# ![](media/image1.jpeg){width="6.000694444444444in" height="1.1097222222222223in"} {#section .Style-Style-Style-Heading-1-+-Underline-+-Pattern:-Clear-(Gray-12.5...1}

 

Chief Clinical Consultant's Corner

Volume 6, No. 4, April 2008

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

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

**High prevalence of HPV infection in American Indian women of the
Northern Plains**

#### From your colleagues page 6 {#from-your-colleagues-page-6 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Current management of gestational diabetes mellitus {#current-management-of-gestational-diabetes-mellitus .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### David Gahn {#david-gahn .Style-Heading-4-+-Arial-14-pt-Underline}

Afghanistan Update

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

Scott Giberson

Women and HIV

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

##### Obstetrics page 8

-Cesarean delivery during nursing change of shift is associated with
increased complications

-No benefit in treating women with average-risk pregnancies for
asymptomatic bacterial vaginosis

-Further risks highlighted for obese pregnant women

-Early maternal feeding following CD is associated with higher maternal
satisfaction

-Physical abuse during pregnancy present a large increase in the risk of
preterm delivery

**Gynecology page 9**

-Co-Occurrence of Pelvic Floor Disorders May Be High in Women 

-The Evolution of Midurethral Slings 

-Acupuncture in dysmenorrhea associated with improved quality of life
plus cost-effective

-Uterine Artery Embolization a Good Alternative to Hysterectomy for
Fibroids 

-Overactive Bladder: Diagnosis and Treatment in Primary Care

**Child Health page 10**

-Maternal grandmothers' alcohol use linked to FAS in the Northern Plains

-Pediatricians often do not pursue answers to questions that arise
during medical visits

**Chronic Illness and Disease page 11**

-Low-dose aspirin is linked to lower risk for all-cause mortality in
women, especially older women

#### -How is Your Sleep: A Neglected Topic for Health Care Screening {#how-is-your-sleep-a-neglected-topic-for-health-care-screening .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Pedometer-Based Walking Programs Helpful for Overweight, Sedentary Adults {#pedometer-based-walking-programs-helpful-for-overweight-sedentary-adults .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Blood Pressure May Predict Incident Type 2 Diabetes in Healthy Women {#blood-pressure-may-predict-incident-type-2-diabetes-in-healthy-women .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Discussing reconstruction options prior to surgery influences breast cancer treatment choices  {#discussing-reconstruction-options-prior-to-surgery-influences-breast-cancer-treatment-choices .Style-Heading-4-+-Arial-14-pt-Underline}

#### Features page 12 {#features-page-12 .Style-Heading-4-+-Arial-14-pt-Underline}

American College of Obstetricians and Gynecologists

-Treatment of Urinary Infections in Nonpregnant Women

-Technologic Advances to Reduce Medication-Related Errors

-Relationships With Industry

-Antenatal Corticosteroid Therapy for Fetal Maturation

-ACOG Supports Effort to Encourage Electronic Prescribing

##### American Family Physician

-Pharmacologic Management of Adult Depression

-Diagnosis and Treatment of Female Sexual Dysfunction

**Agency for Healthcare Research and Quality**

-Care quality is not necessarily better with electronic health records

-Patients with DM and depression skip self-care behaviors that would
help keep their DM in check

-Rural emergency departments have high rate of medication errors with
potential to harm children

**Ask a Librarian**

Women\'s Health Resources

**Behavioral Health Insights**

School Refusal By Elise Fatimi, MD

**Breastfeeding**

What makes a good idea work?

**CCC Corner Digest**

March 2008 Highlights

\-[Minorities underrepresented in umbilical cord blood
banking](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08aom)

\-[HPV brochure for AI/AN: available for broad
dissemination](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08col)

\-[Evidence Favors Late Cord Clamping in
Infants](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ht#ob)

\-[Biofeedback Reduces Psychological Burden in Older Women With Urge
Incontinence](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ht#gyn)

\-[Sex education: Providers need to fill gaps in adolescent
knowledge](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ht#child)

\-[Diuretics most effective blood pressure medicine for people with
metabolic
syndrome](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ht#chrIll)

\-[Fatigue and Patient
Safety](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#acog)

\-[Treating Eating Disorders in
Primary](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#afp)

\-[PTSD: A technique that works for
me](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#bhi)

\-[Report cites high rate of violence against Native
women](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#dv)

\-[Exciting opportunity to develop new resources in
geriatrics](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#ecn)

\-[Ringing Endorsement: Women Prefer Contraceptive Ring Over
Patch](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#fp)

\-[Meeting notes now online: 2007 Native Women's Health and MCH
Conference](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#fws)

\-[How can we actually reduce infant mortality in
AI/AN?](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#faq)

\-[Good intentions and unintended
consequences](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#ih)

\-[Maternal depression as a risk factor affecting child readiness and
school
readiness](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#alert)

\-[Findings from the National Survey of Children\'s Health includes
Native
Americans](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#mchh)

\-[St. John\'s wort for depression in a young woman: The
Answers](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#mmt)

\-[Perineal warm packs reduce 3rd and 4th degree lacerations, pain,
urinary
incontinence](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#midw)

\-[Adnexal Masses during
Pregnancy](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#navajo)

\-[Integrating Nursing and Behavioral
Health](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#nCrnr)

\-[SSRI Use and Bone Loss in Older
Women](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#ost)

\-[Assuring Quality Care for People With Limited Health
Literacy](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#pi)

\-[Usefulness of middle cerebral artery Doppler of the fetus at risk for
anemia](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#peri)

\-[Mental health issues in children and adolescents --Starts March
3rd](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#pcf)

\-[Diabetes A Stronger Risk Factor For Death In Women than In
Men](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#still)

\-[Women and
HIV/AIDS](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#whh)

**Domestic Violence**

-Teens, dating violence, and media use

-Linking dating violence, peer violence, and suicidal behaviors among
high-risk youth

-Non-condom use among young adolescent male perpetrators of dating
violence

-Domestic Violence Resources

-American Psychological Association's Violence Summit

**Elder Care News**

Training in Palliative and End of Life Care

**Family Planning**

#### Increasing contraceptive use and adherence in adolescents

**Featured Website**

#### Meeting notes now online: [2007 Native Women's Health and MCH Conference](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/Intro Slide and Eval Sli14.ppt)

**Frequently asked questions**

-Does anyone have an EHR template that is IHS approved for obstetrical
patients?

\-[How to Strengthen Your Pelvic Floor
Muscles?](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/W/MatPT.cfm%23pelvic)

**Indian Child Health Notes**

April 2008 -- Highlights

-Estimating the effectiveness of screening for scoliosis

-Recent news highlights from the world of vaccines

-Invasive Pneumococcal Disease in Children 5 Years After Conjugate
Vaccine Introduction

**Information Technology**

-Seeking input from the field - Clinician's Information Management
Technology Advisory Council

-HIMSS Davies is proud to announce a new recognition opportunity

-iCare Training

International Health

-Routes to TB treatment in rural Nepal

-Unite For Sight Volunteer Abroad Opportunities

#### MCH Alert

-New Bullying-Prevention Toolkit Released

-Chartbook Reports Findings From National Survey of Children with
Special Health Care Needs

-Breastfeeding Improves Prevalence of Metabolic Syndrome Among Women in
Midlife

#### MCH Headlines

-Maternal, Infant and Child Health Capacity Needs Assessment

-GHSA and State Farm Partner to Keep \'Tweens and Teens Safe age 8 to 18

#### Medical Mystery Tour

You know how to treat yeast infections? Which of these are true about
vulvar pruritus ?

#### Medscape

Overactive Bladder: Diagnosis and Treatment in Primary Care, CME/CE

**Menopause Management**

#### -What Happened to Women in WHI study 3 years after stopping HRT?  {#what-happened-to-women-in-whi-study-3-years-after-stopping-hrt .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Associations between subjective night sweats and sleep study findings  {#associations-between-subjective-night-sweats-and-sleep-study-findings .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Beneficial Effect of HT on Mortality and Coronary Heart Disease in Younger Women {#beneficial-effect-of-ht-on-mortality-and-coronary-heart-disease-in-younger-women .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Black Cohosh and Menopausal Symptoms: [Cases in CAM](http://www.medscape.com/px/viewindex/more?Bucket=columns&SectionId=3089) {#black-cohosh-and-menopausal-symptoms-cases-in-cam .Style-Heading-4-+-Arial-14-pt-Underline}

-FDA Goes After \'Natural\' HRT Claims

**Midwives Corner**

-Midwives Excel at Keeping Birth Normal, and Midwife-Provided
Acupuncture Helps With PROM

-Women given sterile water injection experience less labor pain compared
to acupuncture

-Irrespective of treatment, pelvic girdle pain regresses in majority by
12 weeks after delivery

-Cervical Cancer Screening Practices of Certified Nurse-Midwives in the
United States

**Navajo News**

Sexual Assault Nurse Examiner (SANE) Training Course, June 9 -- 13, 2008

**Nurses Corner**

#### -Call for nominations of nurses working in Indian health: Deadlines looming {#call-for-nominations-of-nurses-working-in-indian-health-deadlines-looming .Style-Heading-4-+-Arial-14-pt-Underline}

-Consider nominating our incredible IHS (CO, CS, Tribal) nurses for the
following awards too

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

#### April 7 -- 13^th^ is National Public Health Week {#april-7-13th-is-national-public-health-week .Style-Heading-4-+-Arial-14-pt-Underline}

**Oklahoma Perspective**

Prenatal Care in Oklahoma

Osteoporosis

#### Drugs that affect bone metabolism {#drugs-that-affect-bone-metabolism .Style-Heading-4-+-Arial-14-pt-Underline}

Patient Education

-Treating Depression: What You Should Know

# -Self-management: Taking Charge of Your Health

Perinatology Picks

-What is this all about the 'minor markers' for Down Syndrome?

-Tobacco use increases the risk of a SGA infant at term across maternal
strata

Primary Care Discussion Forum

Mental health issues in children and adolescents

STD Corner

-USPSTF Recommendations for STI Screening

-ACS Releases Guidelines for HPV Vaccination

#### -Management of HIV Infection in Special Populations {#management-of-hiv-infection-in-special-populations .Style-Heading-4-+-Arial-14-pt-Underline}

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

-Link between type 2 DM in adults and type 1 DM or pregnancy-related
diabetes in their mothers

#### -Joslin Study Finds Restricting Insulin Doses Increases Mortality Risk {#joslin-study-finds-restricting-insulin-doses-increases-mortality-risk .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Low vitamin B12 in the first trimester and high folate in the second predispose insulin resistance {#low-vitamin-b12-in-the-first-trimester-and-high-folate-in-the-second-predispose-insulin-resistance .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Replacing sugar in diet sodas with reduced calorie sweeteners may make weight control harder {#replacing-sugar-in-diet-sodas-with-reduced-calorie-sweeteners-may-make-weight-control-harder .Style-Heading-4-+-Arial-14-pt-Underline}

**Women's Health Headlines**

-Have the Disparities Between AI/ANs and Caucasians Narrowed?

-Sacred Circle Handouts, Slides, and Training Materials available

###### Save the Dates: Upcoming events of interest page 50

#### What's new on the ITU MCH web pages page 51

[Breastfeeding: US Breastfeeding Committee Strategic
Plan](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/bf.cfm)

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

#  {#section-3 .Style-Heading-1-+-Underline}

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

**High prevalence of HPV infection in American Indian women of the
Northern Plains**

[Objectives]{.underline} Cervical cancer is the leading gynecological
malignancy worldwide, and the incidence of this disease is very high in
American Indian women. Infection with the human papillomavirus (HPV) is
responsible for more than 95% of cervical squamous carcinomas.
Therefore, the main objective of this study was to analyze oncogenic HPV
infections in American Indian women residing in the Northern Plains.

[Methods]{.underline} Cervical samples were collected from 287 women
attending a Northern Plains American Indian reservation outpatient
clinic. DNA was extracted from the cervical samples and HPV-specific DNA
was amplified by polymerase chain reaction (PCR) using the L1 consensus
primer sets. The PCR products were hybridized with the Roche HPV Line
Blot assay for HPV genotyping to detect 27 different low- and high-risk
HPV genotypes. The Chi-squared test was performed for statistical
analysis of the HPV infection and cytology diagnosis data.

[Results]{.underline} Of the total 287 patients, 61 women (21.25%)
tested positive for HPV infection. Among all HPV-positive women, 41
(67.2%) were infected with high-risk HPV types. Of the HPV infected
women, 41% presented with multiple HPV genotypes. Additionally, of the
women

infected with oncogenic HPV types, 20 (48.7%) were infected with HPV16
and 18 and the remaining 21 (51.3%) were infected with other oncogenic
types (i.e., HPV59, 39, 73). Women infected with oncogenic HPV types had
significantly higher (p=0.001) abnormal Papanicolaou

smear tests (Pap test) compared to women who were either HPV negative or
positive for non-oncogenic HPV types. The incidence of HPV infection was
inversely correlated (pb0.05) with the age of the patients, but there
was no correlation (p=0.33) with seasonal variation.

[Conclusions]{.underline} In this study, we observed a high prevalence
of HPV infection in American Indian women residing on Northern Plains
Reservations. In addition, a significant proportion of the oncogenic HPV
infections were other than HPV16 and 18.

[Bell
MC](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Bell MC"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVCitation),
[Schmidt-Grimminger
D](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Schmidt-Grimminger D"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVCitation),
[Patrick
S](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Patrick S"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVCitation),
[Ryschon
T](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Ryschon T"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVCitation),
[Linz
L](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Linz L"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVCitation),
[Chauhan
SC](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Chauhan SC"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVCitation).
There is a high prevalence of human papillomavirus infection in American
Indian women of the Northern Plains. [Gynecol
Oncol.](javascript:AL_get(this, 'jour', 'Gynecol Oncol.');) 2007
Nov;107(2):236-41.

<http://www.ncbi.nlm.nih.gov/pubmed/17659767>

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

**Multiple HPV subtypes in Northern Plains and Alaska Natives: Keep up
screening efforts**

Bell et al's findings of multiple co-infections with high risk HPV
subtypes in American Indian women of the Northern Plains mirrors
Sebbelov's data among Alaska Native women in which multiple genotypes
were found in 36.5% of patients.

Sebbelov's retrospective study examining the HPV genotypes in tissue
specimens from 52 patients diagnosed with cervical cancer from 1980 to
1989, identified HPV type 16 in 79%, type 33 in 32%, type 31 in 21%, and
type 18 in 4%. Infections with multiple genotypes were found in 36.5% of
Alaska Native women, much higher than among Greenland Native patients
(4%) and Danish Caucasian patients (7%) in the study. These finding
suggest that up to 83% of Alaska Native cervical cancers are caused by
the HPV types targeted in the vaccine, although the high prevalence of
multiple high risk genotype infections raises concern for how effective
the currently available HPV vaccine may be in preventing cervical cancer
in this population

A few caveats: both studies are small, and although they found that half
of the women were infected with oncogenic HPV infections other than
HPV16 and 18, the other half were infected with HPV16 and 18, and thus
would have received protection from the current HPV vaccine, Gardasil.
Please do not read Bell et al and Sebbelov et al and then decide that
there is no benefit in providing the current vaccine to AI/AN women in
the Northern Plains or Alaska Natives.

Please realize that significant protection can be provided by the
vaccine. Our goal as providers should be to educate women about the need
to continue to receive regular screenings is also important, even if
they receive the quadravalent vaccine.

Sebbelov AM, D.M., Krüger Kjaer S, Jensen H, Gregoire L, Hawkins I,
Parkinson AJ, Norrild B., Comparison of human papillomavirus genotypes
in archival cervical cancer specimens from Alaska natives, Greenland
natives and Danish Caucasians. Microbes Infect, 2000. 2(2): p. 121-6.

<http://www.ncbi.nlm.nih.gov/pubmed/10742684>

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

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

#### Current management of gestational diabetes mellitus {#current-management-of-gestational-diabetes-mellitus-1 .Style-Heading-4-+-Arial-14-pt-Underline}

Diabetes mellitus is one of the most common medical complications of
pregnancy; gestational diabetes mellitus (GDM) accounts for
approximately 90-95% of all cases. GDM is defined as carbohydrate
intolerance of variable severity with onset or first recognition during
pregnancy. It has been demonstrated that good metabolic control
maintained throughout pregnancy can reduce maternal and fetal
complications in diabetes. Diet is the mainstay of treatment in GDM, but
physical activity is a helpful adjunctive therapy when euglycemia is not
achieved by diet alone. When diet and exercise fail to maintain
euglycemia, exogenous insulin is used and the new insulin currently
available on the market may help. Traditionally, insulin therapy has
been considered the gold standard for management. The American College
of Obstetricians and Gynecologists and the American Diabetes Association
do not currently recommend oral hypoglycemic agents as a treatment for
GDM. Concerns regarding safety demand further well-designed studies.

This accompanying sidebar summarizes the key issues in this excellent
review article:

-   Gestational diabetes mellitus (GDM) is one of the most common
    medical complications of pregnancy (5-10%) and has short- and
    long-term implications for both mother and child.

-   Diet is the mainstay of treatment in GDM; physical activity could be
    a helpful adjunctive therapy when euglycemia is not achieved by diet
    alone.

-   Exogenous insulin is used when diet and exercise fail to maintain
    euglycemia. Some recently developed insulin analogues, like aspart
    and lispro, may be considered a valuable treatment option in
    patients with GDM.

-   Oral hypoglycemic agents are not currently recommended as a
    treatment for GDM.

-   There are no indications to pursue delivery before 40 weeks of
    gestation in patients with good glycemic control, unless other
    maternal or fetal indications are present.

-   For insulin-treated GDM patients there is no universal
    recommendation to labor induction at approximately 38-39 weeks.

-   Patients with diet-controlled diabetes will not require intrapartum
    insulin or monitoring of blood glucose levels.

-   Patients with insulin-requiring diabetes need intrapartum capillary
    hourly monitoring of blood glucose levels and maintaining glycemic
    values between 80 and 110 mg/dl during labor.

-   Postpartum periodic glucose tolerance tests need to previously
    identify glucose abnormalities and, consequently, to begin
    strategies for the prevention of diabetes.

The article also cautions against the use of ultra-long acting insulin
until further studies are done and suggests that the use of glyburide or
metformin is unlikely to be harmful.

Guido Menato; Simona Bo; Anna Signorile; Marie-Laure Gallo; Ilenia
Cotrino; Chiara Botto Poala; Marco Massobrio Current Management of
Gestational Diabetes Mellitus Expert Rev of Obstet Gynecol.
 2008;3(1):73-91.  <http://www.medscape.com/viewarticle/568728>

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

#### David Gahn, Tahlequah {#david-gahn-tahlequah .Style-Heading-4-+-Arial-14-pt-Underline}

**Afghanistan Update**

On January 12^th^, 2007, and Indian Health Service team deployed to
Kabul, Afghanistan as part of the HHS Afghanistan Health Initiative. Dr.
Pat O'Connor, MD (Pediatrics, Tuba City, AZ), Dr. Brandon Taylor, Pharm.
D. (Tahlequah), and I endured 6 weeks of a brutal Afghanistan winter
working at Rabia Balkhi Women's Hospital (RBH).

We encountered what we expected -- a hospital staff overwhelmed with
pathology in the face of lack of supplies and training. We all tackled
our problem lists and worked on providing sustainable training, bedside
teaching, and making recommendations to the Office of Global Health
Affairs (OGHA) and the Centers for Disease Control and Prevention (CDC)
on equipment needs, staffing, and training while providing
epidemiological data on the patients.

Two non-governmental organizations (NGO's) are currently working at RBH
under cooperative agreements with HHS. International Medical Corps is
focused on providing training to the hospital staff is general areas
(i.e. infection prevention) as well as specific clinical training to
physicians, nurse midwives, laboratory personnel, et al. Cure
International is responsible for developing the administration of RBH as
well as the supply chain issues. The NGO's are experts at what they do
and, partnering with OGHA, CDC and IHS, they have made a significant
impact on the morbidity and mortality occurring at RBH.

Dr. O'Connor, Dr. Taylor, and I spent a majority of our time at the
bedside with the physicians and pharmacists conducting clinical teaching
and modeling the team approach to patient care. As I mentioned in a
previous article, RBH houses an Ob/Gyn residency training program. The
residents lack a strong foundation in basic sciences, but have superb
clinical skills due mainly to the amount of pathology that presents to
the hospital. The focus of the project is developing the residency
training program, but naturally that involves the entire hospital from
housekeeping to the blood bank. Each system presents challenges for
improvement, but the hospital staff is eager to move forward.

In January 2008, OGHA and IHS entered into an interagency agreement to
allow for IHS clinicians to deploy to Kabul. Money has been identified
by OGHA to reimburse individual service units through IHS headquarters.
I have been assigned to work on the project full time, and we are
assembling another team to deploy in June 2008 to continue the work. We
are currently searching for an Ob/Gyn physician to deploy for four
weeks, and have identified potential candidates in anesthesia,
pediatrics, and an operating room nurse.

If you are interested in the project or have any questions, please
contact <david.gahn@IHS.gov>. The work is exciting, incredibly
rewarding, and very challenging.

**Scott Giberson, HQE**

**Women and HIV**

Please review this 2 part series which is very well referenced as well
as presenting classic artworks involving women through the ages. It is
important to remember that although IHS/AIDS is a medical condition,
women with addictions, depression and other mental illnesses, and most
especially, women struggling with violence in their lives or who have
been victims of violence as children are at greater risk of HIV/AIDS
infection. 

Part 1

<http://www.hivandhepatitis.com/recent/women/womenandhiv/WomenHIV_part_1.pdf>

Part 2

<http://www.hivandhepatitis.com/recent/women/womenandhiv/WomenHIV_part_2a.pdf>

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

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

**Cesarean delivery during nursing change of shift is associated with
increased complications**

RESULTS: Physician change of shift had no measurable effect on maternal
and neonatal outcomes. Neonatal facial nerve palsies were increased at
nursing change of shift (5 vs 0) as were hysterectomies (33 \[0.24%\] vs
23 \[0.53%\]; *P* \_ .007). Nursing change of shift had no impact on
composite maternal morbidity after controlling for age, race, insurance,
medical problems,

prior incision type, weekend day, and prenatal care (odds ratio \_ 0.98;
95% confidence interval \_ 0.89-1.08).

CONCLUSION: Physician change of shift does not appear to be associated
with an increase in morbidities. However, cesarean delivery during
nursing change of shift is associated with increased risk of neonatal
facial nerve palsy and hysterectomy. Further investigation is needed

to understand the cause of this association.

