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Volume 5, No. 7, August 2007
Features
American College of Obstetricians and Gynecologists
Management of Herpes in Pregnancy: Practice Bulletin
Summary of Recommendations and Conclusions
The following recommendations and conclusions are based on limited or inconsistent scientific evidence (Level B):
- Women with active recurrent genital herpes should be offered suppressive viral therapy at or beyond 36 weeks of gestation.
- Cesarean delivery is indicated in women with active genital lesions or prodromal symptoms, such as vulvar pain or burning at delivery, because these symptoms may indicate an impending outbreak.
The following recommendations and conclusions are based primarily on consensus and expert opinion (Level C):
- In women with premature rupture of membranes, there is no consensus on the gestational age at which the risks of prematurity outweigh the risks of HSV.
- Cesarean delivery is not recommended for women with a history of HSV infection but no active genital disease during labor.
- Routine antepartum genital HSV cultures in asymptomatic patients with recurrent disease are not recommended.
- Routine HSV screening of pregnant women is not recommended
Management of Herpes in Pregnancy. ACOG Practice Bulletin No. 82. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007; 109:1233–48.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17569194
Management of Adnexal Masses: Practice Bulletin
Summary of Recommendations and Conclusions
The following recommendations and conclusions are based on limited or inconsistent scientific evidence (Level B):
- In asymptomatic women with pelvic masses, whether premenopausal or postmenopausal, transvaginal ultrasonography is the imaging modality of choice. No alternative imaging modality has demonstrated sufficient superiority to transvaginal ultrasonography to justify its routine use.
- Specificity and positive predictive value of CA 125 level measurements are consistently higher in postmenopausal women compared with premenopausal women. Any CA 125 elevation in a postmenopausal woman with a pelvic mass is highly suspicious for malignancy.
- Simple cysts up to 10 cm in diameter on ultrasound findings are almost universally benign and may safely be followed without intervention, even in postmenopausal patients.
- Unilateral salpingo-oophorectomy or ovarian cystectomy in patients with germ cell tumors, stage I stromal tumors, tumors of low malignant potential, and stage IA, grade 1–2 invasive cancer who undergo complete surgical staging and who wish to preserve fertility does not apper to be associated with compromised prognosis.
The following recommendations and conclusions are based primarily on consensus and expert opinion (Level C):
- Women with ovarian cancer whose care is managed by physicians who have advanced training and expertise in the treatment of women with ovarian cancer, such as gynecologic oncologists, have improved overall survival rates compared with those treated without such collaboration.
- Most masses in pregnancy appear to have a low risk for both malignancy and acute complications and, thus, may be considered for expectant management.
Management of Adnexal Masses ACOG Practice Bulletin No. 83. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007; 110:201–14.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17601923
Sterilization of Women, Including Those With Mental Disabilities
ABSTRACT: Sterilization, like any other surgical procedure, must be carried out under the general ethical principles of respect for autonomy, beneficence, and justice. Women requesting sterilization should be encouraged to discuss their decision and associated issues with their husbands or other appropriate intimate partners. The physician who objects to a patient’s request for sterilization solely as a matter of conscience has the obligation to inform the patient that sterilization services may be available elsewhere and should refer the patient to another caregiver. The presence of a mental disability does not, in itself, justify either sterilization or its denial. When a patient’s mental capacity is limited and sterilization is considered, the physician must consult with the patient’s family, agents, and other caregivers in an effort to adopt a plan that protects what the consulted group believes to be the patient’s best interests while, at the same time, preserving, to the maximum extent possible, the patient’s autonomy.
ACOG Committee Opinion No. 371: Sterilization of Women, Including Those With Mental Disabilities. Obstet Gynecol. 2007 Jul;110(1):217-20
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17601925
The Role of Cystourethroscopy in the Generalist Obstetrician Gynecologist Practice
ABSTRACT: Cystourethroscopy can be performed for diagnostic and a few operative indications by obstetrician–gynecologists to help improve patient care. Perhaps the most important indications for cystourethroscopy are to rule out cystotomy and intravesical or intraurethral suture or mesh placement and to verify bilateral ureteral patency during or after certain gynecologic surgical procedures. The granting of privileges for cystourethroscopy and other urogynecologic procedures should be based on training, experience, and demonstrated competence. Postgraduate education, including residency training programs in obstetrics and gynecology and continuing medical education, should include education in the instrumentation, technique, and evaluation of findings of cystourethroscopy, and in the pathophysiology of diseases of the lower urinary tract.
Although many of the pioneers of cystourethroscopy, most notably Howard Kelly, were gynecologists, for decades the procedure has been performed mainly by urologists. However, cystourethroscopy can be performed for diagnostic and a few operative indications by obstetrician–gynecologists to help improve patient care. This document reviews the definition and indications for cystourethroscopy and discusses the evidence and recommendations for its use in the generalist obstetrician–gynecologist practice. situations and be prepared to respond in a professional, ethical manner to patient requests for information and procedures.
ACOG Committee Opinion No. 372: The Role of Cystourethroscopy in the Generalist Obstetrician Gynecologist Practice. Obstet Gynecol. 2007 Jul;110(1):221
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17601926
Adoption
ABSTRACT: Obstetrician–gynecologists may find themselves at the center of adoption issues because of their expertise in the assessment and management of infertility, pregnancy, and childbirth. Physicians have a responsibility to provide information about adoption to all patients with unwanted pregnancies, to all patients with infertility concerns, and to same-sex partners seeking information on parenting. Unless physicians are truly expert in the field of adoption, they should guard against advocating for a particular action. Physicians should not serve as brokers in independent adoptions. When authorized by patients to fill out forms for adoption agencies, physicians should do so truthfully, with full disclosure to patients of what they intend to say.
Adoption. ACOG Committee Opinion No. 368. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007; 109:1507–10.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17569192
Communication Strategies for Patient Handoffs
ABSTRACT: Handoff communication, which includes up-to-date information regarding patient care, treatment and service, condition, and any recent or anticipated changes, should be interactive to allow for discussion between the giver and receiver of patient information. It requires a process for verification of the received information, including read-back or other methods as appropriate.
Communication Strategies for Patient Handoffs. ACOG Committee Opinion No. 367. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;109:1503–5.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17569191
Institutional Responsibility to Provide Legal Representation
ABSTRACT: Hospitals, academic institutions, professional corporations, and other health care organizations should have policies and procedures by which alleged violations of professional behavior can be reported and investigated. These institutions should adopt policies on legal representation and indemnification to protect those whose responsibilities in managing such investigations may expose them to potentially costly legal actions. The American College of Obstetricians and Gynecologists’ Committee on Ethics supports the position of the American Association of University Professors regarding institutional responsibility for legal demands on faculty.
ACOG Committee Opinion No. 370: Institutional Responsibility to Provide Legal Representation. Obstet Gynecol. 2007 Jul;110(1):215-6
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17601924
Multifetal Pregnancy Reduction
ABSTRACT: Counseling for treatment of infertility should include a discussion of the risks of multifetal pregnancy, and multifetal pregnancy reduction should be discussed with patients before the initiation of any treatment that could increase the risk of multifetal pregnancy. In almost all cases, it is preferable to terminate an ovulation induction cycle or limit the number of embryos to be transferred to prevent a situation in which fetal reduction will have to be considered. The best interests of the patient and the future child or children should be at the center of the risk–benefit equation. Although no physicians need to perform fetal reductions if they believe that such procedures are morally unacceptable, all obstetricians and gynecologists should be aware of the medical and ethical issues in these complex situations and be prepared to respond in a professional, ethical manner
Multifetal Pregnancy Reduction. ACOG Committee Opinion No. 369. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007; 109:1511–5.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17569193
American Family Physician**
Screening for Breast Cancer: Current Recommendations and Future Directions
Breast cancer is one of the most significant health concerns in the United States. Recent reviews have questioned the value of traditional breast cancer screening methods. Breast self-examination has been shown not to improve cancer-specific or all-cause mortality in large studies, but it is commonly advocated as a noninvasive screen. Patients who choose to perform self-examination should be trained in appropriate technique and follow-up. The contribution of the clinical breast examination to early detection is difficult to determine, but studies show that sensitivity is highly dependent on time taken to do the examination. Up to 10 percent of cancers are mammographically silent but evident on clinical breast examination. The U.S. Preventive Services Task Force recommends mammography for women older than 40 years who are in good health, but physicians should consider that sensitivity is lower for younger women. Digital mammography is somewhat more sensitive in younger women and women with dense breasts, but outcome studies are lacking. Although magnetic resonance imaging shows promise as a screening tool in some high-risk women, it is not currently recommended for general screening because of high false-positive rates and cost. The American Cancer Society recommends annual magnetic resonance imaging as an adjunct to screening mammography in high-risk women 30 years and older. Am Fam Physician 2007;5:1660-6
http://www.aafp.org/afp/20070601/1660.html
ACS Recommendations on MRI and Mammography for Breast Cancer Screening
Women at high risk of developing breast cancer should receive annual magnetic resonance imaging (MRI) as an adjunct to mammography, according to new guidelines from the American Cancer Society (ACS).
Groups for whom MRI screening is recommended include the following:
- Women with a BRCA mutation
- Women with a first-degree relative who has a BRCA mutation
- Women with a 20 to 25 percent or greater lifetime risk for breast cancer, based on BRCAPRO or other risk models that depend largely on family history
- Women exposed to chest radiation between the ages of 10 and 30 years
- Women with Li-Fraumeni syndrome, and first-degree relatives of women with this syndrome
- Women with Cowden and Bannayan-Riley-Ruvalcaba syndromes, and first-degree relatives of women with these syndromes
MRI screening has been proven to detect cancer with early-stage tumors, which are associated with better outcomes. Studies have found high sensitivity for MRI, ranging from 71 to 100 percent versus 16 to 40 percent for mammography alone in high-risk populations. MRI also finds smaller tumors compared with mammography, and the types of cancers found with MRI contribute to reduced mortality rates.
Three approaches are available for identifying women with a high risk for breast cancer: family history, genetic testing, and clinical history. Although many women have at least one relative with breast cancer, most of these women are not at increased risk. Only 1 to 2 percent of women have a family history suggestive of the inheritance of an autosomal-dominant, high-penetrance gene that confers up to an 80 percent lifetime risk of breast cancer. In some families, there is also a high risk of ovarian cancer. Family history findings that suggest the presence of such a high-penetrance gene include two or more close relatives (i.e., first- or second-degree) with breast or ovarian cancer; breast cancer occurring before 50 years of age in a close relative; a family history of breast and ovarian cancers; one or more relatives with two cancers (breast and ovarian cancers or two independent breast cancers); and male relatives with breast cancer.
Inherited mutations in the two breast and ovarian cancer susceptibility genes, BRCA1 and BRCA2, are present in approximately one half of families in which an inherited risk is strongly suspected. Several models can help physicians determine risk estimates: the Gail, Claus, and Tyrer-Cuzick models are based on family history, and BRCAPRO and the Breast and Ovarian Analysis of Disease Incidence and Carrier Estimation Algorithm (BOADICEA) estimate the likelihood of BRCA mutations.
Genetic testing for BRCA mutations usually is offered to adult members of families with a known mutation and to women with a 10 percent or greater likelihood of carrying such a mutation. If a woman from a family in which a BRCA mutation has been identified does not have that mutation, her breast cancer risk is no higher than it would have been if she did not have a family history of breast cancer. However, in women from high-risk families without a known mutation, failure to find a mutation does not reduce risk.
http://caonline.amcancersoc.org/cgi/content/full/57/2/75
Ginger: An Overview
Ginger (Zingiber officinale) is one of the more commonly used herbal supplements. Although often consumed for culinary purposes, it is taken by many patients to treat a variety of conditions. Ginger has been shown to be effective for pregnancy-induced and postoperative nausea and vomiting. There is less evidence to support its use for motion sickness or other types of nausea and vomiting. Mixed results have been found in limited studies of ginger for the treatment of arthritis symptoms. Am Fam Physician 2007;75:1689-91.
http://www.aafp.org/afp/20070601/1689.html
CDC Changes Treatment Guidelines for Gonorrhea
Fluoroquinolones (i.e., ciprofloxacin [Cipro], ofloxacin [Floxin], and levofloxacin [Levaquin]) have been used since 1993 for the treatment of gonorrhea because of their effectiveness, availability, and convenience as a single-dose oral therapy. However, the prevalence of fluoroquinolone resistance in Neisseria gonorrhoeae has been increasing in the United States, necessitating changes in treatment regimens. Since 1999, increasing resistance of N. gonorrhoeae to fluoroquinolones has been reported, first in Hawaii, then in California and other Western states, then among men who have sex with men, and now in other populations and regions. Data from 2005 and 2006 show that the prevalence of fluoroquinolone-resistant N. gonorrhoeae has continued to increase among heterosexual men and is present in all regions of the United States.
Because fluoroquinolones are no longer recommended for the treatment of gonorrhea, treatment options are limited. For the treatment of uncomplicated urogenital and anorectal gonorrhea, the CDC now recommends a single 125-mg intramuscular dose of ceftriaxone (Rocephin) or a single 400-mg oral dose of cefixime (Suprax). Alternative regimens include a single 400-mg oral dose of cefpodoxime (Vantin) or a 1-g dose of cefuroxime (Ceftin).
For pharyngeal gonorrhea, the CDC now recommends a single 125-mg intramuscular dose of ceftriaxone. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5614a3.htm
Headache (Chronic Tension-Type)
What are the effects of drug treatments for chronic tension-type headache?
beneficial
Amitriptyline. One systematic review and three small, short duration randomized controlled trials (RCTs) found that amitriptyline reduced the duration and frequency of chronic tension-type headache compared with placebo. One RCT found that amitriptyline was more effective than citalopram in improving headache duration, frequency, and severity. Another RCT found comparable effectiveness between amitriptyline and mirtazapine for the treatment of chronic tension-type headache, although amitriptyline was associated with a less favorable adverse effect profile. One RCT found no significant difference between amitriptyline and cognitive behavior therapy in headache scores or frequency of clinically important improvement after six months.
Mirtazapine (Only Short-term Evidence). One small RCT found that mirtazapine reduced the duration, frequency, and intensity of chronic tension-type headache compared with placebo. One RCT found comparable effectiveness between mirtazapine and amitriptyline for the treatment of chronic tension-type headache, although mirtazapine was associated with a more favorable adverse effect profile.
unknown effectiveness
SSRI Antidepressants. One systematic review and one additional RCT provided insufficient evidence about the effects of selective serotonin reuptake inhibitors (SSRIs) on symptoms of chronic tension-type headache compared with placebo. One systematic review found no significant difference between SSRIs compared with amitriptyline for treatment of chronic tension-type headache; however, more adverse effects occurred in the amitriptyline group.
Tricyclic Antidepressants (Other Than Amitriptyline). We found insufficient evidence about the effects of tricyclic antidepressants other than amitriptyline.
likely to be ineffective or harmful
Benzodiazepines. Two RCTs provided insufficient evidence about the effects of benzodiazepines compared with placebo or other treatments. Benzodiazepines are commonly associated with adverse effects if taken regularly.
Botulinum Toxin. One systematic review and one subsequent RCT provided no evidence that botulinum toxin improved the symptoms of chronic tension-type headache compared with placebo. However, botulinum toxin is associated with important adverse effects.
Regular Acute Pain Relief Medication. We found no systematic review or RCTs. One nonsystematic review of observational studies provided insufficient evidence about the benefits of common analgesics in persons with chronic tension-type headache. It found that sustained and frequent use of some analgesics was associated with chronic headache and reduced the effectiveness of prophylactic treatment.
What are the effects of nondrug treatments for chronic tension-type headache?
likely to be beneficial
Cognitive Behavior Therapy. One systematic review and one subsequent RCT found limited evidence that cognitive behavior therapy reduced the symptoms of chronic tension-type headache at six months compared with placebo. One RCT found no significant difference between cognitive behavior therapy and amitriptyline or in headache scores or frequency of clinically important improvement after six months. One systematic review provided insufficient evidence to compare cognitive behavior therapy versus relaxation or electromyographic biofeedback therapy.
uknown effectiveness
Acupuncture. Two systematic reviews and one subsequent RCT provided insufficient evidence about the effects of acupuncture compared with sham acupuncture in persons with chronic tension-type headache. A second subsequent RCT found that low-power laser acupuncture improved headache intensity, duration, and frequency compared with placebo.
Indian Head Massage. We found no systematic review or RCTs about the effects of Indian head massage in persons with chronic tension-type headache.
Relaxation and Electromyographic Biofeedback. Two systematic reviews and one subsequent RCT provided insufficient evidence about the effects of relaxation and electromyographic biofeedback on symptoms of chronic tension-type headache.
Definition
Chronic tension-type headache is a disorder that evolves from episodic tension-type headache, with daily or very frequent episodes lasting minutes to days. The 2004 International Headache Society criteria for chronic tension-type headache includes having headaches for 15 or more days a month (180 days per year) for at least three months; pain that is bilateral, pressing, or tightening in quality and that is nonpulsating, of mild or moderate intensity, and that does not worsen with routine physical activity such as walking or climbing stairs; presence of no more than one additional clinical feature (e.g., mild nausea, photophobia, phonophobia); and without moderate or severe nausea or vomiting. Chronic tension-type headache is generally regarded as a featureless headache. Not all experts agree that mild features more typically seen in migraine (e.g., photophobia, phonophobia) should be included in the operational definition of chronic tension-type headache, and it is often difficult to distinguish mild migraine headache from tension-type headache.
Chronic tension-type headache is to be distinguished from other causes of chronic daily headache that require different treatment strategies (e.g., new daily persistent headache, medication overuse headache, chronic migraine, hemicrania continua). Many persons who develop chronic daily headache owing to chronic migraine or medication overuse also develop mild migrainous "background" headaches that might be mistaken for coincidental chronic tension-type headache. It is therefore extremely important to take a full headache history to elicit the individual features of the headache and to look for prodromal or accompanying features that might indicate an alternative diagnosis.
In contrast to chronic tension-type headache, episodic tension-type headache can last for 30 minutes to seven days and occurs for fewer than 180 days a year. The greatest obstacle to studying tension-type headache is the lack of any single proven specific or reliable, clinical, or biological defining characteristic of the disorder. Terms based on assumed mechanisms (e.g., muscle contraction headache, tension headache) are not operationally defined. Older studies that used these terms may have included persons with many different types of headache.
Incidence and Prevalence
The prevalence of chronic daily headache from a survey of the general population in the United States was 4.1 percent; one half met the International Headache Society criteria for chronic tension-type headache. In a survey of 2,500 U.S. undergraduate students, the prevalence of chronic tension-type headache was 2 percent. The prevalence was 2.5 percent in a Danish population-based survey of 975 persons. One community-based survey in Singapore (2,096 persons from the general population) found that the prevalence was 1.8 percent in women and 0.9 percent in men.
Etiology
Tension-type headache is more prevalent in women (65 percent of cases in one survey). Symptoms begin before 10 years of age in 15 percent of persons.7 There is a family history of some form of headache in 40 percent of persons with chronic tension-type headache,8 although a twin study found that the risk of headache was similar for identical and nonidentical twins.
Prognosis
The prevalence of chronic tension-type headache declines with age.
Clinical Evidence Concise, A Publication of BMJ Publishing Group
http://www.aafp.org/afp/20070701/bmj.html
Exercise for Older Patients Who Are Acutely Hospitalized
Clinical Question
What are the effects of exercise interventions for patients older than 65 years who are acutely hospitalized?
