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Volume 5, No. 4, April 2007
Features
American College of Obstetricians and Gynecologists
Ob-Gyns Encouraged to Help Reduce Colorectal Cancer Deaths in Women
Washington , DC -- In recognition of Colorectal Cancer Awareness Month, ob-gyns are encouraged to remind all of their patients age 50 and older to be screened for colorectal cancer. Because ob-gyns are the only physicians many women see on a regular basis, they can help increase colorectal cancer screening rates and, thereby, help reduce deaths from one of the most preventable and treatable types of cancer.
"Despite the promising decline in colorectal cancer deaths in the US, many women are still not getting screened for colorectal cancer," says Douglas W. Laube, MD, MEd, president of The American College of Obstetricians and Gynecologists (ACOG). "Ob-gyns can really help by making sure that all eligible patients leave their office with screening recommendations. ACOG encourages its members to educate women about the importance of routine colorectal cancer screening."
Colon and rectal cancer (colorectal cancer) affects the large intestine and rectum. It is the third leading cause of cancer death among women in the US and the second leading cause of cancer deaths overall for all adults. In most cases, colorectal cancer develops slowly over time. It often begins as a tissue growth, called a polyp, in the colon or rectum. Routine screening helps detect these polyps so that they can be removed before they turn into cancer. In many cases, colorectal cancer has no symptoms. The following symptoms, however, may indicate colorectal cancer: a change in bowel habits, bleeding from the rectum, blood in the stool, stools that are more narrow than usual, abdominal discomfort (bloating, cramps, or frequent gas pains), loss of appetite, and weakness and feeling tired.
ACOG recommends that all women age 50 and older be screened for colorectal cancer by one of the following methods:
- Annual patient-collected fecal occult blood test (FOBT) or fecal immunochemical test (FIT)
- Flexible sigmoidoscopy once every five years
- Annual patient-collected FOBT or FIT plus a flexible sigmoidoscopy once every five years
- Double-contrast barium enema once every five years
- Colonoscopy once every 10 years
Some women may need to be screened for colorectal cancer before age 50 if they:
- Have a first-degree relative younger than age 60 with colorectal cancer or colon polyps
- Have two or more first-degree relatives of any age with colorectal cancer or colon polyps
- Have had colorectal cancer
- Have had colon polyps
- Have had inflammatory bowel disease (IBS), chronic ulcerative colitis, or Crohn's disease
- Have a family history of familial adenomatosis polyposis or hereditary nonpolyposis colon cancer
In early 2006, the National Colorectal Cancer Roundtable, of which ACOG is a member, published an evidence-based guide, How to Increase Colorectal Cancer Screening Rates in Practice. It is available free to physicians at
www.nccrt.org/documents/general/increasecolorectalcancerscreeningrates.pdf
The guide offers current screening guidelines and features checklists, chart prompts, tracking sheets, and other tools that physicians can use in their practice.
http://www.acog.org/from_home/publications/press_releases/nr03-01-07.cfm
Medical Futility - Committee Opinion
ABSTRACT: The construct of medical futility has been used to justify a physician’s unilateral refusal to provide treatment requested or demanded by a patient or the family of a patient. It is important that physicians and their institutions develop a process for dealing with conflict surrounding the construct of medical futility. Prospective policies on medical futility are preferable to unilateral decision making by individual physicians. When there is disagreement, patient and family values regarding treatment options and the default position of maintaining life ordinarily should take priority .
Medical Futility. ACOG Committee Opinion No. 362. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;109:791–4
American Family Physician**
Treatment of the Common Cold (see Patient Education)
The common cold is a viral illness that affects persons of all ages, prompting frequent use of over-the-counter and prescription medications and alternative remedies. Treatment focuses on relieving symptoms (e.g., cough, nasal congestion, rhinorrhea). Dextromethorphan may be beneficial in adults with cough, but its effectiveness has not been demonstrated in children and adolescents. Codeine has not been shown to effectively treat cough caused by the common cold. Although hydrocodone is widely used and has been shown to effectively treat cough caused by other conditions, the drug has not been studied in patients with colds. Topical (intranasal) and oral nasal decongestants have been shown to relieve nasal symptoms and can be used in adolescents and adults for up to three days. Antihistamines and combination antihistamine/decongestant therapies can modestly improve symptoms in adults; however, the benefits must be weighed against potential side effects. Newer nonsedating antihistamines are ineffective against cough. Topical ipratropium, a prescription anticholinergic, relieves nasal symptoms in older children and adults. Antibiotics have not been shown to improve symptoms or shorten illness duration. Complementary and alternative therapies (i.e., Echinacea, vitamin C, and zinc) are not recommended for treating common cold symptoms; however, humidified air and fluid intake may be useful without adverse side effects. Vitamin C prophylaxis may modestly reduce the duration and severity of the common cold in the general population and may reduce the incidence of the illness in persons exposed to physical and environmental stresses. Am Fam Physician 2007;75:515-20, 522 http://www.aafp.org/afp/20070215/515.html
Cough: Diagnosis and Management: Practice Guidelines
On a typical day, a family physician will see at least one patient presenting with cough. Cough can be divided into three categories: acute (i.e., lasting less than three weeks), subacute (i.e., lasting three to eight weeks), and chronic (i.e., lasting longer than eight weeks).
Chest, January 2006
http://www.aafp.org/afp/20070215/practice.html
or
http://www.chestjournal.org/content/vol129/1_suppl/
Common Oral Lesions: Part I. Superficial Mucosal Lesions (see Patient Education)
Common superficial oral lesions include candidiasis, recurrent herpes labialis, recurrent aphthous stomatitis, erythema migrans, hairy tongue, and lichen planus. Recognition and diagnosis require taking a thorough history and performing a complete oral examination. Knowledge of clinical characteristics such as size, location, surface morphology, color, pain, and duration is helpful in establishing a diagnosis. Oral candidiasis may present as pseudomembranous candidiasis, glossitis, or perlèche (angular cheilitis). Oral candidiasis is common in infants, but in adults it may signify immune deficiency or other illness. Herpes labialis typically is a mild, self-limited condition. Recurrent aphthous stomatitis most often is a mild condition; however, severe cases may be caused by nutritional deficiencies, autoimmune disorders, or human immunodeficiency virus infection. Erythema migrans is a waxing and waning disorder of unknown etiology. Hairy tongue represents elongation and hypertrophy of the filiform papillae and most often occurs in persons who smoke heavily. Oral lichen planus is a chronic inflammatory condition that may be reticular or erosive. Certain risk factors have been associated with each of these lesions, such as poor oral hygiene, age, tobacco use, and alcohol consumption, and some systemic conditions may have oral manifestations. Many recommended therapies for oral lesions are unsupported by randomized controlled trials. Am Fam Physician 2007;75:501-7.
http://www.aafp.org/afp/20070215/501.html
Common Oral Lesions: Part II. Masses and Neoplasia
Certain common oral lesions appear as masses, prompting concern about oral carcinoma. Many are benign, although some (e.g., leukoplakia) may represent neoplasia or cancer. Palatal and mandibular tori are bony protuberances and are benign anomalies. Oral pyogenic granulomas may appear in response to local irritation, trauma, or hormonal changes of pregnancy. Mucoceles represent mucin spillage into the oral soft tissues resulting from rupture of a salivary gland duct. Oral fibromas form as a result of irritation or masticatory trauma, especially along the buccal occlusal line. Oral cancer may appear clinically as a subtle mucosal change or as an obvious mass. Oral leukoplakia is the most common premalignant oral lesion. For persistent white or erythematous oral lesions, biopsy should be performed to rule out neoplastic change or cancer. Most oral cancers are squamous cell carcinomas. Tobacco and heavy alcohol use are the principal risk factors for oral cancer. Family physicians should be able to recognize these lesions and make appropriate referrals for biopsy and treatment. Am Fam Physician 2007;75:509-12.
http://www.aafp.org/afp/20070215/509.html
Iron Deficiency Anemia (see Patient Education)
The prevalence of iron deficiency anemia is 2 percent in adult men, 9 to 12 percent in non-Hispanic white women, and nearly 20 percent in black and Mexican-American women. Nine percent of patients older than 65 years with iron deficiency anemia have a gastrointestinal cancer when evaluated. The U.S. Preventive Services Task Force currently recommends screening for iron deficiency anemia in pregnant women but not in other groups. Routine iron supplementation is recommended for high-risk infants six to 12 months of age. Iron deficiency anemia is classically described as a microcytic anemia. The differential diagnosis includes thalassemia, sideroblastic anemias, some types of anemia of chronic disease, and lead poisoning. Serum ferritin is the preferred initial diagnostic test. Total iron-binding capacity, transferrin saturation, serum iron, and serum transferrin receptor levels may be helpful if the ferritin level is between 46 and 99 ng per mL (46 and 99 mcg per L); bone marrow biopsy may be necessary in these patients for a definitive diagnosis. In children, adolescents, and women of reproductive age, a trial of iron is a reasonable approach if the review of symptoms, history, and physical examination are negative; however, the hemoglobin should be checked at one month. If there is not a 1 to 2 g per dL (10 to 20 g per L) increase in the hemoglobin level in that time, possibilities include malabsorption of oral iron, continued bleeding, or unknown lesion. For other patients, an endoscopic evaluation is recommended beginning with colonoscopy if the patient is older than 50. Am Fam Physician 2007;75:671-8 http://www.aafp.org/afp/20070301/671.html
Treatment Options for Atopic Dermatitis (see Patient Education)
Atopic dermatitis is a common inflammatory skin condition that usually affects children. It is a chronic disease, with periods of remission and flare-ups, that adversely affects the quality of life of patients and their families. Aggressive therapy with emollients is an important intervention for patients with atopic dermatitis. Patients should avoid individual disease triggers and allergens. Topical corticosteroids are the mainstay of treatment for flare-ups and are the standard to which other treatments are compared. Topical calcineurin inhibitors should not be used in patients younger than two years or in those who are immunosuppressed, and should be second-line therapies in other patients. Rarely, systemic agents (e.g., cyclosporine, interferon gamma-1b, oral corticosteroids) may be considered in adults. Am Fam Physician 2007;75:523-8, 530.
http://www.aafp.org/afp/20070215/523.html
AHRQ
Diagnostic errors that harm outpatients are typically the result
of multiple individual and system breakdowns
http://www.ahrq.gov/research/feb07/0207RA1.htm
Some pregnant women are still prescribed medications with the potential
to harm the fetus
http://www.ahrq.gov/research/feb07/0207RA14.htm
Shifting from a culture of blame to a culture of safety in nursing
homes could help identify and prevent medical errors
http://www.ahrq.gov/research/feb07/0207RA2.htm
Ask A Librarian: Diane Cooper, M.S.L.S. / NIH
Pelvic Inflammatory Disease: The CDC website should be bookmarked
The CDC website is a great resource.
Take a little time to remind yourself about the signs, symptoms, and current alternatives for the management of Pelvic Inflammatory Disease, below. Please note the many alternative oral regimens due to drug resistant strains.
PID comprises a spectrum of inflammatory disorders of the upper female genital tract, including any combination of endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis. Sexually transmitted organisms, especially N. gonorrhoeae and C. trachomatis, are implicated in many cases; however, microorganisms that comprise the vaginal flora (e.g., anaerobes, G. vaginalis, Haemophilus influenzae, enteric Gram-negative rods, and Streptococcus agalactiae) also have been associated with PID. In addition, cytomegalovirus (CMV), M. hominis, U. urealyticum, and M. genitalium might be associated with some cases of PID. All women who are diagnosed with acute PID should be tested for N. gonorrhoeae and C. trachomatis and should be screened for HIV infection.
Diagnostic Considerations
Acute PID is difficult to diagnose because of the wide variation in the symptoms and signs. Many women with PID have subtle or mild symptoms. Delay in diagnosis and treatment probably contributes to inflammatory sequelae in the upper reproductive tract. Laparoscopy can be used to obtain a more accurate diagnosis of salpingitis and a more complete bacteriologic diagnosis. However, this diagnostic tool frequently is not readily available, and its use is not easy to justify when symptoms are mild or vague. Moreover, laparoscopy will not detect endometritis and might not detect subtle inflammation of the fallopian tubes. Consequently, a diagnosis of PID usually is based on clinical findings.
The clinical diagnosis of acute PID is imprecise. Data indicate that a clinical diagnosis of symptomatic PID has a positive predictive value (PPV) for salpingitis of 65%--90% compared with laparoscopy. The PPV of a clinical diagnosis of acute PID depends on the epidemiologic characteristics of the population, with higher PPVs among sexually active young women (particularly adolescents), among patients attending STD clinics, or in other settings where the rates of gonorrhea or chlamydia are high. In all settings, however, no single historical, physical, or laboratory finding is both sensitive and specific for the diagnosis of acute PID (i.e., can be used both to detect all cases of PID and to exclude all women without PID). Combinations of diagnostic findings that improve either sensitivity (i.e., detect more women who have PID) or specificity (i.e., exclude more women who do not have PID) do so only at the expense of the other. For example, requiring two or more findings excludes more women who do not have PID but also reduces the number of women with PID who are identified.
Many episodes of PID go unrecognized. Although some cases are asymptomatic, others are not diagnosed because the patient or the health-care provider fails to recognize the implications of mild or nonspecific symptoms or signs (e.g., abnormal bleeding, dyspareunia, and vaginal discharge). Because of the difficulty of diagnosis and the potential for damage to the reproductive health of women, even by apparently mild or subclinical PID, health-care providers should maintain a low threshold for the diagnosis of PID.
The optimal treatment regimen and long-term outcome of early treatment of women with asymptomatic or subclinical PID are unknown. The following recommendations for diagnosing PID are intended to help health-care providers recognize when PID should be suspected and when they need to obtain additional information to increase diagnostic certainty. Diagnosis and management of other common causes of lower abdominal pain (e.g., ectopic pregnancy, acute appendicitis, and functional pain) are unlikely to be impaired by initiating empiric antimicrobial therapy for PID.
Empiric treatment of PID should be initiated in sexually active young women and other women at risk for STDs if they are experiencing pelvic or lower abdominal pain, if no cause for the illness other than PID can be identified, and if one or more of the following minimum criteria are present on pelvic examination:
- cervical motion tenderness OR uterine tenderness OR adnexal tenderness.
The requirement that all three minimum criteria be present before the initiation of empiric treatment could result in insufficient sensitivity for the diagnosis of PID. The presence of signs of lower genital tract inflammation, in addition to one of the three minimum criteria, increases the specificity of diagnosis. In deciding upon the initiation of empiric treatment, clinicians should also consider the risk profile of the patient for STDs.
More elaborate diagnostic evaluation frequently is needed because incorrect diagnosis and management might cause unnecessary morbidity. These additional criteria may be used to enhance the specificity of the minimum criteria. The following additional criteria can be used to enhance the specificity of the minimum criteria and support a diagnosis of PID:
- oral temperature >101°F (>38.3°C),
- abnormal cervical or vaginal mucopurulent discharge,
- presence of abundant numbers of WBC on saline microscopy of vaginal secretions,
- elevated erythrocyte sedimentation rate,
- elevated C-reactive protein, and
- laboratory documentation of cervical infection with N. gonorrhoeae or C. trachomatis.
The majority of women with PID have either mucopurulent cervical discharge or evidence of WBC on a microscopic evaluation of a saline preparation of vaginal fluid. If the cervical discharge appears normal and no WBCs are observed on the wet prep of vaginal fluid, the diagnosis of PID is unlikely, and alternative causes of pain should be investigated. A wet prep of vaginal fluid offers the ability to detect the presence of concomitant infections (e.g., bacterial vaginosis and trichomoniasis).
The most specific criteria for diagnosing PID include the following:
- endometrial biopsy with histopathologic evidence of endometritis;
- transvaginal sonography or magnetic resonance imaging techniques showing thickened, fluid-filled tubes with or without free pelvic fluid or tubo-ovarian complex, or doppler studies suggesting pelvic infection (e.g., tubal hyperemia); and
- laparoscopic abnormalities consistent with PID.
