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Volume 5, No. 6, June/July 2007
Features
American College of Obstetricians and Gynecologists
Endometrial ablation. ACOG Practice Bulletin No. 81
Summary of Recommendations and Conclusions
The following recommendations and conclusions are based on good and consistent scientific evidence (Level A):
- For women with normal endometrial cavities, resectoscopic endometrial ablation and nonresectoscopic endometrial ablation systems appear to be equivalent with respect to successful reduction in menstrual flow and patient satisfaction at 1 year following index surgery.
- Resectoscopic endometrial ablation is associated with a high degree of patient satisfaction but not as high as hysterectomy.
The following recommendations and conclusions are based on limited or inconsistent scientific evidence (Level B):
- Hysterectomy rates associated with both resectoscopic endometrial ablation and nonresectoscopic endometrial ablation are at least 24% within 4 years following the procedure.
- Women undergoing endometrial ablation with previous or concomitant laparoscopic sterilization are at low risk for the development of cyclic or intermittent pelvic pain subsequent to the procedure.
- Patient satisfaction and reduction in menstrual blood flow after endometrial ablation in women with normal endometrial cavities is similar to that experienced by women using the levonorgestrel-secreting intrauterine system.
The following recommendations and conclusions are based primarily on consensus and expert opinion (Level C):
- Patients who choose endometrial ablation should be willing to accept normalization of menstrual flow, not necessarily amenorrhea, as an outcome.
- Premenopausal patients undergoing endometrial ablation should be counseled to use appropriate contraception.
- in women with endometrial cavities that exceed device limitations.
- The endometrium of all candidates for endometrial ablation should be sampled, and histopathologic results should be reviewed before the procedure.
- Women with endometrial hyperplasia or uterine cancer should not undergo endometrial ablation.
- Performance of nonresectoscopic endometrial ablation in patients with prior classic cesarean delivery or transmural myomectomy may increase the risk of damage to surrounding structures. If endometrial ablation is to be performed in such patients, it may be best to perform resectoscopic endometrial ablation with laparoscopic monitoring. Safety of nonresectoscopic endometrial ablation in women with low transverse cesarean delivery has not been adequately studied.
- For resectoscopic endometrial ablation, it is recommended that a fluid management and monitoring system that provides “real-time” output of fluid balance be used.
Endometrial ablation. ACOG Practice Bulletin No. 81. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007; 109:1233–48.
Seeking and Giving Consultation
ABSTRACT: Consultations usually are sought when practitioners with primary clinical responsibility recognize conditions or situations that are beyond their level of expertise or available resources. One way to maximize prompt, effective consultation and collegial relationships is to have a formal consultation protocol. The level of consultation should be established by the referring practitioner and the consultant. The referring practitioner should request timely consultation, explain the consultation process to the patient, provide the consultant with pertinent information, and continue to coordinate overall care for the patient unless primary clinical responsibility is transferred. The consultant should provide timely consultation, communicate findings and recommendations to the referring practitioner, and discuss continuing care options with the referring practitioner.
Seeking and Giving Consultation. ACOG Committee Opinion No. 365. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;109:1255–9.
Disruptive Behavior
ABSTRACT: Disruptive behavior may have a negative effect on patient care. Consequently, it is important that a systematic process be in place to discourage, identify, and remedy episodes of disruptive behavior.
Disruptive Behavior. ACOG Committee Opinion No. 366. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007; 109:1261–2.
Patents, Medicine, and the Interests of Patients
ABSTRACT: Many basic scientists and clinicians support the right to obtain and enforce patents on drugs, diagnostic tests, medical devices, and most recently, genes. Although those who develop useful drugs, diagnostic and screening tests, and medical technologies have the right to expect a fair return for their efforts and risks, current interpretations of patent law have the potential to impede rather than promote scientific and medical advances. Policies regarding the patenting of scientific inventions, discoveries, and improvements must balance the need for the open exchange and use of information with the need to make the pursuit of such knowledge financially rewarding.
Patents, Medicine, and the Interests of Patients. ACOG Committee Opinion No. 364. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;109:1249–53.
American Family Physician**
Therapies for Overactive Bladder- Nonpharmacologic vs. Anticholinergic
Clinical Question: Cochrane Briefs
How do nonpharmacologic therapies compare with anticholinergic medications in patients with overactive bladder (i.e., urinary urgency)?
