Acrobat
MS Word
PowerPoint
Volume 4, No. 11, November 2006
Features
American College of Obstetricians and Gynecologists
Umbilical Cord Blood Gas and Acid-Base Analysis
ABSTRACT: Umbilical cord blood gas and acid-base assessment are the most objective determinations of the fetal metabolic condition at the moment of birth. Moderate and severe newborn encephalopathy, respiratory complications, and composite complication scores increase with an umbilical arterial base deficit of 12–16 mmol/L. Moderate or severe newborn complications occur in 10% of neonates who have this level of acidemia and the rate increases to 40% in neonates who have an umbilical arterial base deficit greater than 16 mmol/L at birth. Immediately after the delivery of the neonate, a segment of umbilical cord should be double-clamped, divided, and placed on the delivery table. Physicians should attempt to obtain venous and arterial cord blood samples in circumstances of cesarean delivery for fetal compromise, low 5-minute Apgar score, severe growth restriction, abnormal fetal heart rate tracing, maternal thyroid disease, intrapartum fever, or multifetal gestation.
OB/GYN CCC Editorial comment:
Cord gases at cesarean delivery and vaginal birth: A best practice
This is a best practice that Indian Health facilities should put into all guidelines.
Umbilical cord blood gas and acid-base analysis. ACOG Committee Opinion No. 348. American College of Obstetricians and Gynecologists. Obstet Gynecol 2006;108:1319–22 .
Menstruation in Girls and Adolescents: Using the Menstrual Cycle as a Vital Sign
ABSTRACT: Young patients and their parents often are unsure about what represents normal menstrual patterns, and clinicians also may be unsure about normal ranges for menstrual cycle length and amount and duration of flow through adolescence. It is important to be able to educate young patients and their parents regarding what to expect of a first period and about the range for normal cycle length of subsequent menses. It is equally important for clinicians to have an understanding of bleeding patterns in girls and adolescents, the ability to differentiate between normal and abnormal menstruation, and the skill to know how to evaluate young patients’ conditions appropriately. Using the menstrual cycle as an additional vital sign adds a powerful tool to the assessment of normal development and the exclusion of serious pathologic conditions.
Menstruation in girls and adolescents: using the menstrual cycle as a vital sign. ACOG Committee Opinion No. 349. American Academy of Pediatrics; American College of Obstetricians and Gynecologists. Obstet Gynecol 2006;108:1323–8.
Overweight Adolescent: Prevention, Treatment, and Obstetric– Gynecologic Implications
ABSTRACT: The number of overweight adolescents has grown to epidemic proportions in the United States. Adolescent females who are overweight have significant health sequelae. The American College of Obstetricians and Gynecologists recommends that all adolescents be screened annually for overweight by determining weight and stature, calculating a body mass index for age percentile, and asking about body image and eating patterns. Health care providers should promote healthy eating and physical activity to adolescent patients and their parents during routine preventive health care visits. Adolescents with a body mass index greater than or equal to the 95th percentile for age should have an in-depth dietary and health assessment to determine psychosocial morbidity and risk for future cardiovascular disease. Obstetrician–gynecologists are strongly encouraged to provide this assessment. Additional research is needed to determine the most appropriate approach for the successful prevention and treatment of overweight adolescents. Until this research has been completed, it is best to extrapolate an approach from data and studies pertaining to children and adults, while remaining cognizant of the special needs that surround adolescent growth and development. Sound nutritional recommendations and regular physical activity are essential components of prevention and treatment plans
The overweight adolescent: prevention, treatment, and obstetric–gynecologic implications. ACOG Committee Opinion No. 351. American College of Obstetricians and Gynecologists. Obstet Gynecol 2006;108:1337–48.
Breast Concerns in the Adolescent
ABSTRACT: Breast disease in the adolescent female encompasses an expansive array of topics. Benign disease overwhelmingly dominates the differential diagnosis and dictates a different protocol for care in the adolescent compared with the adult patient to avoid inappropriately high assessments of risk and unnecessary diagnostic procedures and surgery. There also are emerging issues pertaining to the care of the adolescent breast, such as breast augmentation, nipple piercing, and management of the adolescent patient with a family history of breast cancer
Breast concerns in the adolescent. ACOG Committee Opinion No. 350. American College of Obstetricians and Gynecologists. Obstet Gynecol 2006;108:1329–36
Using Preimplantation Embryos for Research
ABSTRACT: Human embryonic stem cell research promises an increased understanding of the molecular process underlying cell differentiation. Transplantation of embryonic stem cells or their derivatives may, in the future, offer therapies for human diseases. In this Committee Opinion, the American College of Obstetricians and Gynecologists (ACOG) Committee on Ethics presents an ethical framework for examining issues surrounding research using preimplantation embryos and proposes ethical guidelines for such research. The Committee acknowledges the diversity of opinions among ACOG members and affirms that no physician who finds embryo research morally objectionable should be required or expected to participate in such research. The Committee supports embryo research within 14 days after evidence of fertilization but limits it according to ethical guidelines. The Committee recommends that cryopreserved embryos be the preferred source for research but believes that the promise of somatic cell nuclear transfer is such that research in this area is justified. The Committee opposes reproductive cloning. Intended parents for whom embryos are created should give informed consent for the disposition of any excess embryos. The donors of gametes or somatic cells used in the creation of such tissue should give consent for donation of embryos for research. Abandoned embryos should not be accepted for research. Potential research projects should be described to potential donors as much as possible. Donation of embryos for stem cell research requires specific consent. The Committee believes that compensation for egg donors for research is acceptable, consistent with American Society for Reproductive Medicine guidelines.
Using preimplantation embryos for research. ACOG Committee Opinion No. 347. American College of Obstetricians and Gynecologists. Obstet Gynecol 2006;108:1305–17.
American Family Physician**
Patient-Oriented Evidence that Matters (POEMS)*
No Stirrups Preferred for Pelvic Examinations
Clinical Question: Do women feel more comfortable and less vulnerable if stirrups are not used as part of a speculum examination?
Study Design: Randomized controlled trial (nonblinded)
Synopsis: The embarrassment and fear of discomfort from the speculum examination often prevent women from seeking routine cervical cancer screening. One problem might be the use of stirrups to support the legs of women undergoing a pelvic examination. Stirrups are commonly used in the United States but are not routine in other countries. The authors of this study evaluated whether the use of stirrups increased pain and the feeling of vulnerability in 197 adult women presenting for a routine examination.
The women were randomized to a speculum examination using stirrups or one without stirrups. The stirrups were used to hold the legs at a 30- to 45-degree angle off the table. Women in the no-stirrup group were placed at the end of the table with their heels on the corners of the fully deployed extension of a standard examination table. Women in both groups were fully draped and underwent a standard pelvic examination with the examiner obtaining a cervical smear.
Physical discomfort and sense of vulnerability, measured following the examination using a 100-mm visual analog scale, were significantly lower in the no-stirrup group: the mean physical discomfort score was 43 percent lower (17.2 versus 30.4), and the sense of vulnerability was 44 percent lower (13.1 versus 23.6). Sense of loss of control was not significantly different between the two groups.
The quality of the smears was similar in the two groups. The researchers did not report the comfort of the examiner with either method or how they avoided having the speculum handle hit the table extension. The study was unblinded because the women knew whether they were in stirrups or not. Most of the women had already had one or more speculum examinations; the study would have been more effective had they enrolled women who had never had a pelvic examination using stirrups.
Bottom Line: To decrease discomfort and sense of vulnerability, women undergoing a routine pelvic examination should be offered the option of not using stirrups. On average, women will find this position more comfortable and will feel less exposed.
(Level of evidence: 1b)
Study Reference: Seehusen DA, et al. Improving women's experience during speculum examinations at routine gynaecological visits: randomised clinical trial. BMJ July 22, 2006;333:171. http://www.aafp.org/afp/20061101/tips/18.html
* POEM Rating system : http://www.infopoems.com/levels.html POEM Definition: http://www.aafp.org/x19976.xml
** The AFP sites will sometimes ask for a username and password. Instead just ‘hit; cancel on the pop up password screen, and the page you are requesting will come up without having to enter a username and password.
AHRQ
Over 1 million U.S. babies are delivered by Cesarean delivery
http://www.ahrq.gov/research/sep06/0906RA17.htm
Bone protection therapy shifted from estrogen to nonestrogen anti-osteoporosis medicine after publication of the Women's Health Initiative study
http://www.ahrq.gov/research/sep06/0906RA5.htm
Ask A Librarian: Diane Cooper, M.S.L.S. / NIH
Want to keep up with evidence-based medicine?
Got time to read 50,000 articles? No? Then take a look at Evidence-Based Medicine. From the editorial offices of the British Medical Journal, this journal provides information gleaned from over 100 journals. Published 6 times a year, the most important and valid research articles are presented. For example, here are two current articles that may be of interest.
Physical exertion during pregnancy
1. Physical exertion at work during pregnancy did not increase risk of preterm delivery or fetal growth restriction. (Evidence-Based Medicine 2006; 11: 156). This prospective cohort study included 1,908 women over 16 years of age who were 24-29 weeks pregnant and stood long hours each week, lifted heavy objects 13 times or more each week, worked nights or worked greater than 46 hour weeks.
Continuous dose vs. 28 day OCs
2. Review: 6 RCTs show similar efficacy and safety for continuous dosing and 28 day combination contraceptive pills. (Evidence-Based Medicine 2006; 11: 53). Randomized controlled trials compared continuous or extended combination oral contraceptives with the traditional dosing (21 days of pills) in women of reproductive age.
To find Evidence-Based Medicine on the HSR Library website, click ONLINE JOURNALS found on the left panel of the homepage. Next click “E” to get to all journals starting with “E” and scan down to the journal.
Would you like to have regular updates in your special interest from Evidence-Based Medicine and other journals you select and have complete control over your updates? Email me for an easy “Go By” for this. And as always, if you need any information help, just email me at cooperd@mail.nih.gov
Breastfeeding - Suzan Murphy, PIMC
It is official, breastfeeding counts
Obesity is a rapidly escalating problem that could greatly complicate health care in the future. Finding effective ways that reduce obesity and maintain healthy weight are major challenges for health care providers and planners. But research suggests that there is hope – in numerous studies, breastfeeding has been linked with reduced obesity risk throughout childhood and into early adulthood. Additionally, breastfeeding exclusivity and duration are recognized to be inversely related to obesity risk.
Given the current widespread obesity problem and the research that breastfeeding can reduce obesity risk, a GPRA measure has been born. Beginning in 2007, baseline breastfeeding data at specific ages will be established in I.H.S. country – with the goal of increasing breastfeeding incidence and duration in the first year of life.
It will take numbers to establish baseline data and monitor early feeding practice. The good news is that feeding choice data can now be captured in RPMS and the questions are those already routinely asked by providers in the patient’s first year of life. Using a software patch available to all service units, feeding choice can be indicated at patient visits by PCC, PCC +, and E.H.R. in 2007, than inputted by data entry, and tracked by a V-gen search.
The software patch allows any provider to check one of five feeding choices - exclusively breastfeeding, mostly breastfeeding, ½ and ½ , mostly formula and exclusively formula. The possible confounders that can also be tracked are parity, birth weight, mother’s name/chart number, when solids were started, when breastfeeding stopped, and when regular formula feeding began.
I.H.S. has unique health care records – often spanning entire lifetimes. No other national health care environment provides care for an individual from conception throughout their life. There are limitless opportunities to learn from health behavior/management to improve life long care. How early feeding choice impacts later years is only the beginning.
Please watch for more information about the new GPRA measure and objectives related to breastfeeding. Specific information will be available soon at the I.H.S. MCH Breastfeeding web site, www.ihs.gov/MedicalPrograms/MCH/M/bf.cfm
Other
Breast-Feeding Protects Against Obesity in Children of Diabetic, Overweight Mothers
CONCLUSIONS: Breast-feeding was inversely associated with childhood obesity regardless of maternal diabetes status or weight status. These data provide support for all mothers to breast-feed their infants to reduce the risk for childhood overweight.