A diagnostic evaluation that includes some of these more extensive studies might be warranted in some cases. Endometrial biopsy is warranted in women undergoing laparoscopy who do not have visual evidence of salpingitis, as some women with PID have endometritis alone.
Treatment
PID treatment regimens must provide empiric, broad spectrum coverage of likely pathogens. Several antimicrobial regimens have been effective in achieving clinical and microbiologic cure in randomized clinical trials with short-term follow-up. However, only a limited number of investigations have assessed and compared these regimens with regard to elimination of infection in the endometrium and fallopian tubes or determined the incidence of long-term complications (e.g., tubal infertility and ectopic pregnancy) after antimicrobial regimens.
All treatment regimens should be effective against N. gonorrhoeae and C. trachomatis because negative endocervical screening for these organisms does not rule out upper reproductive tract infection. The need to eradicate anaerobes from women who have PID has not been determined definitively. Anaerobic bacteria have been isolated from the upper reproductive tract of women who have PID, and data from in vitro studies have revealed that some anaerobes (e.g., Bacteroides fragilis) can cause tubal and epithelial destruction. In addition, BV also is present in many women who have PID. Until treatment regimens that do not adequately cover these microbes have been demonstrated to prevent long-term sequelae (e.g., infertility and ectopic pregnancy) as successfully as the regimens that are effective against these microbes, the use of regimens with anaerobic activity should be considered. Treatment should be initiated as soon as the presumptive diagnosis has been made because prevention of long-term sequelae is dependent on immediate administration of appropriate antibiotics. When selecting a treatment regimen, health-care providers should consider availability, cost, patient acceptance, and antimicrobial susceptibility.
Some specialists have recommended that all patients with PID be hospitalized so that bed rest and supervised treatment with parenteral antibiotics can be initiated. However, in women with PID of mild or moderate clinical severity, outpatient therapy can provide short- and long-term clinical outcomes similar to inpatient therapy. Limited data support the use of outpatient therapy in women with more severe clinical presentations. The decision of whether hospitalization is necessary should be based on the discretion of the health-care provider.
The following criteria for hospitalization are suggested:
- surgical emergencies (e.g., appendicitis) cannot be excluded;
- the patient is pregnant;
- the patient does not respond clinically to oral antimicrobial therapy;
- the patient is unable to follow or tolerate an outpatient oral regimen;
- the patient has severe illness, nausea and vomiting, or high fever; and
- the patient has a tubo-ovarian abscess.
Many practitioners have preferred to hospitalize adolescent women whose condition is diagnosed as acute PID. No evidence is available suggesting that adolescents benefit from hospitalization for treatment of PID. Younger women with mild-to-moderate acute PID have similar outcomes with either outpatient therapy or inpatient therapy. Further, clinical response to outpatient treatment is similar among younger and older women. The decision to hospitalize adolescents with acute PID should be based on the same criteria used for older women. Whether women in their later reproductive years benefit from hospitalization for treatment of PID also is unclear, although women aged >35 years who are hospitalized with PID are more likely than younger women to have a complicated clinical course.
Parenteral Treatment
For women with PID of mild or moderate severity, parenteral and oral therapy appears to have similar clinical efficacy. Many randomized trials have demonstrated the efficacy of both parenteral and oral regimens. In the majority of clinical trials, parenteral treatment for at least 48 hours has been used after the patient has demonstrated substantial clinical improvement. Clinical experience should guide decisions regarding transition to oral therapy, which usually can be initiated within 24 hours of clinical improvement. The majority of clinicians recommend at least 24 hours of direct inpatient observation for patients who have tubo-ovarian abscesses.
Recommended Parenteral Regimen A
Cefotetan 2 g IV every 12 hours
OR
Cefoxitin 2 g IV every 6 hours
PLUS
Doxycycline 100 mg orally or IV every 12 hours
Because of the pain associated with infusion, doxycycline should be administered orally when possible, even when the patient is hospitalized. Oral and IV administration of doxycycline provide similar bioavailability.
Parenteral therapy may be discontinued 24 hours after a patient improves clinically, and oral therapy with doxycycline (100 mg twice a day) should continue to complete 14 days of therapy. When tubo-ovarian abscess is present, many health-care providers use clindamycin or metronidazole with doxycycline for continued therapy, rather than doxycycline alone, because it provides more effective anaerobic coverage.
Clinical data are limited regarding the use of other second- or third-generation cephalosporins (e.g., ceftizoxime, cefotaxime, and ceftriaxone), which also might be effective therapy for PID and may replace cefotetan or cefoxitin. However, these cephalosporins are less active than cefotetan or cefoxitin against anaerobic bacteria.
Recommmended Parenteral Regimen B
Clindamycin 900 mg IV every 8 hours
PLUS
Gentamicin loading dose IV or IM (2 mg/kg of body weight), followed by a maintenance
dose (1.5 mg/kg) every 8 hours. Single daily dosing may be substituted.
Although use of a single daily dose of gentamicin has not been evaluated for the treatment of PID, it is efficacious in analogous situations. Parenteral therapy can be discontinued 24 hours after a patient improves clinically; continuing oral therapy should consist of doxycycline 100 mg orally twice a day or clindamycin 450 mg orally four times a day to complete a total of 14 days of therapy. When tubo-ovarian abscess is present, many health-care providers use clindamycin for continued therapy, rather than doxycycline, because clindamycin provides more effective anaerobic coverage.
Alternative Parenteral Regimens
Limited data support the use of other parenteral regimens, but the following three regimens have been investigated in at least one clinical trial, and they have broad spectrum coverage.
Levofloxacin 500 mg IV once daily*
WITH OR WITHOUT
Metronidazole 500 mg IV every 8 hours
OR
Ofloxacin 400 mg IV every 12 hours*
WITH OR WITHOUT
Metronidazole 500 mg IV every 8 hours
OR
Ampicillin/Sulbactam 3 g IV every 6 hours
PLUS
Doxycycline 100 mg orally or IV every 12 hours
* Quinolones should not be used in persons with a history of recent foreign travel or partners' travel, infections acquired in California or Hawaii, or infections acquired in other areas with increased QRNG prevalence.
IV ofloxacin has been investigated as a single agent; however, because of concerns regarding its spectum, metronidazole may be included in the regimen. Levofloxacin is as effective as ofloxacin and may be substituted; its single daily dosing makes it advantageous from a compliance perspective. One trial demonstrated high short-term clinical cure rates with azithromycin, either alone for 1 week (at least one IV dose followed by oral therapy) or with a 12-day course of metronidazole. Ampicillin/sulbactam plus doxycycline is effective coverage against C. trachomatis, N. gonorrhoeae, and anaerobes and for patients who have tubo-ovarian abscess.
Oral Treatment
Oral therapy can be considered for women with mild-to-moderately severe acute PID, as the clinical outcomes among women treated with oral therapy are similar to those treated with parenteral therapy. The following regimens provide coverage against the frequent etiologic agents of PID. Patients who do not respond to oral therapy within 72 hours should be reevaluated to confirm the diagnosis and should be administered parenteral therapy on either an outpatient or inpatient basis.
Recommended Regimen A
Levofloxacin 500 mg orally once daily for 14 days*
OR
Ofloxacin 400 mg orally twice daily for 14 days*
WITH OR WITHOUT
Metronidazole 500 mg orally twice a day for 14 days
* Quinolones should not be used in persons with a history of recent foreign travel or partners' travel, infections acquired in California or Hawaii, or infections acquired in other areas with increased QRNG prevalence.
Oral ofloxacin has been investigated as a single agent in two clinical trials, and it is effective against both N. gonorrhoeae and C. trachomatis. Despite the results of these trials, lack of anaerobic coverage with ofloxacin is a concern; the addition of metronidazole to the treatment regimen provides this coverage. Levofloxacin is as effective as ofloxacin and may be substituted. Azithromycin has been demonstrated in one randomized trial to be an effective regimen for acute PID. The addition of metronidazole should be considered, as anaerobic organisms are suspected in the etiology of the majority of PID cases. Metronidazole will also treat BV, which frequently is associated with PID.
Regimen B
Ceftriaxone 250 mg IM in a single dose
PLUS
Doxycycline 100 mg orally twice a day for 14 days
WITH or WITHOUT
Metronidazole 500 mg orally twice a day for 14 days
OR
Cefoxitin 2 g IM in a single dose and Probenecid, 1 g orally administered concurrently
in a single dose
PLUS
Doxycycline 100 mg orally twice a day for 14 days
WITH or WITHOUT
Metronidazole 500 mg orally twice a day for 14 days
OR
Other parenteral third-generation cephalosporin
(e.g., ceftizoxime or cefotaxime)
PLUS
Doxycycline 100 mg orally twice a day for 14 days
WITH or WITHOUT
Metronidazole 500 mg orally twice a day for 14 days
The optimal choice of a cephalosporin for Regimen B is unclear; although cefoxitin has better anaerobic coverage, ceftriaxone has better coverage against N. gonorrhoeae. Clinical trials have demonstrated that a single dose of cefoxitin is effective in obtaining short-term clinical response in women who have PID. However, the theoretical limitations in cefoxitin's coverage of anaerobes might require the addition of metronidazole to the treatment regimen. Metronidazole also will effectively treat BV, which is frequently associated with PID. No data have been published regarding the use of oral cephalosporins for the treatment of PID. Limited data suggest that the combination of oral metronidazole and doxycycline after primary parenteral therapy is safe and effective.
Alternative Oral Regimens
Although information regarding other outpatient regimens is limited, one other regimen has undergone at least one clinical trial and has broad spectrum coverage. Amoxicillin/clavulanic acid and doxycycline was effective in obtaining short-term clinical response in a single clinical trial; however, gastrointestinal symptoms might limit compliance with this regimen.
Follow-Up
Patients should demonstrate substantial clinical improvement (e.g., defervescence; reduction in direct or rebound abdominal tenderness; and reduction in uterine, adnexal, and cervical motion tenderness) within 3 days after initiation of therapy. Patients who do not improve within this period usually require hospitalization, additional diagnostic tests, and surgical intervention.
If no clinical improvement has occurred within 72 hours after outpatient oral or parenteral therapy (using the criteria for clinical improvement described previously), an examination should be performed. Subsequent hospitalization, parenteral therapy, and diagnostic evaluation, including the consideration of diagnostic laparoscopy for alternative diagnoses, are recommended in women without clinical improvement. Some specialists also recommend rescreening for C. trachomatis and N. gonorrhoeae 4--6 weeks after therapy is completed in women with documented infection with these pathogens. All women diagnosed with acute PID should be offered HIV testing.
Management of Sex Partners
Male sex partners of women with PID should be examined and treated if they had sexual contact with the patient during the 60 days preceding the patient's onset of symptoms. Evaluation and treatment are imperative because of the risk for reinfection of the patient and the strong likelihood of urethral gonococcal or chlamydial infection in the sex partner. Male partners of women who have PID caused by C. trachomatis and/or N. gonorrhoeae frequently are asymptomatic.
Sex partners should be treated empirically with regimens effective against both of these infections, regardless of the etiology of PID or pathogens isolated from the infected woman. Even in clinical settings in which only women are treated, arrangements should be made to provide care for male sex partners of women who have PID. When providing care for male sex partners is not feasible, health-care providers should ensure that sex partners are referred for appropriate treatment.
Prevention
Prevention of chlamydial infection by screening and treating high-risk women reduces the incidence of PID. Theoretically, the majority of cases of PID can be prevented by screening all women or those determined to be at high risk (based on age or other factors) by using DNA amplification on cervical specimens (in women receiving pelvic examinations) and on urine specimens (in women not undergoing examinations). Although BV is associated with PID, whether the incidence of PID can be reduced by identifying and treating women with BV is unclear.
Special Considerations
Pregnancy. Because of the high risk for maternal morbidity and preterm delivery, pregnant women who have suspected PID should be hospitalized and treated with parenteral antibiotics.
HIV Infection. Differences in the clinical manifestations of PID between HIV-infected women and HIV-negative women have not been well-delineated. In previous observational studies, HIV-infected women with PID were more likely to require surgical intervention. More comprehensive observational and controlled studies (published since the 2002 STD Treatment Guidelines) have demonstrated that HIV-infected women with PID had similar symptoms when compared with uninfected controls. They were more likely to have a tubo-ovarian abscess but responded equally well to standard parenteral and oral antibiotic regimens when compared with HIV-negative women. The microbiologic findings for HIV- positive and HIV-negative women were similar, except HIV-infected women had higher rates of concomitant M. hominis, candida, streptococcal, and HPV infections and HPV-related cytologic abnormalities. Whether the management of immunodeficient HIV-infected women with PID requires more aggressive interventions (e.g., hospitalization or parenteral antimicrobial regimens) has not been determined.
IUD. Intrauterine contraceptive devices are becoming a popular contraceptive choice for women. Both levonorgestrel- and copper-containing devices are marketed in the United States. The risk of PID associated with IUD use is primarily confined to the first 3 weeks after insertion and is uncommon thereafter. Given the popularity of IUDs, practitioners might encounter PID in IUD users. No evidence suggests that IUDs should be removed in women diagnosed with acute PID. However, caution should be exercised if the IUD remains in place, and close clinical follow-up is mandatory. The rate of treatment failure and recurrent PID in women continuing to use an IUD is unknown. No data exist on antibiotic selection and treatment outcomes according to type of IUD (e.g., copper or levonorgestrel).
Sexually Transmitted Diseases Treatment Guidelines, 2006 MMWR August 4, 2006 / 55(RR11);1-94
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5511a1.htm
Breastfeeding - Suzan Murphy, PIMC
Inquiring families want to know - what about breastfeeding and……
-Is it okay if the mom smokes or chews tobacco and breastfeeds?
According to American Academy of Pediatrics, the risk benefit of breastfeeding outweighs the potential risk of tobacco metabolites in the mother’s milk. The greater concern is that the baby not be exposed to second hand smoke.
-Can a mom still breastfeed if she has pierced nipples?
La Leche League reports that body piercing, including nipple piercing has been a common practice throughout history. There have not been problems reported that are specifically associated with breastfeeding and pierced nipples. General recommendations include keeping the area clean and removing nipple jewelry before allowing the baby to breastfeed. Also, nipple piercing while breastfeeding is probably not feasible due to the 3 month or longer healing time required. For more information, consider visiting this web site:
http://www.lalecheleague.org/llleaderweb/LV/LVJunJul99p64.html
Can moms drink alcohol and breastfeed?
-Yes and maybe. Numerous professional sources including Thomas W. Hale, R.Ph. Ph.D., University of Texas (author of Medication and Mother’s Milk), American College of Nurse-Midwives, and American Academy of Pediatrics agree that moderate and occasional consumption of alcohol is usually compatible with breastfeeding. Important considerations are:
-The baby’s age - A newborn has an immature liver and will take longer to metabolize any of the alcohol that gets into the mom’s milk.
-Moms body size - A larger mother can metabolize alcohol more quickly than a smaller mom.
-Amount of alcohol consumed - Most sources report that waiting 2 hours for every drink (12 oz beer, 5 oz wine, 1 standard drink - including 1 shot of spirits such as vodka, whiskey, rum, tequila, etc) or until the mother feels neurologically normal, is a reasonable waiting period.
-A helpful calculator for how long alcohol takes to be metabolized can be found at:
http://www.obfocus.com/calculators/alcoholinmilk.htm
Please note that moms do not need to pump to get rid of the alcohol. A mom’s milk is a dynamic fluid, the milk and alcohol are not trapped. A mom’s liver will metabolize the alcohol in the breastmilk like the alcohol in her blood stream.
What about caffeine?
American College of Nurse-Midwives provides a well documented and succinct recommendation. From their web site, www.gotmom.org
Though dietary caffeine appears in breast milk, nursing mothers can safely consume small amounts of caffeine without passing on a significant amount to the baby. Higher caffeine amounts could potentially cause problems such as poor sleeping, nervousness, irritability, and poor feeding, so limiting your caffeine intake makes sense.
Caffeine tends to build up in babies’ systems because their bodies cannot get rid of it very easily. Try using decaffeinated coffee and tea, and avoid colas and other carbonated drinks that have added caffeine. The American Academy of Pediatrics recommends that nursing women limit consumption to the caffeine equivalent of 1 to 3 cups of coffee per day.