Evidence-Based Answer
Anticholinergic medications are more effective than bladder training in reducing the number of voids per day. Combining an anticholinergic medication with bladder training is more effective than either therapy alone.
Practice Pointers
Overactive bladder can be associated with urge incontinence, urinary frequency, and nocturia. Causes of chronic bladder irritation include urinary tract infection; pelvic surgery; estrogen deficiency; diabetes; multiple sclerosis; medications (e.g., neuroleptics, diuretics); cerebral ischemia; dementia; and overflow incontinence.1
The most common treatments for overactive bladder are anticholinergic medications, bladder training, pelvic floor muscle training, biofeedback, and electric stimulation of the detrusor muscles. Compared with placebo, persons taking anticholinergic medications for overactive bladder have about five fewer trips to the bathroom and four fewer leakage episodes per week. Patients taking anticholinergic medications also report modest improvements in quality of life.2
This Cochrane review included randomized or quasi-randomized controlled trials that compared anticholinergic medications with nonpharmacologic therapies for overactive bladder or urinary urge incontinence in adults. Thirteen trials (1,770 total participants treated for three to 12 weeks) were identified; however, most trials were small and protocols varied, making it difficult to draw many firm conclusions.
Bladder training was the most effective nonpharmacologic treatment studied. Six trials (288 total participants) compared anticholinergic medications (4 mg of tolterodine [Detrol], 45 mg of propantheline [Pro-Banthine], or 5 to 45 mg of oxybutynin [Ditropan] daily). Overall, anticholinergic medications improved symptoms compared with bladder training alone (relative risk = 0.73; 95% confidence interval, 0.59 to 0.90). Combining bladder training with an anticholinergic medication improved symptoms compared with either treatment alone. Patients receiving combined treatment had about 5 percent fewer voids per day, and about 15 percent of patients reported a greater change from baseline in the sensation of urgency.
No trials of pelvic floor muscle training or surgery were found. No significant difference between anticholinergic medications and electrostimulation was found. About one third of patients taking anticholinergic medications experienced adverse effects such as dry mouth, headache, constipation, dizziness, decreased visual acuity, and tachycardia.
Alhasso AA, et al. Anticholinergic drugs versus non-drug active therapies for overactive bladder syndrome in adults. Cochrane Database Syst Rev 2006;(4):CD003193.
http://www.aafp.org/afp/20070501/cochrane.html
Exercise Is an Effective Intervention in Overweight and Obese Patients
Clinical Scenario: Cochrane for Clinicians
A 52-year-old overweight man with hypertension and diabetes has made some dietary changes, but he has not initiated an exercise program for weight loss. He wonders if exercise will really make a difference.
Clinical Question
How effective is exercise in reducing body weight and improving cardiac risk factors in overweight or obese patients?
Evidence-Based Answer
Exercise leads to a weight loss of 1 lb, 2 oz to 16 lb, 12 oz (0.5 to 7.6 kg), compared with a 3-oz (0.1-kg) weight loss to a weight gain of 1 lb, 9 oz (0.7 kg) with no treatment. Patients participating in higher-intensity exercise lose 3 lb, 5 oz (1.5 kg) more than those participating in low-intensity exercise. Regardless of whether the patient loses weight, exercise improves diastolic blood pressure and triglyceride, high-density lipoprotein, and glucose levels. When a low-calorie diet is compared with exercise alone, a low-calorie diet leads to more weight loss (6 lb, 3 oz to 29 lb, 16 oz [2.8 to 13.6 kg] versus 1 lb, 2 oz to 16 lb, 12 oz). However, trials with three to 12 months of follow-up show that participants who combine a low-calorie diet with exercise lose 2 lb, 7 oz (1.1 kg) more than those who only diet.