Mayer-Davis EJ, et al Breast-feeding and risk for childhood obesity: does maternal diabetes or obesity status matter? Diabetes Care. 2006 Oct;29(10):2231-7
Herbal Medicines in Pregnancy and Lactation
Just as with prescription drugs, natural health products can present substantial risks and prompt the same areas of concern. Although some of these effects may be life-threatening, current literature on these important issues is scant. With the use of natural health products on the rise, physicians require quality evidence with which to make evidence-based decisions and provide answers to their patients. Herbal Medicines in Pregnancy and Lactation focuses entirely on the therapeutics, safety and risk information of herbs and supplements used during pregnancy and lactation for obstetricians, maternal-fetal medicine specialists, and primary care physicians.
Herbal Medicines in Pregnancy and Lactation
Edward
Mills, Jean-Jacques
Dugoua, Dan
Perri
Publisher: Informa Healthcare (January 17, 2006) ISBN: 0415373921
http://www.informahealthcare.com/
QuickStats: Percentage of Infants Born During 1990--1993 and 1997--2000 Who Were Ever Breastfed, by Race/Ethnicity of Mother --- United States
* Excludes twins and higher-order multiple births.
The percentage of infants ever breastfed increased from 55% among those born during 1990--1993 to 67% among those born during 1997--2000, bringing the levels of breastfeeding initiation closer to the Healthy People 2010 objective of 75% among mothers in all racial/ethnic groups. Substantial progress toward meeting this goal has been observed among Hispanic (75%) and non-Hispanic white (69%) mothers. In addition, breastfeeding initiation nearly doubled among non-Hispanic black mothers, from 25% of infants born during 1990--1993 to 47% of infants born during 1997--2000.
SOURCE: Chandra A, Martinez GM, Mosher WD, Abma JC, Jones J. Fertility, family planning, and reproductive health of U.S. women: data from the 2002 National Survey of Family Growth. Vital Health Stat 2005;23(25).
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5542a6.htm
CCC Corner Digest
Nicely laid out hard copy - A compact digest of last month’s CCC Corner
Highlights include:
- Routine HIV Screening in 13- 64 year olds: Scott Giberson
- 40 years in partnership: American Academy of Pediatrics and Indian Health
- Can a 29% Cesarean Delivery Rate Possibly Be Justified?
- Out with Clomid? Here come the Aromatase inhibitors for ovulation induction
- Fetal injury at cesarean delivery: Indication and type of uterine incision
- Aspirin to Prevent Heart Attack and Stroke: What’s the Right Dose? 160 mg/day
- Postcoital Bleeding and Cervical Cancer Risk only 1/220
- Amnioinfusion Does Not Prevent Meconium Aspiration Syndrome
- Exercise and Pregnancy; Preclampsia Drugs; Calcium Supplementation
- Do you have breastfeeding questions? The new IHS Breast feeding site has the answers
- Ortho Evra Patch Linked to Risk for Venous Thromboembolism
- New Breastfeeding Web Page for the Indian Health System
- Maternal survival worldwide: consensus and controversies
- The words ‘bizarre’ and ‘atypia’ in the same pathology report sentence…hmmm….
- External Fetal Monitors - Can you kick the habit?
- Fracture risk among First Nations people
- A.) Fetal Lung Maturity B.) Blood test for pre-eclampsia? C.) Fish oil for the brain
- Causes of Type 2 Diabetes: Old and New Understandings
- Prevalence of HPV Infection among Men: A Systematic Review of the Literature
- No improvement in fetal outcome, increased maternal morbidity: Who pays for this?
- Special Care Clinic – Phoenix Indian Medical Center
- Heard about prenatal and postpartum care? Here is something on Internatal Care
Go here for the October highlights:
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/06OctOL.pdf
If you want a copy of the CCC Digest mailed to you each month, please contact nmurphy@scf.cc
Domestic Violence
Measuring Intimate Partner Violence Victimization and Perpetration
This compendium provides researchers and prevention specialists with a set of assessment tools with demonstrated reliability and validity for measuring the self-reported incidence and prevalence of Intimate Partner Violence victimization and perpetration. Although the compendium includes more than 20 scales, it is not intended to be an exhaustive listing of available measures. The information is presented to help researchers and practitioners make informed decisions when choosing scales to use in their work.
http://www.cdc.gov/ncipc/dvp/Compendium/Measuring_IPV_Victimization_and_Perpetration.htm
CDC Reports Prevalence of Dating Violence in High School Students
Programs that promote the prevention of dating violence should address risk factors associated with victimization and help educate high school students about healthy behaviors within dating relationships. The Centers for Disease Control and Prevention (CDC) analyzed data from the 2003 Youth Risk Behavior Survey to determine the prevalence of dating violence among high school students. The report, "Physical Dating Violence Among High School Students-United States, 2003," was published in the May 19, 2006, issue of Morbidity and Mortality Weekly Report.
The study showed that 9 percent of the 14,956 high school students who were surveyed had been victims of physical dating violence, and one in 11 high school students reported being a victim within the previous 12 months.
Thirty-four percent of all participants were currently sexually active; 9 percent had attempted suicide; 28 percent drank heavily; and 33 percent had been involved in physical fighting. The survey found that students who were victims of dating violence were more likely to engage in these risky behaviors compared with students who had never experienced dating violence. Additionally, 14 percent of students with self-reported grades of D's and F's experienced physical dating violence victimization compared with only 6 percent of students with self-reported grades of A's.
Appropriate intervention, such as referral for counseling, is more likely if physicians ask teenage patients about their dating behaviors. Therefore, family physicians should be aware of the prevalence of dating violence and appropriately address the associated risky behaviors in teenagers to help prevent further instances of violence.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5519a3.htm
Elder Care News
Diagnosis of Acute Abdominal Pain in Older Patients
Acute abdominal pain is a common presenting complaint in older patients. Presentation may differ from that of the younger patient and is often complicated by coexistent disease, delays in presentation, and physical and social barriers. The physical examination can be misleadingly benign, even with catastrophic conditions such as abdominal aortic aneurysm rupture and mesenteric ischemia. Changes that occur in the biliary system because of aging make older patients vulnerable to acute cholecystitis, the most common indication for surgery in this population. In older patients with appendicitis, the initial diagnosis is correct only one half of the time, and there are increased rates of perforation and mortality when compared with younger patients. Medication use, gallstones, and alcohol use increase the risk of pancreatitis, and advanced age is an indicator of poor prognosis for this disease. Diverticulitis is a common cause of abdominal pain in the older patient; in appropriately selected patients, it may be treated on an outpatient basis with oral antibiotics. Small and large bowel obstructions, usually caused by adhesive disease or malignancy, are more common in the aged and often require surgery. Morbidity and mortality among older patients presenting with acute abdominal pain are high, and these patients often require hospitalization with prompt surgical consultation. Am Fam Physician 2006;74:1537-44. http://www.aafp.org/afp/20061101/1537.html
Indian Health Service History Project
The Indian Health Service has initiated a project to document the 50 years of
work since the federal health responsibilities for American Indians and Alaska
Natives was transferred to the US Public Health Service. The project includes
collecting historic documents, photos, and oral histories relating to the history
of the Indian Health Service. We are researching records at the National Archives,
Library of Congress, National Library of Medicine, and university archives with
Indian health related records. The records tell a fascinating, but at times incomplete
story. Much of the work of the Indian Health Service was carried out in distant,
rural locations by government and tribal programs whose work may not have reached
the official record system.
We are interested in finding people who would be willing to share photos, documents, and memories of their time in the Indian Health Service. Do you have old photos, reports, or documents that you have been saving for years, and are you unsure what to do with them? This is your opportunity. If you are willing to share items from your time in the Indian Health Service, we would like to hear from you. We can accept the donation of items to add to our collection, or we can take them on loan to return to you after viewing and copying.
If you are interested in this unique opportunity or have questions about
the project, please contact:
CAPT Alan Dellapenna, Jr., alan.dellapenna@ihs.gov (301)
443-0097
You can see some items related to the history of the Indian Health Service on the IHS website; the items include the executive summary of the history of the Indian Health Service, The First 50 Years of the Indian Health Service: Caring and Curing, which can be viewed and downloaded at http://info.ihs.gov/. Go to the grey box at the top of the page and select “IHS Gold Book - Part 1” through “IHS Gold Book - Part 4” A collection of historic IHS photos is located at http://www.ihs.gov/publicinfo/photogallery/index.cfm. Follow the instructions to view the photos in the collection.
Family Planning
A strategy to maximize access to emergency contraceptive pills increased use but did not affect incidence of either pregnancy or sexually transmitted infections.
CONCLUSION: This intensive strategy to enhance access to emergency contraceptive pills substantially increased use of the method and had no adverse impact on risk of sexually transmitted infections. However, it did not show benefit in decreasing pregnancy rates. LEVEL OF EVIDENCE: II-1.
Raymond EG,et al Impact of Increased Access to Emergency Contraceptive Pills: A Randomized Controlled Trial. Obstet Gynecol. 2006 Nov;108(5):1098-1106.
EC: Progesterone receptor modulator CDB-2914 as effective as levonorgestrel
CONCLUSION: CDB-2914 is at least as effective as levonorgestrel in preventing
pregnancies after unprotected intercourse and has a similar side effect profile.
LEVEL OF EVIDENCE: I.
Creinin
MD et al Progesterone Receptor Modulator for Emergency Contraception: A Randomized
Controlled Trial., Obstet
Gynecol. 2006 Nov;108(5):1089-1097.
Monophasic oral contraceptives preferred over biphasic for contraception
Conclusions: The trial found no important differences in bleeding patterns between the biphasic and monophasic preparations studied. Since no clear rationale exists for biphasic pills and since extensive evidence is available for monophasic pills, the latter are preferred.
Van Vliet HAAM, Grimes DA, Helmerhorst FM, Schulz KF. Biphasic versus monophasic oral contraceptives for contraception. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD002032. DOI: 10.1002/14651858.CD002032.pub2.
http://www.ihs.gov/MedicalPrograms/CIR/index.cfm?module=cir_answering_clinical_questions
Dispensing a year's supply of OCPs is associated with higher oral contraceptive continuation, improved reproductive health screening, and lower health care costs.
CONCLUSION: Dispensing a year's supply of OCP cycles to women is associated with higher method continuation and lower costs than dispensing fewer cycles per visit. LEVEL OF EVIDENCE: II-2.
Foster
DG, et al Number of oral contraceptive pill packages dispensed, method continuation,
and costs. Obstet
Gynecol. 2006 Nov;108(5):1107-14
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db
=pubmed&list_uids=17077231&dopt=Abstract
Featured Website David Gahn, IHS Women’s Health Web Site Content Coordinator
Check out our new IHS STD website
From Lori de Ravello, National IHS STD Program
http://www.ihs.gov/medicalprograms/epi/index.cfm?module=health_issues&option=std&cat=sub_0
New web site focuses on the history and legacy of maternal child health
MCH Timeline: History, Legacy, and Resources for Education and Practice provides information on some of the most important events in the history of maternal and child health (MCH) in the United States. The Web site, developed by the Health Resources and Services Administration's Maternal and Child Health Bureau (MCHB), displays a timeline of events in MCH history from 1798 to the present. Events on the timeline may be further explored by group (Public Health and Medicine, Government and Policy), by topic (infant mortality, systems of care, performance and accountability), by decade, or by title. Detailed narratives containing images, historical perspectives, current issues, and related resources are provided for select topics and events. The Web site is intended primarily for use as an orientation tool for individuals new to the MCH profession, MCHB grantees, and MCH students. http://www.mchb.hrsa.gov/timeline
Frequently asked questions
Q. Is an informed consent necessary for all x-rays in pregnant women?
A. No, not on routine diagnostic studies. High dose procedures are treated case by case.
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/XrayConsent11506.doc
Indian Child Health Notes - Steve Holve, Pediatrics Chief Clinical Consultant
Highlights November 2006
-Tall Girls: When being tall was a disease - a look at how culture shapes and defines medical care
-Viral gastroenteritis in AI/AN children - do we have more or less than everyone else? Surprising findings.
