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Volume 5, No. 2, February 2007
Features
American College of Obstetricians and Gynecologists
Guidelines Recommend Universal Screening for Down Syndrome: Regardless of age
Summary of Recommendations and Conclusions
The following recommendations are based on good and consistent scientific evidence (Level A):
- First-trimester screening using both nuchal translucency measurement and biochemical markers is an effective screening test for Down syndrome in the general population. At the same false-positive rates, this screening strategy results in a higher Down syndrome detection rate than does the second-trimester maternal serum triple screen and is comparable to the quadruple screen.
- Measurement of nuchal translucency alone is less effective for first-trimester screening than is the combined test (nuchal translucency measurement and biochemical markers).
- Women found to have increased risk of aneuploidy with first-trimester screening should be offered genetic counseling and the option of CVS or second-trimester amniocentesis.
- Specific training, standardization, use of appropriate ultrasound equipment, and ongoing quality assessment are important to achieve optimal nuchal translucency measurement for Down syndrome risk assessment, and this procedure should be limited to centers and individuals meeting these criteria.
- Neural tube defect screening should be offered in the second trimester to women who elect only first-trimester screening for aneuploidy.
The following recommendations are based on limited or inconsistent scientific evidence (Level B):
- Screening and invasive diagnostic testing for aneuploidy should be available to all women who present for prenatal care before 20 weeks of gestation regardless of maternal age. Women should be counseled regarding the differences between screening and invasive diagnostic testing.
- Integrated first- and second-trimester screening is more sensitive with lower false-positive rates than first-trimester screening alone.
- Serum integrated screening is a useful option in pregnancies where nuchal translucency measurement is not available or cannot be obtained.
- An abnormal finding on second-trimester ultrasound examination identifying a major congenital anomaly significantly increases the risk of aneuploidy and warrants further counseling and the offer of a diagnostic procedure.
- Patients who have a fetal nuchal translucency measurement of 3.5 mm or higher in the first trimester, despite a negative aneuploidy screen, or normal fetal chromosomes, should be offered a targeted ultrasound examination, fetal echocardiogram, or both.
- Down syndrome risk assessment in multiple gestation using first- or second-trimester serum analytes is less accurate than in singleton pregnancies.
- First-trimester nuchal translucency screening for Down syndrome is feasible in twin or triplet gestation but has lower sensitivity than first-trimester screening in singleton pregnancies.
The following recommendations are based primarily on consensus and expert opinion (Level C):
- After first-trimester screening, subsequent second-trimester Down syndrome screening is not indicated unless it is being performed as a component of the integrated test, stepwise sequential, or contingent sequential test.
- Subtle second-trimester ultrasonographic markers should be interpreted in the context of a patient’s age, history, and serum screening results.
Screening for fetal chromosomal abnormalities. ACOG Practice Bulletin No. 77. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;109:217–27.
Hemoglobinopathies in Pregnancy
Summary of Recommendations and Conclusions
The following recommendations are based on good and consistent scientific evidence (Level A):
- Individuals of African, Southeast Asian, and Mediterranean descent are at increased risk for being carriers of hemoglobinopathies and should be offered carrier screening and, if both parents are determined to be carriers, genetic counseling.
- A complete blood count and hemoglobin electrophoresis are the appropriate laboratory tests for screening for hemoglobinopathies. Solubility tests alone are inadequate for screening because they fail to identify important transmissible hemoglobin gene abnormalities affecting fetal outcome.
- Couples at risk for having a child with sickle cell disease or thalassemia should be offered genetic counseling to review prenatal testing and reproduction options. Prenatal diagnosis of hemoglobinopathies is best accomplished by DNA analysis of cultured amniocytes or chorionic villi.
Hemoglobinopathies in pregnancy. ACOG Practice Bulletin No. 78. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;109:229–37.
Commercial Enterprises in Medical Practice
ABSTRACT: Increasing numbers of physicians sell and promote both medical and nonmedical products as part of their practices. Physicians always have rendered advice and treatment for a fee, and this practice is appropriate. It is unethical under most circumstances, however, for physicians to sell or promote medical or nonmedical products or services for their financial benefit. The following activities are considered unethical: sale of prescription drugs to be used at home, sale or promotion of nonprescription medicine, sale or promotion of presumptively therapeutic agents that generally are not accepted as part of standard medical practice, sale or promotion of non–health-related items, recruitment of patients or other health care professionals into multilevel marketing arrangements, and sale or promotion of any product in whose sale the physician has a significant financial interest. It is ethical and appropriate, however, to sell products to patients as follows: sale of devices or drugs that require professional administration in the office setting; sale of therapeutic agents, when no other facilities can provide them at reasonable convenience and at reasonable cost; sale of products that clearly are external to the patient–physician relationship, when such a sale would be considered appropriate in an external relationship; and sale of low-cost products for the benefit of community organizations. A rationale is provided for both the prohibited activities and exceptions.
Commercial enterprises in medical practice. ACOG Committee Opinion No. 359. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;109:243–5.
Professional Responsibilities in Obstetric–Gynecologic Education
ABSTRACT: Physicians must learn new skills in a manner consistent with their ethical obligations to benefit the patient, to do no harm, and to respect a patient's right to make informed decisions. Patients should be given the opportunity to consent to or refuse treatment by students. Students must hold in confidence any information they learn about patients. The relationship between teacher and student involves an imbalance of power and the risk of exploitation of a student for the benefit of the teacher. Students should not be placed in situations where they must provide care or perform procedures for which they are not qualified and not adequately supervised. Students have the obligation to be honest, conscientious, and respectful in their relationships with their teachers. They should act in ways that preserve the dignity of patients and do not undermine relationships between patients and their physicians. If a student observes unethical behavior or incompetent conduct by a teacher, the appropriate institutional authority should be informed. Institutions have an obligation to provide a work environment that enhances professional competence by ensuring that students and residents work reasonable hours, helping them balance education and patient care responsibilities; providing adequate support services; and, in the case of residents, providing reasonable salaries and benefits. With increasing numbers of women in education programs, special attention must be given to the parallel demands of pregnancy and career goals.
Education of health care professionals is essential to maintain standards of competent and beneficial practice. Inherent in the education of health professionals is the problem of disparity in power and authority, including the power of teachers over students and the power of practitioners over patients † (1). It is therefore important to clarify both the professional responsibilities to those patients whose care provides educational opportunities and the responsibilities of teachers and students toward one another. Students in the context of this Committee Opinion include both medical students and residents. However, residents have a dual responsibility as teacher and student and must be aware of that in understanding their ethical responsibilities to the students they teach and the patients they care for.
Professional responsibilities in obstetric–gynecologic education. ACOG Committee Opinion No. 358. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;109:239–42.
American Family Physician**
Childhood and Adolescent Depression
Major depression affects 3 to 5 percent of children and adolescents. Depression negatively impacts growth and development, school performance, and peer or family relationships and may lead to suicide. Biomedical and psychosocial risk factors include a family history of depression, female sex, childhood abuse or neglect, stressful life events, and chronic illness. Diagnostic criteria for depression in children and adolescents are essentially the same as those for adults; however, symptom expression may vary with developmental stage, and some children and adolescents may have difficulty identifying and describing internal mood states. Safe and effective treatment requires accurate diagnosis, suicide risk assessment, and use of evidence-based therapies. Current literature supports use of cognitive behavior therapy for mild to moderate childhood depression. If cognitive behavior therapy is unavailable, an antidepressant may be considered. Antidepressants, preferably in conjunction with cognitive behavior therapy, may be considered for severe depression. Tricyclic antidepressants generally are ineffective and may have serious adverse effects. Evidence for the effectiveness of selective serotonin reuptake inhibitors is limited. Fluoxetine is approved for the treatment of depression in children eight to 17 years of age. All antidepressants have a black box warning because of the risk of suicidal behavior. If an antidepressant is warranted, the risk/benefit ratio should be evaluated, the parent or guardian should be educated about the risks, and the patient should be monitored closely (i.e., weekly for the first month and every other week during the second month) for treatment-emergent suicidality. Before an antidepressant is initiated, a safety plan should be in place. This includes an agreement with the patient and the family that the patient will be kept safe and will contact a responsible adult if suicidal urges are too strong, and assurance of the availability of the treating physician or proxy 24 hours a day to manage emergencies. (see Patient Education)
Am Fam Physician 2007;75:73-80, 83-4. http://www.aafp.org/afp/20070101/73.html
AHRQ
Women's self-report of mammography use conflicts with verified reports
using claims data
http://www.ahrq.gov/research/nov06/1106RA7.htm
Free blood glucose monitors for patients with diabetes encourages
self-management
http://www.ahrq.gov/research/nov06/1106RA6.htm
Ask A Librarian: Diane Cooper, M.S.L.S. / NIH
Diet of Pregnant American Indians: Different than Whites?
A pregnant woman’s diet can influence the outcome of her pregnancy. Is the diet of pregnant American Indians different than whites? A Harvard team sought to find the answer using data from the North Dakota WIC (Women, Infants and Children) program.
They found that the diets of the two groups were not much different. There was a statistical difference in the sample of over 5,000 women, but it was “minimal.” Both groups needed improvement, the researchers said. Increases in iron and folate intake were specially recommended. And, as expected, both groups would benefit from eating less fat and more grains and vegetables. AI women had “greater diet diversity,” which was a plus.
Comment: The conclusions were flawed because the study did not include the effect of dietary supplements such as prenatal vitamins. Iron and folate are usually in prenatal supplements. Generalizability is weak since the sample was limited to one state. While the study was published in December, 2006, the data reach back to 1996, another reason results are not generalizable. A finding that may be more important was that smoking among AI women was much higher than whites: 46% vs. 28%.
Watts V, et al.: Assessing Diet Quality in a population of low-income pregnant women. Maternal Child Health Journal, 2006; Dec 27 Epub ahead of print.
*”Informationists help find the information you need.”
Breastfeeding - Suzan Murphy, PIMC
Supporting employee breastfeeding is easier than it sounds
T he Indian Health Services” Lactation Support Circular is part of a new national wave of improvements to the work environment. Establishing guidelines that support moms to work and breastfeed benefits many parts of the work environment.