Shaw K, Gennat H, O'Rourke P, Del Mar C. Exercise for overweight or obesity. Cochrane Database Syst Rev 2006;(4):CD003817.
http://www.aafp.org/afp/20070501/cochrane.html
Evaluation and Treatment of Acute Low Back Pain (See Patient Education)
Acute low back pain with or without sciatica usually is self-limited and has no serious underlying pathology. For most patients, reassurance, pain medications, and advice to stay active are sufficient. A more thorough evaluation is required in selected patients with "red flag" findings associated with an increased risk of cauda equina syndrome, cancer, infection, or fracture. These patients also require closer follow-up and, in some cases, urgent referral to a surgeon. In patients with nonspecific mechanical low back pain, imaging can be delayed for at least four to six weeks, which usually allows the pain to improve. There is good evidence for the effectiveness of acetaminophen, nonsteroidal anti-inflammatory drugs, skeletal muscle relaxants, heat therapy, physical therapy, and advice to stay active. Spinal manipulative therapy may provide short-term benefits compared with sham therapy but not when compared with conventional treatments. Evidence for the benefit of acupuncture is conflicting, with higher-quality trials showing no benefit. Patient education should focus on the natural history of the back pain, its overall good prognosis, and recommendations for effective treatments. Am Fam Physician 2007;75:1181-8, 1190-2.
http://www.aafp.org/afp/20070415/1181.html
Restless Legs Syndrome: Pramipexole (Mirapex)
Pramipexole (Mirapex) is a non-ergot selective dopamine receptor agonist that has been used since 1997 for the treatment of idiopathic Parkinson's disease. It is now labeled for the treatment of moderate to severe restless legs syndrome (RLS),1 which is defined as having symptoms at least two to three days per week for at least three months and having a baseline score higher than 15 on the 40-point International Restless Legs Syndrome Study Group Rating Scale.2
Bottom Line
Although many patients with RLS do not need pharmacologic therapy, pramipexole is one option for treating moderate to severe symptoms. As with other agents used to manage RLS, potentially serious adverse reactions are possible. Am Fam Physician 2007;75
http://www.aafp.org/afp/20070415/steps.html
AHRQ
AHRQ breastfeeding evidence review
Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries.
It can be downloaded at AHRQ Publications Clearinghouse at AHRQPubs@ahrq.hhs.gov or by calling the Clearinghouse at 800-358-9295.
Ask A Librarian: Diane Cooper, M.S.L.S. / NIH
Quick Check for Drugs and Lactation
When you need to know if a drug you prescribe is safe for breastfeeding mothers, here is a new and easy to use database to check.
LactMed is a peer-reviewed database of drugs to which breastfeeding mothers may be exposed. LactMed is part of the National Library of Medicine’s Toxicology Data Network (TOXNET) and contains over 450 drug records. Data include information on the levels of drugs in the breast milk and infant blood, and possible adverse effects on the nursing infant. There are suggested alternatives to those drugs when available. All data are derived from the scientific literature and fully referenced.
LactMed can be accessed using the Health Services Research Library website at http://hsrl.nihlibrary.nih.gov
Find PubMed in the left panel and click.
Once you are in PubMed, click on TOXNET located on their left panel.
Next, select LactMed from the list. In the search box, enter the drug you are interested in.
Sample Record for Prozac (abbreviated for space)
DRUG LEVELS AND EFFECTS:
SUMMARY OF USE DURING LACTATION:
The average amount of drug in breast milk is higher with fluoxetine than
with most other SSRIs and the active metabolite, norfluoxetine, is
detectable in the serum of most breastfed infants during the first 2
months postpartum and a few thereafter…….
DRUG LEVELS:
Fluoxetine is metabolized to norfluoxetine which has antidepressant
activity that is considered to be equal to fluoxetine. In a pooled analysis of serum levels from published studies and 1unpublished case, the authors found that 20 mothers taking an average daily dosage of 28 mg (range 10 to 80 mg) had an average milk fluoxetine
level of 76 mcg/L (range 23 to 189 mcg/L)…
EFFECTS IN BREASTFED INFANTS:
Colic, decreased sleep, vomiting and watery stools occurred in a 6-day-old
breastfed infant probably caused by maternal fluoxetine…….
POSSIBLE EFFECTS ON LACTATION:
Fluoxetine has caused increased prolactin levels and galactorrhea in
nonpregnant, nonnursing patients. The clinical relevance of
these findings in nursing mothers is not known. …….
AAP CATEGORY (comment from the American Academy of Pediatrics)
Effect on nursing infant is unknown but may be of concern.
