September 2004 CCC Corner > Hot Topics

Hot Topics:

• Obstetrics
• Gynecology
• Child Health
• Chronic Disease and Illness

Obstetrics

Treatment for cervical intraepithelial neoplasia and risk of preterm delivery

CONCLUSIONS: LEEP and laser cone treatments were associated with significantly increased risk of pPROM. Careful consideration should be given to treatment of CIN in women of reproductive age, especially when treatment might reasonably be delayed or targeted to high-risk cases.

Sadler L, et al Treatment for cervical intraepithelial neoplasia and risk of preterm delivery. JAMA. 2004 May 5;291(17):2100-6.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15126438

OB/GYN CCC Editorial comment:

For young women who have not yet completed reproduction, LEEP may not be the best therapeutic option for treating CIN, especially of low malignant potential. Women who clearly require surgical intervention may be better served with a procedure such as cryotherapy

Also see Crane et al in Gynecology below  

Outpatient cervical ripening: Successful – Small RCT

CONCLUSION: A single 25-microg outpatient intravaginal dose of misoprostol is effective in decreasing the interval to delivery in women with unfavorable cervices at term

McKenna DS, Ester JB, Proffitt M, Waddell KR. Misoprostol outpatient cervical ripening without subsequent induction of labor: a randomized trial. Obstet Gynecol. 2004 Sep;104(3):579-84.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15339772&dopt=Abstract

OB/GYN CCC Editorial comment:
Outpatient misoprostol has been used successfully in a tertiary care Indian Health setting. This small RCT raises further questions as to its utility in outlying Indian Health facilities, as was discussed at the August IHS Women's Health Biennial Meeting.

Use of Vitamins Containing Folic Acid Among Women of Childbearing Age --- 2004

The fact that 40% of reproductive-age women are now consuming 400 µ g of folic acid every day represents an important step toward meeting that objective; however, the proportion of women not consuming a vitamin containing folic acid is 60%, underscoring the need for continued public health efforts to increase folic acid consumption. These percentages only include supplementation from a vitamin containing folic acid and not consumption of fortified foods. The reported increase in consumption of a vitamin containing folic acid among women of childbearing age from 32% in 2003 to 40% in 2004 suggests a substantial change in behavior. This change has not been previously observed in the March of Dimes survey. Although this increase is encouraging, no clear rationale explains the reported change, and results should be interpreted with caution.

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5336a6.htm

Delaying Epidural Not Necessary During Labor

CONCLUSION: Our data support recent American College of Obstetricians and Gynecologists guidelines that the restraining use of epidural analgesia at <4 cm of cervical dilation is unnecessary.

Vahratian A, et al. The effect of early epidural versus early intravenous analgesia use on labor progression: a natural experiment. Am J Obstet Gynecol. 2004 Jul;191(1):259-65.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15295376

Resistance exercise may help to avoid insulin therapy for overweight women with GDM

CONCLUSION: Resistance exercise training may help to avoid insulin therapy for overweight women with gestational diabetes mellitus. Randomized clinical trial
Brankston GN, Mitchell BF, Ryan EA, Okun NB. Resistance exercise decreases the need for insulin in overweight women with gestational diabetes mellitus. Am J Obstet Gynecol. 2004 Jan;190(1):188-93

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14749658

Intracervical (rather than posterior fornix) placement of dinoprostone decreases time to delivery without increasing complications of labor in mothers who respond to a single dose of the sustained-release preparation. Perry MY, Leaphart WL. Randomized trial of intracervical versus posterior fornix dinoprostone for induction of labor. Obstet Gynecol. 2004 Jan;103(1):13-7.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14704238

Venlafaxine Associated With Neonatal Complications

Neonates exposed to venlafaxine (Effexor and Effexor XR, made by Wyeth) late in the third trimester may develop complications immediately upon delivery and require prolonged hospitalization, respiratory support, and tube feeding, according to a warning issued by MedWatch, the U.S. Food and Drug Administration (FDA) safety information and adverse event reporting program. The warning also applies to other serotonin and norepinephrine reuptake inhibitors (SNRIs) and selective serotonin reuptake inhibitors (SSRIs).

http://www.fda.gov/

Complementary and alternative medicine for labor pain: A systematic review

Conclusion There is insufficient evidence for the efficacy of any of the complementary and alternative therapies for labor pain, with the exception of intracutaneous sterile water injections. For all the other treatments described it is impossible to make any definitive conclusions regarding effectiveness in labor pain control.