- Prevalence of mental health disease in AI/AN children
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ICHN1106.doc
Information Technology
Telehealth Opportunity: Do you need nutrition services at your site?
If your Service Unit, Hospital or Clinic is in need of nutrition services or diabetes education services by a Registered Dietitian/Certified Diabetes Educator, please consider an exciting and innovative approach to providing these services through Telehealth.
If you currently have (or plan to soon have) teleconferencing availability, the IHS Native American Cardiology Program would be interested in potentially working in partnership with you to assist in providing these services. If you are interested, please see the attached documents.
For further information or questions, you may also directly contact our program dietitian, Diane Phillips, RD, LD, CDE at diane.phillips@ihs.gov or by phone at (928) 214-3920.
AHRQ Launches Electronic Preventive Services Selector Tool for Primary Care Clinicians
A new Electronic Preventive Services Selector ( ePSS) tool for primary care clinicians to use when recommending preventive services for their patients was launched at the National Prevention Summit in Washington, DC, on October 26. The interactive tool is designed for use on a personal digital assistant (PDA) or desktop computer to allow clinicians to access the latest recommendations from the AHRQ-sponsored U.S. Preventive Services Task Force. The ePSS is designed to serve as an aid to clinical decision-making at the point of care and contains 110 recommendations for specific populations covering 59 separate preventive services topics. The 'real time' search function allows a clinician to input a patient's age, gender, and selected behavioral risk factors, such as whether or not they smoke, in the appropriate fields. The software cross-references the patient characteristics entered with the applicable Task Force recommendations and generates a report specifically tailored for that patient. "This Electronic Preventive Services Selector will assist physicians in selecting the right preventive service for the right patient in real time," said HHS Secretary Mike Leavitt in announcing the tool. "It will help us create a culture of wellness; a society that thinks of staying healthy rather than simply being treated after we're sick.". http://epss.ahrq.gov/PDA/index.jsp
International Health Update: Claire Wendland, Madison, WI
Anthropology in the clinic: the problem of cultural competency and how to fix it
The article I’ve chosen to review this month is not specifically about international health. Instead, it’s a relevant piece for anyone working in cross-cultural settings – or perhaps any clinical settings at all – abroad or at home. Arthur Kleinman, the lead author, is a well known medical anthropologist whose pioneering work on cultural variation and “explanatory models” of disease was adapted into many medical and nursing school curricula. In an article in last month’s PLoS Medicine, he critiques current models of “cultural competency” and suggests alternatives for high-quality, culturally sensitive clinical care.
So what’s wrong with the cultural competency model? Kleinman and his co-author Benson see several problems. First, no rigorous research shows it to improve clinical care, though training programs have been widely implemented. Second – and to the authors clearly more seriously – “culture” itself becomes another area of technical skill for the clinician, rather than the lived experience in which we (just as much as our patients) are immersed. This approach allows us to overlook the culture of biomedicine and its powerful effect on our interactions with patients. Instead, culture becomes something that belongs to other people, and that can be reduced to a bullet-point list of typical traits, dos and don’ts, or barriers to care. Patients on the receiving end of this approach, the authors note, may feel intruded upon, stereotyped or stigmatized. Finally, as the authors illustrate through several case examples, cultural features are simply not always central to clinical problems of “compliance” or communication. Family issues, personal concerns, and economic constraints may be much more salient in any given situation.
The article is strong on the critique of cultural competency models, and articulates succinctly several concerns that have been corridor talk in medical and anthropological circles for some time. Where it is less strong is in the matter of pragmatic solutions. Kleinman and Benson agree that clinicians should try to be sensitive to culture, and suggest that we attempt to see culture from a more anthropological perspective: as a way of experiencing and interpreting the world that is flexible, dynamic, and often highly variable among individuals, rather than static and wholly predictable on the basis of ethnic group memberships. This anthropological view should allow clinicians to determine what is at stake for any given patient in the course of illness and its treatment. To this end, they develop a six-step model for eliciting patients’ experience (what they call a mini-ethnography) that simply seems to me impractical for the busy clinic setting in which most of us work. Perhaps it might be usefully adapted for more prolonged encounters or problem cases? Take a look and see what you think; you can find the article at www.plosmedicine.org.
Kleinman A, Benson P Anthropology in the clinic: the problem of cultural competency and how to fix it. PLoS Medicine 3(10):e294, October 2006
Other:
Cesarean Delivery: Both Overused and Underused in Developing Countries
INTERPRETATION: In the poorest countries-mostly in sub-Saharan Africa-large segments of the population have almost no access to potentially life-saving caesareans, whereas in some mid-income countries more than half the population has rates in excess of medical need. These data deserve the immediate attention of policymakers at national and international levels.
Ronsmans C, et al Socioeconomic differentials in caesarean rates in developing countries: a retrospective analysis. Lancet. 2006 Oct 28;368(9546):1516-23.
Risk of formula feeding to infants in sub-Saharan Africa: Need for alternative strategies
CONCLUSIONS: Breastfeeding with zidovudine prophylaxis was not as effective as formula feeding in preventing postnatal HIV transmission, but was associated with a lower mortality rate at 7 months. Both strategies had comparable HIV-free survival at 18 months. These results demonstrate the risk of formula feeding to infants in sub-Saharan Africa, and the need for studies of alternative strategies.
Thior I et al Breastfeeding plus infant zidovudine prophylaxis for 6 months vs formula feeding plus infant zidovudine for 1 month to reduce mother-to-child HIV transmission in Botswana: a randomized trial: the Mashi Study. JAMA. 2006 Aug 16;296(7):794-805
MCH Alert
Child Health USA 2005 Released
Child Health USA 2005 is a compilation of secondary data for more than 50 health and health care indicators. The 2005 report, the 16th in an annual series of reports from the Health Resources and Services Administration's Maternal and Child Health Bureau (MCHB), provides both graphical and textual summaries of data and addresses long-term trends where applicable. Data are presented for the target populations of Title V funding, including infants, children, adolescents, children with special health care needs, and women of childbearing age. The report addresses population characteristics, health status, and health services financing and utilization. Progress toward meeting the goals of MCHB's strategic plan is also discussed. The report is intended to provide public health professionals and other individuals in the private and public sectors with a snapshot of measures of children's health in the United States. http://mchb.hrsa.gov/mchirc/chusa_05/index.htm
Medical Mystery Tour
The words ‘bizarre’ and ‘atypia’ in the same pathology report sentence…hmmm….
To recap…
We discussed a 53 yo G6 P5015 who presented to a field facility with ongoing menometrorrhagia despite conservative therapy with medroxyprogesterone 10 mg for 10 days a month for 3 months. Initial ultrasound revealed a 2.7 x 2.4 cm endometrial structure felt to be consistent with an endometrial polyp or a leiomyoma.
The patient subsequently received an uncomplicated total vaginal hysterectomy with a left salpingo-oophorectomy. The patient was discharged on the second post operative day.
ÂThe Pathologist’s initially commented that evaluation revealed cytologic atypia present throughout the neoplasm that was of a degenerative and bizarre type. Occasional mitotic figures were identified. No tumor type necrosis was seen. The increased cellularity was felt to be somewhat increased over what one normally sees in a highly cellular leiomyoma. The pathologic material was sent to a second facility for pathologic re-evaluation and the above impression was confirmed.
What did you think this patient’s diagnosis was?
The second pathologic evaluation revealed:Submucosal atypical leiomyoma with features of symplastic leiomyoma, benign….deeply penetrating adenomyosiis. There was a comment that it was a symplastic leiomyoma, rather than a leiomyosarcoma. It was unusually cellular for this enitity, prompting the staff to qualify it as an atypical symplastic leiomyoma, but it is placed in a benign category. The term atypia underlined the need for follow-up.
So, what is a symplastic leiomyoma?
The term symplastic just refers to pleomorphic, atypical, or bizarre leiomyomas have a wider range of morphologic changes and mitotic activity than previously documented. Grossly, nothing typically distinguishes a symplastic leiomyoma from the usual type of leiomyoma. Microscopically, there are foci of bizarre and pleomorphic tumor cells with atypical nuclei.
This smooth-muscle tumor is defined by the presence of variable numbers of smooth-muscle cells with multiple, gigantic nuclei with abundant nuclear chromatin in an otherwise typical leiomyoma. Mitotic figures are often lacking, but up to 7 per 10 hpf have been reported. They are, however, never atypical.
What is the risk of recurrence?
All symplastic leimyomas are benign. The recognition of this leiomyoma variant is critical, as the marked nuclear atypia can lead to an incorrect diagnosis of leiomyosarcoma. These lesions have a high cure rate with surgery alone (only one of 46 patients failed in the Stanford series and are considered a variant of usual (benign) leiomyoma.
If your learning curve isn’t steep enough at this point, then I just want to add this common sense truism….”the third time is a charm”
I was a little uneasy about the words …’The atypia just underlines the need for follow-up’…because it was not clear what other follow-up might be needed for a benign lesion…so I requested the slides be sent to a third center for evaluation.
The third center’s preliminary diagnosis is leiomyosarcoma and at this time the patient is being notified to return for computerized tomography of the chest, abdomen, and pelvis.
The median age for women with leimyosarcoma (43-53 years) is somewhat lower than that for other uterine sarcomas, and premenopausal patients have a better chance of survival.
The recurrence rate is based on the amount of mitotic activity: less than 5 mitotic figures per 10 high power fields is 98% 5 year survival; 5- 10 MF/ 10HPF is unpredictable at 42%; and greater than 10 is poor at 15%.
Resources:
Robboy, SJ et al Pathology and Pathophysiology of Uterine Smooth-Muscle Tumors Environmental Health Perspectives Supplements Volume 108, Number S5, October 2000
http://www.ehponline.org/members/2000/suppl-5/779-784robboy/robboy-full.html
Classification, clinical manifestations, and staging of uterine sarcoma , UpToDate
http://www.uptodateonline.com/utd/content/topic.do?topicKey
=gyne_onc/2274&type=A&selectedTitle=1~2
Other Background on Leiomyosarcomas
Rapidly enlarging uterine neoplasms are often attributed to leiomyosarcomas, although most women with this finding do not have a sarcoma. This was illustrated in a study of 1332 women admitted to either of two community hospitals for hysterectomy or myomectomy for presumed uterine leiomyomas: the incidence of uterine sarcomas was extremely low (0.23 percent). Among the 341 women with a rapidly growing uterus by clinical or ultrasound examination, only one (0.27 percent) had a uterine sarcoma. Based upon these data, an increased risk of sarcoma among women with "rapidly growing" leiomyomas could not be substantiated. However, the diagnosis of a uterine sarcoma should be considered in postmenopausal women with a pelvic mass, abnormal bleeding, and pelvic pain in whom the incidence of sarcoma is higher (1 to 2 percent). Black women and women with a history of tamoxifen use or pelvic radiation are also at increased risk of sarcoma formation.
Leiomyosarcomas account for one-third of uterine sarcomas. They appear grossly as a large (>10 cm) yellow or tan solitary mass with soft, fleshy cut surfaces exhibiting areas of hemorrhage and necrosis. The mass may bulge into the uterine cavity, but the epicenter is in the myometrium.
Benign leiomyomas (fibroids) and leiomyosarcomas often coexist in the same uterus. However, they are independent entities. Leiomyosarcomas are much less common and not hormonally driven, and leiomyomas only rarely (0.23 percent of cases in one large series degenerate into leiomyosarcomas.
Microscopically, most leiomyosarcomas are overtly malignant, with hypercellularity,
coagulative tumor cell necrosis, abundant mitoses (
10
to 20 per 10 high power fields [HPF]), atypical mitoses, cytologic atypia, and
infiltrative borders (show
histology 2A-B). Occasionally diagnostic problems arise in smooth muscle
tumors that are less cellular, less atypical, and less mitotically active. These
tumors have more worrisome features than the usual leiomyoma, but do not meet
histologic criteria to render an unequivocal diagnosis of leiomyosarcoma, and
few of them behave like a leiomyosarcoma.