ALTERNATE DRUGS TO CONSIDER:
Nortriptyline
REFERENCES:
1. Weissman AM, Levy BT, Hartz AJ et al. Pooled analysis of antidepressant levels in lactating mothers, breast milk, and nursing infants. Am J Psychiatry. 2004;161:1066-9.
2. Kristensen JH, Ilett KF, Hackett LP et al. Distribution and excretion of fluoxetine and norfluoxetine in human milk. Br J Clin Pharmacol. 1999;48:521-7
LactMed can be accessed using the Health Services Research Library website at http://hsrl.nihlibrary.nih.gov
Breastfeeding - Suzan Murphy, PIMC
Long-Term Breastfeeding among Native American Women
Available for purchase the two versions of the “video features Native American women telling in their own words of their experience in learning and teaching breastfeeding in the context of community and family tradition. The discussions include: New mothers' questions, managing at the hospital, working and breastfeeding, sexuality, birth control, attitudes towards extended nursing, fathers' roles, tandem nursing, and more.
http://www.glitc.org/pages/bfvideo.html
Systematic review and meta-analysis confirms long-term positive effects of breastfeeding
The World Health Organization's Department of Child and Adolescent Health, in collaboration with the epidemiology unit in the University of Pelotas, Brazil, conducted this systematic review and meta-analysis of studies to assess the association between breastfeeding and blood pressure, diabetes and related indicators, serum cholesterol, overweight and obesity, and intellectual performance. Two reviewers independently evaluated study quality, using a standardized protocol, and disagreement was resolved by consensus rating. Subjects who were breastfed experienced lower mean blood pressure and total cholesterol, as well as higher performance in intelligence tests. Prevalence of overweight/obesity and type-2 diabetes was lower among breastfed subjects. All effects were statistically significant but for some outcomes their magnitude was relatively modest.
This review confirms what has been widely known for years; that breastfeeding helps infants achieve the highest attainable standard of health.
http://www.who.int/child-adolescent-health/New_Publications
/NUTRITION/ISBN_92_4_159523_0.pdf
FAQs - Breastfeeding and maternal illness
Is breastfeeding okay if mom the gets sick? Most of the time, the answer is yes. The following review is from CDC and references listed below.
When breastfeeding is not recommended:
- The baby is diagnosed with galactosemia, a rare genetic metabolic disorder occurring in 1 in
47,000 births. There is little data on the prevalence of galactosemia in AI/AN
communities.
- The baby’s mother:
- Has been infected with or recently exposed to the human immunodeficiency virus (HIV)
- Is taking antiretroviral medications
- Has untreated, active tuberculosis
- Is infected with human T-cell lymphotropic virus type I or type II
- Is using or is dependent upon an illicit drug
- Is taking prescribed cancer chemotherapy agents, such as antimetabolites that interfere with DNA replication and cell division
- Is undergoing radiation therapies; however, such nuclear medicine therapies require only a temporary interruption in breastfeeding
What about stomach flu?
Yes, moms with diarrhea from food and water sources can keep breastfeeding. The recommendations to increase fluid intake and use oral rehydration salts work well with breastfeeding.
If medication is needed consider kaolin-pectin (Kaopectate) or loperamide (Immodium, Maalox) . Both are described by the American Academy of Pediatrics (AAP) as “usually compatible with breastfeeding,” with kaolin-pectin being preferable to loperamide.
Avoid suggesting anitdiarrheal medications that have bismuth subsalicylate compounds (Pepto-Bismol). They are considered by both AAP and Hale to be of concern because the baby can absorb significant levels of salicylates and pose a theoretical risk of Reye’s syndrome.
For more information go to www.cdc.gov travelers’ health.
Can a mom breastfeed if she contracts hepatitis A?
Yes, she can continue and gamma globulin treatment is compatible with breastfeeding. Encourage the mom to use effective hand washing techniques and food safety recommendations to protect her baby, whether she is breastfeeding or bottle-feeding.
What if she has hepatitis B (HBV) ?
Is it safe for a mom infected with HBV to breastfeed her baby right after birth?
Yes. HBV transmission through breastfeeding was not reported. CDC recommends:
- All babies born to HBV-infected moms need to receive hepatitis B immune globulin and the
first dose of hepatitis B vaccine within 12 hours of birth, the second dose of vaccine at
aged 1–2 months, and the third dose at aged 6 months.