Huntley AL, Coon JT, Ernst E Complementary and alternative medicine for labor pain: a systematic review. Am J Obstet Gynecol. 2004 Jul;191(1):36-44.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15295342

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Gynecology

LEEP - not the best for treating young women who have not completed reproduction

CONCLUSION: LEEP appears to be associated with subsequent preterm birth, even when smoking status is matched. Studies with adequate sample size are needed to further evaluate the relationship of LEEP and preterm birth, controlling for potential confounders, including depth of the tissue sample

ACOG Clinical Review Editorial

Five studies with control groups met the criteria for review. For young women who have not yet completed reproduction, LEEP may not be the best therapeutic option for treating CIN, especially of low malignant potential. Women who clearly require surgical intervention may be better served with a procedure such as cryotherapy.

Crane JM. Pregnancy outcome after loop electrosurgical excision procedure: a systematic review. Obstet Gynecol. 2003 Nov;102(5 Pt 1):1058-62.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14672487

JCAHO Sentinel events: Major issues – Communication, teamwork, and staff competency

Root causes identified: In the 47 cases studied, communication issues topped the list of identified root causes (72 percent), with more than one-half of the organizations (55 percent) citing organization culture as a barrier to effective communication and teamwork, i.e., hierarchy and intimidation, failure to function as a team, and failure to follow the chain-of-communication. Other identified root causes include: staff competency (47 percent), orientation and training process (40 percent), inadequate fetal monitoring (34 percent), unavailable monitoring equipment and/or drugs (30 percent), credentialing/privileging/supervision issues for physicians and nurse midwives (30 percent), staffing issues (25 percent), physician unavailable or delayed (19 percent), and unavailability of prenatal information (11 percent).

http://www.jcaho.org/about+us/news+letters/sentinel+event+alert/sea_30.htm

Surgical Prophylaxis: Start early and keep it simple

For abdominal or vaginal hysterectomy, cefotetan is preferred, but reasonable alternatives are cefazolin and cefoxitin . Metronidazole monotherapy is included in the American College of Obstetricians and Gynecologist's Practice Bulletin as an alternative for patients undergoing hysterectomy, although it may be less effective as a single agent for prophylaxis. In cases of -lactam allergy, the workgroup recommends the use of one of the following regimens: clindamycin combined with gentamicin, aztreonam, or ciprofloxacin; metronidazole combined with gentamicin or ciprofloxacin; or clindamycin monotherapy. A single 750-mg dose of levofloxacin can be substituted for ciprofloxacin.

     Patients undergoing cesarean section can be divided into low- and high-risk groups for postoperative infection . High-risk patients include those undergoing cesarean deliveries after rupture of the membranes and/or onset of labor, as well as with emergency operations for which preoperative cleansing may have been inadequate. Although antimicrobial prophylaxis is recommended for both risk groups, the benefits are greatest for high-risk patients. A narrow-spectrum antimicrobial regimen similar to that recommended for hysterectomy provides adequate prophylaxis ]. In the United States , the antimicrobial is usually not administered until the umbilical cord is clamped. Although there is no evidence to support the delay in administration, it is standard practice and is preferred by neonatologists because of concern of masking septic manifestations in the neonate .

Start GYN prophylaxis 60 minutes prior to surgery

The consensus positions of Surgical Infection Prevention Guideline Writers Workgroup (SIPGWW) meeting include that infusion of the first antimicrobial dose should begin within 60 min before surgical incision and that prophylactic antimicrobials should be discontinued within 24 h after the end of surgery. This advisory statement provides an overview of other issues related to antimicrobial prophylaxis, including specific suggestions regarding antimicrobial selection.

Bratzler DW et al Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis. 2004 Jun 15;38(12):1706-15.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15227616

GYN surgery involving the rectum or colon: Prophylaxis

Antimicrobial prophylaxis for colorectal operations can consist of an orally administered antimicrobial bowel preparation, a preoperative parenteral antimicrobial, or the combination of both. Recommended oral prophylaxis consists of neomycin plus erythromycin or neomycin plus metronidazole, initiated no more than 18 24 h before the operation, along with administration of a mechanical bowel preparation. Cefotetan or cefoxitin are recommended for parenteral prophylaxis and the combination of parenteral cefazolin and metronidazole is also recommended as a cost-effective alternative . Although a recent study suggests that the combination of oral prophylaxis with parenteral antimicrobial prophylaxis may result in lower SSI rates, this is not specified in any published guideline. A survey of colorectal surgeons found that combination oral and parenteral prophylaxis is common practice in the United States . For patients with confirmed allergy or adverse reaction to -lactams, use of one of the following regimens is recommended: clindamycin combined with gentamicin, aztreonam, or ciprofloxacin; or metronidazole combined with gentamicin or ciprofloxacin. A single 750-mg dose of levofloxacin can be substituted for ciprofloxacin.

http://www.journals.uchicago.edu/CID/journal/issues/v38n12/33257/33257.html

Pelvic floor physiotherapy is effective treatment for persistent postnatal SUI: RCT

CONCLUSION: Multimodal supervised pelvic floor physiotherapy is an effective treatment for persistent postnatal stress urinary incontinence.

