-[Planned Early Birth vs. Expectant Management for
PROM](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Feat.cfm#afp)

\-[William H. J. Haffner American Indian / Alaska Native Women's Health
Award](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Feat.cfm#acog)

\-[Pain is one the reasons that moms quit breastfeeding in the first 2
weeks](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Feat.cfm#breast)

\-[Injectable Contraception and Skeletal
Health](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Feat.cfm#fp)

\-[Hospital Computer Keyboards Should Be Disinfected
Daily](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Feat.cfm#it)

\-[Where There is No Doctor & A Book for
Midwives](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Feat.cfm#ih)

\-[Copious post operative mucous secretions: The rest of the
story](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Feat.cfm#mmtour)

\-[Nuchal cords, somersaults, and the value of a pulsing cord: Nuchal
Cord
Management](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Feat.cfm#MidWives)

\-[Methamphetamine abuse among women on Navajo: Part IV - The "Drop- in"
gravida](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Feat.cfm#navajo)

\-[The Association of Nurses in Aids
Care](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Feat.cfm#nurseCorner)

\-[IHS Division of Epidemiology and Disease Prevention Launches New
Website](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Feat.cfm#okie)

\-[Osteoporosis Guidelines Updated: North American Menopause
Society](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Feat.cfm#oste)

\-[Only 29% of ACOG recommendations are level A: Good and consistent
scientific
evidence](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Feat.cfm#periPicks)

\-[September 1, 2006: Palliative Medicine\'s Role in the Continuity of
Care](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Feat.cfm#pcf)

\-[Focus on adolescent sexual behavior this
month](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Feat.cfm#std)

\-[Diabetes Is The Clinical Equivalent of Aging 15
Years](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706_Feat.cfm#stillW)

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/documents/06JulOL.pdf**](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/06JulOL.pdf) {#httpwww.ihs.govmedicalprogramsmchmdocuments06julol.pdf .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

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

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

**Randomized trial assesses screening for intimate partner violence in
health settings**

The findings from this study examining 3 approaches to IPV \[intimate
partner violence\] screening in health care settings suggest that the
face-to-face approach is the least preferred by women, irrespective of
instrument.

The authors found that

\* Twelve-month prevalence of IPV ranged from 4.1% to 17.7%, depending
on screening method, instrument, and health care setting.

\* Prevalence was significantly lower on the written WAST than on the
PVS.

\* Lower levels of missing data occurred for the WAST vs. the PVS and
for the written method vs. the face-to-face and computer-based methods
combined.

\* On all three evaluation indicators (easy, preferred, private), women
chose computerized and written methods over face-to-face questioning.

\* The positive predictive value of the WAST was minimally higher than
that of the PVS, and the negative predictive values were almost the
same, leading to very similar accuracies.

Prevalence, missing data, and preference are all important
considerations for both clinical and research efforts in IPV screening.

MacMillan HL, Wathen CN, Jamieson E, et al. 2006. Approaches to
screening for intimate partner violence in health care settings: A
randomized trial. The Journal of the American Medical Association
296(5):530-536
[[http://jama.ama-assn.org/cgi/content/abstract/296/5/530?etoc]{.underline}](http://jama.ama-assn.org/cgi/content/abstract/296/5/530?etoc)

**Physical Dating Violence Common Among Teens, Linked to Risky
Behaviors**

Nearly 1 out of 11 US high school students is subjected to physical
violence from their boyfriend or girlfriend each year, the results of a
nationwide survey suggest \-- and boys are just as likely as girls to be
the victim of such violence, according to a report in the May 19th issue
of the Morbidity and Mortality Weekly Report . The study also confirms
that these victims of violence have an increased prevalence of high-risk
behaviors.

Physical Dating Violence Among High School Students \-\-- United States,
2003 MMWR May 19, 2006 / 55(19);532-535
<http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5519a3.htm>

**After the Crisis - Resource Papers and Issue Briefs**

As many of you are already aware, the National GAINS Center and the
Center on Women, Violence and Trauma convened a highly successful expert
panel meeting in Bethesda, Maryland on April 24 and 25, 2006. This
meeting brought together approximately 50 individuals with professional
and/or personal experience with trauma following disasters to help guide
the activities of the After the Crisis disaster response initiative.

The expert panel meeting focused on the development of practical
recommendations, strategies, and program concepts for providing
technical assistance to states, communities, and individuals following
disasters, setting the stage for planning and organizing a more
effective collective response to future disasters. The overarching goal
of these activities was to address what we know about how individuals,
particularly those who have histories of mental health issues, justice
involvement and/or previous trauma, respond to traumatic experiences.

You will find resource papers that were originally distributed at the
expert panel meeting, and which have been subsequently revised to
incorporate additional knowledge and recommendations from the panel at
the link below. These papers, on the topics of Retraumatization,
Revictimization, Peer Support, and Criminal Justice Issues, provide an
overview of each of these topics as they relate to disaster response. A
series of four Issue Briefs, also attached, was developed from the
resource papers. The Issue Briefs provide an overview of each topic, key
recommendations from the expert panel meeting and resources on the
topic. Please feel free to distribute these materials. Contact
<Carolyn.Aoyama@ihs.gov>

<http://www.mentalhealth.samhsa.gov/newsroom/speeches/042406.asp>

**AHRQ: Primary care assessment of intimate partner violence and
referrals may prevent its recurrence**
<http://www.ahrq.gov/research/jun06/0606RA10.htm>

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

**Is 75 Years an Appropriate Upper Age Limit for Mammography?**

A major finding of this study is that the screening participation among
elderly women is high. The outcomes of our study suggest a steadily
increasing sojourn time of breast tumours beyond the age of 69, leading
to a strong increase in detection of cancers, and therefore,
disfavouring the balance with the benefits of screening. At present, 75
years of age can be regarded as an appropriate upper age limit for the
Dutch programme.

Fracheboud J, et al Seventy-five years is an appropriate upper age limit
for population-based mammography screening. Int J Cancer. 2006 Apr
15;118(8):2020-5

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16287064>

#### [Elder Care Initiative Director: Editorial comment:]{.underline}

Fracheboud J, et al set out to better understand the risk / benefit
ratio of screening mammography in women aged 70-75 when the Dutch breast
cancer screening program raised its upper age limit from 69 to 75 based
on models suggesting benefit to these older women.  It is well known
that breast cancer incidence increases with increasing age, but that
cancers in older women tend to progress more slowly and that death from
other causes also increases with age. 

While a screening program is more likely to detect cancer in these older
women than in women younger than 69, the cancers detected are less
likely, without early detection, to cause death.   This study (by the
authors\' own admission) adds little to the existing understanding, but
it certainly provides no evidence to argue against screening in these
older women and does point out that screening was well accepted (65.6%
of women aged 70-75 accepted appointments for screening mailed to them).

 

An upper limit of mammography screening is supportable on a population
basis but much less so when faced with the particulars of an individual
patient.  Walter and Covinsky provide an approach mimics (in a more
formal way) the thought processes of many clinicians.   They calculate
the number needed to screen for women in the highest, middle, and lowest
quartiles of life expectancy for selected age groups.  The results can
be quite striking:  the number needed to screen to prevent one cancer
death in an 80 year old in the highest quartile of life expectancy is
quite close to that for a 50 year old woman in the lowest quartile (240
and 226 respectively).  Women unlikely to benefit from mammography
should not be subjected to the test or the inevitable cascade of medical
events that follow, but age is not, by itself, a satisfactory indicator
of likelihood of benefit.  Walter and Covinsky provide an evidence-based
approach for better advising our older patients. 