Many authors believe that mitotic activity is the single most reliable indicator of malignant potential, although opinions vary as to the exact level of mitotic activity required. A large retrospective study from Stanford suggested the use of three main criteria (frequent mitotic figures, significant nuclear atypia, presence of coagulative necrosis of tumor cells) to assign a low-risk or high-risk designation to uterine smooth muscle tumors that were difficult to classify, indicating a risk of malignancy that is below or above 10 percent, respectively.
Using these criteria, they were able to characterize the 218 patients with "problematic" uterine smooth muscle tumors according to their clinical behavior.
Others classify leiomyomas with increased mitotic activity (ie, >5 mitoses per 10 HPF, show histology 3) but no marked cytologic atypia as "mitotically active benign leiomyomas" only when they arise in women under the age of 35. These leiomyoma are typically small, well-circumscribed, and almost always behave in a benign fashion. Leiomyomas are more likely to have a high mitotic count if they are excised during the secretory phase of the menstrual cycle, during pregnancy, or when women are receiving exogenous progestins.
In contrast, the clinical behavior of leiomyomas with increased mitotic activity but no marked cytologic atypia is less certain in older women, and the term "smooth muscle tumor of uncertain malignant potential" (meaning that insufficient tumors have been studied to predict their behavior) has been suggested. Most of these patients are treated with a simple hysterectomy and they have a better prognosis than leiomyosarcoma.
Myxoid leiomyosarcomas do not fit well into the Stanford scheme and are classified separately. The dense myxoid appearance may obscure the smooth muscle etiology of this tumor, the extent of nuclear pleomorphism, and the true number of mitotic figures. Despite their apparently bland features, these tumors behave in a highly malignant manner, and should be considered high-grade leiomyosarcomas.
Medscape*
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
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
High-Dose Gabapentin Equal to Estrogen for Hot Flashes: POEM
Clinical Question: Is high-dose gabapentin (Neurontin) as effective as usual-dose estrogen for the treatment of postmenopausal hot flashes?
Study Design: Randomized controlled trial (double-blinded)
Synopsis: The authors recruited menopausal women 35 to 60 years of age who each had at least 50 moderate to severe hot flashes weekly for at least two months. Any treatments for hot flashes, including hormones, were discontinued for at least one month before enrollment in the study. Sixty women were randomized to gabapentin 2,400 mg daily, conjugated equine estrogen 0.625 mg daily, or placebo. The gabapentin was titrated over 12 days to a total of two 400-mg capsules three times daily.
Women recorded their hot flashes in a diary and indicated the severity of each one on a visual analog scale (1 = mild, 4 = severe). The number of hot flashes was multiplied by the severity of each over the course of a week to obtain a composite hot flash score. The composite scores at 12 weeks were compared with baseline scores. The gabapentin group had a mean reduction of 71 percent, the estrogen group had a mean reduction of 72 percent, and the placebo group's score dropped 54 percent (P < .017 for each active treatment versus placebo). There was no statistical difference between the gabapentin and estrogen groups. Five women dropped out during the study, including one in the gabapentin group because of side effects.
Bottom Line: In this small study, high-dose gabapentin was as effective as the usual dose of conjugated equine estrogens for the treatment of menopausal vasomotor symptoms. Larger studies are needed to confirm this result.
(Level of evidence: 1b)
Study Reference: Reddy SY, et al. Gabapentin, estrogen, and placebo for treating hot flushes: a randomized controlled trial. Obstet Gynecol July 2006;108:41-8.
http://www.aafp.org/afp/20061101/tips/19.html
Hormone Therapy in Postmenopausal and Perimenopausal Women
Clinical Scenario - Cochrane for Clinicians
A healthy 66-year-old woman has been taking combined continuous hormone therapy for menopausal symptoms for six months. She asks for how long she can safely continue taking the medication.
Clinical Question
In perimenopausal and postmenopausal women, is long-term, combined continuous hormone therapy safe and effective?
Evidence-Based Answer
Relatively healthy women taking combined continuous hormone therapy have higher risks of myocardial infarction and venous thromboembolism after one year, stroke after three years, and breast cancer after five years. In women who take hormone therapy continuously for five years, there is a lower incidence of fractures and colon cancer. Although it may be relatively safe and effective for short-term symptom control, hormone therapy should not be given routinely for prevention or chronic disease management.
-Farquhar CM, Marjoribanks J, Lethaby A, Lambets Q, Suckling JA, and the Cochrane HT Study Group. Long term hormone therapy for perimenopausal and postmenopausal women. Cochrane Database Syst Rev 2005;(3):CD004143.
-NHLBI advisory for physicians on the WHI trial of conjugated equine estrogens versus placebo. Accessed September 27, 2006, at: http://www.nhlbi.nih.gov/whi/e-a_advisory.htm.
-LaCroix AZ. Estrogen with and without progestin: benefits and risks of short-term use. Am J Med 2005;118(12 suppl 2):79-87.
http://www.aafp.org/afp/20061101/cochrane.html#c1
Alendronate May Be Best Choice for Postmenopausal Osteoporosis
CONCLUSIONS: Patients receiving 70 mg OW alendronate had greater gains in BMD, were more likely to maintain or gain BMD, and had greater reductions in bone turnover markers than patients receiving 35 mg OW risedronate after 24 months, with no differences in upper gastrointestinal tolerability.
Bonnick S, et al Comparison of weekly treatment of postmenopausal osteoporosis with alendronate versus risedronate over two years. J Clin Endocrinol Metab. 2006 Jul;91(7):2631-7
Estrogen only trial WHI: Significantly lower rates of any arthroplasty
CONCLUSION: These data suggest that hormone therapy may influence joint health, but this observed decrease in risk may be limited to unopposed estrogen and may possibly be more important in hip than in knee osteoarthritis.
Cirillo DJ; Wallace RB; Wu L; Yood RA Effect of hormone therapy on risk of hip and knee joint replacement in the Women's Health Initiative. Arthritis Rheum. 2006; 54(10):3194-204
Progestin in HRT Linked to Hearing Loss in Postmenopausal Women
These findings suggest that the presence of P as a component of HRT results in poorer hearing abilities in aged women taking HRT, affecting both the peripheral (ear) and central (brain) auditory systems, and it interferes with the perception of speech in background noise.
Guimaraes P, et al Progestin negatively affects hearing in aged women. Proc Natl Acad Sci U S A. 2006 Sep 19;103(38):14246-9
Data insufficient to support any complementary and alternative therapy for menopause Sx
The most common symptoms related to menopause include hot flashes, night sweats, vaginal dryness, and sleep disorders. These symptoms cause approximately 40 percent of perimenopausal or menopausal women to seek medical advice. The authors identified 1,432 trials that were reviewed. Of those, 70 met the inclusion criteria for the study. Forty-eight of the trials were biologically based therapies, nine were mind-body therapies, one was a manipulative or body-based therapy, two were energy therapies, and 10 were for whole medical systems. The studies concerning biologic agents (see accompanying table) showed varying results. Four of the 15 trials on phytoestrogens showed a benefit, and one of the four trials on black cohosh showed a benefit. The studies concerning mind-body, energy, manipulative and body-based, and whole medical systems therapies showed little benefit in treating menopausal symptoms.
CONCLUSIONS: Even though some individual studies suggest some benefit to complementary and alternative therapies for menopausal symptoms, there are inadequate data to support the effectiveness of these therapies. They add that many of these therapies need to be evaluated with rigorous controlled trials to assess their effectiveness and safety.
Nedrow A; Miller J; Walker M; Nygren P; Huffman LH; Nelson HD Complementary and alternative therapies for the management of menopause-related symptoms: a systematic evidence review. Arch Intern Med. 2006 Jul 24;166(14):1453-65
Midwives Corner - Lisa Allee, CNM
What Women Want
The Journal of Midwifery and Women’s Health September/October issue has two more wonderful qualitative research articles (see my review of another in the October CCC Corner.) These two studies gather information about women’s experience in early labor at home and their perceptions during pregnancy of what would be a good birthing experience. The sample sizes are small and the populations specific, but the quotes ring with the universal experience of pregnant and birthing women. For example, Beebe’s and Humphreys’ interviews with nulliparous included these:
“It’s interesting because the contractions (that) were described to me in class, or the way I interpreted them, didn’t feel the way I felt when I…it just felt more like cramps. I don’t know, the two just didn’t go together for me. They didn’t’ feel the way I was expecting them to.”
“My body was just moving me around”
“The only thing I worried about was going to the hospital maybe too soon…I just thought it would be bad if we get there only to be told to go back home, It would be discouraging.”
Melender’s interviews produced these quotes about staff:
“Of course I wish that ….mmmhh…the midwife would be a caring person who sees the patient as a human being and not just a patient…takes her character into account.”
“That the midwife would be a person who listens to you…and not such a difficult one (and describing what she meant by difficult:) well, if for example, I ask for something, she won’t do it or if I ask for something, she’ll snap at me….I mean that the atmosphere shouldn’t be in any way tense or like that…I mean that the midwife and obstetrician should be nice.”
These articles remind us to tune into what women are experiencing and wanting. Beebe’s and Humphreys’ encourage us to be sensitive to what women are going through before they come in to hospital-- their doubt about how to tell if they are in labor and the anxiety about and disappointment in finding out that they are not in active labor. This should inspire us to teach as clearly as possible what early and active labor are like and to be readily available to provide reassurance, guidance, support, and encouragement over the phone and during labor checks. Melender’s article reminds us of the importance of our relationship with women in labor, for example, being kind, nice, welcoming, empathetic, and accepting of her as she is, and how we can create an atmosphere conducive to birthing by including things like an unhurried atmosphere, normality, and security.
Expectations, perceptions, and management of labor in nulliparas prior to hospitalization, Beebe, K, Humphreys, J. J Midwifery Women’s Health. 2006 Sep-Oct;51(5):347-53.
What constitutes a good childbirth? A qualitative study of pregnant Finnish women Melender, H-L, J Midwifery Women’s Health. 2006 Sep-Oct;51(5):331-9
Other
From Zelda Collett-Paule, CNM, ANMC
Delayed cord clamping: Benefits in settings with high levels of neonatal anemia
METHODS: This was a randomized, controlled trial performed in 2 obstetrical units in Argentina on neonates born at term without complications to mothers with uneventful pregnancies.
CONCLUSIONS: Delayed cord clamping at birth increases neonatal mean venous hematocrit within a physiologic range. Neither significant differences nor harmful effects were observed among groups. Furthermore, this intervention seems to reduce the rate of neonatal anemia. This practice has been shown to be safe and should be implemented to increase neonatal iron storage at birth.
Ceriani
Cernadas JM et al The effect of timing of cord clamping on neonatal venous
hematocrit values and clinical outcome at term: a randomized, controlled trial. Pediatrics. 2006
Apr;117(4)
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db
=pubmed&list_uids=16567393&dopt=Abstract
Here is except from the Cochrane Review in preterm infants
Authors' conclusions: Delaying cord clamping by 30 to 120 seconds, rather than early clamping, seems to be associated with less need for transfusion and less intraventricular haemorrhage. There are no clear differences in other outcomes.
OB/GYN CCC Editorial comment:
Use caution when fixing a problem that is not broken
Luckily the days of significant problems with neonatal anemia among AI/AN are in the past. I say this because that era was also associated morbidity and mortality rates that approached those still seen in the lowest resource developing countries today.
Hence, for those of you who work in developing countries, Cernadas et al adds a randomized controlled trial to the growing literature that had previously been reported in pre-term infants. Currently in AI/AN we are more likely to see problems associated with polycythemia, than widespread neonatal anemia.
The key will be to rationally apply this practice in a setting where the problem neonatal anemia does not exist because delay cord clamping can be associated with adverse effects from the NeoReview listed below
1.) respiratory - grunting, tachypnea
2.) hyperviscosity / plethora - tachypnea, cyanosis, plethora, apnea, neurologic depression, cardiomegaly, pulmonary congestion, edema, pleural effusion, irritability
‘Why is immediate clamping current practice? ‘
See 5 reasons stated on page 10 in the NeoReview referenced below
One would need a good indication to set up an AI/AN term infant for the exchange transfusions, NICU admission to treat hyperviscosity syndrome. There are indications for exposing term infants to that risk in those areas of the developing world where early infant anemia is a public health problem, just not in Indian Country at this time.