Bailit JL, Landon MB, Lai Y, et al; for the National Institute of Child
Health and Human Development Maternal-Fetal Medicine Units Network.
Maternal-Fetal Medicine Units Network Cesarean Registry: impact of shift
change on cesarean complications. Am J Obstet Gynecol
2008;198:173.e1-173 <http://www.ncbi.nlm.nih.gov/pubmed/18226616>

**No benefit in treating women with average-risk pregnancies for
asymptomatic bacterial vaginosis**

CONCLUSION: No benefit was found in treating women with low- or
average-risk pregnancies for asymptomatic bacterial vaginosis. More
research is needed to better understand these groups and the conditions
under which treatment can be harmful or helpful, and to explore the
relevance of bacterial vaginosis to other adverse pregnancy outcomes,
such as delivery before 34 weeks.

[Nygren
P](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Nygren P"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus),
[Fu
R](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Fu R"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus)
et al Evidence on the benefits and harms of screening and treating
pregnant women who are asymptomatic for bacterial vaginosis: an update
review for the U.S. Preventive Services Task Force. Ann Intern Med. 2008
Feb 5;148(3):220-33 <http://www.ncbi.nlm.nih.gov/pubmed/18252684>

**Further risks highlighted for obese pregnant women**

Obese women were found to have an increased risk of 165% compared with
non-obese women for thromboembolic disease.

CONCLUSIONS: Significant severe morbidity from thromboembolic disease
underlies the maternal deaths from pulmonary embolism in the UK. This
study has shown some cases where thromboprophylaxis was not provided
according to national guidelines, and there may be scope for further
work on guideline implementation.

Knight M on behalf of UKOSS. Antenatal pulmonary embolism: risk factors,
management and outcomes BJOG. 2008 Mar;115(4):453-61.
<http://www.ncbi.nlm.nih.gov/pubmed/18201281>

**Early maternal feeding following CD is associated with higher maternal
satisfaction**

METHODS: A prospective, randomised study was designed including 179
women undergoing first or repeated CD. Women who were assigned to the
early feeding group received clear fluids and solid food within 8 h of
surgery, in accordance with their request. The traditionally fed women
received clear fluids 8-12 h after the surgery subsequent to physician
examination confirming bowel sounds. RESULTS: Some 82 women were
assigned to the traditionally fed group and 97 women were assigned to
the early fed group. Maternal satisfaction was significantly higher
among the early fed women. No significant differences were noted between
the groups regarding post-operative complications. CONCLUSIONS: Early
maternal feeding following CD is associated with higher maternal
satisfaction. However, it is not associated with higher rates of
post-operative complications.

[Bar
G](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Bar G"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus),
et al Early maternal feeding following caesarean delivery: a prospective
randomised study.

Acta Obstet Gynecol Scand. 2008;87(1):68-71.
<http://www.ncbi.nlm.nih.gov/pubmed/18158630>

**Physical abuse during pregnancy present a large increase in the risk
of preterm delivery**

CONCLUSION: Women who have had physical abuse during pregnancy present a
large increase in the risk of preterm delivery, independently from a
large set of sociodemographic and behavioral characteristics usually
recognized as determinants of preterm birth.

[Rodrigues
T](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Rodrigues T"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus)
et al Physical abuse during pregnancy and preterm delivery. Am J Obstet
Gynecol. 2008 Feb;198(2):171.e1-6.
<http://www.ncbi.nlm.nih.gov/pubmed/17905171>

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

**Co-Occurrence of Pelvic Floor Disorders May Be High in Women **

METHODS: Stress urinary incontinence (SUI), overactive bladder (OAB),
pelvic organ prolapse (POP), and anal incontinence were assessed using a
validated questionnaire among 25- to 84-year-old women.

CONCLUSION: Although the prevalence of pelvic floor disorders in a
community-dwelling population is high, age was not a significant
contributor after adjustment for confounders. The high co-occurrence of
pelvic floor disorders suggests that physicians seeing women seeking
care for one condition should inquire about symptoms of other disorders.
LEVEL OF EVIDENCE: II.

[Lawrence
JM](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Lawrence JM"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus)
et al Prevalence and Co-Occurrence of Pelvic Floor Disorders in
Community-Dwelling Women. Obstet Gynecol. 2008 Mar;111(3):678-685.

<http://www.ncbi.nlm.nih.gov/pubmed/18310371>

**The Evolution of Midurethral Slings **

Use of urethral slings in the treatment of incontinence started in the
early 20(th) century. An evolution in understanding the pathogenesis of
urinary incontinence led to development of the midurethral sling, which
was designed to replace the natural suburethral vectors of support, as
described in the integral theory. Since the introduction of tension-free
vaginal tape in 1995, multiple other commercially available types of
midurethral sling have been introduced. In general, these sling types
share the common characteristics of using a thin, type I synthetic mesh
inserted at a midurethral level and applied without tension. The
midurethral sling procedure has subsequently undergone multiple
technical modifications, predominantly alterations to the technique and
route used for sling insertion. Despite the variety in techniques,
available evidence suggests that all sling types provide efficacious and
durable outcomes. Several adverse effects have been reported that are
specific to certain techniques, and include the risk of vascular,
enteric or nerve injury, lower urinary tract injury, urinary retention
or voiding dysfunction, and vaginal erosion. Nonetheless, the
midurethral sling provides a safe surgical option overall, and
represents a notable advance in the treatment of stress urinary
incontinence

[Rapp
DE](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Rapp DE"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus)
et al The evolution of midurethral slings. Nat Clin Pract Urol. 2008 Mar
4;

<http://www.ncbi.nlm.nih.gov/pubmed/18317496>

**Acupuncture in dysmenorrhea associated with improved quality of life
plus cost-effective**

CONCLUSION: Additional acupuncture in patients with dysmenorrhea was
associated with improvements in pain and quality of life as compared to
treatment with usual care alone and was cost-effective within usual
thresholds

[Witt
CM](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Witt CM"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus)
et al Acupuncture in patients with dysmenorrhea: a randomized study on
clinical effectiveness and cost-effectiveness in usual care. Am J Obstet
Gynecol. 2008 Feb;198(2):166

<http://www.ncbi.nlm.nih.gov/pubmed/18226614>

**Uterine Artery Embolization a Good Alternative to Hysterectomy for
Fibroids **

CONCLUSION: Both UAE and hysterectomy improved HRQOL. No differences
were observed between groups regarding HRQOL at 24-month follow-up. On
the basis of HRQOL results, the authors determined that UAE is a good
alternative to hysterectomy. (c) RSNA, 2008. [Hehenkamp
WJ](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Hehenkamp WJ"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus)
et al Symptomatic uterine fibroids: treatment with uterine artery
embolization or hysterectomy\--results from the randomized clinical
Embolisation versus Hysterectomy (EMMY) Trial. Radiology. 2008
Mar;246(3):823-32. <http://www.ncbi.nlm.nih.gov/pubmed/18187401>

**Overactive Bladder: Diagnosis and Treatment in Primary Care**

<http://www.medscape.com/viewprogram/8987?src=nlcmealert&spon=16&uac=77433SY>

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

**Maternal grandmothers' alcohol use linked to FAS in the Northern
Plains**

Introduction: Characteristics of Northern Plains American Indian
maternal grandmothers who had grandchildren with fetal alcohol syndrome
(FAS) or incomplete FAS are described to more effectively prevent fetal
FAS and alcohol use during pregnancy.

Methods: Study 1 had 27 maternal grandmothers who had grandchildren with
FAS and Study 2 had 18 grandmothers with grandchildren who had
incomplete FAS (cases) which were compared with 119 maternal
grandmothers who had grandchildren without FAS (controls). The
grandchildren were born between 1981 and 1993 on the Northern Plains.
Medical records were manually reviewed for each case and control
grandmother. Data were analyzed using Mantel--Haenszel chi square.

Results: Study 1 case grandmothers were more likely to experience
medical problems (70.4%) including trauma (48.1%) and injuries (51.9%)
than the controls. Most of the Study 1 and 2 case grandmothers (92.6%
and 77.8%, respectively) had alcohol use documented in their medical
records compared to less than half of the control grandmothers. Seven
(15.6%) of the case grandmothers had more than one grandchild in either
Study 1 or Study 2.

Conclusion: Maternal grandmothers who had grandchildren with FAS had
significantly higher rates of alcohol use and alcohol-related medical
problems than control grandmothers. Antenatal care providers should
screen pregnant women for alcohol use at their first visit. The provider

needs to ask the women who are using alcohol about their mothers' use of
alcohol to provide appropriate care and counseling for the women and
prevent FAS.

[Kvigne
VL](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Kvigne VL"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVCitation),
[Leonardson
GR](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Leonardson GR"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVCitation),
[Borzelleca
J](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Borzelleca J"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVCitation),
[Welty
TK](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Welty TK"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVCitation).
Characteristics of Grandmothers who have Grandchildren with Fetal
Alcohol Syndrome or Incomplete Fetal Alcohol Syndrome. [Matern Child
Health J.](javascript:AL_get(this, 'jour', 'Matern Child Health J.');)
2008 Jan 15 <http://www.ncbi.nlm.nih.gov/pubmed/17659767>

**[Comments from the authors:]{.underline}**

**When a child is diagnosed with FAS the mother should be evaluated for
a FASD**

Over a decade ago we conducted a case control study of children with FAS
and incomplete FAS in northern Plains Indian communities.  The recently
published report of grandmothers of the case children indicates a
familial pattern of alcohol use during pregnancy that we hope will help
with the understanding and prevention of FAS.  The report emphasizes the
importance of screening for substance use at the first antenatal visit
and for interventions to help women who are drinking to stop. 
Evaluation of the family situation is a critical component of promoting
abstinence throughout pregnancy in pregnant women who are drinking.  The
pregnant mom herself may be adversely affected by fetal alcohol exposure
and need considerable support to cope with her social situation. A
multidisciplinary approach to such cases will likely be the most
successful.  Reduction or elimination of fetal alcohol exposure will
give the offspring of such pregnancies the best chance of being
productive citizens in their communities. It seems that that when a
child is diagnosed with Fetal Alcohol Syndrome perhaps the mother needs
to also be evaluated for a Fetal Alcohol Spectrum Disorder.  (Tom Welty,
Valborg Kvigne)

**Pediatricians often do not pursue answers to questions that arise
during medical visits**

<http://www.ahrq.gov/research/mar08/0308RA9.htm>

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

**Low-dose aspirin is linked to lower risk for all-cause mortality in
women, especially older women**

CONCLUSIONS: In women, low to moderate doses of aspirin are associated
with significantly lower risk of all-cause mortality, particularly in
older women and those with cardiac risk factors. A significant benefit
is evident within 5 years for cardiovascular disease, whereas a modest
benefit for cancer is not apparent until after 10 years of use.

[Practice Pearls ]{.underline}

-Women who take low to moderate doses of aspirin (1 - 5 tablets per
week) have lower risk for mortality

from all causes.

-Women who take low to moderate doses of aspirin have lower risk for
mortality from cardiovascular

disease within 5 years and lower risk for mortality from cancer after 10
years. However, current clinical

practice should not be changed yet based on the results from this
observational study.

[Chan
AT](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Chan AT"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus)
et a; Long-term aspirin use and mortality in women. Arch Intern Med.
2007 Mar 26;167(6):562-72. <http://www.ncbi.nlm.nih.gov/pubmed/17389287>

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

#### How is Your Sleep: A Neglected Topic for Health Care Screening {#how-is-your-sleep-a-neglected-topic-for-health-care-screening-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### RESULTS: Direct questions about sleep health are often not included in health history questionnaires. Eight of 14 (57%) database batteries reviewed in this study featured no sleep-related questions. Other lifestyle issues were screened with much greater frequency. For example, questions about healthy eating patterns and regular physical activity were present in 13 and 12 of the 14 batteries (93% and 86%), respectively. CONCLUSIONS: Despite the significant burden that sleep disorders place on human health, this study found that clinics do not screen for them as frequently as they do for other lifestyle/behavioral issues when they establish a health history database for new patients. {#results-direct-questions-about-sleep-health-are-often-not-included-in-health-history-questionnaires.-eight-of-14-57-database-batteries-reviewed-in-this-study-featured-no-sleep-related-questions.-other-lifestyle-issues-were-screened-with-much-greater-frequency.-for-example-questions-about-healthy-eating-patterns-and-regular-physical-activity-were-present-in-13-and-12-of-the-14-batteries-93-and-86-respectively.-conclusions-despite-the-significant-burden-that-sleep-disorders-place-on-human-health-this-study-found-that-clinics-do-not-screen-for-them-as-frequently-as-they-do-for-other-lifestylebehavioral-issues-when-they-establish-a-health-history-database-for-new-patients. .Style-Heading-4-+-Arial-14-pt-Underline}

#### Sorscher AJ. How is Your Sleep: A Neglected Topic for Health Care Screening. J Am Board Fam Med. 2008 Mar-Apr;21(2):141-8. [**http://www.ncbi.nlm.nih.gov/pubmed/18343862?dopt=Abstract**](http://www.ncbi.nlm.nih.gov/pubmed/18343862?dopt=Abstract) {#sorscher-aj.-how-is-your-sleep-a-neglected-topic-for-health-care-screening.-j-am-board-fam-med.-2008-mar-apr212141-8.-httpwww.ncbi.nlm.nih.govpubmed18343862doptabstract .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Pedometer-Based Walking Programs Helpful for Overweight, Sedentary Adults {#pedometer-based-walking-programs-helpful-for-overweight-sedentary-adults-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: Pedometer-based walking programs result in a modest amount of weight loss. Longer programs lead to more weight loss than shorter programs. {#conclusion-pedometer-based-walking-programs-result-in-a-modest-amount-of-weight-loss.-longer-programs-lead-to-more-weight-loss-than-shorter-programs. .Style-Heading-4-+-Arial-14-pt-Underline}

[Richardson
CR](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Richardson CR"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus)
et al A meta-analysis of pedometer-based walking interventions and
weight loss.

Ann Fam Med. 2008 Jan-Feb;6(1):69-77.
<http://www.ncbi.nlm.nih.gov/pubmed/18195317>

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

#### Blood Pressure May Predict Incident Type 2 Diabetes in Healthy Women {#blood-pressure-may-predict-incident-type-2-diabetes-in-healthy-women-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSION: Baseline BP and BP progression are strong and independent predictors of incident type 2 diabetes among initially healthy women. {#conclusion-baseline-bp-and-bp-progression-are-strong-and-independent-predictors-of-incident-type-2-diabetes-among-initially-healthy-women. .Style-Heading-4-+-Arial-14-pt-Underline}

[Conen
D](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Conen D"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus)
et al Blood pressure and risk of developing type 2 diabetes mellitus:
the Women\'s Health Study. Eur Heart J. 2007 Dec;28(23):2937-43. Epub
2007 Oct 9.

#### [**http://www.ncbi.nlm.nih.gov/pubmed/17925342**](http://www.ncbi.nlm.nih.gov/pubmed/17925342) {#httpwww.ncbi.nlm.nih.govpubmed17925342 .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Discussing reconstruction options prior to surgery influences breast cancer treatment choices  {#discussing-reconstruction-options-prior-to-surgery-influences-breast-cancer-treatment-choices-1 .Style-Heading-4-+-Arial-14-pt-Underline}

RESULTS: Only 33% of patients had a general surgeon discuss breast
reconstruction with them during the surgical decision-making process for
their cancer. Surgeons were significantly more likely to have this
discussion with younger, more educated patients with larger tumors.
Knowing about reconstructive options significantly increased patients\'
willingness to consider a mastectomy (OR, 2.06; P \<.01). In addition,
this discussion influenced surgical treatment. Patients who discussed
reconstruction with their general surgeon were 4 times more likely to
receive a mastectomy compared with those who did not (OR, 4.48; P \<
.01).

CONCLUSIONS: Most general surgeons do not discuss reconstruction with
their breast cancer patients before surgical treatment. When it occurs,
this discussion significantly impacts women\'s treatment choice, making
many more likely to choose mastectomy. This highlights the importance of
multidisciplinary care models to facilitate an informed surgical
treatment decision-making process.

[Alderman
AK](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Alderman AK"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus),
[Hawley
ST](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Hawley ST"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus),
[Waljee
J](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Waljee J"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus),
[Mujahid
M](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Mujahid M"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus),
[Morrow
M](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Morrow M"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus),
[Katz
SJ](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Katz SJ"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus).
Understanding the impact of breast reconstruction on the surgical
decision-making process for breast cancer.
[Cancer.](javascript:AL_get(this, 'jour', 'Cancer.');) 2008 Feb
1;112(3):489-94 <http://www.ncbi.nlm.nih.gov/pubmed/18157830>

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

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

**Treatment of Urinary Infections in Nonpregnant Women**

Summary of Recommendations and Conclusions:

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

-   Screening for and treatment of asymptomatic bacteriuria is not
    recommended in nonpregnant, premenopausal women.

-   Resistance rates higher than 15--20% necessitate a change in
    antibiotic class.

-   In all cases of acute pyelonephritis, whether treatment is on an
    inpatient or outpatient basis, 14 days of total antimicrobial
    therapy should be completed.

-   A 3-day antimicrobial regimen is the preferred treatment duration
    for uncomplicated acute bacterial cystitis in women, including women
    aged 65 years and older.

**The following conclusion is based on limited or inconsistent evidence
(Level B):**

-   The initial treatment of a symptomatic lower UTI with pyuria or
    bacteriuria or both does not require a urine culture.

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

-   Beta-lactams, such as first-generation cephalosporins and
    amoxicillin, are less effective in the treatment of acute
    uncomplicated cystitis than those antimicrobials listed in

> Table 1.

-   To diagnose bacteriuria, decreasing the colony count to
    1,000--10,000 bacteria per milliliter in symptomatic patients will
    improve the sensitivity without significantly compromising
    specificity.

ACOG Practice Bulletin No. 91: Treatment of Urinary Tract Infections in
Nonpregnant Women.

Obstet Gynecol. 2008 Mar;111(3):785-94.
<http://www.ncbi.nlm.nih.gov/pubmed/18310389>

**Technologic Advances to Reduce Medication-Related Errors**

ABSTRACT: The Institute of Medicine estimates that up to 7,000
individuals die each year as a result of medication errors. Despite the
significant national attention medical errors are receiving, they
continue to pervade the U.S. health care system. Medication-related
errors consistently rank at the top of all medical errors, accounting
for thousands of deaths annually in the United States. Many new
technologies are available that, when integrated into the various
medication-related processes, can significantly reduce the incidence of
preventable medication errors. Practicing obstetrician--gynecologists
should be familiar with these technologies and the evidence supporting
their use.

ACOG Committee Opinion No. 400: Technologic Advances to Reduce
Medication-Related Errors. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2008
Mar;111(3):795-8. <http://www.ncbi.nlm.nih.gov/pubmed/18310390>

**Relationships With Industry**

ABSTRACT: Although physicians and their professional organizations have
routinely accepted gifts from the health care industry, evidence now
indicates that such gifts may misdirect physicians from their primary
responsibility to act in the best interests of their patients. The
American College of Obstetricians and Gynecologists' Committee on Ethics
offers revised recommendations for relationships with industry.
Physicians should understand the potential for influence when
considering accepting gifts, including those of apparently nominal
value. If any gifts are accepted, they should primarily entail benefit
to patients or be related to the physician's work and should not be of
substantial value. Sample drugs (or vouchers) may be dispensed but
preferably as a full course of therapy on the basis of true need.
Physicians are obligated to seek the most accurate, up-to-date,
evidence-based, and balanced source of information about products.
Neither patient referral nor industry support of institutions should be
contingent on physician use or advocacy of a product. Physicians should
disclose their financial interests to patients and colleagues. Support
from industry for continuing medical education and professional

meetings may be accepted, but subsidies should be disclosed and should
not be accepted directly by physicians. Speakers may receive reasonable
honoraria. Reimbursement for research should not exceed reasonable
direct and indirect costs, and reasonable compensation for subsequent
consulting and lecturing is permissible. Investigators who are or may
become involved in a company's research may not buy or sell its stock
until their involvement ends and the research is published or
disseminated.

ACOG Committee Opinion No. 401: Relationships With Industry. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2008
Mar;111(3):799-804. <http://www.ncbi.nlm.nih.gov/pubmed/18310391>

**Antenatal Corticosteroid Therapy for Fetal Maturation**

ABSTRACT: A single course of corticosteroids is recommended for all
pregnant women between 24 and 34 weeks of gestation who are at risk of
preterm delivery within 7 days. A single course of antenatal
corticosteroids should be administered to women with premature rupture
of membranes (PROM) before 32 weeks of gestation to reduce the risks of
respiratory distress syndrome, perinatal mortality, and other
morbidities. The efficacy of corticosteroid use at 32--33 completed
weeks of gestation for preterm PROM is unclear based on available
evidence, but treatment may be beneficial, particularly if pulmonary
immaturity is documented. No data exist on the efficacy of
corticosteroid use before viability, and such use is not recommended at
this time. Because of insufficient scientific evidence, repeat
corticosteroid courses, including so-called "rescue therapy,"

should not be used routinely but should be reserved for women enrolled
in clinical trials.

ACOG Committee Opinion No. 402: Antenatal Corticosteroid Therapy for
Fetal Maturation. [Obstet
Gynecol.](javascript:AL_get(this, 'jour', 'Obstet Gynecol.');) 2008
Mar;111(3):805-7. <http://www.ncbi.nlm.nih.gov/pubmed/18310392>

**ACOG Supports Effort to Encourage Electronic Prescribing**

As of January 1, 2009 all computer generated prescriptions for Medicare
Part D patients must comply with the NCPDP script standard and thus be
transmitted electronically and not by computer-generated fax. If not,
prescriptions must be printed and then manually faxed -- a time
consuming process. The Medicaid requirement for using tamper resistant
prescription pads, effective October 1, 2008, also allows an exception
for electronic prescribing. It is likely that other state and national
regulations will soon require or encourage electronic prescribing. 

More importantly to most ob/gyns, an electronic connection with
pharmacies can improve the efficiency of a practice and the overall
quality of a patient's prescription information, improving patient care.

 With this in mind, the American College of Obstetricians and
Gynecologists is collaborating with the American Academy of Family
Physicians, the American Academy of Pediatrics, the American College of
Cardiology, the Medical Group Management Association and several other
medical organizations to launch a nationwide program to assist physician
practices with electronic subscribing, called the Get Connected
program.  The heart of the program is the
[www.GetRxConnected.com](http://www.acog.org/cgi-shl/leaving.pl?http://www.getrxconnected.com/)
web portal, which helps assess a practice's readiness for electronic
prescribing, and guides users through the steps that they need to take
to use e-prescribing.

 Many EMR users are unaware that they are generating faxes that arrive
on paper at the pharmacy's fax machine. These computer-generated, faxed
prescriptions will not be in compliance with the new regulations, and
they fail to achieve the patient safety improvements that true
e-prescribing offers.  The
[www.GetRxConnected.com](http://www.acog.org/cgi-shl/leaving.pl?http://www.getrxconnected.com/)
web site will help physicians that currently have EMRs that fax or print
prescriptions, as well as those without EMRs.