Dumoulin C, et al. Physiotherapy for persistent postnatal stress urinary incontinence: a randomized controlled trial. Obstet Gynecol. 2004 Sep;104(3):504-10
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15339760&dopt=Abstract

Estimating blood loss: can teaching significantly improve visual estimation?

CONCLUSION: Error in estimating blood loss is dependent on actual blood loss volume. Medical students and experienced faculty demonstrate similar errors, and both can be improved significantly with limited instruction. This educational process may assist clinicians in everyday practice to more accurately estimate blood loss and recognize patients at risk for hemorrhage-related complications

Dildy GA 3rd, Paine AR , George NC, Velasco C. Estimating blood loss: can teaching significantly improve visual estimation? Obstet Gynecol. 2004 Sep;104(3):601-6.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15339775&dopt=Abstract

High intrauterine pressure improves success in thermal balloon endometrial ablation

CONCLUSION(S): Maintaining high intrauterine pressure during the treatment cycle and correction of the retroversion may help to improve treatment success in thermal balloon endometrial ablation.

Lok IH, Leung PL, Ng PS, Yuen PM. Life-table analysis of the success of thermal balloon endometrial ablation in the treatment of menorrhagia. Fertil Steril. 2003 Nov;80(5):1255-9.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14607584

Serious complications associated with global endometrial ablation not yet reported

RESULTS: Traditional MEDLINE and bibliography searches yielded reports of two cases of hemorrhage, one case of pelvic inflammatory disease, 20 cases of endometritis, two cases of first-degree skin burns, nine cases of hematometra, and 16 cases of vaginitis and/or cystitis.

A search of the US Food and Drug Administration MAUDE database yielded reports of 85 complications in 62 patients. These included major complications: eight cases of thermal bowel injury, 30 cases of uterine perforation, 12 cases in which emergent laparotomy was required, and three intensive care unit admissions. One patient developed necrotizing fasciitis and eventually underwent vulvectomy, ureterocutaneous ostomy, and bilateral below-the-knee amputations. One of the patients with thermal injury to the bowel died.

CONCLUSION: Use of the US Food and Drug Administration MAUDE database is helpful in identifying serious complications associated with global endometrial ablation not yet reported in the medical literature.

Gurtcheff SE, Sharp HT. Complications associated with global endometrial ablation: the utility of the MAUDE database. Obstet Gynecol. 2003 Dec;102(6):1278-82.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14662215

Stress urinary incontinence affects one third of adult women and is usually reduced or eliminated with either nonsurgical or surgical therapy.

Stress urinary incontinence, the complaint of involuntary leakage during effort or exertion, occurs at least weekly in one third of adult women. The basic evaluation of women with stress urinary incontinence includes a history, physical examination, cough stress test, voiding diary, postvoid residual urine volume, and urinalysis. Formal urodynamics testing may help guide clinical care, but whether urodynamics improves or predicts the outcome of incontinence treatment is not yet clear. The distinction between urodynamic stress incontinence associated with hypermobility and urodynamic stress incontinence associated with intrinsic sphincter deficiency should be viewed as a continuum, rather than a dichotomy, of urethral function. Initial treatment should include behavioral changes and pelvic floor muscle training. Estrogen is not indicated to treat stress urinary incontinence. Bladder training, vaginal devices, and urethral inserts also may reduce stress incontinence. Bulking agents reduce leakage, but effectiveness generally decreases after 1–2 years. Surgical procedures are more likely to cure stress urinary incontinence than nonsurgical procedures but are associated with more adverse events. Based on available evidence at this time, colposuspension (such as Burch) and pubovaginal sling (including the newer midurethral synthetic slings) are the most effective surgical treatments.

Nygaard IE, Heit M. Stress urinary incontinence. Obstet Gynecol. 2004 Sep;104(3):607-20.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15339776&dopt=Abstract

Self-testing for human papillomavirus (HPV) DNA is feasible for cervical cancer screening

Conclusion: Self-assessment for HPV DNA is an easy, feasible, and well-accepted method for HPV testing and for cervical cancer screening in internal medicine outpatient clinics.