Evidence-Based Answer
The effects of exercise interventions on functional outcomes are unclear, but there is a trend toward functional improvement. Multidisciplinary interventions that include exercise also show several other benefits, including reduction in length of hospitalization and hospital costs; these benefits have not been shown with exercise-only interventions, however.
Practice Pointers
Older adults experience declines in physical strength, mobility, and functioning during and after acute hospitalization.1 Exercise training can improve functional outcomes in these patients.2
In this Cochrane review, the authors searched for studies evaluating the effectiveness of inpatient exercise programs for older patients admitted to the hospital with general medical problems. Nine studies with 4,223 total patients were included. Patients in specialized stroke, intensive care, or rehabilitation units or those with primarily orthopedic diagnoses were excluded. Interventions were started within three days of admission and were compared with usual hospital care. The exercise interventions ranged from increased physical activity to individually tailored walking and strengthening programs.
The review found that older patients benefited from a multidisciplinary intervention program that incorporated exercise. The benefits included a decrease in hospital costs of about $300 per hospital stay, an average one-day reduction in length of hospitalization, and a 6 percent increase in the proportion of patients discharged to home rather than to a nursing home or other facility (number needed to treat = 16). It is important to note that exercise-only programs did not demonstrate these outcomes. In addition, the exercise portion of the multidisciplinary interventions was not explained in detail, thus limiting the practical implication of the studies. The authors conclude that the benefits may be from the multidisciplinary effort rather than the exercise itself.
These data support including exercise in multidisciplinary programs initiated as early as hospital admission and continuing until discharge. Multidisciplinary programs generally include individually designed patient exercise plans, a specialized geriatric inpatient unit, and evaluation and treatment by physical and occupational therapists and a physician or nurse trained as a geriatrician. Small but important clinical outcomes can be expected with this multidisciplinary approach. Cochrane Brief
de Morton NA, Keating JL, Jeffs K. Exercise for acutely hospitalised older medical patients. Cochrane Database Syst Rev 2007(1):CD005955.
http://www.aafp.org/afp/20070701/cochrane.html
Evaluation of Nausea and Vomiting
A comprehensive history and physical examination can often reveal the cause of nausea and vomiting, making further evaluation unnecessary. Acute symptoms generally are the result of infectious, inflammatory, or iatrogenic causes. Most infections are self-limiting and require minimal intervention; iatrogenic causes can be resolved by removing the offending agent. Chronic symptoms are usually a pathologic response to any of a variety of conditions. Gastrointestinal etiologies include obstruction, functional disorders, and organic diseases. Central nervous system etiologies are primarily related to conditions that increase intracranial pressure, and typically cause other neurologic signs. Pregnancy is the most common endocrinologic cause of nausea and must be considered in any woman of childbearing age. Numerous metabolic abnormalities and psychiatric diagnoses also may cause nausea and vomiting. Evaluation should first focus on detecting any emergencies or complications that require hospitalization. Attention should then turn to identifying the underlying cause and providing specific therapies. When the cause cannot be determined, empiric therapy with an antiemetic is appropriate. Initial diagnostic testing should generally be limited to basic laboratory tests and plain radiography. Further testing, such as upper endoscopy or computed tomography of the abdomen, should be determined by clinical suspicion based on a complete history and physical examination. Am Fam Physician 2007;76:76-84.
http://www.aafp.org/afp/20070701/76.html
AHRQ
Use of high-risk medications by pregnant women is not uncommon
http://www.ahrq.gov/research/may07/0507RA19.htm
Gastrointestinal complaints in young women of low to normal weight
may indicate possible eating disorders
http://www.ahrq.gov/research/apr07/0407RA11.htm
Model shows contribution of mammography screening and adjuvant therapy
to reducing breast cancer deaths from 1975 to 2000
http://www.ahrq.gov/research/apr07/0407RA13.htm
Pediatricians with more knowledge of and confidence in identifying
and managing child abuse are more likely to identify abuse
http://www.ahrq.gov/research/may07/0507RA10.htm
Oncologists appear to communicate differently with breast cancer
patients depending on women's age, race, education, and income
http://www.ahrq.gov/research/apr07/0407RA12.htm
Clinic-based and community-based strategies can promote the use of
key preventive services by Latina women
http://www.ahrq.gov/research/apr07/0407RA14.htm
Ask A Librarian: Diane Cooper, M.S.L.S. / NIH
Scopus ™ : A New Database
Scopus ™ is an interdisciplinary, bibliographic database that indexes the contents of more than 15,000 journals in the physical sciences, engineering, earth and environmental sciences, life and health sciences, social sciences, psychology, business, and management. Scopus coverage includes 535 open access journals, 12,850 academic journals, conference proceedings, trade publications, 13 million patents, and more than 200 million scientific web pages. The coverage of Scopus is strongest from 1996 to the present and it is updated daily.
In terms of functionality, Scopus:
- provides the ability to view search results and refine them to the most relevant hits,
- offers an email alerting service that notifies you when a new publication matches your search terms, and when a new publication cites a selected publication,
- presents patent search results from four patent offices,
- includes seamless links to full-text articles and other library resources.
| Search Functions | ||
| Function | Symbol/Method | Example |
| Freetext searching | Select "All fields" | |
| Spelling | Use all variations | colour, color |
| Phrases | use quotation marks - " " | "avian flu" |
| Truncation | * | arter* gives artery or arteries |
| Wildcard | * | wom*n gives woman or women |
| Optional wildcard | ? | p?ediatric gives pediatric or paediatric |
| Controlled vocabulary | none | |
| Boolean | AND, OR, AND NOT | human AND NOT rat |
You can access Scopus via Research Tools Databases on the green menu bar on the HSR Library webpage. For more information about using Scopus email me at cooperd@mail.nih.gov
Breastfeeding - Suzan Murphy, PIMC
What to do when: Mom says, “My newborn likes the bottle better.”
Why does it happen?
In a normal, healthy newborn, bottle preference is usually from overuse of a bottle and/or pacifier. However, it is helpful to rule out unusual newborn issues that can effect sucking like a short frenulum or thrush.
What is the cause?
Formula or breast milk comes out of the bottle quickly, just a little tug. Also, the plastic nipple can rub the roof of the mouth, stimulating the suck. It is not much work for the baby - and there is no waiting for let down. It is easy. Breastfeeding takes more work. Often, but not always, a baby will begin to favor the bottle and avoid breastfeeding. Unfortunately, it is hard to know which baby will be influenced by frequent bottles/pacifiers.
In the first couple weeks, there is probably still time for the mom’s supply to bounce back. To get mom and baby back to breastfeeding:
Assure the mom that her baby is getting enough:
Have her count diaper changes - if her baby has least 6 in 24 hours, her baby is probably has an adequate intake.
Check her baby’s weight gain – ½ oz – 1 oz per day, 3.5 - 7 oz per week is normal
Tell the mom to breastfeed about 2 hours – 8 to 12 times in 24 hours. The baby’s suck muscles and mom’s milk supply will get up to speed together and the frequency will slow down within a couple days.
Discourage the “pump and feed” method – it has a near 100% burn out rate.
Tell the mom to praise her baby for sucking well. The baby knows mom’s happier voice and will respond appropriately.
Recommend less use of the bottle. If the bottle can be weaned down to once or twice a day, the mom’s milk supply will probably be protected. Less is best in the first 4-6 weeks.
Suggest that the pacifier be avoided – and saved for difficult times like car trips with screaming a baby or challenging moments.
If it looks like it really is a supply issue, or the “bounce back” is not happening, consider medication. Clinical studies indicate that metoclopromide can increase milk supply in difficult situations. For more information, refer to Thomas Hales’ text, Medications and Mother’s Milk or sources like the San Diego Breastfeeding Coalition web page.
If the baby won’t latch, refer the mom to WIC or a Lactation Consultant. It is OK to call us for over-the-phone-ideas at 1- 877-868-9473. It is toll-free - best times are 7 am – 10 pm, Mountain Standard Time.
What about extra fluids?
Clinical studies have not agreed with the common practice of encouraging fluids to increase milk supply. Unfortunately the studies were small, each with less than 30 participants, and did not correct for climate issues – such as excessive heat/cold, or the typical amount of outdoor exposure the mother experienced. So while encouraging water is a healthy practice, excessive fluids are not necessary. A reasonable recommendation is to keep water nearby and drink to thirst.
Please note: If it is believed that a specific (safe) beverage will help, it probably will. Confidence is a powerful tool with parenting, especially breastfeeding.
References
Dusdieker LB et al. Prolonged maternal fluid supplementation in breast-feeding. Pediatrics,
1990 Nov;86(5):737-40.
Morse JM et al. The effect of maternal fluid intake on breast milk supply: a pilot study.
Canadian Journal of Public Health, 1992 May-Jun;83(3):213-6.
Other
New IHS Breast feeding Family Support web page: Have pictures to share?
When family and friends support breastfeeding,
it makes the challenges easier.
Your encouragement will touch a lifetime.
Tell mom that she is doing great.
Let dad know that his patience is beautiful.
Let the new family how proud you are of them.
Praise grandparents/aunts/uncles/cousins/friends
for their wonderful care and wisdom.
Give the new family a boost:
- Tackle some household chores
- Bring a meal over
- Change some diapers
- Make the trip to the grocery store
- Give the baby a bath
- Take the new siblings to the park
- Read a book or watch TV with the new siblings
- Keep mom resting, bring the baby to her
If you have pictures to share, please email them to suzan.murphy@ihs.gov
http://www.ihs.gov/MedicalPrograms/MCH/M/bfFamily.cfm
Cup feeding not be recommended over bottle feeding as a supplement to breastfeeding
AUTHORS' CONCLUSIONS: Cup feeding cannot be recommended over bottle feeding as a supplement to breastfeeding because it confers no significant benefit in maintaining breastfeeding beyond hospital discharge and carries the unacceptable consequence of a longer stay in hospital.
Flint A, et al Cup feeding versus other forms of supplemental enteral feeding for newborn infants unable to fully breastfeed. Cochrane Database Syst Rev. 2007 Apr 18;(2):CD005092
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17443570
CCC Corner Digest
Nicely laid out hard copy - A compact digest of last month’s CCC Corner
June / July Highlights include:
-A new management category: ‘First Trimester GDM’
-Control over schedule: Most important predictor of staff work-life balance / burnout
-Placental problems with previous caesarean delivery: Abruptio, previa
-Discharge 24 Hours After Vaginal Hysterectomy Safe, Acceptable
-Guidelines for School-Based STD Screening in Indian Country
-Malabsorption of Oral Antibiotics in Pregnancy after Gastric Bypass Surgery
-Seeking and Giving Consultation
-Long-Term Breastfeeding among Native American Women
-The failure to protect Indigenous women from sexual violence in the USA
-Reasons for unprotected intercourse
-What are the Unnecessary Tests?
-Improve HIV screening in pregnancy? Preliminary GPRA Related Results
-Social context of maternal deaths and morbidity
-Improve the system - Improve the care: Underpinnings
-Which Indian Health facilities lead the U.S. in national benchmarks?
-Earlier hormone therapy closer to menopause tended to have reduced CHD risk
-Adjustable Urethral Slings: Hope for Patients with Complex Incontinence
-Personal Digital Assistants: Practical Advice for Nurses in 2007
-Placental cultures and histology poor predictors of infectious amniotic fluid
-Electronic Health Record (EHR) Implementation: Worth the effort?
-Fluoroquinolones No Longer Recommended for Gonococcal Infections
-High rate of DM among indigenous people ?not due to thrifty gene
-Women’s Early Drinking Problems More Likely to Escape Diagnosis
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/CCCC_v5_06.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
IHS-ACF DV Project: Conference CD
I want to make you aware that you can obtain a copy of the National Conference on Health and Domestic Violence Conference – Presenter CD by clicking on the URL:
http://fvpfstore.stores.yahoo.net/2007-conference-presentation2008.html
You may find the CD content helpful as you work towards improving your DV screening, patient education and patient safety planning
Carolyn Aoyama Carolyn.Aoyama@ihs.gov
Family Violence Prevention Funds Screen to End Abuse Video
IHS-ACF DV Project: Free online DV training video and CME: The Family Violence Prevention Funds Screen to End Abuse video is now up on Medscape with a free 1 hour CEU. People may view the video and then take a CME test to receive credit.
Now Available on Medscape with CME: Screen to End Abuse
Screen to End Abuse, a 30 minute training video produced by the Family Violence Prevention Fund (FVPF) includes five clinical vignettes demonstrating techniques for screening and responding to domestic violence in primary care settings. The FVPF partnered with Medscape, an internet provider of educational tools for health care professionals and students to develop the Screen to End Abuse video into a Continuing Education activity. The free 1 hour activity includes the five vignettes, learning objectives and statistics from Screen to End Abuse and incorporates Pre and Post-test questions to facilitate the user’s learning experience.
-To view the video visit : www.medscape.com
(log in free and search: “ Domestic Violence and Your Patient's Health: Asking the Right Questions” )
Perceptions of Adult Patients’ History of Child Abuse
The providers in our exploratory study seemed to lack awareness and strategies about how and when to incorporate inquiry into a history of child abuse in their clinical assessment. Contradictory discourses exist among them about the potential significance of routine inclusion of child abuse history in the initial and/or ongoing assessment of adult patients. Despite the fact that primary care providers are in an ideal position to identify and treat the physical and emotional sequelae of early abuse, and that patients, including those with abuse histories, favor screening about childhood physical and sexual abuse, these family physicians expressed reluctance to enter these troubled waters.
The potential benefits of a patient's disclosure of a history of childhood abuse to his or her family physician are many: A survivor might feel relief from the burden of the secret and might finally hear that the abuse was not his or her fault. The patient might be able to make a connection between current emotional and physical symptoms with past abuse and might take the opportunity to engage in counseling or psychotherapy around these painful issues. The patient might realize that his or her own body is not shameful and start to be able to take better care of it and make healthier lifestyle choices. 9 Finally, a caring relationship with a nonabusive adult such as a family physician may facilitate healing and speed a survivor's journey to recovery. 10 The potential for such inquiry to have a therapeutic effect deserves further investigation.
Weinreb, L et al Perceptions of Adult Patients’ History of Child Abuse in Family Medicine Settings Journal of the American Board of Family Medicine 20 (4): 417-419 (2007)
http://www.jabfm.org/cgi/content/full/20/4/417?etoc
Study finds connection between teenage violence and domestic violence
Researchers tracing the development of violent behavior have found a link between teenage violence and domestic violence.
Adolescents who engaged in violent behavior at a relatively steady rate through their teenage years and those whose violence began in their mid teens and increased over the years are significantly more likely to engage in domestic violence in their mid 20s than other young adults, according to a new University of Washington study.
"Most people think youth violence and domestic violence are separate problems, but this study shows that they are intertwined," said Todd Herrenkohl, lead author of the study and a UW associate professor of social work.
The study also found no independent link between an individual's use of alcohol or drugs and committing domestic violence. In addition it showed that nearly twice as many women as men said they perpetrated domestic violence in the past year including kicking, biting or punching their partner, threatening to hit or throw something at their partner, and pushing, grabbing or shoving their partner.
Data from the study came from the on-going Seattle Social Development Project which has been tracing youth development and the social and antisocial behavior of more than 800 participants. It began when they were in the fifth grade and continues to follow them into adulthood.
That project earlier showed four patterns of youth violence taken by teens between the ages of 13 and 18.
- Non-offenders, the largest group (60 percent), did not engage in violent behavior in adolescence.
- Desisters (15 percent) engaged in violence early on but stopped by age 16.
- Chronic offenders (16 percent) began violent behavior early and it persisted at a moderate level up to age 18.
- Late increasers (9 percent) became involved with violence in mid adolescence with the behavior increasing up to age 18.
The new study found that individuals from the last two groups were significantly more likely than non-offenders to have committed moderately severe forms of domestic violence when they were 24 years old. At that age, nearly 650 of the original students had a partner and about 19 percent of them, or 117 individuals, reported having committed domestic violence in the past year.
The finding that a perpetrator's use of alcohol is not significantly related to domestic violence was somewhat surprising since other studies have shown such an association. The reasons for this are unclear, according to Herrenkohl, who speculated such a relationship may have shown up if more severe forms of domestic violence, such as those requiring hospitalization had been measured.
The study also showed a number of personal characteristics, partner characteristics and neighborhood conditions that increased an individual's chances of being involved in domestic violence as a young adult. Being diagnosed with a major episode of depression or receiving welfare were significantly related to committing domestic violence, as were having a partner who used drugs heavily, sold drugs, had a history of violence toward others, had an arrest record or was unemployed.
Disorganized neighborhoods where attitudes toward drug sales and violence were favorable also increased a person's likelihood of committing domestic violence.
"Individuals who have a history of anti-social behavior may be more likely to find a partner with a similar history and re-create what they experienced as children. They may also be more likely to be in places in their communities where they interact with people with the same types of behavior," said Herrenkohl.
"The take-home message from this study is that it may be possible to prevent some forms of domestic violence by acting early to address youth violence. Our research suggests the earlier we begin prevention programs the better, because youth violence appears to be a precursor to other problems including domestic violence."
http://uwnews.washington.edu/ni/article.asp?articleID=34626
Co-authors of the study were Rick Kosterman, a research scientist; W. Alex Mason, a research analyst; and J. David Hawkins, professor of social work. All are affiliated with the UW's Social Development Research Group. The paper appears in the current issue of the journal Violence and Victims and the research was funded by the National Institute on Drug Abuse and the National Institute of Mental Health.
SANE: Is there a center near you?
From the International Association of Forensic Nurses "Beyond Tradition, Advancing Humanity"
Web site - US Map with state-by-state links to local sites. http://www.iafn.org/registry/reghome.cfm
Frequently Asked Questions:
-Standards of Practice: Domestic Violence Is there any source available for standards for care of domestic violence victims?
http://www.iafn.org/about/aboutFAQ.cfm?nav=registry#29
-Publications on line at the following link:
https://www.iafn.org/store/storeHome.cfm
-Standards of Practice: Forensic Nursing Where can I find Forensic Nursing Standards of Practice?
http://www.iafn.org/about/aboutFAQ.cfm?nav=registry#20
-Website Tools: Listing Tools How can I make changes to our program on line?
http://www.iafn.org/about/aboutFAQ.cfm?nav=registry#90
Certification chapters committees education events jobs membership projects publications registry (includes Canadian provinces)
Elder Care News
AAN Guidelines on Reporting Medical Conditions That May Affect Driving Competency
Driving laws for persons with medical conditions that affect cognition, consciousness, vision, or motor skills vary from state to state. Physicians are expected to report a patient's driving-related condition to authorities if the condition might pose a safety risk, especially when the patient does not comply with requests to be tested or stop driving. Requiring mandatory reporting, however, may negatively affect the patient-physician relationship. Reporting also may not result in safety benefits to the public or the patient, who may consequently withhold important medical information.
Poorly designed reporting laws may also expose physicians to liability for a patient's driving outcomes, even when a physician has followed all applicable laws. Most states have full legal immunity for physicians who follow applicable laws in good faith. However, physicians in some states (e.g., Arkansas, Georgia) may be sued for reporting a patient with questionable driving abilities, resulting in a suggested violation of patient-physician privilege. In other states (e.g., Michigan, Montana), a physician who does not report a patient who appears to be a sound driver is at risk of being sued if that patient later causes an accident.