[Walter LC, Covinsky
KE.](http://www.ncbi.nlm.nih.gov.libproxy.unm.edu/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11386931&query_hl=1)
Cancer screening in elderly patients: a framework for individualized
decision making. JAMA. 2001 Jun 6;285(21):2750-6

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=11386931>

**Performance by Elderly on 400-Meter Walk Predicts Disability and
Death**

CONCLUSIONS: Older adults in the community who reported no difficulty
walking had a wide range of performance on this extended walking test.
Ability to do the test and performance were important prognostic factors
for total mortality, cardiovascular disease, mobility limitation, and
mobility disability in persons in their eighth decade.

[Newman
AB](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Newman+AB"%5BAuthor%5D),
et al Association of long-distance corridor walk performance with
mortality, cardiovascular disease, mobility limitation, and disability.
[JAMA.](javascript:AL_get(this, 'jour', 'JAMA.');) 2006 May
3;295(17):2018-26

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16670410>

**Second Annual American Indian and Alaska Native Long Term Care
Conference**

Honoring Our Elders:  Best Practices in Long Term Care 2006 

September 18 & 19, 2006

Tulsa, Oklahoma

This conference is designed to support the development of long term care
services for Elders throughout Indian Country.  Highlights include an
intensive overview of the first Tribal PACE (Program of All-Inclusive
Care for the Elderly) and the presentation of other promising practices
in AI/AN Long Term Care. 

[www.aianlongtermcare.org](http://www.aianlongtermcare.org/) or contact
Alvin Rafaelito at
[Alvin@nicoa.org](javascript:parent.ComposeTo('Alvin@nicoa.org');),
505-292-2001

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

#### Addressing Depression in Family Planning Services {#addressing-depression-in-family-planning-services .Style-Heading-4-+-Arial-14-pt-Underline}

#### This policy brief explores family planning programs as a possible site for incorporating interventions around depression, including screening and treatment, in reproductive age women.  The brief looks at the opportunities to reach women who otherwise may have little contact with the health care system, as well as the challenges of locating these services within family planning programs, and offers a list of potential interventions and recommendations for further action for FP programs, state and local public health agencies, and mental health providers. [[http://www.jhsph.edu/wchpc/publications/ConsiderIntervenDepressionWomenFPP.pdf]{.underline}](http://www.jhsph.edu/wchpc/publications/ConsiderIntervenDepressionWomenFPP.pdf) {#this-policy-brief-explores-family-planning-programs-as-a-possible-site-for-incorporating-interventions-around-depression-including-screening-and-treatment-in-reproductive-age-women.-the-brief-looks-at-the-opportunities-to-reach-women-who-otherwise-may-have-little-contact-with-the-health-care-system-as-well-as-the-challenges-of-locating-these-services-within-family-planning-programs-and-offers-a-list-of-potential-interventions-and-recommendations-for-further-action-for-fp-programs-state-and-local-public-health-agencies-and-mental-health-providers.-httpwww.jhsph.eduwchpcpublicationsconsiderintervendepressionwomenfpp.pdf .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

**I saw a blip in the May 2006 CCCC about the Utah website**.

You think it is good? **Well try Michigan's site. It's super!**

<http://www.michigan.gov/surgeongeneral/>

From Barbara Stillwater <Barbara_Stillwater@health.state.ak.us>

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

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

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

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

Go here to explore the frequently asked question page

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

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

**August 2006 Highlights**

\- High levels of bilirubin in newborns - more good than bad news

\- The elevated risk of jaundice in AI/AN infants

\- A round up of new vaccines for 2006 by Ros Singleton

\- Mental Health disorders in parents of AI/AN adolescents

[[http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ICHn806.doc]{.underline}](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ICHn806.doc)

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

**Hospital Computer Keyboards Should Be Disinfected Daily**

CONCLUSIONS: Our data suggest that microbial contamination of keyboards
is prevalent and that keyboards may be successfully decontaminated with
disinfectants. Keyboards should be disinfected daily or when visibly
soiled or if they become contaminated with blood.

[Rutala
WA](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Rutala+WA"%5BAuthor%5D),
et al Bacterial contamination of keyboards: efficacy and functional
impact of disinfectants. [Infect Control Hosp
Epidemiol.](javascript:AL_get(this, 'jour', 'Infect Control Hosp Epidemiol.');)
2006 Apr;27(4):372-7.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16622815>

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

**HIV/AIDS in Latin America and the Caribbean**

This month the sixteenth international AIDS conference will be held in
Toronto. In a fascinating series of articles, Science reporter Jon Cohen
documents the state of the epidemic in Latin America and the Caribbean,
where typical modes of transmission, economic and social conditions, and
government response vary dramatically from country to country. (In
Puerto Rico, for instance, injection drug use is a major vector of HIV
transmission; in the Caribbean sex tourism is a significant part of the
problem. In Argentina, it's a primarily heterosexual epidemic, while in
Mexico and much of the rest of Central America, men who have sex with
men are the major group at risk.) Check out the stories and photographs
at [www.sciencemag.org/sciext/aidsamericas]{.underline}

Cohen's look at Brazil is particularly interesting. When expensive
multi-drug regimens first proved effective at controlling HIV in 1996,
Brazil's government inspired activists and troubled corporate leaders
around the world by not only mounting a strong prevention campaign, but
by promising free antiretrovirals to any citizen who needed them -- in
part by negotiating aggressively with BigPharma, in part by
manufacturing cheap knockoffs of drugs domestically. At the time, Brazil
had the worst epidemic in the region. Ten years later, HIV prevalence
rates are less than half of what had been predicted, and the Ministry of
Health says 90,000 deaths have been averted. But increasing drug
resistance among patients on long-term antiretroviral treatment means
the country is spending more and more on second-line patented
medications. Many critics, both on the left and the right, believe
Brazil's universal access program will not be sustainable for much
longer. Will the country be the first to break patent restrictions under
the so-called "compulsory licensing" clause of the World Trade
Organization's intellectual property rights act? Though this clause was
meant to ensure that countries could manufacture affordable medications
in a public health emergency, no government has yet invoked it for fear
of the trade sanctions that would likely follow. HIV-infected
Brazilians, and health workers in poor and middle-income countries
around the world, watched the Brazilian government take the lead on
universal access ten years ago; they -- and we -- are now waiting to see
what the next move will be.