Kahn JA. Self-testing for human papillomavirus using a vaginal swab: placing prevention of cervical cancer in the patient's hands. Ann Oncol. 2004 Jun;15(6):847-9.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15151937

Efficacy of Cone Biopsy of the Uterine Cervix During Frozen Section for the Evaluation of Cervical Intraepithelial Neoplasia Grade 3

We retrospectively selected 22 cases in which patients with a biopsy-proven diagnosis of cervical intraepithelial neoplasia grade 3 underwent cervical conization for frozen section (FS) evaluation followed by hysterectomy at the University of California Irvine Medical Center, Orange, during the August 1995 to September 9, 2001. All slides from FS and permanent section (PS) and hysterectomy specimens were reviewed. FS diagnoses were compared with those of previous biopsies, PS, and hysterectomy specimens. The PS correlated with FS in all cases but 1. Appropriate surgery was performed for all patients based on FS diagnosis. The McNemar test was used to compare the results of FS and PS, with a 2-sided P value of 1.0 and a c coefficient of 0.7755 with a 95% confidence level, indicating that the 2 groups were not significantly different. FS evaluation of cervical conization is as efficacious and accurate as evaluation of regular specimens in providing information for the appropriateness of same-day surgery.

Conclusion: We recommend that entire tissue be submitted for FS to avoid sampling errors and to increase diagnostic accuracy. Gu M, Lin F. Efficacy of cone biopsy of the uterine cervix during frozen section for the evaluation of cervical intraepithelial neoplasia grade 3. Am J Clin Pathol. 2004 Sep;122(3):383-8

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15362368

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Child Health

No benefit seen for suctioning meconium-stained newborns: RCT

INTERPRETATION: Routine intrapartum oropharyngeal and nasopharyngeal suctioning of term-gestation infants born through MSAF does not prevent MAS. Consideration should be given to revision of present recommendations.

Vain NE, et al Oropharyngeal and nasopharyngeal suctioning of meconium-stained neonates before delivery of their shoulders: multicentre, randomised controlled trial. Lancet. 2004 Aug 14;364(9434):597-602.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15313360

Role of vaginal douching in the reproductive health of adolescents and young women

"The initiation and maintenance of douching behavior in young women is a complicated behavior influenced by many factors, including family, sexual partners, body image, and advertising, among many others,"

* Numerous studies have shown that douching is prevalent and often begins in adolescence.

* Motivation for the initiation and maintenance of douching appears complex and presents challenges to intervention efforts. Recent studies implicate high-risk sexual behaviors as motivators for sustaining douching behavior.

* Douching has been implicated in numerous adverse reproductive health outcomes such as pelvic inflammatory disease, ectopic pregnancy, reduced fertility, and bacterial vaginosis. However, most studies linking douching to adverse reproductive health outcomes are case control studies; thus the causal relationship between douching and these outcomes remains unknown.

* Recent publications involving participants from developing countries seem to indicate that vaginal douching under certain circumstances may be harmless or even beneficial.

The authors note that although "the need for prospective longitudinal studies of the effects of douching was recognized decades ago . . . very little advancement has been published in recent decades”

Simpson T, Merchant J, Grimley DM, et al. 2004. Vaginal douching among adolescent and young women: More challenges than progress. Journal of Pediatric and Adolescent Gynecology 17(4):249-255 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15288026

Whole environment intervention improves asthma associated morbidity in children

-The intervention group reported significantly fewer asthma symptoms during both the intervention year and the follow-up year. The greater reduction in asthma-related symptoms in the intervention group occurred within 2 months after randomization and was sustained for the 2 years of the study.

-Levels of cockroach allergens and dust-mite allergens in the bedroom decreased in both groups over the course of the study; however, greater reductions occurred in the intervention group.

-Relationships between the reduction in the levels of dust mite allergens and improvements in reported asthma-associated morbidity were similar in both groups.

"We have shown that remediation strategies can be implemented that result in both sustained reductions in indoor allergen levels and sustained improvements in reported asthma-associated morbidity in this high-risk population," conclude the authors.

Morgan WJ, Crain EF, Gruchalla RS, et al. 2004. Results of a home-based environmental intervention among urban children with asthma. New England Journal of Medicine 351(11):1068-1080. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15356304

SIDS Resource kits available

If you are in need of a SIDS resourse kit(s) please go to the www.cjsids.com web site

there are about 1000 left - they are free and take 3 weeks to deliver.