- When new moms can keep breastfeeding their infants, their children have half the clinic visits for diarrhea and otitis media and dramatically lower rates of hospitalizations rates for lung and gastrointestinal illnesses. (1,2,3)
- Breastfeeding moms need less leave for sick infants, reducing the burden to their co-workers for unexpected absences.
- Breastfed babies are cheaper to care for medically. Ball et al found significantly less health care/insurance dollars spent for illness with breastfed babies compared to formula fed babies.
- Aetna Life and Casualty, Hartford CT is a forerunner in supporting breastfeeding. They established a employee breastfeeding center in the 1996s because those families required employee sick leave and lower insurance claims. Their return on investment is $2.18 for every $1.00 spent. (5)
- Research on employee and management satisfaction indicates that supporting the choice to breastfed improves job satisfaction and productivity. (6)
So what is the easy part about supporting employee breastfeeding ?
- It is mom-driven. Once the work place adapts the Circular’s suggestions that fit the local needs, it is almost a turn-key operation. Moms use the available resources to continue breastfeeding. Available resource will vary depending on the location – for example, in some work environments, this may mean more flexible schedules, in others it could mean using existing hospital electric breast pumps or encouraging employees to rent their own.
Want some ideas/options about pumps, tips for employees to store their milk, ideas for breastfeeding room etiquette, policy and procedures, etc?
- Watch for Tool Kit to be released soon.
- For more information, check the I.H.S. MCH Breastfeeding website sections, Going back to work or school and Staff Resources.
The Lactation Support Circular can be found at www.ihs.gov/MedicalPrograms/MCH/M/bf.cfm
1. Policy Statement: Breastfeeding and the Use of Human Milk. Pediatrics, Vol. 115 No. 2 February 2005, pp. 496-506.
2. Benefits of breastfeeding. Department of Health and Human Service Office on Women's Health. Nutr Clin Care. 2003 Oct-Dec;6(3):125-31.
3. Dewey KG, Heinig MJ, Nommsen-Rivers LA. Differences in morbidity between breast-fed and formula-fed infants. J Pediatr. 1995;126 :696 –702
4. Ball TM, Wright AL. Health care cost of formula-feeding in the first year of life. Pediatrics. 1999;103 :870 –876.
5. Danyliw NC, US News and World Report, Dec 15, 1997, pp 79-81
6. www.wicworks.ca.gov/breastfeeding/EmployerResources/bf_bestinvestment.pdf
Other
Simple antenatal intervention improves breastfeeding practice until 6 months postpartum
CONCLUSION: Where breastfeeding practices are suboptimal, simple one-encounter antenatal education and counseling significantly improve breastfeeding practice up to 3 months after delivery. Provision of printed or audiovisual educational material is not enough. Health care workers should make every effort to have one face-to-face encounter to discuss breastfeeding with expectant mothers before they deliver. LEVEL OF EVIDENCE: I.
Mattar CN, et al Simple antenatal preparation to improve breastfeeding practice: a randomized controlled trial. Obstet Gynecol. 2007 Jan;109(1):73-80
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17197590
CCC Corner Digest
Nicely laid out hard copy - A compact digest of last month’s CCC Corner
-Organizational silence threatens patient safety
-The 2nd International Meeting on Indigenous Child Health
-Shoulder dystocia: Only 43% participants could achieve delivery before training
-HPV vaccine is effective: Why do we not provide it to most AI/AN?
-Why do disparities in infant mortality persist between AIAN and white infants?
- Firearm Safety in Homes with Adolescents
- Treatment With Selective Serotonin Reuptake Inhibitors During Pregnancy
- Levothyroxine Reduces Preterm Birth in Euthyroid Women
- Flu season and Breastfeeding
- Improving the Health Care Response to Domestic Violence in AI/AN Communities
- Bone Loss With Use of Depot Medroxyprogesterone Acetate Slows After 2 Years
- The IHS Breastfeeding Home Page is live!
- Patent Wellness Handout
- A nurse, a doctor, and an epidemiologist were standing by the river……
- A boy has been born in Chile with a fetus in his stomach
- Start ‘Em Young for Future Success and Maybe No One Will Be Left Behind
- GYN Spotlight: Endometrial ablation
- Nurses less satisfied than physicians or nurse managers: Perceptions of teamwork
- Reduction in Teen Pregnancies
- 97 cesarean deliveries (NNT) prevent serious morbidity / mortality in second twins
- Less than half of parents with HIV tell their children about the diagnosis
- Diabetes Prevention Study: Participants Still Benefiting Three Years Later
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/CCCC_v5_01.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:
A Compendium
http://www.cdc.gov/ncipc/dvp/Compendium/Measuring_IPV_Victimization_and_Perpetration.htm
Physical Dating Violence Among High School Students – United
States, 2003
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5519a3.htm
Elder Care News
Risk of Poor Outcomes From Bariatric Surgery May Be Greater in Elderly
CONCLUSIONS: Age, male sex, electrolyte disorders, and congestive heart failure were independent risk factors for bariatric surgical mortality. Limiting bariatric surgical procedures to those younger than 65 years is warranted because of the high morbidity and mortality associated with these operations in older patients.
Livingston EH, Langert J. The impact of age and Medicare status on bariatric surgical outcomes. Arch Surg. 2006 Nov;141(11):1115-20; discussion 1121
Family Planning
Continuous Contraceptive Therapy Safely Abolishes Menstrual Cycles
CONCLUSIONS: Continuous daily regimen of levonorgestrel (LNG) 90 mug/ethinyl estradiol (EE) 20 mug demonstrated a good safety profile and efficacy similar to cyclic OCs. The regimen continuously inhibited menses, increased the incidence of amenorrhea over time and, except for a subset of women, decreased the number of bleeding and spotting days.
Archer DF, et al Evaluation of a continuous regimen of levonorgestrel/ethinyl estradiol: phase 3 study results. Contraception. 2006 Dec;74(6):439-45
FDA Questions and Answers: Ortho Evra (norelgestromin/ethinyl estradiol)
Ortho-McNeil and FDA notified healthcare professionals and patients about
revisions to the prescribing information to inform them of the results of two
separate epidemiology studies that evaluated the risk of developing a serious
blood clot in women using Ortho Evra compared to women using a different oral
contraceptive. The first study found that the risk of non-fatal venous thromboembolism
(VTE) associated with the use of Ortho Evra contraceptive patch is similar to
the risk associated with the use of oral contraceptive pills containing 35 micrograms
of ethinyl estradiol and norgestimate.The second study found an approximate two-fold
increase in the risk of medically verified VTE events in users of Ortho Evra
compared to users of norgestimate-containing oral contraceptives containing 35
micrograms of estrogen. Although the results of the two studies differ, the results
of the second study support FDA's concerns regarding the potential for Ortho
Evra use to increase the risk of blood clots in some women.
Prescribing information for Ortho Evra continues to recommend that women with
concerns or risk factors for thromboembolic disease talk with their healthcare
professionals about using Ortho Evra versus other contraceptive options.
http://www.fda.gov/cder/drug/infopage/orthoevra/qa20060920.htm
Access to emergency contraceptive enhances use but not reduce unintended pregnancy
CONCLUSION: Increased access to emergency contraceptive pills enhances use but has not been shown to reduce unintended pregnancy rates. Further research is needed to explain this finding and to define the best ways to use emergency contraception to produce a public health benefit.
Raymond EG, et al Population Effect of Increased Access to Emergency Contraceptive Pills: A Systematic Review. Obstet Gynecol. 2007 Jan;109(1):181-188.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17197603
Featured Website David Gahn, IHS Women’s Health Web Site Content Coordinator
Vaccine Preventable Diseases
The IHS National Immunization Program is a partnership between CDC and IHS, working with IHS and tribal immunization programs across the country.
The program is based in the IHS Division of Epidemiology & Disease Prevention in Albuquerque, NM. IHS National Immunization Program staff are assigned from the CDC Immunization Services Division. Each IHS Area also has a designated Immunization Coordinator.
Frequently asked questions
Are varicella titers necessary prior to immunization?
Some providers and/or nurses are ordering varicella titers on patients during pregnancy, if they do not have a clear history of having had the disease, with the purpose of vaccinating those with negative titers postpartum. Is that is a reasonable approach? Or would it be better to assume that all without a history of the disease are susceptible and immunize them postpartum without doing titers?
Answer
For individuals with a reliable history of varicella, it can be assumed that they are immune and vaccination is unnecessary. The vast majority of adults (70 to 90 percent) without a reliable history of varicella are also immune. In light of these data, the American Academy of Pediatrics has suggested that it may be cost effective to perform serologic testing on persons 13 years of age and older and immunize those who are seronegative. This requires that serologic results will be tracked and susceptible patients will be immunized. However, serologic testing is not required because the vaccine is well tolerated in patients with immunity; thus in some situations, universal immunization may be more practical and preferable.
Health care and child care workers who do not have a history of varicella should be tested serologically, and those who are seronegative, and without a contraindication, should be immunized. (more Background below)
….so…. my suggestion is that unless you want to develop a specific tracking system for this issue
#1 ask the patient if she has had chickenpox or been immunized
#2 if not, then treat with vaccine
…if you have a robust infrastructure, then
#1 ask the patient if she has had chickenpox or been immunized
#2 if not, then test and vaccinate the sero-negative patients postpartum
OB/GYN CCC Editorial comment:
The Perinatology Corner offers a module on this topic
The Chickenpox (varicella) in Pregnancy module presents other resources, as well as free CME / CEUs if desired
http://www.ihs.gov/MedicalPrograms/MCH/M/VC01.cfm
Other references:
Perinatal Viral and Parasitic Infections, ACOG Practice Bulletin, No. 20, American College of Obstetricians and Gynecologists, September 2000
American Academy of Pediatrics. Committee on Infectious Diseases. Varicella vaccine update. Pediatrics 2000; 105:136. (Updated May 16, 2006).