**Reference:**

Cohen J. Brazil: ten years after. Science 313:484-7, 28 July 2006
[www.sciencemag.org/cgi/content/full/313/5786/484b]{.underline}

**The next influenza pandemic: what public health measures might help?**

The "basic reproductive number" (R0) of any given virus is the average
number of people infected by a single typical infected person. The
higher R0, the more rapidly an epidemic will typically spread, while
clearly, if R0 is less than one a disease will tend to die out. R0
depends not only on the virus itself, but on host behavior.
(Body-washing burial customs in Congo significantly boosted the R0 of
Ebola virus there, for instance, as did inability to sterilize medical
equipment due to a devastated public health sector.) Wu and colleagues
modeled mathematically which measures might mitigate the spread of the
next influenza pandemic (avian or otherwise). Their goal was to help
public health workers with pandemic preparedness by evaluating various
strategies that have been suggested for reducing initial "first-wave"
influenza attack rates. Using transmissibility data from the 1918
influenza pandemic, demographic and epidemiologic data from the
present-day city of Hong Kong, and published efficacy studies of
oseltamivir, the authors modeled effects of four public health measures:
voluntary segregation of household contacts of a suspected case (a.k.a.
quarantine); voluntary isolation of symptomatic patients -- including
those not ill enough to require hospitalization -- in separate
facilities; antiviral administration for known household exposures; and
contact tracing with subsequent quarantine and antiviral administration
in school, peer and work networks. None of these policies stopped the
modeled epidemic, but even with only moderate (50%) compliance assumed,
all improved transmission rates substantially. Voluntary household
quarantine was the most effective measure modeled in reducing R0,
followed by individual isolation and targeted antiviral use, while
contact tracing did not add much and dramatically increased the
proportion of the population in quarantine. The combination of household
quarantine, isolation, and targeted antivirals was predicted to reduce
the proportion of the population who became ill from 49 to 27% in the
first year of epidemic influenza, while preventing about 16,000 deaths
in a city the size of Hong Kong (6.8m). Modeling showed that populations
with large stockpiles and effective delivery of antivirals could do
almost as well without imposing isolation (but with quarantine); for
those without, isolation was a vital control measure.

**Reference:**

Wu, JT, S Riley, C Fraser and GM Leung. Reducing the impact of the next
influenza pandemic using household-based public health interventions.
PLoS Medicine 3(9):e361

[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16881729]{.underline}

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

**AAP encourages implementation of new shopping cart standards to
prevent child injury**

The current US standard for shopping carts should be revised to include
clear and effective performance criteria for shopping cart
child-restraint systems and cart stability to prevent falls from carts
and cart tip-overs.

AAP recommendations outlined in the policy statement include the
following:

\* Incorporate an effective performance standard in existing and future
state and federal laws on shopping cart safety; transport children only
in carts that meet this minimum safety standard.

\* Encourage businesses that provide customers with shopping carts to
adopt safety strategies to help prevent shopping-cart-related injuries
to children.

\* Educate families about the risks of transporting children in shopping
carts.

\* Inform the public through the media about shopping cart hazards.

\* Evaluate the effectiveness of education programs and public-awareness
initiatives focused on shopping cart safety.

\* Until an effective revised performance standard for shopping cart
safety is implemented in the United States, seek alternatives to
transporting children in shopping carts.

American Academy of Pediatrics Committee on Injury, Violence, and Poison
Prevention. 2006. Shopping cart-related injuries to children. Pediatrics
118(2):825-827
[[http://pediatrics.aappublications.org/cgi/content/abstract/pediatrics;118/2/825]{.underline}](http://pediatrics.aappublications.org/cgi/content/abstract/pediatrics;118/2/825)

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

#### First trimester screening: How would you counsel this patient? {#first-trimester-screening-how-would-you-counsel-this-patient-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Ms. L. is a 40 y/o G1P0 at 9 weeks gestation (by a 6 week ultrasound) and is aware of her age-related risks for fetal aneuploidy. She inquires about the possibility of early screening.  Which ONE of the statements below is the most accurate way to counsel her: {#ms.-l.-is-a-40-yo-g1p0-at-9-weeks-gestation-by-a-6-week-ultrasound-and-is-aware-of-her-age-related-risks-for-fetal-aneuploidy.-she-inquires-about-the-possibility-of-early-screening.-which-one-of-the-statements-below-is-the-most-accurate-way-to-counsel-her .Style-Heading-4-+-Arial-14-pt-Underline}

#### A. Ultrasonic measurement of fetal nuchal translucency combined with biochemical tests between 11 and 13 weeks may detect close to 90% of chromosomally abnormal fetuses {#a.-ultrasonic-measurement-of-fetal-nuchal-translucency-combined-with-biochemical-tests-between-11-and-13-weeks-may-detect-close-to-90-of-chromosomally-abnormal-fetuses .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### B. Early trimester screening has a better detection rate, but a higher false positive rate rate, than midtrimester screening {#b.-early-trimester-screening-has-a-better-detection-rate-but-a-higher-false-positive-rate-rate-than-midtrimester-screening .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### C. Women who have first trimester screening that is negative will not need further testing {#c.-women-who-have-first-trimester-screening-that-is-negative-will-not-need-further-testing .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Stay tuned till next month to find out more  {#stay-tuned-till-next-month-to-find-out-more .Style-Heading-4-+-Arial-14-pt-Underline}

#### (or see comment below) {#or-see-comment-below .Style-Heading-4-+-Arial-14-pt-Underline}

#### 

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

#### For more background on this and other Prenatal genetic screening questions, please go to this free CME module which is also just a great resource {#for-more-background-on-this-and-other-prenatal-genetic-screening-questions-please-go-to-this-free-cme-module-which-is-also-just-a-great-resource .Style-Heading-4-+-Arial-14-pt-Underline}

#### Prenatal genetic screening: Serum and ultrasound {#prenatal-genetic-screening-serum-and-ultrasound .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/TM01.cfm**](http://www.ihs.gov/MedicalPrograms/MCH/M/TM01.cfm) {#httpwww.ihs.govmedicalprogramsmchmtm01.cfm .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

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

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

######### 

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

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

**Clinical Discussion Board Index, Medscape**

Hundreds of ongoing clinical discussions available

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

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

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

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

**Menopause Management**

**Gabapentin is an effective alternative to estrogen for the treatment
of hot flushes**

CONCLUSION: Despite the small scale of this study, gabapentin appears to
be as effective as estrogen in the treatment of postmenopausal hot
flushes. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov, NCT 00276081.
LEVEL OF EVIDENCE: I.

[Reddy
SY](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Reddy+SY"%5BAuthor%5D),
et al Gabapentin, estrogen, and placebo for treating hot flushes: a
randomized controlled trial. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Jul;108(1):41-8.\
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16816054>

**AHRQ: Menopausal hormone therapy declined after published WHI trial
results**

<http://www.ahrq.gov/research/jun06/0606RA14.htm>

#### Midwives Corner Lisa Allee, CNM, Chinle {#midwives-corner-lisa-allee-cnm-chinle .Style-Heading-4-+-Arial-14-pt-Underline}

**VBAC: Pendulums and Ecstasy**

The first article I'll review is yet another nudge for the pendulum to
swing back to sanity for VBACs in this country and the second article
has some thought-provoking information on ways to enhance the natural
birth process, VBAC or not, but certainly incredibly relevant to
supporting women in achieving successful VBACs.

Landon, et al, in a large multi-center prospective observational study
found that women with histories of multiple cesarean deliveries are not
at higher risk for uterine rupture than women with single prior cesarean
deliveries, 0.9% and 0.7% respectively. (Also notice how low these rates
are---less than 1%, less than 1 in a hundred!!) They also found that
while having had a prior vaginal delivery was protective for uterine
rupture, it was not significant enough to warrant requiring this in
order to be a VBAC candidate.