On a somewhat related topic
….but one that applies to maternal effect of placental management in Stage III of labor, just not to infant outcome… Soltani H – Cochrane Review
….. in term patients, there does appear to be some potential maternal benefit from the use of placental cord drainage in terms of reducing the length of the third stage of labour. More research is required to investigate the impact of cord drainage on the management of the third stage of labour.
Authors' conclusions: It is difficult to draw conclusions from such a small number of studies, especially where the review outcomes were presented in a variety of formats. However, there does appear to be some potential benefit from the use of placental cord drainage in terms of reducing the length of the third stage of labour. More research is required to investigate the impact of cord drainage on the management of the third stage of labour.
NB: The Soltani discussion refers to draining the blood out into a basin, not draining the blood into a term infant.
References :
Rabe H, Reynolds G, Diaz-Rossello J. Early versus delayed umbilical cord clamping in preterm infants. The Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.: CD003248.pub2. DOI: 10.1002/14651858.CD003248.pub2.
http://www.ihs.gov/MedicalPrograms/CIR/index.cfm?module=cir_answering_clinical_questions
Soltani H, Dickinson F, Symonds I. Placental cord drainage after spontaneous vaginal delivery as part of the management of the third stage of labour. The Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD004665.pub2. DOI: 10.1002/14651858.CD004665.pub2.
http://www.ihs.gov/MedicalPrograms/CIR/index.cfm?module=cir_answering_clinical_questions
Phillip AG et al When should we clamp the umbilical cord? NeoReviews Vol.5 No.4 2004 e142
http://neoreviews.aappublications.org/cgi/content/extract/5/4/e142
Navajo Corner, Jean Howe, Chinle
Prevalence of diabetes: Diagnosed Diabetes Among AI/AN Aged <35 Years
This report was based on a CDC analysis of Indian Health Service data and revealed that the age-adjusted prevalence of diabetes among American Indians and Alaska Natives (AI/AN) aged <35 increased from 8.5 to 17.1 per 1000 among the 60% of AI/AN who use IHS facilities for care. The analysis also indicated that the number of AI/AN aged <35 with diabetes diagnosed by IHS more than doubled in the decade under study (from 6,001 in 1994 to 12,313 in 2004). Importantly, the annual percentage change (APC) of diagnosed diabetes was greatest among females aged 25-34 years of age (9.1%).
The accompanying discussion notes that this dramatic increase could be due to an increased incidence of diabetes or increased screening for diabetes or both. As the editor points out, the extraordinary increase in diabetes in reproductive age women is especially concerning as the offspring of women with diabetes are at increased risk for having diabetes themselves as well as for congenital anomalies and perinatal morbidity and mortality. The long-term health consequences of early-onset diabetes are particularly daunting.
Figure. Prevalence* of diagnosed diabetes among American Indians and Alaska Natives aged <35 years, by sex and age group - United States, 1994-2004
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5544a4.htm?s_cid=mm5544a4_e
Great, low-cost, fun CME opportunity
The Telluride Conference, to be held on January 26-28, 2007
This is a great, low-cost, fun CME opportunity attended by many current IHS providers and IHS alumni. Please share this announcement with anyone who might be interested at your facilities.
Hope to see you there! Jean.Howe@ihs.gov
http://www.ihs.gov/MedicalPrograms/MCH/F/CN01.cfm#Jan07
Nurses Corner - Sandra Haldane, HQE
Exclusively for Nurses: IHS has a Biomedical Librarian / Informationist dedicated to I/T/U
Please pass this information on to all nursing staff. IHS has a clinical Biomedical Librarian / Informationist dedicated to IHS (I/T/U) nursing staff. Judith Welsh, RN, MLS is available via email on the global or per her contact phone below to assist nurses with literature searches or other NIH Library information needs. IHS pays NIH Library yearly for the support of informationists so please take advantage of their assistance. If you do a literature search and find that you need document retrieval because the Library does not carry the document, inter-library loans and retrieval are free of charge to you. Please go to Judith’s link below to access the NIH Library for searching and PLEASE call or email Judith should you require any assistance. She will walk you through searches if need be and believe me she knows the in’s and out’s of searching the various databases.
Judith Welsh, RN, MLS welshju@ors.od.nih.gov
Health Services Research Library
10 Center Drive, Room 1L09B
Bethesda, MD 20892-1150
Phone: 301.594.6211
Executive Nurse Fellows Program, Robert Wood Johnson
Below is information regarding the Robert Wood Johnson Executive Nurse Fellow's Program. This program is exceptional at developing leadership skills. Deadline for application is Feb. 2007.
Please take a look at the information and consider applying or passing along to a colleague who is an up and coming executive health care leader or should be. Thanks, Sandy
The National Program Office is pleased to announce the launch of the online application for the 2007 cohort of the RWJ Executive Nurse Fellows Program.
Details about the application process are available at the link below and the deadline for completed online applications is February 1, 2007. Please share this information with colleagues who you think would make great Fellows. http://futurehealth.ucsf.edu/Program/rwj/Default.aspx?tabid=339
Contact Sally Durgan, 415-502-4594, sdurgan@thecenter.ucsf.edu
Robert Wood Johnson Executive Nurse Fellows Program home http://futurehealth.ucsf.edu/Program/rwj/
Office of Women's Health, CDC
Measuring HIV Risk in the U.S. Population Aged 15-44
Results from Cycle 6 of the National Survey of Family Growth - This report presents national estimates of the percentage and number of persons in the U.S. population aged 15–44 who report behaviors that place them at increased risk for acquiring or transmitting human immunodeficiency virus, or HIV. The report also contains data on condom use and HIV testing by persons who report risk behaviors. In addition, estimates of self-reported risk for HIV from the Cycle 6 National Survey of Family Growth are compared with data from other recent national surveys. Overall, 8.9 percent of persons 15–44 years of age had engaged in sexual behaviors in the past year that put them at increased risk of HIV, and 1.5 percent had engaged in drug use behaviors that put them at risk. In all, an estimated 9.9 percent engaged in either drug use or sexual behavior that placed them at increased risk for HIV. Including those who were treated for a sexually transmitted disease in the past year, 11.9 percent of persons 15–44 years of age—13.0 percent males and 10.8 percent of females—were at risk of HIV in 2002.
http://www.cdc.gov/nchs/data/ad/ad377.pdf
HPV and HPV Vaccine: Information for Healthcare (Revised)
This three page fact sheet provides information on provisional recommendations, HPV vaccine safety, HPV vaccine efficacy, duration of vaccine protection, HPV vaccine delivery, cost effectiveness, policies, other vaccines in development, genital HPV infection, natural history of HPV, HPV-associated disease, prevention of cervical cancer, and additional sources of information. http://www.cdc.gov/std/HPV/hpv-vacc-hcp-3-pages.pdf
Oklahoma Perspective Greggory Woitte – Hastings Indian Medical Center
Preoperative Evaluation
As we often deal with very healthy patients in our specialty, it is good to remind ourselves that surgery, even in healthy patients, can have serious consequences. Fortunately, the majority of the time healthy patients have very uneventful surgical procedures, but occasionally what we perceive as a healthy patient may have risk factors that may cause us to take additional precautions prior to surgery. A preoperative questionnaire can identify those at risk and can be as useful as a detailed history and physical. A modified questionnaire
- Do you feel unwell?
- Have you ever had any serious illnesses in the past?
- Do you get any more short of breath on exertions than other people of your age?
- Do you have any coughing?
- Do you have any wheezing?
- Do you have any chest pain on exertion (anginal type)?
- Do you have any ankle swelling?
- Have you taken any medicine or pills in the last 3 months including excess alcohol?
- Have you any allergies?
- Have you had an anesthetic in the last 2 months?
- Have you or your relatives had any problems with a previous anesthetic?
- Observation of serious abnormality from “end of bed” which might affect anesthetic?
- What is the date of your last menstrual period?
Recommended lab tests for the preoperative evaluation of the healthy patient include:
- Pregnancy test
- Hematocrit for surgery with expected major blood loss
- Serum creatinine if major surgery, hypotension expected, nephrotoxic drugs to be used or >50 yrs
Other lab tests such as LFTs, routine UA, blood glucose have little if any predictive value of pre or postoperative performance
EKGs should be obtained on: (within 1 month of surgery)
- all women >55 years,
- known cardiac disease,
- clinic eval. suggestive of cardiac disease, patient at risk of electrolyte abnormality,
- systemic disease associated with possible unrecognized heart disease (DM or HTN)
Chest x-ray (within 6 months of surgery) for patients over 60 years or those with suspected cardiac or pulmonary disease.
(Adapted from Wilson, ME, Williams, MB, Baskett, PJ, et al, Br Med J 1980; 1:509)
Preoperative evaluation of the healthy patient, UpToDate
http://www.uptodateonline.com/utd/content/topic.do?topicKey=med_cons/6474
Estimation of cardiac risk prior to noncardiac surgery, UpToDate
http://www.uptodateonline.com/utd/content/topic.do?topicKey=periart/7170
Osteoporosis
Potassium Citrate Beneficial for Osteopenia
Twelve-month daily alkali therapy with potassium citrate supplements resulted in a nearly 2% increase in lumbar spine and hip bone mineral density (BMD) in a small randomized controlled trial of postmenopausal women with osteopenia. These results suggest that citrate partially reverses the high acidity of the modern Western diet and that this promotes better skeletal health.
Jehle S, et al Partial neutralization of the acidogenic Western diet with potassium citrate increases bone mass in postmenopausal women with osteopenia. J Am Soc Nephrol. 2006 Nov;17(11):3213-22
Patient Information
Assessment of Adult Health Literacy
The Health Literacy of America's Adults: Results from the 2003 National Assessment of Adult Literacy describes how health literacy varies across the population and where adults with different levels of health literacy obtain information about health issues. The report, produced by the National Center for Education Statistics, contains analyses that examine differences related to health literacy that are based on self-reported background characteristics among groups in 2003. Topics include health literacy levels, demographic characteristics and health literacy, overall health, health insurance coverage, and sources of information about health issues. The appendices contain sample health-literacy-assessment question, definitions of all subpopulation and background variables reported, technical notes, standard errors for tables and figures, and additional analyses. References are also included. The full report, executive summary, and appendices are available at http://nces.ed.gov/pubsearch/pubsinfo.asp?pubid=2006483
Is patient education really working? GDM patients smoke more and eat less vegetables
CONCLUSIONS: Despite their elevated risk for future diabetes, women with history of GDM who lived with children were less likely to meet fruit and vegetable consumption guidelines and more likely to smoke than women with children who did not have history of GDM.
Kieffer EC et al Health Behaviors Among Women of Reproductive Age With and Without a History of Gestational Diabetes Mellitus Diabetes Care. 2006 Aug;29(8):1788-93
HPV Vaccine: What You Need to Know (Interim Vaccine Information Statement)
This two page fact sheet answers the following questions: what is HPV, why get vaccinated, who should get HPV vaccine and when, who should not get vaccinated (or should wait), what are the risks from HPV vaccine, what if there is a severe reaction, and how can I learn more.
http://www.cdc.gov/nip/publications/VIS/vis-hpv.pdf
Stress: How to Cope with Life's Challenges
http://www.aafp.org/afp/20061015/1385ph.html
Anxiety and Panic: Getting Control over Your Feelings
http://www.aafp.org/afp/20061015/1393ph.html
Depression: What You Should Know
http://www.aafp.org/afp/20061015/1395ph.html
Emotional Health: What You Should Know
http://www.aafp.org/afp/20061015/1388ph.html
Shingles Vaccine: What You Need to Know
This two page fact sheet discusses the following issues: what is shingles, shingles vaccine information, who should not get the shingles vaccine (or should wait), risks, reactions, and more.
http://www.cdc.gov/nip/publications/VIS/vis-shingles.pdf
Cardiovascular Disease: What You Should Know
http://www.aafp.org/afp/20061015/1342ph.html
Perinatology Picks - George Gilson, Maternal Fetal Medicine, ANMC
Be Prepared: The Boy Scout motto…er…the Maternity Care Provider motto, too
CONCLUSION: These data demonstrate that most emergent cesarean deliveries develop during labor in low-risk women and cannot be anticipated by prelabor factors. The outcomes demonstrate that infants are at risk in these clinical situations and suggest that strategies to improve performance in these clinical situations are important.