Treatment and prevention of chickenpox , UpToDate
Centers for Disease Control and Prevention. Prevention of varicella: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep 1996;45(RR-11):1–36 (Level III)
Glantz JC, Mushlin AI. Cost-effectiveness of routine antenatal varicella screening. Obstet Gynecol 1998;91:519–528 (Level III)
Rouse DJ, Gardner M, Allen SJ, Goldenberg RL. Management of the presumed susceptible varicella (chickenpox)-exposed gravida: a cost-effectiveness/cost-benefit analysis. Obstet Gynecol 1996;87:932–936 (Level III)
McGregor JA, Mark S, Crawford GP, Levin MJ. Varicella zoster antibody testing in the care of pregnant women exposed to varicella. Am J Obstet Gynecol 1987; 157:281–284 (Level II-3)
More Background
Nonpregnant women of childbearing age should be questioned about previous infection with varicella preconceptionally and offered vaccination if no report of chickenpox is elicited. Varicella vaccine is approved for use in healthy susceptible persons 12 months or older. Conception should be delayed until 1 month after the second vaccination dose is given.
Among women who do not recall a history of varicella, 70–90% have detectable antibodies. Antenatal VZV screening of all pregnant women with negative or indeterminate varicella histories is not believed to be cost-effective by some. However, others argue that from a cost-effectiveness/cost-benefit standpoint, management based on immune testing is preferable to universal VZIG administration when caring for pregnant women exposed to VZV with a negative or indeterminate infection history. Patients known to be nonimmune to VZV should be counseled to avoid contact with individuals who have chickenpox.
Indian Child Health Notes - Steve Holve, Pediatrics Chief Clinical Consultant
February 2007
-Needle size: “less is more” versus “more is less”
-2007 Childhood and Adolescent Immunization Schedules: Evolution or Intelligent Design?
-Embracing a Common Destiny: Health for All.
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ICHN107.doc
Information Technology
Computerized Public Health Activity Data System, Version 1.0 Announcement
The Portland Area and OIT are pleased to announce the release the Computerized Public Health Activity Data System, Version 1.0. The package was tested at: Chinle Comprehensive Health Care Facility, Warm Springs Health and Wellness Center, Cherokee Indian Hospital and Stillaguamish Tribal.
The Indian Health Service (IHS) Computerized Public Health Activity Data System (CPHAD) application provides for the entry of public health activity being performed by clinicians or other providers of public health activities. This software application will work in conjunction with the existing Resource and Patient Management (RPMS) applications.
Please contact Mary Brickell mary.brickell@ihs.gov
IHS Web page http://www.ihs.gov/Cio/RPMS/index.cfm?module=home&option=software
International Health Update: Claire Wendland, Madison, WI
What does the future hold in store?
Important news in the world of international health is the recent update of the Global Burden of Disease (GBD) study. The original and groundbreaking 1990 GBD project gathered data from around the world to provide the first truly global estimates of morbidity and mortality due to various causes. Researchers at Harvard University and the WHO, funded by the World Bank, also used their data to make projections of global death rates through 2020. These GBD projections have been used extensively by policymakers at national and international levels to guide resource allocation; however, some of the predictions have already proven to be badly off. In particular, the original report gravely underestimated the impact of HIV/AIDS.
The researchers used 2002 WHO disease prevalence data to model patterns of illness and death under three scenarios of socioeconomic change: a baseline scenario, a pessimistic scenario (in which economic growth is less than expected) and an optimistic scenario (projecting a faster rate of economic growth). In all three cases, they predict that the risk of death for children below 5 will drop substantially by 2030. Life expectancy at birth will rise in all regions, and the disparity between life expectancies in rich and poor countries will narrow somewhat, though in both baseline and pessimistic scenarios the gap will remain very large. Death due to non-communicable disease – particularly ischemic heart disease – will rise, as will death from HIV/AIDS and from road traffic accidents, even in the most optimistic projections. (In fact, greater economic growth is expected to result in more road traffic fatalities.) Diabetes and cancer will increase while measles, malaria, and lower-respiratory conditions are projected to decline. By 2015, tobacco will be responsible for 10% of deaths worldwide. The three leading causes of disability are projected to be HIV/AIDS, depression, and coronary artery disease.
Of course it is too much to expect that any such projections can truly accurately forecast the future, and no model, however well constructed, can account for unpredictable events like a world war, pandemic influenza, or the discovery of antibiotics. Two serious and potentially preventable flaws in the study concern me, however. First, the mathematical models assume that future mortality trends in poor countries will respond to economic growth in the same way that they did historically for now-rich countries. There is already evidence to suggest this rosy prediction may not hold true, as overall economic growth in poor countries has in a number of cases been associated with worsening internal inequalities and worsening population health. The second flaw is the failure to address issues of climate change, which researchers believe will have a profound effect on both infectious disease and nutrition. Including some of the climate and disease change models would have added a new level of complexity to an already complicated problem, but omitting them entirely has probably hurt the accuracy of these projections. Even with these two serious caveats, though, this study will be useful and interesting for people who work in health policy, and represents an important update of the now outdated 1990 GBD figures.
Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Medicine 3(11):e442, November 2006
or
Available atwww.plosmedicine.org
MCH Alert
School based care: 3 articles - Obesity, exercise, and vaccinations
Physical activity and sedentary behavior during adolescence
Findings indicate that adolescents are experiencing unfavorable shifts in activity patterns, such as longitudinal decreases in MVPA [moderate to vigorous physical activity], coupled with longitudinal and secular increases in sedentary behaviors that are attributable specifically to computer use. Low levels of MVPA and high levels of sedentary behavior have been shown to be associated with obesity. Project EAT-1 (Eating Among Teens) and Project Eat II (a follow-up study) follow a large cohort of individuals longitudinally through various stages of the adolescent transition to young adulthood. The authors found that:
* MVPA among female adolescents declined dramatically from 5.9 to 3.9 hours per week during the transition from early to mid-adolescence and from 5.1 to 3.5 hours per week during the transition from mid- to late adolescence.
* Computer use significantly increased among older female adolescents during the transition from mid- to late adolescence.
* MVPA among male adolescents did not decline during the transition from early to mid-adolescence but did decline significantly from mid- to late adolescence (from 6.5 to 5.1 hours per week). Leisure-time computer use increased substantially from both early to mid-adolescence (from 11.4 to 14.2 hours per week) and from mid- to late adolescence (from 10.4 to
14.2 hours per week).
* Television viewing time did not change among adolescent males across the adolescent transition period.
* Between 1999 and 2004, secular trends during mid-adolescence indicate further striking increases in computer use. Mid-adolescent males engaged in 10.4 hours of use in 1999, compared with 15.2 hours in 2004.
Mid-adolescent females engaged in 2.3 more hours of use per week in 2004 than in 1999.
* There was no evidence of a secular decline in MVPA between 1999 and 2004 for either female or males adolescents.
As the prevalence of obesity continues to rise in this and other age groups, we need to continue to advance our understanding of dynamic population-wide trends in behavior patterns, so as to inform effectively a broad array of health promotion strategies and public policies that aim to prevent obesity.
Nelson MC, Neumark-Stzainer D, Hannan PJ, et al. 2006. Longitudinal and secular trends in physical activity and sedentary behavior during adolescence. Pediatrics Electronic Pages 118:1627-1634 http://pediatrics.aappublications.org/cgi/content/abstract/118/6/e1627
School bases obesity research, challenges, and recommendations
Choosing which obesity prevention components to include in a curriculum should be based on the evidence.
The authors found that two types of programs have potential for reducing childhood obesity:
* For older students, classroom instruction and physical education can promote moderate to vigorous physical activity both in and out of school, especially for adolescent girls.
* Younger students benefit from behavior-change programs that reduce sedentary behavior.
Based on the findings, the authors offer the following conclusions:
* Classroom programming should provide behavior-modification strategies to help students and their families reduce the amount of fast food, high-sugar drinks, and high-fat foods they consume and increase fruit and vegetable consumption. In addition, food service must be involved in obesity-prevention initiatives, and sales of unhealthy foods for fundraising purposes should be restricted.
* Physical education that promotes at least 30 minutes of vigorous activity three to five times a week is the goal. Achieving this with a cumulative approach through physical education classes, intramural sports, and before- and after-school programs is recommended.
* Schools must consider the reduction of sedentary behavior as a separate issue from increasing physical activity. Classroom programs for reducing sedentary behavior should use a behavior-change approach, start in the early grades, and be repeated every few years.
Budd GM, Volpe SL. 2006. School-based obesity prevention: Research, challenges, and recommendations. Journal of School Health 76(10):485-495.
http://www.blackwell-synergy.com/doi/abs/10.1111/j.1746-1561.2006.00149.x.
School based influenza vaccination is effective
This school-based vaccination intervention resulted in a reduction in influenza-related outcomes in household members of children attending intervention schools.
The authors found that
* A total of 2,717 of 5,840 students (47%) in intervention schools received the vaccine after parental consent had been granted.
* The number of reported episodes of influenza-like illness during the predicted peak influenza week was significantly lower in intervention-school households than in control-school households.
* Compared with children in control-school households, children in intervention-school households had fewer visits to doctors or clinics for influenza-like illness, and adults in these households had a trend toward fewer such visits.
* Compared with control-school households, intervention-school households reported significantly lower absentee rates for influenza-like illness among students in elementary school and significantly fewer workdays missed by parents to care for their own, or someone else's, influenza-like illness.
* Both intervention and control schools had increased rates of overall absenteeism during the influenza outbreak. Within intervention schools, unvaccinated students had a significantly greater increase in absentee rates over baseline than did vaccinated students for the predicted peak week, the intense influenza outbreak period, and the influenza outbreak period.
Conclusion: Our multicenter study . . . demonstrates that school-based immunization influenza directly and indirectly reduces outcomes related to influenza-like illness.
King JC, Stoddard JJ, Gaglani MJ, et al. 2006. Effectiveness of school-based influenza vaccination. The New England Journal of Medicine 355(24):2523-2532. http://content.nejm.org/cgi/reprint/355/24/2523.pdf
Medical Mystery Tour
A boy has been born in Chile with a fetus in his stomach
To recap from last month…
A boy had been born in Chile with a fetus in his stomach in what doctors said was a rare case of "fetus in fetu" in which one twin becomes trapped inside another during pregnancy and continues to grow inside it.