 A visit to
[www.GetRxConnected.com](http://www.acog.org/cgi-shl/leaving.pl?http://www.getrxconnected.com/)
can provide you with more detail on these benefits and other valuable
information including:

 ·Information on the benefits of e-prescribing/pharmacy connectivity,
including the business case and social case for e-prescribing.

·An estimate of the value of the time your practice spends annually
managing prescription renewal requests by phone/fax -- time better spent
on patient care, or other reimbursable activity. 

·A listing of pharmacies in your area that can exchange prescription
information with your practice electronically.

·The value of e-prescribing for your patients. 

<http://www.acog.org/departments/dept_notice.cfm?recno=19&bulletin=4479>

#### AFP American Family Physician {#afp-american-family-physician .Style-Heading-4-+-Arial-14-pt-Underline}

**Pharmacologic Management of Adult Depression (Also See Patient
Education)**

Major depression is a common and treatable disease. Many patients
benefit from pharmacologic treatment and, because there is little
variation in antidepressant effectiveness, medication choices should be
made based on patient characteristics, safety, and anticipated side
effects. Most patients respond favorably to treatment, but many do not
have complete symptom relief. Changing medications or augmenting with a
second medication is helpful for some partial or nonresponders. All
antidepressants are capable of producing harmful side effects, and some
are particularly prone to dangerous drug-drug interactions. The risk of
suicide is always a concern in depression and this risk is not
necessarily reduced by the use of antidepressants. Some persons may have
an increase in suicidal thoughts with antidepressant treatment. Close
follow-up is required when initiating therapy and adjusting dosages.

Stephen M. Adams , MD; Karl E. Miller, MD; and Robert G. Zylstra, EdD,
LCSW, Pharmacologic Management of Adult Depression, *Am Fam Physician.*
2008;77(6):785-792, 795-796.

<http://www.aafp.org/afp/20080315/785.html>

**Diagnosis and Treatment of Female Sexual Dysfunction**

Female sexual complaints are common, occurring in approximately 40
percent of women. Decreased desire is the most common complaint. Normal
versus abnormal sexual functioning in women is poorly understood,
although the concept of normal female sexual function continues to
develop. A complete history combined with a physical examination is
warranted for the evaluation of women with sexual complaints or
concerns. Although laboratory evaluation is rarely helpful in guiding
diagnosis or treatment, it may be indicated in women with abnormal
physical examination findings or suspected comorbidities. The PLISSIT
(Permission, Limited Information, Specific Suggestions, Intensive
Therapy) or ALLOW (Ask, Legitimize, Limitations, Open up, Work together)
method can be used to facilitate discussions about sexual concerns and
initiation of treatment. Developments in the treatment of male erectile
dysfunction have led to investigation of pharmacotherapy for the
treatment of female sexual dysfunction. Although sexual therapy and
education (e.g., cognitive behavior therapy, individual and couple
therapy, physiotherapy) form the basis of treatment, there is limited
research demonstrating the benefit of hormonal and nonhormonal drugs.
Testosterone improves sexual function in postmenopausal women with
hypoactive sexual desire disorder, although data on its long-term safety
and effectiveness are lacking. Estrogen improves dyspareunia associated
with vulvovaginal atrophy in postmenopausal women. Phosphodiesterase
inhibitors have been shown to have limited benefit in small subsets of
women with sexual dysfunction.

Am Fam Physician 2008;77(5):635-642.
<http://www.aafp.org/afp/20080301/635.html>

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

**Care quality is not necessarily better with electronic health
records**

Electronic health records (EHR) do not automatically guarantee higher
quality care in medical settings, a new study finds. Researchers from
Harvard and Stanford looked at the effect EHRs had on 17 indicators of
quality, including disease management, antibiotic use, preventive
counseling, screening tests, and drugs prescribed for elderly patients.
They found EHRs improved performance for 2 indicators, worsened
performance for 1, and offered no real advantage for the remaining 14.

Physicians using EHRs scored well in not prescribing sedatives
(benzodiazepines) to depressed patients and avoiding routine urinalyses
at general medical visits. In addition, when researchers limited the
study sample to primary care and heart physicians, those who employed
EHRs more often counseled smokers to quit. Yet, doctors who had EHR
systems didn\'t do as good a job in prescribing medication for patients
with high cholesterol as those who didn\'t use EHR systems, notes
Jeffrey A. Linder, M.D., M.P.H.

Dr. Linder and colleagues used 2003 to 2004 data from more than 50,000
patient records collected by the National Ambulatory Medical Care Survey
of patient visits to U.S. physician practices. Electronic health records
were used in 18 percent of about 1.8 million ambulatory medical visits
during the study period.

The authors note that performance for both groups---with and without
EHRs---was below par, indicating there is room for improvement across
the board. They stress that no one should assume that quality improves
as EHR use widens. Earlier studies conducted by the Agency for
Healthcare Research and Quality, however, found that EHRs can boost the
amount of care that meets with guidelines, improve care through clinical
monitoring, and curtail medical errors.

The authors recommend that physicians adopting EHR systems consider ones
that include clinical decision support and use that feature to improve
care.

This study was funded in part by the Agency for Healthcare Research and
Quality (HS14563 and HS11313).

See \"Electronic health record use and the quality of ambulatory care in
the United States,\" by Dr. Linder, Jun Ma, M.D., R.D., Ph.D., David W.
Bates, M.D., M.Sc., and others, in the July 9, 2007, Archives of
Internal Medicine; pp. 1400-1405.
<http://www.ncbi.nlm.nih.gov/pubmed/17620534>

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

**Seek improvement in record documentation, but be aware of patient
outcomes**

This AHRQ study raises some excellent questions which we should all be
aware of. In the meantime EHR implementation is with us, regardless. It
is incumbent on us to follow patient outcomes closely and be willing to
modify the EHR, or shut it down if patient safety is endangered.

The Primary Care Discussion Forum had a thoughtful discussion on this
topic which is available here:

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

**Patients with diabetes and depression tend to skip self-care behaviors
that would help keep their diabetes in check**

<http://www.ahrq.gov/research/mar08/0308RA13.htm>

**Rural emergency departments have a high rate of medication errors with
the potential to harm children**

<http://www.ahrq.gov/research/mar08/0308RA16.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}

**Women\'s Health Resources**

A new Web resource providing scientists and consumers with the latest
information on significant topics in women\'s health research from
scientific journals and other peer-reviewed sources is now available
through the National Library of Medicine (NLM). The NLM Division of
Specialized Information Services, Office of Outreach and Special
Populations has partnered with the NIH Office of Research on Women\'s
Health (ORWH) to create this one-stop resource.\
\
The 2008 National Institutes of Health (NIH) Research Priorities for
Women\'s Health were used to identify overarching themes, specific
health topics, and research initiatives in women\'s health. Within each
section of the Web site are topics with links to relevant and
authoritative resources and research initiatives for women\'s health.\
\
Women\'s Health Resources from the NLM Web site can be found at:

<http://sis.nlm.nih.gov/outreach/womenshealthoverview.html>

##### Behavioral Health Insights Peter Stuart, IHS Psychiatry Consultant

**School Refusal**

By Elise Fatimi, MD\*

It is estimated that up to 4% of children refuse school because of
anxiety. Ten- to 14-year-olds are especially prone to school refusal.
These children may go on to be less likely to ever marry or have
children, and are at increased risk for future anxiety disorders and
depression. Because anxiety is strongly hereditary, a parent may be too
fearful to set firm limits in the face of their child's panic. With each
day's unexcused absence it grows harder to reestablish regular school
attendance.

Sometimes the goal of returning to full attendance is abandoned, and a
child may be home-schooled, or provided home-based instruction by the
school. This may maintain academic achievement, but social confidence
and age-appropriate friendships often suffer. It takes a strong
commitment of time and social networking for a parent to engage with
other home-schooling families. For working parents, or those with
anxiety problems of their own, this is a tall order.

A child who refuses school may have a real illness or a good reason to
worry (e.g. a depressed parent, a bully in the playground). But when
these have been ruled out with reasonable confidence, explore for
anxiety symptoms. Have other separations been difficult? Is the child a
'worrier'? Have there been past attempts at school refusal after holiday
breaks or illnesses? Is there a family history of anxiety?

There are many "flavors" of anxiety. Children who refuse school may have
Separation Anxiety Disorder. A child may also have Generalized Anxiety
Disorder, with worries about illness, worst-case scenarios, or far-off
events, and physical symptoms such as headaches and stomachaches. In
Social Anxiety Disorder, children are fearful of embarrassment,
scrutiny, or interacting with unfamiliar people.

I consider school refusal to be a genuine psychiatric emergency, much
like heavy bleeding. A child's confidence in his ability to "make it"
is, in a sense, hemorrhaging. Time is of the essence. Here are some
elements of an effective treatment plan:

1.  ***Educate the whole family***. Explain clearly that the goal is a
    return to full attendance, but that you will work hard to make this
    tolerable. Avoid bargaining ("let's wait until after Spring break,
    it's only another week") or granting of retroactive medical excuses.
    Get permission to contact school staff. Refer for therapy as needed
    to develop and follow a plan for reintroduction to school- children
    with more severe problems may start with a class period and increase
    steadily to a full day.

2.  ***Work with school staff***. Most principals will allow a child to
    use a 'time-out' in the nurse's office is he/she is too upset to
    stay in class. Ask the nurse not to send the child home before the
    agreed time unless there is objective evidence of illness. Devise a
    specific strategy for morning drop off at school. Parents should
    keep goodbyes brief. Avoid parent-child phone contact during the
    school day, as it tends to exacerbate anxiety.

> 3\. ***Medication may be indicated*** when a child is severely
> anxious. Short-term use of benzodiazepines (e.g. clonazepam at bedtime
> before a school day) can help with anticipatory anxiety and insomnia.
> If the child is sleepy in the morning, reassure parents and teachers
> that "asleep at school is better than awake at home" at the start of
> treatment. Ongoing treatment of anxiety disorders is best achieved
> with SSRI medications (e.g. fluoxetine, sertraline). Self-injurious or
> aggressive behavior may (rarely) require inpatient management.

Most children can resume full school attendance within days to weeks,
and many seem to forget the episode in a little while. In overcoming
this challenge, the whole family will build confidence and skills for
the future.

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

Here's a link to the American Academy of Child and Adolescent Psychiatry
that has information on this topic as well as a large range of other
psychosocial/mental health related ones:

<http://www.aacap.org/cs/root/facts_for_families/children_who_wont_go_to_school_separation_anxiety>

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

\*This month's column is provided by Elise Fatimi, MD, a child and
adolescent psychiatrist with long experience in IHS in the Southwest.
She currently presides over the Greater Phoenix Chapter of the Academy
of Child and Adolescent Psychiatry. She mixes clinical acumen and
patient advocacy exceedingly well.

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

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

**What makes a good idea work?**

The concept of supporting breastfeeding is agreeable to most of us. The
immunological impact and long term health benefits for both mom and baby
make breastfeeding a sound and reasonable behavior to encourage.
However, when the findings that breastfeeding can also significantly
reduce risk of obesity/overweight and type 2 diabetes are added to the
rationale, supporting breastfeeding becomes important tool in tackling a
daunting and far reaching public health problem.

So, what will increase initiation and duration?

Baby Friendly Hospital Initiative, (USA) and Baby Friendly, UNICEF/WHO
have similar steps that promote breastfeeding perinatally. Generally
they are:

1.  Maintain a written, well-communicated hospital breastfeeding policy.

2.  Train clinical staff to effectively implement policy.

3.  Inform all pregnant women about benefits and management of
    breastfeeding.

4.  Help mother initiate breastfeeding ½ hour (UNICEF/WHO)/1 hour (USA)
    after birth.

5.  Show mothers how to continue breastfeeding, even if they are
    separated from their babies.

6.  Do not supplement babies unless medically indicated.

7.  Practice rooming in -- mother and infants remain together 24
    hours/day.

8.  Encourage unrestricted breastfeeding.

9.  Give no pacifiers or artificial nipples to breastfeeding infants

10. Foster the establishment of breastfeeding support groups and refer
    mothers to them at discharge.

Research indicates that when the steps are implemented, breastfeeding
initiation can increase by as much as 400%. Federal agencies surveyed
women who planned to breastfeed and experienced five of the ten steps --
early breastfeeding initiation (step 4), no supplementation unless
medically indicated (step 6), rooming in (step 7), unrestricted
breastfeeding encouraged (step) 8, and no pacifiers or artificial
nipples used (step 9). Families who did not experience any of the steps
were 8 times more likely to stop breastfeeding before 6 weeks. The more
steps experienced, the more likely the family was to continue
breastfeeding to 6 weeks and beyond. The strongest risk factors for
stopping breastfeeding early were late breastfeeding initiation (missing
step 4) and supplementing the baby (missing step 6). For more
information, please see DiGirolamo AM, LM Grummer-Strawn, S Fein. 2001.
Maternity care practices: implications for breastfeeding. Birth
28:94-100.

National goals help support breastfeeding. Watch for upcoming
information about Healthy People 2020 goals that enlist the community at
large. New points of focus include:

Increasing the number of:

-   Women who take family medical leave

-   Employers with workplace lactation programs

-   Baby Friendly hospitals

-   Mothers who see lactation consultants in hospital

-   Maternity staff receiving 18 hours of lactation training

-   Mothers seen by appropriately trained lactation care providers post
    discharge

-   Third party payers and employers who cover lactation care and
    services

-   Number of hospitals that make donor human milk available

And reducing the number of breastfed neonates receiving supplemental
formula that is not medically indicated.

Supporting breastfeeding is sometimes about a paradigm shift -- big and
little changes that may not be easy. It is also about education and
choice. For our families it is about improving wellness now and later.
[www.babyfriendlyusa.org](http://www.babyfriendlyusa.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}

#### March 2008 highlights include {#march-2008-highlights-include .Style-Heading-4-+-Arial-14-pt-Underline}

\-[Minorities underrepresented in umbilical cord blood
banking](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08aom)

\-[HPV brochure for AI/AN: available for broad
dissemination](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08col)

\-[Evidence Favors Late Cord Clamping in
Infants](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ht#ob)

\-[Biofeedback Reduces Psychological Burden in Older Women With Urge
Incontinence](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ht#gyn)

\-[Sex education: Providers need to fill gaps in adolescent
knowledge](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ht#child)

\-[Diuretics most effective blood pressure medicine for people with
metabolic
syndrome](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ht#chrIll)

\-[Fatigue and Patient
Safety](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#acog)

\-[Treating Eating Disorders in
Primary](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#afp)

\-[PTSD: A technique that works for
me](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#bhi)

\-[Report cites high rate of violence against Native
women](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#dv)

\-[Exciting opportunity to develop new resources in
geriatrics](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#ecn)

\-[Ringing Endorsement: Women Prefer Contraceptive Ring Over
Patch](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#fp)

\-[Meeting notes now online: 2007 Native Women's Health and MCH
Conference](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#fws)

\-[How can we actually reduce infant mortality in
AI/AN?](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#faq)

\-[Good intentions and unintended
consequences](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#ih)

\-[Maternal depression as a risk factor affecting child readiness and
school
readiness](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#alert)

\-[Findings from the National Survey of Children\'s Health includes
Native
Americans](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#mchh)

\-[St. John\'s wort for depression in a young woman: The
Answers](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#mmt)

\-[Perineal warm packs reduce 3rd and 4th degree lacerations, pain,
urinary
incontinence](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#midw)

\-[Adnexal Masses during
Pregnancy](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#navajo)

\-[Integrating Nursing and Behavioral
Health](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#nCrnr)

\-[SSRI Use and Bone Loss in Older
Women](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#ost)

\-[Assuring Quality Care for People With Limited Health
Literacy](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#pi)

\-[Usefulness of middle cerebral artery Doppler of the fetus at risk for
anemia](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#peri)

\-[Mental health issues in children and adolescents --Starts March
3rd](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#pcf)

\-[Diabetes A Stronger Risk Factor For Death In Women than In
Men](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#still)

\-[Women and
HIV/AIDS](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08ft#whh)

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/documents/CCCC_v6_03.pdf**](http://www.ihs.gov/MedicalPrograms/MCH/M/documents/CCCC_v6_03.pdf) {#httpwww.ihs.govmedicalprogramsmchmdocumentscccc_v6_03.pdf .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-12 .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-13 .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Teen dating violence: 3 articles**

**Teens, dating violence, and media use**

Dating violence is highly prevalent among adolescents. Of importance,
dating violence has been associated with negative physical and mental
health outcomes for teens and high-risk behaviors such as unsafe sex
practices. Although a growing body of research has examined the extent
and nature of this problem, little research has considered aspects of
the media that might be associated with risk for teen dating violence,
such as time spent using media and effects of media content. This
article provides an overview of the prevalence of teen dating violence,
describes the potential for assessing media use as a risk factor, offers
a conceptual model, and suggests ideas for future research.

[Manganello
JA](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Manganello JA"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus).
Teens, dating violence, and media use: a review of the literature and
conceptual model for future research. Trauma Violence Abuse. 2008
Jan;9(1):3-18. <http://www.ncbi.nlm.nih.gov/pubmed/18182628>

**Linking dating violence, peer violence, and suicidal behaviors among
high-risk youth**

CONCLUSIONS: There is a substantial overlap among different forms of
violent behavior, suggesting that additional research is needed to
better understand the factors that contribute to involvement in multiple
forms of violence.

[Swahn
MH](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Swahn MH"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus)
et al Linking dating violence, peer violence, and suicidal behaviors
among high-risk youth. Am J Prev Med. 2008 Jan;34(1):30-8.
<http://www.ncbi.nlm.nih.gov/pubmed/18083448>

**Non-condom use among young adolescent male perpetrators of dating
violence**

These results indicate that non-use of condoms is occurring among
adolescent male perpetrators of dating violence, particularly in the
context of their steady relationships and despite reports of very high
risk sexual activity including sexual infidelity, involvement in
\'trains\' and multiple sex partners. Sexual health interventions
integrated with dating violence and sexual assault prevention efforts
and tailored to adolescents are needed.

[Raj
A](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Raj A"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus)
et al Contexts of condom use and non-condom use among young adolescent
male perpetrators of dating violence. AIDS Care. 2007 Sep;19(8):970-3.
<http://www.ncbi.nlm.nih.gov/pubmed/17851992>

**Domestic Violence Resources**

Two domestic violence resources have been forwarded by Carolyn Aoyama.
For the first one, open the link below then scroll down to the DV
section:

<http://www.cdc.gov/ncipc/pub-res/pubs.htm>

One link of particular use is
<http://www.cdc.gov/ncipc/dvp/IPV/ipv-SViolence.htm>

This manual surveys several different screening tools for use by
healthcare providers.

The second link is: <http://www.chooserespect.org/scripts/index.asp>

Also please note, The Surgeon General's Women\'s Mental Health Workshop
Report has been posted to the SG\'s website: 
<http://www.surgeongeneral.gov/topics/womensmentalhealth/>

**American Psychological Association's Violence Summit**

I am passing the following web addresses to you courtesy of Rose Weahkee
from the American Psychological Association's Violence Summit.

Click on the first site from CDC and scroll down to violence for info on
DV.

<http://www.cdc.gov/ncipc/pub-res/pubs.htm>

This is a successful CDC resource called "Choose Respect" which also
provides useful information.

<http://www.chooserespect.org/scripts/index.asp>

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

#### (From Carolyn Aoyama [**Carolyn.Aoyama@ihs.gov**](mailto:Carolyn.Aoyama@ihs.gov) ) {#from-carolyn-aoyama-carolyn.aoyamaihs.gov .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Elder Care News Bruce Finke, Elder Care Initiative {#elder-care-news-bruce-finke-elder-care-initiative .Style-Heading-4-+-Arial-14-pt-Underline}

**Training in Palliative and End of Life Care**

-   April 22-24, 2008

-   Flagstaff, AZ

-   Contact Tim Domer, MD <tim.domer@ihs.gov>

**Few nursing home residents receive medications and supplements for
osteoporosis**

<http://www.ahrq.gov/research/mar08/0308RA10.htm>

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

#### Increasing contraceptive use and adherence in adolescents

#### Tony Ogburn MD presented a lecture at the [2007 Native Women's Health and MCH Conference](http://www.ihs.gov/MedicalPrograms/MCH/F/lecNotes.cfm#wHealthConf%23wHealthConf) entitled '[Contraception for teens: What's new?](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/Ogburn - Contraception-adolescents IHS 8-07.ppt)' which can be found at the link below. 

#### The lecture notes are posted in alphabetical order

<http://www.ihs.gov/MedicalPrograms/MCH/F/lecNotes.cfm#wHealthConf>

In addition, below is an excerpt from the UpToDate discussion entitled
'**Issues concerning the use of hormonal contraception by adolescents**'
for which the link is available at the end of this posting. Please refer
to the full chapter for complete details.

**Background**

#### Oral contraceptive pills (OCPs) are the most popular prescriptive contraceptive method used by adolescents (44 percent), followed by condoms (37 percent), and depot [medroxyprogesterone acetate](http://www.uptodateonline.com/utd/content/topic.do?topicKey=ped_drug/109186&drug=true) (DMPA) (10 percent).

#### Although a variety of hormonal contraceptive methods are available, this discussion will focus on those commonly used by adolescents: OCPs and DMPA. In addition, the transdermal patch will be discussed since it appears to be increasing in popularity among adolescents. Use of the vaginal ring is increasing among older adolescents who are comfortable inserting it. There also appears to be an emerging interest in the intrauterine device by some practitioners.

#### Emergency contraception, which is discussed in detail separately, is available by prescription and should be mentioned to all sexually active adolescents.

#### Motivating factors --- The sexually active adolescent is more likely to seek contraception in the following situations:

#### -Perceiving pregnancy as a negative outcome 

#### -Having long-term educational goals 

#### -Being of older age 

#### -Experiencing a pregnancy scare or actual pregnancy 

#### -Having family, friends, and/or a clinician who sanction the use of contraception 

#### 

#### Adolescents are more likely to use condoms if they understand condoms can prevent HIV/AIDS, if they carry condoms and are not embarrassed to use them, and if they are worried about getting AIDS.

#### Initiating contraception --- Adolescents vary in their readiness to initiate contraception. From a developmental perspective, sexually active girls in early adolescence have difficulty planning events and activities; they often live for the moment. Therefore, implementing a contraceptive method that requires planning and forethought is difficult at this age without monitoring and adult support. Girls in middle and late adolescence are more capable of higher-level planning, decision making, and problem solving, skills essential to effective contraceptive behavior.