Lagrew DC, et al Emergent (crash) cesarean delivery: indications and outcomes. Am J Obstet Gynecol. 2006 Jun;194(6):1638-43; discussion 1643
Editorial comment: George Gilson, MFM, ANMC
Emergency drills are a good thing….. for your L/D team, and for your JCAHO accreditation
Our system expends a large amount of time and effort on ACLS and NRP that maternity care providers infrequently apply, yet 1:159 deliveries is a "crash section" that we aren't prepared for, and subsequent neonatal outcomes are often poor.
Lagrew DC, et al, above, reviews the new "15 minute rule", skipping asepsis, Foley, importance of the clinical team ‘in house’, that only 13% of them were associated with VBAC attempts despite the disproportionately strict VBAC recommendations from our professional organizations, need for staff drills for cord prolapse, etc,....a lot of practical information for small and large facilities.
The Advanced Life Support in Obstetrics (ALSO) model could be helpful if applied in this setting
http://www.aafp.org/online/en/home/cme/aafpcourses/clinicalcourses/also.html
Adverse neonatal outcomes associated with antenatal dexamethasone vs betamethasone
RESULTS: A total of 3600 infants met entry criteria. Compared with no antenatal steroids, there were trends for a reduced risk for PVL associated with dexamethasone and betamethasone but no difference in risk between dexamethasone and betamethasone. Dexamethasone reduced the risk for IVH and severe IVH, compared with no antenatal steroid exposure. Betamethasone reduced the risk for IVH, severe IVH, and neonatal death, compared with no antenatal steroids. Compared with betamethasone, dexamethasone had a statistically significant increased risk for neonatal death. There were trends for greater risks associated with dexamethasone compared with betamethasone for IVH and severe ROP.
CONCLUSIONS: Betamethasone was associated with a reduced risk for neonatal death, with trends of decreased risk for other adverse neonatal outcomes, compared with dexamethasone. It may be in the best interest of neonates to receive betamethasone rather than dexamethasone when available.
Lee BH, et al Adverse neonatal outcomes associated with antenatal dexamethasone versus antenatal betamethasone. Pediatrics. 2006 May;117(5):1503-10
Metformin Exposure During First Trimester Seen Safe for Fetus
After adjustment for publication bias, metformin was associated with a statistically significant protective effect of 57%" against major malformations in the fetus. This study considered only major malformations of the fetus. Other studies assessing the incidence of spontaneous abortion, stillbirth, minor abnormalities, intrauterine growth retardation and preterm labor still need to be conducted. CONCLUSION(S): On the basis of the limited data available today, there is no evidence of an increased risk for major malformations when metformin is taken during the first trimester of pregnancy. Large studies are needed to corroborate these preliminary results.
Gilbert C , Valois M , Koren G . Pregnancy outcome after first-trimester exposure to metformin: a meta-analysis. Fertil Steril. 2006 Sep;86(3):658-63.
Predicting glyburide failure is difficult, not associated with adverse pregnancy outcomes
RESULTS: Of the 235 gestational diabetics identified, 79% of the 101 A2DMs were successfully treated with glyburide as first-line therapy. Those that failed had a higher mean glucose value on glucose challenge test (GCT) (200.5 +/- 57.3 vs 176.6 +/- 33.8 mg/dL, P = .019) and were more likely to have a GCT > or = 200 mg/dL (45 vs 22%, P = .043). Only GCT and GCT > or = 200 mg/dL were predictive of failure.
CONCLUSION: Predicting glyburide failure is difficult, but failure does not appear to be associated with increased adverse pregnancy outcomes.
Rochon M, et al Glyburide for the management of gestational diabetes: risk factors predictive of failure and associated pregnancy outcomes. Am J Obstet Gynecol. 2006 Oct;195(4):1090-4.
The current pregnancy loss rate after amniocentesis is closer to 1 in 1,600
CONCLUSION: The procedure-related fetal loss rate after midtrimester amniocentesis performed on patients in a contemporary prospective clinical trial was 0.06%. There was no significant difference in loss rates between those undergoing amniocentesis and those not undergoing amniocentesis. LEVEL OF EVIDENCE: II-2.
Eddleman
KA, et al Pregnancy Loss Rates After Midtrimester Amniocentesis. Obstet
Gynecol. 2006 Nov;108(5):1067-1072.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd
=retrieve&db=pubmed&list_uids=17077226&dopt=Abstract
Treatment of periodontitis: Is it a case of association does not imply causation ?
CONCLUSIONS: Treatment of periodontitis in pregnant women improves periodontal disease and is safe but does not significantly alter rates of preterm birth, low birth weight, or fetal growth restriction.
Michalowicz BS, et al Treatment of periodontal disease and the risk of preterm birth. N Engl J Med. 2006 Nov 2;355(18):1885-94.
Insulin drip versus rotation of IV fluids between glucose and non-glucose containing fluids
CONCLUSION: In patients with insulin requiring gestational diabetes, intrapartum glycemic control may be comparable with a standard adjusted insulin drip or a rotation of intravenous fluids between glucose and non-glucose containing fluids.
Rosenberg VA ; Eglinton GS; Rauch ER; Skupski DW Intrapartum maternal glycemic control in women with insulin requiring diabetes: a randomized clinical trial of rotating fluids versus insulin drip. Am J Obstet Gynecol. 2006 Oct;195(4):1095-9.
No Benefit for Delivering Twins by 38 Weeks' Gestation
CONCLUSION: This study suggests that the optimal date of delivery for twins should be <40 weeks of gestation; there was no compelling evidence for delivering at <38 weeks of gestation.
Soucie JE, et al Neonatal mortality and morbidity rates in term twins with advancing gestational age. Am J Obstet Gynecol. 2006 Jul;195(1):172-7.
Diagnostic accuracy of noninvasive fetal Rh genotyping from maternal blood
CONCLUSION: The diagnostic accuracy of noninvasive fetal Rh determination using maternal peripheral blood is 94.8%. Its use can be applicable to Rh prophylaxis and to the management of Rh alloimmunized pregnancies. Improvements of the technique and further study of structure and rearrangements of the RhD gene may improve accuracy of testing and enable large-scale, risk-free fetal RhD genotyping using maternal blood.
Geifman-Holtzman O, et al Diagnostic accuracy of noninvasive fetal Rh genotyping from maternal blood--a meta-analysis. Am J Obstet Gynecol. 2006 Oct;195(4):1163-73
Maternal exposure to low levels of ambient air pollution is associated with preterm birth
METHODS: Average maternal exposure estimates for ambient particulate matter (PM(10) and bsp), ozone (O(3)) and nitrogen dioxide were calculated over the first 3 months after last menstrual period (LMP) and the last 3 months prior to birth (individually and combined as trimesters).
RESULTS: Exposure to PM(10) and O(3) during trimester one was associated with an increased risk of PTB (OR = 1.15, 95% CI 1.06-1.25 and OR = 1.26, 95% CI 1.10-1.45, respectively). The PM(10) exposure effect associated with trimester one was strongly related to exposure during the first month post-LMP (PM(10), month one; OR = 1.19, 95% CI 1.13-1.26).
CONCLUSION: These results suggest that maternal exposure to low levels of ambient air pollution is associated with PTB.
Hansen C; Neller A; Williams G; Simpson R Maternal exposure to low levels of ambient air pollution and preterm birth in Brisbane, Australia. BJOG. 2006 Aug;113(8):935-41
Antenatal hydronephrosis as a predictor of postnatal outcome: Even mild findings
CONCLUSIONS: The findings of this meta-analysis can potentially be used for prenatal counseling and may alter current postnatal management of children with antenatal hydronephrosis. Overall, children with any degree of antenatal hydronephrosis are at greater risk of postnatal pathology as compared with the normal population. Moderate and severe antenatal hydronephrosis have a significant risk of postnatal pathology, indicating that comprehensive postnatal diagnostic management should be performed. Mild antenatal hydronephrosis may carry a risk for postnatal pathology, but additional prospective studies are needed to determine the optimal management of these children. A well-defined prospective analysis is needed to further define the risk of pathology and the appropriate management protocols.
Lee RS; Cendron M; Kinnamon DD; Nguyen HT Antenatal hydronephrosis as a predictor of postnatal outcome: a meta-analysis. Pediatrics. 2006; 118(2):586-93
http://www.medscape.com/medline/abstract/16882811?cid=med&src=nlbest
With prior PTD, 17 hydroxyprogesterone caproate results in cost-savings
OBJECTIVE: To evaluate whether the use of 17alpha-hydroxyprogesterone caproate for the prevention of recurrent preterm deliveries is cost-effective.
CONCLUSION: Within our baseline assumptions, 17alpha-hydroxyprogesterone caproate was associated with cost-savings when used for the prevention of preterm deliveries in women with prior preterm deliveries.
Odibo
AO, et al 17alpha-hydroxyprogesterone caproate for the prevention of preterm
delivery: A cost-effectiveness analysis. Obstet
Gynecol. 2006 Sep;108(3 Pt 1):492-9.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd
=retrieve&db=pubmed&list_uids=16946206&dopt=Abstract
Impact of the recent randomized trials on the use of progesterone to prevent preterm birth
CONCLUSION: Although the use of progesterone to prevent PTB has increased significantly since our last survey, there remain a substantial number of nonusers. Among users, many are using it for indications not yet proven in clinical trials. Current nonusers have higher levels of concerns compared to nonusers in the first survey and their major concern is the need for more data.
Ness A, et al Impact of the recent randomized trials on the use of progesterone to prevent preterm birth: a 2005 follow-up survey. Am J Obstet Gynecol. 2006 Oct;195(4):1174-9
BV with Ureaplasma enhances risk of preterm delivery, SGA, and low birth weight
OBJECTIVE: To examine associations of vaginal Ureaplasma urealyticum (UU) and bacterial vaginosis (BV) with preterm delivery (PTD), small for gestational age (SGA), and low birth weight (LBW). CONCLUSION: This analysis suggests that UU is independently associated with fetal growth and LBW and that BV with UU may enhance the risk of these outcomes.
Vogel I; Thorsen P; Hogan VK; Schieve LA; Jacobsson B; Ferre CD The joint effect of vaginal Ureaplasma urealyticum and bacterial vaginosis on adverse pregnancy outcomes. Acta Obstet Gynecol Scand. 2006;85(7):778-85.
Do Antioxidants Prevent Preeclampsia?
Dysfunction in the antioxidant defenses has been suggested as an important factor in the pathogenesis of preeclampsia. Patients were randomized to receive vitamin C (1,000 mg) and vitamin E (400 IU) or placebo daily, beginning between 14 and 22 weeks' gestation.
There were no differences in the risks of preeclampsia or other primary outcome measures between the supplementation and placebo groups. Furthermore, among women who developed preeclampsia, there were no differences between the two groups in the time of onset or the severity. One limitation noted by the authors was that the trial participants had a high dietary intake of vitamins C and E at baseline, so the results may not be applicable to women with low dietary antioxidant intake. Trials with women at increased risk of preeclampsia are ongoing.
Conclusions: The authors do not recommend vitamin C or E supplementation to reduce preeclampsia or other serious outcomes.
Rumbold AR , et al., for the ACTS Study Group. Vitamins C and E and the risks of preeclampsia and perinatal complications. N Engl J Med April 27, 2006;354:1796-806.
A single course of antenatal corticosteroids should be considered routine for PTD
AUTHORS' CONCLUSIONS: The evidence from this new review supports the continued use of a single course of antenatal corticosteroids to accelerate fetal lung maturation in women at risk of preterm birth. A single course of antenatal corticosteroids should be considered routine for preterm delivery with few exceptions. Further information is required concerning optimal dose to delivery interval, optimal corticosteroid to use, effects in multiple pregnancies, and to confirm the long-term effects into adulthood.