Doctors noticed the 4-inch-long fetus inside the boy's abdomen. It had limbs and a partially developed spinal cord but no head and stood no chance of survival, doctors said.
After the birth, doctors operated and removed the fetus from the boy's stomach. The boy, who has not been named, was recovering at Temuco's Hernan Henriquez hospital.
Background
Fetus in fetu is a malformed parasitic monozygotic diamniotic twin that is found inside the body of the living child or adult. Thirty one cases have been published before 1900 and only 11 have been published from 1900 to 1956. This pathology is rare and the incidence is 1 per 500 000 births.
The living children with fetus in fetu were <18 months except in 11 cases: 20 months (1 case), 5 years (2 cases), 7 years (1 case), 9 years (2 cases), 10 years (1 case), 12 years (1 case) and >15 years (3 cases). Sex ratio was 47 boys to 35 girls (the sex of 5 other cases was undetermined). In 70% of cases, the chief complaint was an abdominal mass. As far as location was concerned, it was predominantly retroperitoneal in 80% of cases, but could be atypical including the skull as in 6 cases, the sacrum as in 6 cases, the scrotum as in 1 case, and the mouth as in 1 case.
In almost all cases (88%), there was a single parasitic fetus apart from 5 reports in which the number of the fetus ranged from 2 to 5. The size and weight of the fetus varied, from 4 cm to 24.5 cm, respectively, and from 1.2 g to 1.8 kg, respectively.
The organs present in the fetus in fetu were as follows: vertebral column, 91%; limbs, 82.5% (number varied from 1 to 4); central nervous system, 55.8%; gastrointestinal tract, 45%; vessels, 40%; and genitourinary tract, 26.5%.
The fetus was always anencephalic, the vertebral column and the limbs were present in the fetus in fetu in almost all cases (91% and 82.5%, respectively). The lower limbs were more developed than the upper limbs. Fetus in fetu was rarely found in the central nervous system, gastrointestinal tract, vessels, or the genitourinary tract; however, it was found in 55.8%, 45%, 40% and 26.5% of cases, respectively. It was rarer still to find fetus in fetu in the lungs, adrenal glands, pancreas, spleen, and lymph nodes. The heart was very rarely found in fetu.
The absence of cardiovascular system almost led to misdiagnosis of acardiac fetus in 1 case as the morphology is otherwise similar with findings of anencephaly, absent or rudimentary limbs, absent lungs, short intestine, and single umbilical artery. However, in the case of acardiac twin fetus, the karyotype is abnormal in at least 50% of cases including both trisomy or triploidy whereas the karyotype of fetus in fetu is normal and similar to his host's.
Eighty-nine per cent of fetus in fetu lesions were noted before 18 months of age. In reviewing literature most case reports up to 1980 showed the preoperative diagnosis of fetus in fetu was made only in 16.7% of cases because CT scan was not performed. Nowadays, CT scan has proven very helpful in suggesting the preoperative diagnosis. Magnetic resonance imaging was also used in 4 cases.
The differential radiologic diagnoses were teratoma and meconium pseudocyst. Indeed, these masses often had calcified components, so they were sometimes difficult to differentiate with fetus in fetu.
Treatment was complete resection of the mass except when it was adherent to the host's organs. Relapse was observed in 1 case (out of 87 cases) with recurrent right abdominal mass 4 months after surgery. This was a teratoma, which contained cystic, solid, and calcified components. It measured 13 cm in diameter and 5% of the tumor was yolk sac carcinoma. After surgical excision, the patient was treated with chemotherapy and recovered at 2 years of age.
PS:
Which venerable medical resource was the original
source of this story?
While I did not spend enough time in the grocery check out line this month to definitively say if the venerable medical journal, the National Enquirer, also covered this story, I did ask our readers who regularly subscribe the National Enquirer to peruse their personal subscription to National Enquirer. ‘Hearing few replies, I will say I first saw this story on Reuters, before I launched my literature review in Pediatrics, PubMed, Journal of Pediatric Surgery, etc….though the Yeti who ate Portland article sounded quite promising when I was standing in line to buy milk.
References:
Hoeffel CC, et al. Fetus in fetu: a case report and literature review. Pediatrics. 2000 Jun;105(6):1335-44.
Brand A et al Fetus in fetu--diagnostic criteria and differential diagnosis--a case report and literature review. J Pediatr Surg. 2004 Apr;39(4):616-8
Medscape*
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Menopause Management
Local estrogen just as effective for vaginal atrophy in postmenopausal women
Authors' conclusions Creams, pessaries, tablets and the oestradiol vaginal ring appeared to be equally effective for the symptoms of vaginal atrophy. One trial found significant side effects following cream (conjugated equine oestrogen) administration when compared to tablets causing uterine bleeding, breast pain and perineal pain. Another trial found significant endometrial overstimulation following use of the cream (conjugated equine oestrogen) when compared to the ring. As a treatment choice women appeared to favour the oestradiol-releasing vaginal ring for ease of use, comfort of product and overall satisfaction.
Suckling J, Lethaby A, Kennedy R. Local oestrogen for vaginal atrophy in postmenopausal women. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD001500. DOI: 10.1002/14651858.CD001500.pub2.
http://www.ihs.gov/MedicalPrograms/CIR/index.cfm?module=cir_answering_clinical_questions
Life After WHI: Postmenopausal Symptoms and Use of Alternative Therapies After HRT
RESULTS: Reasons why the women discontinued therapy and any nonhormonal alternative therapies that they may have used to manage subsequent menopausal symptoms were recorded. The primary investigator contacted the 78 women to complete a telephone survey. In most women, at least one menopausal symptom recurred. Vasomotor symptoms (hot flashes) were most common and occurred in 41 (53%) women. In addition, 59 (76%) women reported using nonhormonal alternative therapies, and 40 (68%) of this group deemed the alternatives helpful. CONCLUSION: We strongly believe that health care providers, including pharmacists, must continue to communicate with and educate women regarding treatment options for menopausal symptoms. Clinical pharmacists are ideally suited to contribute to ongoing research in this area.
Shrader SP, Ragucci KR. Life after the women's health initiative: evaluation of postmenopausal symptoms and use of alternative therapies after discontinuation of hormone therapy. Pharmacotherapy. 2006 Oct;26(10):1403-9
Conjugated Equine Estrogen Treatment May Not Increase Breast Cancer Risk
CONCLUSIONS: Treatment with CEE alone for 7.1 years does not increase breast cancer incidence in postmenopausal women with prior hysterectomy. However, treatment with CEE increases the frequency of mammography screening requiring short interval follow-up. Initiation of CEE should be based on consideration of the individual woman's potential risks and benefits.
Stefanick ML, et al Effects of conjugated equine estrogens on breast cancer and mammography screening in postmenopausal women with hysterectomy. JAMA. 2006 Apr 12;295(14):1647-57
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16609086
Midwives Corner - Lisa Allee, CNM
The Blessed Perineum: PubMed
As I went hunting for an article to review for this month, I started playing around on PubMed and found an amazing array of articles about the blessed perineum. I encourage you to go looking when you have a spare moment at a computer. However, for the reality that you may only read this, here is a smattering of what I found:
- Leah Albers, et al, our esteemed sisters at UNM, did an awesome study (N=1211) of perineal techniques and found that it made no difference if the midwives used warm compresses, perineal massage, or hands off ‘til crowning. But they did find that a sitting upright position and delivering the head between contractions did lower the risk of perineal trauma.
- Terry, et al, (N=198) found that nonsupine positions (defined as sitting, squatting, or kneeling/hands and knees) led to less perineal tearing, less vulvar edema, and less blood loss. They also found that the length of second stage was shorter in nonsupine positions, but this wasn’t statistically significant.
- Soong and Barnes (N=3756) found that the semi-recumbent position was associated with more need for perineal suturing and all-fours with less, especially with first births and babies over 3500g. With regional anesthesia they again found the semi-recumbent position associated with more suturing and found that the lateral position caused less need for perineal suturing. The authors suggest that women be given the choice to find the most comfortable position to give birth in and that providers should inform women of the likelihood of perineal trauma in the preferred birth position.
- Shorten, et al, (N=2891) found that the lateral position was the best (66.6% intact perineums) and squatting the worst (42% intact), especially for primiparas. They also found a difference by accoucheur. Intact perineum was achieved by 56-61% of women attended by midwives and 31.9% of women attended by obstetricians, who also had a five times higher rate of episiotomies. (OK I’m bragging for us just a little…)
- Aikins and Feinland (N=1068) studied planned home births and found 69.6% of the women gave birth with an intact perineum! (Way to go home birth midwives and mothers!) In multiparous women, low socioeconomic status and higher parity were associated with intact perineum, whereas older age (>/= 40 yr), previous episiotomy, weight gain of over 40 pounds, prolonged second stage, and the use of oils or lubricants were associated with perineal trauma. Among primiparas, low socioeconomic status, kneeling or hands-and-knees position at delivery, and manual support of the perineum at delivery were associated with intact perineum, whereas perineal massage during delivery was associated with perineal trauma.
So, from the research it sounds like getting women up on their knees, hands and knees, sitting, or lying on their sides is probably a good idea and using the oils and massage for other parts of the body rather than the perineum may be good, too. Soong and Barnes’ suggestion to talk with women about the relationship between birth positions and perineal trauma risk is a great suggestion, but starting the conversation during prenatal care or birth classes would be advisable rather than waiting until second stage.
Over the years I have noticed that my previous enthusiasm for perineal massage and stretching has waned greatly—now I rarely do more than a little pressure just inside the introitus to help the woman focus where to push, if she needs that. I only use warm compresses if I can tell the perineum is so taut that it needs any help I can give it to melt. Most of the time, though, I have noticed that if I can help the whole woman (and everyone else in the room, too) relax, then her perineum melts just fine (I figure that hormone relaxin is doing it’s thing!) I also have noticed that I don’t say much at all anymore about how she should push and I have noticed the absolute brilliance of women shine through—they push perfectly—letting up when I would have suggested it and pushing when I would have said push…..women know how to give birth in the best way for themselves and their babies—have faith.