They did find that "the risks of other adverse maternal events
(hysterectomy and transfusion) is increased in women with multiple prior
cesarean deliveries, but the absolute level of these risks is small"
(3.2% and 0.6% respectively.) Another finding was that pitocin induction
or augmentation, epidural, and less than 2 years since the cesarean
delivery were associated with higher rates of uterine rupture. Perinatal
outcomes of term infants were no different in women with one or multiple
prior cesarean deliveries and in women with trials of labor or elective
repeat cesarean.

**Ecstatic Birth**

In the second article Ecstatic Birth, Sarah Buckley, MD writes
eloquently and informatively about the hormonal aspects of labor, birth,
postpartum, and breastfeeding. She covers oxytocin, the love hormone and
mediator of all the ejection reflexes---sperm, baby, placenta, and milk;
beta-endorphins, our naturally occurring analgesics levels of which rise
and rise during labor; catecholamines that inhibit oxytocin and blood
flow to the uterus when stimulated by fear and anxiety; and prolactin
the milk and protection hormone. She discusses the ways in which this
hormonal mix is essential to the normal processes of giving birth,
breastfeeding, and bonding and ways that it can be supported and
enhanced. She draws the parallel of the hormones of birthing a baby
being the ones involved in making the baby and, thus, the possibility of
ecstatic birth. She also reviews the ways in which interventions such as
induction or augmentation of labor, analgesia or anesthesia, cesarean
delivery, and early separation can wreak havoc on this beautifully
crafted hormonal milieu.

She closes the article with a beautiful quote from Dutch professor of
obstetrics G. Kloosterman:

Spontaneous labour in a normal woman is an event marked by a number of
processes so complicated and so perfectly attuned to each other that any
interference will only detract from the optimal character. The only
thing required from the bystanders is that they show respect for this
awe-inspiring process by complying with the first rule of medicine\--nil
nocere \[do no harm\].

Buckley, S Ecstatic Birth: The hormonal blueprint of labor. Mothering.
2002 March-April; 111: 51-61.

**[Editorial Comment Lisa Allee, CNM]{.underline}**

Landon's article is yet more evidence that VBAC should be available and
encouraged for most women with a prior cesarean delivery, or cesarean
deliveries. This research was reported in USA Today and in the article
the chairman of the ACOG practice committee was quoted as saying that he
expects his group to revise their VBAC recommendations. Hallelujah!
Let's hope they even change that fateful wording "immediately available"
back to the much more helpful "readily available" so even women in rural
and small towns and cities can have VBACs again!

The second article is not from a peer reviewed journal, but check out
the references and see that many of them are. This article gives
scientific backing to the ancient art of midwifery\--supporting women in
their natural processes of giving birth. I included it here because
while all women deserve us knowing and thinking about ways we can
support, enhance, and, hopefully, not trample on their hormonal cascade
for birth, women having a VBAC need us to do so even more. I fully admit
that creating truly undisturbed births in most of our practice settings
is difficult, if not impossible, but there are many, many things that we
can do to move closer to that goal---speak softly and gently; make the
surroundings comforting and soothing to all the senses; use words that
induce calm and confidence, not fear and doubt; keep the sounds of other
women giving birth to a minimum (close the door); turn down the lights;
turn down the monitor; use touch and voice for relaxation; use
relaxation, movement, water, massage, heat/cold, etc. for helping with
pain instead of medications; welcome the people the woman loves; keep
mothers and babies together.....

These oxytocin-friendly procedures can help women VBAC successfully and
decrease (dare I say prevent?) the need for the interventions Landon and
others have found to increase the risk of uterine rupture, namely
pitocin and epidurals. Our own hormones rock, let them flow!

**References:**

Landon, M, et al , Risk of uterine rupture with a trial of labor in
women with multiple and single prior cesarean delivery. Obstetrics &
Gynecology.2006 Jul;108(1):12-20.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16816050>

Buckley, S Ecstatic Birth: The hormonal blueprint of labor. Mothering.
2002 March-April; 111: 51-61.
<http://www.mothering.com/articles/pregnancy_birth/birth_preparation/ecstatic.html>

**Navajo News Jean Howe, Chinle**

#### Please See Abstract of the Month {#please-see-abstract-of-the-month-1 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Nurses Corner**

**Native Alaskan and American Indian Nurses Scholarship Opportunity**

I am writing to you about a scholarship opportunity for American Indian
and Native Alaskan (AI/NA) Commission Corps Officers through the Native
Nurses Career Opportunity Program. We are a small grant-based
scholarship program funded by IHS at the University of Minnesota -
School of Nursing. We award scholarships to AI/NA registered nurses
pursuing their Master degree at the University of Minnesota School of
Nursing. It is our goal to increase the number of Masters prepared AI/NA
nurses. We have several scholarship recipients who are currently
Commission Corps Officers and would like to get the word out to other
Officers who might also benefit from our program.

The U of MN offers courses online and we encourage our students to stay
and serve in their current communities. We also understand the nature of
being a Commission Corps Officer and understand that our students need
to respond when called to duty.

I would appreciate it if you would forward this e-mail to the
appropriate person. We would like to send your office information
regarding our scholarship program and would appreciate it if you could
share the information with any American Indian and Native Alaskan
officers looking to increase further their education. <NativeRN@umn.edu>
or
[[www.nursing.umn.edu/NNCOP]{.underline}](../www.nursing.umn.edu/NNCOP)

####  {#section-16 .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}

**Final Births for 2004**

This report from the CDC summarizes the 2004 final births and birth
rates for the United States. The number of births rose very slightly,
the birth rate for teenagers declined 1 percent in 2004, and for the
second consecutive year, all measures of childbearing by unmarried women
rose sharply.
<http://www.cdc.gov/nchs/products/pubs/pubd/hestats/finalbirths04/finalbirths04.htm>

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

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

**The indications for IUD use have vastly expanded**

Intrauterine devices are the most common reversible method of
contraception worldwide. However, here in the US, less than 1% of
contraceptive users use an IUD. Due to the Dalkon Shield controversy,
many different forms of IUDs were removed from the market. Today, there
are only two IUDs on the market here in the US, the copper T380A
(Paraguard) and the Levonorgesterel intrauterine system (Mirena).
Today's IUDs have corrected a design flaw that was unique to the Dalkon
Shield and recent research has shown that they are safe and very
effective, with pregnancy rates approaching that of tubal sterilization.
The Levonorgesterel intrauterine system offers the non-contraceptive
benefit of reducing menstrual flow and can be used for idiopathic
menorrhagia. Recent evidence suggests that IUDs can be used in the
Adolescent population and that 75% of adolescents that had IUDs placed
were very happy with their contraceptive choice at 1 year. IUD use in
the properly selected adolescent could be a useful weapon in the
prevention of teenage pregnancy. One of the largest concerns with IUD
use is the increased risk of pelvic infections which appears to be
greatest at the time of insertion but returns to the background rate 1
month after insertion. Candidates for IUDs include:

Multiparous and nulliparous women at low risk for STDs

Women who desire long-term reversible contraception

Women with the following medical conditions:

Diabetes, Thromboembolism, Menorrhagia / dysmenorrhea, breastfeeding,

breast cancer, and liver disease

When your next patient is searching for a contraceptive option, and
isn't absolutely certain she does not want to have more children, an IUD
is an excellent option.