The American Academy of Neurology (AAN) encourages physicians to review applicable driving laws with their patients and to discuss and document their medical recommendations with their patients. The AAN also supports optional reporting of persons with medical conditions that may affect their ability to drive safety, especially for cases in which public safety has already been compromised or when the person clearly no longer has the skills to drive safely.
Physician immunity policies should be clarified so that physicians are granted immunity for reporting or not reporting a patient's condition when such action is taken in good faith, when the patient is reasonably informed of his or her driving risks, and when such actions are documented by the physician in good faith.
American Academy of Neurology http://www.neurology.org/content/vol68/issue15/#SPECIAL_ARTICLES
AFP Practice Guideline Briefs http://www.aafp.org/afp/20070701/practice.html
Elderly Medicare patients with low health literacy receive little tangible support for their health care needs
http://www.ahrq.gov/research/may07/0507RA20.htm
Family Planning
Waiting until the menses to start hormonal contraceptives: Needless Obstacle
CONCLUSION: Protocols that require a woman to wait until the next menses to start hormonal contraceptives are an obstacle to contraceptive initiation. Directly observed, immediate initiation of the pill improves short-term continuation
Westhoff C, et al Initiation of oral contraceptives using a quick start compared with a conventional start: a randomized controlled trial. Obstet Gynecol. 2007 Jun;109(6):1270-6.
http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db
=pubmed&list_uids=17540797&dopt=Abstract
One In Four with Unplanned Pregnancy Experience Gaps In BCM Or Do Not Use A Method
Fifteen percent of U.S. women in a recent survey who were at risk of unplanned pregnancy had had a gap in contraceptive use of one or more months during the previous year, while 8% had not used any method
CONCLUSIONS: Providers could better help women avoid unintended pregnancy by initiating regular assessments of method use difficulties, improving counseling on method choice and pregnancy risk, and identifying and assisting women at higher risk for inconsistent method use because of disadvantage, relationship characteristics or ambivalence about pregnancy prevention. In addition to providers' efforts, broader societal commitment is critical for increasing contraceptive knowledge and expanding access to contraceptive care for all women who are at risk of having an unintended pregnancy
Frost J et al Factors associated with contraceptive use and nonuse, United States, 2004. Perspect Sex Reprod Health. 2007 Jun;39(2):90-9
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17565622
Little variation in the frequency of reported symptoms among oral contraceptive pills
CONCLUSION: In the absence of sufficient evidence-based data to support the existence of differences in the tolerance profile of low-dose combined OCPs, future well-designed randomized trials are needed to guide providers in their choice of OCPs. However, research should also assess the effectiveness of counseling on the tolerance of OCPs, an intervention that may prove to be more rewarding than basing the choice of OCPs on their theoretical properties.
Moreau, C et al Does the Type of Pill Matter? Oral Contraceptive Tolerance. Obstet Gynecol. 2007 Jun;109(6):1277-85.
http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db
=pubmed&list_uids=17540798&dopt=Abstract
FDA Approves Contraceptive for Continuous Use
The Food and Drug Administration (FDA) approved Lybrel, the first continuous use drug product for prevention of pregnancy on May 22, 2007
The new contraceptive, Lybrel, comes in a 28 day-pill pack with low-dose combination tablets that contain 90 micrograms of a progestin, levonorgestrel, and 20 micrograms of an estrogen, ethinyl estradiol, which are active ingredients available in other approved oral contraceptives. Continuous contraception works the same way as the 21 days on-seven days off cycle. It stops the body's monthly preparation for pregnancy by lowering the production of hormones that make pregnancy possible.
Other contraceptive pill regimens have placebo or pill-free intervals lasting four to seven days that stimulate a menstrual cycle. Lybrel is designed to be taken without the placebo or pill-free time interval. Women who use Lybrel would not have a scheduled menstrual period, but will most likely have unplanned, breakthrough, unscheduled bleeding or spotting.
The safety and efficacy of Lybrel as a contraceptive method were supported by two one-year clinical studies, enrolling more than 2,400 women, ages 18 to 49. Health care professionals and patients are advised that when considering the use of Lybrel, the convenience of having no scheduled menstruation should be weighed against the inconvenience of unscheduled bleeding or spotting. The occurrence of unscheduled bleeding decreases over time in most women who continue to take Lybrel for a full year. In the primary clinical study, 59 percent of the women who took Lybrel for one year had no bleeding or spotting during the last month of the study.
Like other available oral contraceptives, Lybrel is effective for prevention of pregnancy when used as directed. The risks of using Lybrel are similar to the risks of other conventional oral contraceptives and include an increased risk of blood clots, heart attacks, and strokes. The labeling also carries a warning that cigarette smoking increases the risk of serious cardiovascular side effects from the use of combination estrogen and progestin-containing contraceptives. Birth control pills do not protect against HIV infection (AIDS) or other sexually transmitted diseases.
Because Lybrel users will eliminate their regular periods, it may be difficult for women to recognize if they have become pregnant. Women should take a pregnancy test if they believe they may be pregnant. Women should also discuss contraceptive use, and the precautions and warnings for use of the drug product, with their doctors or other health care professional.
The approval of Lybrel concludes a comprehensive review process that included expert advice from a meeting of an FDA's Reproductive Health Drugs advisory committee and an opportunity for public comment on issues regarding hormonal contraception.
Lybrel is manufactured by Wyeth of Philadelphia, PA.
http://www.fda.gov/bbs/topics/NEWS/2007/NEW01637.html
Implanon and bone mineral density: Two Articles
BMD during long-term use of the progestagen contraceptive implant
An open, prospective, comparative study was done in healthy women, aged between 18 and 40 years, to study the effects of long-term etonogestrel treatment on bone mineral density (BMD). The control group used a non-hormone-medicated intrauterine device (IUD). The BMD was measured using a dual energy X-ray absorptiometry instrument. Measurements included the lumbar spine (L(2)-L(4)), the proximal femur (femoral neck, Ward's triangle, trochanter) and distal radius. The period of treatment was 2 years and 44 women in the Implanon group and 29 in the IUD group provided data. Groups were comparable at baseline with respect to age, weight, body mass index, BMD and 17beta-oestradiol status. Changes from baseline in BMD in the Implanon group were not essentially different from those in the IUD group. There was no relationship between 17beta-oestradiol concentrations and changes in BMD in this study population. The results of the present study indicate that Implanon((R)) can safely be used in young women who have not yet achieved their peak bone mass.
Beerthuizen R, et al Bone mineral density during long-term use of the progestagen contraceptive implant Implanon compared to a non-hormonal method of contraception. Hum Reprod. 2000 Jan;15(1):118-22
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=10611199
and
BMD with Implanon (etonorgestrel- and levonorgestrel-releasing contraceptive implants)
CONCLUSIONS: Women of 19-43 years of age using either one of the implants showed lower BMD at 18 months of use at the midshaft of the ulna, however, without a difference at the distal radius.
Bahamondes l et al A prospective study of the forearm bone density of users of etonorgestrel- and levonorgestrel-releasing contraceptive implants. Human Reproduction. 21(2):466-470, February 2006.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=16253974
Oral Contraceptives - Individualized Treatment -- Optimal Results (Slides with Audio)
http://www.medscape.com/viewarticle/557225
Featured Web Site David Gahn, IHS MCH Portal Web Site Content Coordinator
From Roberta Ward, CNM, ANMC
In case you didn't know about this website: +++
A couple of good handouts from Contraception Online that you may want to use with your patients are:
-Implantable Rod
-Extended Dosing
There are other handouts on that website also.
Contraception Online http://www.contraceptiononline.org/index.cfm
Last Special Issue on Methamphetamine in Indian Country: Now online
This is to let you know that the third (and last) special issue on meth in the IHS Primary Care
Provider is now available on-line at this link below
Thanks again to everyone who contributed to this important series.
Lori de Ravello, MPH lori.deravello@ihs.gov
Methamphetamine in Indian Country: Part 3
http://www.ihs.gov/PublicInfo/Publications/HealthProvider/issues/PROV0407.pdf
Wrong link for National Sexual Violence Resource Center
www.nsvrc.org is the CORRECT link for National Sexual Assault Resource Center NOT www.ncvrc.org
From Yohanah B LeivaYohanah.Leiva@ihs.gov
Frequently asked questions
Q. Can oral or sublingual misoprostol be used for postpartum hemorrhage?
A. Yes and both have a more rapid onset of action than rectal adminstraion
The doses are smaller than some of the rectal doses that are being used. The sublingual and oral doses of misoprostol mentioned below are: 400, and 600 microg.
Sublingual and oral doses reach a peak concentration much more rapidly, so sublingual or oral dosing may have more of a role in the acute management of PPH, rather the mid and long term management as with rectal misoprostol. (The time to peak concentration (Tmax) was similar in both the sublingual (26.0 +/- 11.5 min) and oral groups (27.5 +/- 14.8 min) and was significantly shorter than those in both vaginal groups.)
Here are a few articles on sublingual and oral doses of misoprostol used in postpartum hemorrhage.
Effect of sublingual misoprostol on severe postpartum haemorrhage in a primary health centre in Guinea-Bissau: randomised double blind clinical trial.
CONCLUSION: Sublingual misoprostol reduces the frequency of severe postpartum haemorrhage.
Høj L, et al Effect of sublingual misoprostol on severe postpartum haemorrhage in a primary health centre in Guinea-Bissau: randomised double blind clinical trial. BMJ. 2005 Oct 1;331(7519):723.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=16195287
Sublingual misoprostol versus methylergometrine for active management of the third stage of labor
CONCLUSION: Sublingual misoprostol appears to be as effective as intravenous methylergometrine in the prevention of postpartum hemorrhage. However, larger randomized studies are needed to advocate its routine use.
Vimala N, et al Sublingual misoprostol versus methylergometrine for active management of the third stage of labor. Int J Gynaecol Obstet. 2004 Oct;87(1):1-5
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=15464767
A pilot-randomized comparison of sublingual misoprostol with syntometrine on the blood loss in third stage of labor
CONCLUSION: The use of sublingual misoprostol or intravenous syntometrine in spontaneous vaginal delivery resulted in a comparable amount of blood loss. Transient side effect such as fever and shivering which resolved within a day occurred more frequent to those who received sublingual misoprostol.
Lam H, et al A pilot-randomized comparison of sublingual misoprostol with syntometrine on the blood loss in third stage of labor. Acta Obstet Gynecol Scand. 2004 Jul;83(7):647-50
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=15225189
A multicentre randomized controlled trial of oral misoprostol and i.m. syntometrine in the management of the third stage of labour
Oral misoprostol might be used in the management of the third stage, especially in situations where the use of syntometrine is contraindicated and facilities for storage and parenteral administration of oxytocics are limited.
Ng PS, et al A multicentre randomized controlled trial of oral misoprostol and i.m. syntometrine in the management of the third stage of labour. Hum Reprod. 2001 Jan;16(1):31-35
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=11139532
A double-blind randomized controlled trial of oral misoprostol and intramuscular syntometrine in the management of the third stage of labor.
CONCLUSION: Orally administered misoprostol at a dose of 400 mug is an acceptable alternative in preventing post-partum blood loss, as measured by the peri-partum change in hemoglobin level and was not associated with an increased incidence of side effects.
Ng PS, et al A double-blind randomized controlled trial of oral misoprostol and intramuscular syntometrine in the management of the third stage of labor. Gynecol Obstet Invest. 2007;63(1):55-60
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=16940738
Oral misoprostol in preventing postpartum haemorrhage in resource-poor communities: a randomised controlled trial
INTERPRETATION: Oral misoprostol was associated with significant decreases in the rate of acute postpartum haemorrhage and mean blood loss. The drug's low cost, ease of administration, stability, and a positive safety profile make it a good option in resource-poor settings.
Derman RJ, et al Oral misoprostol in preventing postpartum haemorrhage in resource-poor communities: a randomised controlled trial. Lancet. 2006 Oct 7;368(9543):1248-53
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17027730
A randomised placebo controlled trial of oral misoprostol in the third stage of labour.
CONCLUSIONS: Shivering has been shown in this study to be a specific side effect of misoprostol administered orally in the puerperium. No serious side effects were noted. Misoprostol shows promise as a method of preventing postpartum haemorrhage. Because of the potential benefits for childbearing women, particularly those in developing countries, further research to determine its effects with greater certainty should be expedited.
Hofmeyr GJ, et al A randomised placebo controlled trial of oral misoprostol in the third stage of labour. Br J Obstet Gynaecol. 1998 Sep;105(9):971-5
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=9763047
A double-blind placebo controlled randomised trial of misoprostol and oxytocin in the management of the third stage of labour
CONCLUSIONS: In low risk women oral misoprostol appears to be as effective in minimising blood loss in the third stage of labour as intramuscular oxytocin. Shivering was noted more frequently with misoprostol use, but no other side effects were noted. Misoprostol has great potential for use in the third stage of labour especially in developing countries.
Walley RL, et al A double-blind placebo controlled randomised trial of misoprostol and oxytocin in the management of the third stage of labour. BJOG. 2000 Sep;107(9):1111-5
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=11002954
Pharmacokinetics of different routes of administration of misoprostol.
CONCLUSION: The new sublingual route of administration of misoprostol demonstrated a great potential to be developed into a method of medical abortion.
Tang OS, et al Pharmacokinetics of different routes of administration of misoprostol. Hum Reprod. 2002 Feb;17(2):332-6
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=11821273
Q. How should you greet your patients?
A. Most Patients Prefer Their Physicians to Greet Them With a Handshake and Introduction
CONCLUSIONS: Physicians should be encouraged to shake hands with patients but remain sensitive to nonverbal cues that might indicate whether patients are open to this behavior. Given the diversity of opinion regarding the use of names, coupled with national patient safety recommendations concerning patient identification, we suggest that physicians initially use patients' first and last names and introduce themselves using their own first and last names.
Makoul G, et al An evidence-based perspective on greetings in medical encounters. Arch Intern Med. 2007 Jun 11;167(11):1172-6
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17563026
Q. How can I better counsel my patient to adhere to therapy?
A. Treatment effects expressed in terms of number needed to treat (NNT) yielded higher consent rates than did those expressed as equivalent postponements.
Background: Ways to communicate the benefits of risk-reducing drug therapies include the number needed to treat (NNT) to prevent adverse events, such as heart attacks or hip fractures, and gains in disease-free life expectancy or postponement of adverse events.
Methods: Respondents were randomized to a scenario with 1 of 3 outcomes after 5 years of treatment. For the drug to prevent heart attacks, the outcomes were postponement by 2 months for all patients, postponement by 8 months for 1 of 4 patients, or an NNT of 13 patients to prevent 1 heart attack.For the drug to prevent hip fractures, the outcomes were postponement by 16 days for all patients, postponement by 16 months for 3 of 100 patients, or an NNT of 57 patients to prevent 1 fracture. Study endpoints were consent to receive the intervention and perceived ease of understanding the treatment effect.
CONCLUSIONS: Treatment effects expressed in terms of NNT yielded higher consent rates than did those expressed as equivalent postponements. This result suggests that the description of the anticipated outcome may influence the patient's willingness to accept a recommended intervention.
Halvorsen PA, et al Different ways to describe the benefits of risk-reducing treatments: a randomized trial Ann Intern Med. 2007 Jun 19;146(12):848-56
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17577004
Q. Should patients use sweat lodges during pregnancy?
A. A sweat lodge that does not elevate the maternal core temperature would be acceptable
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/SweatLodge7607.doc
Q. What is recommended about peyote use in pregnancy?
A. Use of hallucinogens are not recommended in pregnancy
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/Peyote7607.doc
Indian Child Health Notes - Steve Holve, Pediatrics Chief Clinical Consultant
August 2007 – Highlights
-Lactose intolerance in infants, children, and adolescents.
-Influenza activity, 2006-7
-Inhalant abuse
-Fatal Injuries Among Children by Race and Ethnicity
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ICHN807.doc
Information Technology
Integrated case management software application release
The IHS Office of Information Technology (OIT) is pleased to announce the release of iCare, the next generation of RPMS Population Management software. We would like to thank Cherokee Indian Hospital, Phoenix Indian Medical Center, Red Lake Hospital Service Unit; Sells Service Unit, and SouthEast Alaska Regional Health Consortium for testing this application.
IHS Office of Information Technology initiated this population health care software application to provide an easy-to –use tool with multiple uses to a wide variety of providers. iCare is a Windows-based graphical user interface (GUI) component of the IHS Resource and Patient Management System (RPMS) that presents diverse patient data in a user-friendly perspective.
This initial version of iCare will provide IHS providers the ability to view patient data from an individual patient as well as a "population-centric" perspective. The application will assist the user in identifying trends in care for individuals and populations as well as increase awareness of the services that patients need by highlighting the status of key clinical prevention and treatment measures.
User-defined patient lists (panels) can be created, sorted and filtered in a variety of ways to form the core functionality of iCare. Additionally, auto-tagging" of patients with one or more clinical diagnoses and facilitating provider review of clinical quality of care measures for their own patients should enable improvement in the quality of healthcare delivery.
iCARE can be used by sites that are on RPMS-EHR as well as those that are not on RPMS-EHR. We encourage all sites to start using this software.
To encourage use, OIT is pleased to offer WebEx training for the new iCare (Population Management) software application. You will be able to participate in the training from your office or conference room and will not be required to travel to obtain this training. For more information on these training sessions, please visit our website: http://www.ihs.gov/CIO/ca/icare/index.asp and download the training schedule.
The new release of this software is available on the IHS Web site: http://www.ihs.gov/Cio/RPMS/index.cfm?module=home&option=software
or ITSC system, cmbsyb, in the /usr/spool/uucppublic/DIST/2006cert directory
iCare Training
The IHS Office of Information Technology is pleased to continue offering WebEx training for the new iCare (Population Management) software application. You will be able to participate in the training from the comfort of your office or conference room and will not be required to travel to obtain this training.
iCare is a tool with multiple uses for a wide variety of providers that presents diverse RPMS data through an easy to use graphical user interface (GUI).
There are two types of training offered:
- iCare Technical Overview
- iCare – Nuts and Bolts
The target audience is any provider who cares for patients (e.g. physicians, mid-level providers, nurses, case managers, public health personnel, pharmacists etc.)
NOTE:You must register for these classes. They are NOT limited to participants in a particular Area; they are open to all, however, space is limited so be sure to register right away. Below are the agendas and date/times for both classes. It is recommended that you attend them sequentially.
Each session is limited to 30 participants. Therefore, if there is a group of people who would like to attend at your facility, our recommendation is that you attend as a group and have only one person register for the session. For the group, you will need a conference room, conference phone, computer and projector. Please ensure someone at your facility is responsible for taking care of these arrangements.
Please note this is a live, internet-based training, not a recorded session, and people will be able to ask questions and actively participate in the class.
NOTE: All training times shown above are for the Pacific Daylight Time zone. Please ensure you adjust the time for your particular time zone.
Training Schedule
- iCare – Nuts and Bolts
Target Audience – Patient Care Providers (e.g. physicians, mid-level providers, nurses, case managers, public health personnel, pharmacists etc.)