#### Education --- Several points should be discussed at the time of initiating a contraceptive:

#### Selecting the best method 

#### Risk of side effects 

#### Tips on adherence 

#### Use of condoms to protect against STIs 

#### Practical suggestions to promote use, such as keeping condoms in a purse 

#### The availability of and indications for emergency contraception 

#### Sometimes an adolescent is sexually active and does not desire a pregnancy but is undecided about starting a method. In these cases, the discussion should raise her awareness of her risk of pregnancy and STIs. Reviewing stories of her sister(s), friends, or peers at school who are teen mothers may be helpful. Girls who are not engaging in sexual activity also should be educated about the use of condoms and emergency contraception, in case their status changes. 

#### Selecting the best method --- A careful history should be obtained prior to beginning the counseling process. This step will help the clinician facilitate counseling regarding any possible absolute or relative contraindications to starting an estrogen-progesterone product. 

####  

#### Anticipated adverse effects --- The anticipated side effects from hormonal contraception should be reviewed. Breakthrough bleeding or amenorrhea from OCPs, DMPA, and the transdermal patch can be very upsetting. These methods are likely to be discontinued unless the adolescent has been counseled about potential problems and their treatment. As an example, in one study of women treated with DMPA, women who were told about the possibility of amenorrhea were 2.5 times more likely to continue DMPA than those not given this information.

####  

#### A rash and itching at the application site may be of concern to adolescents using the transdermal patch. Partial or complete detachment of the transdermal patch was reported in 35 percent of adolescents in one study, compared with less than 5 percent in adults. Of note, no detachments were reported when the patch was worn on the arm. The likely explanation may be inadequate care in application and increased activity among teenagers compared with adults.

#### Noncontraceptive benefits --- Reviewing the noncontraceptive benefits of OCPs, DMPA, and the transdermal patch with adolescents also is important. Benefits of OCPs and the transdermal patch include improved bone density and protection against ovarian cancer, endometrial cancer, salpingitis, ectopic pregnancy, benign breast disease, dysmenorrhea, and iron deficiency. The same benefits, with the exception of improved bone density, are provided by DMPA. 

#### 

#### Informed consent --- Although it is not necessary to obtain written informed consent before the initiation of hormonal contraception in adolescents, the use of a structured informed consent form can ensure that the risks and benefits are adequately discussed. The form used by Texas Children\'s Hospital for combination hormonal contraceptives is an example.

#### Barriers to use and adherence --- Barriers to the use of hormonal contraception by adolescents include fear of side effects, some of which are not substantiated by evidence.

#### Fear of side effects --- A fear of side effects from OCPs and DMPA injections is a common barrier to the use of hormonal methods. As an example, in one review, adolescents in a private practice setting were overwhelmingly more concerned about weight gain from OCPs and those in an urban hospital-based adolescent clinic were concerned about weight gain, blood clots, birth defects, and infertility .

#### Weight gain --- Many adolescents are concerned that oral contraceptives cause weight gain. However, available data suggest this is not the case. In the review described above, adolescents who did not adhere to their OCPs were more likely to feel they had gained weight, although actual weight often was unchanged . Most young women did not gain more than 2.3 kg while using OCPs or 3.6 kg while using DMPA during a two-year period. 

#### In another study, the effect of OCP use on body weight and fat distribution was assessed in 49 healthy young women initiating treatment with a low-dose OCPs (30 microgram ethinyl [estradiol](http://www.uptodateonline.com/utd/content/topic.do?topicKey=ped_drug/70684&drug=true) plus 75 microgram gestodene); anthropometric measurements before and after the initiation of OCP use were compared with those in 31 age-and-weight matched women not using OCPs. Baseline body mass index (BMI), percent fat, percent water, and waist-to-hip ratio (WHR) did not change significantly after six cycles in the OCP users. A similar number of women gained weight in both groups (30.6 percent of users, 35.4 percent of controls); the typical weight gain in the OCP group was only 0.5 kg. The weight gain in these women was caused by accumulation of fat, not body water. Approximately 20 percent of women in both groups lost weight. Thus, adolescents should be reassured that OCP use does not result in an increase in body weight or percent body fat over that seen in nonusers.

#### Adolescents also are increasingly concerned about weight gain from DMPA. Although weight gain and DMPA use may be concomitant events, a causal relationship has not been established. Factors other than DMPA may be playing a role. As an example, in one study, after six months of DMPA use, weight gain was greater among black than white subjects (4.2 versus 1.2 percent increase or mean weight gain of 2.9 versus 0.9 kg). A higher baseline weight, eating restraint, eating disinhibition, and other medications were predictive for weight gain in the black adolescents. In contrast, the only predictive factor for weight gain in white adolescents was a higher baseline weight. Thus, weight gain while using DMPA appears to occur in adolescents with a propensity for weight gain 

#### 

#### Bone density --- DMPA and ultra low-dose estrogen (20 microgram) pills may interfere with achieving optimal peak bone mass in very young women by causing loss in bone density or interference with the increase during a time of expected bone accretion 

#### 

#### Rare cases of osteoporosis, including osteoporotic fractures, have been reported postmarketing in patients taking DMPA. For this reason, the United States Food and Drug Administration has a labeling change to include a warning that DMPA be used as a long-term birth control method (eg, longer than two years) only if other birth control methods are inadequate

#### .

#### It is important to review information regarding DMPA and bone density with adolescents. The general opinion is that, if possible, DMPA should be avoided in a girl during early adolescence. However, the data are not sufficient to limit the use of the transdermal patch in adolescents; nor are they sufficient to limit the use of DMPA in older adolescents. In fact, some experts argue that for adolescents in whom DMPA is the only acceptable contraceptive option, the benefit of pregnancy prevention outweighs the potential risk to bone health. This conclusion is based upon the following points :

#### -Pregnancy also appears to decrease BMD

#### -Most adolescents who use DMPA do so for less than two years

#### -There is at least partial recovery of bone density after discontinuation of DMPA

#### The adolescent can modify other lifestyle factors to maximize bone health (ie, calcium intake, exercise, avoidance of tobacco use).

####  

#### Estrogen supplementation may provide additional bone protection and may be warranted for girls in whom BMD may already be decreased (eg, family history of osteoporosis, anorexia nervosa, chronic renal disease). The optimal dose and route for estrogen supplementation is not known; (0.625 mg equine estrogen per day is the only oral dose that has been tested).

####  

#### Spinal bone mineral density can be monitored with dual energy absorptiometry (DXA) and compared with normative data to determine whether DMPA should be continued or discontinued. DXA should be obtained in all young women who use DMPA continuously for two years

#### . 

#### The Society for Adolescent Medicine has published a position paper regarding the black box warning for DMPA. The position paper suggests that:

#### -With adequate explanation of benefits and potential risks, DMPA may continue to be prescribed to adolescent girls who need contraception 

#### -Decisions regarding bone density monitoring of adolescents using DMPA for contraception should be individualized; the decisions should be made by the clinician in concert with the adolescent, and potentially the adolescent\'s guardian 

#### -Duration of use of DMPA need not be restricted to two years 

#### -Adolescents using DMPA should be encouraged to take 1300 mg and 400 IU [vitamin D](http://www.uptodateonline.com/utd/content/topic.do?topicKey=ped_drug/27837&drug=true) and to exercise each day. Calcium and vitamin D supplements are available separately in tablet form or combined in a single tablet. 

#### Estrogen supplementation should be considered for girls who are doing well on DMPA and have osteopenia or are at risk for osteopenia and who have no contraindications to estrogen 

#### The effects of DMPA on bone density are discussed separately. 

#### Pelvic inflammatory disease --- The relationship between OCPs pelvic inflammatory disease (PID) is complex. Whereas some studies indicate that the use of OCPs increases the risk of PID, others suggest that OCPs increase the risk for cervicitis and endometritis, but not salpingitis, thereby decreasing the severity of PID. 

#### No association between DMPA and risk of PID has been reported. The intrauterine device (IUD) itself does not increase the risk for PID. However, the presence of the IUD may increase the severity of PID in an adolescent due to their increased risk for STIs. 

#### 

#### Venous thromboembolism --- The association between OCPs and risk of venous thromboembolism (VTE) appears to be related to estrogen dose and type of progestin. Even low-dose OCPs (30 to 50 microgram estrogen pills) can be associated with a modest increase (three- to sixfold) in the risk of VTE. OCPs containing third-generation progestins also may be associated with a slight increase in risk of VTE.

#### 

#### The risk of VTE with OCPs or the transdermal patch should be considered in relation to the risk of VTE during pregnancy. The risk of VTE may be 3- to 10-fold higher in pregnant than nonpregnant women. 

#### Many adolescents and their parents also have raised questions about the reports of increased risk of VTE from the transdermal patch. The FDA has required the label for the transdermal patch to contain a warning regarding the possible increased risk of thrombotic events related to a higher-than-average circulating estrogen level. This warning is controversial because it is unclear whether the increased circulating estrogen level will in fact be associated with a higher frequency of adverse events. 

#### 

#### Nonetheless, it is important to take a careful personal and family history of deep venous thrombosis to identify those adolescent women who might be at high risk before prescribing an OCP or the patch (eg, those who have antiphospholipid antibodies or nephrotic syndrome). 

#### Other effects --- Other side effects from OCPs of concern to adolescents include blood clots (22 percent), birth defects (11 percent), and infertility (10 percent). Many adolescents hear about these effects from an adult who may have used higher-dose OCPs in the 1960s and 1970s or is otherwise misinformed. This situation underscores the importance of dispelling misconceptions about the adverse effects of OCPs, as well as DMPA, especially in adolescent women. There is no evidence to support an association between OCPs and either birth defects or infertility. 

#### Summary --- The perceived adverse effects of hormonal contraception is a real barrier to the use of this method among some adolescents.

#### Weight gain is a common concern. However, there is no evidence to suggest OCP use results in an increased body weight or percentage of body fat beyond that seen in nonusers. Among users of DMPA, weight gain appears to occur in those who have an underlying propensity for weight gain. 

#### DMPA and low-dose estrogen OCPs may interfere with the achievement of peak bone mass in very young adolescent women. The general opinion is that, if possible, DMPA should be avoided in girls during early adolescence. The data are not sufficient to limit the use of the transdermal patch in adolescents; nor are they sufficient to limit the use of DMPA in older adolescents. 

#### Low-dose OCPs are associated with a modest increase in the risk of venous thromboembolism. 

#### Inadvertent OCP administration during early pregnancy has not been associated with an increase in risk of congenital anomalies. 

#### OCPs do not increase the risk of infertility; in fact, the risk of primary infertility may be reduced in women who have taken an OCP. 

#### 

**Issues concerning the use of hormonal contraception by adolescents,
UpToDate**

<http://www.uptodateonline.com/utd/content/topic.do?topicKey=adol_med/2363&selectedTitle=4~150&source=search_result>

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

#### Meeting notes now online: [2007 Native Women's Health and MCH Conference](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/Intro Slide and Eval Sli14.ppt)\*

#### -More lecture notes added daily

-Lectures listed in alphabetical order by author

**Kelly Acton, M.D.**

-   [Diabetes in American Indian & Alaska Native
    Women](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/2007 OB GYN conf DM & women.ppt)

**Gail Bolan MD**

-   [Current Issues in STD Management: Implications for Improving
    Women's Reproductive Health
    Outcomes](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/IHS womens STD update 8.16.07.ppt)

**Karen Carey CNM MS**

-   [Obstetric
    Drills](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/McBride - OB Emergency Drills.ppt)

**Peter Cherouny, MD**

-   [Idealized Design of Perinatal Care:
    Plenary](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-15Wed/9-15 am - Cherouny - New Mexico 0815.ppt)

-   [Quality Care in Obstetrics-Clinical Bundles:
    Workshop](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-15Wed/WS 1 AND 20 - New Mexico 0815 breakout.ppt)

**Donald Coustan, M.D.**

-   [GESTATIONAL
    DIABETES](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/9-00am Coustan -- NewMex17.ppt)

-   [Gestational
    Diabetes](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-16Thur/9-00am Coustan -- NewMexicoGDM2007.ppt)

-   [Use of Oral Antidiabetic Agents in Obstetrics:
    Workshop](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-16Thur/Ws 42 - Coustan -- Albuquerque Workshop 2007 oral_1.ppt)

**Scott Deasy, M.D.**

-   [Navajo Nation Breast & Cervical Cancer Prevention
    Program](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8.16.07 Presentation.ppt)

**Willeen Druley, RN, MS, BC, FNP**

-   [Mobile Women's Health
    Unit](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/Mobile Unit-presentation updated 8-7-07.ppt)

**Denise Findlay, RN BSN**

-   [Using the Feeding & Teaching Scales to Plan Effective
    Interventions](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-15Wed/WS 7 - Findlay - Albuquerque PCI.ppt)

-   [Promoting Maternal Mental Health During
    Pregnancy](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-15Wed/WS 10 - Findlay -- Albuquerque PMMH.ppt)

**Terry Friend, CNM**

-   [SCHOOL-BASED HEALTH (BY
    ACCIDENT)](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/SCHOOL PRESENTATION 2.ppt)

**Cindy Gebremariam, RN**

-   [iCare: A population management
    tool](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/iCare presentation Nashville Best Practices Conference 2007_.ppt)
    )

**Scott Giberson, Ph.C, PharmD, MPH**

-   [IHS HIV Program: Risk and
    Response](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/Women's Health HIV Program Final Aug 14.ppt)

**George Gilson, M.D.**

-   [HIV Infection in Pregnancy: 2007
    Update](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/HIV-2007.ppt)

-   [Prenatal Testing Update
    2007](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/prenataltesting2007.ppt)

-   [THE OB-PEDS INTERFACE:"GOT
    ISSUES?"](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/Gilson - OB-Peds talk.ppt)

**Amy Groom, MPH**

-   [HPV Vaccine
    Implementation](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/Groom HPV Vaccine.ppt)

**Kathleen Harner, M.D.**

-   [Balancing Motherhood: Helping Moms Stay Drug
    Free](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/Balancing Motherhood power point%5B1%5D.ppt)

**Howard Hays, M.D.**

-   [Women's Health Software Application V
    3.0](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/WHPresNAWConference FINAL 2007_08.ppt)

**Mary Henrikson MN, RNC**

-   [Us versus Them and Being in the
    Middle](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-17Fri/8-00 am --Henrickson -- Us Versus Them.ppt)

**Stephen W. Heath, MD, MPH**

-   [Risk Management in Maternal Child
    Health](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/MCH Talk.ppt)

**Lynn Hoefer, DV Advocate**

-   [Ketchikan Indian Clinic Domestic Violence Project: Take Home
    Tips](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/Native Women's Health and MCH Conference 081507.ppt)

-   [Take Home Tips from Alaska IPV/DV Screening Project: Linking
    Culture and Community to
    Action](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/Take Home Tips DV 8-14-07.ppt)

**Diane Jeanotte RN**

-   [Billings Area SIDS / Infant Mortality
    Reduction](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/Jeanotte - August PresentationNO.ppt)

**Wanda K. Jones, Dr.P.H.**

-   [Optimizing Women's Health in the United States:
    Deaths](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-15Wed/Jones Handout -- OWHhandhout-deaths.doc)

-   [Optimizing Women's Health in the United States:
    URLs](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-15Wed/Jones Handout -- OWHhandout-URLs.doc)

**Favian Kennedy, MSW**

-   [Northern Plains Smoke-Free Homes
    Campaign](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/SFH for IHS.pdf)

**Nancy Knapp MPH & Brenda Isaacs**

-   [Integrating Brief Motivation Enhancing Interventions into the
    Primary Care
    Setting](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-15Wed/WS 21 0 Knapp - WISEWOMAN IHS womens health conf Aug 2007-ha.ppt)

-   [Integrating Brief Motivation Enhancing Interventions into the
    Primary Care Setting:
    Handout](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-15Wed/WS 21 0 Knapp -Hand Out ONLY.ppt)

**Michele R. Lauria, MD, MS**

-   [Optimizing Care Through Simulations and Structured Communication:
    Plenary](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-15Wed/10-15am - Lauria - New Mexico 2007.ppt)

-   [Vaginal Birth after Cesarean: Still a Viable Option?
    Workshop](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-15Wed/WS 8 - Lauria Indian Health servcie to use.ppt)

-   **Rachel Locker, M.D.**

-   [Domestic Violence: Screening and
    Documentation](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/MCH DV locker clark.ppt)

**Tami McBride, CNM, MS, RNC**

-   [Obstetric Emergency
    Drills](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/OBEmergDrills.ppt)

-   [Obstetric Drill De-Brief
    Form](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/OBDrillDebriefForm.doc)

**Richard McClain, MD**

-   [MONARC vs. Paravaginal wall Repair: A system and surgeon
    perspective](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/WS 30 - McClain -- Stress Urinary Incontinence Pres.ppt)

**Paul Melinkovich, M.D.**

-   [Denver School-Based Health
    Centers](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/IHS MCH 8 07.ppt)

**Connie Monahan, MPH**

-   [Challenges of SANE in the Clinical Setting
    (Plenary)](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/Nat Am & MCH 07 - genera12.ppt)

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-   [Making SANE Work: Operational Details
    (Workshop)](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/Nat Am & MCH 07 - breakout.ppt)

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-   [Challenges of SANE in the Clinical
    Setting](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-16Thur/10-15 am - Monahan - Nat Am & MCH 07 - general session.ppt)