**Resources:**

ACOG practice bulletin. Number 59, January 2005. Intrauterine device.
Obstet Gynecol. 2005 Jan;105(1):223-32

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=15625179>

ACOG committee opinion. No. 337: Noncontraceptive uses of the
levonorgestrel intrauterine system. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2006
Jun;107(6):1479-82.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16738186>

Revisiting the intrauterine contraceptive device in adolescents. J
Pediatr Adolesc Gynecol. 2006 Aug;19(4):291-6.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16873034>

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

**Soy Isoflavones Protect Postmenopausal Women From Bone Loss **

CONCLUSION: There is a significantly dose-dependent effect of soy
isoflavones on attenuating bone loss at the spine and femoral neck
possibly via the inhibition of bone resorption in non-obese
postmenopausal Chinese women with high Kuppermann Scale

[Ye
YB](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Ye+YB"%5BAuthor%5D),
et al Soy isoflavones attenuate bone loss in early postmenopausal
Chinese women : A single-blind randomized, placebo-controlled trial.
[Eur J Nutr.](javascript:AL_get(this, 'jour', 'Eur J Nutr.');) 2006 Jun
8

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16763748>

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

#### Antidepressant Discontinuation Syndrome: What You Should Know {#antidepressant-discontinuation-syndrome-what-you-should-know-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20060801/457ph.html**](http://www.aafp.org/afp/20060801/457ph.html) {#httpwww.aafp.orgafp20060801457ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Tips to Help You Quit Smoking {#tips-to-help-you-quit-smoking-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20060715/276ph.html**](http://www.aafp.org/afp/20060715/276ph.html) {#httpwww.aafp.orgafp20060715276ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Health Care for Lesbians and Bisexual Women {#health-care-for-lesbians-and-bisexual-women-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.aafp.org/afp/20060715/287ph.html**](http://www.aafp.org/afp/20060715/287ph.html) {#httpwww.aafp.orgafp20060715287ph.html .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-20 .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}

**Glyburide flows from fetus to mother by placental transport system**

RESULTS: There was highly significant transfer of glyburide against
concentration gradient from the fetal to the maternal circulation.
Fetal-to-maternal concentration ratio was 0.92 +/- 0.23 at the start of
the experimental period and 0.31 +/- 0.47 3 hours later (P = .01) (n =
5). Verapamil did not modify glyburide transport. CONCLUSION: This is
the first direct evidence of active glyburide transport from the fetus
to the mother and, in general, of any medicinal drug used during
pregnancy. These experiments suggest that glyburide is actively efflux
by a transporter other than P-glycoprotein. Alternatively, it is
possible that a minority of glyburide is carried by P-glycoprotein, but
most of the fetal load is pumped to the mother by a yet-unidentified
placental transport system.

[Kraemer
J](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Kraemer+J"%5BAuthor%5D)
et al Perfusion studies of glyburide transfer across the human placenta:
implications for fetal safety. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Jul;195(1):270-4.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16579925>

**Inappropriate Discontinuation of Asthma Medication Common in Early
Pregnancy**

CONCLUSIONS: Utilization of all categories of asthma medications
decreased in early pregnancy, with the largest declines occurring for
inhaled and rescue corticosteroids.

[Enriquez
R](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Enriquez+R"%5BAuthor%5D),
et al Cessation of asthma medication in early pregnancy. [Am J Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Am J Obstet Gynecol.');) 2006
Jul;195(1):149-53.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16631099>

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

#### September 1, 2006: Palliative Medicine\'s Role in the Continuity of Care Moderator: Tim Domer, M.D.

-   Management of acute vs chronic pain

-   Quality of Life in chronic illness

-   The meaning of \"Code Status\"

-   Preparing for a \"Good Death\"

-   End-of-Life Care as part of Continuity of Care and Prevention

[http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForum.cfm#](http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForum.cfm#disc)

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

Subscribe to the Primary Care listserv

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

Unsubscribe from the Primary Care listserv

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

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

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

# Condom Use and the Risk of Genital Human Papillomavirus Infection in Young Women

[Results]{.underline} The incidence of genital HPV infection was 37.8
per 100 patient-years at risk among women whose partners used condoms
for all instances of intercourse during the eight months before testing,
as compared with 89.3 per 100 patient-years at risk in women whose
partners used condoms less than 5 percent of the time (adjusted hazard
ratio, 0.3; 95 percent confidence interval, 0.1 to 0.6, adjusted for the
number of new partners and the number of previous partners of the male
partner). Similar associations were observed when the analysis was
restricted to high-risk and low-risk types of HPV and HPV types 6, 11,
16, and 18. In women reporting 100 percent condom use by their partners,
no cervical squamous intraepithelial lesions were detected in 32
patient-years at risk, whereas 14 incident lesions were detected during
97 patient-years at risk among women whose partners did not use condoms
or used them less consistently. [Conclusions]{.underline} Among newly
sexually active women, consistent condom use by their partners appears
to reduce the risk of cervical and vulvovaginal HPV infection.

# Winer RL et al Condom Use and the Risk of Genital Human Papillomavirus Infection in Young Women New England Journal of Medicine   June 22, 2006 Volume 354: pages 2645-2654

#### [**http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16790697**](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16790697) {#httpwww.ncbi.nlm.nih.goventrezquery.fcgicmdretrievedbpubmedlist_uids16790697 .Style-Heading-4-+-Arial-14-pt-Underline}

COMMENTARY: Condoms and Sexually-Transmitted Infections

Steiner MJ et al New England Journal of Medicine   June 22, 2006 Volume
354: pages 2642-2643
<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16790696>

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

#### Other: {#other-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Latest STD Treatment Guidelines Just Released, 2006, CDC {#latest-std-treatment-guidelines-just-released-2006-cdc .Style-Heading-4-+-Arial-14-pt-Underline}

**Summary**

These guidelines for the treatment of persons who have sexually
transmitted diseases (STDs) were developed by CDC after consultation
with a group of professionals knowledgeable in the field of STDs who met
in Atlanta, Georgia, during April 19--21, 2005. The information in this
report updates the Sexually Transmitted Diseases Treatment Guidelines,
2002 (MMWR 2002;51\[No. RR-6\]).