Agenda
- Introductions and Context
- Set Up and Background (Server) Processes
- Establishing and Changing User Preferences
- Panel Creation
- Panel Modification
- Flags
- Diagnostic Tags
- National Performance Measures
- Patient Record
- Question and Answer Session
| Session | Date and Time | Reg Password | |
| iCare Nuts and Bolts | Mon 07/16/2007 | 12:00-14:00 PDT | coyote |
| Tue 07/31/2007 | 11:00-13:00 PDT | coyote | |
| Thur 08/23/2007 | 09:00-11:00 PDT | coyote | |
| Mon 08/27/2007 | 13:30-15:30 PDT | coyote | |
| Fri 09/14/2007 | 10:30-12:30 PDT | coyote |
- The Practical Use of iCare
Target Audience – Patient Care Providers (e.g. physicians, mid-level providers, nurses, case managers, public health personnel, pharmacists etc.)
Agenda
- Introductions and Context
- Scenarios
- Tips
- Using the Performance Measure views to improve outcomes
- Questions and Answers
| Session | Date and Time | Reg Password | |
| The Practical Use of iCare | Wed 07/18/2007 | 09:00-10:30 PDT | coyote |
| Thur 08/02/2007 | 09:30-11:00 PDT | coyote | |
| Fri 08/24/2007 | 10:00-11:30 PDT | coyote | |
| Thur 08/30/2007 | 12:00-13:30 PDT | coyote | |
| Wed 09/19/2007 | 11:00-12:30 PCT | coyote |
Registration Information
- Click this link:https://ihs-training.webex.com/
- At the Search For box, type in "iCare" (do not type in the quotation marks) and click the Go button. NOTE: If you do not see the Search For box, ensure the Training Center tab is selected at the top of the WebEx window, immediately under “webex.”
- All of the scheduled sessions will then be displayed in the window below. Choose the one you want to attend and click “Registration” in the Status column.
- Enter the Registration password that is shown above that corresponds to the class you want to attend.
- Click the OK button.
- Complete the registration form.
- Click the Register button.
- A Registration confirmation is displayed that contains all of the information for the training session, including the link for the session and the password to enter when you are ready to attend the session. Click the OK button to finish.
Setup (Software Install) Information:
You must have the WebEx software installed on your computer prior to attending the WebEx session. You should setup the software at least a day before the training session. You should not need anyone such as the Site Manager to install it for you. Below are the instructions.
- Click this link:
https://ihs-training.webex.com/ihs-training/mywebex/
default.php?Rnd0969=0.20680128403018566
- On the left side of the window, click Set Up.
- Immediately under Set Up you will see two options: Training Manager, Preferences.
- Click Training Manager.
- A message is displaying giving you information about the setup process. Click the Set Up button.
- After the software is installed, click the OK button.
Attending the Session:
When you are ready to attend the session, connect to the WebEx session first using the information contained in your registration confirmation e-mail and then connect to the conference line. The dial information for the conference line is shown below and is also included in your registration confirmation message.
Phone Number: (877) 781-4791
Passcode: 135963#
Questions? Contact Cynthia Gebremariam at Cynthia.Gebremariam@ihs.gov
International Health Update: Claire Wendland, Madison, WI
Maternal survival redux: a view from Malawi - Failure of justice
Last November this column reviewed the Lancet’s recent series on maternal survival, which assessed the progress and pitfalls of the Safe Motherhood movement. This month I want to revisit the issue of maternal survival from a more personal perspective. I spent the first five months of 2007 in Blantyre, Malawi, the largest city in a country in which a woman’s lifetime chance of dying from childbirth complications is around one in eight. While there I spent part of each week working clinically in a busy public referral and teaching hospital, alongside many of the nation’s new nurse midwives- and doctors-in-training. During these five months we averaged two to three maternal deaths every week in the hospital. I also spent time out in the community, interviewing nurse midwives at area health centers, and speaking with traditional midwives (TBAs in the biomedical lexicon). Many health workers – both within and outside of the formal medical sector -- shared their perceptions of maternal risk in Malawi. Some thoughts based on these experiences:
- Birth in a safe facility, attended by a skilled health worker, is just a start. And it doesn’t necessarily equate with “birth in a hospital with a biomedically trained doctor or nurse midwife.” Can a referral hospital be considered a “safe facility” if it has no sutures, runs out of all antibiotics except penicillin G, or has such poor staffing that one nurse covers a ward of eighty patients? Can a government health center be considered safe if there is no equipment to start an IV, nor any blood pressure cuff? What if the “skilled health worker” is demoralized and apathetic because he hasn’t been paid in two months? What if she is a brand new intern – poorly trained and supervised – who learned how to do a Cesarean from another intern and isn’t too sure how to use oxytocin? Making motherhood safer won’t happen simply by bringing women into the hospital. It is going to require detailed attention to sector-wide issues like supply chains, health sector funding, training and brain drain.
- Infection is playing a huge role in maternal deaths, at least in countries with high HIV prevalence, and the role of Cesarean section needs to be investigated carefully in these settings. Since I first worked in Malawi, the pattern of maternal deaths has shifted. In 1990, deaths from septic unsafe abortion were common, as was death from hemorrhage. In 2007, both of these have declined, but postpartum – and especially postoperative – infection deaths have skyrocketed. HIV-positive women are especially (but not exclusively) at risk. HIV treatment and prevention are crucial. And in this setting, the increased morbidity and mortality attendant upon surgical intervention should affect the risk/benefit analysis for Cesarean: the adoption of First World standards like surgical delivery for breech needs careful re-evaluation.
- We should rethink -- AGAIN -- the question of traditional birth attendant training. TBA training has all but vanished from international funders’ priorities, based on conflicting data on effectiveness. This despite the fact that TBAs continue to be the attendants at many births in the developing world; half of Malawi’s births are outside of formal-sector health facilities. TBAs I spoke with in Malawi very strongly advocated for a restoration of training programs that they felt provided them not only with valuable information and skills, but perhaps even more importantly enabled them to forge mutually respectful connections with district health offices and staff at local hospitals. These proved invaluable when it came time to manage difficult cases together.
- Women’s empowerment is more than a buzzword. In too many families, a woman’s value is in her capacity to bear children. In too many places, a girl’s ability to access schooling or employment depends on her willingness to trade sex for the patronage of an older male. In too many countries, women do not make the policy decisions that affect their lives. When a fifteen-year-old dies after an unsafe abortion, when a woman who knows she has AIDS dies of postpartum sepsis after her third attempt in three years to bear a son, maternal death is not just a biomedical problem, remediable by technical interventions. It is a failure of justice.
November 2006 International Health Update
http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1106_Feat.cfm#ih
Other
Q. How about these two malarial drugs in early pregnancy?
Mefloquine Hydrochloride
Sulfadoxine and pyrimethamine (Fansidar)
Response from George Gilson, MFM
The above two drugs are not known to be teratogenic to human pregnancy. There has been
extensive experience with their use for malaria prophylaxis in developing countries. I will summarize what is known about each drug below. The ReproTox website, which is an excellent resource, has all the references. While the two drugs are not known to have adverse effects at a specific week of pregnancy, depending on one’s menstrual history it is somewhat unsure, and it would be best to date the pregnancy with ultrasound for the usual obstetric reasons. One may not even have been pregnant at the time they took the drugs.
Mefloquine is a quinine derivation useful for the prophylaxis of chloroquine-resistant malaria. Several large studies involving several thousand women have shown it not to be associated with an increased incidence of congenital anomalies or miscarriage above that of the general population when taken in the first trimester.
Sulfadoxine/pyrimethamine (Fansidar, Malarid, etc) is a combination of a sulfonamide with a folic acid antagonist used as an antimalarial and as treatment for toxoplasmosis (in pregnancy). While it has been noted to be teratogenic in rodents (cleft lip/palate, embryo resorbtion) at doses 12 times the usual human dose, it has not been shown to be teratogenic in humans. It is not recommended in pregnancy because it has been associated with serious maternal adverse effects (severe sulfa allergy, agranulocytosis, etc) and there are many effective alternatives.
In this situation should one continue the pregnancy?
Let’s assume the medications were taken during the time of organogenesis. While the information is in general reassuring that the medications are not thought to be teratogenic, the information about the Malarid is limited. The decision to terminate is always up to the woman; I can't tell you what she should do, sorry! If one does decide to continue the pregnancy, then I would suggest one get a fetal anatomic survey (detailed ultrasound) at 18 weeks for reassurance
Malaria Preventive Therapy Useful for Pregnant Women Despite Resistance
CONCLUSIONS: In areas in which 1 of 4 treatments with sulfadoxine-pyrimethamine fail in children by day 14, the 2-dose IPT with sulfadoxine-pyrimethamine regimen continues to provide substantial benefit to HIV-negative semi-immune pregnant women. However, more frequent dosing is required in HIV-positive women not using cotrimoxazole prophylaxis for opportunistic infections.
ter Kuile FO, et al Effect of sulfadoxine-pyrimethamine resistance on the efficacy of intermittent preventive therapy for malaria control during pregnancy: a systematic review. JAMA. 2007 Jun 20;297(23):2603-16
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17579229
Multivitamins should be considered for all pregnant women in developing countries CONCLUSIONS: Multivitamin supplementation reduced the incidence of low birth weight and small-for-gestational-age births but had no significant effects on prematurity or fetal death. Multivitamins should be considered for all pregnant women in developing countries
Fawzi WW et al Vitamins and perinatal outcomes among HIV-negative women in Tanzania.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17409323
MCH Alert
Who needs liquor stores when parents will do?
The present study findings "highlight the need for alcohol prevention efforts to address . . . social sources of alcohol, particularly before high school; a major challenge for alcohol prevention efforts.
The authors found that
* At the beginning of 6th grade, parents and guardians were the most common source of alcohol (32.7%), followed by another adult age 21 or older (15.7%) and someone age 20 or younger (9.7%).
* By the end of 8th grade, another adult age 21 or older (22.7%) surpassed parents and guardians (18.9%) as the most prevalent source reported.
* Consistent users followed a pattern similar to that of the entire sample, with social sources outstripping commercial sources.
* Over time, student reports of taking alcohol from home or a friend's home, receiving alcohol from a friend's parent or guardian, and purchasing alcohol from commercial sources were lower in prevalence compared to accessing alcohol from parents or guardians, another adult age 21 or older, or someone age 20 or younger.
* Among the entire sample of alcohol users, increases over time were observed across the following sources of alcohol: another adult age 21 or older, someone age 20 or younger, took it from home, and commercial.
* Parents as a source of alcohol use decreased over time.
* Males were more likely than females to get alcohol from commercial sources. Among consistent users, males were more likely than females to get alcohol from a friend's parent.
* No significant racial and ethnic differences (white adolescents vs.
African-American or Hispanic adolescents) were observed across sources of alcohol use over time.
"Recognizing the importance of social sources of alcohol and how social sources change as children age offers an ideal opportunity for primary prevention," the authors conclude.
Hearst MO, Fulkerson JA, Maldonado-Molina MM, et al. 2007. Who needs liquor stores when parents will do? The importance of social sources of alcohol among young urban teens. Preventive Medicine 44(6):471-476.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17428525
Home visiting associated with decreased infant death
Infant death may be considered the 'tip of the iceberg' in which children of families at risk experience suboptimal care, poor health outcomes, and the possibility of lifelong disability; some die before their first birthday.
The authors found that
* After controlling for race, prenatal care, maternal smoking, maternal education, and maternal age, enrollment in greater Cincinnati's Every Child Succeeds (ECS) was associated with a 60% decrease in the likelihood of infant death.
* The differences between black participants in ECS and black nonparticipants tended to be much larger than the differences observed for nonblack infants.
* Among all the independent variables identified, adequacy of prenatal care had the strongest association with the likelihood of infant death.
* Black mothers enrolled in ECS before birth were more likely to received adequate prenatal care, compared with control subjects.
* The largest association between ECS participation and reduced infant mortality rate was seen for black infants.
* No influence of ECS enrollment on gestational age at birth was observed.
The authors conclude that "our study findings are consistent with the findings from randomized, controlled trials and suggest that home visiting reduces the risk of infant death."
Donovan EF, Ammerman RT, Besl J, et al. 2007. Intensive home visiting is associated with decreased risk of infant death. Pediatrics 119 (6):1145-1151.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17545382
Resident fathers’ prenatal behaviors, pregnancy intentions and involvement with infants
Men's Pregnancy Intentions and Prenatal Behaviors: What They Mean for Fathers' Involvement with Their Children examines how men feel about a pregnancy (pregnancy intentions), how men act during the pregnancy (prenatal behaviors), and the effects of these intentions and behaviors on men's involvement with very young children following birth. The research brief, published by Child Trends, draws on data from the 2001 Early Childhood Longitudinal Study -- Birth Cohort, 9-month Resident Father Survey, which tracks a nationally representative sample of children from infancy to first grade. The brief includes a summary, a discussion of the implications for policy and practice, and a conclusion. References and statistical charts and graphs are also included. http://www.childtrends.org/Files//Child_Trends-2007_05_31_RB_Prenatal.pdf
Office based motivational interviewing to prevent overweight in children
This feasibility study demonstrates that pediatricians and RDs (registered dieticians) can be taught to use some of the tools and techniques of MI (motivational interviewing) and that this approach is well received by parents.
The authors found that
* At the 6-month follow-up, there were mean decreases in BMI of 0.6 percentiles among children in the control group, 1.9 among those in the minimal group, and 2.6 among those in the intensive group.
* Parents in the minimal group reported a significant within-group decrease in their child's intake of snacks, a change that was significantly greater than the change reported by parents in the control group. Parents in the intensive group reported a significant net decrease in dining out compared with parents in the minimal group.
* Ninety-four percent of the parents reported being very satisfied with the pediatrician visit, and all were very satisfied with the RD visit; 94% of the parents also reported that the pediatrician and RD helped them think about changing their family's eating habits.
The authors conclude that "many challenges remain in designing and implementing research to test the effectiveness of the MI approach in practice settings, but practice-based research networks afford the opportunity to conduct the additional studies needed to make the office setting an effective site for obesity intervention."
Schwartz RP, Hamre R, Dietz WH, et al. 2007. Office-based motivational interviewing to prevent childhood obesity. Archives of Pediatrics and Adolescent Medicine 161(5):495-501
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17485627
Association between confidential services and parent adolescent communiciation
This study supports the hypothesis that availability of services is not a barrier to adolescent-parent communication about their health.
The authors found that
* Fifty-eight percent of the adolescents came to the clinic for confidential services.
* Overall, 69.5% (N=41) of the adolescents told their parents they were coming to the clinic.
* Less than half (43.1%, N=25) of the adolescents reported that they would tell their parents if they were found to have a serious and sensitive reproductive health problem (sexually transmitted infection or pregnancy). Of those who would tell their parents, approximately half had come in for confidential services and half for non-confidential services.
* In terms of adolescents' decisions about whether to discuss their reasons for coming to the clinic and their future communication related to serious and sensitive reproductive health care issues with their parents, there was no significant difference between adolescents who came in for confidential vs. non-confidential services.
The authors suggest that further research is needed to explore health professionals' role in helping adolescents share information about a serious and sensitive reproductive health problem and assisting them in obtaining support from their parents. The authors add that interventions need to be in place to educate parents about communication with their adolescent and the rights of their adolescent under the minor's consent laws.
Lerand SJ , Ireland M, Boutelle K. 2007. Communication with our teens:
Associations between confidential service and parent-teen communication. Journal of Pediatric and Adolescent Gynecology 20():173-178.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17561185
Policy options to better serve adolescents who age out of foster care
Time for Reform: Aging Out and on Their Own briefly discusses the history of permanency and federal child welfare policy, presents the latest state-by-state data on the number of adolescents who have aged out of foster care, and offers recommendations for public policy reforms to decrease the number of adolescents who age out of care each year. The report, published by the Pew Charitable Trusts, draws on findings from focus groups conducted with adolescents who aged out or expect to age out of foster care, research studies, and interviews to document the adverse long-term effects that aging out of foster care has had on a growing number of adolescents each year. The appendix contains charts depicting the number and percentage of adolescents aging out and length of stay by state, describes the characteristics of focus group participants and methodology, and presents selected outcomes for adolescents who age out of foster care (education, health, employment and income, living arrangements, contact with the criminal justice system). The report is intended for use by program administrators, policymakers, and others to improve the system so that all children in foster care achieve permanency with families, and to ensure that proper support is in place for those who may age out of the system without a permanent family. http://www.pewtrusts.org/pdf/Aging_Out_May2007.pdf
MCH Headlines: Judy Thierry HQE
Taking a harder line on blood transfusions
Hospitals trying to zero in on the key factors that put patients at risk for blood transfusions might start by looking within.
“One of the biggest risks in the U.S. of being transfused is which doors you happen to walk through on the day of surgery,” anesthesiologist Timothy Hannon, MD, MBA, said in a recent G-2 Reports audioconference on blood management. Even within a group of surgeons or anesthesiologists, he said, you see considerable variation in blood use, with some ordering quite a bit and others very little.
In fact, he told CAP TODAY, a hospital is a “quantifiable risk factor for transfusion” for all patients, whether or not they have surgery. That’s because the hospital tends to have a “culture” for how it approaches transfusion therapy, says Dr. Hannon, medical director of the blood management program at St. Vincent Hospital, Indianapolis, and president and CEO of Strategic Healthcare Group, which offers, among other services, blood management consultation.
It has been known for some time that a restrictive transfusion strategy may be better for adult patients than a liberal strategy. Now, a new study has found that a restrictive strategy (hemoglobin threshold of 7 g/dL) for red-cell transfusion can decrease transfusion requirements without increasing adverse outcomes in stable, critically ill children (Lacroix 2007). The mounting more-may-be-less data is why some hospitals are implementing conservative, evidence-based blood management programs.
The College of American Pathologists article below gives multiple other successful examples from adult medicine, orthopedics, and other disciplines.
Lacroix J, et al. Transfusion strategies for patients in pediatric intensive care units. N Engl J Med. 2007;356:1609–1619
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17442904
Are you interested in the bigger picture of Indian Health care? Join a listserv
Perhaps you should join an Indian Health list serve on your topic(s) of interest?
Centering prenatal care, breastfeeding, primary care discussion forum, CCC newsletter … elder care - the linked site below has many choices on the “available list”.
http://www.ihs.gov/cio/listserver/index.cfm
Do you know your state's teen-driving-laws?
How does your state line up with THE FOLLOWING:
- An extended learner period of supervised driving
- Required hours of adult supervision during the learner period
- Restrictions on late-night driving during initial months of licensure
- Restrictions on transporting teen passengers during initial months of licensure
- Seat belt requirements for drivers and passengers
- CUT AND PAST THIS LINK INTO YOUR BROWSER
http://www.allstate.com/citizenship/foundation/teen-driving/teen-driving-laws.aspx
VEHICLE RELATED FATALITIES BY TYPE OF VEHICLE, YEAR AND BY state
http://www.ite.org/crashes/index.htm
Program for At-Risk Infants and Mothers Recognized
Baby Love, a social work program for at-risk infants and mothers based out of University of Rochester Medical Center’s Strong Memorial Hospital, has been recognized by the Healthcare Association of New York State as one of the state’s best examples of an institutional commitment to improve the health of the surrounding community.
The Baby Love program, which was started in 1988, is a home visit program designed to reduce infant mortality, premature births, low birth weight rates, and foster care placement in poor inner-city neighborhoods. The program works in close partnership with neighborhood based health and social service providers, integrated health service systems, county health and social service agencies, and insurers.
Teams of social workers and outreach workers work with at-risk pregnant women and teens – visiting their homes on a weekly basis – to ensure patients have access to regular health and social services and that their homes are ready for the arrival of the newborn. The outreach teams also help the families secure needed goods and services such as food, clothing, and baby items. Families referred into the program are enrolled as early in the pregnancy as possible and the home visits continue until the child’s third pediatric well care visit. The program is currently seeking funding that would allow it to continue visits until the child enters early childhood education.