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-   [Challenges of SANE in the Clinical Setting:
    Handout](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-16Thur/10-15 am - Monahan - HANDOUT ONLY.ppt)

```{=html}
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-   [Making SANE Work: Operational
    Details](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-16Thur/WS 40 - Slides - Monahan - Nat Am & MCH 07 - breakout.ppt)

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-   [Appendices: Making SANE
    work](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-16Thur/WS 40 - HANDOUT - Monahan - Nat Am & MCH 07 - APPENDICES for.doc)

**Neil Murphy MD**

-   [2007 Data
    Tally](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/HandoutsPres/Dr Muphys 2 -- DataTally81107.doc)

-   [2007 Birth Statistics by
    Facility](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/HandoutsPres/Murphy - Packet BirthStats7904.xls)

-   [2007 Narrative
    Tally](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/HandoutsPres/Dr Murphys 3 -- NarrativeTally81107.doc)

-   [Human Papilloma Virus Vaccine
    2007](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/ABQHPV81607.ppt)

-   [Save the
    World](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/SaveTheWorld81407.ppt)

-   [How to keep
    current](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/HowtokeepcurrentABQ81607.ppt)

**Sue Murphy, RD, MPH, CDE, CLE**

-   [Breastfeeding
    Update](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/Murphy - MCH OB-GYN conf 8-15-07.ppt)

**Tony Ogburn MD**

-   [Contraception for teens: What's
    new?](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/Ogburn - Contraception-adolescents IHS 8-07.ppt)

**Sharon Phelan MD**

-   [Obesity: A weighty
    problem](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/Phelan - OBESITY IHS August 2007.ppt)

**Marilyn Pierce Bulger**

-   [Community Approaches to Reducing Infant Mortality: Nutaqsiivik
    Program](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/Community Approaches To Reducing IM Nutaq.ppt)

-   [Approaches To Reducing Infant Mortality- Nutaqsiivik
    Program](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/Pierce-Bulger - Community Approaches To Reducing IM Nutaq.ppt)

**Usha Ranji, M.S.**

-   [Health Coverage and Access to Care: Key Issues for Native
    Women](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-15Wed/Ranji IHS Conference August 2007.ppt)

**Brigg Reilley**

-   [Prenatal HIV Screening:
    Workshop](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-15Wed/WS 4 - Reilley - native women conference.ppt)

-   **Sharon Schindler Rising, MSN, CNM**

-   [Essential Elements of the Centering
    Model](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/HandoutsPres/Suzan Murphy HO - Model overview-4 page-8-07.doc)

**Greg Shorr, M.D.**

-   [PCC+ Obstetric Care
    Module](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/ShorrMCH_aug_07.ppt)

**Melanie Taylor MD, MPH**

-   [Chlamydia Among AI/AN Adolescents: The Stop Chlamydia
    Project](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/Taylor - NewMexPresentation Aug1407.ppt)

**Judy Thierry, DO MPH**

-   [Improve the System, Improve the
    Outcome](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-15Wed/8-00am -Welcome -- slides - thierry.ppt)

-   [PCC+ Obstetric Care
    Module](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/MCH_aug_07.ppt)

**Shelley Thorkelson , CNM MSN CDE**

-   [Case Tracking Strategies Using RPMS , CMS, DMS and Hard
    Copy](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/DM and Preg Program Over12.ppt)

-   [Diabetes in Pregnancy: Case Tracking
    Strategies](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-16Thur/Ws 42 - Handout 2 Thorkelson SJT GDM Flowsheet.doc)

-   [DM & Pregnancy Program
    Flowsheet](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-16Thur/WS 42 - Slides - Thorkelson DM and Preg Program Overview2006.ppt)

**Sheila Warren, MPH, RN, CPHQ**

-   [Patient Safety in Maternal Child
    Health](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/MCH conference 8 2007 sheila.ppt)

**Judy Whitecrane MSN, CNM**

-   [What We Did About Prenatal Substance
    Abuse](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-15Wed/WS 9 - Whitecrane - Special Care Clinic Services-2007.ppt)

**Nancy Whitney, MS, LMHC**

-   [Intervention as Prevention: Working Effectively with Mothers Who
    Abuse Alcohol and Drugs During
    Pregnancy](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-15Wed/WS 16 - Slides (Print 3 slides per pg) Nancy Whitney HANDOUT.ppt)

-   [Parent-Child Assistance Program
    (PCAP)](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/8-15Wed/WS 16 - HANDOUT 2 Nancy Whitney HANDOUT 2.doc)

    [**2007 Native Women's Health and MCH
    Conference**](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/Intro Slide and Eval Sli14.ppt)

[Conference
Brochure](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NWHMCH51507.pdf)

<http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NWHMCH51507.pdf>

\*Web link
<http://www.ihs.gov/MedicalPrograms/MCH/F/lecNotes.cfm#wHealthConf>

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

**Does anyone have an EHR template that is IHS approved for obstetrical
patients?**

**Question**

I am new to IHS, but does anyone have an EHR template that is IHS
approved for obstetrical patients? 

From Maureen Sullivan CNM, WHNP, MS, Rosebud

**Answer**

We have a template that we use just for the initial intake visit.

Please contact Mary Morphet-Brown <Mary.Morphet-Brown@IHS.GOV>

Yakama Indian Health Center Public Health Nursing

If you have other resources to offer, please let me know
<nmurphy@scf.cc>

[**How to Strengthen Your Pelvic Floor
Muscles?**](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/W/MatPT.cfm%23pelvic)

[http://www.ihs.gov/MedicalPrograms/MCH/W/MatPT.cfm#pelvic](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/W/MatPT.cfm%23pelvic)

 

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

**April 2008 -- Highlights**

-Estimating the effectiveness of screening for scoliosis

-Recent news highlights from the world of vaccines

-Invasive Pneumococcal Disease in Children 5 Years After Conjugate
Vaccine Introduction

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ICHN408.doc>

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

**Seeking input from the field - Clinician's Information Management
Technology Advisory Council** What do you see as the most important
issues or needs at this time?  What do you see as our future needs? 

CIMTAC has been in existence for a number of years.  We have been the
clinicians (doctors and nurses) PSG - Professional Specialty Group. 
Requests for RPMS packages and enhancements filter through us for
approval and/or prioritization.  We are going to be taking a more active
role in strategic planning for RPMS.  We would appreciate your input.

Contact Kathy Ray at <Kathy.Ray@IHS.GOV> with your suggestions and
input.

**HIMSS Davies is proud to announce a new recognition opportunity**

Since 1994, the Nicholas E. Davies Awards have rewarded excellence in
the implementation and value derived from the use of electronic health
records (EHRs) by provider organizations, private practices and public
health systems. HIMSS proudly announces the expansion of this
prestigious national award to recognize Community Health Organizations
(CHOs), that are uniquely characterized as providing direct patient care
and health services to safety-net underserved and vulnerable
populations.

Why Apply?

> "For me personally, the Davies Award started me down a very exciting
> path of opportunity in healthcare, a chance to make a difference on a
> larger scale, and to ultimately influence the healthcare of those who
> I could have never reached without this recognition.\"
>
> \~ Jim Morrow, MD, North Fulton Family Practice, 2004 Davies
> Ambulatory\
> Award

-Learn from the application process itself as it serves as an
introspective self-assessment that is valuable for planning and
optimizing use of EHR technologies in practice.\
-Be recognized for effective adoption of technology and your expertise
and achievements in providing primary care and associated health
services to safety-net underserved and vulnerable populations, while
maintaining an open door policy.\
-Be an inspiration to your peers, professional associations, patients
and communities, who aspire to better patient safety, quality,
effectiveness and efficiency.\
-Have an impact by providing education to the larger health care
community to testify before congressional committees making a difference
on a larger scale, sharing model practices, innovative approaches, and
lessons learned.

How to Apply:

Written applications are due May 30, 2008 and site visits for qualified
applicants will be scheduled during the summer.  Visit
[www.himss.org/davies](http://www.himss.org/davies) to learn more about
the Davies award, view the application pre-requisites, and download the
application. 

For more information, e-mail HIMSS, Davies Awards Manager,
<dcollins@himss.org>.

If you have any questions or problems please contact us at
<techsupport@himss.org>.

**iCare Training**

The IHS Office of Information Technology (OIT) and the IHS Clinical
Support Center (Accredited Sponsor) present WebEx training sessions for
the iCare (Population Management) software application. You will be able
to participate in the training from the comfort of your office or
conference room and will not be required to travel to obtain this
training.

iCare is a tool with multiple uses for a wide variety of providers that
presents diverse RPMS data through an easy to use graphical user
interface (GUI).

**[NEW!]{.underline}** We are now offering a new training that will
address the additions in the next version of iCare. At this time, we
**will not** be offering CEUs for this class

-   What\'s New with iCare? 1.5 hours

We will continue to offer a brief intro session that will just
[introduce]{.underline} the software to participants. This session does
not offer any training and CEUs **will not** be given for this session

-   A Brief Introduction to iCare 30 minutes

We will continue to off the 2 standard training sessions and are
offering CEUs for these classes. We recommend these 2 classes be taken
sequentially. These sessions will be updated to include the new
functionality.

-   iCare - Nuts and Bolts 2.0 hours

-   Tthe Practical Use of iCare 1.5 hours

The target audience is [any]{.underline} provider who cares for patients
(e.g. physicians, mid-level providers, nurses, case managers, public
health personnel, pharmacists etc.)

**[NOTE:]{.underline}** **You must register for these classes.** They
are NOT limited to participants in a particular Area; they are open to
all. Below are the agendas and date/times for both classes.

You can choose to register individually or as a group. If you register
individually, all you need is your computer, the ability to sign on to
the internet and a telephone. If you\'d like to attend as a group, one
person will need to register and then sign in at the designated time.
You will need a conference room, conference phone, computer and
projector.  Please ensure someone at your facility is responsible for
taking care of these arrangements.

Please note that these are live, internet-based trainings, not recorded
sessions, and people will be able to ask questions and actively
participate in the class.

**[NOTE:  All training times shown above are in the Pacific Daylight
Time (California) zone.  Please ensure you adjust the time for your
particular time zone.]{.underline}**

ACCREDITATION:

The Indian Health Service (IHS) Clinical Support Center is accredited by
the Accreditation Council for Continuing Medical Education to sponsor
continuing medical education for physicians.

The IHS Clinical Support Center designates this continuing medical
education as Category 1 credit toward the Physician's Recognition Award
of the American Medical Association. Each physician should claim only
those hours of credit he or she actually spent in the educational
activity.

This Category 1 credit is accepted by the American Academy of Physician
Assistants and the American College of Nurse Midwives.

The Indian Health Service Clinical Support Center is accredited as a
provider of continuing nursing education by the American Nurses
Credentialing Center's Commission on Accreditation.

**[Training Schedule]{.underline}**

1.  **[What\'s New with iCare?]{.underline}**

> Target Audience -- Patient Care Providers (e.g. physicians, mid-level
> providers, nurses, case managers, public health personnel, pharmacists
> etc.)
>
> **[Agenda]{.underline}**

-   New Panel Definitions

-   Panel Reminders

-   Aggregate Reminders

-   PCC Tab

-   Adding Historical Events

**[Session                          Date and Time                Reg
Password]{.underline}**

What\'s New with iCare? Thurs 04/03/2008 11:00-12:30 PDT coyote

Tues 04/22/2008 13:00-14:30 PDT coyote

Thurs 05/08/2008 12:30-14:00 PDT coyote

Wed 05/28/2008 09:30-11:00 PDT coyote

2.  **[iCare -- Nuts and Bolts]{.underline}**

> Target Audience -- Patient Care Providers (e.g. physicians, mid-level
> providers, nurses, case managers, public health personnel, pharmacists
> etc.)
>
> **[Agenda]{.underline}**

-   Introductions and Context

-   Set Up

-   Background Processes

-   Establishing and Changing User Preferences

-   Panel Creation

-   Panel Modification

-   Patient Record

**[Session                          Date and Time                Reg
Password]{.underline}**

iCare Nuts and Bolts Mon 03/24/2008 11:00-13:00 PDT coyote

Wed 04/16/2008 09:30-11:30 PDT coyote

Mon 05/19/2008 13:00-15:00 PDT coyote

3.  **[The Practical Use of iCare]{.underline}**

> Target Audience -- Patient Care Providers (e.g. physicians, mid-level
> providers, nurses, case managers, public health personnel, pharmacists
> etc.)
>
> **[Agenda]{.underline}**

-   Introductions and Context

-   Scenarios

-   Tips

-   Using the Performance Measure views to improve outcomes

**[Session                         Date and
Time                              Reg Password]{.underline}**

The Practical Use of iCare Wed 03/26/2008 14:00-15:30 PDT coyote

Tues 04/01/2008 08:00-09:30 PDT coyote

Thurs 04/17/2008 12:00-13:30 PDT coyote

Wed 05/21/2008 09:30-11:00 PDT coyote

1.  **[A Brief Introduction to iCare]{.underline}**

> Target Audience -- Patient Care Providers (e.g. physicians, mid-level
> providers, nurses, case managers, public health personnel, pharmacists
> etc.) who don\'t have time to attend a longer session.
>
> **[Agenda]{.underline}**

-   Highlights

-   Background Processes

-   Panel Creation and Modification

**[Session Date and Time Reg Password]{.underline}**

A Brief Introduction to iCare Mon 04/07/2008 10:00-10:30 PDT coyote

Wed 05/07/2008 09:30-10:00 PDT coyote

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

1.  Click this link:

> [https://ihs-hhs.webex.com](https://ihs-hhs.webex.com/)

1.  In the Search box, type in \"iCare\" (do not type in the quotation
    marks) and click the Search button.  **NOTE:  If you do not see the
    Search For box, ensure the Training Center tab is selected at the
    top of the WebEx window.**

2.  All of the scheduled sessions will then be displayed in the window
    below.  Choose the one you want to attend and click "Registration"
    in the Status column.

3.  Enter the Registration password that is shown above that corresponds
    to the class you want to attend.

4.  Click the OK button.

5.  Complete the registration form.

6.  Click the Register button.

7.  A Registration confirmation is displayed that contains all of the
    information for the training session, including the link for the
    session and the password to enter when you are ready to attend the
    session.  Click the OK button to finish.

**[Setup (Software Install) Information:]{.underline}**

You must have the WebEx software installed on your computer prior to
attending the WebEx session.  **[You should setup the software at least
a day before the training session.]{.underline}**  You should not need
anyone such as the Site Manager to install it for you.  Below are the
instructions.

1.  Click this link:

> [https://ihs-hhs.webex.com](https://ihs-hhs.webex.com/)

1.  On the left side of the window, locate Set Up

2.  Click Training Manager

3.  A message is displaying giving you information about the setup
    process. Click the Set Up button

4.  After the software is installed, click the OK button.

**[Attending the Session:]{.underline}**

On the day of the scheduled training, you will receive a confirmation
email. When you are ready to attend the session, connect to the WebEx
session by clicking on the link in that email. You will then need to
connect to the conference line.  The dial information for the conference
line is shown below and is also included in your registration
confirmation message.

Phone Number:  (877) 781-4791

Passcode:         135963#

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

**Routes to TB treatment in rural Nepal**

Tuberculosis remains a serious problem in many low and middle-income
countries, and as readers of this newsletter well know, it can also be
an issue in impoverished parts of wealthy countries. Several factors
associated with poverty make TB more likely: overcrowded living
conditions, immune suppression (for instance due to HIV or substance
abuse), chronic malnutrition. Besides increasing the chances of
acquiring TB, poverty affects the likelihood of getting it properly
diagnosed and treated.

A new qualitative study from Nepal explores just how people who develop
symptoms from TB find their way to diagnosis and therapy. A team of
Dutch and Nepalese researchers interviewed a convenience sample of
twenty-six patients undergoing TB treatment at various public health
centers -- some remote, some more central -- in lowland Nepal. They
found that all of these patients had consulted more than one provider
before beginning therapy. When patients decided where to seek help,
their decisions were based on a combination of economic factors, their
perceptions of whether the symptoms were serious or not, and the
reputations and perceived quality of the providers. The opinions of
family members or friends influenced their choices as well. Most
patients reported that they began their journeys at a private
practitioner's facility. Lines were long at the free public clinics,
these clinics were often far away, and they were known to run short on
medications. Patients knew they could get quicker care at nearby private
clinics. Many of these places were "medical shops," places where one can
buy drugs with no medical consultation or physical exam. Others were
staffed by providers (sometimes medically trained, sometimes not) who
offered consultation for a fee.

Unfortunately, only one of these private providers referred a patient to
someone more qualified, a problem the authors suggest may relate to
financial incentives to keep patients. Most patients self-referred
elsewhere only when treatment failed or they lost trust in the
competence of their providers. The delay introduced by this chain of
referrals lasted an average of seven months before a TB diagnosis was
made. (The one positive finding was that once anyone entertained the
possibility of TB, appropriate referral for diagnosis and initiation of
treatment was quite prompt.)

This article has significant limitations. Chief among these: the
sampling strategy means we cannot know what is happening to those who do
*not* find their way to the national treatment program. Nonetheless,
these researchers uncovered several practical and counter-intuitive
findings for health system planners. First, reputation of the public
clinics deterred many people from seeking care there, at least initially
-- even though the care was free. Second, educational strategies
intended to improve TB case-finding will probably need to involve
private practitioners. Third, not one person interviewed mentioned
anything that could be considered a "cultural barrier" to care, though
these are often assumed to be significant in public health programs
targeting the underserved.

Ten Asbroek AH, Bijlsma MW, Malla P, Shrestha B, Delnoij DM.. 2008 The
road to tuberculosis treatment in Nepal: a qualitative assessment of 26
journeys. [BMC Health Serv
Res.](javascript:AL_get(this, 'jour', 'BMC Health Serv Res.');) 2008 Jan
11;8:7.

<http://www.ncbi.nlm.nih.gov/pubmed/18190698>

**Unite For Sight Volunteer Abroad Opportunities**

Volunteer Abroad in Summer, Fall, Winter, or Spring:

WITH THE ASSISTANCE OF VOLUNTEERS LIKE YOU, UNITE FOR SIGHT RESTORED
SIGHT TO 10,062 PATIENTS AND PROVIDED EYE CARE TO 300,000 IN 2006 AND
2007

**How Do I Apply?** The application as well as complete details about
Unite For Sight\'s international opportunities are available at
[http://www.uniteforsight.org/intl_volunteer/](http://slate.technolutions.com/go?c8bcd94735994180a0d7738889cc44bd&r=http%3A%2F%2Fwww.uniteforsight.org%2Fintl_volunteer%2F)\
\
**Who Is Eligible To Volunteer Abroad?:** Volunteers are 18 years and
older, and there is no upper age limit. Volunteers range from
undergraduate/college students to medical and optometry students, public
health students and professionals, business students, filmmakers and
photographers, nurses and nursing students, social workers, physician\'s
assistants, teachers and educators, opticians, optometrists and
ophthalmologists.

Unite For Sight welcomes volunteers who may not have previous health or
eye care experience. Volunteers receive all necessary training from
Unite For Sight so that they are able to assist eye doctors with
community eye outreach programs. Unite For Sight also welcomes
volunteers to participate as photographers and filmmakers.\
\
**What is Unite For Sight\'s Mission?** Unite For Sight is a 501(c)(3)
nonprofit organization that empowers communities worldwide to improve
eye health and eliminate preventable blindness.

Unite For Sight\'s work to prevent blindness and restore sight is
**featured weekly on CNN INTERNATIONAL** from September 2007-August
2008.\
\
**What Do Volunteers Do?:** Volunteers receive hands-on clinical
experience while assisting doctors in remote, rural villages. Volunteers
learn about international health and eye care, learn clinical skills
while working with patients and doctors, and, in one program location,
have an opportunity to practice cataract surgery on a goat\'s eye.

The goal of Unite For Sight and its partner eye clinics and communities
is to create eye disease-free communities. Unite For Sight's volunteers
(local and visiting) work with partner eye clinics to provide eye care
in communities without previous access. The eye clinic's eye doctors and
Unite For Sight volunteers jointly provide community-based screening
programs in rural villages. The clinic's eye doctors diagnose and treat
eye disease in the field, and surgical patients are brought to the eye
clinic for surgery. Patients receive free surgery funded by Unite For
Sight so that no patient remains blind due to lack of funds. Volunteers
immediately see the joy on patients\' faces when their sight is restored
after years of blindness. These memories last a lifetime.

While helping the community, volunteers are in a position to witness and
draw their own conclusions about the failures and inequities of global
health systems. It broadens their view of what works, and what role they
can have to insure a health system that works for everyone and that
leaves no person blind in the future.

**What Do Volunteers Say?**\
\
"During my volunteering experience, I realized that Unite for Sight's
service is a campaign for the salvation of humanity that allows the
light of compassion to shine through each of us. I believe it is this
display of altruism and commitment that makes the organization's service
so virtuous and treasured by both volunteers and patients. After all,
making a difference in the world is not so difficult if only one would
care enough to sacrifice a part of oneself in order to change the world
for the better. My experience as a Unite for Sight volunteer has
inspired me to dedicate my future career to serving underprivileged
communities around the world."---Chiwing "Jessica" Qu, Yale University
Undergraduate Student, Unite For Sight Volunteer in Chennai, India

\"I can honestly say that everything I learned in 3 years of medical
school paled in comparison to the 3 week experience I had in Accra
(Ghana) in October 2007 as part of Unite For Sight. The program provides
volunteers with a unique and hands-on involvement -- being able to help
out to the level of your training and comfort. My experience taught me
that Ghanaian people are the friendliest people I have interacted with
anywhere in the world, that ordinary people involved with Unite For
Sight are making extraordinary differences, and that sitting in a
classroom receiving a world-class education cannot match real life
experiences while volunteering.\"\--Varun Verma, UMDNJ Medical Student,
Unite For Sight Volunteer in Accra, Ghana

\"While in Ghana, I worked with an ophthalmologist (Dr. James Clarke),
two eye nurses (Robert Dolo, Kartee Karloweah), an assistant (Bismark
Boryor), and a coordinator (Seth). Working with the Unite for Sight team
on these outreaches in service to these wonderful people of Ghana was
the single most rewarding work I\'ve done in my life. The people of
Ghana are some of the friendliest and most thankful of anyone I have
ever met. Overall, the experience has changed the way I view the world,
my own country, and my role in the world forever. The only way to
understand the way 4/5 of the world lives is to go yourself and get
involved. The staff I worked with that are the heart and soul of Unite
for Sight in Accra were some of the brightest and hard working
individuals I have ever met. They are accomplishing feats few ever
accomplish in their lives, and I am truly blessed to have had the
opportunity to work with them and now call them my friends. I look
forward to future work with Unite for Sight as an Ophthalmologist. The
task at hand in Ghana, and I\'m sure in all of Unite for Sight\'s
locations throughout the world, is enormous. The more people that get
involved, the more accessible services will be to these wonderful
people. Plain and simple, the more we help, the more people can see the
world they live in!"---Brian Fowler, Medical Student at University of
Virginia, Unite For Sight Volunteer in Accra, Ghana

Hundreds of volunteer narratives, volunteer diaries, as well as videos
of alumni volunteers and partner eye doctors are available on the Unite
For Sight website:
[http://www.uniteforsight.org/intl_volunteer](http://slate.technolutions.com/go?c8bcd94735994180a0d7738889cc44bd&r=http%3A%2F%2Fwww.uniteforsight.org%2Fintl_volunteer)

Also, Unite For Sight\'s Fifth Annual International Health Conference is
coming up at Yale on April 12-13, 2008. Keynote addresses by Dr. Jeffrey
Sachs, Dr. Sonia Sachs, Dr. Jim Yong Kim, Dr. Allan Rosenfield, and Dr.
Susan Blumenthal. Plus 180 Speakers and 2,000+ conference attendees.
Register for the conference at
[http://www.uniteforsight.org/conference](http://slate.technolutions.com/go?c8bcd94735994180a0d7738889cc44bd&r=http%3A%2F%2Fwww.uniteforsight.org%2Fconference)

From Jennifer Staple <Jennifer.Staple@AYA.YALE.EDU> via Advanced
Practice Nurses LISTSERV

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

#### New Bullying-Prevention Toolkit Released Eyes on Bullying . . . What Can You Do? A Toolkit to Prevent Bullying In Children\'s Lives offers a variety of tools to help parents and other caregivers understand bullying in a new way, reexamine their knowledge and beliefs about bullying, and shape the beliefs and behaviors of the children in their care. The toolkit, created at Education Development Center, is designed especially for parents and other caregivers of preschool- and school-age children and adolescents to use in child care programs, after-school programs, and camps. Topics include (1) the issue of bullying; (2) why bullying can sometimes be difficult to see; (3) the concepts of bully, victim, and bystander; (4) recommendations and strategies for addressing bullying when it occurs; (5) a strategic approach to creating an environment where everyone takes responsibility for preventing bullying; and (6) resources and references on bullying prevention. The toolkit is available at [**http://www.eyesonbullying.org/pdfs/toolkit.pdf**](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.eyesonbullying.org/pdfs/toolkit.pdf) {#new-bullying-prevention-toolkit-released-eyes-on-bullying-.-.-.-what-can-you-do-a-toolkit-to-prevent-bullying-in-childrens-lives-offers-a-variety-of-tools-to-help-parents-and-other-caregivers-understand-bullying-in-a-new-way-reexamine-their-knowledge-and-beliefs-about-bullying-and-shape-the-beliefs-and-behaviors-of-the-children-in-their-care.-the-toolkit-created-at-education-development-center-is-designed-especially-for-parents-and-other-caregivers-of-preschool--and-school-age-children-and-adolescents-to-use-in-child-care-programs-after-school-programs-and-camps.-topics-include-1-the-issue-of-bullying-2-why-bullying-can-sometimes-be-difficult-to-see-3-the-concepts-of-bully-victim-and-bystander-4-recommendations-and-strategies-for-addressing-bullying-when-it-occurs-5-a-strategic-approach-to-creating-an-environment-where-everyone-takes-responsibility-for-preventing-bullying-and-6-resources-and-references-on-bullying-prevention.-the-toolkit-is-available-at-httpwww.eyesonbullying.orgpdfstoolkit.pdf .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### All the content from the toolkit and additional information, materials, and resources are available from the Eyes on Bullying Web site at [**http://www.eyesonbullying.org**](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.eyesonbullying.org). {#all-the-content-from-the-toolkit-and-additional-information-materials-and-resources-are-available-from-the-eyes-on-bullying-web-site-at-httpwww.eyesonbullying.org. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Chartbook Reports Findings From National Survey of Children with Special Health Care Needs The National Survey of Children with Special Health Care Needs Chartbook 2005-2006 highlights major findings on the prevalence of special health care needs among children, both nationally and within each state, and on access to and satisfaction with health care among children with special health care needs (CSHCN) and their families. The survey, sponsored by the Maternal and Child Health Bureau and carried out by the National Center for Health Statistics, provides information about six core outcomes used to measure progress toward the Healthy People 2010 objectives to increase the proportion of states that have integrated service systems for CSHCN. The chartbook is available at [**http://mchb.hrsa.gov/cshcn05/index.htm**](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://mchb.hrsa.gov/cshcn05/index.htm). {#chartbook-reports-findings-from-national-survey-of-children-with-special-health-care-needs-the-national-survey-of-children-with-special-health-care-needs-chartbook-2005-2006-highlights-major-findings-on-the-prevalence-of-special-health-care-needs-among-children-both-nationally-and-within-each-state-and-on-access-to-and-satisfaction-with-health-care-among-children-with-special-health-care-needs-cshcn-and-their-families.-the-survey-sponsored-by-the-maternal-and-child-health-bureau-and-carried-out-by-the-national-center-for-health-statistics-provides-information-about-six-core-outcomes-used-to-measure-progress-toward-the-healthy-people-2010-objectives-to-increase-the-proportion-of-states-that-have-integrated-service-systems-for-cshcn.-the-chartbook-is-available-at-httpmchb.hrsa.govcshcn05index.htm. .Style-Heading-4-+-Arial-14-pt-Underline}

**Breastfeeding Improves Prevalence of Metabolic Syndrome Among Women in
Midlife**

We have found that duration of lactation is associated with prevalence
of MetSyn \[metabolic syndrome\] in parous midlife women in a
dose-response manner.\
The authors found that\
\* There were 536 prevalent cases of MetSyn (21.3%).\
\* Among women who breast fed, 297 (18.3%) met the criteria for MetSyn,
compared with 239 among those who did not (26.7%).\
\* Women who developed MetSyn were more likely to have a higher body
mass index (BMI) at time of interview and at completion of high school,
to be African American, to smoke, and to be of lower socioeconomic
status. They also breast fed for shorter periods of time.\
\* Duration of lactation was inversely correlated with current BMI,
waist circumference, systolic blood pressure, diastolic blood pressure,
fasting levels of glucose, insulin, triglycerides, total cholesterol,
and low-density lipoprotein cholesterol. There was a positive
correlation with fasting high-density lipoprotein levels.\
\* After adjusting for age, current smoking, parity, ethnicity,
socioeconomic status, study site, physical activity, caloric intake, and
high-school BMI, parous women who had ever breast fed had a
significantly lower prevalence of MetSyn.\
\* The rate of MetSyn was significantly lower with increasing duration
of lactation, suggesting a dose-response relationship.\
The authors conclude that \"in addition to the pediatric benefits of
breast-feeding, these findings of maternal benefit may encourage more
women to initiate and maintain breast-feeding behavior.\"\
Ram KT, Bobby P, Hailpern S. 2008. Duration of lactation is associated
with lower prevalence of the metabolic syndrome in midlife \-- SWAN, the
Study of Women\'s Health Across the Nation. American Journal of
Obstetrics and Gynecology 198(3):268.e1-268e6.\
[http://www.ajog.org/article/S0002-9378(07)02226-0/abstract](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.ajog.org/article/S0002-9378(07)02226-0/abstract)

**MCH Headlines Judy Thierry HQE**

**Maternal, Infant and Child Health Capacity Needs Assessment**

In an effort to better understand the maternal, infant and child health
(MICH) services available to urban American Indians and Alaska Natives
(AI/AN); the Urban Indian Health Institute (www.uihi.org) conducted a
Maternal, Infant and Child Health Capacity Needs Assessment with 34
urban Indian health organizations (UIHO) funded through Title V of the
Health Care Improvement Act. The purpose of the assessment was to assist
in identifying specific assets, limitations or gaps in the urban Indian
health program as a whole.

The findings of this capacity needs assessment highlight current areas
of strength and need in providing MICH care to urban AI/AN.  Findings
document a need for additional pregnancy and infant health services at
many sites. Increased resources to support MCH services offered by UIHOs
may effectively reduce observed MCH disparities among urban AI/AN in the
risk of adverse birth outcomes and infant mortality.

 

For a link to the report: <http://www.uihi.org/publications/reports/>.
Please contact the Project Coordinator with any questions or comments:
Shira Rutman, <shirar@uihi.org> or 415-374-7868.

**Key Findings:**

[Pregnancy and Infant Health Services]{.underline}

-   The majority of sites provide immunizations, well-child visits and
    parenting support. However, around one-third of sites does not offer
    or refer clients for maternity case management, childbirth classes,
    home visits/public health nurse visits and SIDS counseling. Slightly
    more sites offer or refer for newborn screening and lactation
    support.

-   The need for pregnancy and infant health services is also seen in
    the large number of sites reporting shortages of providers/services
    and resources/funding for MICH services.

-   The specific need for OBGYN providers and services was a theme
    repeated throughout the survey.

-   Limited funding for an OB provider was also reported as a barrier to
    care for pregnant women.

[Dental Care]{.underline}

-   The need for dental and prenatal dental care providers was mentioned
    specifically by site representatives and was reported as an unmet
    need by both clients and providers.

[Child Care and Transportation]{.underline}

-   Most sites provide transportation assistance to their sites, but
    only one of the participating sites offers childcare, and only on an
    informal basis.

-   The need for child care and transportation was mentioned expressly
    by clients and may be an important barrier to the provision of
    health services for UIHO.

**GHSA and State Farm Partner to Keep \'Tweens and Teens Safe age 8 to
18**

-   Leading cause of death for children 3 and older, but ... low support
    for programs for 5 to 16 year olds.

-   Training courses by/for educators not readily available. \[i.e. see
    emails on drive it right curriculum\]

-   The strong and well informed constituency of early childhood safety
    'falls away' as children get older.

 

Assessment tool for state highway safety offices to examine their OPC
programs and focus their resources where they are most needed.

Five priority areas for which the respondents

requested additional information:

1.  programs for "tweens",