(Source: International Food Information Council
Foundation)
www.GotMom.org is
brought to you by
If you have other asked/unasked questions (and answers) about breastfeeding, please send them to suzan.murphy@ihs.gov for the future articles.
Editorial Comment: Suzan Murphy
The above questions and answers are short phone call answers to sometimes complex issues. For more in-depth information, please consider the following:
Regarding alcohol:
- When moms plan for a 12 oz of beer with pizza next weekend or a standard mixed drink or 5 oz of wine at the annual office party, the “2 hours for every drink” has clinical support.
- Often moms will choose to not drink alcohol rather than worry about timing feedings.
- Choosing to drink non-alcoholic beverages is the safest choice, for breastfeeding and driving home. Alcohol goes into the breast milk and until is metabolized out, safe levels have not been determined. Drinking extra water, more coffee, or pumping have not been shown to make the breast milk have less alcohol, like the rest of the body, the milk glands have to wait for the liver to do its job.
- Sometimes moms ask or call after drinking alcohol and need to know when it is safe to resume breastfeeding – it helps to “do the math” with moms – count the drinks, review portion size, multiple by 2 hours, - also consider when the last drink was.
- If the moms describe risky drinking patterns (defined by ACOG as more than 7 drinks per week or more than 3 drinks at a time) – consider using this opportunity to ask more questions, offer resources and information, and provide pathways for moms and families to healthier lives. ACOG link below
- Sometimes it is hard to find behaviors to praise with those who have risky or serious drinking issues. For those moms who are seeking sobriety and choose to use formula to keep their baby safe, it can be a difficult and painful choice. It may help them to acknowledge the wisdom of their decision.
Regarding tobacco, chewed or smoked:
- Mom/families often call about using (legal) tobacco. They ask if they should stop breastfeeding if they smoke or chew.
- Exposure to the baby can be from the mom smoking or smoking/chewing and breastfeeding, from 2 nd hand smoke, or 2 nd hand to mother and then to the baby by way of environmental exposure or breast milk. The tobacco by products that appear in breast milk and infant’s urine are cotinine and nicotine. Cotinine and nicotine are associated with SIDS and colic. There are no known safe levels. In one study, the urinary cotinine levels were higher babies breastfed by smoking moms than babies formula fed by smoking moms. ( Becker AB et al1999)
- However, study results vary. A recent study reported that babies breastfed by mothers who smoked had lower cotinine and nicotine urine levels than babies whose mothers smoked, but were formula fed. (Bajanowski T et al 2007)
- Regarding nicotine patches for smoking cessation: A recent study found use of nicotine patches to be safer option than continued smoking. When mothers were smoking almost 1 ppd, the nicotine and cotinine levels their breast milk were similar to those mothers using the 21-mg/day patch. But when the patch strength was tapered to 14-mg and 7–mg, the nicotine and cotinine concentrations decreased significantly. There was also no significant influence on the milk supply when the patch was used. (Ilett KF et al 2003)
- When a family does not use tobacco, it greatly reduces the risk of exposing new life to known problem agents. There is more to be learned. Currently, the American Academy of Pediatrics (AAP) states that the benefits of breastfeeding are greater than known risks of tobacco by products in breast milk.
Other
Breast-Feeding Enhances Vision Development in Infants
CONCLUSIONS: These findings support the hypothesis that breastfeeding benefits long-term stereoscopic development. An effect of DHA cannot be excluded, but the lack of difference in stereoacuity between infants randomly assigned to DHA-containing and those assigned to control formula raises the hypothesis that factors in breast milk other than DHA account for the observed benefits.
Singhal
A, et al Infant nutrition and stereoacuity at age 4-6 y. Am
J Clin Nutr. 2007 Jan;85(1):152-9 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd
=Retrieve&dopt=AbstractPlus&list_uids=17209191
Simple antenatal preparation to improve breastfeeding practice: RCT
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. CLINICAL TRIAL REGISTRATION: (www.ClinicalTrials.gov), NCT002770192 LEVEL OF EVIDENCE: I.
Mattar CN at al Simple antenatal preparation to improve breastfeeding practice: a randomized controlled trial. Obstet Gynecol. 2007; 109(1):73-80
Longer duration of lactation associated with favorable changes in metabolic risk factors
CONCLUSION: Lactation may attenuate unfavorable metabolic risk factor changes that occur with pregnancy, with effects apparent after weaning. As a modifiable behavior, lactation may affect women's future risk of cardiovascular and metabolic diseases. LEVEL OF EVIDENCE: II
Gunderson EP et al Lactation and Changes in Maternal Metabolic Risk Factors. Obstet Gynecol. 2007 Mar;109(3):729-738.
Postpartum Mastitis and Community-Acquired Methicillin-Resistant S. Aureus
Summary: Community Acquired (CA) MRSA has emerged as an increasingly common pathogen in PPM. Therapy against CA-MRSA should be considered in refractory or severe cases of PPM until wound, drainage, or breast milk cultures can be obtained. Adjunct surgical drainage or aspiration is often warranted in such cases. Additional study is required to determine the utility of routine cultures in postpartum mastitis, the prevalence of CA-MRSA in this emerging problem, and the consequences of CA-MRSA colonization for breastfeeding infants.
Pavani Reddy et al Emerg Infect Dis. 2007;13(2):298-301
http://www.medscape.com/viewarticle/551382?src=mp
Resources
ACOG
Clinician Tools - Drinking and Reproductive Health
www.acog.org/from_home/misc/dept_pubs.cfm
Becker AB , et al, Breast-Feeding and Environmental Tobacco Smoke Exposure, Arch Pediatr Adolesc Med, 1999 Jul;153(7):689-91
Bajanowski T et al, Nicotine and cotinine in infants dying from sudden infant death syndrome. Int J Legal Med. 2007 Feb 7
Ilett KF et al, Use of nicotine patches in breast-feeding mothers: transfer of nicotine and cotinine into human milk. Clin Pharmacol Ther. 2003 Dec;74(6):516-24.
American Academy of Pediatrics
http://www.aap.org/
CCC Corner Digest
Nicely laid out hard copy - A compact digest of last month’s CCC Corner
- Healing words: The power of 'I'm sorry' in medical practice
- Ryan White HIV / AIDS Treatment Modernization Act of 2006
- GDM Guidelines: Major discrepancies to identify GDM and predict pregnancy outcome
- Cystocoele Repair: The Mesh Controversy
- Review and Comment: Newborn record form IHS-298 and its revision
- Does Delay in Diagnosis of Breast Cancer Impact Prognosis?
- ACOG Opposes Sex Selection for Family Planning Purposes
- ACOG Calls on Employers to Support Breastfeeding
- Abstinence counseling vs family planning: Which is more effective?
- The MCH Coordinators Site has a clean new look, plus new functionality
- How many rubella vaccines does a mother really need to get?
- Sexual behavior in context: A public health perspective
- Scrub Club
- Prolonged second stage with an epidural
- Maternal positioning and pain relief: Promoting effective pushing
- Clomiphene “bests” Metformin in a NEJM study
- A "Small Fall" and a Trip to the Emergency Department
- Indian Health Surveillance Report—Sexually Transmitted Diseases 2004
- Ultrasound is better at finding Neural Tube Defects than AFP
- Adolescent with knee pain, Web M+M, Terry Cullen - Moderator
- A First: STD Rates Available by IHS Area
- Fertility rises as weight drops
- Women's Health Week will be celebrated May 13-19, 2007
- 2nd methamphetamine issue of the IHS Primary Care Provider online
Link to entire issue, below
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/CCCC_5_3.pdf
If you want a copy of the CCC Digest mailed to you each month, please contact nmurphy@scf.cc
Domestic Violence – Denise Grenier, Rachel Locker
Violence Threatens the Health of Pregnant Women and Newborns
CONCLUSION: Women experiencing intimate partner violence both prior to and during pregnancy are at risk for multiple poor maternal and infant health outcomes, suggesting prenatal risks to children from mothers' abusive partners.
Silverman JG et al Intimate partner violence victimization prior to and during pregnancy among women residing in 26 U.S. states: associations with maternal and neonatal health. Am J Obstet Gynecol. 2006 Jul;195(1):140-8.
or
http://www.endabuse.org/newsflash/index.php3?Search=Article&NewsFlashID=787
Intimate Partner Violence in Pregnancy: Clinicians Guidelines Tutorial, CDC
http://www.cdc.gov/reproductivehealth/violence/IntimatePartnerViolence/sld044.htm#44
Health Cost Higher for Survivors of Domestic Violence
CONCLUSIONS: Women with a history of IPV had significantly higher healthcare utilization and costs, continuing long after IPV ended. Given its high prevalence, IPV has a major impact on medical care resource utilization and efforts to prevent its occurrence and consequences are clearly indicated.
Rivara FP, et al Healthcare utilization and costs for women with a history of intimate partner violence Am J Prev Med. 2007 Feb;32(2):89-96
Elder Care News
Guidelines for Palliative Care Services in the Indian Health: Now Online
The newly released Guidelines for Palliative Care Services in the Indian Health System provide guidance and common language around what constitutes a program of palliative care for our IHS, Tribal, and Urban Indian Health programs as well as a tool for implementation of services. The Guidelines were adapted from the work of the National Consensus Project for Quality Palliative Care (NCP) whose purpose is “to promote the implementation of Clinical Practice Guidelines that ensure care of consistent and high quality, and that guide the development and structure of new and existing palliative care services.” http://www.nationalconsensusproject.org/.
An interdisciplinary Indian Health workgroup adapted the NCP guidelines to the Indian Health setting, aiming for guidelines that were feasible within our system and still provided a high level of quality. This workgroup had the help of a large number of national experts in palliative care who reviewed the guidelines and provided valuable suggestions in their development. For questions or assistance in the development of palliative care services contact Mary Jo Crissler, Tim Domer, or Bruce Finke. Bruce.Finke@ihs.gov
Reference:
Guidelines for Palliative Care Services in the Indian Health
http://www.ihs.gov/NonMedicalPrograms/nc4/Documents/FINALPCGUIDELINES.pdf
3rd annual American Indian and Alaska Native Long Term Care Conference
Plan now to attend the 3rd annual American Indian and Alaska Native Long Term Care Conference in Albuquerque, New Mexico, from September 5-6, 2007.
For more information, visit http://www.aianlongtermcare.org
Disability among older Americans continues significant decline
Changes in the health and functioning of the Medicare-enrolled population aged 65+ are tracked by using the 1982-2004/2005 National Long-Term Care Surveys. We found a significant rate of decline in the prevalence of chronic disability that accelerated from 1982 to 2004. These declines are significant for both persons with less severe chronic disability, which might be compensated by modifying the built environment and providing assistive devices, and for persons with more serious disability, which may be affected by reductions in the incidence and severity of disease through biomedical interventions. Declines in chronic disability continued over the 22-year period at a rate fast enough (i.e., 1.52% per annum) to contribute significantly to the long-term fiscal stability of the Medicare (and Medicaid) programs. Changes in the rate and substance of disability declines seem consistent with the intentions of policy interventions in Medicare and Medicaid.
Manton KG, et al Change in chronic disability from 1982 to 2004/2005 as measured by long-term changes in function and health in the U.S. elderly population. Proc Natl Acad Sci U S A. 2006 Nov 28;103(48):18374-9
Family Planning
Non-latex versus latex male condoms for contraception
AUTHORS' CONCLUSIONS: Although the nonlatex condoms were associated with higher rates of clinical breakage than their latex comparison condoms, the new condoms still provide an acceptable alternative for those with allergies, sensitivities, or preferences that might prevent the consistent use of latex condoms. The contraceptive efficacy of the nonlatex condoms requires more research.
Gallo MF et a; Non-latex versus latex male condoms for contraception. Cochrane Database Syst Rev. 2006; (1):CD003550
Population effect of increased access to emergency contraceptive pills: Systematic review
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; Trussell J; Polis CB Population effect of increased access to emergency contraceptive pills: a systematic review. Obstet Gynecol. 2007; 109(1):181-8
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17197603
Featured Web Site David Gahn, IHS MCH Portal Web Site Content Coordinator
Welcome to the Indian Health Service Methamphetamine Initiative Site
This is the online source for information about METH prevention activities across Indian Country and across the United States… in the next few months the site will be updated for better viewing and ease of navigation.
http://www.ihs.gov/MedicalPrograms/Behavioral/index.cfm?module=BH&option=Meth
For access to an article on best practice strategies for dealing with Meth, developed out of Montana, please contact Carolyn.Aoyama@ihs.gov
FYI - this web site may be of interest to you
Thanks to science.gov, we have had great success in the beta stages of implementing the Science Diversity Center (SDC), we are planning a larger release sometime in January. We have not only had great input during the beta stages, averaging about 15,000 "hits" a month and going as high as 24,000 hits, but have also learned about other features that faculty "wished" were included.
The site features the following:
1. Research grants and awards, including portfolio and folder features.
2. A "Career Consultants" feature which will evolve into a comprehensive " Career Center" in the next few weeks to allow students to develop personal portfolios as well as secure resumes plus much much more.
3. An education initiative that will evolve into two new "Cabinets," one with searchable learning support materials and the other with an expanded education feature (We, along with other partners, are having productive meetings centered on establishing an online-higher education campus to complement our online high school).
4. A new unique eMeeting rooms feature that will allow users to establish online meetings with colleagues.
5. The establishment of a webinar series (hopefully starting in February) that highlights funding opportunities at federal agencies for MSI faculty, administrators and staff. Other webinar series are offered. During the beta testing of this feature, users have really utilized the feature. The feedback has been great. It is paying dividends for participants (no charge to MSIs).
http://sciencediversitycenter.org
National Network of Libraries of Medicine, Pacific Northwest Region
University
of Washington nnlm@u.washington.edu
NN/LM PNR 800-338-7657
Box 357155 206/543-8262
Seattle , Washington 98195-7155 206/543-2469 (FAX)
Frequently asked questions
Q. Does misoprostol aid prior to IUD insertion?
A. Yes, misoprostol appears to soften the cervix and decrease complications.
Answer
Evidence is suggestive that misoprostol is useful for IUD insertions. Misoprostol softens the cervix and reduces the chance of complications such as perforation, pain, and bleeding. In addition, RCTs have shown that misoprostol improves the ease with which the cervix can be dilated and reduces complications in premenopausal women, postmenopausal women, and nulliparous women undergoing operative hysteroscopy, though the studies are small. As with many issues surrounding misoprostol, the optimum dosing and regimen remain in question. The doses referenced below range from 200 – 400 mcg given 12 -24 hours before the procedure.
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/MisoSAB121105.doc
Other Resources:
FAQ: For nulliparous women undergoing IUD insertion does cervical priming with misoprostol or other agents facilitate the insertion?
http://www.ffprhc.org.uk/admin/uploads/No1456.pdf
Q. What are Pilates? (pronounced puh-LAH-teez)
A. Pilates once a body-conditioning regime known only to elite athletes, dancers, performers and models, has gone mainstream. Details below
The following is an article referenced from the University of Alaska Health Sciences Information Service Newsletter : December 2006
http://consortiumlibrary.org/hsis/site/about/newsletters/Dec06.pdf
Pilates : The Mind-Body Workout that Transforms!
Pilates (pronounced puh-LAH-teez), once a body-conditioning regime known only to elite athletes, dancers, performers and models, has gone mainstream. It stresses mind-body synchronization and is based on six principles and over 500 exercises which emphasize precision rather than quantity.1 A maximum of 3, 5 or 10 repetitions are initiated and controlled in the core of the body, and breathing is carefully synchronized with them. With over 500 Pilates studios in North America alone, Pilates is the new Fountain of Youth for baby boomers seeking to extend heir youth and vitality into old age.