The Baby Love program emerged from a community-wide effort to respond to the health challenges facing inner-city families and the program is an integral part of two community-wide initiatives – the Rochester Early Enhancement Program and Rochester Healthy Start. Rochester currently ranks eleventh in the nation in the number of children living in poverty. Low birth weight rates for city residents are twice as high as those who live in the suburbs and the infant mortality rate is three times higher.
Baby Love serves approximately 200 medically and psychosocially at-risk pregnant women and teens, their newborns, and families per year and has demonstrated that this model of direct, home-based intervention can be highly successful. Since 2002 the Baby Love program has provided outreach service to high-risk pregnant women for the Monroe Plan for Medical Care, a local health management organization that primarily serves low-income individuals and the working poor. In subsequent years the Monroe Plan experienced a 60% drop in its neonatal intensive care unit (NICU) admission rates. Another pilot project using Baby Love outreach workers has reduced the disparity in NICU admission rates between African-American and white teens. http://www.urmc.rochester.edu
Adolescent Pregnancy Prevention Knowledge Path
The MCH Library has released a new edition of Knowledge Path: Adolescent Pregnancy Prevention. This electronic guide presents a selection of current, high-quality resources that measure, document, and monitor the problem; identify risk and protective factors; and report on promising intervention strategies. The knowledge path is intended for use by health professionals, policymakers, researchers, and others who are interested in tracking information on this topic. Separate sections identify resources for families and schools.
View the path online at http://www.mchlibrary.info/KnowledgePaths/kp_adolpreg.html
Knowledge paths on other maternal and child health topics are available at http://mchlibrary.info/KnowledgePaths/index.html
Dental Care for Children Tips on Preventing Cavities
3.5 minute spot education for the public
Video feed of Dr. Lisa Thebner providing tips on how to prevent cavities in children.
Link is available online at:
v Teeth are a place holder for surrounding and next teeth
v Cavities can actually lead to nerve damage
v Children need assistance in learning to brush, early brushing of gums
v 1-2 minute brushing – parent modeling the behavior
v Visit to Oral Health Practitioner - First tooth or by first year – PREVENTION
v Cavities are contagious – bacteria transmitted causes cavities
v Brush after milk intake
v No sippy-cup or bottle all-day-long – bathing the teeth
v Fluoride toothpaste by age 2 -3 – ‘pea size’ amount
http://video.wnbc.com/player/?id=101888
Prevent cavities – water only in the sippy cup
Tooth decay in young children's baby teeth is on the rise, a concerning trend
that signals toddlers and preschoolers are eating too much sugar, according to
a recent Centers for Disease Control and Prevention study of dental health.
Experts are concerned about the prevalence of cavities in baby teeth of children ages 2 to 5.
Cavities in that age group increased to 28 percent in 1999-2004, from 24 percent in 1988-1994, according to the report. Tooth decay in young children had been decreasing for 40 years, but this report shows there are new concerns likely linked to sugar intake.
An easy solution? Put water in that sippy cup instead of juice or sugary beverages, says the American Academy of Pediatric Dentistry.
Revised guidelines from the AAPD say sippy cups should only be filled with water when used at anytime other than mealtime. Sugar from beverages other than water can cause tooth decay in young teeth.
The lidded cups were created to help children transition from a bottle to a regular cup, but they're used too often and too long by most parents because they are convenient for reducing spills, AAPD experts say.
Using them at nap time, bedtime, or playtime with beverages other than water can lead to serious cavity problems, dentists warn. Additional research has shown that nearly one-third of toddlers with tooth decay problems used sippy cups, the AAPD says.
Tooth decay is the single most common chronic childhood disease
90 percent of all tooth decay is preventable, the AAPD says.
Stop Bullying Now
“Come on, take a stand, lend a hand – stop bullying now” the mantra of the bullying campaign at this Interactive web site – student friendly – material for teacher and school projects on what is accessible and readable and interesting for kids to manage bullying in their world and their friends, classmates and school’s culture.
- Webisodes – scenarios with a Q&A
- Toon Characters, teacher interactions, has you listening to dialogue
- Acts of kindness, diverse characters
- Gets at myths – beyond big bullies and small victims…
- Same gender, girl bullying, clics, peer suppression of speaking up and speaking out.
- Having ‘different’ ‘sets’ of friends.
- Parent child sharing and divulging and covering up “just great”
- Passivity versus standing up and speaking out
- By scenario 6 -7 the HEAT builds
- Identifiable messages
- Skills in altering relationships with bullies
- Sharing, confidence building and peer to peer support.
http://stopbullyingnow.hrsa.gov/index.asp
New Parent Advocacy Brief--Preschool Services under IDEA
The National Center for Learning Disabilites has created a new Parent Advocacy Brief, Preschool Services Under IDEA, to help parents understand their children's education rights.
No two children learn at the same pace or in the same way.
While the preschool years can be a time of learning and discovery for many children, approximately eight (8) percent of all young children are identified as having disabilities that may prevent them from reaching developmental milestones as expected. Often times children are not identified at birth as having a disability, but exhibit more subtle issues between the ages of three to five, such as:
- Speech and language delays or disorders;
- Putting shoes or mittens on the wrong feet or hands;
- Having difficulty remembering direction;
- Seeming uninterested in playing early learning games or listening to stories;
- Seeming mildly uncoordinated.
If you think you need to wait until your child's enrolled in school to address your concerns—think again.
- The Individual with Disabilities Education Act (IDEA) is for children from birth to age 21.
- If your child is between ages 3-5, they can be evaluated for a developmental delay or specific learning disability (SLD) and access intervention services under IDEA part B section 619 for free.
For more information about the law and your preschool age child, visit NCLD's Parent Center and download our free Parent Advocacy Brief, Preschool Services Under IDEA.
Remember to visit NCLD's Parent Center message boards and online chats to talk about the parenting and education issues that matter to you.
http://www.ncld.org/images/stories/downloads/parent_center/preschool_brief.pdf
Births to Cohabiting Couples at All-Time High
Movie stars do it. Big-time athletes do it. And so do ordinary Jane(s) and Joe(s). "It," in this case, is having children outside of marriage. The proportion of births in the United States that occur outside of marriage has climbed dramatically over the last few decades, and more of these births are occurring to "cohabiting couples" - unmarried couples who live together.
A new research brief published by Child Trends, ‘ The Relationship Context of Births Outside of Marriage: The Rise of Cohabitation’, takes a closer look at trends in childbearing outside of marriage in general, and trends within cohabiting relationships in particular. A news release is also available.
ABOUT THE RESEARCH SOURCES FOR THIS BRIEF
All the 2001 data on relationship status at birth in this brief were obtained from the Early Childhood Longitudinal Study - Birth Cohort (ECLS-B), gathered by the National Center for Education Statistics within the U.S. Department of Education. The ECLS-B is a nationally representative study of 10,688 children born in 2001. Unless otherwise noted, the analyses presented in this brief refer to a sample of 10,040 children who lived with their biological
or adoptive mother at the time of the ECLS-B baseline interview, and whose mothers provided information on their marital or cohabitation status at the child’s birth. Findings in this brief are drawn from two papers and are supplemented by original analyses by Child Trends.
Unmarried and Living Together With Children: Births to Cohabiting Couples
at All-Time High
http://www.childtrends.org/Files//Child_Trends-2007_05_14_RB_OutsideBirths.pdf
2nd National Summit on Preconception Health and Health Care
…will be held in Oakland, California on Monday October 29 through Wednesday October 31, 2007, at the Oakland Marriott City Center, 1001 Broadway. The Summit is being planned and hosted by the Preconception Care Council of California, March of Dimes California Chapter, and the California Department of Health Services, in collaboration with the Centers for Disease Control and Prevention (CDC) and the Health Resources and Services Administration (HRSA). On-line registration and links to abstract submission are available on THE SUMMIT WEBSITE .
http://www.marchofdimes.com/california/4947_24789.asp
Please note that the deadline for abstract and proposal submission is June 18, 2007, the deadline for early registration is September 15, 2007 and the deadline for all registration is October 15, 2007.
2008 National Conference of State Breastfeeding Coalitions
January 26-28, 2008 in Arlington, VA.
The United States Breastfeeding Committee is inviting proposals for coalitions to share their experience, expertise, and problem-solving approaches during
75 minute breakout sessions, poster session, or at breakfast topic tables.
To access the Call for Abstracts documents on the State Coalition section of the USBC site:
▪ Go to www.usbreastfeeding.org/State-Coalitions/2008-NCSBC
▪ Enter the UserName “StateCoalitions” and the password “USBC”. These are case-sensitive and spacing-sensitive, so enter them exactly as they appear here.
Complete – 2-page fillable form or download and complete.
Medical Mystery Tour
Nausea and Vomiting in Pregnancy
Case 1
MTB is a 24 y/o G1P0 at 10 weeks by her dates who presents to her first prenatal visit complaining of morning sickness. Her symptoms are not incapacitating, but she would like to feel better. She has tried various herbal teas without much relief. Your most useful recommendation at this initial visit would be:
- reassurance, small frequent intake, pyridoxine (vitamin B-6)
- prescribe a cholinomimetic agent (e.g., metoclopramide)
- prescribe a 5-HT-3 receptor inhibitor (e.g., ondansetron)
- clear liquid diet and bismuth subsalicylate (Pepto-Bismol)
Case 2
HB is a 30 y/o G3P2 at 9 weeks by her dates who presents for her first prenatal visit complaining of nausea with vomiting that lasts pretty much all day, but she is able to keep some food down. She says this has occurred with each of her pregnancies, but this time it is especially troublesome. She has had a small amount of spotting but no cramping. She appears to be well hydrated. Your initial work up at this time should include:
- complete metabolic panel, thyroid functions, amylase and lipase
- electrolytes, alanine aminotransferase, pelvic ultrasound
- upper abdominal ultrasound, H.pylori antigen testing, stool guiac testing
- no laboratory studies are indicated at this time
Case 3
EP is a 19 y/o G1P0 at 11 weeks by her dates who presents to the emergency department complaining of severe nausea and vomiting. She is wretching, appears ill, and is only able to produce a small amount of concentrated urine that is strongly positive for ketones. Your initial management should include:
- oral hydration, mental health consult
- intravenous hydration, admit for parenteral alimentation
- intravenous hydration, nasogastric tube, H2-blocker drip
- intravenous hydration, parenteral anti-emetics
What do you think?
Stay tuned for the discussion in next month’s CCC CornerMedscape*
Public Health Impact of HPV Vaccination: Aligning Policy With Science
http://www.medscape.com/viewprogram/7219?sssdmh=dm1.285905&src=nlcmealert
Premenstrual Dysphoric Disorder: A New Treatment Paradigm
http://www.medscape.com/viewarticle/557445
Hormone Therapy Safer in Younger Women? A Best Evidence Review
http://www.medscape.com/viewprogram/7404?sssdmh=dm1.285646&src=nlcmealert
Ask the Experts topics in Women's Health and OB/GYN Index, by specialty,
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Free CME: MedScape CME Index by specialty
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Menopause Management
Hormone Replacement Therapy Linked to Ovarian Cancer
The Million Women Study, a trial in the United Kingdom of postmenopausal women, has found that those receiving hormone replacement therapy (HRT) were, on average, 20% more likely to develop and die from ovarian cancer than women who never received therapy. Authors say that since 1991, HRT has resulted in some 1300 additional ovarian cancers and 1000 additional deaths from this malignancy in the United Kingdom alone.
In the United Kingdom, ovarian cancer is the fourth most common cancer in women, with 6700 new cases and 4600 deaths from ovarian cancer every year. Studies of the association between use of HRT and later risk of developing ovarian cancer are inconclusive, with some showing a significantly increased risk for fatal and incident ovarian cancer in users of HRT, but with most lacking statistical power.
The current study used a large cohort of women in the United Kingdom (Million Women Study), in which about half the postmenopausal women had used HRT, to evaluate the effect of HRT on women's risk of developing and dying from ovarian cancer
http://www.medscape.com/viewarticle/555597?sssdmh=dm1.276434&src=top10#
Menopause Linked to Elevated Fasting Plasma Glucose Levels in Nondiabetic Women
Stepwise multivariate regression analysis showed that the independent risk factors for elevated FPG levels were body mass index, menopause, and triglycerides level, whereas age and low-density lipoprotein cholesterol level did not contribute to FPG levels. CONCLUSIONS: Menopause, but not age, is directly involved in augmented FPG levels in nondiabetic women.
Otsuki M, et al Menopause, but not age, is an independent risk factor for fasting plasma glucose levels in nondiabetic women. Menopause. 2007 May-Jun;14(3 Pt 1):404-7
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17213751
Exercise Plus Isoflavones May Improve Body Composition in Postmenopausal Women
CONCLUSIONS:: Compared to an aerobic exercise program alone, 70 mg/day of isoflavones combined with exercise may promote significant improvements in body composition parameters that are known to influence cardiovascular disease risk in postmenopausal women.
Aubertin-Leheudre M, et al Effect of 6 months of exercise and isoflavone supplementation on clinical cardiovascular risk factors in obese postmenopausal women: a randomized, double-blind study. Menopause. 2007 Feb 6;
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17290158
Relation of Cortisol Levels and BMD Among Premenopausal Women WithDepression
Major depression had important effects on BMD and bone turnover markers. Depression should be considered among risk factors for osteoporosis in premenopausal women.
Altindag O, et al Relation of cortisol levels and bone mineral density among premenopausal women with major depression. Int J Clin Pract. 2007 Mar;61(3):416-20
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17313608&
New Guidelines Issued for Treatment of Vaginal Atrophy: NAMS
In general, creams may be associated with more adverse effects than ring or tablet formulations, perhaps because there is more potential for women to apply higher-than-recommended dosing with cream. However, a Cochrane review reported no significant differences among the delivery methods in terms of hyperplasia, endometrial thickness, or the proportion of women with adverse events. The most commonly reported adverse effects associated with vaginal estrogen therapy are vaginal bleeding and breast pain, with nausea and perineal pain reported less frequently.
When low-dose estrogen is administered locally for vaginal atrophy, progestogen is generally not indicated. Data are insufficient to recommend annual endometrial surveillance in asymptomatic women using vaginal estrogen therapy.
Vaginal estrogen therapy should be continued as long as women continue to have distressing symptoms. Management of vaginal atrophy is similar for the group of women without a cancer history and for women treated for non–hormone-dependent cancer. However, for women with a history of hormone-dependent cancer, management recommendations are individualized and vary based on each woman's preference in consultation with her oncologist.
Specific recommendations are as follows:
- The primary goals of vaginal atrophy management are symptom relief and reversal of atrophic anatomic changes.
- For women with vaginal atrophy, first-line treatments include nonhormonal vaginal lubricants and moisturizers.
- Symptomatic vaginal atrophy that does not respond to nonhormonal vaginal lubricants and moisturizers may require prescription therapy.
- Randomized controlled trials in postmenopausal women are limited. However, they have demonstrated that low-dose, local, prescription vaginal estrogen delivery is effective and well tolerated for treating vaginal atrophy while limiting systemic absorption.
- Low-dose vaginal estrogen products approved in the United States for treating vaginal atrophy include estradiol vaginal cream, conjugated estrogens vaginal cream, the estradiol vaginal ring, and the estradiol hemihydrate vaginal tablet. These are equally effective at the doses recommended in labeling, so specific choice depends on clinical experience and patient preference.
- When low-dose estrogen is administered locally for vaginal atrophy, progestogen is generally not indicated.
- Closer surveillance may be required for women at high risk for endometrial cancer, those using a higher dose of vaginal estrogen therapy, or those with symptoms such as spotting or breakthrough bleeding. Evidence is insufficient to recommend annual endometrial surveillance in asymptomatic women using vaginal estrogen therapy.
- Vaginal estrogen therapy should be continued for as long as women have distressing symptoms.
- For women treated for non–hormone-dependent cancer, management of vaginal atrophy is similar to that for women without a cancer history, but for those with a history of hormone-dependent cancer, management recommendations should be based on each woman's preference and the advice of her oncologist.
Overall, subjective improvement occurs in 80% to 90% of women treated with local vaginal estrogen," the authors conclude. "Vaginal atrophy unresponsive to estrogen may be due to undiagnosed dermatitis/dermatosis or vulvodynia, so treatment failure warrants future evaluation and careful examination.
The role of local vaginal estrogen for treatment of vaginal atrophy in postmenopausal women: 2007 position statement of The North American Menopause Society. Menopause. 2007 May-Jun;14(3):370-1
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17489067
Ineffectiveness of sertraline for treatment of menopausal hot flushes: RCT
CONCLUSION: Treatment with sertraline did not improve hot flush frequency or severity in generally healthy perimenopausal and postmenopausal women, but was associated with bothersome side effects.
Grady D et al Ineffectiveness of sertraline for treatment of menopausal hot flushes: a randomized controlled trial. Obstet Gynecol. 2007; 109(4):823-30
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17400842
Hormone Therapy Safer in Younger Women? A Best Evidence Review
http://www.medscape.com/viewprogram/7404?sssdmh=dm1.285646&src=nlcmealert
Midwives Corner - Lisa Allee, CNM
Midwifery’s approach to pre-labor SROM supported by professional organization’s journal
Morwitz and Jordan present a review of the literature on pre-labor rupture of membranes at term. Most significantly, they point out some of the flaws in the TERMPROM study by Hannah et al. The biggest problem was that there was no control of the number of vaginal exams, which have been shown to be directly correlated with increased risk of infection by Hannah et al. and others. Speculation has been made that if the number of vaginal exams had been limited in the study pool the results may have been different. Another problem has to do with GBS-positive management being very different and inconsistent during the study time period as compared to today. The authors’ concluding statements support the time-honored midwifery practice of having options in the management of pre-labor SROM tailored to the individual patient and setting and the integral role played by the woman herself in the decision making process.
‘Two practices supported by current research findings should be incorporated into midwifery care of women with term PROM. The first is to strictly limit vaginal examinations. There is considerable evidence documenting the increased risk of perinatal infection related to digital vaginal examination, yet little change has occurred in this aspect of practice. Despite ACOG’s recommendation that vaginal examination should be deferred during the initial evaluation, doing a “baseline vaginal exam” is common practice. Requiring vaginal examinations at set intervals to prove labor progression is another entrenched habit. A speculum examination to determine initial cervical status is sufficient in most cases, and digital examinations should be done only when the information is needed to make management decisions. The second practice is to consistently provide information about the options of expectant management and immediate induction to women with term PROM, and to involve them in the decision-making process. This is congruent with midwifery hallmarks and philosophy of care. In addition, it is explicitly supported by Cochrane reviewers and the TERMPROM researchers.
In an editorial accompanying the publication of the term PROM study, Duff stated his view that the practice of expectant management should be abandoned. An unquestioning acceptance of this view is not justified based on available evidence. Women should be fully informed on the risks and benefits of induction and expectant management, and offered both options. Midwives should strive to remain champions of a care approach that involves women in decision making and supports the value of nonintervention.’