```{=html}
<!-- -->
```
1.  funding and resources,

2.  marketing strategies,

3.  data and evaluation, and

4.  law enforcement.

-   The Manual highlights programs that are designed to address the
    needs of children who fall between a booster seat program and
    traditional driver education programs.

-   Ages of eight and 16.

-   data-driven and research-based program.

-   various program components that be replicated throughout the
    country.

-   PDF document online

-   advisory team led by GHSA Executive Director Barbara Harsha and made
    up of representatives from GHSA, NHTSA, The Children\'s Hospital of
    Philadelphia, and State Farm provided direction and leadership for
    the project.

166 page pdf on line:  [www.ghsa.org](http://www.ghsa.org/) Jonathan
Adkins [www.ghsa.org](http://www.ghsa.org/)

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

**You know how to treat yeast infections, right? Which of these are true
about vulvar pruritus ?**

1.) It is important to ask patients presenting with vulvar pruritus if
symptoms vary with their cycles

True

False

2.) *Candida glabrata* tends to respond to intravaginal boric acid
therapy

True

False

3.) Nystatin successfully treats the majority of patients with tinea
cruris.

True

False

4.) Topical steroid ointments at the correct treatment for lichen
sclerosus

True

False

5.) Classic psoriasis occurs often on the vulva

True

False

Please think about the above scenarios.

The answers, with discussion and references, will be available in next
month's CCC Corner Medical Mystery Tour.

**Stay tuned to next issue**

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

**Overactive Bladder: Diagnosis and Treatment in Primary Care, CME/CE**

<http://www.medscape.com/viewprogram/8987>

######### 

######### 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**

#### What Happened to Women in WHI study 3 years after stopping HRT?  {#what-happened-to-women-in-whi-study-3-years-after-stopping-hrt-1 .Style-Heading-4-+-Arial-14-pt-Underline}

RESULTS: The risk of cardiovascular events after the intervention was
comparable by initial randomized assignments, 1.97% (annualized rate) in
the CEE plus MPA (343 events) and 1.91% in the placebo group (323
events). A greater risk of malignancies occurred in the CEE plus MPA
than in the placebo group (1.56% \[n = 281\] vs 1.26% \[n = 218\];
hazard ratio \[HR\], 1.24; 95% confidence interval \[CI\], 1.04-1.48).
More breast cancers were diagnosed in women who had been randomly
assigned to receive CEE plus MPA vs placebo (0.42% \[n = 79\] vs 0.33%
\[n = 60\]; HR, 1.27; 95% CI, 0.91-1.78) with a modest trend toward a
lower HR during the follow-up after the intervention. All-cause
mortality was somewhat higher in the CEE plus MPA than in the placebo
group (1.20% \[n = 233\] vs 1.06% \[n = 196\]; HR, 1.15; 95% CI,
0.95-1.39). The global index of risks and benefits was unchanged from
randomization through March 31, 2005 (HR, 1.12; 95% CI, 1.03-1.21),
indicating that the risks of CEE plus MPA exceed the benefits for
chronic disease prevention.

CONCLUSIONS: The increased cardiovascular risks in the women assigned to
CEE plus MPA during the intervention period were not observed after the
intervention. A greater risk of fatal and nonfatal malignancies occurred
after the intervention in the CEE plus MPA group and the global risk
index was 12% higher in women randomly assigned to receive CEE plus MPA
compared with placebo.

[Heiss
G](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Heiss G"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus),
[Wallace
R](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Wallace R"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus),
[Anderson
GL](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Anderson GL"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus),
[Aragaki
A](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Aragaki A"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus),
[Beresford
SA](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Beresford SA"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus),
[Brzyski
R](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Brzyski R"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus),
[Chlebowski
RT](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Chlebowski RT"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus),
[Gass
M](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Gass M"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus),
[LaCroix
A](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="LaCroix A"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus),
[Manson
JE](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Manson JE"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus),
[Prentice
RL](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Prentice RL"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus),
[Rossouw
J](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Rossouw J"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus),
[Stefanick
ML](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Stefanick ML"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus);
[WHI
Investigators](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="WHI Investigators"%5BCorporate Author%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus).
Health risks and benefits 3 years after stopping randomized treatment
with estrogen and progestin.
[JAMA.](javascript:AL_get(this, 'jour', 'JAMA.');) 2008 Mar
5;299(9):1036-45. <http://www.ncbi.nlm.nih.gov/pubmed/18319414>

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

#### Associations between subjective night sweats and sleep study findings {#associations-between-subjective-night-sweats-and-sleep-study-findings-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### CONCLUSIONS: Subjective night sweats are associated with a variety of other sleep-related symptoms, but we could find no evidence for an association between subjective night sweats and objective evidence of specific sleep disorders. {#conclusions-subjective-night-sweats-are-associated-with-a-variety-of-other-sleep-related-symptoms-but-we-could-find-no-evidence-for-an-association-between-subjective-night-sweats-and-objective-evidence-of-specific-sleep-disorders. .Style-Heading-4-+-Arial-14-pt-Underline}

[Mold
JW](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Mold JW"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus)
et al Associations between subjective night sweats and sleep study
findings. J Am Board Fam Med. 2008 Mar-Apr;21(2):96-100.
<http://www.ncbi.nlm.nih.gov/pubmed/18343856?dopt=Abstract>

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

#### The Beneficial Effect of Hormone Therapy on Mortality and Coronary Heart Disease in Younger versus Older Postmenopausal Women {#the-beneficial-effect-of-hormone-therapy-on-mortality-and-coronary-heart-disease-in-younger-versus-older-postmenopausal-women .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.medscape.com/viewarticle/569935?src=mp**](http://www.medscape.com/viewarticle/569935?src=mp) {#httpwww.medscape.comviewarticle569935srcmp .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Black Cohosh and Menopausal Symptoms: [Cases in CAM](http://www.medscape.com/px/viewindex/more?Bucket=columns&SectionId=3089) {#black-cohosh-and-menopausal-symptoms-cases-in-cam-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### What\'s the evidence regarding black cohosh? Your older female patients may be using it. {#whats-the-evidence-regarding-black-cohosh-your-older-female-patients-may-be-using-it. .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.medscape.com/viewarticle/569485**](http://www.medscape.com/viewarticle/569485) {#httpwww.medscape.comviewarticle569485 .Style-Heading-4-+-Arial-14-pt-Underline}

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

# FDA Goes After \'Natural\' HRT Claims

Federal regulators warned several pharmacy companies Wednesday to stop
marketing so-called \"natural\" hormone replacement therapy, calling
their sales to women \"false and misleading.\"

#### [**http://www.medscape.com/viewarticle/568648?src=sr**](http://www.medscape.com/viewarticle/568648?src=sr) {#httpwww.medscape.comviewarticle568648srcsr .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Midwives Corner** **Lisa Allee, CNM, 4 Corners Regional Health Center,
Red Mesa, AZ**

**Midwives Excel at Keeping Birth Normal, and Midwife-Provided
Acupuncture Helps With PROM**

Amy Romano, CNM with the Lamaze Institute for Normal Birth presents four
fabulous studies in a review of research that further support the
extensive benefits of normal birth.

The first study convincingly shows that midwifery care is more effective
in keeping birth normal and, thus, women healthier. The study focused on
care for women at moderate obstetrical risk. This prospective cohort
study made use of an intriguing new tool called the "Optimality
Index-US" which assesses care processes as well as outcomes giving
better information than just mortality and morbidity. The study found
provider type to be predictive of optimality with midwifery care having
higher scores. For example: "The cesarean-section rate was 13% among
women in the midwife group versus 34% in the physician group, a
difference that also was not explained by health status alone. (The
rates were 5.6% and 15.6%, respectively, after excluding women with
preexisting chronic medical conditions.) In various statistical
analyses, only type of provider accurately predicted cesarean rates in
the two groups." As to why this may have been true some of the processes
of care looked at included: "Compared to women in the physician group,
women in the midwife group were more likely to drink or eat (95% vs.
80%); maintain mobility in labor (68% vs. 28%); and use nonpharmacologic
methods of pain relief (88% vs. 51%). Epidural use was lower in the
midwife group than in the physician group (31% vs. 51%), as was use of
any pharmacologic pain-relief methods (64% vs. 82%)." Romano concludes
her review with the following: "In this and other studies, midwifery
care has been associated with high optimality, demonstrating appropriate
use of interventions and good outcomes given the individual women\'s
clinical situations. Midwives are often assumed to care for only
low-risk women, but many midwives also care for women at moderate or
high risk. This study finds that midwifery may be optimal for a
moderate-risk population by promoting good outcomes with less reliance
on technological and surgical intervention and greater attention to the
care practices that support normal birth." This certainly rings very
true for midwifery in the Indian Health Service---we care for women of
all risk levels and have impressive outcomes and I would bet
"optimality" scores as well. Anyone ready to do the research with this
new tool?

The second study looked at third and forth degree perineal tears and
again found the less interventionist path to be the preferred route.
They looked at six modifiable factors\-- forceps, vacuum, episiotomy,
prolonged second-stage labor, fetal occiput posterior position during
crowning, and epidural---and found that avoiding these individually and
definitely in combination helped prevent third and forth degree tears.
In her assessment of this study in regards to normal birth Romano says:
"Third- and fourth-degree anal tears are highly associated with pain and
incontinence in the postpartum period and contribute to long-term pelvic
floor dysfunction. Unfortunately, this argument has fueled the debate
about the rights of women to choose medically unnecessary cesarean
surgeries rather than prompting examination of the obstetric management
practices that contribute to excess risk of anal sphincter damage in
vaginal births. This study provides evidence of a strong link between
modifiable obstetric practices such as episiotomy, epidural use, and
instrumental vaginal birth and anal sphincter tears. This study also
reinforces that, when instrumental vaginal birth becomes necessary,
episiotomy should be avoided and vacuum extraction is less likely to
injure the anal sphincter than forceps birth. Although some instances
will always occur when these interventions are necessary for fetal or
maternal well-being, their overuse contributes to excess maternal
morbidity with long-term consequences. Care practices such as avoiding
routine interventions, promoting comfort in labor through mobility and
nonpharmacologic techniques, and encouraging physiologic, spontaneous
pushing in nonsupine positions (none of which were assessed in this
study) minimize the risk of severe lacerations both directly in the case
of spontaneous nonsupine pushing and indirectly, by reducing the need
for epidural, promoting optimal positioning of the fetus, and reducing
forceps and vacuum use." Again these are all aspects of the midwifery
model of care.

The third study looked at midwives providing a 20-minute acupuncture
treatment to women with PROM. The women in the treatment group had
significantly shorter active labor---4.4 hours vs. 6.1 hours---and the
relationship was even stronger when they controlled for parity, epidural
use, and infant birth weight. For women who were induced the active
phase in the control group was *twice* as long as in the acupuncture
group and acupuncture was associated with less augmentation of labor as
well. This study was small but the results are impressive. Romano makes
some very meaningful conclusions as to the relevance of this to the
promotion of normal birth: "Although the majority of women will go into
labor on their own after membranes rupture at term, many providers
encourage pharmacologic induction out of concern about infection.
Minimal evidence suggests that a policy of routine induction for PROM
prevents infection, and several studies report an increase in cesarean
rates with induction for PROM versus expectant management. Furthermore,
pharmacologic induction always requires other interventions such as
intravenous lines, electronic fetal monitoring, and restrictions on
mobility in labor, transforming a normal birth into a medicalized one
and introducing potentially unnecessary risks. Low-risk techniques to
encourage labor to start may be beneficial in preventing complications
of both prolonged membrane rupture\` and aggressive induction protocols.
This small but well-designed study suggests that acupuncture treatment
influences labor initiation and progress in women with PROM. A larger
trial may be able to confirm an effect on mode of birth, rates of
induction, and likelihood of infection. However, in the meantime, the
fact that acupuncture has not been shown to be harmful to birthing women
or their newborns suggests that it is an optimal first-line approach
when the option of encouraging labor to start is desirable." Some IHS
sites are providing acupuncture services (finally!) for patients. I
think it behooves midwives to work with acupuncture providers in IHS
and/or outside IHS to get trained in this technique of promoting labor.

The forth study was published in the ACNM journal and looked at the
experience of women in early labor. The study's results and Romano's
comments are very encouraging for all of us to examine how we prepare
and care for women in early labor. Romano says: "For women who choose
hospital birth, mounting evidence suggests that their likelihood of
achieving vaginal birth is strongly influenced by how long they stay
home. However, simply advising women to stay home until active labor is
well established may contribute to anxiety and confusion if they are not
equipped with appropriate information, support, and anticipatory
guidance. This small study suggests that women spend energy and time in
early labor sorting out their expectations, devising new plans, managing
mixed emotions, and second-guessing decisions. Providing women with
strategies to anticipate and deal with gaps between expectations and
experiences may help them adapt better to early labor and have
confidence in their management strategies. Reassessing how childbirth
educators teach women to self-diagnose labor---or introducing models
that include home visitation or outpatient early-labor assessment and
support, as proposed by the study authors---may help women who choose
hospital birth to optimize the timing of hospitalization to achieve
normal births." I highly recommend that each midwifery service in IHS
read this study, examine how early labor is talked about with patients
in classes, groups, or clinic, and how early labor triaging and care is
provided for in the labor and birthing areas.

Romano, A., Research Summaries for Normal Birth, J Perinat Educ. 2007
Spring; 16(2): 47--50.

<http://www.ncbi.nlm.nih.gov/pubmed/18311339>

**Women given sterile water injection experience less labor pain
compared to acupuncture**

RESULTS: The main results of this study were that sterile water
injections yielded greater pain relief (p\<0.001) during childbirth
compared to acupuncture. The secondary outcome showed that women in the
sterile water group had a higher degree of relaxation (p\<0.001)
compared to the acupuncture group. The women\'s own assessment of the
effects also favoured sterile water injections (p\<0.001). There were no
significant differences regarding requirements for additional pain
relief after treatment between the 2 groups. CONCLUSIONS: Women given
sterile water injection experience less labour pain compared to women
given acupuncture.

[Mårtensson
L](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Mårtensson L"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus)
et al Acupuncture versus subcutaneous injections of sterile water as
treatment for labour pain. Acta Obstet Gynecol Scand. 2008;87(2):171-7.
<http://www.ncbi.nlm.nih.gov/pubmed/18231884>

**Irrespective of treatment, pelvic girdle pain regresses in majority by
12 weeks after delivery**

RESULTS: Approximately three-quarters of all the women were free of pain
3 weeks after delivery. There were no differences in recovery between
the 3 treatment groups. According to the detailed physical examination,
pelvic girdle pain had resolved in 99% of the women 12 weeks after
delivery. CONCLUSIONS: This study shows that irrespective of treatment
modality, regression of pelvic girdle pain occurs in the great majority
of women within 12 weeks after delivery.

[Elden
H](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Elden H"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus)
et al Regression of pelvic girdle pain after delivery: follow-up of a
randomised single blind controlled trial with different treatment
modalities. Acta Obstet Gynecol Scand. 2008;87(2):201-8.

<http://www.ncbi.nlm.nih.gov/pubmed/18231889>

**Cervical Cancer Screening Practices of Certified Nurse-Midwives in the
United States**

Many nurse-midwives initiate cervical cancer screening earlier than
guidelines recommend; 72% would initiate screening in an 18-year-old
within 1 month of coitarche, while 36% would begin screening virginal
girls at age 18, and many continue cervical cancer screening after
guidelines recommend cessation. More than 60% of the respondents would
continue screening a woman who had undergone total hysterectomy for
symptomatic fibroids who had no history of dysplasia, and half would
continue to screen a 70-year-old woman with a 30-year history of
previous normal Pap tests. In addition, despite guidelines which
recommend less frequent screening, more than one-quarter (28%) would
continue annual screening in a 35-year-old woman with three or more
normal tests. Certified nurse-midwives are performing cervical cancer
screening more frequently than current guidelines recommend. Comparisons
to the practice of other providers are offered. Education to limit
unnecessary testing is needed.

[Murphy
PA](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Murphy PA"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus)
et al Cervical cancer screening practices of certified nurse-midwives in
the United States. J Midwifery Womens Health. 2008 Jan-Feb;53(1):11-8.
<http://www.ncbi.nlm.nih.gov/pubmed/18164429>

**Navajo News Jean Howe, Chinle**

**Sexual Assault Nurse Examiner (SANE) Training Course, June 9 -- 13,
2008**

Navajo Nation Museum, Window Rock, Arizona.

 

This 5-day intensive training course will focus on the basic forensic
medical examination techniques and issues in providing care for adult
and adolescent victims of sexual assault. It will provide nurses and
other licensed healthcare professionals with the didactic training
necessary for certification as a Sexual Assault Nurse Examiner (SANE) or
a Sexual Assault Forensic Examiner (SAFE) and discuss next steps after
training. Strategies for developing a multi-disciplinary Sexual Assault
Response Team (SART) will also be reviewed.

 

This course provides the classroom curriculum portion of SANE/SAFE
training. For nurses or other healthcare professionals who do not
routinely perform pelvic examinations, practical experience to acquire
pelvic examination skills should be arranged outside of this course. It
would be beneficial to begin this process prior to attending the course
if possible. After completion of the course, proctoring is also strongly
recommended for the initial forensic examinations performed.

 

This course is open to Indian Health Service healthcare professionals,
including nurses, advanced practice nurses, PAs, and physicians. A
brochure and registration forms will be available soon, as well as
information on lodging. There is no fee to attend the course.
Transportation, lodging, and per diem are the responsibility of the home
health system or individual.

 

This course is being co-sponsored by Carolyn Aoyama, Senior Consultant
for Women's Health and Advanced Practice Nursing Program at IHS
Headquarters and by the Chinle Family Violence Prevention Task Force and
the Navajo-Hopi-Zuni SANE/SART Work Group. For questions about content,
please contact Sharon Jackson (<Sharon.jackson@ihs.gov>) or Sandra Dodge
(<Sandra.dodge@ihs.gov>). For questions about registration or logistics,
please contact Alberta Gorman (<Alberta.gorman@ihs.gov>).

IHS and Tribal sites throughout the Four Corners area are working with
the Northern Arizona Center Against Sexual Assault to formulate an
integrated approach to sexual assault. This training is a part of that
effort. The goal is to have SANE and SART services available throughout
the Four Corners area. 

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

**Nurses Corner Sandra Haldane, HQE**

#### Call for nominations of nurses working in Indian health: Deadlines looming {#call-for-nominations-of-nurses-working-in-indian-health-deadlines-looming-1 .Style-Heading-4-+-Arial-14-pt-Underline}

The National Nurse Leadership Council (NNLC) is happy to call for award
nominations of nurses working in Indian Health Service, Tribal, or Urban
Indian Health Programs.  Awards will be given in the following
categories:

-   Nurse Administrator

-   Advanced Practice Nurse

-   Clinical Nurse

-   Public Health Nurse

-   Ancillary Nurse Assistant

-   Nursing Group

-   Special Friend of Nursing

These Awards will be presented at the Nurse Leadership in Native Care
(NLiNC) meeting, formerly NCONA, in Anchorage, AK, May 14, 2008.  Please
see the attached documents for the nominations form and criteria. 
Nomination deadline for these awards is **[ASAP]{.underline}**.  Travel
costs to receive these awards, with the exception of the Chief Nurse
Officer Awards, will be picked up by the IHS Headquarters Division of
Nursing.  Your assistance in disseminating this call for nominations as
well as for nominating one or several of the outstanding nurses we have
in the Indian health system is greatly appreciated.    

#### [**Sandra.Haldane@IHS.GOV**](mailto:Sandra.Haldane@IHS.GOV) {#sandra.haldaneihs.gov .Style-Heading-4-+-Arial-14-pt-Underline}

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

**Please consider nominating our incredible IHS (CO, CS, Tribal) nurses
for the following awards**

Deadline for submission is April 4. 

**Mabel May Wagner Award**

This award, established in 1979, is open to all professional nurses in