Reference:
Albers LL, Sedler KD, Bedrick EJ, Teaf D, Peralta P. Midwifery care measures in the second stage of labor and reduction of genital tract trauma at birth: a randomized trial. J Midwifery Womens Health. 2005 Sep-Oct;50(5):365-72
Terry RR, Westcott J, O'Shea L, Kelly F. Postpartum outcomes in supine delivery by physician vs nonsupine delivery by midwives. J Am Osteopath Assoc. 2006 Apr;106(4):199-202
Soong B, Barnes M. Maternal position at midwife-attended birth and perineal trauma: is there an association? Birth. 2005 Sep;32(3):164-9
Shorten A, Donsante J, Shorten B. Birth position, accoucheur, and perineal outcomes: informing women about choices for vaginal birth. Birth. 2002 Mar;29(1):18-27
Aikins Murphy P, Feinland JB. Perineal outcomes in a home birth setting. Birth. 1998 Dec;25(4):226-34
Navajo Corner, Tomekia Strickland, Chinle
GYN Spotlight: Endometrial ablation
Pre-menopausal dysfunctional uterine bleeding unrelated to malignancy continues to be a significant problem for women wrought with social embarrassment, disruption of daily activities, and morbidity associated with anemia. Not only is it a challenging condition for the patient but dysfunctional uterine bleeding usually requires lengthy and frequent outpatient visits for appropriate evaluation and management. Many times, patients have suffered for years with the condition and often present discouraged after a series of failed hormonal regimens. Hysterectomy, the only procedure that is 100% effective in eliminating abnormal uterine bleeding, is often less acceptable to Native American women than other populations, both for cultural reasons and because of a general reluctance to undergo major surgery. Thus endometrial ablation has risen as an ideal treatment option for women who have completed child bearing, failed conservative management, and desire uterine conservation.
The Department of Gynecology at Chinle Service Unit is now offering endometrial ablation to appropriate candidates, as are some other I.H.S. sites. There are several global endometrial ablation techniques that have become available nationally over the past few years. Global endometrial ablation refers to a series of FDA approved newer generation technologies that do not require an operative hysteroscope. These include Thermachoice (hot liquid filled balloon), hydrothermal ablation (circulating hot water), Novasure (bipolar desiccation), Her Option (cryoablation)and Microwave ablation. This is in contrast to the standard technique which uses monopolar energy via a rollerball, roller barrel, or resectoscope requiring operative hysteroscopy. There is also increased risk of uterine perforation and fluid overload with the standard techniques. We have started using the Novasure system which is a global ablative technique that utilizes a three dimensional bipolar gold mesh that when inserted conforms to the shape of the uterine cavity. The average ablation time for Novasure® is 90 seconds.*It also has the advantage of not requiring hormonal pretreatment to thin the endometrial lining. When
used correctly, the global ablative techniques are considered safe, effective, fast, simple to perform, painless and cost effective to both physician and patient. Many of these procedures can also be performed as office based procedures.
Like the standard technique, global ablation techniques are considered successful not so much according to amenorrhea rates, but by reduction in menstrual flow. Hypomenorrhea correlates with high rates of subjective patient satisfaction usually greater than 80-90%. The amenorrhea rates for some of the devices are as follows: Thermachoice 14% at 12-24 months; Microwave 38% at 3 years; and Novasure 51% at 1 year.
In conclusion, global endometrial ablation will most likely continue to become an increasingly popular and primary minimally invasive surgical treatment option for women who have completed childbearing and continue to suffer for abnormal uterine bleeding despite medical therapy. Like all medical and surgical interventions, care must be taken to evaluate each patient carefully and individualize their treatment plan accordingly. “Endometrial Ablation” by UpToDate www.uptodate.com provides a detailed discussion on the indications, contraindications and safety profiles for each ablative procedure. If you would like more information about our exciting but still new experience with Novasure, please feel free to contact me at tomekia.strickland@ihs.gov
Nurses Corner - Sandra Haldane, HQE
Getting Your Patient Back to Work: Return-to-Work Restrictions After Illness or Injury
Getting the patient back to work after an illness or injury is a major goal for clinicians. How to write back-to-work restrictions and instructions so that they are both understood and implemented by both the employee and employer is important for patient safety. It is also often a complicated process. The healthcare provider has the responsibility to determine when and under what restrictions an employee should return to work.
Recovery from injury and illness is influenced by many conditions: pre-existing medical conditions, workers' compensation issues, surgical or medical complications, and emotional or family stress associated with recovery from illness and injury.
Employees should be encouraged to return to work as soon as they are able. Research has suggested that the longer the recovery time, the less the chance that individuals will return to work. Effective return-to-work programs can decrease medical costs, improve outcomes, and decrease the recovery time. Some individuals may develop a "disability mindset" as soon as 2 weeks after an injury, so a plan for return to work needs to be in place as soon as it is feasible and begins with the first employee visit.
Who gets injured? The top 10 jobs that are responsible for 30% of job injuries are topped by truck drivers and then followed by laborers, nurses aides, construction laborers, janitors and cleaners, assemblers, carpenters, cooks, registered nurses, and stock handlers or baggers. Men have 65% of the injuries, people between the ages and 20 and 44 years have more injuries, and 42% of injuries occur within the first year of work. It is often this later group of individuals who recover and then move on to another job to avoid re-injury.
The standard process followed in getting employees back to work involves 4 distinct tasks: gathering data, assessing expectations, performing the physical examination, and writing restrictions.
Gathering data helps establish the diagnosis and clarify any problems that might arise. It will also rule out any serious medical conditions. In order to determine a back-to-work plan, the clinician should collect a description of the injury, the past and current status of symptoms, medications being taken, allergies, and work history. A visit to the workplace to meet with safety and management personnel is important, particularly if the work site is associated with many injuries or they have requested your input about return-to-work issues.
Part of talking with the patient should include assessing their expectations for recovery and return to work. Assessing the patient's perceived ability to do the work involved, as well as psychological and financial issues, should be explored. The patient who is able to return quickly to work is likely to have more financial security, positive self-image, and reinforcement of other efforts for recovery. Injury or illness may surface or aggravate other problems such as substance abuse, somatoform or personality disorders, depression, or anxiety. Personnel issues with others at work may also influence the desire of the patient to return to work. Discussing and dealing with these issues are important if the patient is going to be willing to cooperate in going back to work.
The physical examination is important in determining the physical fitness of the individual and their ability to do the specific work of their job. In addition to the relevant musculoskeletal, neurologic, cardiac, or respiratory examinations, mood, pain behaviors, gait, vital signs, and preinjury limitations all impact current ability to work.
Work restrictions should then be crafted in a way that is clear and meaningful. Functional activity requires comparing job demands and the patient's abilities. This is a step-by-step process facilitated by a treatment plan to promote recovery. The conditions under which the employee can work need to be stated in a way that management can understand and apply. Based on the physical evaluation, functional limitations should be based on an assessment of the stamina, strength, and cognitive function that will affect the patient's ability to do the job. This will involve looking at what the patient must physically and cognitively do on the job and writing specific restrictions that the patient must face as they initially return to work. The clinician may make a table indicating what physical activity is required for a job using the neck, shoulders, elbow, back, or knees and then writing any restrictions the patient may have in those areas. For example, the patient may be unable to squat or kneel, climb stairs, or stand for long periods of time. The employer may be required to offer some accommodation or modification of the job for the employee to return to work. This requires that all levels of management support the employee in their gradual resumption of work activities.
Sometimes it is required that the work environment be modified so that a patient could sit or avoid turning in a particular direction. Based upon the clinician's recommendations, the patient may also return to work for reduced hours. The progress in returning to work should be monitored frequently and consistently and the restrictions gradually removed as the patient improves.