- The infant needs to be tested after completing the vaccine series, at aged 9–18 months to
confirm that the vaccine worked and the infant is not infected with HBV through exposure
to the mother’s blood during the birth process.
What if the mom’s nipples are cracked and bleeding?
Like hepatitis C, both viruses are spread by infected blood. There is not enough data to make recommendations at this point. Until more information is available, the wisest course is to encourage the mom to temporarily interrupt breastfeeding her baby until she is healed. Although sore nipples seem to last forever, they usually heal quickly, often within 24 hours. It is helpful to pump and dump during this time. Since both hepatitis b and c are resilient viruses, it would be prudent to discard the breast pump when through.
What about HBV vaccinations for a breastfeeding mom?
It is okay for a breastfeeding mom to receive HBV vaccinations. The vaccines contain noninfectious HBsAg particles and are given to newborns also.
For more information, refer to CDC. A Comprehensive Immunization Strategy to Eliminate Transmission of Hepatitis B Virus Infection in the United States. MMWR, Recommendations and Reports, December 23, 2005 / 54(RR16);1-23
What about mom with hepatitis C (HCV) – is it safe for her to breastfeed?
Yes, like HBV, there is no evidence that breastfeeding spreads HCV.
What if the mom in infected with HCV and has cracked and bleeding nipples?
See recommendations above for HBV and cracked and bleeding nipples.
For more information, refer to CDC. Recommendations for prevention and control of Hepatitis C virus (HCV) infection and HCV-related chronic disease. MMWR, October 16, 1998, 47(RR-19):1–39.
What if a mom becomes infected with West Nile Virus, is it safe for her to breastfeed her baby?
So far, there is no evidence that it is harmful for a mom infected with West Nile Virus to breastfeed infant. In According to CDC, there have been 4 documented cases of West Nile Virus transmission through breast milk (1 in 2002 and 3 in 2003) with no recognizable illness in the baby. As a result, CDC recommends that moms with West Nile Virus illness continue breastfeeding because the benefits of breast milk are thought to outweigh the theoretical risk of harm to the baby.
For more information go to http://www.cdc.gov/ncidod/dvbid/westnile/
Resources
American Academy of Pediatrics' Breastfeeding and the Use of Human Milk, available at:
http://aappolicy.aappublications.org/cgi/content/abstract/pediatrics;115/2/496
American Academy of Pediatrics Committee on Drugs. (2001) The transfer of drugs and other chemicals into human milk. Pediatrics 108:776-789.
Department of Health and Human Services, Centers of Disease Control and Prevention, www.cdc.gov
Hale, T. (2006) Medications and Mothers’ Milk. 12 th edition. Amarillo, TX: Pharmasoft Publishing.
Lawrence RA, Lawrence R. (2005) Breastfeeding: A guide for the medical professional, 6th Edition. St. Louis: Mosby.
Need fast information about drugs and breastfeeding? Go to Lactnet at www.toxnet.nlm.nih.gov
Other
RCT of very early mother-infant skin-to-skin contact and breastfeeding status
Conclusion: Very early skin-to-skin contact enhanced breastfeeding success during the early postpartum period. No significant differences were found at 1 month.
Moore ER, et al Randomized controlled trial of very early mother-infant skin-to-skin contact and breastfeeding status. J Midwifery Womens Health. 2007;52(2):116-125.
and
http://www.medscape.com/viewarticle/555315?src=mp
CCC Corner Digest
Nicely laid out hard copy - A compact digest of last month’s CCC Corner
Highlights include
Social Change Might Save More Lives Than Medical Advances
New HPV Brochures for Clinicians, CDC
More stillbirths after previous cesarean delivery
Young women with CIN: Any treatment increases preterm delivery - LEEP
Public Opinion vs. Science Concerning Sex Education
New Guideline for Screening Mammography for Women 40 to 49 Yrs
Premature Rupture of Membranes, Practice Bulletin
Quick Check for Drugs and Lactation
Breastfeeding - it’s all about synergy
Extended OCP Regimen; Acceptable Breakthrough Bleeding
Must See Website: Indian Health Service HIV-AIDS Program
Ethics of medicine with economically vulnerable populations: 2nd in series
Do you walk around your vehicle before getting in it? You should
Which Indian Health facilities lead the U.S. in national benchmarks?