the PHS who are engaged in clinical nursing practice.  The award
consists of an engraved plaque and \$1000 in cash.  The award is
presented annually at the COA Symposium to a professional nurse in the
Public Health Service (Commissioned Corps, Tribal or Civil Service) who:

\* Exemplifies resourcefulness and dedication in helping to accomplish
the mission of the Public Health Service;

\* Demonstrates professional and technical skills and competence raising
the quality of nursing;

\* Displays evidence of exceptional ability to apply nursing standards
of practice;

\* Remains involved in continuing education as a participant, organizer
or sponsor of it;

\* Is of such excellence as to merit Public Health Service recognition.

Nominations:

Nominations may be made by an HHS employee or employee where the nurse
officer, tribal nurse or civil service nurse is detailed, in the form of
a letter containing:

\* Name, title and grade or rank of the nominee;

\* Work experience and educational background of the nominee;

\* A brief description of the nominee's present duties and
responsibilities including the scope of work;

\* A narrative statement of how the person meets the criteria for the
award including a description of the specific accomplishments and/or
contributions on which the nomination is based as well as exploring
current practice vs. lifetime achievement.  The achievements for which
the nurse is being recognized should be within the last three years. 

\* Must state, in writing, that the individual is in good standing and
has an active RN license on file (for Commissioned Corps officers in
must be on file with DCP); and

\* An endorsement by the nominee's supervisor (responsible for ensuring
the candidate's good standing and work performance) and the final
verification (for the recommended award recipient) will be by the Chief
Nurse Officer (who will check with DCP to ensure that there are no
outstanding actions and that an active license is on file).

\* Award nominations should be limited to two pages.

The deadline for receipt of nominations for the 27th annual Mabel May
Wagner Nursing Award is April 4, 2008.  Please send nominations via
email to CDR Suzanne England, COA Team Leader, at <suzieq@gwtc.net>

#### Lucille Woodville Award {#lucille-woodville-award .Style-Heading-4-+-Arial-14-pt-Underline}

#### This award was established in the Public Health Service\'s (PHS) centennial year as a memorial to the professional career of Lucille Woodville, who began her illustrious career in the Indian Health Service (IHS) in 1956.  As part of her work in IHS, Ms. Woodville established the first Nurse Midwifery Service in Bethel, Alaska.  She retired in 1973, after serving as Assistant Chief (1964-1971) and Chief (1971-1973) of the Maternal Child Health Branch, Division of Indian Health, Health Resources Services Administration, of the PHS. {#this-award-was-established-in-the-public-health-services-phs-centennial-year-as-a-memorial-to-the-professional-career-of-lucille-woodville-who-began-her-illustrious-career-in-the-indian-health-service-ihs-in-1956.-as-part-of-her-work-in-ihs-ms.-woodville-established-the-first-nurse-midwifery-service-in-bethel-alaska.-she-retired-in-1973-after-serving-as-assistant-chief-1964-1971-and-chief-1971-1973-of-the-maternal-child-health-branch-division-of-indian-health-health-resources-services-administration-of-the-phs. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### This award honors a nurse midwife or a maternal/child health nurse whose work has resulted in significant contribution to the health and well-being of mothers and newborns. Each nominee must demonstrate outstanding contributions in improving maternal/child health.  This contribution may be the commitment of their time and skills in the clinical setting, or may be in the design, implementation and/or management of innovative maternal/child health programs.  All registered nurses,  Civil Service, Tribal and Commissioned Corps, are eligible for the award.  Any employer or employee of the PHS or Associate of a PHS contract or grant program may nominate a PHS nurse for this award. {#this-award-honors-a-nurse-midwife-or-a-maternalchild-health-nurse-whose-work-has-resulted-in-significant-contribution-to-the-health-and-well-being-of-mothers-and-newborns.-each-nominee-must-demonstrate-outstanding-contributions-in-improving-maternalchild-health.-this-contribution-may-be-the-commitment-of-their-time-and-skills-in-the-clinical-setting-or-may-be-in-the-design-implementation-andor-management-of-innovative-maternalchild-health-programs.-all-registered-nurses-civil-service-tribal-and-commissioned-corps-are-eligible-for-the-award.-any-employer-or-employee-of-the-phs-or-associate-of-a-phs-contract-or-grant-program-may-nominate-a-phs-nurse-for-this-award. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### Nominations: {#nominations .Style-Heading-4-+-Arial-14-pt-Underline}

#### Nominations may be made by an HHS employee or employee where the nurse officer, tribal or civil service nurse is detailed, in the form of a letter containing: {#nominations-may-be-made-by-an-hhs-employee-or-employee-where-the-nurse-officer-tribal-or-civil-service-nurse-is-detailed-in-the-form-of-a-letter-containing .Style-Heading-4-+-Arial-14-pt-Underline}

#### \* Name, title and grade or rank of the nominee; {#name-title-and-grade-or-rank-of-the-nominee .Style-Heading-4-+-Arial-14-pt-Underline}

#### \* Work experience and educational background of the nominee; {#work-experience-and-educational-background-of-the-nominee .Style-Heading-4-+-Arial-14-pt-Underline}

#### \* A brief description of the nominee's present duties and responsibilities including the scope of work; {#a-brief-description-of-the-nominees-present-duties-and-responsibilities-including-the-scope-of-work .Style-Heading-4-+-Arial-14-pt-Underline}

#### \* A narrative statement of how the person meets the criteria for the award including a description of the specific accomplishments and/or contributions on which the nomination is based. {#a-narrative-statement-of-how-the-person-meets-the-criteria-for-the-award-including-a-description-of-the-specific-accomplishments-andor-contributions-on-which-the-nomination-is-based. .Style-Heading-4-+-Arial-14-pt-Underline}

#### \* Must state, in writing, that the individual is in good standing and has an active RN license on file (for Commissioned Corps officers in must be on file with DCP); and {#must-state-in-writing-that-the-individual-is-in-good-standing-and-has-an-active-rn-license-on-file-for-commissioned-corps-officers-in-must-be-on-file-with-dcp-and .Style-Heading-4-+-Arial-14-pt-Underline}

#### \* An endorsement by the nominee's supervisor (responsible for ensuring the candidate's good standing and work performance) and the final verification (for the recommended award recipient) will be by the Chief Nurse Officer (who will check with DCP to ensure that there are no outstanding actions and that an active license is on file). {#an-endorsement-by-the-nominees-supervisor-responsible-for-ensuring-the-candidates-good-standing-and-work-performance-and-the-final-verification-for-the-recommended-award-recipient-will-be-by-the-chief-nurse-officer-who-will-check-with-dcp-to-ensure-that-there-are-no-outstanding-actions-and-that-an-active-license-is-on-file. .Style-Heading-4-+-Arial-14-pt-Underline}

#### \* Award nominations should be limited to two pages. {#award-nominations-should-be-limited-to-two-pages. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### The award is presented annually at the COA Symposium. {#the-award-is-presented-annually-at-the-coa-symposium. .Style-Heading-4-+-Arial-14-pt-Underline}

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

#### The deadline for receipt of nominations for the Lucille Woodville Nursing Award is April 4, 2008.  Please send nominations via email to CDR Suzanne England, COA Team Leader, at [**suzieq@gwtc.net**](mailto:suzieq@gwtc.net). {#the-deadline-for-receipt-of-nominations-for-the-lucille-woodville-nursing-award-is-april-4-2008.-please-send-nominations-via-email-to-cdr-suzanne-england-coa-team-leader-at-suzieqgwtc.net. .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-45 .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}

#### April 7 -- 13^th^ is National Public Health Week {#april-7-13th-is-national-public-health-week-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### This year's focus is on Climate Change and it's effect on vulnerable populations.  {#this-years-focus-is-on-climate-change-and-its-effect-on-vulnerable-populations. .Style-Heading-4-+-Arial-14-pt-Underline}

#### More information on planning events for your community is available at: [**http://www.nphw.org/nphw08/08_pg_ideas.htm**](http://www.nphw.org/nphw08/08_pg_ideas.htm)  {#more-information-on-planning-events-for-your-community-is-available-at-httpwww.nphw.orgnphw0808_pg_ideas.htm .Style-Heading-4-+-Arial-14-pt-Underline}

####  {#section-46 .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}

**Prenatal Care in Oklahoma**

A study released last fall compared the state of Oklahoma statistics of
Native American women receiving prenatal care versus White women. The
study showed a significant increase in the numbers of Native American
women receiving prenatal care since the previous study was done in 1994.
Today 76.7% of Native American women receive prenatal care in the first
trimester, not significantly different from White women (78.8%). This
improvement is greatly attributed to the significant improvement in
access to care through construction of new and expansion of existing
Indian Health Service, Tribal and Urban Health facilities. Barriers to
care included in decreasing order: Lack of pregnancy recognition
(51.8%), inability to get an earlier appointment (21.2%) and no Medicaid
card (16.7%).

Other Statistics

Native American women were more likely to have their first baby before
18 (24.5% versus 14.3%)

Number one barrier to obtaining prenatal care as early as desired for
Native American mothers was "I didn't know I was pregnant".

[http://www.ok.gov/health/documents/PRAMS_Native%20Am_2007.pdf](http://www.ok.gov/health/documents/PRAMS_Native Am_2007.pdf)

or

<http://www.tulsaworld.com/news/article.aspx?articleID=071213_1_A24_hAnew76523>

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

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

#### Drugs that affect bone metabolism {#drugs-that-affect-bone-metabolism-1 .Style-Heading-4-+-Arial-14-pt-Underline}

Many drugs can affect bone metabolism. As an example,
[heparin](http://www.uptodateonline.com/utd/content/topic.do?topicKey=drug_a_k/121468&drug=true),
[warfarin](http://www.uptodateonline.com/utd/content/topic.do?topicKey=drug_l_z/280743&drug=true),
[cyclosporine](http://www.uptodateonline.com/utd/content/topic.do?topicKey=drug_a_k/47003&drug=true),
[glucocorticoids](http://www.uptodateonline.com/utd/content/topic.do?topicKey=drug_l_z/209553&drug=true),
[medroxyprogesterone
acetate](http://www.uptodateonline.com/utd/content/topic.do?topicKey=drug_l_z/154223&drug=true),
cancer drugs and thyroid hormone can cause bone loss, while [thiazide
diuretics](http://www.uptodateonline.com/utd/content/topic.do?topicKey=drug_a_k/124238&drug=true)
can minimize bone loss

<http://www.uptodateonline.com/utd/content/topic.do?topicKey=minmetab/15467>

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

**Treating Depression: What You Should Know**

<http://www.aafp.org/afp/20080315/785.html>

# 

# Self-management: Taking Charge of Your Health

<http://familydoctor.org/online/famdocen/home/healthy/prevention/785.html>

####  {#section-49 .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}

**What is this all about the 'minor markers' for Down Syndrome?**

I just wanted to share some info with you (that you may already know)
about sonographic 2nd trimester markers for fetal Down syndrome and
their significance.

The minor markers: echogenic intraventricular focus (EIF), choroids
plexus cyst (CPC), 'sandal-gap' toes, pyelectasis, clinodactyly, etc.
are poor predictors of DS (but excellent predictors of overwhelming
maternal anxiety!). They are found in about 1% of normal fetuses between
15-20 wks. Younger women (\<35 y/o) with a negative quad screen are at
very low risk if they have one of these minor markers; amnio is not
recommended for this group.

An enlarged nuchal thickness (NT), echogenic bowel, more than one
marker, or any anomaly, are stronger predictors. Older women (\>35 y/o),
with or without a positive quad screen, are at higher risk with even a
minor marker however, and counseling about amnio may be appropriate for
this group.

The EIF is often the most worrisome to women; they should be reassured
that it is NOT a marker that something is wrong with the baby's heart;
and they do NOT need fetal echocardiography for follow up. They should
also be reassured that a CPC does not mean there is something wrong with
their baby's brain! Nevertheless, if the patient is anxious about these
findings, it would be appropriate to obtain a follow up scan to reassure
the patient that the marker has resolved.

Attached is a chart of the relative risks of each of the markers. Notice
that a negative ultrasound (no markers found) will actually lower the
pt's risk (RR = 0.6) and should be reassuring (although it can't be 100%
so.....).

Also, as more patients get 1st trimester testing (to include BOTH nuchal
translucency and PAPP-A and free bHCG at 11-13 wks, not just NT), it is
important to know that that's all they need; 2nd trimester testing is
NOT indicated.  If the results of 1st trimester screening are negative,
no further (noninvasive) testing is indicated, and 2nd trimester testing
will then only increase the number of false positives.

# Trisomy-21 (Down syndrome) Second Trimester Ultrasonographic Markers

RR

-   thickened nuchal fold\* 19.0

-   short femur 2.3

-   short humerus 2.5

-   cardiac abnormality (VSD, AV canal, Tetralogy) 25.0

-   echogenic bowel 5.5

-   choroid plexus cyst 1.5

-   hypoplasia of the middle phalanx of the 5th finger (clinodactyly)
    1.5

-   widened iliac wings

-   echogenic intracardiac focus 1.5

-   pyelectasis 1.5

-   sandal gap toes

-   double bubble sign of duodenal atresia (usually 3rd trimester)

-   absent nasal bone

\- 2-vessel umbilical cord

\- normal scan/no markers 0.6

\* NF by GA

> Weeks Mean 95th%
>
> 16 2.8 4
>
> 17 3.0 5
>
> 18 3.3 5
>
> 19 3.6 5
>
> 20 3.7 6
>
> 21 3.9 6

# Trisomy-21 (Down syndrome) Second Trimester Ultrasonographic Markers

RR

-   thickened nuchal fold\* 19.0

-   short femur 2.3

-   short humerus 2.5

-   cardiac abnormality (VSD, AV canal, Tetralogy) 25.0

-   echogenic bowel 5.5

-   choroid plexus cyst 1.5

-   hypoplasia of the middle phalanx of the 5th finger (clinodactyly)
    1.5

-   widened iliac wings

-   echogenic intracardiac focus 1.5

-   pyelectasis 1.5

-   sandal gap toes

-   double bubble sign of duodenal atresia (usually 3rd trimester)

-   absent nasal bone

\- 2-vessel umbilical cord

\- normal scan/no markers 0.4

Multiple markers increase the likelihood of DS: LR

Two markers 10

\> 3 markers 115

\* Nuchal Fold by GA

> Weeks Mean 95th%
>
> 16 2.8 4
>
> 17 3.0 5
>
> 18 3.3 5
>
> 19 3.6 5
>
> 20 3.7 6
>
> 21 3.9 6

In a meta-analysis of 2nd trimester ultrasound to detect fetuses with
Down syndrome (Smith-Bindman R, et al. JAMA 2001 (N=132,295; DS
incidence =1.5%) the following information was derived:

In the absence of a major anomaly, the US markers had the following
diagnostic values: sensitivity: 69%; FPR: 8%; PPV 1.5%; NPV: 99%

Smith-Bindman R, et al. Second-trimester ultrasound to detect fetuses
with Down syndrome: a meta-analysis. JAMA. 2001 Feb 28;285(8):1044-55.
<http://www.ncbi.nlm.nih.gov/pubmed/11209176>

**Tobacco use increases the risk of a SGA infant at term across maternal
strata**

CONCLUSION: Self-identified tobacco use increases the risk of a SGA
infant at term across maternal strata.

[Aagaard-Tillery
KM](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Aagaard-Tillery KM"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus)
et al In utero tobacco exposure is associated with modified effects of
maternal factors on fetal growth. Am J Obstet Gynecol. 2008
Jan;198(1):66 <http://www.ncbi.nlm.nih.gov/pubmed/18166310>

#### Primary Care Discussion Forum Ann Bullock, Cherokee, NC {#primary-care-discussion-forum-ann-bullock-cherokee-nc .Style-Heading-4-+-Arial-14-pt-Underline}

**Topic:** **Mental health issues in children and adolescents**

** **

**When:** Discussion ongoing now. Still time to join in

 

**Moderator**: Dr. Frank Armao, Psychiatry staff at Winslow

 

**Salient points for discussion**

-The complex influence of early life stress and trauma in shaping
development.

-The increased burden of developmental stress as it pertains to Native
Americans.

-How to distinguish teens with relatively normal perturbation in
development from those needing more intensive management and/or referral
to behavioral health.

-What constitutes a significant mood disorder in an adolescent, and what
are the options for management.

-The serious limitations of DSM-IV and current nosology in "diagnosing"
adolescent behavioral health conditions.

 

**Primary Care Discussion Forum website**

[http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForum.cfm](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForum.cfm)

** **

### 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](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.ihs.gov/cio/listserver/index.cfm?module=list%26option=list%26num=46%26startrow=51)

 

Unsubscribe from the Primary Care listserv

[http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=51](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.ihs.gov/cio/listserver/index.cfm?module=list%26option=list%26num=46%26startrow=51)

 

Questions on how to subscribe, contact <ANNBULL@nc-cherokee.com>
directly

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

USPSTF Recommendations for STI Screening

Since 2000, the U.S. Preventive Services Task Force (USPSTF) has issued
eight clinical recommendation statements on screening for sexually
transmitted infections. This article, written on behalf of the USPSTF,
is an overview of these recommendations. The USPSTF recommends that
women at increased risk of infection be screened for chlamydia,
gonorrhea, human immunodeficiency virus, and syphilis. Men at increased
risk should be screened for human immunodeficiency virus and syphilis.
All pregnant women should be screened for hepatitis B, human
immunodeficiency virus, and syphilis; pregnant women at increased risk
also should be screened for chlamydia and gonorrhea. Nonpregnant women
and men not at increased risk do not require routine screening for
sexually transmitted infections. Engaging in high-risk sexual behavior
places persons at increased risk of sexually transmitted infections. The
USPSTF recommends that all sexually active women younger than 25 years
be considered at increased risk of chlamydia and gonorrhea. Because not
all communities present equal risk of sexually transmitted infections,
the USPSTF encourages physicians to consider expanding or limiting the
routine sexually transmitted infection screening they provide based on
the community and populations they serve.

Am Fam Physician. 2008;77(6):819-824.
<http://www.aafp.org/afp/20080315/819.html>

ACS Releases Guidelines for HPV Vaccination

The American Cancer Society (ACS) guideline for the early detection of
cervical cancer was last reviewed and updated in 2002.^1^ Since then,
two vaccines against the most common cancer-causing types of human
papillomavirus (HPV) have been developed and tested in clinical trials
(i.e., quadrivalent HPV vaccine \[Gardasil\] and bivalent HPV vaccine
\[Cervarix\], not yet approved by the U.S. Food and Drug Administration
\[FDA\]).^2-7^ An expert panel was convened by the ACS to review the
data on HPV vaccines and to develop recommendations for their use.^8^
This group worked independently from the Advisory Committee on
Immunization Practices (ACIP) of the Centers for Disease Control and
Prevention, but reviewed the same data sources. Recommendations from
both groups for the use of the quadrivalent HPV vaccine were published
in 2007 and are summarized in *Table 1*.^2-4,8-10^ The ACIP
recommendations, which the American Academy of Family Physicians
endorses, apply specifically to the quadrivalent vaccine because it
currently is the only FDA-approved HPV vaccine. The ACS recommendations
are meant to include the quadrivalent vaccine and, pending FDA approval,
the bivalent vaccine.

<http://www.aafp.org/afp/20080315/practice.html>

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

#### Management of HIV Infection in Special Populations {#management-of-hiv-infection-in-special-populations-1 .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.medscape.com/viewprogram/8951?src=nlcmealert&spon=1&uac=77433SY**](http://www.medscape.com/viewprogram/8951?src=nlcmealert&spon=1&uac=77433SY) {#httpwww.medscape.comviewprogram8951srcnlcmealertspon1uac77433sy .Style-Heading-4-+-Arial-14-pt-Underline}

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

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

**Link between type 2 DM in adults and type 1 DM or pregnancy-related
diabetes in their mothers**

The rate of diabetes or pre-diabetes was 21 percent in subjects born to
mothers who had pregnancy-related diabetes (termed gestational
diabetes), 12 percent in those whose mothers had a genetic
predisposition for diabetes, 11 percent when the mothers had type 1
diabetes, and 4 percent in subjects born to women with no history of
gestational or other types of diabetes.

The findings support the idea that exposure to high blood sugar levels
in the womb contributes to the development of type 2 diabetes in
adulthood, the researchers conclude. Aiming for normal blood glucose
levels in pregnant women \"may reduce the risk of type 2 diabetes in
future generations.\"

CONCLUSIONS: A hyperglycemic intrauterine environment appears to be
involved in the pathogenesis of type 2 diabetes/pre-diabetes in adult
offspring of primarily Caucasian women with either diet-treated GDM or
type 1 diabetes during pregnancy.

[Clausen
TD](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Clausen TD"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus)
et al High prevalence of type 2 diabetes and pre-diabetes in adult
offspring of women with gestational diabetes mellitus or type 1
diabetes: the role of intrauterine hyperglycemia.

Diabetes Care. 2008 Feb;31(2):340-6.
<http://www.ncbi.nlm.nih.gov/pubmed/18000174>

####  {#section-52 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Joslin Study Finds Restricting Insulin Doses Increases Mortality Risk {#joslin-study-finds-restricting-insulin-doses-increases-mortality-risk-1 .Style-Heading-4-+-Arial-14-pt-Underline}

Study highlights important women's health issue in diabetes and says
behavior occurs in context of eating disorder symptoms. A new study led
by researchers at the Joslin Diabetes Center has found that women with
type 1 diabetes who reported taking less insulin than prescribed had a
three-fold increased risk of death and higher rates of disease
complications than those who did not skip needed insulin shots.

CONCLUSIONS: Our data demonstrate that insulin restriction is associated
with increased rates of diabetes complications and increased mortality
risk. Mortality associated with insulin restriction appeared to occur in
the context of eating disorder symptoms, rather than other psychological
distress. We propose a screening question appropriate for routine
diabetes care to improve detection of this problem.

[Goebel-Fabbri
AE](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Goebel-Fabbri AE"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus),
et al Insulin restriction and associated morbidity and mortality in
women with type 1 diabetes. Diabetes Care. 2008 Mar;31(3):415-9.

<http://www.ncbi.nlm.nih.gov/pubmed/18070998>