Majerus SI, Miller SK, Asp KM Getting Your Patient Back to Work: Writing Return-to-Work Restrictions After Illness or Injury Journal for Nurse Practitioners. 2006;2(10):533-538
Other Medscape case studies, here:
http://www.medscape.com/viewarticle/547779?src=mp
Office of Women's Health, CDC
I have to go really far just to exercise . . . er . . . actually no you don’t
Results
No statistically significant relationships were found between activity and perceived or objectively measured proximity to parks. Pearson correlation coefficients for perceptions of distance and objectively measured distance to physical activity resources ranged from 0.40 (gyms, schools) to 0.54 (parks). Perceived distance to gyms and objective number of schools within 1-mile buffers were negatively associated with activity. No statistically significant relationships were found between activity and perceived or objectively measured proximity to parks
Jilcott SB, Evenson KR, Laraia BA, Ammerman AS. Association between physical activity and proximity to physical activity resources among low-income, midlife women. Prev Chronic Dis 2007 Jan http://www.cdc.gov/pcd/issues/2007/jan/06_0049.htm
OWH - Year End Re-cap of Available Resources from CDC
Guidelines and Recommendations
2006 Sexually Transmitted Disease Treatment Guidelines
http://www.cdc.gov/std/treatment/default.htm
Immunization Strategy to Eliminate Transmission of Hepatitis B Virus
Infection
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5516a1.htm?s_cid=rr5516a1_e
HIV Testing in Health-Care Settings
http://www.cdc.gov/hiv/topics/testing/healthcare/index.htm
HPV Vaccine
http://www.cdc.gov/std/HPV/default.htm#vaccine
Recommendations to Improve Preconception Health and Health Care-
United States
www.cdc.gov/mmwr/preview/mmwrhtml/rr5506a1.htm
Revised Recommendations for HIV Testing of Adults, Adolescents, and
Pregnant Women
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm
Sexual Violence Prevention: Beginning
the Dialogue
http://www.cdc.gov/ncipc/dvp/SVPrevention.htm
Successful Business Strategies to Prevent Heart Disease and Stroke
Toolkit
http://www.cdc.gov/dhdsp/library/toolkit/index.htm
Science and Research
2003 Assisted Reproductive Technology Success
Rates
http://www.cdc.gov/ART/ART2003/preface.htm
2004 Chlamydia Prevalence Monitoring Project Annual Report
http://www.cdc.gov/std/Chlamydia2004/default.htm
2004 STD Surveillance Report
http://www.cdc.gov/std/stats/toc2004.htm
Birth and Fertility Rates for States by Hispanic Origin Subgroups:
1990 and 2000
www.cdc.gov/nchs/data/series/sr_21/sr21_057.pdf
Chronic Fatigue Syndrome
http://www.cdc.gov/cfs/
Contraceptive Use: United
States and Territories, BRFSS, 2002
http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5406a1.htm
Critical Needs in Caring for Pregnant Women during Times of Disaster
http://www.bt.cdc.gov/disasters/pregnantdisasterhcp.asp
Disability and Health State Chartbook – 2006 Profiles of Health
for Adults with Disabilities
http://www.cdc.gov/ncbddd/dh/chartbook/default.htm
Fatalities and Injuries from Falls Among Older Adults – 1993-2003
and 2001-2005
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5545a1.htm
Fertility, Family Planning, and Reproductive Health of U.S. Women: 2002 www.cdc.gov/nchs/data/series/sr_23/sr23_025.pdf
Genomic Tests for Ovarian Cancer Detection & Management
http://www.cdc.gov/genomics/gtesting/EGAPP/docs/announcement2006-10-26.htm
HIV/AIDS Among Women
http://www.cdc.gov/hiv/topics/women/index.htm
Identifying Best Practices for WISEWOMAN Programs Using a Mixed-Methods
Evaluation
http://www.cdc.gov/pcd/issues/2006/jan/05_0133.htm
Lymphocytic Choriomeningitis Virus (LCMV) and Pregnancy: Facts and
Prevention
http://www.cdc.gov/ncbddd/bd/lcmv.htm
Measuring Intimate Partner Violence Victimization and Perpetration:
A Compendium
http://www.cdc.gov/ncipc/dvp/Compendium/Measuring_IPV_Victimization_and_Perpetration.htm
Physical Dating Violence Among High School Students – United
States, 2003
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5519a3.htm
Racial and Socioeconomic Disparities
in Breastfeeding - United States , 2004
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5512a3.htm?s_cid=mm5512a3_e
Recent Trends in Teenage Pregnancy in the United States, 1990-2002
http://www.cdc.gov/nchs/products/pubs/pubd/hestats/teenpreg1990-2002/teenpreg1990-2002.htm
Smoking Among Women: Cardiovascular Disease
and Stroke
http://www.cdc.gov/tobacco/factsheets/Cardiovascular.htm
The Health Consequences of Involuntary Exposure to Tobacco Smoke:
Surgeon General
http://www.cdc.gov/tobacco/sgr/sgr_2006/index.htm
U.S. Cancer Statistics: 2002 Incidence and Mortality
Report
http://www.cdc.gov/cancer/npcr/uscs/index.htm
Oklahoma Perspective Greggory Woitte – Hastings Indian Medical Center
What do patients recall from our counseling?
In scanning over the journals this month I ran across this article from the British Medical Journal
Quick synopsis was that providing mothers of babies in the neonatal ICU audiotaped conversations between the mothers and the neonatalogists helped improve the mother’s recall of the diagnosis, treatment plan and, prognosis.
Although we certainly can not provide every patient with a tape recorded conversation, it is important to remember that despite us as providers giving a clear description and recommendations for treatment plans, there are times of stress that the patients do not understand our plan. Fetal demise and missed abortions are two prominent examples where it is probably better to inform the patient of your findings and schedule follow up appointment when the patient can have their social support system available and have had time to let the diagnosis register.
Koh TH, et al Provision of taped conversations with neonatologists to mothers of babies in intensive care: randomised controlled trial. BMJ. 2007 Jan 6;334(7583):28
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17142256
Osteoporosis
Steroidal contraceptives influence fracture risk cannot be determined from existing data
AUTHORS' CONCLUSIONS: Whether steroidal contraceptives influence fracture risk cannot be determined from existing information. Due to different interventions, no trials could be combined for meta-analysis. Many trials had small numbers of participants and some had large losses to follow up. Health care providers and women should consider the costs and benefits of these effective contraceptives. For example, injectable contraceptives and implants provide effective, long-term birth control yet do not involve a daily regimen. Progestin-only contraceptives are considered appropriate for women who should avoid estrogen due to medical conditions.
Lopez LM, Grimes DA, Schulz KF, Curtis KM. Steroidal contraceptives: effect on bone fractures in women. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD006033. DOI: 10.1002/14651858.CD006033.pub2.
http://www.ihs.gov/MedicalPrograms/CIR/index.cfm?module=cir_answering_clinical_questions
Strontium ranelate decreases fractures in the spine and slightly decreases other fractures
Authors' conclusions There is silver level evidence (www.cochranemsk.org) to support the efficacy of strontium ranelate for the reduction of fractures (vertebral and to a lesser extent non-vertebral) in postmenopausal osteoporotic women and an increase in BMD in postmenopausal women with/without osteoporosis. Diarrhea may occur however, adverse events leading to study withdrawal were not significantly increased with taking 2 g of strontium ranelate daily. Potential vascular and neurological side-effects need to be further explored.
O'Donnell S, Cranney A, Wells GA, Adachi JD, Reginster JY. Strontium ranelate for preventing and treating postmenopausal osteoporosis. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD005326. DOI: 10.1002/14651858.CD005326.pub3
http://www.ihs.gov/MedicalPrograms/CIR/index.cfm?module=cir_answering_clinical_questions
Patient Information
Health literacy and depression: Literacy education improves self-efficacy scores
CONCLUSION: The results of this preliminary study suggest that among persons with low literacy and symptoms of depression, depression symptoms lessen as self-efficacy scores improve during participation in adult basic literacy education.
Francis
L, Weiss
BD, Senf
JH, et al Does Literacy Education Improve Symptoms of Depression and Self-efficacy
in Individuals with Low Literacy and Depressive Symptoms? A Preliminary Investigation. J
Am Board Fam Med. 2007 Jan-Feb;20(1):23-7.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd
=retrieve&db=pubmed&list_uids=17204731&dopt=Abstract
Depression in Children and Teens
http://www.aafp.org/afp/20070101/83ph.html
Perinatology Picks - George Gilson, Maternal Fetal Medicine, ANMC
Fish Oil Supplements During Pregnancy Are Safe and Beneficial
CONCLUSION: Maternal fish oil supplementation during pregnancy is safe for the fetus and infant, and may have potentially beneficial effects on the child's eye and hand coordination. Further studies are needed to determine the significance of this finding.
Dunstan JA, et al Cognitive assessment at 21/2 years following fish oil supplementation in pregnancy: a randomized controlled trial.
Arch Dis Child Fetal Neonatal Ed. 2006 Dec 21
Planned cesarean delivery doubles rate of NICU and the risk for pulmonary disorders
Results Compared with planned vaginal deliveries, planned cesarean delivery increased transfer rates to the neonatal intensive care unit from 5.2% to 9.8% (P < .001). The risk for pulmonary disorders (transient tachypnea of the newborn infant and respiratory distress syndrome) rose from 0.8% to 1.6% (P = .01). There were no significant differences in the risks for low Apgar score and neurologic symptoms. Conclusion A planned cesarean delivery doubled both the rate of transfer to the neonatal intensive care unit and the risk for pulmonary disorders, compared with a planned vaginal delivery.
Kolas T, et al Planned cesarean versus planned vaginal delivery at term: comparison of newborn infant outcomes. Am J Obstet Gynecol. 2006 Dec;195(6):1538-43.
Health of children born as a result of IVF was worse than that of singletons
Perinatal outcomes of in vitro fertilization children were worse and hospital episodes were more common than among control children. Risks for cerebral palsy and psychological and developmental disorders were increased. Among in vitro fertilization singletons, worse results for perinatal outcomes and hospitalizations, but no increased risk for specific diseases, were found. The health of in vitro fertilization multiple births was comparable to the health of control multiple births. CONCLUSIONS: Reducing the number of transferred embryos would improve the health of in vitro fertilization children. Klemetti R et al Health of children born as a result of in vitro fertilization. Pediatrics. 2006; 118(5):1819-27
Preterm birth is significantly associated with antenatal depression
CONCLUSIONS: These findings provide evidence that antenatal depression is significantly associated with spontaneous preterm birth in a population of European women receiving early and regular care. Dayan J et al Prenatal depression, prenatal anxiety, and spontaneous preterm birth: a prospective cohort study among women with early and regular care. Psychosom Med. ; 68(6):938-46
Hydroxychloroquine in lupus pregnancy: continuation recommended
CONCLUSION: We recommend the continuation of HCQ treatment during pregnancy. Our findings are consistent with prior reports of the absence of fetal toxicity. Similar to studies of nonpregnant women, the cessation of HCQ treatment during pregnancy increases the degree of lupus activity.
Clowse ME et al Hydroxychloroquine in lupus pregnancy. Arthritis Rheum. 2006; 54(11):3640-7
Primary Care Discussion Forum
Adolescent with knee pain
- February 1, 2007
- Moderator: Terry Cullen, MD
- Web M + M
We will explore these issues
-A 12 year old male presents to a busy outpatient clinic complaining of knee pain after football practice
-How do you approach the provision of patient care with limited access to services and consultants?
-Is medical diagnostic decision making different in a rural setting? Do we tolerate increased ambiguity?
-When do you ‘start over’ to find a different diagnosis?
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
First Indian Health Special Issue on Methamphetamine is now available online
The Indian Health Service Primary Care Provider’s December 2006 issue is dedicated to the problems and solutions for Methamphetamine abuse in Indian Country. There are 2-3 more planned installments. If you have questions, or want to contribute contact Lori.deRavello@ihs.gov
http://www.ihs.gov/PublicInfo/Publications/HealthProvider/issues/PROV1206.pdf
Key Trainers for Rural HIV Providers
The National Rural Health Association (NRHA) has developed several new documents on delivery of HIV care in rural settings. The first two documents listed below identify AIDS EDUCATION & TRAINING CENTERS (AETCs) as crucial resources for training providers on delivery of HIV care. NRHA’s work was sponsored by the HHS Office of HIV/AIDS Policy, with input from HRSA/HAB and other Federal agencies.