How it all began
Born in Germany in 1880, Joseph Pilates was a weak and sickly child. Determined to improve his health, he took up bodybuilding, skiing, diving and gymnastics, and became an accomplished boxer and circus performer. He also studied eastern philosophies, yoga and martial arts, incorporating the best attributes of each into a unique practice he called “contrology”, which he used to treat the sick and injured during World War I. Using old hospital beds, unused springs and other surplus gear at hand, he designed his “signature” equipment to improve muscle strength in the bedridden, who regained mobility unexpectedly quickly. In 1926, Pilates moved to New York and with his wife Clara set up his first studio, attracting modern dancers and other performers. One student, Romana Kryzanowska, was hand-picked to train authentic Pilates instructors after Pilates’ death in 1960, when the training regimen became known as Pilates.2 Now in her eighties, Romana is still teaching.3
What’s so special?
Pilates training is designed to strengthen the body core – the “powerhouse” of muscles in the deep abdomen, buttocks, and around the spine. Strengthening these muscles has been found effective in alleviating and preventing back pain. Body and mind are developed together. Instructors focus on developing awareness of proper alignment of the body and isolation of specific muscles, balance, smooth breathing, mental focus, and graceful flow of the movements. Stretching and lengthening exercises are done on mats and specially designed apparatus offering resistance and support, including the Reformer, Arc Barrel, Cadillac and Wunda Chair.4 Other “props” include the fitness circle, flex band, and Bosu (a hemisphere with a soft top and firm base, used to develop balance).
The Benefits
Pilates reshapes and conditions the body for speed, power and precision. Pilates provides cross-training for athletes, and improves athletic performance by increasing muscular endurance, mind-body awareness, understanding of body position and placement, and balance.5 It also helps the non-athletic: injuries are minimized when the core is strong, and movement is carefully controlled and coordinated. Athletes such as Tiger Woods and Jason Kidd, have endorsed Pilates for developing superior posture, body strength and flexibility.4 Film stars and models have discovered Pilates to help maintain their sculpted figures. (An added bonus is “killer” kegels – you can avoid incontinence as one ages)
Getting started
A “boot camp” or introductory session with certified Pilates instructors helps the novice learn to isolate and engage the body’s deep core muscles. Instructors then offer hour-long mat or Reformer sessions with individuals or small groups, who are allowed to progress at their own speed. Level I and Level II classes are available. Ongoing correction ensures the exercises are being done properly. Some health clubs have incorporated Pilates-inspired exercises into their program, providing an easy transition for athletes unfamiliar with Pilates, though less rigorous than the environment of licensed Pilates studios.7 After correctly mastering the basic techniques, some excellent self-instruction programs on DVD are available if the student wants to continue on his/her own.
HSIS Newsletter, 12/06
http://consortiumlibrary.org/hsis/about/newsletters/Dec06.pdf
Resources
- Tomlinson, J. (2003). Core conditioning with Pilates. Total Health 25(2) Mar./Apr. Full text available in Academic Search Premier database. http://sled.alaska.edu/databases/home.html
- Hamilton, J. & D. Simon. (2003) The Pilates story. New Life Journal: Carolina Edition, 4(3). Full text available in Alt HealthWatch database. http://sled.alaska.edu/databases/home.html
- Romana’s Pilates website. http://www.romanaspilates.com/
- Shulman, L. (2006). Pilates for every “body.” Alive: Canadian Journal of Health & Nutrition. Feb.:92-93. Full text available in Alt Healthwatch database. http://sled.alaska.edu/databases/home.htm
- Kostka, Ericka.(2005). Pilates: A classic workout for a new body. http://tinyurl.com/y5n5ms
- Studio One Pilates ( Anchorage) website. http://www.pilatesalaska.com/
- “What is true Pilates.” http://www.romanaspilates.com/pgs/aboutpilates.html
Consortium Library, University of Alaska Anchorage, HSIS Newsletter Home
http://consortiumlibrary.org/hsis/about/newsletter.php
Indian Child Health Notes - Steve Holve, Pediatrics Chief Clinical Consultant
March 2007
- Low iron - it's bad to be poor and it's even worse to be poor and anemic: especially for your brain
- Spending priorities and public health - Dr. Esposito
is not happy
- Home visits to AI/AN infants to improve child health outcomes
Information Technology
2007 Physician Quality Reporting Initiative Webpage Is Now Available
The Centers for Medicare & Medicaid Services (CMS) is pleased to announce that the 2007 Physician Quality Reporting Initiative (PQRI) webpage is now available.
On December 20, 2006 the President signed the Tax Relief and Health Care Act of 2006 (TRHCA). Section 101 under Title I authorizes the establishment of a physician quality reporting system by CMS. CMS has titled the statutory program the 2007 Physician Quality Reporting Initiative.
PQRI establishes a financial incentive for eligible professionals to participate in a voluntary quality reporting program. Eligible professionals who successfully report a designated set of quality measures on claims for dates of service from July 1 to December 31, 2007, may earn a bonus payment, subject to a cap, of 1.5% of total allowed charges for covered Medicare physician fee schedule services.
This newly established webpage will be updated regularly, so check it often for timely and reliable information from CMS. http://www.cms.hhs.gov/PQRI/01_Overview.asp#TopOfPage
HIPPA mandated standard unique identifiers for health care providers: NPPES
The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandated the adoption of standard unique identifiers for health care providers, as well as the adoption of standard unique identifiers for health plans. The purpose of these provisions is to improve the efficiency and effectiveness of the electronic transmission of health information. The Centers for Medicare & Medicaid Services (CMS) has developed the National Plan and Provider Enumeration System (NPPES) to assign these unique identifiers.
https://nppes.cms.hhs.gov/NPPES/Welcome.do
International Health Update: Claire Wendland, Madison, WI
Testing New Drugs on the World’s Poorest Patients
In the film The Constant Gardener, based on the novel by John LeCarré, the protagonist battles representatives of a nefarious pharmaceutical company intent on concealing evidence of unethical medical research on impoverished African subjects. Though fictional, the film and book film drew public attention to a real and growing phenomenon in which wealthy pharmaceutical corporations farm out basic medical research to so-called “CROs” (contract research organizations). In order to secure the large numbers of human test subjects required to meet the gold standard criteria for drug approval demanded by the FDA – the randomized placebo-controlled double-blind trial – the CROs turn to economically vulnerable populations. Increasingly, they look beyond the domestic poor to international settings where signing up for a research protocol may provide the patient’s best (or only) chance of receiving medical care. In an era in which drugs are one of the most lucrative businesses around, human research subjects have thus become a hot international commodity.
For those who are interested in the facts behind the popular fiction, a recent book by investigative journalist Sonia Shah explores the phenomenon of international clinical drug trials at some length. In The Body Hunters, Shah details the factors driving US-based pharmaceutical companies, unable to find sufficient numbers of enrollees at home, to outsource their drug trials to countries like India, South Africa, and the former Soviet Socialist Republics. Here, she argues, wealthy corporations benefit from a combination of less restrictive regulatory environments and more desperate patient populations, the end result of which is larger enrollments in their trials. While much of this ground has been trodden before – one could plausibly argue that she makes very little original contribution to the discussion – Shah does a commendable job of consolidating a wide and unwieldy range of academic, historical and journalistic investigations in a readable, largely balanced, and engagingly written book.
In a PLoS Medicine piece, Trudo Lemmens and Paul Miller explore a related issue: financial compensation of physicians who recruit patients from their practices to join clinical trials. Though their legal status remains murky, explicit “finders fees” are clearly prohibited by most professional medical ethical codes (including that of the AMA). Nonetheless, various recruitment incentives have been designed to wiggle through loopholes in these various professional codes, with the net effect of insuring that “patients have become de facto market products,” as Lemmens and Miller put it. Like Shah, these authors believe that institutional review boards have proved inadequate to the task of protecting vulnerable populations from the powerful vested interests of big pharma. The authors call for a rethinking of national and international regulations to prevent “jurisdiction shopping,” in which companies scout the world for those countries with the most favorable (or least onerous) legal and financial climate for patient recruitment.
The globalization of biomedicine and the increasing interpenetration of medicine and industry are combining to ensure that formerly distinct borders – geopolitical, professional, disciplinary – are increasingly fluid, arbitrary, and manipulable. Whose interests will be served and how the vulnerable will be protected in the context of these shifting alliances and opportunities are questions of urgent and ongoing importance to all of us.
Shah S. The Body Hunters: Testing New Drugs on the World’s Poorest Patients. New York: The New Press, 2006
Lemmens T, Miller PB. Regulating the market in human research participants. PLoS Medicine 3(8):e330, August 2006 www.plosmedicine.org
MCH Alert
How science has revolutionized the understanding of drug addiction
Drugs, Brains, and Behavior: The Science of Addiction provides information about drug addiction, including the many harmful consequences of drug abuse and the basic approaches that have been developed to prevent and treat it. The 30-page, full-color booklet, published by the National Institutes on Drug Abuse, discusses the reasons people take drugs, why some people become addicted while others do not, how drugs work in the brain, and how addiction can be prevented and treated. Information about NIDA's addiction-research program and efforts to share findings with professional audiences and the general public are provided, along with information about NIDA's special initiatives to target students and teachers, designated populations, and ethnic groups. The booklet is intended for use by health professionals and the general public in making informed choices in their own lives, adopting science-based policies and programs that reduce drug abuse and addiction in their communities, and supporting scientific research that improves the nation's well-being. http://www.drugabuse.gov/scienceofaddiction/sciofaddiction.pdf
Disparities in Fetal and Perinatal Mortality
Fetal and Perinatal Mortality, United States, 2003 presents detailed data on fetal and perinatal deaths and mortality rates for the United States for 2003. For the purposes of the report, published by the National Center for Health Statistics, fetal mortality refers to the intrauterine death of a fetus at any gestational age, and perinatal mortality refers to death around the time of delivery and includes both fetal deaths (at least 20 weeks of gestation) and early infant
(neonatal) deaths. The authors examine data from the 2003 fetal death data file and the 2003 period linked birth and infant death data file by a variety of characteristics, including race and Hispanic origin, maternal age, marital status, sex of fetus, plurality (multiple deliveries), birthweight, and period of gestation. Fetal and perinatal mortality rates by state are provided. A discussion, references, a list of detailed tables, and technical notes are also included. http://www.cdc.gov/nchs/data/nvsr/nvsr55/nvsr55_06.pdf
MCH Headlines: Judy Thierry HQE
Training opportunity – Infant mental health
July 20 & 21, 2007 NCAST-AVENUW Summer Institute
Risky Beginnings: Examining Case Stories about Effective Intervention with Young Children & Families - Hyatt Regency Hotel, Bellevue, WA
http://www.ncast.org/events.asp
OB/GYN CCC Editorial comment:
NCAST will be at the August meeting in Albuquerque, too
Denise Findlay, RN, BSN, the Training Programs & Development Coordinator from NCAST has graciously agreed to present 1-2 workshops at the National Indian Women’s Health and MCH Conference, August 15- 17, 2007. Still another reason you should go to the meeting in Albuquerque. http://www.ihs.gov/MedicalPrograms/MCH/F/CN01.cfm#Aug07
The Magic of Play
Child care involves PLAY. Parenting involves play.
For those of you working directly or indirectly with day care programs, in child care settings, Early and Head Start programs you will find this short news article “the Magic of Play” interesting and possibly something you want to begin in your projects and programs. Cuidando los Niños a non-profit in Albuquerque, NM serves children of homeless families as they reenter community. The program meets the needs of the children while their mother is also supported in seeking housing, work and educational and social services. Their article links the child play and parent ‘play’ and interaction into a meaningful approach and intervention.
http://www.cuidandolosninos.org/home.html
Cervical Cancer in America
96 page national update on distribution of disease, economic burden, 1 page state-by-state reports, Women In Government is a national 501(c)(3), non-profit, bi-partisan organization of women state legislators providing leadership opportunities, networking, expert forums, and educational resources to address and resolve complex public policy issues. Women In Government leads the nation with a bold, courageous, and passionate vision that empowers and mobilizes all women legislators to effect sound policy.
Women In Government. Partnering For Progress 2007: The “State” of Cervical Cancer Prevention in America. Washington, DC, 2007.
To request free copies of this report or to send inquiries, contact: Toll free: 1.888.333.0164
E-mail:resourcecenter@womeningovernment.org
Web:www.womeningovernment.org/prevention
A MUST reference tool for multidisciplinary teams reviewing infant and child deaths
Keeping Kids Safe – has a comprehensive manual you can download or order
A review manual available for reviewing child deaths makes a complex public health and child advocacy activity doable. It frames the local approaches in this 190 page document answering questions, concerns and all of the step by step how to’s that any review committee would have.
Useful for hospital M&M, mch case reviews, EMS and PIMR’s the final pages contain specific one-page Guides to Effective Child Death Reviews by specific causes of death – SIDS, asthma, children with disabilities, natural infant and pediatric deaths, suffocation, fires and burns, drowning, child abuse and neglect, motor vehicle deaths, suicides, teen homicides. Contact 800-656-2434 or info@childdeathreview.org or http://www.childdeathreview.org/Finalversionprotocolmanual.pdf
Home page: http://www.childdeathreview.org/home.htm has many resources including a state -map of the US http://www.childdeathreview.org/statistics.htm links further to other sites with stats such as perinatal, kids count…!!!
Remember the car seat video I sent out in the past year about being 4’9” tall?
A link to a poster to remember those who are nooooottt quiiiiiiiite tall enough to ride safely in an adult harness virtual POSTER communication tool and link to a ‘must see’ 5 minute video _helps to focus on the right ‘seat’ for infants and children of all ages and you will appreciate what Law Enforcement does to promote child passenger safety.
From: NHTSA press release: “Since 2000, 38 States have strengthened their child restraint laws to require booster seat use by children who have outgrown their child safety seats, but who still cannot ride safely using adult seat belts. These booster seat provisions have been enacted to better protect child passengers in the 4 to 8 age group. Although progress has been made in many respects, nearly 1,700 of these children have been killed and more than 265,000 have been injured in crashes since 2001.
Knowing that law enforcement agencies appreciate specially designed tools to facilitate the enforcement of new requirements, this new six-minute roll-call video was developed to help officers enforce booster seat requirements during traffic stops. "Booster Seats -- The Missing Link" provides meaningful details about the need for booster seat use, as well as moving personal accounts about booster seats (including longtime booster seat advocate Autumn Alexander Skeen), and suggestions for how best to enforce these new requirements.”
http://www.boosterseat.gov/?gclid=CNK0lancs4oCFSh-UAodEDhGCA
To view the video, please go towww.boosterseat.gov and click on the “Roll-Call Video” link at the bottom of the page. ftp://ftp.nhtsa.dot.gov/WMPVideo/Roll-Call/NHTSA-ver2_pre.wmv
In conjunction with Child Passenger Safety Week (February 11-17, 2007), NHTSA announces the availability of a new roll-call video to assist law enforcement agencies in enforcing booster seat use requirements now in effect in more than two-thirds of the States, and the District of Columbia.http://www.nhtsa.dot.gov/
Studies Show Hearing Loss of Any Degree Has Significant Impact on Children
Numerous cognitive and developmental delays, including the ability to pay attention have been associated with hearing loss. A child's ability to regulate his or her attention (sustaining attention, disregarding distractions, staying attentive to task goals, etc.) can affect school readiness and later academic performance. This pilot study shows how learning and using appropriate parenting techniques can help children with hearing loss develop these skills. 2006 Convention of the American Speech- Language-Hearing Association (ASHA).
http://releases.usnewswire.com/GetRelease.asp?id=76204
Pediatric Resource Guide to Infant and Childhood Hearing Loss 2nd edition - free copy
I have a $95 copy of the ‘PEDIATRIC RESOURCE GUIDE TO INFANT AND CHILDHOOD HEARING LOSS 2 ND EDITION
Developed by the Center for Early Intervention on Deafness the web site has multiple resources:
CHECKLIST FOR HEARING DEVELOPMENT
0-4 months
· Startles to loud sounds during light sleep.
· Smiles when you talk and smile at him.
· Cries in response to sudden, loud sounds.
4-7 months
· Turns toward new and interesting sounds (both sides).
· Stops playing in response to new and interesting sounds.
7-9 months
· Enjoys playing with sound toys.
· Enjoys babbling and making sounds; reciprocal voice play.