Protecting our children from environmental hazards in the face of limited data

- Low-dose exposure is not necessarily safe exposure

- No evidence of harm is not equivalent to evidence of no harm

- Taking action

Shea KM  Protecting our children from environmental hazards in the face of limited data-a precautionary approach is needed. J Pediatr. 2004 Aug;145(2):145-7
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15289755

or full text

www2.us.elsevierhealth.com/scripts/om.dll/serve?action=searchDB&searchDBfor=art&artType=fullfree&id=as0022347604003816

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Chronic disease and Illness

Tamoxifen for breast cancer prevention: a framework for clinical decisions

CONCLUSION: Tamoxifen chemoprevention is cost-effective for women aged 40-50 years who are at significant breast cancer risk. Whether this holds true for older women depends on the initial breast cancer risk, fear of breast cancer, and presence of the uterus.

Cykert S, Phifer N, Hansen C. Tamoxifen for breast cancer prevention: a framework for clinical decisions. Obstet Gynecol. 2004 Sep;104(3):433-42

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15339751&dopt=Abstract

New cholesterol guidelines pose a challenge for doctors and patients

The Adult Treatment Panel III (ATP III) of the National Cholesterol Education Program issued an evidence-based set of guidelines on cholesterol management in 2001. Since the publication of ATP III, 5 major clinical trials of statin therapy with clinical end points have been published. These trials addressed issues that were not examined in previous clinical trials of cholesterol-lowering therapy. The present document reviews the results of these recent trials and assesses their implications for cholesterol management. Therapeutic lifestyle changes (TLC) remain an essential modality in clinical management. The trials confirm the benefit of cholesterol-lowering therapy in high-risk patients and support the ATP III treatment goal of low-density lipoprotein cholesterol (LDL-C) <100 mg/dL. They support the inclusion of patients with diabetes in the high-risk category and confirm the benefits of LDL-lowering therapy in these patients. They further confirm that older persons benefit from therapeutic lowering of LDL-C. The major recommendations for modifications to footnote the ATP III treatment algorithm are the following. In high-risk persons, the recommended LDL-C goal is <100 mg/dL, but when risk is very high, an LDL-C goal of <70 mg/dL is a therapeutic option, ie, a reasonable clinical strategy, on the basis of available clinical trial evidence. This therapeutic option extends also to patients at very high risk who have a baseline LDL-C <100 mg/dL. Moreover, when a high-risk patient has high triglycerides or low high-density lipoprotein cholesterol (HDL-C), consideration can be given to combining a fibrate or nicotinic acid with an LDL-lowering drug. For moderately high-risk persons (2+ risk factors and 10-year risk 10% to 20%), the recommended LDL-C goal is <130 mg/dL, but an LDL-C goal <100 mg/dL is a therapeutic option on the basis of recent trial evidence. The latter option extends also to moderately high-risk persons with a baseline LDL-C of 100 to 129 mg/dL. When LDL-lowering drug therapy is employed in high-risk or moderately high-risk persons, it is advised that intensity of therapy be sufficient to achieve at least a 30% to 40% reduction in LDL-C levels. Moreover, any person at high risk or moderately high risk who has lifestyle-related risk factors (eg, obesity, physical inactivity, elevated triglycerides, low HDL-C, or metabolic syndrome) is a candidate for TLC to modify these risk factors regardless of LDL-C level. Finally, for people in lower-risk categories, recent clinical trials do not modify the goals and cutpoints of therapy

Grundy SM et al. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation. 2004 Jul 13;110(2):227-39. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15249516&dopt=Abstract

Broken Promises - What is the status of American Indian / Alaska Native Health?
The U.S. Commission on Civil Rights has issued a follow-up report to its "Quiet Crisis" report from last year that focused on the lack of federal funding addressing unmet needs in Indian Country. The new report, entitled "Broken Promises: Evaluating the Native American Health Care System," is now available on the Commission's website at http://www.usccr.gov/

-In the end, as a result of our examination of the Native American health care system and the nature of historical relationship between tribes and the federal government, it is possible to reduce this report to a single compelling observation. That observation is that persistent discrimination and neglect continue to deprive Native Americans of a health system sufficient to provide health care equivalent to that provided to the vast majority of Americans."

-The report examines: health disparities in Indian Country; social and cultural barriers that limit access to care and contribute to the disparities; financial barriers; and proposed legislation changes. In the chapter on legislative changes, the report finds that reauthorizing the Indian Health Care Improvement Act would provide the "most promise for improving the lives of Native Americans" (p. 121) and recommends the passage of the reauthorization as "a priority item on the legislative agenda."

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OB/GYN

Dr. Neil Murphy is the Obstetrics and Gynecology Chief Clinical Consultant (OB/GYN C.C.C.). Dr. Murphy is very interested in establishing a dialogue and/or networking with anyone involved in women's health or maternal child health, especially as it applies to Native or indigenous peoples around the world. Please don't hesitate to contact him by e-mail or phone at 907-729-3154.