Included in these updated guidelines are an expanded diagnostic
evaluation for cervicitis and trichomoniasis; new antimicrobial
recommendations for trichomoniasis; additional data on the clinical
efficacy of azithromycin for chlamydial infections in pregnancy;
discussion of the role of Mycoplasma genitalium and trichomoniasis in
urethritis / cervicitis and treatment-related implications; emergence of
lymphogranuloma venereum protocolitis among men who have sex with men
(MSM); expanded discussion of the criteria for spinal fluid examination
to evaluate for neurosyphilis; the emergence of azithromycin resistant
Treponema pallidum; increasing prevalence of quinolone-resistant
Neisseria gonorrhoeae in MSM; revised discussion concerning the sexual
transmission of hepatitis C; postexposure prophylaxis after sexual
assault; and an expanded discussion of STD prevention approaches*.*

#### [**http://www.cdc.gov/std/treatment/default.htm**](http://www.cdc.gov/std/treatment/default.htm) {#httpwww.cdc.govstdtreatmentdefault.htm .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Rapid HIV Test Distribution Picks up Thousands of Infections in US**

#### The distribution of 372,960 rapid HIV tests by the Centers for Disease Control and Prevention from September 2003 to December 2005 resulted in the identification of 4650 infections. The findings in this report suggest that HIV testing might be increased by using rapid tests and that RTDP might have enabled diagnosis of HIV infection in persons who would not have known their HIV status otherwise. {#the-distribution-of-372960-rapid-hiv-tests-by-the-centers-for-disease-control-and-prevention-from-september-2003-to-december-2005-resulted-in-the-identification-of-4650-infections.-the-findings-in-this-report-suggest-that-hiv-testing-might-be-increased-by-using-rapid-tests-and-that-rtdp-might-have-enabled-diagnosis-of-hiv-infection-in-persons-who-would-not-have-known-their-hiv-status-otherwise. .Style-Heading-4-+-Arial-14-pt-Underline}

#### Rapid HIV Test Distribution \-\-- United States, 2003---2005 MMWR June 23, 2006 / 55(24);673-676 [**http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5524a2.htm**](http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5524a2.htm) {#rapid-hiv-test-distribution-----united-states-20032005-mmwr-june-23-2006-5524673-676-httpwww.cdc.govmmwrpreviewmmwrhtmlmm5524a2.htm .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

**Obese Girls: Threefold Risk for Early Death than Slim Counterparts**\
Among more than 100,000 women in the Nurses\' Health Study II, those
with a body mass index (BMI) greater than 30 kg/m2 when age 18 had a
nearly threefold risk for premature death compared with women with BMIs
below 18.5 kg/m2 at age 18.\
Effects of childhood overweight on quality of life at younger ages may
be substantial, and higher mortality rates in middle age may represent
\'the tip of the iceberg\' of detrimental health consequences. Our
findings support preventive action in children aimed at reducing their
risk for becoming overweight.

Women with higher BMIs in their late teens were at greater risk of
premature death. Compared with women who had a BMI between 18.5 and 21.9
kg/m2 at age 18, the hazard ratio for premature death for women between
the ages of 22 and 44 at baseline was 0.98, for those with a BMI less
than 18.5 kg/m2, 1.18 for a BMI of 22.0 to 24.9 kg/m2, 1.66 for a BMI of
25.0 to 29.9 kg/m2 , and 2. for a BMI of 30 kg/m2 or greater.

During adolescence, women with a higher BMI at age 18 years had higher
levels of alcohol consumption, were more likely to smoke cigarettes, and
were less likely to engage in physical activity or use oral
contraceptives.

This paper underscores the importance of efforts to prevent excessive
weight gain in children, not only to prevent obesity but also to prevent
moderate overweight.

Given the prevalence of overweight, large-scale preventive strategies
aimed at increasing physical activity and stimulating healthy eating
habits in U.S. children and adolescents are warranted.

**Practice Pearl:**

Explain to interested patients that this study adds to the substantial
body of evidence indicating that excessive weight in childhood is
associated with significant negative health consequences later in life,
including increased risk for premature death.\
van Dam RN et al. The Relationship between Overweight in Adolescence and
Premature Death in Women. [Ann Intern
Med.](javascript:AL_get(this, 'jour', 'Ann Intern Med.');) 2006 Jul
18;145(2):91-7.

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16847291>

**New Recommendations Regarding Exercise and Type 2 Diabetes Issued **

Recommended lifestyle measures for prevention of type 2 diabetes are as
follows:

-   People with impaired glucose tolerance should begin and continue a
    program of weight control, including at least 150 minutes per week
    of moderate to vigorous physical activity and a healthful diet with
    modest energy restriction (Level of evidence: A).

-   The amount and intensity of recommended aerobic exercise vary
    according to goals. To improve glycemic control, assist with weight
    maintenance, and reduce risk for cardiovascular disease (CVD), the
    panel recommends 150 minutes per week or more of moderate-intensity
    aerobic physical activity (40% - 60% of oxygen consumption per unit
    time \[VO2max\] or 50% - 70% of maximum heart rate), and/or 90
    minutes per week or more of vigorous aerobic exercise (\> 60% of
    VO2max or \> 70% of maximum heart rate). The physical activity
    should be distributed over at least 3 days per week, with no more
    than 2 consecutive days without physical activity (Level of
    evidence: A).

-   Compared with lower volumes of activity, performing at least 4 hours
    per week of moderate to vigorous aerobic and/or resistance exercise
    physical activity is associated with greater CVD risk reduction
    (Level of evidence: B).

-   For long-term maintenance of major weight loss (≥ 13.6 kg or 30 lb),
    larger volumes of exercise (7 hours per week of moderate or vigorous
    aerobic physical activity) may be helpful (Level of evidence: B).

-   Unless contraindicated, people with type 2 diabetes should be
    encouraged to perform resistance exercise 3 times per week,
    targeting all major muscle groups. This should progress to 3 sets of
    8 to 10 repetitions at a weight that cannot be lifted more than 8 to
    10 times (level of evidence: A). Initial supervision and periodic
    reassessments by a qualified exercise specialist are recommended to
    ensure that resistance exercises are performed correctly, to
    maximize health benefits, and to minimize the risk of injury.

The most successful programs for long-term weight control have involved
combinations of diet, exercise, and behavior modification. Exercise
alone, without concomitant dietary caloric restriction and behavior
modification, tends to produce only modest weight loss of
\[approximately\] 2 kg. Weight loss is typically this small primarily
because obese people often have difficulty performing sufficient
exercise to create a large energy deficit, and it is relatively easy to
counterbalance increased energy expenditure through exercise by eating
more or becoming less active outside of exercise sessions.

[Sigal
RJ](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="Sigal+RJ"%5BAuthor%5D),
et al Physical activity/exercise and type 2 diabetes: a consensus
statement from the American Diabetes Association. [Diabetes
Care.](javascript:AL_get(this, 'jour', 'Diabetes Care.');) 2006
Jun;29(6):1433-8

<http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16732040>

**Just how effective are diabetes management programs?**\
The answer, according to UCLA researchers, is that they lead to better
examination and testing---but not to better control of key factors
associated with diabetes complications, such as blood pressure,
cholesterol or blood sugar levels.

A new study, finds that health care providers' use of management
programs resulted in higher rates among their patients of recommended
examinations, such as eye and foot exams, testing for kidney function or
damage due to the disease, cholesterol checks, and getting influenza
vaccinations.

These management strategies, however, had no impact on good medication
management and were not linked to improved sugar, blood pressure or
cholesterol levels.

The three disease-management strategies include physician reminders
(reminders that health plans or physician groups can send to their
clinicians, including preprinted guidelines, flow sheets, and flags or
customized alerts for medical records); regular feedback from physician
groups to their doctors on the care they provide; and structured care
management, which is when patients also see case managers, attend
diabetes education classes and/or receive reminders about the care they
need, such as eye examinations or flu shots, between doctor visits.