9-13 months
· Turns directly towards the source of sound.
· Continues to babble and experiment with new sounds.
· Follows your simple commands when not looking at your face.
http://www.ceid.org/ or Judith.Thierry@ihs.gov
Fetal and Perinatal Mortality, NVSR
Results—The U.S. fetal mortality rate in 2003 was 6.23 fetal deaths of 20 weeks of gestation or more per 1,000 live births and fetal deaths. Fetal and perinatal mortality rates have declined slowly but steadily from 1990 to 2003. Fetal mortality rates for 28 weeks of gestation or more have declined substantially, whereas those for 20–27 weeks of gestation have not declined. Fetal mortality rates are higher for a number of groups, including non-Hispanic black women, teenagers, women aged 35 years and over, unmarried women, and multiple deliveries. Over one-half (51 percent) of fetal deaths of 20 weeks of gestation or more occurred between 20 and 27 weeks of gestation.
Fetal and Perinatal Mortality, United States, 2003 by Marian F. MacDorman, Ph.D.; Donna L. Hoyert, Ph.D.; Joyce A. Martin, M.P.H.; Martha L. Munson, M.S.; and Brady E. Hamilton, Ph.D., Division of Vital Statistics
Click on the PDF in the press release for the full report. http://www.cdc.gov/nchs
12th Annual MCH EPI Conference online presentation archive now live
Content is broad MCH: Teens, tobacco, injury, gestational diabetes, breastfeeding, international health, poster presentations, prematurity….
Please visit http://www.cademedia.com/archives/cdc/mchepi2006/index.htm to access video clips, text transcripts and slide presentations from the plenary and many breakout sessions.
The site is also available through the 'Conferences' section of http://www.mchcom.com. Please help us to promote the site by notifying all appropriate audiences and posting to relevant listserv(s) etc.
1918 Flu Epidemic Teaching Valuable Lessons : Actions Taken Apparently Were Effective
New analysis of how American cities responded to the killer Spanish flu of 1918 suggests that closing schools, banning large gatherings, staggering work hours and quarantining households of the ill may have saved tens of thousands of lives.
Which of the many non-pharmaceutical interventions was especially effective in reducing mortality is unknown, but all would theoretically be available should pandemic influenza again sweep the country.
The new findings run counter to previous research that concluded that the public health measures instituted in 1918 may have delayed or dampened the epidemic in many cities but probably had little effect on the ultimate death toll.
The new data were presented this week to Centers for Disease Control and Prevention experts, who are helping to draw up guidelines for what local health departments might do during the early stage of an influenza pandemic, when a vaccine would be unavailable and there would be too few antiviral drugs to go around…..Excerpted from an article by David Brown Washington Post Staff Writer Wednesday, December 13, 2006.
Week by week flu activity, CDC http://www.cdc.gov/flu/weekly/fluactivity.htmMedical Mystery Tour
Prolonged second stage with an epidural
Let’s review last month’s case briefly…..a primigravid at 41 3/7 weeks with a history of polycystic ovarian syndrome, a 41 lb. weight gain, a known female infant, and one abnormal result on a 3 hour glucose tolerance test had a prolonged second stage with epidural anesthesia. Exam had revealed an estimated fetal weight of “9 + lbs”. Her temperature rose to 100.6 F and she was started on intravenous gentamicin and ampicillin. Stage I was desultory after misoprostol cervical ripening and required pitocin augmentation.
As Stage II neared 4 hours the risks and benefits of vacuum assistance were discussed with the patient and it was agreed to proceed. The vacuum extractor was placed during 3 contractions. Subsequently, the fetal presenting part descended to +3/5 with the scalp visible without pushing. The fetal heart tones were reassuring throughout. The patient is noticeably beginning to tire and subjectively seems to be pushing less effectively.
What would you have done at that point?
-Allow the patient to push for 30 minutes more and re-evaluate
-Notify the OR team and discuss cesarean delivery
-Wait for the epidural to completely wear off
-Apply the vacuum for a second trial
-Add clindamycin
-Other…
Let’s take a ‘time out’ here
A valid argument could be made for virtually all the above choices. Assuming a reassuring fetal tracing there is no magic to a certain numerical length of Stage II, especially if the patient did not have a strong sensation throughout and was allowed to ‘labor down’ with an epidural. If you choose that course be sure your documentation reflects that the patient was not actively pushing during that period. On the other hand, the delivery provider should be aware that the patient has developed several risk factors that make a successful vaginal delivery fraught with potential difficulty.
The one exception would the choice to reapply the vacuum for a second trial. Before we explore that option though, perhaps we may want to re-explore the use of the vacuum the first time. This patient had several risk factors that predispose patients to a possible shoulder dystocia.
Risk factors for shoulder dystocia
-Fetal macrosomia
-Glucose Intolerance
-Operative vaginal delivery
-History of shoulder dystocia
-Labor abnormalities
-Postterm pregnancy
-Male fetal gender
-Obesity and high weight gain
-Advanced maternal age
-Shoulder-pelvis disproportion
Shoulder dystocia is best defined as the need for additional obstetric maneuvers to effect delivery of the fetal shoulders at the time of vaginal delivery. It occurs in 0.2 to 3 percent of all births and represents an obstetric emergency. Shoulder dystocias can be anticipated only rarely, as many occur in the absence of identifiable risk factors. Therefore, all obstetric care providers must be prepared to recognize a shoulder dystocia immediately and proceed through an orderly sequence of steps to effect delivery in a timely manner and minimize risk to the mother and fetus. It should be noted, however, that permanent birth injury, and even fetal death, can result in cases of shoulder dystocia that are appropriately identified and managed.
This patient has the majority of the above risk factors. Let us explore a two of the more salient aspects:
One abnormal glucose tolerance test result:
This condition is often overlooked, but is associated with macrosomia. Women with one abnormal value on the oral GTT demonstrate fasting insulin concentrations and insulin resistance comparable to that of women with GDM, and they are more likely to deliver a macrosomic infant than women without GDM or women with GDM that is treated. The management of these patients is controversial. Some have recommended that they be treated the same as women who meet standard criteria for GDM, others have not considered further intervention or recommended repeating the oral GTT in four weeks . Studies have shown that treatment of women with one abnormal GTT value decreases the risk of a macrosomic infant and is cost-effective.
Operative vaginal delivery:
Operative vaginal delivery is a risk factor for shoulder dystocia. It is not known whether shoulder dystocia is a result of instrument-aided descent of the fetus or is the underlying reason the fetus has not descended naturally. In a classic study, the combination of macrosomia (defined as birth weight greater than 4000 g), prolonged second stage, and midpelvic operative delivery was associated with a 21 percent incidence of shoulder dystocia. By comparison, when only prolonged second stage and midpelvic operative delivery were present, the risk fell to 4.57 percent and was 0.16 percent in the absence of these risk factors. One review concluded that instrumental delivery was the intrapartum risk factor most associated with permanent brachial plexus injury.
While operative vaginal delivery is just one of many risk factors, it represents a ‘sin of commission’. In many cases one never knows exactly what will / will not occur without prior intervention in a rare event like shoulder dystocia. On the other hand, if one has performed an operative vaginal delivery, then right or wrong, all the subsequent events are viewed within the purview of that action. Hence, it becomes a post hoc assumption that the fetus was ‘pulled’ into the shoulder dystocia.
Back to our case
In this case, the vacuum extractor was re-applied for 3 more applications of traction which brought the presenting part to crowning shortly followed by the ‘turtle sign’. Gentle traction, McRoberts, and nuchal cord release x2 were performed without success. A procto-episotomy was performed without success, followed by the Woods screw maneuver without success. Attention was then paid to the posterior arm and delivery was accomplished after a total of 2 minutes on the perineum. The parturient was taken to the OR for a 4 th degree laceration repair. The patient notes continued fecal incontinence at this writing.
The infant had good cord pH(s), but Apgars of 2/5. The infant was admitted to the special care nursery for one day after resuscitation in the labor suite due to hypotension and ventilation requirements. The infant weighted slightly more than 9 pounds and had a fractured clavicle. The infant was discharged in stable condition after one subsequent day in the step down unit. There were no neurologic deficits and the child has done well in well child care.
In retrospect, though shoulder dsytocia is a rare event and this one was managed quite well, I think there is an element of it being ‘lucky rather than good’. Perhaps this represents a ‘near miss’, if you will. In either case, I submit that if you have what is very likely a macrosomic infant with a prolonged labor, that you not perform operative vaginal delivery.
In addition, I strongly suggest that when you do attend a macrosomic delivery, that you encourage the fetus to ‘deliver through’. In other words, once the fetus is in the final expulsive effort, that you continue the downward momentum until the anterior shoulder is visible, e. g., do not stop the downward progress to suction the oropharynx.
In regard to operative vaginal delivery in this setting, it is perhaps best to remember the Latin phrase Primum non nocere "First, do no harm".
Online resources:
Diagnosis and management of pregnancies at risk for shoulder dystocia, UpToDate
http://www.uptodateonline.com/utd/content/topic.do?topicKey
=labordel/6688&type=A&selectedTitle=1~14
Screening and diagnosis of gestational diabetes mellitus, UpToDate
References:
-Jovanovic-Peterson L; Bevier W; Peterson CM. The Santa Barbara County Health Care Services program: birth weight change concomitant with screening for and treatment of glucose-intolerance of pregnancy: a potential cost-effective intervention? Am J Perinatol 1997 Apr;14(4):221-8.
-Bevier WC; Fischer R; Jovanovic L Treatment of women with an abnormal glucose challenge test (but a normal oral glucose tolerance test) decreases the prevalence of macrosomia. Am J Perinatol 1999;16(6):269-75.
-Langer O et al Management of women with one abnormal oral glucose tolerance test value reduces adverse outcome in pregnancy. Am J Obstet Gynecol 1989 Sep;161(3):593-9.
-Benedetti TJ; Gabbe SG Shoulder dystocia. A complication of fetal macrosomia and prolonged second stage of labor with midpelvic delivery. Obstet Gynecol 1978 Nov;52(5):526-9.
-Gherman RB et al Shoulder dystocia: the unpreventable obstetric emergency with empiric management guidelines. Am J Obstet Gynecol. 2006 Sep;195(3):657-72.Medscape*
Exercise in the Age of Evidence-Based Medicine: A Clinical Update
http://www.medscape.com/viewprogram/6375?sssdmh=dm1.244743&src=top10#
Genital Warts: Best Practices for Diagnosis and Management
http://www.medscape.com/viewprogram/6385?src=sr
Routine Testing for HIV Infection: CDC Screening Recommendations for the
US Population
http://www.medscape.com/viewprogram/6673?sssdmh=dm1.247224&src=nlcmealert
Preventing STD-Related Cancers: An Update on Vaccination Strategies
http://www.medscape.com/viewprogram/6403?src=mp
What Primary Care Providers Need to Know, in 2006, to Optimize the
Management of Acid-Peptic Disorders
http://mp.medscape.com/cgi-bin1/DM/y/hBIvg0Ou5N60Rrh0IK1Q0EU
Weighing the Evidence: NNRTIs vs Boosted PIs for First-line Antiretroviral
Therapy
http://www.medscape.com/viewprogram/5174?
sssdmh=dm1.253215&src=0_mp_cmenl_0
Ask the Experts topics in Women's Health and OB/GYN Index, by specialty,
Medscape
http://www.medscape.com/pages/editorial/public/ate/index-womenshealth
OB GYN & Women's Health Clinical Discussion Board Index, Medscape
http://boards.medscape.com/forums?14@@.ee6e57b
Clinical Discussion Board Index, Medscape
Hundreds
of ongoing clinical discussions available
http://boards.medscape.com/forums?14@@.ee6e57b
Free CME: MedScape CME Index by specialty
http://www.medscape.com/cmecenterdirectory/Default
*NB: Medscape is free to all, but registration is required. It can be accessed from anywhere with Internet access. You just need to create a personal username and password.
Menopause Management
Oral, not Transdermal, Estrogen Increases Risk for VTE in Women
CONCLUSIONS: Oral but not transdermal estrogen is associated with an increased VTE risk. In addition, our data suggest that norpregnane derivatives may be thrombogenic, whereas micronized progesterone and pregnane derivatives appear safe with respect to thrombotic risk. If confirmed, these findings could benefit women in the management of their menopausal symptoms with respect to the VTE risk associated with oral estrogen and use of progestogens
Canonico M, et al Hormone therapy and venous thromboembolism among postmenopausal women: impact of the route of estrogen administration and progestogens: the ESTHER study. Circulation. 2007 Feb 20;115(7):840-5
New low dose estradiol transdermal gel for postmenopausal symptoms
CONCLUSION: The 0.87 g/d dose of this new transdermal E2 gel, which delivers an estimated 0.0125 mg E2 daily, delivered the lowest effective dose for treatment of vasomotor symptoms and vulvovaginal atrophy in a population of postmenopausal women. LEVEL OF EVIDENCE: I.
Simon
JA et al Low Dose of Transdermal Estradiol Gel for Treatment of Symptomatic
Postmenopausal Women: A Randomized Controlled Trial. Obstet
Gynecol. 2007 Mar;109(3):588-596. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd
=retrieve&db=pubmed&list_uids=17329509&dopt=Abstract
Unopposed estradiol: Anticipate uterine bleeding and the possibility of endometrial biopsy
CONCLUSION: Short-term, unopposed estradiol therapy with gynecologic monitoring may be an option for the treatment of menopausal symptoms. Menopausal women choosing estradiol therapy, especially if obese, should anticipate uterine bleeding and the possibility of an endometrial biopsy. LEVEL OF EVIDENCE: I.
Steiner AZ et al Unopposed Estradiol Therapy in Postmenopausal Women: Results From Two Randomized Trials. Obstet Gynecol. 2007 Mar;109(3):581-587.
Nonhormonal therapies for menopausal hot flashes: systematic review and meta-analysis
CONCLUSION: The SSRIs or SNRIs, clonidine, and gabapentin trials provide evidence for efficacy; however, effects are less than for estrogen, few trials have been published and most have methodological deficiencies, generalizability is limited, and adverse effects and cost may restrict use for many women. These therapies may be most useful for highly symptomatic women who cannot take estrogen but are not optimal choices for most women.
Nelson HD et al Nonhormonal therapies for menopausal hot flashes: systematic review and meta-analysis. JAMA. 2006; 295(17):2057-71
Midwives Corner - Lisa Allee, CNM
Being Present
The spirituality of presence in midwifery care
Pembroke and Pembroke have written an article that is a must-read for all of us that attend women in pregnancy, labor and birth, and, actually, it is highly relevant in the provision of any kind of health care. It is essential reading for the student who needs to learn the art and not just the technical science of what we do and it will remind experienced providers of the human contact we must strive to achieve even on the busiest day. I highly recommend that you read the entire article (if you can not get the full text through PubMed please contact me and I will email it to you) but here are a few of the juiciest morsels.
“Presence involves an offering of self (Scoppo, 2003). In being present to the other, one generously makes available one’s personal resources. To be present as a midwife is to be open, available and receptive to the needs and preferences of the woman (Berg et al., 1996; Lundberg, 2004).”
“A caring presence involves creating an environment of trust and security.”
The authors present a discussion of spirituality, which is a clear reminder that our work is not about us and our egos—it is about being with the other.
“The spiritual person identifies making meaning out of one’s existence on earth as a central human task. The journey into meaning usually involves self-transcendence. To be spiritual is to break through the confining and limiting grip of egoism. Egotistic persons are locked up inside themselves; they have little or no capacity to reach out to others and to the world around them. Overcoming selfish tendencies in order to help others is central in an authentic spirituality.”
Next they present two concepts that make presence possible—responsibility and availability. The discussion of responsibility is based on Buber’s work: “He is talking about ‘responsiveness’, about the ability to respond to the other person and her needs and aspirations. For Buber responsibility is a deep capacity to respond to the claims others make on us. It requires an acute awareness of the other through which she becomes present in her wholeness and uniqueness.”
“In order to be genuinely responsive to a woman, it is necessary to include oneself in her inner world. That is, one must discover precisely what it is that she needs and values. Women ask to be sensitively listened to. Further they ask that the midwife approach them with a respect for their uniqueness.”