Emergence of a range of nonhormonal treatments for vasomotor symptoms
Ultrasound affects mice brains in negative ways
BTL: Nearly 1/2 of women under 25 yo request information on reversal
Two summer programs for high school students
Calcium Supplementation May Not Benefit Healthy Children
Preconception counseling for women with DM and HTN: Which meds?
Electronic Health Record (EHR) Implementation: Worth the effort?
HIV/AIDS among AI/AN Fact Sheet
New recommendations for gestational weight gain may be required
Weaving it all together: 2007 Behavioral Health Conference
May newsletter here
http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0507.cfm
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
The failure to protect Indigenous women from sexual violence in the USA
The Amnesty International report entitled “Maze of Injustice – The failure to protect Indigenous women from sexual violence in the USA” is an important and timely reminder for all individuals and agencies that provide services to American Indian and Alaska Native (AI/AN) women. The Amnesty International report calls attention to the disproportionate impact on Indian women, focusing on three disparate communities that vary with respect to law enforcement, jurisdiction, and health care and support services. This report helps remind us that no one is immune from sexual violence.
The Indian Health Service (IHS) and our health care providers need to be aware of the prevalence of sexual assault and the need to address acute injuries as well as the long term negative health effects of sexual violence. As a result of this report, the IHS will help develop a prototype policy on sexual assault that can be used by facilities to help ensure the provision of best practices and culturally appropriate medical and supportive care for victims.
The health care response to intimate partner violence (IPV) has been improved by the existence of policies and procedures at all IHS facilities. Screening for IPV has improved as well, with aggregate national rates exceeding Agency targets. IPV policies and procedures, screening and education for health care providers are the result of Agency clinical performance measures developed to improve care.
The Indian Health Service and the Administration for Children and Families (ACF) jointly fund activities at twenty IHS, Tribal and Urban facilities to help improve the health care response to domestic violence. This work is led by multi-disciplinary teams of health service staff and tribal and community domestic violence advocates. The IHS-ACF project seeks to build a sustainable response to domestic violence that prioritizes safety and autonomy for victims and provides outreach and education, utilizing the experience and commitment of community members. Partners in this collaborative effort include the Family Violence Prevention Fund (FVPF), Mending the Sacred Hoop Technical Assistance (MSHTA) Project and Sacred Circle. MSHTA and Sacred Circle specialize in developing sexual assault and domestic violence policies and programs in Indian Country.
Sexual assault has long been recognized as a dynamic of domestic violence. In response to the alarming statistics of sexual assault experienced by AI/AN women, several of the project sites, including the Cherokee Indian Hospital and Zuni Comprehensive Community Health Center, have trained sexual assault nurse examiners (SANE) who are on call and available for emergency room care. For other sites, identifying and cooperating with pre-existing sexual assault community resources have been key to strengthening their response. At the Kanza Health Center in Oklahoma, the Dearing House, a nearby child advocacy center, was instrumental in improving exams for pediatric/adolescent sexual assault cases identified in the clinic. The Warm Springs Health and Wellness Center’s Domestic Violence team leaders collaborated with the local Victims of Crime office to assist high school students in the production of a film about sexual assault against children and teens. This effort complements the efforts at the Warm Springs facility and community hospital where SANE nurses are available for follow-up. Both institutions maintain policies and procedures on sexual assault. Many of the domestic violence project sites expanded their work beyond the walls of the health care facility, and the focus has increasingly moved toward prevention.
The experience of the IHS-ACF project sites demonstrates that chances for success for improving the health care response to domestic violence are greatest when health care teams and local domestic violence advocacy groups collaborate in the delivery of services to women. This model of care can be combined with existing best practices to improve the health care response to victims of sexual assault. Clinical guidelines have been shown to improve the quality of care for a number of health conditions, such as type 2 diabetes. Similarly, the incorporation of guidelines and policies concerning domestic violence and sexual assault will strengthen the ability of our providers and health care system to address sexual violence against American Indian and Alaska Native women. Our expectation should be that the health care response will be consistently safe, professional, timely, accessible, culturally and personally respectful, and coordinated with law enforcement and legal and community services. We must not re-victimize women who seek care in our hospitals and clinics.