Marowitz, A; Jordan, R Midwifery management of prelabor rupture of membranes at term. J Midwifery Womens Health. 2007 May-Jun;52(3):199-206
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17467586
Editorial Comment by Lisa Allee, CNM:
I couldn’t have said it better myself. But I will add my two cents, too. I think the ACOG statement that induction should be started immediately upon SROM is over interventionist, not evidence based, and disrespectful of the inherent wisdom and intelligence of women’s bodies and minds. I encourage midwives to feel supported by our professional organization’s journal in continuing evidence-based approaches to pre-labor SROM by offering options of induction or awaiting spontaneous labor. AND most importantly keep your fingers out of there!!! (Really folks, the vaginal exam does not make much difference –her cervix is what is and her labor goes as it goes no matter if we check the cervix or not AND there are other ways to tell how her labor is progressing—tune in and labor sit.)
Hannah ME, et al Induction of labor compared with expectant management for prelabor rupture of the membranes at term. TERMPROM Study Group. N Engl J Med. 1996 Apr 18;334(16):1005-10 http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=8598837
Duff P. Premature rupture of the membranes at term. N Engl J Med. 1996 Apr 18;334(16):1053-4
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=8598845
Let it pulse—the cord that is
I have previously written in this column that letting the cord pulse has physiological benefits for the baby, mainly citing writings by Judith Mercer, CNM. Here is another excellent article demonstrating that this practice should be incorporated as a standard of care. Hutton and Hassan did a meta-analysis of the literature on early vs. late cord clamping. They found strong evidence that late cord clamping improves iron stores in babies and helps prevent anemia in infancy. They also address concerns that have been raised over the years about delayed cord clamping causing neonatal problems due to polycythemia and found the fears unfounded by the evidence.
‘Although late clamping was associated with a moderate increase in blood viscosity and increased rates of polycythemia, there was no evidence of any significant harm as measured by the need for phototherapy to treat jaundice or by admission to the NICU. The risk of polycythemia was not significant when only high-quality studies were considered. In addition, none of the polycythemic infants evaluated in this review were symptomatic (ie, had symptoms of central nervous system, cardiopulmonary, gastrointestinal tract, or renal impairment).
They also discuss concerns about active management of the third stage and though their analysis did not address this because few of the studies looked at maternal outcomes, their conclusion is as follows:
Although conclusions about maternal outcomes cannot be drawn from our research, it is likely that delayed clamping is compatible with active management of the third stage of labor. Uterotonic agents administered following birth and prior to cord clamping have been shown to increase the rate of placental transfusion and are thus likely to enhance the effect of delayed clamping. Although this approach has not been studied, a joint statement from the International Federation of Gynaecology and Obstetrics and the International Confederation of Midwives on active management of the third stage of labor already recommends that delayed clamping be incorporated as part of the active management approach to placental delivery. In a recent literature review, similar practice recommendations pertaining to third-stage management were made for providing care in resource-poor settings.
And their final conclusion:
Late clamping of the umbilical cord is a physiological and inexpensive means of enhancing hematologic status, preventing anemia over the first 3 months of life and enriching iron stores and ferritin levels for as long as 6 months. Although this is of particular importance for developing countries in which anemia during infancy and childhood is highly prevalent, it is likely to have an important impact on all newborns, regardless of birth setting. Additional research may be helpful in refining the timing of clamping by determining the minimum time required to provide maximum benefit associated with placental transfusion. Questions remain about whether the optimal time for clamping is affected by the use of oxytocic drugs before the delivery of the placenta or by milking of the umbilical cord. We believe that this meta-analysis supports incorporating into clinical practice a minimum delay of 2 minutes before clamping the umbilical cord following birth for all full-term newborns.’
Hutton, EK; Hassan, ES Late vs early clamping of the umbilical cord in full-term neonates: systematic review and meta-analysis of controlled trials. JAMA 2007 Mar 21;297(11):1241-52.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17374818
Editorial Comment by Lisa Allee, CNM:
I have let many, many cords pulse until they are done and I can anecdotally report that the outcomes are good. More than one baby I expected to have a hard time came around quickly as they continued to get oxygen from their mom and received their blood volume (Hutton and Hassan state that this could be 25-60% of their volume!) from the placenta. As for third stage, in the last couple years since we started using active management of third stage*, I have continued to let the cord pulse at least a couple of minutes. I have found that this fits right in with the active management as the delay in cord cutting is during the time of placental separation and I have seen significantly fewer postpartum hemorrhages, as predicted.
*(At Chinle we came to a consensus that our active management of third stage would be Pitocin 20 units in 1000ml LR at 200ml/hour after the baby is born (frequently after the cord is clamped), gentle cord traction, and bolus rate for the Pitocin after the placenta is born. Each provider decides when to clamp and cut the cord.)
Other
Upright position during the first stage of labor did not contribute towards a shorten labor
CONCLUSIONS: The upright position during the first stage of labor did not contribute towards a shorter duration of labor; however, it proved to be a safe and well-accepted option for the women of this study.
Miquelutti MA, et al Upright position during the first stage of labor: a randomised controlled trial. Acta Obstet Gynecol Scand. 2007;86(5):553-8
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17464583
Cesarean rate can be reduced by health workers in analyzing and modifying their practice
CONCLUSIONS: The cesarean rate can be safely reduced by interventions that involve health workers in analyzing and modifying their practice. Our results suggest that multifaceted strategies, based on audit and detailed feedback, are advised to improve clinical practice and effectively reduce cesarean section rates. Moreover, these findings support the assumption that identification of barriers to change is a major key to success.
Chaillet N; Dumont A Evidence-based strategies for reducing cesarean section rates: a meta-analysis. Birth. 2007; 34(1):53-64
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17324180
Midwives’ perspectives improves risk assessment in early pregnancy
CONCLUSIONS: Replacing the routine consultation with the doctor early in pregnancy with a planning conference had no negative impact on risk identification. The results support that the different perspectives of the two professions in combination are important for the safety of surveillance and the psychosocial support expected from antenatal care.
Berglund A et al Combining the perspectives of midwives and doctors improves risk assessment in early pregnancy. Acta Obstet Gynecol Scand. 2007; 86(2):177-84
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17378102
Acupuncture better results compared to physiotherapy: Pelvic and back pain in pregnancy
AUTHORS' CONCLUSIONS: All but one study had moderate to high potential for bias, so results must be viewed cautiously. Adding pregnancy-specific exercises, physiotherapy or acupuncture to usual prenatal care appears to relieve back or pelvic pain more than usual prenatal care alone, although the effects are small. We do not know if they actually prevent pain from starting in the first place. Water gymnastics appear to help women stay at work. Acupuncture shows better results compared to physiotherapy.
Pennick VE et al Interventions for preventing and treating pelvic and back pain in pregnancy. Cochrane Database Syst Rev. 2007 Apr 18;(2):CD001139.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17443503
12-week group training effective in preventing lumbopelvic pain in pregnancy
CONCLUSIONS: A 12-week specially designed training program during pregnancy was effective in preventing lumbopelvic pain in pregnancy.
Mørkved S et al Does group training during pregnancy prevent lumbopelvic pain? A randomized clinical trial. Acta Obstet Gynecol Scand. 2007; 86(3):276-82
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17364300
Interpregnancy intervals longer than 5 years associated with preeclampsia and dysotcia
Overall, long interpregnancy intervals, possibly longer than 5 years, are independently associated with an increased risk of preeclampsia. There is emerging evidence that women with long interpregnancy intervals are at increased risk for labor dystocia and that short intervals are associated with increased risks of uterine rupture in women attempting a vaginal birth after previous cesarean delivery and uteroplacental bleeding disorders (placental abruption and placenta previa).
Conde-Agudelo A et al Effects of birth spacing on maternal health: a systematic review. Am J Obstet Gynecol. 2007 Apr;196(4):297-308
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17403398
Navajo News, John Heusinkveld, Shiprock
The evolution of management of Actinomyces on a Pap report
Actinomyces is an anaerobic Gram-positive bacterium that may be found as normal flora in the mouth and GI tract. It can also colonize the female genital tract and, in rare cases, cause pelvic abscesses. Such abscesses tend to be slow-growing, are typically described as “woody”, and may be mistaken for a neoplasm. Actinomyces grows preferentially on foreign bodies such as the intrauterine device (IUD) and the likelihood of colonization increases with duration of use. For women using an IUD, the finding of actinomyces on a pap report can be a common and perplexing challenge, especially as the vast majority will be without symptoms and at very low risk for serious disease.
I am intrigued by the management of actinomyces because it also serves as a reminder about the evolution of medical knowledge and the importance of common sense in clinical practice. Perhaps I’m revealing my age but, when I was in training, a report of Actinomyces on a pap inevitably led to a recall of the patient for removal of her IUD. This caused a great deal of contraceptive consternation and an urgent search for an acceptable alternative method. Soon after my training was completed it became more acceptable to leave the IUD in situ, but only if a relatively long course of penicillin-based antibiotics was administered. More recently, awareness is growing that it is no longer necessary to remove the IUD or treat in most cases.
A recent review article by Westhoff in the journal Contraception provides useful background information. Studies of the Pap smear results of IUD users reported a prevalence of 0 to 31% of actinomyces-like-organisms noted on pap, with an average of 7%. (For women without IUDs the rate of positive paps remained close to 0%). Interestingly, the review also states that, in studies of women with Actinomyces pelvic abscesses, only half of pap tests performed were positive for the bacteria. Given the lack of specificity of this test result, the author endorses the position of the UK Faculty of Family Planning and the Planned Parenthood Federation of America that such patients can continue IUD use. They should be informed of the potential risk of subsequent pelvic abscess, which is not precisely known but is believed to be substantially less than 1/1000. This review also notes the finding that rate of actinomyces-positive pap results is lower with levonorgestrel IUDs than with Paraguard IUDs.
Both UpToDate and ACOG provide a similar perspective. UpToDate recommends that the patient be notified of the finding and examined. In the absence of symptoms, the finding of actinomyces likely represents colonization and IUD removal or antibiotic treatment is unnecessary. The patient should be given instructions to seek medical care if symptoms of PID are noted. If she is symptomatic, then removal of the IUD would be an important part of management due to the heightened growth of actinomyces on foreign bodies. This position is also endorsed by the ACOG Practice Bulletin on IUDs, published in 2005, which states that “The options for management of asymptomatic IUD users with actinomyces on Pap test are expectant management, an extended course of oral antibiotics, removal of the IUD, and both antibiotic use and IUD removal.”
A recent CME article of IUD use in Contemporary Ob/Gyn by IHS alumni Tony Ogburn and Eve Espey seeks to dispel many misconceptions about IUD use. Amongst other helpful recommendations, they make note of the changes to the Paraguard package insert which endorses IUD use in nulliparous women. This same revision removed genital actinomycosis from the list of contraindications to Paraguard use.
This evolution of recommended medical practice, from a very conservative management plan that undoubtedly increased the risk of unwanted pregnancy for some women, to a more practical and evidence-based approach encouraging symptom evaluation and ongoing IUD use for almost all women, is refreshing.
Resources:
Westhoff C. IUDs and colonization or infection with Actinomyces. Contraception
75 (2007) S48-S50. http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17531616
Ogburn T, Espey E, “Encouraging more patients to choose an IUD”, Contemporary Ob/Gyn, June 2007 72-77http://www.contemporaryobgyn.net/obgyn/article/articleDetail.jsp?id=431651
Intrauterine Device, ACOG Practice Bulletin 59, January 2005
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=15625179
Intrauterine Contraception, UpToDate
http://www.utdol.com/utd/content/topic.do?topicKey=gen_gyne/15313
Nurses Corner - Sandra Haldane, HQE
Health Care Without Harm: Nurses Take Action
http://www.medscape.com/viewarticle/555467?sssdmh=dm1.275928&src=0_tp_nl_0#
A Complementary Approach to Pain Management
http://www.medscape.com/viewarticle/556408?sssdmh=dm1.279748&src=0_tp_nl_0#
Office of Women's Health, CDC
One Test. Two Lives Campaign
The One Test. Two Lives. campaign CDC focuses on ensuring that all women are tested for HIV early in their pregnancy. One Test. Two Lives. provides quick access to a variety of resources for providers, and materials for their patients, to help encourage universal voluntary prenatal testing for HIV. http://www.cdc.gov/hiv/topics/perinatal/1test2lives/default.htm
Human Papillomavirus: HPV Information for Clinicians
CDC recently updated the HPV brochure for clinicians and posted four sets of counseling messages to assist providers in their HPV-related discussions with patients. The counseling messages address (1) information for parents about the HPV vaccine, (2) information for women about the Pap and HPV tests, (3) information for women who receive a positive HPV test result, and (4) information for patients receiving a genital warts diagnosis.
http://www.cdc.gov/std/hpv/hpv-clinicians-brochure.htm
Oklahoma Perspective Greggory Woitte – Hastings Indian Medical Center
Preconception Health of Women Delivering Live-Born Infants — Oklahoma, 2000–2003
The U.S. Public Health Service recommends that all women of childbearing age consume >400 µg of folic acid daily through either supplementation or fortified foods. CDC recommends offering, as a component of maternity care, one pre-pregnancy visit to a health care provider for women planning pregnancy to enable women to receive risk assessment, health education, and specific interventions to address identified risks before conception. Analysis of data collected from women in Oklahoma during 2000–2003 from the Pregnancy Risk Assessment Monitoring System (PRAMS) indicated that 21.5 percent of women with a recent live birth were not aware of folic acid benefits before they became pregnant, 73.5 percent did not consume multivitamins at least four times per week during the month before pregnancy, and 84.8 percent did not receive preconception counseling from a health-care provider. Although pre-pregnancy awareness of the benefits of taking vitamins with folic acid in the prevention of some birth defects was high among Oklahoma women with a recent live birth, actual consumption of multivitamins during the month before pregnancy was low. Promoting preconception health of women is a key public health strategy in the United States to decrease morbidity and mortality associated with negative maternal and infant outcomes. Increased folic acid consumption before conception and during the first trimester of pregnancy can reduce the incidence of neural tube defects by 50–70 percent.
Surveillance of Preconception Health Indicators Among Women Delivering Live-Born Infants --- Oklahoma, 2000—2003 MMWR June 29, 2007 / 56(25);631-634
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5625a3.htm
Editorial comment: Greggory Woitte – Hastings Indian Medical Center
Preconception Counseling
I am sure that most of your patients are similar to mine in that your first visit with them is after they have become pregnant. They show up at the clinic for a confirmatory pregnancy test, to schedule their first prenatal visit and to get started on prenatal vitamins (or as I am frequently seeing to start Flintstones vitamins). However, as I am sure you are aware, by the time the patient reaches our doorstep, we have missed a very important part of the pregnancy that we may have had some dramatic affect upon.
Between 2000 and 2003, the state of Oklahoma developed and administered a preconception survey. (See above) They found that 84.8% of women did not have any preconception counseling by a provider. 21.5% of women did not know about the benefits of preconception folic acid and equally disturbing was that 73.5% did not take vitamins before trying to become pregnant.
In accordance with the ACOG Committee Opinion No. 313, patients who are in the reproductive ages should be questioned about the possibility of becoming pregnant, especially if they are not on contraception. Women should be encouraged to formulate a reproductive health plan. We, as practitioners of Women’s Health, should be encouraging women to take steps to get as healthy as possible at every visit. This is especially important in women of reproductive ages where we have the opportunity to provide education regarding the benefits to the fetus, as well as to identify patients at high risk for adverse pregnancy outcomes.
We also need to remind our colleagues from other disciplines of medicine to ask their patients about potentially becoming pregnant and refer those who may be in need of pre-conceptional counseling or those in need of contraceptive counseling.
ACOG Committee Opinion Number 313. The importance of preconception care in the continuum of women's health care. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2005 Sep;106(3):665-6 .
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=16135611
Center for Chronic Disease Prevention and Health Promotion http://www.cdc.gov/nccdphp/
Office of Communication (770) 488-5131
Osteoporosis
Dietary calcium is better than supplements at protecting bone health
Women who get most of their daily calcium from food have healthier bones than women whose calcium comes mainly from supplemental tablets
CONCLUSION: Calcium from dietary sources is associated with a shift in estrogen metabolism toward the active 16 alpha-hydroxyl metabolic pathway and with greater BMD and thus may produce more favorable effects in bone health in postmenopausal women than will calcium from supplements.
Napoli N, et al Effects of dietary calcium compared with calcium supplements on estrogen metabolism and bone mineral density. Am J Clin Nutr. 2007 May;85(5):1428-33
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17490982
Calcium, Vitamin D supplements may help prevent weight gain in postmenopausal women
Largest national study of its kind finds popular nutritional supplements have minimal, but statistically significant effects on weight change over seven years. Postmenopausal women who take calcium and vitamin D supplements may gain less weight than those who do not, although the overall effect is small.
CONCLUSION: Calcium plus cholecalciferol supplementation has a small effect on the prevention of weight gain, which was observed primarily in women who reported inadequate calcium intakes
Caan B, et al Calcium plus vitamin D supplementation and the risk of postmenopausal weight gain. Arch Intern Med. 2007 May 14;167(9):893-902
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17502530
Down to the Bone: Issues in the Maintenance and Evaluation of Bone Health: CME
http://www.medscape.com/viewprogram/7087?sssdmh=dm1.277363&src=nlcmealert
Patient Information
Heavy Periods (Menorrhagia)
http://www.aafp.org/afp/20070615/1820ph.html
Perinatology Picks - George Gilson, Maternal Fetal Medicine, ANMC
Anemia in Pregnancy Briefly: The Common to the Unusual – including IV therapy
BACKGROUND
Anemia is very common in pregnant women, and 99% of such women (in non-malarious areas) are iron deficient. Iron deficiency is seen frequently because of prior menstrual losses, prior pregnancy related losses, and nutritional factors. As a result of a dilutional effect, the normal hematocrit for third trimester pregnant women at sea level is 33+3 %. Women with a hematocrit over 30% should not be considered anemic.
DIAGNOSIS
Sophisticated studies are usually not needed in the work up of a woman with pregnancy associated anemia. The CBC that revealed the low hemoglobin/hematocrit will usually also reveal a low MCV (microcytosis), a low MCH (hypochromia), and an increased RDW (anisocytosis), characteristic of iron deficiency. Women with mild (or acute) anemia may not yet have these typical red cell morphologic changes however. The most sensitive and specific test for iron deficiency during pregnancy (even prior to overt anemia) is a low serum ferritin, which reflects total body iron stores. Normal values are 40-200 ng/mL. Serum iron, TIBC (transferrin), and the per cent transferrin saturation, are all less accurate indices during pregnancy. Hemoglobin electrophoresis should be reserved for women who, on the basis of their ethnicity or family history, are suspected of having a hereditary hemoglobinopathy (e.g., thalassemia, sickle cell disease, etc.).
TREATMENT
- Oral iron therapy
Most women with iron deficiency can be treated with oral iron. Ferrous sulfate 325 mg contains 57 mg of elemental iron, and is the most efficient form. The evidence is unclear as to the value of adding ascorbic acid. Oral iron commonly causes gastrointestinal symptoms however. These are usually dose dependent, but may be severe enough that women will not, or cannot, adhere to their regimen, even with stool softeners and/or acid reducing agents. Slow-release iron formulations may prevent gastric irritation, but not constipation, and are significantly more expensive. Stools will become black after taking iron, and asking about stool color is a good way to check adherence to therapy. To see if the patient is responding to (or taking) therapy, a reticulocyte count may be obtained 7 days after starting treatment, but a rise in the hemoglobin or hematocrit will usually not occur until 3-4 weeks. It may also be prudent to prescribe supplemental folic acid, at least 1 mg daily, as this nutrient will also commonly be deficient in women who are iron deficient.
b. Parenteral iron therapy
Anemia may become severe enough to cause symptoms (fatigue, tachycardia, etc.). Since acute post partum hemorrhage is such a common event (approximately 5 per cent of births), this has the potential to becoming a life-threatening condition. Women with a known placenta previa are at special risk. Fetal growth and oxygenation will usually not be affected until the maternal hemoglobin is less than 5 g/mL however. In such symptomatic or worrisome cases, where adherence is a limiting factor, parenteral iron therapy may be considered.