The authors discuss availability in terms of receptivity and being open and “porous” or permeable to the communication from others. They also discuss hospitality as pivotal and present a fascinating picture of midwife as host: “Hospitality plays a vitally important role in engaging on a personal, friendly level with women. We need to ask, however, whether or not it is appropriate to refer to a midwife as a host. Many would rather have it that the midwife is the invited guest (Leap, 2000; Kenedy, 2003). The primary actor in the birthing experience is the woman. She invites others to be with her as she gives birth. There is still a place, we contend, for the appellation ‘host’ in relation to the midwife’s role. It is clearly wrong to refer to him or her as host of the birthing process. To speak of him or her as host in the context of the relationship he or she shares with the woman is, however, not only appropriate but also illuminating. It is illuminating because it reminds us that the midwife is called upon to mentally establish an open space that will be filled by the woman’s needs and preferences. To be available to the woman involves listening to her and following her lead through the process of childbirth (Lundgren, 2004). Midwives need a certain ‘incohesion’ in order to be truly receptive. If they fill their internal spaces with their own commitments and preferences, there is no place for the woman to make contact.”
Read this article. It’s important.
The spirituality of presence in midwifery care. Pembroke, NF, Pembroke, JJ
Midwifery 2007 Feb 1 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd
=Retrieve&dopt=AbstractPlus&list_uids=17275972
Other
History and Evidence Base for Normal Birth
The Winter 2007 supplement to the Journal of Perinatal Education describes the history of the Coalition for Improving Maternity Services as part of a global effort to promote "normal birth" (as established by universal guidelines for the routine care of women during uncomplicated labor and childbirth). The supplement presents the principles underlying the Mother-Friendly Childbirth Initiative (MFCI), the first consensus declaration in the history of North America in which a multidisciplinary body of professional organizations and individuals address the issues of labor and birth. The supplement also identifies the Ten Steps of Mother-Friendly Care that lay out the practical application of the philosophy and principles of the MFCI and introduce the evidence base for the Ten Steps. Discussion and commentary are provided. The supplement is intended for use by health professionals, families, and others in supporting normal birth and breastfeeding as the standard of care for all women. The supplement is available to journal subscribers at http://www.ingentaconnect.com/content/lamaze/jpe
Navajo Corner, Jean Howe, Chinle
New ACOG recommendations challenging for rural IHS sites—a plea for sharing strategies to meet national standards in the face of limited resources…
One new challenge facing Navajo Area prenatal providers, and probably many others providing care to pregnant women at rural sites throughout IHS, is what to do about all the new options for prenatal genetic screening. ACOG recently issued a Practice Bulletin, Screening for Fetal Chromosomal Abnormalities, which reviews the tests currently available and acknowledges how confusing this area has become. You know you’re in a difficult situation when ACOG includes a section entitled, “With so many Down syndrome screening tests available, how do I decide which tests to offer?”
Before one wades through the array of available tests, it seems important to acknowledge a couple of new guiding principles that we are being asked to incorporate into our practice:
- It’s not just about age any more. Although the risk of Down syndrome and other chromosome abnormalities increase with age for individual women, most Down syndrome babies are born to young women. It has become the standard of care to offer prenatal screening for chromosome abnormalities to all women as part of routine prenatal care.
- It’s not just about second trimester screening anymore. There are now well-established methods of first trimester screening. We need to figure out how to make these testing options available to our patients.
Other principles haven’t changed at all. Our job as providers is to share information about screening options and offer non-directive counseling. It is still the woman’s choice to decide what (if any) tests she would like to have done and her right to decline testing altogether. Some women seek information to consider termination of pregnancy, others to make special preparations before the birth of a baby with additional needs. Also, because of the distance to tertiary care facilities, some infants may benefit from prenatal diagnosis that allows planned deliveries in urban centers with additional resources.
There are several markers that can be used to calculate a risk for Down syndrome. One relatively new test is the nuchal translucency measurement (NT), a measure of the thickness of the fluid collection at the back of the fetal neck in the first trimester. To be used for calculating Down syndrome risk, NT measurements must be performed by certified sonographers with special training and ongoing monitoring. Optimal NT measurements are obtained at 12-13 weeks although the test may be performed from 10 4/7 to 13 6/7 weeks. Not all patients sent for NT testing will be able to have images successfully obtained. Serum first trimester measurements include PAPP-A (pregnancy-associated plasma protein A) and total or free β hCG. Second trimester serum markers include MSAFP (maternal serum alpha-fetoprotein), hCG, and unconjugated estriol which are used in calculation of a “triple screen”; with the addition of inhibin A this becomes a “quad screen”. The main focus of this testing has become the identification of Down syndrome although some of these markers are also used in the identification of other conditions, including trisomy 18 and open neural tube defects.
The ACOG Practice Bulletin provides much detail about the different screening tests, their detection rates, and their false positive rates. One relevant comparison for any facility still doing second trimester triple screen testing is the improved detection of Down syndrome with the change to Quad screening (from <70% to over 80%). ACOG answers the question about how to choose with several considerations, including the following:
“...If nuchal translucency measurement is not available or cannot be obtained in an individual patient, a reasonable approach is to offer serum integrated screening [with a detection rate of 85-88%] to patients who present early and second-trimester screening to those who present later.”
This still leaves a great deal of work to be done. A review of the tests available through our contracted laboratory provider fails to identify any test options that combine first and second trimester serum testing but do not also rely on NT measurements. And as NT measurements are only available at tertiary care facilities several hours away, this just isn’t a realistic option for wholesale screening for our rural facility, especially given the narrow window of dates when testing can be done. So, for our site, and some other sites in Navajo, we’ve transitioned to Quad screening but haven’t resolved the first trimester dilemma. If you work at a rural site and have successfully addressed this problem, we’d like to hear from you. Also, if anyone has found or created a culturally sensitive patient education brochure about prenatal genetic screening, please share!
OB/GYN CCC Editorial comment:
Let’s begin a dialogue
I want to thank Jean Howe for bringing up this issue, as it is a major concern nationwide. Various suggestions have included that we adapt a serum screening strategy whereby we only refer the women who have abnormal results. Each Area would need to negotiate with their lab, or find a new lab, e. g., is the lab able to integrate the NTD results? The PAPP-A and free bHCG can be done at 10-13 wks if the patient comes early enough. If so, then perform the quad screen at 15-20 and integrate the results, or refer if there is an abnormal 1st trimester result. Patients who come later can get a quad screen, and refer those with abnormal results if they so wish.
Let us know how your Area has solved this emerging problem. nmurphy@scf.cc
Reference:
Screening for fetal chromosomal abnormalities. ACOG Practice Bulletin No. 77. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;109:217–27 .
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17197615
Nurses Corner - Sandra Haldane, HQE
Assessment of Adverse Drug Events Among Patients in a Tertiary Care Medical Center
CONCLUSION: Certain age groups, diagnoses, admission sources, types of insurance, and the use of specific medications or medication classes were associated with increased AE rates at a tertiary care medical center.
Johnston PE, et al Assessment of adverse drug events among patients in a tertiary care medical center. Am J Health Syst Pharm. 2006 Nov 15;63(22):2218-27
Family Support in Patient-Centered Care: New Guidelines Issued
CONCLUSIONS: More than 300 related studies were reviewed. However, the level of evidence in most cases is at Cochrane level 4 or 5, indicating the need for further research. Forty-three recommendations are presented that include, but are not limited to, endorsement of a shared decision-making model, early and repeated care conferencing to reduce family stress and improve consistency in communication, honoring culturally appropriate requests for truth-telling and informed refusal, spiritual support, staff education and debriefing to minimize the impact of family interactions on staff health, family presence at both rounds and resuscitation, open flexible visitation, way-finding and family-friendly signage, and family support before, during, and after a death. Davidson JE, et al Clinical practice guidelines for support of the family in the patient-centered intensive care unit: American College of Critical Care Medicine Task Force 2004-2005. Crit Care Med. 2007 Feb;35(2):605-22
A Call to Action for Caregivers and Patients: Imaging X-rays Cause Cancer
http://www.medscape.com/viewprogram/5063?src=mp
Role of Exercise in Treating Postpartum Depression: A Review of the Literature
Limited evidence supports a relationship between participation in exercise and reduction in postpartum depression. Given the reluctance by some women to use antidepressant medication postpartum and the limited availability of psychological therapies, exercise as a therapeutic possibility deserves further exploration. Further research using well-designed randomised controlled trial methodologies are warranted.
Daley AJ, et al The role of exercise in treating postpartum depression: a review of the literature. J Midwifery Womens Health. 2007 Jan-Feb;52(1):56-62
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17207752
Office of Women's Health, CDC
QuickStats: Birth Rates* Among Females Aged 15--19 Years, by State
* Per 1,000 females in age group.
Age of mother is a predictor of maternal and infant health risk. Pregnant teens aged 15--19 years are less likely to receive timely prenatal care and gain appropriate weight and more likely to smoke during pregnancy than pregnant women aged >20 years. These factors are associated with poor birth outcomes. For example, infants born to mothers who smoke during pregnancy are 65% more likely to have low birthweight and 70% more likely to die in infancy than infants born to nonsmokers. In 2004, the overall U.S. birth rate for mothers aged 15--19 years was 41.1 births per 1,000 females in that age group. Among states, rates ranged from 62.6 ( Texas) to 18.2 ( New Hampshire).
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5551a6.htm?s_cid=mm5551a6_e
Fetal and Perinatal Mortality, United States , 2003
This report presents 2003 fetal and perinatal mortality data by a variety of characteristics, including maternal age, marital status, race, Hispanic origin, and state of residence; and by infant birthweight, gestational age, plurality, and sex. Trends in fetal and perinatal mortality are also examined. The rate of fetal deaths occurring at 20 weeks of gestation or more (also known as stillbirths) declined substantially between 1990 and 2003. Although fetal mortality rates declined among all racial and ethnic groups from 1990-2003, the rate for non-Hispanic black women was more than double that of non-Hispanic white women (11.56 per 1,000 vs. 4.94 per 1,000).
http://www.cdc.gov/nchs/pressroom/07newsreleases/stillbirths.htm
Oklahoma Perspective Greggory Woitte – Hastings Indian Medical Center
Cesarean Delivery on Maternal Request
It was in June of last year when I last wrote about the NIH Consensus conference on Cesarean Delivery on Maternal Request (CDMR). Over the past year there has been several articles written on the subject. The most recent of which is published in the New England Journal of Medicine by Ecker and Frigoletto (excerpted below).
Here at Hasting’s Indian Medical Center, we are beginning to explore this issue through journal clubs and dialogue. We have had more patients recently requesting Cesarean Delivery over the past year. A review of the NIH Consensus conference points out that most of the evidence is weak or non-existent to support planned vaginal or cesarean delivery. Moderate quality evidence is available for only three outcome variables (postpartum hemorrhage, maternal length of stay, and neonatal respiratory morbidity). .
ACOG sent out a news release on May 9, 2006 after the NIH consensus conference. In it they point out that more research is needed and that CDMR is not recommended for women planning on having several children due to the risks of placenta previa and placenta accreta increasing with each cesarean delivery. In addition, Dr. Zinberg, Deputy Executive Vice President of ACOG states “ACOG continues to review all of the issues surrounding maternal-request cesarean, but at this time our position is that cesareans should be performed for medical reasons.”
A number of the articles written have pointed out ACOG’s position that a cesarean delivery on maternal request can be ethically justified at times. In ACOG’s “Surgery and Patient Choice: The Ethics of Decision Making,” ACOG states that “In the absence of significant data on the risks and benefits of cesarean delivery, the burden of proof should fall on those who are advocates for a change in policy in support of elective cesarean delivery (ie, the replacement of a natural process with a major surgical procedure.”
As many of the articles and editorials written over the past year have pointed out, caution should be used when a patient requests a cesarean delivery. Moving slowly in the absence of good evidence is a prudent option. While support for a women’s choice is without question of paramount importance, performing cesarean deliveries on maternal request may ultimately lead to a violation of the Hippocratic Oath to do no harm.
OB/GYN CCC Editorial comment:
Looking for sanity in the ever increasing cesarean delivery rate
Ecker and Frigoletto state the key question centers on both the number needed to treat to avoid one adverse neonatal outcome and the level of risk that is currently considered acceptable. As practicing obstetricians, we find that the risk that women are now willing to assume in exchange for a measure of potential benefit, especially for the neonate, has changed: for many, the level of risk of an adverse outcome that was tolerated in the past to avoid cesarean delivery is no longer acceptable, and the threshold number needed to treat has thus been reset.
In the face of the resulting continued increase in cesarean deliveries, our obligation as providers is to educate patients about the trade-offs entailed in choosing a particular course or intervention and to ensure that their choices are congruent with their own philosophy, plans, and tolerance of risk. In areas in which there is still uncertainty, we must organize clinical trials that will produce the data we require for counseling patients. For the moment, however, few of the relevant factors seem likely to change, and the cesarean rate can be predicted to continue its climb.
The March 2006 National Institutes of Health (NIH) State-of-the-Science Conference report concluded that there was a need for research that explicitly compared outcomes of planned cesarean delivery with outcomes of planned vaginal delivery. Declercq et al examines 6 years of data from a population-based linked data system to create a refined measure identifying women with planned cesareans and planned vaginal births and comparing maternal outcomes and costs associated with these two options.
1.) planned cesarean increases complications and re-hospitalizations and
2.) planned cesarean increases cost
Declercq et al document a small, but consistent growth in planned primary cesareans, but higher costs, longer hospital stays, and substantially greater risks of maternal re-hospitalization associated with these deliveries.
The authors found that
* The rate of re-admission to a hospital (per 1,000) within 1 month of delivery for planned vaginal births was significantly lower than that for planned primary cesarean births (7.5 vs. 19.2). Adjusting for age, race or ethnicity, and parity, a woman who had a planned primary cesarean birth was 2.3 times as likely as a woman who had a planned vaginal birth to be re-admitted in the first month after the birth.
* The leading reason for re-admission associated with planned primary cesarean births in the first 30 days after birth was surgical wound complications. Postpartum infections were a major cause of re-admission for both groups, with the rate of re-admission for infection after planned primary cesarean births almost twice as high as that of infection after planned vaginal births.
* The average initial maternal (excluding infant) hospital costs in 2003 dollars for a planned primary cesarean birth were 76% higher than the average initial costs for a planned vaginal birth ($4,372 vs. $2,487).
* Women who had a planned primary cesarean birth averaged 4.3 days in their initial stay and 4.4 days in cases of re-admission, compared with
2.4 and 3.9 days, respectively, for those with a planned vaginal birth.
* Costs associated with a planned primary cesarean birth, compared with costs associated with a planned vaginal birth, were higher for both delivery (65%) and postpartum re-admission (11%).
Kennare R, et al just reported that after the first cesarean, the risks increase in next pregnancy. Specifically, cesarean delivery is associated with increased risks for adverse obstetric and perinatal outcomes in the subsequent birth. However, some risks may be due to confounding factors related to the indication for the first cesarean.
Dr. Woitte reminds us to do no harm. Declercq et al and Kennare R, et al findings suggest that planned primary cesareans are not without immediate health consequences for mothers and financial implications for society. Clinicians should be aware of the increased risk for maternal re-hospitalization after cesarean deliveries to low-risk mothers when counseling women about their choices.
Reference:
Declercq E, Barger M, Cabral HJ, et al. 2007. Maternal outcomes associated with planned primary cesarean births compared with planned vaginal births. Obstetrics and Gynecology 109(3):669-677. http://www.greenjournal.org/cgi/content/abstract/109/3/669?etoc or
Ecker
JL, Frigoletto
FD Jr. Cesarean delivery and the risk-benefit calculus. N
Engl J Med. 2007 Mar 1;356(9):885-8. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd
=retrieve&db=pubmed&list_uids=17329693&dopt=Abstract
Or http://content.nejm.org/cgi/content/full/356/9/885
Kennare R, et al Risks of adverse outcomes in the next birth after a first cesarean delivery. Obstet Gynecol. 2007 Feb;109(2 Pt 1):270-6
NIH Consensus Conference Report
http://consensus.nih.gov/2006
/2006CesareanSOS027html.htm
Patient-Requested Cesarean Update, ACOG Press Release
http://www.acog.org/from_home/publications/press_releases/nr05-09-06-1.cfm
Surgery and Patient Choice: The Ethics of Decision Making
http://www.acog.org/from_home/publications/ethics/ethics021.pdf
Osteoporosis
Bisphosphonate Related Osteonecrosis of the Jaws (BRONJ)
Again with the Phossy Jaw?