####  {#section-53 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Low vitamin B12 in the first trimester and high folate in the second predispose insulin resistance {#low-vitamin-b12-in-the-first-trimester-and-high-folate-in-the-second-predispose-insulin-resistance-1 .Style-Heading-4-+-Arial-14-pt-Underline}

Insulin resistance at 6 years of age was significantly more common in
the offspring of mothers who had low B12 levels at 18 weeks and high
folate levels at 28 weeks of pregnancy, and was highest among those with
a combination of both.

Adiposity was greater among the offspring of mothers with higher folate
levels, they add.\
Increased plasma levels of homocysteine and methylmalonic acid as a
consequence of low plasma B12 results in lipogenesis, reduced protein
synthesis and reduced lean body mass, and may be the precursor of
insulin resistance, the researchers postulate. Epigenetic regulation,
involving DNA methylation, may be another mechanism of nutritional
programming.

An imbalance in the vitamin B12 and folic acid levels produces the
\"undesirable effects.\
Multigenerational vegetarianism means that vitamin B12 deficiency is
common in Indians, but folate deficiency is relatively rare. High folate
intakes in vitamin B12-deficient mothers could increase the risk of type
2 diabetes in the offspring.

The National Anemia Program recommends use of iron and folic acid in
pregnancy but ignores vitamin B12. This needs to be reconsidered and due
attention needs to be given to vitamin B12.

CONCLUSIONS / INTERPRETATION: Low maternal vitamin B(12) and high folate
status may contribute to the epidemic of adiposity and type 2 diabetes
in India.

[Yajnik
CS](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Yajnik CS"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus)
et al Vitamin B(12) and folate concentrations during pregnancy and
insulin resistance in the offspring: the Pune Maternal Nutrition Study.
Diabetologia. 2008 Jan;51(1):29-38.

<http://www.ncbi.nlm.nih.gov/pubmed/17851649>

#### Replacing sugar in diet sodas with reduced calorie sweeteners may make weight control harder {#replacing-sugar-in-diet-sodas-with-reduced-calorie-sweeteners-may-make-weight-control-harder-1 .Style-Heading-4-+-Arial-14-pt-Underline}

The data clearly indicate that consuming a food sweetened with
no-calorie saccharin can lead to greater body-weight gain and adiposity
than would consuming the same food sweetened with a higher-calorie
sugar," the authors wrote.

The authors acknowledge that this outcome may seem counterintuitive and
might not come as welcome news to human clinical researchers and
health-care practitioners, who have long recommended low- or no-calorie
sweeteners. What's more, the data come from rats, not humans. However,
they noted that their findings match emerging evidence that people who
drink more diet drinks are at higher risk for obesity and metabolic
syndrome, a collection of medical problems such as abdominal fat, high
blood pressure and insulin resistance that put people at risk for heart
disease and diabetes.

Why would a sugar substitute backfire?

Swithers and Davidson wrote that sweet foods provide a "salient
orosensory stimulus" that strongly predicts someone is about to take in
a lot of calories. Ingestive and digestive reflexes gear up for that
intake but when false sweetness isn't followed by lots of calories, the
system gets confused. Thus, people may eat more or expend less energy
than they otherwise would.

The good news, Swithers says, is that people can still count calories to
regulate intake and body weight. However, she sympathizes with the
dieter's lament that counting calories requires more conscious effort
than consuming low-calorie foods.\
Swithers adds that based on the lab's hypothesis, other artificial
sweeteners such as aspartame, sucralose and acesulfame K, which also
taste sweet but do not predict the delivery of calories, could have
similar effects. Finally, although the results are consistent with the
idea that humans would show similar effects, human study is required for
further demonstration.

[Conclusion]{.underline}

We found that reducing the correlation between sweet taste and the
caloric content of foods using artificial sweeteners in rats resulted in
increased caloric intake, increased body weight, and increased
adiposity, as well as diminished caloric compensation and blunted
thermic responses to sweet-tasting diets. These results suggest that
consumption of products containing artificial sweeteners may lead to
increased body weight and obesity by interfering with fundamental
homeostatic, physiological processes. (PsycINFO Database Record (c) 2008
APA, all rights reserved).

Susan E. Swithers, PhD and Terry L. Davidson, PhD, "A Role for Sweet
Taste: Calorie Predictive Relations in Energy Regulation by Rats,"
[Behav Neurosci.](javascript:AL_get(this, 'jour', 'Behav Neurosci.');)
2008 Feb;122(1):161-73.

#### [**http://www.ncbi.nlm.nih.gov/pubmed/18298259**](http://www.ncbi.nlm.nih.gov/pubmed/18298259) {#httpwww.ncbi.nlm.nih.govpubmed18298259 .Style-Heading-4-+-Arial-14-pt-Underline}

#### Women's Health Headlines Carolyn Aoyama, HQE {#womens-health-headlines-carolyn-aoyama-hqe .Style-Heading-4-+-Arial-14-pt-Underline}

**National Trends in the Perinatal and Infant Health of Rural American
Indians (AIs) and Alaska Natives (ANs): Have the Disparities Between
AI/ANs and Caucasians Narrowed?**

Major Findings:

-   Rates of inadequate prenatal care decreased for both AI/ANs and
    whites (figure), but a sizeable disparity between the groups
    persisted. Only two-thirds of rural AI/AN women

received first-trimester prenatal care in 1995-1997.

-   Rates of postneonatal death among rural AI/ANs decreased over time
    (figure), but again, a sizeable disparity between AI/ANs and whites
    persisted.

-   Preventable causes of death, predominantly infectious disease and
    sudden infant death syndrome, were largely responsible for
    AI/AN-white differences.

<http://depts.washington.edu/uwrhrc/uploads/RHRC_WP111_1Pager.pdf>

**Sacred Circle Handouts, Slides, and Training Materials available**

The slides really condense and explain the effect of colonial power on
indigenous culture and families. 

The slides came from Sacred Circle and they were used in a presentation
by Sarah Deer at the Tribal Law and Policy Institute.

Contact Carolyn Aoyama for copies <Carolyn.Aoyama@ihs.gov>

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

**IHS Basic Colposcopy Course**

-   April 9-11, 2008

-   Albuquerque, NM

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

**IHS Colposcopy Update & Refresher Course**

-   April 9-11, 2008

-   Albuquerque, NM

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

**Keeping Native Women and Families Healthy and Strong**

**Bemidji Area MCH Conference**

-   April 23-24, 2008

-   Milwaukee, WI

-   Great Lakes Tribal Epidemiology Center

-   E-mail contact <EpidemiologyCenter@gmail.com>

**Advances in Indian Health (AIH) Conference**

-   April 29-May 2, 2008

-   Albuquerque, NM

-   28 credits, Indian Country's Primary Care Conference

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

**Sexual Assault Nurse Examiner (SANE) Training Course**

-   June 9 -- 13, 2008

-   Navajo Nation Museum, Window Rock, Arizona

-   40 hour didactic portion of SANE/SAFE training

-   Contacts: Sharon Jackson <Sharon.jackson@ihs.gov>, Sandra Dodge
    <Sandra.dodge@ihs.gov>, or Alberta Gorman
    (<Alberta.gorman@ihs.gov>).

>  

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

[**Breastfeeding: US Breastfeeding Committee Strategic
Plan**](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/bf.cfm)

[http://www.ihs.gov/MedicalPrograms/MCH/M/bf.cfm](https://webmail.hhs.gov/exchweb/bin/redir.asp?URL=http://www.ihs.gov/MedicalPrograms/MCH/M/bf.cfm)

There are several upcoming **Conferences**

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

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

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

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

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

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

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

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

#### The March 2008 CCC Corner is available at: {#the-march-2008-ccc-corner-is-available-at .Style-Heading-4-+-Arial-14-pt-Underline}

#### [**http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08**](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=3_08) {#httpwww.ihs.govmedicalprogramsmchmob.cfmmodule3_08 .Style-Heading-4-+-Arial-14-pt-Underline}

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

-Minorities underrepresented in both public and private umbilical cord
blood banking

  

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

Burt Attico

#### More advantages with folic acid supplementation in pregnancy {#more-advantages-with-folic-acid-supplementation-in-pregnancy .Style-Heading-4-+-Arial-14-pt-Underline}

Sally Bremner

MRSA in the Community: A Growing Threat to Young People

Scott Giberson

-Antiretroviral Corner Articles

-Division of Behavioral Health HIV/AIDS Collaborative Regional Trainings
2008

-IHS HIV/AIDS Work Plan Released

-Early Planning Resources for National Native HIV/AIDS Awareness Day

-IHS HIV Podcast: Collaboration between DHHS Office of HIV/AIDS Policy
and IHS HIV Program

**Melissa Toffolon-Weiss**

HPV brochure for AI/AN: available for broad dissemination

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

##### Obstetrics page 10

-Evidence Favors Late Cord Clamping in Infants

-Continuous suturing for perineal closure vs interrupted methods - Less
pain

-Minor trauma in pregnancy: Commonly used measures not predictive

-Amphetamine hospitalizations doubled: Familiarize yourself with the
adverse outcomes

-Pregnant smokers reluctant to use smoking cessation medications
recommended

**Gynecology page 12**

-Biofeedback Reduces Psychological Burden in Older Women With Urge UI

-Not enough evidence to evaluate routine antibiotic prophylaxis with
SAB: Cochrane

-Intracervical catheter placement: Less pain during an saline infusion
sonohysterography

-Acupuncture in dysmenorrhea: improvements in pain and quality of life

-The diagnosis and management of endometrial cancer are reviewed

**Child Health page 13**

## -Sex education: Providers need to fill gaps in adolescent knowledge: Comment by Beth Crow

-Physical Activity Twice Weekly Helps Prevent Teens From Becoming
Overweight Adults

-Early menarche associated with increased all-cause mortality

-School-Associated Student Homicides \-\-- United States, 1992---2006

-Mediterranean diet in pregnancy helps ward off childhood asthma and
allergy

**Chronic Illness and Disease page 15**

-Diuretics most effective blood pressure medicine for people with
metabolic syndrome

-\'Aspirin resistance\' linked to increased cardiovascular events and
death

-Chantix (varenicline)- Associated With Reports Of Changes In Behavior:
FDA

-Older Women More Susceptible to Depression Than Older Men

-Chronic constipation more pronounced in women and the elderly

....and more

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

American College of Obstetricians and Gynecologists page 18

-Fatigue and Patient Safety

-ACOG Statement on Home Births

-Alcohol and Pregnancy: Know the Facts

-Asthma in Pregnancy

-Surrogate Motherhood

##### American Family Physician

-Treating Eating Disorders in Primary Care

-End-of-Life Care: Guidelines for Patient-Centered Communication

-CDC Reports on Lead Exposure in Women of Childbearing Age

-Dietary Supplements for Osteoarthritis

**Agency for Healthcare Research and Quality**

-Providers want to learn from mistakes but say current error-reporting
systems are inadequate

-Maternal, baby, and episiotomy factors contribute to high rates of
maternal birth trauma in Iowa

-Effectiveness of Second-Generation Antidepressants in Pharmacologic
Treatment

-Nurse midwives deliver more babies in hospitals than homes in
Washington State

-Study of young Head Start children links overweight to worsened asthma

**Ask a Librarian**

Cervical Cancer Community-Based Research Project in a Native American
Community

**Behavioral Health Insights**

PTSD: A technique that works for me

**Breastfeeding**

Promoting, Protecting, Supporting

**CCC Corner Digest**

\-[Concern for rising Cesarean rates in Native American
populations](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08aom)

\-[Save the Dates!! Earn up to 28 hours of CME/CE specific to Indian
Health](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08col)

\-[Knowledge of cervical length / fetal fibronectin: Shorter evaluation
and
PTB](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ht#ob)

\-[Misoprostol is as effective as manual vacuum aspiration in SAB of
\<12
weeks](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ht#gyn)

\-[Secondhand smoke during infancy linked in dose-response fashion with
allergies](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ht#child)

\-[\'Awake\' during surgery: Examining intraoperative
awareness](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ht#chrIll)

\-[Elective and risk--reducing
salpingo-oophorectomy](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#acog)

\-[Prevention and Treatment of Sexually Transmitted Diseases: An
Update](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#afp)

\-[Cervical Cancer Community-Based Research Project in a Native American
Community](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#lib)

\-[Autism
Screening](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#bhi)

\-[Breast Pumps: The good, the bad, and the
ugly](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#bf)

\-[National Report: National Indian Child
Welfare](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#dv)

\-[Palliative / End of Life Care Training- SAVE THE DATES -- March and
April
Courses](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#ecn)

\-[Continuous Oral Contraception May Not Reduce Bleeding Days but May
Improve
Sx](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#fp)

\-[New and Improved MCH Conferences page - More user
friendly](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#fws)

\-[Multiple Chlamydia species pose an unexpected challenge for blindness
prevention](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#ih)

\-[Insights on Implementing Cultural and Linguistic Competence in
MCH](http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn01.cfm?module=2008&option=janFeat#alert)

\-[Announcing the 2008 PREVENT Child Maltreatment
Institute](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#mchh)

\-[St. John\'s wort for depression in a young
woman](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#mmt)

\-[Smoking Status as a Predictor of Hip Fracture Risk in Postmenopausal
Women](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#meno)

\-[AI / AN women - successful at this; Evidence supports this; Women
benefit from
this](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#midw)

\-[Judy Whitecrane: Tireless Improvement of Care for Native American
women](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#midw)

\-[Biliary Gallstone Disease and
Pregnancy](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#navajo)

\-[AWHONN -- numerous on line courses -- materials and fees
listed](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#nCrnr)

\-[Cesarean Delivery: What are the risks and
benefits?](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#okp)

\-[Patients Prefer \"Tell Back- Collaborative Inquiry\" Method to Assess
Understanding](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#pi)

\-[Women with cardiovascular risk factors may be predisposed to
pre-eclampsia](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#peri)

\-[Mental health issues in children and adolescents --Starts in
March](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#pcf)

\-[The cervical cancer risk is still increased 25 years after treatment
for CIN
3](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#std)

\-[Resolving to Lose Weight in the New
Year?](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#still)

\-[Women\'s Leadership
Scholarship](http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#whh)

**Domestic Violence**

-IHS-sponsored training in sexual assault forensic examination

-Report cites high rate of violence against Native women

-Resource for interrupting the cycle violence

-Affects of cueing on providers discussion of intimate partner violence

#### -Women who have had physical abuse during pregnancy: risk of preterm delivery

**Elder Care News**

-Exciting opportunity to develop new resources in geriatrics

#### -2008 End-of-Life Nursing Education Consortium Schedule announced {#end-of-life-nursing-education-consortium-schedule-announced .Style-Heading-4-+-Arial-14-pt-Underline}

\-[End-of-Life Care in the Setting of Cancer: Withdrawing Nutrition and
Hydration](http://www.medscape.com/viewprogram/8617)

**Family Planning**

-Ringing Endorsement: Women Prefer Contraceptive Ring Over Patch

#### -Misconceptions About OCPs Among Adolescents and Providers {#misconceptions-about-ocps-among-adolescents-and-providers .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Copper containing IUDs are more effective for contraception than other IUDs: Cochrane {#copper-containing-iuds-are-more-effective-for-contraception-than-other-iuds-cochrane .Style-Heading-4-+-Arial-14-pt-Underline}

-Ortho Evra Contraceptive Transdermal Patch: Higher risk of serious
blood clots

#### -Levonorgestrel / Ethinyl Estradiol (Lybrel) for Continuous Contraception {#levonorgestrel-ethinyl-estradiol-lybrel-for-continuous-contraception .Style-Heading-4-+-Arial-14-pt-Underline}

**Featured Website**

#### Meeting notes now online: [2007 Native Women's Health and MCH Conference](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/Intro Slide and Eval Sli14.ppt)

**Frequently asked questions**

How can we actually reduce infant mortality in AI/AN?

**Indian Child Health Notes**

-Honey, dextromethorphan, and no treatment on nocturnal cough and sleep
quality

-Respiratory syncytial virus season and hospitalizations in the Alaskan
Yukon-Kuskokwim Delta

-Health disparities persisting and in some cases, sadly widening.

**Information Technology**

iCare Training

International Health

-Good intentions and unintended consequences

-Peanuts +Vegetable oil +milk powder+vitamins + minerals = Plumpynut

-CCGHE Launches Online HIV Training Course in Zambia

-Stunting In First Two Years Of Life Leads To Huge Negative Consequences
In Later Life

#### MCH Alert

-Maternal depression as a risk factor affecting child readiness and
school readiness

-Role of nurses in oral health of children and women

-Relationship between air pollution and postneonatal infant mortality

-Influence of multiple social risk factors on children's health

#### MCH Headlines

-Findings from the National Survey of Children\'s Health includes Native
Americans

-Medicaid Reimbursement for Car Seats Is Cost-Effective Health Policy\
-2008 MCH EPI Grand Rounds Schedule 7 one-hour calls

#### Medical Mystery Tour

#### St. John\'s wort for depression in a young woman: The answers {#st.-johns-wort-for-depression-in-a-young-woman-the-answers .Style-Heading-4-+-Arial-14-pt-Underline}

#### Medscape

\-[Turning Adverse Drug Events Into Better Patient
Care](http://www.medscape.com/viewprogram/8715)

######### -A Rational Approach to Constipation

-Angiogenesis as a Strategic Target for Ovarian Cancer Therapy

-Premenstrual Dysphoric Disorder Resource Center Update

**Menopause Management**

-Calcium supplements may increase heart attacks in older women

-Postmenopausal Systemic Hormone Therapy: Putting Risks Into Perspective

-Black Cohosh and Menopausal Symptoms

**Midwives Corner**

-Perineal warm packs reduce 3^rd^ and 4^th^ degree lacerations, pain and
urinary incontinence

-The Business of Being Born

-Factors for the fear of childbirth in first-time mothers

-Women's fear of childbirth boosts cesareans

**Navajo News**

Adnexal Masses during Pregnancy

**Nurses Corner**

-Integrating Nursing and Behavioral Health

-UCLA post-doc program for nurses

#### -New Report on American Indian/Alaskan Native Disparity & Strengths from RWJ {#new-report-on-american-indianalaskan-native-disparity-strengths-from-rwj .Style-Heading-4-+-Arial-14-pt-Underline}

![](media/image2.png){width="4.002083333333333in"
height="2.220833333333333in"}-Creating a Healing Community: Partnerships
to Improve the Care of Indian People

#### -Fraud - SPAM {#fraud---spam .Style-Heading-4-+-Arial-14-pt-Underline}

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

-Cervical Cancer Awareness

-United States Life Tables, 2004

**Oklahoma Perspective**

Cesarean Delivery: What are the risks and benefits?

Osteoporosis

-SSRI Use and Bone Loss in Older Women

#### -Nonpharmacologic Management of Osteoporosis to Minimize Fracture Risk {#nonpharmacologic-management-of-osteoporosis-to-minimize-fracture-risk .Style-Heading-4-+-Arial-14-pt-Underline}

-Supplementation With Calcium and Vitamin D: Efficacy Against Fracture
and Total Mortality

#### -The Impact of Adherence and Persistence in the Pharmacological Management of Osteoporosis {#the-impact-of-adherence-and-persistence-in-the-pharmacological-management-of-osteoporosis .Style-Heading-4-+-Arial-14-pt-Underline}

Patient Education

#### -Assuring Quality Care for People With Limited Health Literacy {#assuring-quality-care-for-people-with-limited-health-literacy .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Knowing Importance of Prenatal Folic Acid May Affect Neural Tube Defect Incidence {#knowing-importance-of-prenatal-folic-acid-may-affect-neural-tube-defect-incidence .Style-Heading-4-+-Arial-14-pt-Underline}

#### -Anorexia and Bulimia: What You Should Know {#anorexia-and-bulimia-what-you-should-know .Style-Heading-4-+-Arial-14-pt-Underline}

Perinatology Picks

-Usefulness of middle cerebral artery Doppler of the fetus at risk for
anemia

-Results indicate the presence of dyslipidemia in women with spontaneous
preterm birth

-High maternal weight increases risk of neonatal mortality, especially
after preterm PROM

# -Caffeine intake during pregnancy increases the risk of miscarriage 

-Prognosis of fetal cystic hygroma detected during the first trimester
is poor, NT is crucial

Primary Care Discussion Forum

Mental health issues in children and adolescents -- Starts March 2008

STD Corner

#### -Routine HIV Screening in the Emergency Department  {#routine-hiv-screening-in-the-emergency-department .Style-Heading-4-+-Arial-14-pt-Underline}

-New Updates to U.S. HIV Treatment Guidelines

-SAMHSA opportunity for funding community based organizations

-IHS HIV Program and SAMHSA sign Memorandum of Understanding (MOU) on
Jan 16, 2008

-FDA Approves Etravirine (TMC125)

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

-Diabetes A Stronger Risk Factor For Death In Women than In Men

-Pedometers help people lose weight even without changes in diet

-New Position Statement for Glucose Intolerance in PCOS

-Low-Carbohydrate Diets Rich in Vegetable Sources of Fat and Protein:
Reduce Diabetes

**Women's Health Headlines**

-Women and HIV/AIDS: PINN POINT ON WOMEN'S HEALTH

-APN brochures

-Knowing What Works in Health Care: A Roadmap for the Nation

-SAMHSA Compendium of primary mental health activities now online

-DV Announcements: Grants, trainings and resources shared by various
project faculty

###### Save the Dates: Upcoming events of interest page 58

#### What's new on the ITU MCH web pages page 59

Meeting notes now online: [2007 Native Women's Health and MCH
Conference](http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NativeWHealth/Intro Slide and Eval Sli14.ppt)

The past CCC Corners are archived at:

<http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN02.cfm>

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

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

or 907 729 3154 (with voicemail)

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

3/21/08 njm