There are 3 parenteral iron therapy options available in the United States at the present time: iron dextran, ferric gluconate, and iron sucrose. Iron dextran is no longer widely used because of its significant risk of anaphylaxis (0.6%), or other hypersensitivity reactions (0.2-3%). It is also usually given intramuscularly, and is painful, can cause skin discoloration, and is unpredictably absorbed. Ferric gluconate and iron sucrose are both given intravenously, and are safe and effective alternatives, although they are somewhat more expensive. Iron sucrose has the lowest rate of serious adverse reactions (anaphylaxis 0.002%, hypersensitivity 0.005%), and so is our drug of choice.
Our current protocol is to give iron sucrose 200 mg in 100 mL of normal saline IV over 1 hour. A test dose (25 mg IV slow push) is not necessary, but may be considered at the discretion of the provider. The woman’s exact dose can be calculated, taking into account her weight and the current and desired hematocrit, but, since most women who will be receiving the drug are severely anemic, we have elected to empirically give 5 doses of 200 mg (total of 1000 mg) at 24-48 hour intervals. The patient should be observed and vital signs and fetal heart rate documented prior to her discharge. The hemoglobin or hematocrit may be repeated 7 days after the last dose, as hematopoeisis proceeds rapidly after intravenous iron administration. If you wish to see if total iron stores have been replenished, a serum ferritin may provide guidance, and a second course of iron sucrose considered.
In the rare event of a serious adverse reaction, the infusion should be stopped, the patient hydrated with normal saline, and preparations for possible need for respiratory support (endotracheal intubation) initiated. The following drugs should be administered: epinephrine 0.3-0.5 of 1:1000 SQ every 5 minutes, diphenhydramine 50 mg IV, and methylprenisolone 125 mg IV.
REFERENCES
- Baker WF. Iron deficiency in pregnancy, obstetrics, and gynecology. Hematol Oncol Clin North Am 2000; 14:1061-77.
- Bayoumeu F, et al. Iron therapy in iron deficiency anemia in pregnancy: Intravenous route versus oral route. Am J Obstet Gynecol 2000; 186:518-22.
- Charytan C, et al. Efficacy and safety of iron sucrose for iron deficiency in patients with dialysis-associated anemia. Am J Kidney Dis 2001; 37:300-7.
- Van Wych DB, et al. Safety and efficacy of iron sucrose in patients sensitive to iron dextran. Am J Kidney Dis 2000; 36:88-97.
Other
Contingent sequential screening is the most cost-effective form of Down syndrome
CONCLUSION: Analysis of this actual data from the FASTER Trial demonstrates that the Contingent Sequential test is the most cost-effective. This information can help shape future policy regarding Down syndrome screening
Ball RH, et al First- and Second-Trimester Evaluation of Risk for Down Syndrome. Obstet Gynecol. 2007 Jul;110(1):10-17
http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db
=pubmed&list_uids=17601890&dopt=Abstract
Aspirin during pregnancy could reduce risk of pre-eclampsia
Women who receive aspirin or other antiplatelet drugs during pregnancy are at lower risk of pre-eclampsia. INTERPRETATION: Antiplatelet agents during pregnancy are associated with moderate but consistent reductions in the relative risk of pre-eclampsia, of birth before 34 weeks' gestation, and of having a pregnancy with a serious adverse outcome.
Askie LM, et al Antiplatelet agents for prevention of pre-eclampsia: a meta-analysis of individual patient data. Lancet. 2007 May 26;369(9575):1791-8
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17512048
Abnormal Doppler is the best predictor of adverse perinatal outcome in IUGR
RESULTS: We identified 151 singleton pregnancies with intrauterine growth restriction meeting the inclusion criteria. On bivariate analysis significant variables associated with adverse outcomes were as follows: history of chronic hypertension, corticosteroid administration, and gestational age of delivery. These were adjusted by using logistic regression. The positive predictive values of abnormal Doppler for respiratory distress syndrome and the composite of adverse outcomes were 36% and 42% respectively. Of the testing modalities compared, only abnormal Doppler significantly predicted respiratory distress syndrome and the composite of adverse outcome.
CONCLUSION: In cases of intrauterine growth restriction, the presence of abnormal Doppler is the best predictor of adverse perinatal outcome.
Gonzalez JM, et al Relationship between abnormal fetal testing and adverse perinatal outcomes in intrauterine growth restriction Am J Obstet Gynecol. 2007 May;196(5):e48-51
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17466679
Changes in prepregnancy body mass index between the first and second pregnancies and risk of large-for-gestational-age birth
CONCLUSION: In comparison with women with normal BMI in both pregnancies, any increase or decrease in prepregnancy BMI between normal and obese is associated with increased risk of LGA birth. A modification in the risk of LGA births by long-term maternal BMI status or maternal genetic factors appears likely.
Getahun D, et al Changes in prepregnancy body mass index between the first and second pregnancies and risk of large-for-gestational-age birth. Am J Obstet Gynecol. 2007 Jun;196(6):530.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17547882
17-alpha-hydroxyprogesterone caproate decreases cervical ripening during preterm
CONCLUSION: Undelivered patients after preterm labor undergo progressive shortening of the cervix, which is attenuated by 17P treatment.
Facchinetti F et al Cervical length changes during preterm cervical ripening: effects of 17-alpha-hydroxyprogesterone caproate. Am J Obstet Gynecol. 2007 May;196(5):453.e1-4; discussion 421
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17466698
Betamethasone and dexamethasone comparable: Dexamethasone is more effective in IVH
CONCLUSION: Betamethasone and dexamethasone are comparable in reducing the rate of most major neonatal morbidities and mortality in preterm neonates. However, dexamethasone seems to be more effective in reducing the rate of intraventricular hemorrhage compared with betamethasone
Elimian A, et al Antenatal betamethasone compared with dexamethasone (betacode trial): a randomized controlled trial. Obstet Gynecol. 2007 Jul;110(1):26-30
http://www.ncbi.nlm.nih.gov/sites/entrez?cmd
=retrieve&db=pubmed&list_uids=17601892&dopt=Abstract
Correlates of anxiety symptoms during pregnancy with perinatal outcomes
CONCLUSION: Anxiety symptoms during pregnancy appear to be associated with similar psychosocial variables as anxiety at other times. There is no evidence of an association of anxiety symptoms with adverse perinatal outcomes among those studied thus far. However, significant gaps still exist in the literature in this area.
Littleton HL, et al Correlates of anxiety symptoms during pregnancy and association with perinatal outcomes: a meta-analysis. Am J Obstet Gynecol. 2007 May;196(5):424-32 .
http://www.ncbi.nlm.nih.gov/sites/entrez?Db
=pubmed&Cmd=ShowDetailView&TermToSearch=17466693
Safety of inhaled corticosteroids for asthma with regard to the congenital malformation
CONCLUSION: This study adds evidence to the safety of inhaled corticosteroids for the treatment of asthma during pregnancy, with regard to the likelihood of congenital malformation.
Blais L et al Use of inhaled corticosteroids during the first trimester of pregnancy and the risk of congenital malformations among women with asthma. Thorax. 2007 Apr;62(4):320-8
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17121872
Maternal leptin across pregnancy in women with small-for-gestational-age infants
CONCLUSION: Maternal leptin was correlated with maternal adiposity; however, after adjustment for body composition, leptin was lower across pregnancy in women with SGA.
Catov JM, et al Maternal leptin across pregnancy in women with small-for-gestational-age infants Am J Obstet Gynecol. 2007 Jun;196(6):558
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17547894
Green Journal Cochrane Update:
Oxytocin receptor antagonists for inhibiting preterm labour
AUTHORS' CONCLUSION: This review failed to demonstrate the superiority of atosiban over betamimetics or placebo in terms of tocolytic efficacy or infant outcomes. The finding of an increase in infant deaths in one placebo-controlled trial warrants caution. A recent Cochrane Review suggests that calcium channel blockers (mainly nifedipine) are associated with better neonatal outcome and fewer maternal adverse effects than betamimetics. However, a randomized comparison of nifedipine with placebo is not available. Further well-designed randomized controlled trials of tocolytic therapy are needed. Such trials should incorporate a placebo arm.
Oxytocin receptor antagonists for inhibiting preterm labour. Obstet
Gynecol. 2007 Jul;110(1):180-1 http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db
=pubmed&list_uids=17601917&dopt=Abstract
Interval > 14 days between corticosteroids and delivery: Risk for ventilatory support
CONCLUSION: A time interval of > 14 days between the administration of antenatal corticosteroids and delivery is associated with an increased risk for ventilatory support and surfactant use in neonates who deliver at > 28 weeks of gestation.
Ring AM et al The effect of a prolonged time interval between antenatal corticosteroid administration and delivery on outcomes in preterm neonates: a cohort study. Am J Obstet Gynecol. 2007 May;196(5):457
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17466700
Sex hormone-binding globulin optimal to predict subsequent gestational diabetes
STUDY DESIGN: A nested case-control design was used to evaluate the association of sex hormone-binding globulin, high-sensitive C-reactive protein, and measures of fasting glucose and insulin (homeostasis assessment model) obtained in the late first trimester and early second trimester of pregnancy with the diagnosis of gestational diabetes mellitus.
CONCLUSION: Among 3 biomarkers examined prospectively, first-trimester nonfasting sex hormone-binding globulin appeared to be the optimal marker to predict subsequent gestational diabetes mellitus.
Smirnakis KV et al Predicting gestational diabetes: choosing the optimal early serum marker. Am J Obstet Gynecol. 2007; 196(4):410.e1-6; discussion 410.e6-7
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17403439
Maternal serum levels of alpha-FP and hCG were statistically associated with stillbirth risk
CONCLUSIONS: Maternal serum levels of alpha-FP and hCG were statistically associated with stillbirth risk. However, the predictive ability was generally poor except for losses at extreme preterm gestations, where prevention may be difficult and interventions have the potential to cause significant harm.
Smith GC et al Maternal and biochemical predictors of antepartum stillbirth among nulliparous women in relation to gestational age of fetal death. BJOG. 2007; 114(6):705-14
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17516962
Variation in birth weight may be determined by fetal growth in the first 12 weeks
CONCLUSION: Variation in birth weight may be determined, at least in part, by fetal growth in the first 12 weeks after conception through effects on timing of delivery and fetal growth velocity.
Bukowski R et al Fetal growth in early pregnancy and risk of delivering low birth weight infant: prospective cohort study. BMJ. 2007; 334(7598):836
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17355993
Factor XII deficiency is associated with recurrent miscarriage
CONCLUSION: Factor XII deficiency is associated with recurrent miscarriage. Data on the other factors either fail to show association or are quite limited.
Sotiriadis A et al Fibrinolytic defects and recurrent miscarriage: a systematic review and meta-analysis Obstet Gynecol. 2007; 109(5):1146-55
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17470597
Amniocentesis Results and Anxiety
CONCLUSIONS: Rapid testing was a beneficial addition to karyotyping, at least in the short term. This does not necessarily imply that early results would be preferred to comprehensive ones if women had to choose between them. Because there are no clear advantages in anxiety terms of issuing karyotype results as soon as they become available, or on a fixed date, women could be given a choice between them.
Hewison J et al A randomised trial of two methods of issuing prenatal test results: the ARIA (Amniocentesis Results: Investigation of Anxiety) trial. BJOG. 2007; 114(4):462-8
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17378819
Nitric oxide for preventing pre-eclampsia and its complications
AUTHORS' CONCLUSIONS: There is insufficient evidence to draw reliable conclusions about whether nitric oxide donors and precursors prevent pre-eclampsia or its complications.
Meher S; Duley L Nitric oxide for preventing pre-eclampsia and its complications. Cochrane
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17443623
Gestational age and perinatal mortality: South Asian and black women at increased risk
Conclusions The risk of perinatal mortality increased earlier in gestation among South Asian women than among white women. The most important factor associated with antepartum stillbirth among white women was placental abruption, but among South Asian and black women it was birth weight below 2000 g.
Balchin I et al Racial variation in the association between gestational age and perinatal mortality: prospective study. BMJ. 2007; 334(7598):833
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17337455
Usage of spot urine protein to creatinine ratios in the evaluation of preeclampsia
RESULTS: Random spot P:C ratios were strongly correlated with 24 hour urine protein levels (Pearson r = 0.88). The optimal P:C cut-offs were 0.21 (300 mg per 24 hours) and 3.0 (5000 mg per 24 hours). A P:C ratio of less than 0.21 (300 mg per 24 hours) had a negative predictive value (NPV) of 83.3% and a P:C ratio of less than 3.0 (5000 mg per 24 hours) had 100% NPV. CONCLUSION: Urine spot P:C ratio correlated well with 24 hour urine collections for protein but was not justified as a substitute for timed collections.
Wheeler TL, et al Usage of spot urine protein to creatinine ratios in the evaluation of preeclampsia Am J Obstet Gynecol. 2007 May;196(5):465
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17466704
No benefit to therapy in 1 elevated oral glucose tolerance test value
Conclusion: In our patient population, women with 1 elevated oral glucose tolerance test value did not benefit from a structured program of medical nutritional therapy and self- blood glucose monitoring.
Fassett, MJ et al Effects on perinatal outcome of treating women with 1 elevated glucose tolerance test value Am J Obstet Gynecol. 2007 Volume 196, Issue 6, Pages 597.e1-597.e4
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17547912
Limited support for fetal pulse oximetry in the presence of a nonreassuring FHR
AUTHORS' CONCLUSIONS: The data provide limited support for the use of fetal pulse oximetry when used in the presence of a nonreassuring CTG, to reduce caesarean section for nonreassuring fetal status. The addition of fetal pulse oximetry does not reduce overall caesarean section rates. A better method to evaluate fetal well-being in labour is required.
East CE et al Fetal pulse oximetry for fetal assessment in labour. Cochrane Database Syst Rev. 2007 Apr 18;(2):CD004075
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17443538
Primary Care Discussion Forum
September 1, 2007
Moderator: Andrew Narva, MD
Chronic Renal Disease: How is Primary Care Effected?
- What is an appropriate work up?
- Anticipated benefits of acting now
- What is the impact of diabetes on chronic renal disease?
How to subscribe / unsubscribe to the Primary Care Discussion Forum?
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Questions on how to subscribe, contact nmurphy@scf.cc directly
STD Corner - Lori de Ravello, National IHS STD Program
Updated Screening for Chlamydial Infection Recommendations, USPSTF
- The U.S. Preventive Services Task Force (USPSTF) recommends screening for chlamydial infection for all sexually active non-pregnant young women aged 24 and younger and for older non-pregnant women who are at increased risk . This is a grade A Recommendation.
- The USPSTF recommends screening for chlamydial infection for all pregnant women aged 24 and younger and for older pregnant women who are at increased risk . This is a grade B Recommendation.
- The USPSTF recommends against routinely providing screening for chlamydial infection for women aged 25 and older, whether or not they are pregnant, if they are not at increased risk . This is a grade C Recommendation.
- The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for chlamydial infection for men . This is a grade I Statement.
http://www.ahrq.gov/clinic/uspstf/uspschlm.htm
Sexually active women benefit from HPV vaccine
INTERPRETATION: Administration of HPV vaccine to HPV-naive women, and women who are already sexually active, could substantially reduce the incidence of HPV16/18-related cervical precancers and cervical cancer
Ault KA Effect of prophylactic human papillomavirus L1 virus-like-particle vaccine on risk of cervical intraepithelial neoplasia grade 2, grade 3, and adenocarcinoma in situ: a combined analysis of four randomised clinical trials. Lancet. 2007; 369(9576):1861-8
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17544766
HPV vaccine against human papillomavirus to prevent anogenital diseases
CONCLUSIONS: The quadrivalent vaccine significantly reduced the incidence of HPV-associated anogenital diseases in young women.
Garland SM et al Quadrivalent vaccine against human papillomavirus to prevent anogenital diseases. N Engl J Med. 2007; 356(19):1928-43
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17494926
Vulvar Vaccinia Infection After Sexual Contact with a Military Smallpox Vaccinee - 2006
On October 10, 2006, an otherwise healthy woman visited a public health clinic in Alaska after vaginal tears that she had first experienced 10 days before became increasingly painful. The patient reported having a new male sex partner during September 22-October 1, 2006. This report describes the clinical evaluation of the woman and laboratory testing performed to identify the isolate. Health-care providers should be aware of the possibility of vaccinia infection in persons with clinically compatible genital lesions who have had recent contact with smallpox vaccinees. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5617a1.htm
A Series on Adolescence Sexual Activity
Dating, sex, and substance use as correlates of adolescents’ subjective experience of age
This study examined in a random community-based sample of 664 12–19-year-olds, the relation of subjective experience of age (SEA) with chronological age, dating experience, sexual activity, and substance use. The results revealed a positive linear relation between SEA and chronological age: individuals who were chronologically older felt subjectively older than their actual age. Several possible sources of interindividual differences in SEA were identified. Adolescents who were dating an older partner felt older compared to other dating adolescents. Sexually experienced adolescents felt older than their non-experienced counterparts. Smoking (in boys), higher alcohol use, and higher drug use were also related to an older SEA. These results suggest an increasing discrepancy between SEA and chronological age across the teen years as young people experience the normative changes associated with adolescence. Dating, sexual, and substance use activities may figure importantly in the way that adolescents experience their age.
Arbeau KJ et al Dating, sex, and substance use as correlates of adolescents’ subjective experience of age Journal of Adolescence Volume 30, Issue 3, June 2007, Pages 435-447
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=16764917
Parental communication and youth sexual behaviour
The role of parental communication and instruction concerning sexual behaviour were studied in a community-based sample of 1083 youth aged 13–17 (mean age of 15 years; 51% girls, 49% White). The Youth Asset Survey was administered along with items measuring demographics and youth risk behaviours. After controlling for demographic factors, multivariate analysis revealed that youth were much less likely to have initiated sexual intercourse if their parents taught them to say no, set clear rules, talked about what is right and wrong and about delaying sexual activity. If youth were sexually active, they were more likely to use birth control if taught at home about delaying sexual activity and about birth control. Having only one sexual partner was associated with having an adult role model who supports abstinence, being taught at home about birth control, and being taught at home how to say no. If parents reported talking with youth about birth control and sexually transmitted disease (STD) prevention, youth were significantly more likely to use birth control. Our conclusion is that parents have the opportunity and ability to influence their children's sexual behaviour decisions.
Aspy CB et al Parental communication and youth sexual behaviour Journal of Adolescence Volume 30, Issue 3, June 2007, Pages 449-466
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=16750265
Adolescent use of psychologically, physically, and sexually abusive behaviours in dating
We examined the co-occurrence of and risk factors for adolescent boys’ and girls’ self-reported use of psychologically, physically, and sexually abusive behaviours in their dating relationships. The participants were 324 boys and 309 girls in grades 7, 9, or 11 who completed surveys at school. Descriptive analyses showed that 19% of boys and 26% of girls reported having used two or more forms of dating violence. One third of students in grade 7 had already used at least one form of aggressive behaviour in this context.