“Provider Training Techniques” discusses barriers to training providers in rural areas and offers strategies on how to effectively train rural providers.
http://nrharural.org/opporty/pdf/HIV_Provider_Training.pdf
Resources on HIV services in rural areas are available at:
http://nrharural.org/opporty/sub/rural_HIV.html#Resources
Transportation and HIV Care” includes best practices for providing transportation services such as conducting a needs assessment, use of vouchers, and shuttle services.
http://nrharural.org/opporty/pdf/HIV_Transportation.pdf
Webcast Explores Partnerships between Community Health Centers and AIDS SERVICE ORGANIZATIONS (ASO)
A Web-Based In-Service Training, sponsored by the AETC Network, HRSA’s Bureau of Primary Health Care (BPHC), and the National Association of Community Health Centers, explores opportunities and strategies for partnership across community health centers and other providers of HIV-related care. BPHC-supported health centers are a major component of America's health care safety net. Community health centers care for people regardless of their ability to pay and status of health insurance coverage. They provide primary and preventive health care, as well as services such as transportation and translation. Many community health centers also offer dental, mental health, and substance abuse care. The training provides an overview of the community health centers role in HIV care and treatment. It also discusses the capacity of health centers in HIV prevention and testing. http://www.aidsetc.org/aetc/aetc?page=cf-bphc-info
Presentation
Bureau of Primary Health Care (BPHC), Community Health Centers, and the AETC Network: Opportunities and Strategies for Partnership
View the web conference
(Link to TARGET Center Web site) http://www.careacttarget.org/media.htm
Supplemental Resources and Materials
HRSA Bureau of Primary Health Care
National Association of Community Health Centers, Inc.
Putting Patients First: Health Centers as Leaders in HIV Prevention and Testing
New Website Links to All Federal HIV Information and Resources
The Federal Government has launched a new website, AIDS.gov, designed to link users to Federal domestic HIV/AIDS information and resources. The goal is to ease access to information on Federal HIV/AIDS prevention, testing, treatment, and research programs, policies, and resources. It provides comprehensive government-wide information on HIV/AIDS for the general public, Federal agencies, state staff/public health departments, Federal grantees, medical institutions, research institutions, and HIV/AIDS-related organizations. http://www.aids.gov/
Other
Routine HIV Screening Deemed Cost-Effective in Average-Risk Populations
CONCLUSIONS: Routine, rapid HIV testing is recommended for all adults except in settings where there is evidence that the prevalence of undiagnosed HIV infection is below 0.2%.
Paltiel AD, et al Expanded HIV screening in the United States: effect on clinical outcomes, HIV transmission, and costs. Ann Intern Med. 2006 Dec 5;145(11):797-806
Genital Warts: Best Practices for Diagnosis and Management CME/CE
This Medscape CME combines a visual discussion of genital warts (effects of low risk HPV strains) and reinforces also our continued focus on high risk strains. The photos themselves are worth the quick 20 minute review. The session is more reinforcement for the HPV vaccine as well. http://www.medscape.com/viewprogram/6385?src=mp from Judith.Thierry@ihs.gov
Barbara Stillwater, Alaska State Diabetes Program
Diabetic Moms' Babies Have Impaired Sucking Reflexes
Immature sucking patterns are often seen in infants whose mothers developed diabetes
during pregnancy and had to be treated with insulin, new research indicates.
On the other hand, babies of mothers with diabetes that was managed with a careful
diet do not seem to have impaired sucking reflexes. The findings suggest that
the nervous system of newborns of insulin-treated diabetic mothers is less mature
than that of babies born to healthy mothers. CONCLUSION: Poorer sucking patterns
were found among infants of insulin-managed mothers with diabetes. The present
findings indicate some degree of neurologic immaturity during the early neonatal
period. Bromiker
R, et al Immature sucking patterns in infants of mothers with diabetes. J
Pediatr. 2006 Nov;149(5):640-3 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd
=Retrieve&dopt=AbstractPlus&list_uids=17095335
HbA1c Early in Diabetic Pregnancy Predicts Outcomes
CONCLUSIONS: Starting from a first-trimester A1C level slightly <7%, there is a dose-dependent association between A1C and the risk of adverse pregnancy outcome without indication of a plateau, below which the association no longer exits. A1C, however, seems to be of limited value in predicting outcome in the individual pregnancy.
Nielsen GL, Moller M, Sorensen HT. HbA1c in early diabetic pregnancy and pregnancy outcomes: a Danish population-based cohort study of 573 pregnancies in women with type 1 diabetes. Diabetes Care. 2006 Dec;29(12):2612-6
Prenatal Multivitamins for Undernourished Women May Reduce Risk of Low Birth Weight
Undernourished women who take a vitamin and mineral supplement while pregnant may be less likely than women taking only iron and folic acid supplements to have babies weighing less than 2,500 grams, and their newborns may be less likely to have morbidity in the first seven days of life. CONCLUSION: Compared with iron and folic acid supplementation, the administration of multimicronutrients to undernourished pregnant women may reduce the incidence of low birth weight and early neonatal morbidity Gupta P, et al Multimicronutrient Supplementation for Undernourished Pregnant Women and the Birth Size of Their Offspring: A Double-blind, Randomized, Placebo-Controlled Trial. Arch Pediatr Adolesc Med. 2007 Jan;161(1):58-64.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17199068
Women's Health Headlines, Carolyn Aoyama, HQE
What Causes Breast Cancer?
The Sister Study must enroll 20,000 more women in 2007 to help find the answers.
You can help get these 20,000 sisters in 2007 by:
-Forwarding this to everyone in your contact address list
-Taking Sister Study materials to places where eligible women may be such as doctors’ offices, beauty salons, churches/synagogues, meetings, workplaces, conferences, events, etc.
-Make a pledge to personally find 5 eligible women to enroll in the study
-Write a letter to your newspaper editor with a personal story
Help the Sister Study now! Let’s put a stop to Breast Cancer!
For questions or more information:
Call toll-free telephone number 1-877-474-7837
Or log on to www.sisterstudy.org
A woman is eligible to join this landmark national breast cancer study which looks at how environment and genes may affect the chances of getting breast cancer if -
Your sister (living or deceased), related to you by blood, had breast cancer
You are between the ages of 35 and 74
You have never had breast cancer yourself
You live in the United States or Puerto Rico
Conducted by National Institute of Environmental Health Sciences one of the National Institutes of Health of the U.S. Department of Health and Human Services
Women’s History Month: March 2007
National Women’s History Month’s roots go back to March 8, 1857, when women from New York City factories staged a protest over working conditions. International Women’s Day was first observed in 1909, but it wasn’t until 1981 that Congress established National Women’s History Week during the second week of March. In 1987, Congress expanded the week to a month. Every year since, Congress has passed a resolution for Women’s History Month, and the president has issued a proclamation.
152 million
The number of females in the United States as of Nov. 1, 2006.
That exceeds the number of males (148 million). http://www.census.gov/popest/national/asrh/2005_nat_res.html
As of July 1, 2005, males outnumbered females in every five-year age group through the 35 to 39 age group. Starting with the 40 to 44 age group, women outnumbered men. At 85 and over, there were more than twice as many women as men.
http://www.census.gov/popest/national/asrh/NC-EST2005-sa.html
Motherhood
82.5 million
Estimated number of mothers of all ages in the United States.
(From unpublished data.)
1.9
Average number of children that women 40 to 44 had given birth to as
of 2004, down from 3.1 children in 1976, the year the Census Bureau began collecting
such data. Likewise, the percentage of women in this age group who were mothers
was 81 percent in 2004, down from 90 percent in 1976.
http://www.census.gov/population/www/socdemo/fertility.html
Earnings
$32,168
The median annual earnings of women 16 or older who worked year-round,
full time, in 2005. Women earned 77 cents for every $1 earned by men. (Source:
American Community Survey at
http://www.census.gov/PressRelease/www/releases/archives/income_wealth/007419.html
91 cents
The amount women in the District of Columbia, who worked year-round,
full time, earned for every $1 their male counterparts earned in 2005. Among
all states or state equivalents, the district was where women were closest to
earnings parity with men. Maryland and Connecticut were the only states where
median earnings for women were above $40,000, as was the District of Columbia.
(Source: American Community Survey at
http://www.census.gov/PressRelease/www/releases/archives/income_wealth/007419.html
$58,906
Median earnings of women working in computer and mathematical jobs,
the highest for women among the 22 major occupational groups. Among these groups,
community and social services was the only group where women’s earnings
as a percentage of men’s earnings were higher than 90 percent. (Source:
American Community Survey http://www.census.gov/PressRelease/www/releases/archives/income_wealth/007419.html
Education
32%
Percent of women 25 to 29 who had attained a bachelor’s degree
or higher in 2005, which exceeded that of men in this age range (25 percent).
Eighty-seven percent of women and 85 percent of men in this same age range had completed high school. http://www.census.gov/PressRelease/www/releases/archives/education/007660.html
85.4%
Percent of women 25 or older who had completed high school as of 2005.
High school graduation rates for women continued to exceed those of men (84.9
percent).
http://www.census.gov/PressRelease/www/releases/archives/education/007660.html
26.1 million
Number of women 25 or older with a bachelor’s degree or
more education in 2005, more than double the number 20 years earlier.
http://www.census.gov/PressRelease/www/releases/archives/education/007660.html
27%
Percent of women 25 or older who had obtained a bachelor’s degree
as of 2005. This rate was up 10.5 percentage points from 20 years earlier
http://www.census.gov/PressRelease/www/releases/archives/education/007660.html
870,000
The projected number of bachelor’s degrees that will be awarded
to women in the 2006-07 school year. Women also are projected to earn 369,000
master’s
degrees during this period. Women would, therefore, earn 58 percent of the bachelor’s
and 61 percent of the master’s degrees awarded during this school year.
(Source: National Center for Education Statistics, Projections of Education Statistics
to 2015, at http://nces.ed.gov/pubsearch/pubsinfo.asp?pubid=2006084
Businesses
More than $939 billion
Revenue for women-owned businesses in 2002, up 15
percent from 1997. There were 116,985 women-owned firms with receipts of $1 million
or more.