IHS-ACF Domestic Violence Project
Project Faculty, IHS and FVPF
Sexual Violence Resources:
Amnesty International: Native American and Alaska Native Women
http://www.amnestyusa.org/Womens_Human_Rights/Join_Voices_with_Native_
American_and_Alaska_Native_Women/page.do?id=1021163&n1=3&n2=39&n3=1410
Amnesty Internation, home page
www.AmnestyUSA.org
Mending the Sacred Hoop Technical Assistance (MSHTA) Project
www.msh-ta.org
Sexual Assault Forensic Examiner Technical Assistance
www.safeta.org
National Sexual Violence Resource Center
www.ncvrc.org
National Protocol for Sexual Assault Medical Forensic Examinations,
September 2004
http://www.ncjrs.gov/pdffiles1/ovw/206554.pdf
Southwest Center for Law and Policy -
free legal training and technical assistance to tribal communities and to organizations
and agencies serving Native people:
www.swclap.org
Tribal Law and Policy Institute - education, research, training,
and technical assistance programs which promote the enhancement of justice in
Indian country and the health, well-being, and culture of Native peoples.
www.tlpi.org
Other
Physical and sexual abuse in adulthood are associated with complaints concerning general and reproductive health and a poor sex life
CONCLUSION: Abusive experiences were common in gynecologic outpatients. Women with abusive experiences had ill health and poor sexual life more often than the controls. In contrast to the results of previous studies, most of the women did not want to be asked about abuse by their gynecologist. LEVEL OF EVIDENCE: II
Pikarinen
U, et al Experiences of Physical and Sexual Abuse and Their Implications
for Current Health. Obstet Gynecol. 2007 May;109(5):1116-1122
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db
=pubmed&list_uids=17470592&dopt=Abstract
WH Pregnancy and DV education online session
Excerpts
– Video vignettes and text walk you through a 15 minute session with a WH client, mom with child in pediatric setting, adolescent clients and considerations in screening gay and lesbian clients - with audio, patient interviews and Q&A:
“Physical Abuse during Pregnancy”
In a 1996 review, in studies that asked about violence more than once during personal interviews or asked later in pregnancy, the prevalence of physical abuse during pregnancy ranged from 7.4% to 20.1%. The results of this review indicated that abuse during pregnancy occurs more frequently than gestational diabetes or preeclampsia. Even more disturbing: Homicide is the second leading cause of traumatic death for pregnant and postpartum women in the United States accounting for 31% of maternal injury deaths.
AND the maternal child dyad
“Effects of IPV on Children” In families in which IPV occurs, it is not only the woman's life that is at risk; identifying and intervening on behalf of battered women is perhaps one of our most effective ways to prevent child abuse as well. The effects of IPV can also adversely affect the mental and physical development of children from infancy into adulthood. Infants who have witnessed violence have eating and sleeping problems, decreased responsiveness to adults, and increased crying.
Exposure to violence increases the likelihood of children experiencing the following:
FTT
HA
Bed wetting
Speech disorders
Vomiting and diarrhea
Furthermore, the effects of such exposure follow the child throughout his or her life. A 1998 study reported the following risks in persons with 4 or more adverse childhood experiences: 4- to 12-fold risk for alcoholism, drug abuse, depression, and suicide attempts as well as a 2- to 4-fold risk of smoking, poor self-rated health, having 50 or more sexual intercourse partners, and sexually transmitted diseases. Finally the many resources include patient and provider information, CME slides, etc. http://www.medscape.com/viewarticle/553333_3
Domestic
Violence and Your Patient's Health: Asking the Right Questions
http://www.medscape.com/viewprogram/6760?src=mp
Elder Care News
Gynecologic Assessment of the Elderly Patient
Review physiologic changes associated with aging, normal and abnormal physical findings, symptoms and conditions commonly encountered, and age-specific aspects of pelvic examination
http://www.medscape.com/viewarticle/554398
Family Planning
Reasons for unprotected intercourse
RESULTS: Of 7856 respondents, 33% felt they could not get pregnant at the time of conception, 30% did not really mind if they got pregnant, 22% stated their partner did not want to use contraception, 16% cited side effects, 10% felt they or their partner were sterile, 10% cited access problems and 18% selected "other." Latent class analysis showed seven patterns of response, each identifying strongly with a single reason. CONCLUSIONS: Almost half of women with viable unintended pregnancies ending in a birth felt they could not/would not get pregnant at the time of conception. Most women identified with a single reason for having unprotected intercourse.