Canonical correlation analyses indicated that boys’ and girls’ use of multiple forms of dating violence were predicted by their attitudes toward and experiences with violence. After controlling for general abusiveness, boys’ use of sexually abusive behaviour and girls’ use of psychologically abusive behaviour were linked to specific risk factors that suggest an enactment of social scripts associated with their respective gender roles.
Sears HA et al The co-occurrence of adolescent boys’ and girls’ use of psychologically, physically, and sexually abusive behaviours in their dating relationships Journal of Adolescence Volume 30, Issue 3, June 2007, Pages 487-504
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=16884766
Validation of a ‘triangular love scale’ for adolescents: Intimacy, passion, and commitment
This study examined the psychometric properties of an adolescent version of the ‘triangular love scale’ (TLS), which assesses three components of romantic relationships: intimacy, passion, and commitment. Using data from 435 Dutch adolescents aged 12–18 years, we found evidence for convergent validity, showing that dimensions of intimacy, passion, and commitment were all positively correlated with relationship satisfaction and duration. Evidence was also found for divergent validity, as adolescents’ perceptions of the main (dis)advantages of being involved in romantic relationships showed a specific pattern of associations with intimacy, passion, and commitment. Finally, CFA analyses in LISREL showed that a model in which all separate questionnaire items were specified to load on three underlying, correlated factors (intimacy, passion, commitment) fit the data adequately. Overall, this measure seems appropriate for use with adolescents.
Overbeek G et al Brief report: Intimacy, passion, and commitment in romantic relationships—Validation of a ‘triangular love scale’ for adolescents Journal of Adolescence Volume 30, Issue 3, June 2007, Pages 523-528
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17320166
Partnerships: Developing Adolescent Health Community-Researcher Partnerships
RESULTS: Sites chose as their primary target population young women who have sex with men (n = 8 sites), young men who have sex with men (n = 6), and intravenous drug users (n = 1). Of 1162 agencies initially interviewed, 281 of 335 approached (84%) agreed to join the partnership (average 19/site). A diverse array of community agencies were represented in the final collaborative network; specific characteristics included: 93% served the sites' target population, 54% were predominantly youth oriented, 59% were located in the geographical area of focus, and 39% reported provision of HIV/STI (sexually transmitted infection) prevention services. Relationship-building activities, development of collaborative relationships, and lessons learned, including barriers and facilitators to partnership, are also described. CONCLUSIONS: Study findings address a major gap in the community partner research literature. Health researchers and policymakers need an effective partner selection framework whereby community-researcher partnerships can develop a solid foundation to address public health concerns.
Straub DM et al Partnership Selection and Formation: A Case Study of Developing Adolescent Health Community-Researcher Partnerships in Fifteen U.S. Communities. J Adolesc Health. 2007 Jun;40(6):489-498.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17531754
Mycoplasma genitalium among Adolescent Women and their Partners
Results: Cumulatively, 13.6% (52/383) of women tested positive for M. genitalium. All women with M. genitalium, except one, were sexually experienced. M. genitalium was associated with number of sexual partners (p < .001) and C. trachomatis infection (p < .03). M. genitalium was more likely among male partners of M. genitalium-positive women (p < .02); 31.3% of untreated M. genitalium cases had infection lasting over 8 weeks. M. genitalium was not associated with the presence of clinical signs or symptoms of infection.
Conclusions: Findings support sexual transmissibility of M. genitalium and add to understanding of M. genitalium natural history and clinical findings.
Tosh AK et al Mycoplasma genitalium among Adolescent Women and their Partners. Journal of Adolescent Health, Volume 40, Issue 5, Pages 412-417 (May 2007)
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17448398
Update on Male Chlamydia (Ct) Screening
Summary of Recommendations
The consultants did not consider any recommendations pertaining to whether programs should adopt or expand male Ct screening programs. For state and local programs that have decided to screen, the following guidance is provided to assist with decisions about which populations of males to screen for Ct and how best to screen.
- Males attending STD clinics should be screened for Ct
- Males attending Job Corps should be screened for Ct
- Males <30 years of age entering jails should be screened for Ct
- Males with Ct infection should be re-screened at 3 months for repeat Ct
- Urine is the specimen of choice for screening asymptomatic men for Ct
- Nucleic acid amplification test: NAATs are the test of choice. LET is not recommended for screening males for Ct
- Pooling of urine specimens should be considered for Ct testing in low prevalence settings to conserve resources
- Partner services should be offered to partners of males with Ct
11 page report with appendices: Male Chlamydia Screening Consultation
Atlanta , Georgia -March 28 – 29, 2006
1) a review of venues and Ct prevalence;
2) a review of prevalence of Ct among men in the U.S.;
3) a review of behavioral and demographic features associated with Ct among men;
4) cost-effectiveness issues;
5) laboratory issues;
6) partner management; and
7) re-infection.
http://www.cdc.gov/std/chlamydia/ChlamydiaScreening-males.pdf
Use of a Computer for HIV and Sexually Transmitted Infection Risk Reduction
RESULTS: Users were 58% nonwhite with mean age 24.7 years (74% < 25). Patients could use CARE with minimal to no assistance. Time for session completion averaged 29.6 minutes. CARE usefulness was rated an average of 8.2 on an ascending utility scale of 0 to 10. Patient themes raised as strengths were novelty, simplicity, confidentiality, personalization, and plan development, increased willingness to be honest, lack of judgment, and a unique opportunity for self-evaluation. Staff themes raised as strengths were enhanced data collection, handout customization, education standardization, behavioral priming, and expansion of services. Patient limitation themes included limited responses and lack of personal touch. Staff limitation themes were selecting users, cost, patient-provider role, privacy, and time for use. CONCLUSIONS: CARE was well-received and easily usable by most (especially 18-25-year-olds). Patient and staff perceptions support the use of CARE as an adjunct to usual practice and as a method to expand services. Honesty, reduced time constraints, and lack of judgment associated with CARE appeared to enhance self-evaluation, which may prove an important component in moving patients forward in the behavior change process.
Mackenzie SL et al Patient and Staff Perspectives on the Use of a Computer Counseling Tool for HIV and Sexually Transmitted Infection Risk Reduction. J. Adolesc Health. 2007 Jun;40(6):572.e9-572.e16.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17531766
Barbara Stillwater, Alaska State Diabetes Program
(How) can we prevent type 2 diabetes?
Our knowledge base in this field is still quite rudimentary, and we have no information about truly long-term (ie, for decades) prevention of type 2 diabetes.
Type 2 diabetes is a progressive disease. It develops over years as a result of declining pancreatic ß-cell compensation for chronic and often worsening insulin resistance. Preventing type 2 diabetes requires modification of the underlying disease biology to slow, stop, or reverse the decline in ß-cell compensation. Data from six randomized trials reveal several interventions that reduce the number of high-risk people who develop diabetes during relatively short periods of treatment. Interventions that reduce body fat or that mitigate the effect of excess fat to cause insulin resistance provide the greatest risk reduction and the best evidence for real disease modification. At least two studies indicate that disease modification is possible soon after glucose levels enter the diabetes range. These findings, combined with the fact that falling ß-cell compensation leads to rising glycemia, provide a rationale for an intervention strategy that begins with lifestyle modification and progresses to pharmacological therapy aimed at reducing insulin resistance if lifestyle approaches fail to prevent glucose from rising to the diabetes range. Our knowledge base in this field is still quite rudimentary, and we have no information about truly long-term (i.e., for decades) prevention of type 2 diabetes. Even for the short to intermediate term, additional work is needed to determine optimal application of the general strategy described above, to examine combination approaches to prevention, and to test new interventions as they become available. Such work should focus on disease modification, not just cases of diabetes, as a major outcome.
Buchanan TA. (How) can we prevent type 2 diabetes? Diabetes. 2007 Jun;56(6):1502-7.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17389328
Prenatal Omega 3 Fatty Acid Consumption Improves Infant Problem Solving
Mothers who regularly ate a functional food containing an Omega 3 fatty acid during pregnancy gave birth to infants with better problem solving abilities as measured at nine months of age
CONCLUSION: These data point to a benefit for problem solving but not for recognition memory at age 9 mo in infants of mothers who consumed a DHA-containing functional food during pregnancy.
Judge MP, et al Maternal consumption of a docosahexaenoic acid-containing functional food during pregnancy: benefit for infant performance on problem-solving but not on recognition memory tasks at age 9 mo. Am J Clin Nutr. 2007 Jun;85(6):1572-7
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17556695
More Women than Men Having Mid-Life Stroke
More women than men appear to be having a stroke in middle age, according to a study
CONCLUSIONS: A higher prevalence of stroke may exist among women aged 45 to 54 years compared with similarly aged men. This potential disparity could be due in part to inadequate stroke risk factor modification in women and is deserving of further study.
Towfighi
A, et al A midlife stroke surge among women in the United States. Neurology. 2007
Jun 20 http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17581944
Diabetes Reduces Life Expectancy by 8 Years
Before heart disease even develops among patients with heart disease, the effects on life expectancy have already begun, found researchers. In an analysis of the Framingham Heart Study, diabetic men and women age 50 and older died on average 7.5 and 8.2 years earlier, respectively, than those who did not have diabetes. CONCLUSIONS: The increase in the risk of CVD and mortality from diabetes represents an important decrease in life expectancy and life expectancy free of CVD. Prevention of diabetes is a fundamental task facing today's society in the pursuit of healthy aging
Franco OH, et al Associations of diabetes mellitus with total life expectancy and life expectancy with and without cardiovascular disease. Arch Intern Med. 2007 Jun 11;167(11):1145-51
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17563022
GDM represents a significant risk factor for future DM development regardless of ethnicity
High glycosylated hemoglobin levels in women with gestational diabetes are associated with the development of diabetes in the future, new research indicates.
CONCLUSION: GDM represents a significant risk factor for future DM development regardless of ethnicity. Glycated haemoglobin values at GDM diagnosis have value in predicting future diabetes mellitus.
Oldfield MD, et al Long term prognosis of women with gestational diabetes in a multiethnic population. Postgrad Med J. 2007 Jun;83(980):426-3
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17551077
Prediction of Incident Diabetes Mellitus in Middle-aged Adults
CONCLUSION: Parental diabetes, obesity, and metabolic syndrome traits effectively predict T2DM risk in a middle-aged white population sample and were used to develop a simple T2DM prediction algorithm to estimate risk of new T2DM during a 7-year follow-up interval
Wilson PW, et al Prediction of incident diabetes mellitus in middle-aged adults: the Framingham Offspring Study. Arch Intern Med. 2007 May 28;167(10):1068-74
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17533210
Women With Heart Disease And Diabetes Less Likely To Receive Proper Care
Women with heart disease and diabetes are less likely to receive several types of routine outpatient medical care than men who have similar health problems,
CONCLUSION: Gender differences in the quality of cardiovascular and diabetic care were common and sometimes substantial among enrollees in Medicare and commercial health plans. Routine monitoring of such differences is both warranted and feasible.
Bird CE et al Does quality of care for cardiovascular disease and diabetes differ by gender for enrollees in managed care plans? Womens Health Issues. 2007 May-Jun;17(3):131-8
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17434752
Women's Health Headlines, Carolyn Aoyama, HQE
Why do Native American women have the poorest 5-year survival rate for breast cancer?
Encourage American Indian/Alaska Native women to join the Sister Study TODAY!
The Sister Study needs your help
Please help the Sister Study recruit more AI/AN women.
- So far, less than 500 AI/AN women have enrolled out of a total of (37,000) in the Sister Study
- Breast cancer is the 2nd leading cause of cancer death among Native women.
- Their 5-year survival rate is lower than that of white women.
- Scientists have very little information on cancer histories in American Indian/Alaska Native communities.
Please help recruit patients into this study:
Eligibility criteria include the following:
35 and 74 years old
AND the patient has never had breast cancer
AND the patient lives in the U.S. or Puerto Rico
AND the patient (living, deceased), is a blood relative and had breast cancer.
https://sisterstudy.niehs.nih.gov/webscreener/DisplayPage.asp?_PageNumber=1
Motivational Interviewing training and Promoting Motivational Incentives: NIDA
Two new products designed to speed the adoption of science-based interventions into clinical practice are now available from the National Institute on Drug Abuse (NIDA), part of the National Institutes of Health (NIH). These new "Blending Team" products are part of an expanding portfolio that includes the latest research findings on drug abuse approaches and interventions. Blending Teams are composed of NIDA researchers, community-based substance abuse treatment practitioners, and trainers from the Substance Abuse and Mental Health Services Administration's Addiction Technology Transfer Center Network. In addition to the Blending Teams, NIDA sponsors a number of Blending conferences which are held periodically around the country to facilitate communication between researchers and treatment providers.
The two new Blending Team products are:
-- "Motivational Interviewing Assessment: Supervisory Tools for Enhancing
Proficiency" (MIA:STEP), tailored for clinical supervisors to train front-line
treatment providers to improve their motivational interviewing skills. It
also includes a new package of tools designed to enhance patient engagement and
retention.
-- "Promoting Awareness of Motivational Incentives" (PAMI). These
tools provide information about the science-based intervention called motivational
incentives (low or no-cost reinforcements such as vouchers, prizes and privileges)
and describes how the use of positive reinforcement has reduced drug abuse and
has enhanced client retention in treatment programs. The PAMI products include
support materials, resources, PowerPoint presentations for both clinicians and
for policy makers, and an introductory video.
Blending Team products and more information on the NIDA Blending initiative can be accessed at http://www.drugabuse.gov/blending/
OB/GYN CCC Editorial comment:
Motivational Interviewing and virtually every other topic of interest….
Motivational Interviewing and virtually every other topic of interest to Women’s Health in Indian Country will be covered at the Native Women’s Health and MCH Conference, August 15 -17, 2007 in Albuquerque, NM. It is not too late to sign up.
http://www.ihs.gov/MedicalPrograms/MCH/F/CN01.cfm#Aug07
Aiming Higher: Results from a State Scorecard on Health System Performance
The Commonwealth Fund Commission on a High Performance Health System released the first-ever comprehensive comparison of health system performance in all 50 states. ‘Aiming Higher: Results from a State Scorecard on Health System Performance’ ranks states on 32 performance indicators of access, quality, avoidable hospital use and costs, equity, and "healthy lives."
The report compares each state's performance to benchmarks that have already been achieved in states across the country. Although some states ranked highly on multiple indicators, no single state or group of states scored top marks in every area. Some, however, far surpassed others: Hawaii and states in the Northeast and Upper Midwest often rank high in multiple areas, while states with the lowest rankings tend to be concentrated in the South. Across states, health care access and quality were found to be highly correlated
http://www.commonwealthfund.org/publications/publications
_show.htm?doc_id=494551&#doc494551
Women's emotional health and wellness materials
The HRSA Office of Women’s Health has recently developed a series of tools under its Bright Futures for Women's Health and Wellness Initiative (BFWHW) to promote emotional health and wellness among women and adolescent girls. This family of tools includes (1) an adult female educational booklet, (2) an adolescent female educational booklet, (3) an educational and awareness booklet for primary care providers, (4) a poster for clinical settings, and (5) a community idea kit. These tools contain a compilation of evidence-based information, tips, and messages on core elements of psychological, emotional, and spiritual wellness.
Pending final clearance, HRSA OWH will be printing a limited number of hard copies of the tools in FY07 for distribution primarily to HRSA grantees. In order to make the tools available to the broadest possible audience, we would like to provide CCWH members the opportunity to supplement the print order in order to ensure distribution of the tools to your selected audiences. Based on existing estimates, the per-item cost for each tool is as follows: Adult booklet: $0.90; Adolescent booklet: $0.92; Clinical booklet: $0.53; Clinical flyer: $0.26; Community booklet: $1.03. Please note these are estimates and may change based upon final quantities ordered.
Please let me know if you would be interested in riding the print order for some or all of the BFWHW emotional health and wellness tools. Please specify which tools you are interested in and the quantity you would like. Once we have the requisition number from PSC, we will provide this to you for your printing orders through your respective agencies and offices. Thanks!
Reem M. Ghandour, M.P.A
HRSA Office of Women's Health
Parklawn Building , Room 18A-44
5600 Fishers Lane
Rockville , MD 20857
tel: 202-276-0345
fax: 301-443-8587
Native American Rehabilitation Association: Children, Youth & Family Services Director
The Native American Rehabilitation Association of the NW, Inc. ( NARA) is a first class organization in terms of leadership, vision, services and value to the AI/AN community. Please contact Jackie Mercer (in Microsoft Outlook) if you are interested in this position.
Carolyn
RE: We are recruiting for the following key position.
Any help that you could give us in distributing this announcement would be greatly appreciated.
This is a great opportunity to make a difference in the lives of Native Families.
Thanks for your help,
Jackie Mercer
CEO
NARA NW
NARA NW POSITION ANNOUNCEMENT
CHILDREN, YOUTH & FAMILY SERVICES DIRECTOR
The Native American Rehabilitation Association of the NW, Inc (NARA NW) is an Indian-owned & operated private, non-profit agency that provides culturally appropriate physical & mental health services & substance abuse treatment for American Indians, Alaska Natives & other vulnerable people. We are currently seeking a qualified and motivated team member to lead our multi-disciplinary team serving families in the Portland Native American Community.
The Children, Youth & Family Services Director is an exciting new position we created to direct the daily operations of NARA Mental Health Team, Family Wellness Program, Early Childhood Education and related prevention programs (Meth, Youth Suicide, Elders) as well as assure that all service delivery is in compliance with county, state and federal regulations and funding source requirements.
This position will plan, direct, and implement mental health and designated prevention services for all 4 NARA locations. Will provide supervision of program leaders; provide/assure clinical direction/supervision, develop and review mental health treatment, approve programming schedules, coordinate staff in-service trainings, and develop program policies and procedures.
Externally this position acts as a liaison with appropriate local, county, state, and federal agencies and organizations as directed and assure that assigned programs develop and maintain relationships with tribes and the Portland Indian community.
jobs@naranorthwest.org or fax 503-224-4494 www.naranorthwest.org
What's new on the ITU MCH web pages?
Q. Should patients use sweat lodges during pregnancy?
http://www.ihs.gov/MedicalPrograms/MCH/M/Sfaqs.cfm#sweatLodge
New Breast feeding Family Support web page: Have pictures to share?
http://www.ihs.gov/MedicalPrograms/MCH/M/bfFamily.cfm
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
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
I.H.S. / A.C.O.G. Obstetric, Neonatal, and Gynecologic Care Course
- September 16 – 19, 2007
- Denver , CO
- Contact Yvonne Malloy at 202-863-2580 or YMalloy@acog.org
Second National Summit on Preconception Health and Health Care
- October 29-31 2007
- Oakland , CA
- CDC and March of Dimes
- http://www.marchofdimes.com/california/4947_24789.asp
Did you miss something in the last OB/GYN Chief Clinical Consultant Corner?
The June/July 2007 OB/GYN CCC Corner is available.
Hot Topics ‹ Previous
OB/GYN
Dr. Neil Murphy is the Obstetrics and Gynecology Chief Clinical Consultant (OB/GYN C.C.C.). Dr. Murphy is very interested in establishing a dialogue and/or networking with anyone involved in women's health or maternal child health, especially as it applies to Native or indigenous peoples around the world. Please don't hesitate to contact him by e-mail or phone at 907-729-3154.