Roberts D, Dalziel S. Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm birth. Cochrane Database Syst Rev. 2006 Jul 19;3:CD004454
Vaginal birth after cesarean delivery in twin gestations: Similar rupture rates as singletons
CONCLUSION: Our study showed a significantly higher rate of uterine rupture in the trial of labor group that is similar to the rates reported for trial of labor after cesarean in singleton pregnancies.
Ford AA, et al Vaginal birth after cesarean delivery in twin gestations: a large, nationwide sample of deliveries. Am J Obstet Gynecol. 2006 Oct;195(4):1138-42
Impact of time of day on cesarean complications
CONCLUSION: Maternal and neonatal complications of cesarean delivery do not increase with delivery during the night shift.
Bailit JL, et al The MFMU Cesarean Registry: impact of time of day on cesarean complications. Am J Obstet Gynecol. 2006 Oct;195(4):1132-7
Increasing birth weight relative to the first birth weight diminishes the VBAC success
CONCLUSION: For women with previous cesarean delivery for dystocia, increasing birth weight in the subsequent trial of labor relative to the first birth weight diminishes the chances of successful vaginal delivery.
Peaceman AM, et al The MFMU Cesarean Registry: impact of fetal size on trial of labor success for patients with previous cesarean for dystocia. Am J Obstet Gynecol. 2006 Oct;195(4):1127-31
Consider TOL for women undergoing preterm delivery with a history of prior cesarean
CONCLUSION: The likelihood of VBAC success after TOL in preterm pregnancies is comparable to term gestations, with a lower risk of uterine rupture. Perinatal outcomes are similar with preterm TOL and RCD. TOL should be considered as an option for women undergoing preterm delivery with a history of prior cesarean delivery.
Durnwald CP, et al The Maternal-Fetal Medicine Units Cesarean Registry: safety and efficacy of a trial of labor in preterm pregnancy after a prior cesarean delivery. Am J Obstet Gynecol. 2006 Oct;195(4):1119-26
Aggressive potent glucocorticoids constitute the cornerstone of management HELLP
We recommend for the present that aggressively used potent glucocorticoids constitute the cornerstone of management for patients considered to have HELLP syndrome. Use of dexamethasone 12 mg IM q12h for HELLP improves the platelet count. Nevertheless, giving steroids does not prevent the serious sequelae of maternal death, abruption, intracranial hemorrhage, hepatic hematoma, and perinatal outcome. The advantage of a platelet count >100.000 is that one can have regional anesthesia and a vaginal delivery, but beyond that, steroids have little impact.
Martin JN Jr, et al Understanding and managing HELLP syndrome: the integral role of aggressive glucocorticoids for mother and child. Am J Obstet Gynecol. 2006 Oct;195(4):914-34
Primary Care Discussion Forum
December 1, 2006
Causes of Type 2 Diabetes: Old and New Understandings
Moderator: Ann Bullock M.D.
In 2002, the International Diabetes Federation determined that the medical literature supports 4 etiologies of type 2 diabetes:
--Genetics
--Fetal Origins
--Lifestyle
--Stress
We will explore these issues
- Diabetes prevention programs focus on lifestyle modification—what might these programs look like if lifestyle is only one factor?
- What else can be learned from the DPP (Diabetes Prevention Program)?
- Pregnancy and early life risk factors
- What are the particular roots of the diabetes and obesity epidemics in Indian Country
How to subscribe / unsubscribe to the Primary Care Discussion Forum?
Subscribe to the Primary Care listserv
http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=51
Unsubscribe from the Primary Care listserv
http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=51
Questions on how to subscribe, contact nmurphy@scf.cc directly
STD Corner - Lori de Ravello, National IHS STD Program
IHS Consent Form for an HIV Antibody Test is Hereby Cancelled
On September 22, 2006, the Center for Disease Control (CDC) issued revised recommendations for HIV testing of adults, adolescents, and pregnant women in health care settings. The recommendations for patients in all health-care setting is that a separate written consent for HIV testing should not be required; general consent for medical care should be considered sufficient to encompass consent for HIV testing. To remove any barriers in implementing the CDC recommendations, IHS Form 509*, previously required by the IHS as a separate and specific patient consent form for an HIV antibody test, is hereby cancelled and no longer recommended. If a facility chooses to implement these recommendations and is within state guidelines, patients still must be informed orally or in writing (and documented) that HIV testing will take place – unless they decline the test (opt-out screening). Cancellation of Form 509 does not mean IHS mandates full implementation of CDC recommendations. Rather, it has removed an existing form that may create a barrier within IHS to implementing more streamlined processes for HIV testing. Depending upon individual state guidelines and relationships, local facilities may choose to fully or partially implement all or some of CDC recommendations. More time is needed this year to assess how these recommendations are adopted at the state level and how CDC will identify and manage implementation barriers and challenges.
Full story on CDC HIV Revised Recommendations, October CCC Corner
Wonder what your State consent requirements are? Click here
*NOTICE OF HIV ANTIBODY TEST INFORMATION AND AUTHORIZATION FOR HIV ANTIBODY TEST - IHS Form 509
If you should have questions regarding the CDC recommendations and/or IHS policy and guidelines on HIV testing, please contact CDR Scott Giberson, National IHS HIV/AIDS Principal Consultant, by phone at (301) 443-4644 or by e-mail at Scott.Giberson@ihs.gov
Check out our new IHS STD website
http://www.ihs.gov/medicalprograms/epi/index.cfm?module
=health_issues&option=std&cat=sub_0
Adapting condoms to community values in Native American communities: Snag bags
HIV/AIDS researchers working among Native Americans have consistently noted resistance to discussions of sexuality and the distribution of condoms. This resistance is inspired by long held values about shame and public discussions of sexuality. Also, American Indians have been reluctant to welcome public discussions of HIV/AIDS and sexuality from external entities, such as governmental agencies. As a result, Native peoples have some of the lowest documented condom use rates. However, innovations in culturally integrating condoms and safe sex messages into Native cultural ideals are proving beneficial. One such innovation is the snag bag, which incorporates popular Native sexual ideology while working within local ideals of shame to distribute condoms and safe sex materials to sexually active young people and adults. Using snag bags as an example, this research proposes that an effective approach to HIV prevention among Native peoples is not cultural sensitivity but cultural integration. That is, HIV prevention strategies must move beyond the empty promise of merely culturally-sensitizing ideas about disease cause. Instead of simply 'translating' HIV/AIDS programming into Native culture, prevention strategies must be integrated by Native peoples into their own disease theories and contemporary
Gilley BJ. 'Snag bags': Adapting condoms to community values in Native American communities. Cult Health Sex. 2006 Nov-Dec;8(6):559-70.
Barriers to condom purchasing: Effects of product positioning on reactions to condoms
Correct and consistent condom use has been promoted as a method to prevent sexually transmitted infections including HIV. Yet research has repeatedly shown that people fail to use condoms consistently. One influence on the pervasive lack of condom use that has received relatively little attention is the context in which consumers are exposed to condoms (i.e., how condoms are displayed in retail settings). In this paper we present two studies explored variations in condom shelf placement and its effects on people's condom attitudes and acquisition. Study 1 explored the shelf placement of condoms in 59 retail outlets in Connecticut, USA and found that condoms were typically located in areas of high visibility (e.g., next to the pharmacy counter) and on shelves adjacent to feminine hygiene and disease treatment products. In Study 2, 120 heterosexual undergraduate students at the University of Connecticut were randomly assigned to evaluate condoms adjacent to sensual, positive, neutral, or negative products and found that overall men reported more positive attitudes and acquired more condoms when exposed to condoms in a sensual context compared to women in the same condition. Among women, condom attitudes were more positive in the context of neutral products; condom acquisition was strongest for women exposed to condoms in the positive aisles. These results suggest a gender-specific approach to condom promotion. Implications of these studies for HIV prevention, public health, and condom marketing strategies are discussed.
Scott-Sheldon LA, et al Barriers to condom purchasing: Effects of product positioning on reactions to condoms Social Science & Medicine, Soc Sci Med. 2006 Dec;63(11):2755-69.
Interventions for Molluscum Contagiosum: Cochrane Briefs
Clinical Question
Is there an effective treatment for molluscum contagiosum?
Evidence-Based Answer
There is insufficient evidence to determine whether treatments for molluscum are effective.
Practice Pointers
Molluscum contagiosum, a poxvirus skin infection that largely affects children and adolescents, presents as single or multiple painless white papules with a central dimple. Lesions enlarge slowly and may reach a diameter of 0.2 to 0.4 inches (5 to 10 mm) in six to 12 weeks. After trauma, or spontaneously after several months, inflammatory changes result in the production of pus, crusting, and eventual destruction of the lesions. Most cases are self-limited and resolve within six to nine months. Treatments include cryotherapy, expression or pricking with a sterile needle, topical preparations (e.g., podofilox [Condylox], liquefied phenol, tretinoin [Retin-A], cantharidin, potassium hydroxide), and systemic treatment (e.g., cimetidine [Tagamet]).1
Five randomized controlled trials addressing the effectiveness of different topical treatments for raised molluscum lesions were identified. The participants included children, adolescents, and adults with molluscum. Immunocompromised patients and those with genital molluscum were excluded. The studies reported medium and long-term cure rates, time to cure, and adverse effects for the following treatments: povidone iodine plus salicylic acid (Keralyt); sodium nitrite plus salicylic acid; potassium hydroxide; systemic cimetidine; and calcarea carbonica (a homeopathic and impure form of calcium carbonate). No studies examined cryotherapy or needle expression. The included studies followed a total of 137 participants, with numbers of participants in each study ranging from 20 to 38. Overall, these studies were limited by small size and high drop-out rates, and some did not include an intention-to-treat analysis.
Only one study showed a statistically significant difference in the rate of complete cure in the treatment group. This study (n = 30) demonstrated that treatment with 5% sodium nitrite coapplied daily with 5% salicylic acid under occlusion resulted in a significantly higher rate of lesion cure after three months than treatment with salicylic acid alone (12 out of 16 participants [75 percent] compared with three out of 14 participants [21 percent], respectively [number needed to treat = 2]). The mean number of treatment days was lower in the treatment group than in the control group (38 versus 49 days, respectively). Adverse effects of the sodium nitrite plus salicylic acid treatment included brown staining of skin and irritation.
Another study (n = 35) found a shorter mean time to cure in the group treated with iodine plus salicylic acid plaster compared with iodine alone or salicylic plaster alone (26, 86, and 47 days, respectively). There was no significant difference in complete cure rates between the groups treated with 10% povidone iodine solution plus 50% salicylic acid plaster compared with povidone iodine alone (100 versus 60 percent [risk ratio = 1.67; 95% confidence interval, 0.81 to 3.41]). All participants developed redness of the skin at the treatment site within three to seven days after the start of the treatment.
The other three studies included in the review showed no significant difference in complete cure or lesion improvement with the use of topical 10% potassium hydroxide, systemic cimetidine, or calcarea carbonica compared with the placebo groups.
In the absence of evidence about treatment effectiveness, many experts recommend watchful waiting.
- van der Wouden JC, et al. Interventions for cutaneous molluscum contagiosum. Cochrane Database Syst Rev 2006;(2):CD004767.
-Sladden MJ, Johnston GA. Common skin infections in children. BMJ 2004;329:95-9.
http://www.aafp.org/afp/20061101/cochrane.html#c1
In 2002, the percentage of females aged 15--44 years reporting that they had ever been treated for PID varied by age at first vaginal intercourse and by number of male sex partners in the preceding 12 months. Higher prevalence of PID treatment was reported among females who had their first vaginal intercourse at younger ages, particularly <15 years, and among those who had greater numbers of male sex partners in the preceding 12 months.
SOURCE: Chandra A, Martinez GM, Mosher WD, Abma JC, Jones J. Fertility, family planning, and reproductive health of U.S. women: data from the 2002 National Survey of Family Growth. Vital Health Stat 2005;23(25 ).