Nearly 6.5 million
The number of women-owned businesses in 2002, up 20 percent
from 1997. (The increase was twice the national average for all businesses.)
Women owned 28 percent of all non-farm businesses.
More than 7.1 million
Number of people employed by women-owned businesses.
There were 7,231 women-owned firms with 100 or more employees, generating $274
billion in gross receipts.
Nearly one in three women-owned firms operated in health care and social assistance, and other services such as personal services, and repair and maintenance. Women owned 72 percent of social assistance businesses and just over half of nursing and residential care facilities. Wholesale and retail trade accounted for 38.2 percent of women-owned business revenue.
43%
Rate of growth in the number of women-owned firms in Nevada between 1997
and 2002, which led the nation. Georgia (35 percent), Florida (29 percent) and
New York (28 percent) followed.
Source for the statements in this section:
http://www.census.gov/prod/ec02/sb0200cswmnt.pdf
http://www.census.gov/prod/ec02/sb0200cscosumt.pdf
Voting
65%
Percentage of women citizens who reported voting in the 2004 presidential
election, higher than the 62 percent of their male counterparts who cast a ballot
http://www.census.gov/PressRelease/www/releases/archives/voting/004986.html
Jobs
59%
Percent of women 16 or older who participated in the labor force in 2005.
This amounted to 69.3 million women. More than 35 million women in 2005 had worked year-round, full time, in the past 12 months. Men in this age range had a participation rate of 73 percent. (Sources: http://www.bls.gov/cps/cpsaat2.pdf and 2005 American Community Survey via American FactFinder.)
37%
Percent of women 16 or older who work in management, professional and
related occupations, compared with 31 percent of men. (Source: 2005 American
Community Survey via American FactFinder)
21.1 million
Number of female workers in educational services, health care
and social assistance industries. More women work in this industry group than
in any other. Within this industry group, 10.7 million work in the health care
industry and 8 million in educational services. (Source: 2005 American Community
Survey via American FactFinder)
Military
203,000
Total number of active duty women in the military, as of Sept. 30,
2005. Of that total, 35,000 women were officers, and 168,000 were enlisted.
(Source: Statistical Abstract of the United States: 2007, Table 500.)
15%
Proportion of members of the armed forces who were women, as of Sept.
30, 2005. In 1950, women comprised less than 2 percent.
(Source: Statistical Abstract of the United States: 2007, Table 500.)
1.7 million
The number of military veterans who are women.
(Source: Statistical Abstract of the United States: 2007, Table 508.)
Marriage
63 million
Number of married women (including those who are separated or
have an absent spouse) in 2005. There are 55 million unmarried (widowed, divorced
or never married) women. (Source: 2005 American Community Survey via American
FactFinder)
17%
Percentage of married couples in which the wife earns at least $5,000
more than the husband in 2005. Among 22 percent of married couples, the wife
has more education than the husband. http://www.census.gov/PressRelease/www/releases/archives/families_households/006840.html
5.6 million
Number of stay-at-home mothers nationwide in 2005, up from 4.4
million a decade earlier. http://www.census.gov/population/socdemo/hh-fam/shp1.pdf
Computers
84%
Proportion of women who used a computer at home in 2003, 2 percentage
points higher than the corresponding proportion for men. This reverses the computer
use “gender gap” exhibited during the 1980s and 1990s. http://www.census.gov/PressRelease/www/releases/archives/miscellaneous/005863.html
Sports and Recreation
2.9 million
Number of girls who participated in high school athletic programs
in the
2004-05 school year. In the 1973-74 school year, only 1.3 million girls were members of a high school athletic team. (Source: Statistical Abstract of the United States: 2007, Table 1232.)
166,728
Number of women who participated in an NCAA sport in 2004-05.
(Source: Statistical Abstract of the United States: 2007, Table 1234.)
85%
Among those who purchased aerobic shoes in 2004, the proportion who were
women. Women also comprised a majority (64 percent) of those who bought walking
shoes.
(Source: Statistical Abstract of the United States: 2007, Table 1237.)
57%
Percentage of women who participated in gardening at least once in the
past
12 months, compared with 37 percent of men. Women were also much more likely than men to have done charity work (32 percent versus 26 percent), attended arts and crafts fairs (39 percent versus 27 percent) and read literature (55 percent versus 38 percent).
(Source: Statistical Abstract of the United States: 2007, Tables 1221, 1222 and 1223.)
Hormone replacement therapy and survival after colorectal cancer diagnosis
CONCLUSION: Current postmenopausal estrogen use before diagnosis of colorectal cancer was associated with improved colorectal cancer-specific and overall mortality. This benefit was principally limited to women who initiated estrogens within 5 years of diagnosis. Additional efforts to understand mechanisms through which estrogens influence colorectal carcinogenesis and cancer progression seem warranted.
Chan
JA, et al Hormone replacement therapy and survival after colorectal cancer
diagnosis. J
Clin Oncol. 2006 Dec 20;24(36):5680-6.
http://ezproxyhhs.nihlibrary.nih.gov:2067/entrez/query.fcgi?cmd
=retrieve&db=pubmed&list_uids=17179103&dopt=Abstract
New Report on the Detection and Treatment of Ovarian Cancer
According to a new evidence report supported by a partnership of the Agency for Healthcare Research and Quality (AHRQ), the Centers for Disease Control and Prevention's (CDC) Division of Cancer Prevention and Control, and CDC's National Office of Public Health Genomics, many genomic tests currently used to diagnose and guide treatment of ovarian cancer have not been shown to decrease the number of women who die from the disease or improve their quality of life.
About the CDC/AHRQ partnership that produced the new report, Janet Collins, Ph.D., Director of CDC's National Center for Chronic Disease Prevention and Health Promotion, says, "This first-ever collaboration of the CDC's cancer and genomics programs with AHRQ provides important evidence-based guidance to inform both public health and medical practitioners about the appropriate use of genetic testing in cancer prevention and control."
The report indicates that physical exams, ultrasounds, and other routine screening efforts have been unsuccessful in reducing the numbers of women affected by and who die from ovarian cancer, compared with similar efforts aimed at other causes of cancer deaths in women. Because current strategies have not proven to be effective, there is tremendous interest in identifying the disease in its earliest stages by looking at genes, gene expression levels, proteins, and tumor markers. These tests focus on (1) detecting a gene-based tumor marker, such as CA-125; or (2) identifying genetic mutations such as BRCA1 and BRCA2 that indicate increased risk for developing cancer; or (3) identifying genetic changes that predict response to therapy in women with ovarian cancer.
Researchers performed a comprehensive review of the literature and found few studies evaluated genetic tests other than CA-125 or BRCA1 and BRCA2 to diagnose ovarian cancer or identify women at risk. Among the tests evaluated in the report, the researchers found no studies showing that changing treatment based on test results reduced deaths or improved quality of life in women who were diagnosed with ovarian cancer.
The team stated that research aimed at improving treatment options and the discovery of treatment, lifestyle, or dietary choices that could prevent ovarian cancer would likely offer greater promise for major reductions in deaths from the disease. http://www.ahrq.gov/clinic/tp/genovctp.htm
ACOG Releases Revised Recommendations for Women's Health Screenings and Care
Washington , DC -- Recent recommendations for HIV screening, human papillomavirus (HPV) vaccination, and preconception care are among those highlighted in the revised primary and preventive care periodic assessments recommended for women by The American College of Obstetricians and Gynecologists (ACOG). The updated recommendations, published in the December issue of Obstetrics & Gynecology, provide ob-GYNs with a comprehensive schedule of age-appropriate screening exams, laboratory tests, immunizations, and counseling for non-pregnant adolescents and adult women.
The document incorporates recent guidance from individual ACOG committees on specific issues in women's health.
HIV Testing
Routine HIV testing should be offered to women ages 19 to 64 regardless of personal
risk factors, following the new Centers for Disease Control and Prevention (CDC)
guidelines. Ob-GYNs should be aware of and follow their states' HIV testing requirements.
In addition, ACOG recommends HIV testing for adolescents who are or ever have
been sexually active. ACOG previously recommended HIV testing only for women
considered high risk or for those in areas with high HIV prevalence.
Preconception Care
Ob-GYNs should encourage women of childbearing age to develop a reproductive
health plan to help conscientiously assess the desire for a child or children
or desire not to have children. The plan also should address the optimal number,
timing, and spacing of children; determine the steps needed to prevent or plan
for and optimize a pregnancy; and evaluate current health status and other issues
relevant to the health of a pregnancy.
Colorectal Cancer Screening
Women age 50 and older should be screened for colorectal cancer using one of
five recommended screening strategies. If fecal occult blood testing (FOBT) is
used, patients should collect two or three samples at home and return them for
laboratory analysis. Single samples obtained by digital rectal examination in
the ob-gyn's office are not adequate for colorectal cancer screening.
HPV Vaccine
An HPV vaccine was made available for the first time in 2006. ACOG recommends
that HPV vaccination be offered to all girls and women 9 to 26 who have not previously
been vaccinated. The vaccine protects against four HPV strains that cause most
cervical cancers and genital warts and is most effective when administered before
the onset of sexual activity.
Tdap Vaccine
Pertussis has been added to the tetanus and diphtheria booster recommendation
in accordance with CDC recommendations. Adolescents should receive the Tetanus,
Diptheria, Pertussis (Tdap) booster once between ages 11 and 16, then every 10
years thereafter up to age 64.
Meningococcal Vaccine
ACOG now recommends that adolescents not previously immunized receive meningococcal
conjugate vaccination before entry into high school. Older women at high risk
also should receive the vaccine.
Committee Opinion #357, "Primary and Preventive Care: Periodic Assessments," is published in the December 2006 issue of Obstetrics & Gynecology.
http://www.acog.org/from_home/publications/press_releases/nr12-01-06-2.cfm
What's new on the ITU MCH web pages?
Andy Narva moved to NIH, but is still our Renal CCC
http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-neph.asp
Diabetes: Understandings About the Causes of Type 2 - Old / New
http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForumMod.cfm#diabetes
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 December 2006/January 2007 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.