M. Winkler DDS, MS and K. Martin DDS
In the mid 1800s, English matchstick factory workers started presenting with horrific jaw bone exposures and infections which led to disfigurements and sometimes death. This was before the advent of antibiotics and most of these patients received copper and surgery for their plight – with less than desirable results. Eventually, this disease process became linked to the white phosphorus used in the matchstick making industry.(Hellstein)
Currently, oral and maxillofacial surgeons and dentists are seeing a revival of this type of presentation from IV and oral bisphosphonate drugs. Our current pathogenesis has only been linked to drugs which contain nitrogen side chains: zolendronic acid, pamidronate, risedronate, ibandronate, and alendronate. Rates are now reported to be 6-7% with Zolendronic acid, 4+% with Pamidronate, and <1% with Alendronate. Early inconsistencies in terminology and diagnosis have probably led to a lower report of the actual incidence. Another compounding factor is current literature remains at level 3 studies only. We lack any randomized controlled trials/prospective studies. Consequently, our understanding of pathogenesis, progression, treatment, and identification of risk factors (steroid therapy, hormone replacement, age, clinical and radiographic presentation) is sorely lacking. Reports of this type of osteonecrosis are significantly increasing. The two major initial case reports on BRONJ in 2003 and 2004 have more than doubled their original number of patients.(Marx and Ruggiero)
Pathogenesis of this disease has not yet been identified, but the preponderance of evidence and response to treatments suggests a metabolic origin rather than vascular etiology. Especially considering hyperbaric oxygen treatments are not effective in treating this disease (unlike patients with osteoradionecrosis or osteomyelitis). These drugs are diffused through out the jaws and not just a focal area like osteomyelitis or a slightly larger area like osteoradionecrosis. There is NO such thing as debriding until we find healthy bone. This type of osteonecrosis (consider the bisphosphonate bone response like osteopetrosis) has only been shown in the jaws with one exception involving the auditory canal in a patient with maxillary BRONJ.(Polizzotto) It is believed this is due to the well vascularized jaw structures and significantly higher bone turnover of the jaws compared to the long bones, especially in areas of tooth extractions/implant. (Hughes et al., Rogers et al., Rodan et al., Stepan et al., Strewler) Couple this with the unique anatomy of the oral environment: significant bony prominences, exceptionally thin mucosa tissue covering (<1mm in some areas), and constant exposure to trauma (eating, habits, etc.) …And yes, a potato chip can do you in!
Please realize bisphosphonates are phenomenal drugs and have been and will continue to be a keystone treatment for osteoporosis and certain malignancies, but for people with bad habits, in particular bristle allergies, these drugs pose exponentially more
problems. This is where bad habits catch up to people. Studies have shown >80% of inciting events (induction of osteonecrosis) have been linked to previous dentoalveolar surgeries, e.g., extractions, etc.(Durie et al) SO, if you have patients in their 50s who still are not orally stable (poor-fair oral hygiene) and require treatments like extractions – this is exactly the type of patient whose bad habits will be a factor. There are spontaneous inductions noted in both IV and oral bisphosphonates, but the incidence is significantly higher in IV forms compared to orals. BRONJ appears to be potency related with zolendronic acid the highest in vitro potency and alendronate the lowest.(O’connell) Usually the incidence begins after 2-3 years of use with these drugs.(Durie et al.) Realize the risk of BRONJ increases with time. With the long half lives of these drugs (alendronate, the weakest drug, is greater than 10 years) the incidence of osteonecrosis is unlikely to decrease with time, even if the drug(s) have been discontinued. Bottomline for bisphosphonates: if you need it, YA NEED IT!
Some general treatment recommendations include:
PATIENT EDUCATION! Stress what to look for and regular dental care
Discussion with patients: risks, benefits, and options
Visual Inspection of oral cavity by ALL providers at each visit, note key areas
Routine dental exams – yes, I realize access to care is a problem
An ounce of prevention is truly worth more than a pound of jaw bone
Hopefully as more information is elucidated and patient education grows we will better tailor our bisphosphonate therapies (nitrogen vs. non-nitrogen side chain drugs, loading vs. maintenance dosing, drug holidays?) and prevent what can be an exceedingly frustrating and unrewarding disease to manage.
For more information/references use key words: bisphosphonates, osteonecrosis, jaws
Online Resources:
Postmenopausal Osteoporosis: Putting the Risk for Osteonecrosis of the Jaw Into Perspective, Medscape
http://www.medscape.com/viewprogram/6720?sssdmh=dm1.250302&src=nlcmealert
American Association of Oral & Maxillofacial Surgery Position Paper
aaoms.org
American Dental Association Position Paper
ada.org
Additional information can be found at:
Woo, S., et al. Systematic Review: Bisphosphonates and Osteonecrosis of the jaws. Ann Intern
Med. 2006;144:753-761 Review. Erratum in: Ann Intern Med. 2006 Aug 1;145(3):235. PMID:
16702591 [PubMed - indexed for MEDLINE] (good summary)
References:
- Hellstein, J.and Marek C., Bisphosphonate osteochemonecrosis (bis-phossy jaw): is this phossy jaw of the 21st century? J Oral Maxillofac Surg. 2005 May;63(5):682-9. Review. PMID: 15883944 [PubMed - indexed for MEDLINE]
- Marx, R., Pamidronate (Aredia) and zoledronate (Zometa) induced avascular necrosis of the jaws: a growing epidemic. J Oral Maxillofac Surg. 2003 Sep;61(9):1115-7. No abstract available. PMID: 12966493 [PubMed - indexed for MEDLINE]
- Ruggiero, S., et al., Osteonecrosis of the jaws associated with the use of bisphosphonates: a review of 63 cases. J Oral Maxillofac Surg. 2004 May;62(5):527-34. PMID: 15122554 [PubMed - indexed for MEDLINE]
- Polizzotto, M., et al., Bisphosphonate-associated osteonecrosis of the auditory canal. Br J Haematol. 2006 Jan; ;132(1):114. PMID: 16371027 [PubMed - indexed for MEDLINE]
- Hughes, D., Bisphosphonates promote apoptosis in murine osteoclasts in vitro and in vivo. J Bone Miner Res. 1995 10:1478-1487. Review PMID: 8686503 [PubMed - indexed for MEDLINE
- Rodan, G., et al., Bisphosphonate mechanism of action. Curr Mol Med. 2002 Sep;2(6):571-7. Review. PMID: 12243249 [PubMed - indexed for MEDLINE
- Rogers , M., From molds and macrophages to mevalonate: a decade of progress in understanding the molecular mode of action of bisphosphonates. Calcif Tissue Int. 2004 Dec;75(6):451-61. Epub 2004 Aug 31. Review. PMID: 15332174 [PubMed - indexed for MEDLINE]
- Stepan, J., Mechanisms of action of antiresorptive therapies of postmenopausal osteoporosis. Endocr Regul. 2003 Dec;37(4):225-38. Review. PMID: 15106819 [PubMed - indexed for MEDLINE
- Strewler, G. Decimal point--osteoporosis therapy at the 10-year mark. N Engl J Med. 2004 Mar 18;350(12):1172-4. PMID: 15028820 [PubMed - indexed for MEDLINE]
- Durie, B., et al. Osteonecrosis of the jaw and bisphosphonates [Letter]. N Engl J Med. 2005;353:99-102 PMID: 16000365 [PubMed - indexed for MEDLINE]
- O’Connell, M., et al. Osteoporosis and osteomalacia. In: T. Dipiro, Editor, Pharmacotherapy A Pathophysiologic Approach (5thed), Mcgraw-Hill, New York, NY. 2002 p.1690.
- Lin, J., et al., Pharmacokinetics of alendronate: an overview. Int J Clin Pract Suppl. 1999 Apr;101:18-26. PMID: 12669737 [PubMed - indexed for MEDLINE]
Patient Information
Anemia: When Low Iron Is the Cause
http://familydoctor.org/009.xml
Iron Deficiency Anemia in Infants and Children: How to Prevent It
http://familydoctor.org/751.xml
Does Diabetes Run in Your Family?
This is a new brochure on diabetes and family history.
http://www.cdc.gov/genomics/public/file/print/2007-02_Diabetes_Broch.pdf
Canker Sores: What Are They and What Can You Do About Them?
http://familydoctor.org/613.xml
The Common Cold: What You Should Know
http://www.aafp.org/afp/20070215/522ph.html
Atopic Dermatitis: What You Should Know
http://www.aafp.org/afp/20070215/530ph.html
Perinatology Picks - George Gilson, Maternal Fetal Medicine, ANMC
What is the best management plan for the woman with suspected preterm labor?
As is well known, the incidence of preterm birth (PTB) is increasing in the United States, and is currently approaching 13% of all births. Of importance to us, the incidence of PTB in Native American women is actually slightly higher than that of the general population. So, when one of our clients comes in with preterm contractions, and may be in true preterm labor, what is the best management plan for her?
First, I’d like to review a few salient points about deciding if this is the real thing. Is she really in true preterm labor and at risk of an imminent preterm birth? It’s often not that easy to decide. The fetal fibronectin test (fFN), while not the greatest test in our armamentarium, may be quite helpful as a triage tool. If your patient must be transferred a long distance for tertiary care, the fFN is quite cost-effective, and will pay for itself many times over compared to a costly transport and hospitalization. The negative predictive value of the fFN approaches 98%. If the test is negative, it is very unlikely that this woman with preterm contractions is actually going to deliver in the next 7-14 days. The positive predictive value of the test is not so great, only 12-15%, but it does “up the ante”, and make you more likely to consider transport.
The fFN only requires a 15 second sample taken from the posterior fornix, and the currently available rapid test will provide an answer in less than 2 hours. Remember, blood, amniotic fluid, semen, and lubricant gel, will all make the test positive, so it will not be helpful to you in those situations. Remember to collect the fFN before you do your digital exam! If you find that there is advanced cervical dilation, you can toss the sample. However, if, as is common, there are contractions, but minimal cervical change, the test can be quite helpful in your decision-making and management.
Another helpful maneuver to decide if the woman who has preterm contractions, but an unimpressive cervical exam, is actually in true preterm labor, is to do “one-shot terbutaline triage”. While beta agonists like terbutaline are not currently thought to have a satisfactory risk-benefit profile to qualify them as primary agents for tocolysis, they may be helpful to sort out the clinical picture just described. A single subcutaneous injection of terbutaline 0.25 mg will usually ameliorate preterm contractions in women not destined to actually deliver early. Contrary to widespread opinion, intravenous fluid boluses are NOT effective at stopping preterm contractions, and may be dangerous if given too energetically.
So, let’s say that despite the single shot terbutaline, your client has persistent contractions, and her cervix has gone from fingertip to 1-2 cm over 2 hours of observation. Her fFN returns positive. You decide this is the real thing, and make plans for hospitalization or transport. What tocolytic agent is best for her? Actually, none of the currently available tocolytics are ideal. Likewise, none of the available tocolytic agents are FDA approved for this indication, they are currently all “off-label” use. Their main purpose at this time is to try to buy 48 hours for the administration of corticosteroids for fetal lung maturation. So, if you think this is real preterm labor and that this fetus is at considerable risk of PTB, your first maneuver should be to start steroids. Betamethasone 12 mg intramuscularly for 2 doses at 24 hour intervals (over 48 hours) is probably the best choice. If not available, dexamethasone 6mg intramuscularly every 12 hours x4 doses (over 48 hours) is also fine. Steroids are probably the most important, and most evidence-based, intervention at this time as regards improving ultimate perinatal outcome.
Is antibiotic therapy appropriate for this patient? There is no evidence that antibiotics are of any benefit for idiopathic preterm labor (i.e., no evidence of overt chorioamnionitis or urinary tract infection). In the situation of preterm premature rupture of membranes without labor however, antibiotics are appropriate, but I won´t discuss that situation here. However, antibiotics are indicated in idiopathic preterm labor as prophylaxis for group B streptococcus (GBS) carriage. When you collect your fFN, you should also take a rectovaginal culture for GBS and begin empiric treatment with penicillin or ampicillin (or cefazolin or clindamycin if there is a history of penicillin allergy). This should be continued for 48 hours until the culture is back. Antibiotics may be stopped if the culture is negative or if labor has stopped.
In order to allow time for steroids, which tocolytic is best? As noted above, beta agonists, such as terbutaline and ritodrine (the latter no longer manufactured), when used at the doses needed to stop contractions, have prominent cardiovascular side effects. They carry a significant risk of pulmonary edema, especially combined with over vigorous intravenous hydration. Beta agonists can no longer be recommended as first line tocolytic agents.
Likewise, despite overwhelming evidence of its lack of efficacy, magnesium sulfate (MgSO4) tocolysis remains a North American anomaly. Cochrane reviews have found it to be an ineffective tocolytic (no significant benefit in preventing preterm birth compared to placebo). Moreover, the risk of total pediatric mortality was significantly higher for infants exposed to MgSO4 (RR = 2.8, CI 1.2-6.6). It also has quite unpleasant maternal side effects and requires an intravenous drip that is cumbersome during transport. MgSO4 should no longer be used as a tocolytic.
How about another calcium channel blocker such as nifedipine, the popular anti-hypertensive? Several meta-analyses have found them to be superior to beta agonists, and considerably safer. Unfortunately, none of the individual randomized are sufficiently powered (the largest had only 95 patients enrolled), and none of them compared nifedipine to placebo or no treatment.
Calcium channel blockers achieve tocolysis by blocking myometrial L-type voltage dependent calcium channels. They also block them in vascular smooth muscle and myocardium. They have been associated with headache, flushing, hypotension, secondary fetal distress, pulmonary edema (especially in combination with beta agonists), and myocardial infarction These adverse effects were most prominent in women with multiple gestation, preterm labor associated with infection, and women with underlying cardiovascular disease.
Dosage regimens have not been standardized, and are based on regimens designed to treat hypertension. A reasonable protocol would be to give 20 mg orally initially, and repeat in 30 minutes if no effect. Thereafter, 20 mg orally every 6 hours for 48 hours (maximum dose 160 mg) may be given. Maintenance tocolysis with the extended release forms of the drug have been shown to neither decrease the recurrence of preterm labor, nor improve perinatal outcomes. I would consider nifedipine to be a second line tocolytic agent.
The next agents available are the non-steroidal anti-inflammatory agents, of which indomethacin is the best studied. These agents are cyclo-oxygenase inhibitors and block prostaglandin synthesis in the myometrium. The randomized controlled trials also lack power, but those available demonstrate efficacy compared to placebo. Indomethacin is essentially free of maternal side effects. Several retrospective reports from the early 1990’s called attention to an increased incidence of necrotizing enterocolitis, intraventricular hemorrhage, constriction of the ductus arteriosus, and oligohydramnios in infants treated in utero with this agent. These adverse effects became non-significant however when multivariate analysis corrected for gestational age, and have not been found to be significant in the prospective studies. NSAIDs do constrict the ductus, especially in fetuses over 32 weeks, but this effect is reversed when the drug is stopped, and is uncommon when administration is limited to 48 hours. A cost-benefit analysis has clearly demonstrated an improvement in perinatal outcomes with use versus non-use of indomethacin. The regimen recommended is a loading dose of 100 mg orally, followed by 50 mg orally every 6 hours, not to exceed 400 mg in 48 hours. Based on the evidence for its safety and efficacy, I would consider indomethacin to be the best first line tocolytic agent.