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5543a8.htm?s_cid=mm5543a8_e
Barbara Stillwater, Alaska State Diabetes Program
Gestational Diabetes Linked to High Prevalence of Periodontal Disease
OBJECTIVE: We examined the relationship between periodontal disease and different types of diabetes in pregnant and nonpregnant women. STUDY DESIGN: This study was based on the data from the third National Health and Nutrition Examination Survey (NHANES III), including 256 pregnant and 4234 nonpregnant women. Women were classified into those with gestational diabetes mellitus (GDM) in current pregnancy, with GDM in previous pregnancy, and with type 1 or 2 diabetes. RESULTS: In pregnant women, the prevalence of periodontitis was 44.8% in women with GDM and 13.2% in nondiabetic women, with adjusted odds ratio (aOR) of 9.11 (95% confidence interval [CI] 1.11-74.9). In nonpregnant women, the prevalence of periodontitis was 40.3% in women with type 1 or 2 diabetes, 25.0% in women with previous history of GDM, and 13.9% in nondiabetic women, with aOR of 2.76 (1.03-7.35) for women with type 1 or 2 diabetes. CONCLUSION: We found an association between periodontal disease and GDM.
Editorial comment: Todd Smith, DDS, MSD IHS Periodontal Consultant
It is not surprising that there was a significant, positive association between periodontitis and GDM. Both pregnancy and diabetes are associated with increased inflammation in the gums and tissues surrounding the teeth. The same microvascular changes occurring throughout the body in patients with diabetes (ie formation of advanced glycation end products, increased cross linking of collagen and accumulation in blood vessel walls, vascular smooth muscle proliferation with narrowing of the lumen, poor oxygenation and perfusion) occurs in the periodontal tissues. Taylor (2004) reported in a review of 55 studies involving subjects with dm that there was consistent evidence of greater periodontitis prevalence, incidence, severity, and progression. This relationship appears to be bidirectional, with the chronic, gram-negative anaerobic infection of periodontitis perpetuating a systemic inflammatory state with a resultant increase in insulin resistance and aggravation of glycemic control. This is supported in treatment studies where treatment of periodontitis has been associated with significant drops in HbA1c.
The same may be true for pregnancy and periodontitis. The systemic inflammation associated with periodontitis, with bacteremia and increases in PgE2, TNF-α, Il-1 and –6, and CRP, has been associated with adverse pregnancy outcomes such as PTB, LBW, and preeclampsia (Offenbacher, Jeffcoat, Boggess, Radnai, and others). Some studies have demonstrated a decrease in prevalence of adverse pregnancy outcomes with periodontal therapy during the second trimester; the most recent in the NEJM did not. A larger multicenter periodontal treatment study with 1800 patients is ongoing and due to be published within 2 years. In the meantime, if your patients are having trouble controlling their blood sugar, or are pregnant, look in their mouths to see how healthy the gums look. Expectant mothers should be counseled in the importance of oral health, and referral to a dentist is strongly recommended.
OB/GYN CCC Editorial comment:
Diabetes can impair the healing process: May result in increased periodontal disease
There was a presentation / overview of studies on periodontal disease and birth outcomes at the 2006 National Oral Health Conference. The summary was that studies are building the case for links of periodontal disease and adverse birth outcomes. The conclusion of the presenters that we aren't quite yet in the position to make very strong statements about causation but the studies have pointed to clear associations with some evidence of biological plausibility and a couple of intervention studies indicating that treatment of periodontal disease during pregnancy can reduce the risk of adverse birth outcomes or the mother's health (preeclampsia, preterm birth and low birth-weight).
Xiong X, et al might assist in identification of women most at-risk. Generally, the indications are still not that diabetes causes periodontal disease. The model has generally been that diabetes can impair the healing process so it is that aspect that can result in increased periodontal disease. It is clear that individuals with diabetes are at much greater risk for periodontal disease and this study seems to support that is the case even with gestational diabetes.
It is hoped that NIH, CDC and others to be doing consensus conferences over the next year or two for review of the studies and literature to make more definitive statements about roles of periodontal disease in relation to pregnancy and birth outcomes.
References:
Xiong X, et al Periodontal disease and gestational diabetes mellitus. Am J Obstet Gynecol. 2006 Oct;195(4):1086-9.
Taylor GW et al. Diabetes, periodontal diseases, dental caries, and tooth loss: a review of the literature. Compendium of Contin Ed in Dent 2004. Mar;25(3):179-84, 186-8, 190
Other Background:
Southerland, Taylor, Offenbacher. Diabetes and Periodontal Infection: Making the Connection. Clinical Diabetes. Fall 2005. Vol23, Issue 4. 171.
Offenbacher. Periodontal infection as a possible risk factor for preterm low birth weight. J. Periodontol 1996. 67: 1103-1113.
Jeffcoat et al. Periodontal disease and preterm birth: Results of a pilot intervention study. J Periodontol 2003; 74: 1214-1218
Boggess et al. Maternal periodontal disease is associated with increased risk for preeclampsia. Obstet gynecol 2003; 101:227-231.
Radnai etal. A possible association between preterm birth and early periodontitis. A pilot study. J Clin Periodontol 2004. Sep;31(9):736-41
Physical activity before pregnancy or during pregnancy reduces gestational diabetes
CONCLUSION: Physical activity, especially vigorous activity before pregnancy and at least light-to-moderate activity during pregnancy, may reduce risk for abnormal glucose tolerance and GDM. LEVEL OF EVIDENCE: II-2.
Oken E, Ning Y, Rifas-Shiman SL, Radesky JS, Rich-Edwards JW, Gillman MW. Associations of physical activity and inactivity before and during pregnancy with glucose tolerance. Obstet Gynecol. 2006 Nov;108(5):1200-7.
Mothers with type 2 diabetes during pregnancy can transmit risk factors
to their children
Type 2 diabetes is the result of both genetic and environmental factors. Fetal
exposure to maternal diabetes is associated with a higher risk of abnormal glucose
homeostasis in offspring beyond that attributable to genetic factors, and therefore,
may participate in the excess of maternal transmission of type 2 diabetes.
A MEDLINE search covering the period from 1960–2005. In studies performed in children and adolescents suggest that offspring who had been exposed to maternal diabetes during fetal life exhibit higher prevalence of impaired glucose tolerance and markers of insulin resistance. Recent studies that directly measured insulin sensitivity and insulin secretion have shown an insulin secretory defect even in the absence of impaired glucose tolerance in adult offspring. In animal models, exposure to a hyperglycemic intrauterine environment also led to the impairment of glucose tolerance in the adult offspring. These metabolic abnormalities were transmitted to the next generations, suggesting that in utero exposure to maternal diabetes has an epigenetic impact. At the cellular level, some findings suggest an impaired pancreatic ß-cell mass and function. Several mechanisms such as defects in pancreatic angiogenesis and innervation, or modification of parental imprinting, may be implicated, acting either independently or in combination.
Therefore it was concluded that, fetal exposure to maternal diabetes may
contribute to the worldwide diabetes epidemic. Public health interventions targeting
high-risk populations should focus on long-term follow-up of subjects who have
been exposed in utero to a diabetic environment and on a better glycemic control
during pregnancy.
Fetita
LS, et al Consequences of Fetal Exposure to Maternal Diabetes in Offspring
Journal of Clinical Endocrinology & Metabolism Vol. 91, No. 10 3718-3724
Does coffee reduce the risk of type 2 diabetes in individuals with impaired glucose?
In a large study, current and past coffee consumption reduced the risk for type 2 diabetes by 60% compared with those who did not drink coffee.
RESULTS: Past and current coffee drinkers had a reduced risk of incident diabetes (odds ratio 0.38 [95% CI 0.17-0.87] and 0.36 [0.19-0.68], respectively) compared with those who never drank coffee. CONCLUSIONS: This study confirms a striking protective effect of caffeinated coffee against incident diabetes and extends these findings to incident diabetes based on OGTT independent of multiple plausible confounders.
Smith B, et al Does coffee consumption reduce the risk of type 2 diabetes in individuals with impaired glucose? Diabetes Care. 2006 Nov;29(11):2385-90
Every kilogram of weight loss resulted in 16% reduction of diabetes risk
Among participants in the intensive lifestyle intervention arm of the Diabetes Prevention Program, weight reduction had the strongest effect on reduction of diabetes risk compared with diet and physical activity. The Diabetes Prevention Program (DPP) reported a 58% reduction in the incidence of diabetes over almost three years in [participants] treated with an intensive lifestyle intervention compared with participants treated with placebo.
Hamman RF, et al Effect of weight loss with lifestyle intervention on risk of diabetes.
Diabetes Care. 2006 Sep;29(9):2102-7
New
Measure Predicts Blood Glucose Variability in Diabetics
Traditionally, statistical estimation of glycemic variability includes
computing standard deviation of glucose readings or related statistics (eg, M
value, mean amplitude of glucose excursions, and so forth). We advocate an alternative
approach using risk measures of variability, which have substantial clinical
and numerical advantages. In addition, continuous glucose monitoring (CGM) data
have clinically important inherent temporal structure that should be taken into
consideration. Thus, temporal variability methods are discussed for the analysis
and interpretation of CGM output. Kovatchev
BP. Is glycemic variability important to assessing antidiabetes therapies? Curr
Diab Rep. 2006 Nov;6(5):350-6
Racial/Ethnic and Socioeconomic Differences in Multiple Risk Factors
for Heart Diseases and Stroke in Women: Behavioral Risk Factor Surveillance System,
2003
Heart disease and stroke are among the leading causes of death in women. The
risk of heart disease and stroke can be reduced by controlling risk factors such
as high blood pressure, high cholesterol, diabetes, smoking, obesity and physical
inactivity. This CDC study shows that over a third of U.S. women have two
or more of these risk factors with significant disparities among socioeconomic
and racial/ethnic groups. Those who were older, less educated, unemployed, and
with a lower income were more likely to have multiple risk factors. Black and
Native American women were at increased risk, while Hispanic women were at lower
risk, compared to white women. To decrease the disproportionate burden of multiple
risk factors on minority populations, public health programs should focus on
improving identification and treatment of affected women and promote policy and
lifestyle changes conducive to cardiovascular health.
Hayes DK, et al Racial/Ethnic and Socioeconomic Differences in Multiple Risk Factors for Heart Diseases and Stroke in Women: Behavioral Risk Factor Surveillance System, 2003. Journal of Women’s Health http://www.liebertonline.com/jwh
What's new on the ITU MCH web pages?
What medications, foods, and beverages irritate the bladder?
CDC Compendium of Domestic Violence Assessment Tools
Compendium of State Laws Impacting HIV Screening and Treatment
There are several upcoming Conferences
and Online CME/CEU resources, etc….
and the latest Perinatology Corners (free online CME from IHS)
…or just take a look at the What’s New page
Save the dates
22nd Annual Midwinter Indian Health OB/PEDS Conference
- For providers caring for Native women and children
- January 26-28, 2007
- Telluride, CO
- Contact Alan Waxman awaxman@salud.unm.edu
TeenScreen Conference: Second Annual
- March 14 and 15, 2007
- Washington D.C.
- ContactTSConference@childpsych.columbia.edu
2nd International Meeting on Indigenous Child Health
- April 20-22, 2007
- Montreal , Quebec, Canada
- Solutions, not Problems
- Joint meeting of IHS, AAP-CONACH, First Nations and several other stakeholders
- http://www.aap.org/nach/2InternationalMeeting.htm
2007 Indian Health MCH and Women’s Health National Conference
- August 15 -17, 2007
- Albuquerque , NM
- THE place to be for anyone involved in care of AI/AN women, children
- Internationally recognized speakers
- Save the dates. Details to follow
- Want a topic discussed? Contact nmurphy@scf.cc
Did you miss something in the last OB/GYN Chief Clinical Consultant Corner?
The October 2006 OB/GYN CCC Corner is available.
Hot Topics ‹ Previous
OB/GYN
Dr. Neil Murphy is the Obstetrics and Gynecology Chief Clinical Consultant (OB/GYN C.C.C.). Dr. Murphy is very interested in establishing a dialogue and/or networking with anyone involved in women's health or maternal child health, especially as it applies to Native or indigenous peoples around the world. Please don't hesitate to contact him by e-mail or phone at 907-729-3154.