"The good news is that physician groups that are investing in
care-management strategies are doing a better job of delivering eye
care, screening for kidney problems and high cholesterol, and providing
regular foot exams to more of their patients with diabetes," said Dr.
Carol Mangione, professor of medicine in the department of medicine at
the David Geffen School of Medicine at UCLA and in the department of
health services at the UCLA School of Public Health. "These results also
suggest that it is much more challenging to achieve better control of
the factors that are most strongly associated with the long-term
complications of diabetes that patients care about, such as heart
attacks and strokes. To prevent these serious complications, disease
management programs may need to directly monitor the levels of blood
pressure, cholesterol and glucose, and the treatments used to control
them."

The researchers studied 8,661 patients from 63 physician groups in
several health plans, seven of them sponsored by Translating Research
Into Action for Diabetes (TRIAD), a multi-center study of diabetes care
within managed care systems, and four plans with individual physician
contracts. The patients were recruited between July 2000 and October
2001.

The study shows that use of any of the three disease-management
strategies resulted in higher rates of retinal screening, kidney checks,
foot examinations and hemoglobin measurements. These are important
because diabetes can lead to blindness, kidney failure and loss of limbs
when not properly controlled.

Additionally, the researchers found that greater use of structured care
management and performance feedback were linked with serum lipid level
testing and influenza vaccine administration. They also found a
correlation between the use of performance feedback and increased rates
of foot examinations, and between physician reminders and increased
rates for microalbuminuria checks, which test for small but abnormal
amounts of the protein albumin in the urine.

Over the past 10 years, disease-management programs have focused on
improving processes of care rather than outcomes. The study's findings
suggest that to achieve better control of blood pressure, cholesterol
and sugar---and ultimately reduce the risk of complications such as
heart attacks and strokes---these programs will need to actively engage
the participation of doctors and patients and will need to measure and
report on the levels of these outcomes on a regular basis.

[Mangione
CM](http://ezproxyhhs.nihlibrary.nih.gov:2067/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term="Mangione+CM"%5BAuthor%5D),
et al The association between quality of care and the intensity of
diabetes disease management programs. [Ann Intern
Med.](javascript:AL_get(this, 'jour', 'Ann Intern Med.');) 2006 Jul
18;145(2):107-16.\
<http://ezproxyhhs.nihlibrary.nih.gov:2067/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16847293>

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

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

-   September 17 -- 21, 2006

-   Denver, CO

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

-   Neonatal Resuscitation Program available

-   Brochure

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

**Second Annual AI / AN Long Term Care Conference**

-   September 18 & 19, 2006

-   Tulsa, Oklahoma

-   [www.aianlongtermcare.org](http://www.aianlongtermcare.org/)

-   Contact Alvin Rafaelito at
    [Alvin@nicoa.org](javascript:parent.ComposeTo('Alvin@nicoa.org');),
    505-292-2001

-   Honoring Our Elders:  Best Practices in Long Term Care 2006 

**Best Practices** **and GPRA Tracking**

-   Nov 1-2, 2006

-   Sacramento CA

-   California IHS Area Office, Contact <Elaine.brinn@ihs.gov>

-   <http://www.ihs.gov/MedicalPrograms/MCH/F/documents/BestPracticesFlyer1.pdf>

**22nd Annual Midwinter Indian Health OB/PEDS Conference**

-   For providers caring for Native women and children

-   January 26-26, 2007

-   Telluride, CO

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

**2nd** **International Meeting on Indigenous Child Health**

-   April 20-22, 2007

-   Montreal, Quebec, Canada

-   Solutions, not Problems

-   Joint meeting of IHS, AAP-CONACH, First Nations and several other
    stakeholders

-   <http://www.aap.org/nach/2InternationalMeeting.htm>

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

-   August 15 -17, 2007

-   Albuquerque, NM

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

-   Internationally recognized speakers

-   Save the dates. Details to follow

-   12 months away and counting

-   Want a topic discussed? Contact <nmurphy@scf.cc>

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

## New Deputy CCC for Family Practice, Ann Bullock, MD 

<http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-fmDep.asp>

There are several upcoming **Conferences**

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

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

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

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

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

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

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

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

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

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706.cfm**](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0706.cfm) {#httpwww.ihs.govmedicalprogramsmchmobgyn0706.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}

**Point / Counterpoint: Refusals by pharmacists to dispense emergency
contraception**

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

Carolyn Aoyama

-Excellent article on breast cancer in American Indian women seen at
PIMC

#### -The APN policy is on the Web! {#the-apn-policy-is-on-the-web .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Science of Sex and Gender in Human Health Online Course Web Site {#science-of-sex-and-gender-in-human-health-online-course-web-site .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Women of Color Health Data Book and AI/AN Health Education materials {#women-of-color-health-data-book-and-aian-health-education-materials .Style-Heading-4-+-Arial-14-pt-Underline}

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

Burt Attico

Pregestational Diabetes Linked to Higher Rates of Perinatal Death and
Anomalies

#### David Boyd {#david-boyd .Style-Heading-4-+-Arial-14-pt-Underline}

#### The AUDIT has been reported to outperform the CAGE {#the-audit-has-been-reported-to-outperform-the-cage .Style-Heading-4-+-Arial-14-pt-Underline}

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

Terry Cullen

Best Practices and GPRA Tracking

Judy Thierry

-Top 10 Preventive Services

-Observing and reading cues from our infants - researched based
education tool

#### -Accurate data means better programs and more funding {#accurate-data-means-better-programs-and-more-funding .Style-Heading-4-+-Arial-14-pt-Underline}

-Have you ordered your 2006-07 flu vaccine?

### -The Health Consequences of Involuntary Exposure to Tobacco Smoke

Mark Traeger

How to address health disparities? One story of success -- Whiteriver,
AZ

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

##### Obstetrics page 12

-The return of the vaginal breech delivery

-Nalbuphine Injection (Nubain) Linked to Risk for Fetal Adverse Events

-VBAC pendulum is posed to swing back

-Avoiding post-term pregnancy improves perinatal mortality

-Adverse neonatal outcomes were not increased after 30 minute decision
to incision times

and more....

**Gynecology page 15**

-CDC's Advisory Committee Recommends Human Papillomavirus Virus
Vaccination

-Speculum lubrication does not affect cervical cytology: Traditional or
liquid based

-Three Questions Distinguish Urge From Stress Incontinence

-Burch colposuspension combined with uterine prolapse repair reduces
incontinence

-Monsel\'s paste and fulguration with ball electrode equally effective
for hemostasis after LEEP

**Child Health page 18**

-Boyfriends, girlfriends, and Adolescents' risk of sexual involvement

-New Guidelines for Pediatric and Neonatal Emergency Cardiovascular Care

-2nd International Meeting on Indigenous Child Health

**Chronic Illness and Disease page 19**

-Driving, Other Erratic Behaviors Reported After Taking Zolpidem
(Ambien)

-New shingles vaccine is a smart precaution with little downside

-Medical Management of Common Urinary Calculi

-Diagnosis and Treatment of Antiphospholipid Syndrome

-Few Americans with Diabetes Receive Multiple Preventive-Care Services

and more....

#### Features: page 23 {#features-page-23 .Style-Heading-4-+-Arial-14-pt-Underline}

##### American Family Physician

Planned Early Birth vs. Expectant Management for PROM

American College of Obstetricians and Gynecologists

-William H. J. Haffner American Indian / Alaska Native Women's Health
Award

-Antibiotic Prophylaxis for Gynecologic Procedures

-Ethical Ways for Physicians to Market a Practice

**Agency for Healthcare Research and Quality**

## Gender disparities in the quality of preventive care / management of heart disease/ DM

**Ask a Librarian**

How to find Evidence?