Another drug in this class is ketorolac, which we have found to be very effective in our population. We use an initial dose of 30 mg intravenously or intramuscularly, and then give 30 mg IV every 6 hours over 48 hours, not to exceed 240 mg. Because it is given parenterally, its effect is usually immediate, probably contributing to our seeing a high success rate with its use. We have seen one case of significant oligohydramnios, and one case of maternal oliguria (in a woman with chronic hypertension and mildly increased creatinine), both of which resolved without sequelae after stopping therapy. There is only one published study of this agent that I was able to find; it involved 88 women and compared ketorolac to MgSO4 (where it was superior). At this time its use cannot be considered an evidence-based recommendation.
In conclusion, as long as the etiology of “idiopathic” preterm remains cryptic, we are reduced to using interventions that are suboptimal. Nevertheless, attempts at an accurate diagnosis, use of steroids when indicated, and use of indomethacin or nifedipine as our “best bet” tocolytics, will hopefully be the most efficacious way to help us reduce the incidence of preterm birth and poor perinatal outcomes in our population.
Online Resource:
REFERENCES
- Goldenberg RL. The management of preterm labor. Obstet Gynecol 2002; 100:1020-37.
- King JF, et al. Beta-mimetics in preterm labor: an overview of the randomized controlled trials. Br J Obstet Gynaecol 1988; 95:211-22.
- Benedetti TJ. Maternal complications of parenteral beta-sympathomimetic therapy for preterm labor. Am J Obstet Gynecol 1983; 145:1-6.
- Grimes DA, et al. Magnesium sulfate tocolysis: time to quit. Obstet Gynecol 2006; 108:986-9.
- King JT, et al. Calcium channel blockers for inhibiting preterm labour: a systematic review of the evidence and a protocol for administration of nifedipine. Aust NZ J Obstet Gynaecol 2003; 43:192-8.
- van Geijn HP, et al. Nifedipine trials: efficacy and safety aspects. BJOG 2005; 112:79-83.
- Macones GA, et al. Is there a justification for use of indomethacin in preterm labor? Am J Obstet Gynecol 1997; 177:819-24.
Other
Short Interval Between Pregnancy and Cervical Conization May Raise Preterm Birth Risk
CONCLUSION: Women with a short conization-to-pregnancy interval are at increased risk for preterm birth. Women of reproductive age who must have a conization procedure can be counseled that conceiving within 2 to 3 months of the procedure may be associated with an increased risk of preterm birth. LEVEL OF EVIDENCE: II.
Himes KP, Simhan HN. Time from cervical conization to pregnancy and preterm birth. Obstet Gynecol. 2007 Feb;109(2 Pt 1):314-9.
Concern about women taking bromocriptine long term for hyperprolactinemia?
CONCLUSIONS: The frequency of clinically important valve regurgitation was significantly increased in patients taking pergolide or cabergoline, but not in patients taking non-ergot-derived dopamine agonists, as compared with control subjects. These findings should be considered in evaluating the risk-benefit ratio of treatment with ergot derivatives
Zanettini R et al Valvular heart disease and the use of dopamine agonists for Parkinson's disease. N Engl J Med. 2007 Jan 4;356(1):39-46
OB/GYN CCC Editorial comment:
Keep this one in the back of your mind
The valvular heart disease and pulmonary and retroperitoneal fibrosis seem to be a class effect of the ergot-derived dopamine agonists (these are bromocriptine, cabergoline, and pergolide but not pramipexole or ropinirole which are not ergot-derived.) In reality, this seems to occur with higher doses of cabergoline, but is sometimes used for prolactinomas, especially in lower doses. These issues have not yet been seen with the doses of bromocriptine that we generally use for prolactinoma, however, we should stay tuned about this.
Results caution against a repeat dose of glucocorticoid in high-risk pregnancies
RESULTS: A total of 249 mothers had been enrolled by the time the study was discontinued. All of the 159 infants in the betamethasone group and 167 in the placebo group were born before 36 weeks of gestation. The intact survival rate was unaffected and was lower than anticipated, because the gestational age-adjusted incidence of respiratory distress syndrome was higher than the population incidence. The requirement for surfactant therapy in respiratory distress syndrome was increased in the betamethasone group. According to posthoc analysis of the data for 206 infants who were delivered within 1 to 24 hours, the betamethasone booster tended to increase the risk of respiratory distress syndrome and to decrease intact survival rates
CONCLUSIONS: According to this study, a single booster dose of betamethasone just before preterm birth may perturb respiratory adaptation. These results caution against uncontrolled use of a repeat dose of glucocorticoid in high-risk pregnancies
Peltoniemi OM et al Randomized trial of a single repeat dose of prenatal betamethasone treatment in imminent preterm birth. Pediatrics. 2007; 119(2):290-8
If normal ultrasound at 22-24 weeks the risk of developmental delay is not increased
CONCLUSION: Parents should be informed that when the fetus is shown to be normal by ultrasound at 22-24 weeks of gestation the risk of adverse neonatal outcome or developmental delay in early childhood is not increased.
Senat MV et al Long-term outcome of children born after a first-trimester measurement of nuchal translucency at the 99th percentile or greater with normal karyotype: a prospective study. Am J Obstet Gynecol. 2007; 196(1):53.e1-6
Local anesthesia before amniocentesis does not decrease maternal pain perception
RESULTS: Two hundred four women were enrolled; 101 women received local, 102 women received no local, and 1 woman declined the amniocentesis after randomization. There was no difference in pain perception between the 2 groups as measured by either the visual analogue scale or the numeric rating scale (P = .28 and .18 respectively). The correlation coefficient between the 2 pain scales was strong with 0.86 for the local group and 0.92 for the no local group, (P < .001).
CONCLUSION: Administration of local anesthesia before amniocentesis does not decrease maternal pain perception.
Gordon MC et al. Does local anesthesia decrease pain perception in women undergoing amniocentesis? Am J Obstet Gynecol. 2007; 196(1):55.e1-4
No benefits have been found from the use of diuretics to prevent pre-eclampsia
AUTHORS' CONCLUSIONS: There is insufficient evidence to draw reliable conclusions about the effects of diuretics on prevention of pre-eclampsia and its complications. However, from this review, no clear benefits have been found from the use of diuretics to prevent pre-eclampsia. Taken together with the level of adverse effects found, the use of diuretics for the prevention of pre-eclampsia and its complications cannot be recommended.
Churchill D et al Diuretics for preventing pre-eclampsia. Cochrane Database Syst Rev. 2007; (1):CD004451
Primary Care Discussion Forum
Electronic Health Record (EHR) Implementation: Worth the effort?
May 1, 2007
Moderator: David Johnson, MD
-Anticipated benefits of an EHR: Demonstrated through experience?
-What are the real costs: Decreased efficiency, IT support requirements, etc…
-Effect on the provider – patient relationship
How to subscribe / unsubscribe to the Primary Care Discussion Forum?
Subscribe to the Primary Care listserv
http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=26
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STD Corner - Lori de Ravello, National IHS STD Program
HPV Vaccine FAQs
Q. Some providers at our facility will not start the HPV vaccine series on a young woman if she will turn 18 before the series can be completed. Is this a common approach?
A. No, this doesn’t make sense from a biologic, or fiscal sense. The Vaccines for Children program covers up to age 19 (that is THROUGH age 18 years and 364 days). (See link to the Vaccines for Children program, below). Biologically, one or two doses are better than none. (See next question.)
After the patient loses her VFC eligibility, the vaccine is covered by Medicaid up to 20-21 years old in most states. In addition, Merck has a Patient Assistance Program (PAP) to provide vaccine to low income women. (More on PAP below.) PAP covers vaccine for women 19-26 years old who are less than ~200% of poverty. None of our patients have been denied so far and it usually takes less than one hour to hear back from Merck to get their approval.
Q. Is there a certain amount of immunity a woman will get from even one dose (like the hepatitis B vaccine)?
A. In general, it is not yet known how much protection girls/women would get from receiving only one or two doses of the vaccine. For this reason, it is very important that girls/women get all three doses of the vaccine if possible.
We have no information on the efficacy of a partial series. But as noted above it is reasonable to assume that one or two doses will provide some protection, although it may not be the same as with a complete 3-dose series.
Q. Does the HPV vaccine need to be given on an exact schedule? If this schedule is not followed, does the series have to be started over again? What is the "grace period" the doses can be given in and still be effective?
A. The series absolutely does NOT need to be given exactly on schedule. The second dose needs to follow the first by at least 4 weeks, and the third needs to follow the second by at least 12 weeks. Extended intervals do NOT require restarting the series. (See pp.14 from the Pink Book, below.)
Q. How does the Merck Vaccine Patient Assistance Program (PAP) work?
A. Briefly, the Merck PAP allows patients over age 19 years old to obtain Gardasil free, if they meet certain income and insurance coverage criteria. In general the income requirements are less than:
--$20,240 for individuals
--$27,380 for couples or
--$41,300 for a family of four
Different criteria exist for Alaska, Hawaii, Puerto Rico, U.S. Virgin Islands, and Guam. Merck recognizes that sometimes exceptions need to be made based on a patient's individual circumstances. Individuals who do not meet these criteria may still qualify for the vaccine program if the patient has special circumstances of financial and medical hardship.
The applicant must apply from a facility that is not ”wholly owned and operated by the government”. Hence, all tribal and urban facilities would qualify, plus those IHS facilities that receive additional funding other than federal funding (e. g., grants, contracts, private funding).
If you are in doubt whether your facility qualifies, contact (800) 293-3881 between 8:00 AM–8:00 PM EST Monday – Friday. If your facility does not qualify, the patient could apply from a different facility (e. g., private or semi-governmental clinic).
The application process is very straightforward. To-date none of our patients who have met the age criteria have been denied. We usually hear within the hour if the application is approved, though it can sometimes take up to 4 hours. Fax the completed application form* to (800) 528-2551
In general, the patient fills out the first page, the case manager fills out the back page, and the provider signs it. The vaccine is replaced by Merck to the dispensing pharmacy on a periodic basis (quarterly). The application process needs to be repeated for each dose.
* PAP Application Form
http://www.merck.com/merckhelps/vaccines/mvpap_app.pdf
Additional background on PAP
http://www.merck.com/merckhelps/vaccines/home.html
OB/GYN CCC Editorial comment:
Do you still have other HPV vaccine questions?
If one has HPV vaccine questions, first go to the CDC FAQ page
http://www.cdc.gov/nip/vaccine/hpv/hpv-faqs.htm#top
If your question is not covered there, then contact the National Immunization Program (NIP) Hotline. They will get back to you a timely manner. http://www.cdc.gov/nip/webutil/contact/other-contact.htm
You could also e-mail it to the NIP here nipinfo@cdc.gov
Resources:
Amy V. Groom, MPH
IHS Immunization Program Manager/CDC Field Assignee
IHS Division of Epidemiology
5300 Homestead RD., NE
Albuquerque , NM 87110
Phone: (505) 248 - 4374
Fax: (505) 248 - 4393
Email: Amy.Groom@ihs.gov
Vaccines for Children program
http://www.cdc.gov/nip/vfc/acip_resolutions/0606hpv.pdf
Pink Book, CDC, Feb 26, 2007
http://www.cdc.gov/nip/publications/pink/genrec.pdf
General Recommendations on Immunization: Recommendations of the Advisory Committee on Immunization Practices. MMWR December 2006 / Vol. 55 / No. RR—18http://www.cdc.gov/mmwr/indrr_2006.html
A Word document which describes the PAP in greater detail is available. Contact nmurphy@scf.cc
Other
Updated CDC Guidelines for the Treatment of STDs
The Centers for Disease Control and Prevention (CDC) updated its 2002 guidelines for the treatment of sexually transmitted diseases (STDs) after consultation with professionals and a systematic review of the evidence. The updated guidelines contain new approaches to patient-centered counseling, expanded discussions of prevention screening for human immunodeficiency virus (HIV) and other STDs, and several diagnosis and treatment updates, discussed below.
The new guidelines cite further data on the effectiveness of azithromycin for chlamydial infection during pregnancy, and azithromycin is the primary recommended regimen for this indication.
Morbidity and Mortality Weekly Report, August 4, 2006
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5511a1.htm
CDC Releases Data on HIV-Related Risk Behaviors in U.S. High School Students
U.S. high school students who use illicit injection drugs or have unprotected sexual intercourse are at higher risk of human immunodeficiency virus (HIV) infection. The Centers for Disease Control and Prevention (CDC) analyzed data from eight national surveys between 1991 and 2005 to determine if there was any change in the sexual behaviors of these students. A summary of those results was published in the August 11, 2006, issue of Morbidity and Mortality Weekly Report.http://www.aafp.org/afp/20070215/practice.html
Barbara Stillwater, Alaska State Diabetes Program
Northern Women at Most Risk: Vitamin D Deficiency Widespread During Pregnancy
These results suggest that black and white pregnant women and neonates residing in the northern US are at high risk of vitamin D insufficiency, even when mothers are compliant with prenatal vitamins. Higher-dose supplementation is needed to improve maternal and neonatal vitamin D status
Bodnar LM et al High prevalence of vitamin D insufficiency in black and white pregnant women residing in the northern United States and their neonates J Nutr. 2007 Feb;137(2):447-52
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17237325
Women's Health Headlines, Carolyn Aoyama, HQE
Can you dispense birth control agents to minors without parental consent?
If you work in South Dakota, we have clarification on IHS policy as it relates to State law in the prescription and dispensing of contraceptives and contraceptive devices to minors thanks to Mary Lynn Eaglestaff. For copies of the letter from the Chief Counsel in Region VIII, contact Carolyn.Aoyama@ihs.gov
OB/GYN CCC Editorial comment:
Encourage family communication first. IHS honors State laws and regulations
Here is a common question:
I am seeking input regarding I.H.S. policy for parental consent when providing pregnancy-related, STD, and family planning services to minors. I looked it up on the I.H.S. Manual which seems to imply that state and local regulations apply. As a federal facility, are we bound by applicable state law in these matters or does I.H.S. have a federal policy which supersedes state law?
The first answer is always to encourage complete communication within the family. In the meantime, yes, the IHS honors State laws and regulations, so we keep the links below on our Indian Health MCH website.*
The best resource to find out what your state allows / requires is here, State Policies in Brief http://www.guttmacher.org/sections/adolescents.php?pub=spib
Here is a link from the Alan Guttmacher Institute which updates the State by State information
http://www.guttmacher.org/index.html
*Here are 2 links to FAQs on the MCH page with more information
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/Minorconsent21907.doc
and
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/MinorsRepro4105.doc
Welcome to the Indian Health Service Methamphetamine Initiative Site
This is the online source for information about METH prevention activities across Indian Country and across the United States… in the next few months the site will be updated for better viewing and ease of navigation.
http://www.ihs.gov/MedicalPrograms/Behavioral/index.cfm?
module=BH&option=Meth
For access to an article on best practice strategies for dealing with Meth, developed out of Montana, please contact Carolyn.Aoyama@ihs.gov
What's new on the ITU MCH web pages?
Can one dispense birth control agents to minors without parental
consent?
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/Minorconsent21907.doc
Are birthing center regulations less restrictive than hospitals?
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/RegionCare21907b.doc
How many rubella vaccines does a mother really need to get?
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/Rubella21107.doc
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
Advances in Indian Health
- May 1-4, 2007
- Albuquerque , NM
- 26 credits
2007 IHS APN/PA Meeting
- May 21-25, 2007
- Scottsdale , AZ
- Nearly 20 hours of credit
Training Course in MCH Epidemiology
- Albuquerque , New Mexico
- June 10 - 15, 2007
- Sponsored by HRSA / MCHB and CDC
Native Women’s Health and MCH Conference
- August 15 -17, 2007
- Albuquerque , NM
- Questions? Contact nmurphy@scf.cc
http://www.ihs.gov/MedicalPrograms/MCH/F/CN01.cfm#Aug07
3rd Annual American Indian and Alaska Native Long Term Care Conference
- September 5-6, 2007
- Albuquerque , New Mexico
- Visit http://www.aianlongtermcare.org
- Contact Bruce.Finke@ihs.gov
Did you miss something in the last OB/GYN Chief Clinical Consultant Corner?
The March 2007 OB/GYN CCC Corner is available.
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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.