**Breastfeeding**

Pain is one the reasons that moms quit breastfeeding in the first 2
weeks

**CCC Corner Digest**

-Varicella Prophylaxis for high risk persons (including pregnancy):
VariZIG replaces VZIG

-Achievements in Public Health: Reduction in Perinatal Transmission of
HIV Infection

-What is the rate of preterm birth in Native Americans?

-Incontinence not correlated with vaginal delivery

-FDA Licenses HPV Vaccine for Prevention of Cervical Cancer in Females

-Co-occurring maternal conditions and behavior problems in children

-Group visits: Promising for chronic care management for the motivated
patient

-Hormonal Contraception: Coexisting Medical Conditions, Practice
Bulletin

-Early breastfeeding choice, GDM, and BMI

-4x more common than breast cancer, major morbidity / mortality: Can't
be ignored

-Refusals by pharmacists to dispense emergency contraception: a critique

-GREAT site for Health Promotion Disease Prevention Utah Department of
Health

-Copious post operative mucous secretions

-Empowering women to find the power of birth is of great value

-Methamphetamine abuse among women on Navajo (Part 3 of 4)

-SANE/SAFE training and capacity

-Recommendations to Improve Preconception Health and Health Care

-Patient-Requested Cesarean: Should be performed for medical reasons

-Cesarean delivery rate: Continues to increase without improving
outcomes

-September 1, 2006: Palliative Medicine\'s Role in the Continuity of
Care

-HIV Testing and Additional Analysis of National Survey on HIV/AIDS

-Women Who Don\'t Snooze Enough Gain Weight

**Domestic Violence**

-Sexual assault victims: factors associated with follow-up care

-10th National Indian Nations: Conference for Victims of Crime - Call
for Indian Health Input

-4th Biennial National Conference on Health and Domestic Violence

-Rural pilot project funds for violence against women

**Elder Care News**

When in doubt -- Involve a geriatrician in your elderly female patient's
care

**Family Planning**

-Depo-Provera: Baseline bone density / follow-up studies not needed

#### -Initiating Hormonal Contraception {#initiating-hormonal-contraception .Style-Heading-4-+-Arial-14-pt-Underline}

#### -FDA says one reported abortion pill death was unrelated {#fda-says-one-reported-abortion-pill-death-was-unrelated .Style-Heading-4-+-Arial-14-pt-Underline}

**Featured Website**

Try Michigan's site. It's super!

**Frequently asked questions**

The Indian Health MCH Frequently Asked Question (FAQ) site

**Indian Child Health Notes July 2006 -- Highlights**

-Free on-line full text journals and textooks are available to all
Indian Health and 638 sites.

-Fever treatment - Motrin versus Tylenol and together

-Human Papillomavirus (HPV) vaccine approved

-Substance Abuse and AI/AN adolescents

-Find out who won the AAP Native American Child Advocacy Award

**Information Technology**

-Hospital Computer Keyboards Should Be Disinfected Daily

-Health Information Technology: A rural provider's roadmap to quality

-UpToDate 14.2 is now available

International Health

-Where There is No Doctor & A Book for Midwives

-Convenience makes a big difference in HIV testing: a Zimbabwe study

-A new way to develop reliable tests for neglected diseases: Doctors
Without Borders

#### MCH Alert

Summary of Adolescent Pregnancy Prevention Programs

#### Medical Mystery Tour

Copious post operative mucous secretions: The rest of the story

#### Medscape

**Menopause Management**

-Conjugated Equine Estrogen Treatment May Not Increase Breast Cancer
Risk

-Changes in U.S. Prescribing patterns of menopausal hormone therapy

-ACOG Reports on Compounded Bioidentical Hormones

**Midwives Corner**

-Nuchal cords, somersaults, and the value of a pulsing cord: Nuchal Cord
Management

-Midwives in IHS- Choose Midwifery: A Perfect Match

-Short and Long Pregnancy Spacing Impairs Perinatal Outcomes

-Coitus is associated with reduced requirement for labor induction at 41
weeks

-Coitus During Early Pregnancy Not Linked to Recurrent Preterm Birth

**Navajo News**

-Methamphetamine abuse among women on Navajo: Part IV - The "Drop- in"
gravida

-Impact of Methamphetamine on Family Well Being

**Nurses Corner**

-The Association of Nurses in Aids Care

#### -Are you aware of a school curriculum dealing with STI/HIV prevention activities?  {#are-you-aware-of-a-school-curriculum-dealing-with-stihiv-prevention-activities .Style-Heading-4-+-Arial-14-pt-Underline}

#### **-2006 ANAC 19th Annual Conference: Scaling the Heights of HIV/AIDS Nursing**  {#anac-19th-annual-conference-scaling-the-heights-of-hivaids-nursing .Style-Heading-4-+-Arial-14-pt-Underline}

#### -2007 Evidence-Based Practice Conference {#evidence-based-practice-conference .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Important for sites to promote height and weight standardization {#important-for-sites-to-promote-height-and-weight-standardization .Style-Heading-4-+-Arial-14-pt-Underline}

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

New Data on Priority Health Risk Behaviors among Adolescents and Young
Adults

**Oklahoma Perspective**

IHS Division of Epidemiology and Disease Prevention Launches New Website

Osteoporosis

Osteoporosis Guidelines Updated: [North American Menopause
Society](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term="North+American+Menopause+Society"%5BCorporate+Author%5D)

Patient Education

-Do you need a Native oriented sex education resource in your clinic?

#### -Kidney Stones: What You Should Know {#kidney-stones-what-you-should-know .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Recovering from a Hip Fracture: What You Should Know {#recovering-from-a-hip-fracture-what-you-should-know .Style-Heading-4-+-Arial-14-pt-Underline}

Perinatology Picks

-Only 29% of ACOG recommendations are good / consistent evidence. What's
at fault?

-Evidence-based surgery for cesarean delivery

-Higher rate of pain-free coitus at 6 weeks after delivery:
Fast-absorbing polyglactin

-Progestational agents, initiated in the second trimester, reduce
preterm delivery

-Calcium reduced preeclampsia severity, maternal morbidity, and neonatal
mortality

Primary Care Discussion Forum

September 1, 2006: Palliative Medicine\'s Role in the Continuity of Care

STD Corner

-Focus on adolescent sexual behavior this month: 5 relevant articles

#### -Risk taking occurs, even among couples provided ready and free access to condoms / EC {#risk-taking-occurs-even-among-couples-provided-ready-and-free-access-to-condoms-ec .Style-Heading-4-+-Arial-14-pt-Underline}

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

-Diabetes Is The Clinical Equivalent of Aging 15 Years

-Escaping the Tyranny of the Urgent by Delivering Planned Care

-Mindset, Weight Tied to Willingness to Exercise

-Walking Faster Improves Diabetes Control

-Low-fat Dairy Foods Lower Women\'s Diabetes Risk

and more....

###### Save the Dates: Upcoming events of interest page 48

#### What's new on the ITU MCH web pages page 48

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

The past CCC Corners are archived at:

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

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

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

or 907 729 3154 (with voicemail)

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

8/13/06njm