Nettleman MD, Chung H, Brewer J, et al. 2007. Reasons for unprotected intercourse: Analysis of the PRAMS survey. Contraception 75(5):361-366.
Adolescent sexual behavior and strategies for reducing early pregnancy and childbearing
With One Voice 2007: America's Adults and Teens Sound Off About Teen Pregnancy assesses public opinion on adolescent pregnancy. The survey is the fifth in a series of nationally representative surveys conducted by the National Campaign to Prevent Teen Pregnancy that have asked adolescents (ages 12-19) and adults (ages 20 and older) a consistent, core set of questions about adolescent pregnancy and related issues.
Topics include parental and other adult influence; abstinence and contraception; regret, virginity, older partners, and attitudes about adolescent sex; gender differences; religion; social norms and beliefs; and media. Data are presented in charts and, where available, results from previous surveys (2001-2006) are included. A description of the survey methodology and a summary are also provided. The survey is intended to provide insights for policymakers, program administrators, families, and others about adolescent pregnancy and factors that influence adolescents' decisions about sex. http://www.teenpregnancy.org/resources/data/pdf/WOV2007_fulltext.pdf
Effect of Medicaid Family Planning Expansions on Unplanned Births
Overall, Medicaid family planning expansions led to lower birth rates, The authors found that
* Average annual birthrates were significantly lowered by income-based expansions; a statistically significant effect of postpartum expansions was not found.
* Significant maternal and infant health care cost offsets were identified in all income-expansion states for which data are available.
Theses health care cost offsets exceeded total program costs in most cases.
Overall, our results suggest that both types of Medicaid family planning expansions either yield financial benefits to states or, at the very least, are cost neutral. The experience of these early family planning expansions should be a guide for other states considering family planning benefit expansions.
Lindrooth RC, McCullough JS. 2007. The effect of Medicaid family planning expansions on unplanned births. Women's Health Issues 17(2):66-74. http://www.jiwh.org/content.cfm?sectionid=84&IssueSelected=137
Guidelines for Selection of Contraception in Women with Rheumatic Diseases
http://www.medscape.com/viewprogram/6990?sssdmh=dm1.265392&src=nlcmealert
Featured Web Site David Gahn, IHS MCH Portal Web Site Content Coordinator
MCHB Launches Web Site to Increase Awareness of Perinatal Depression
Depression During and After Pregnancy: A Resource for Women, Their Families, and Friends contains tips on identifying depression in mothers and offers steps to help treat it successfully. The Web site was launched by the Health Resources and Services Administration's Maternal and Child Health Bureau to increase awareness among women and health professionals of the impact and pervasiveness of perinatal depression.
Selected topics include steps a woman can take if she believes she is at risk of, or is experiencing, perinatal depression. A section of the Web site is devoted to information for families and friends.
A list of print and electronic resources is also provided.
http://www.mchb.hrsa.gov/pregnancyandbeyond/depression
An accompanying 22-page booklet is also available at ftp://ftp.hrsa.gov/mchb/pregnancyandbeyond/depression.pdf
Frequently asked questions
Q. What are the Unnecessary Tests done in Obstetrics and Gynecology?
A. Here are a few examples
1.) Unnecessary Testing by Clinicians and Independent Companies
Certain once-broadly accepted monitoring tests that were used routinely have not been supported by outcome data. Examples from obstetric practice include electronic fetal heart rate monitoring and fetal pulse oximetry. Routine electronic fetal heart rate monitoring has not been demonstrated to decrease the rate of cerebral palsy, but has been linked to increases in the overall rate of cesarean delivery. It has also been determined that routine use of fetal pulse oximetry is not associated with either reduced rates of cesarean delivery or improvement in the condition of newborns.[ Although these tests are not recommended for routine assessment, they remain in use in many hospitals in the United States.
Other monitoring tests may be misused. One example of this is fetal ultrasonography. Although it is helpful in estimating gestational age, identifying twin pregnancies, and detecting genetic anomalies, the American College of Obstetrics and Gynecology (ACOG) position is that routine ultrasonographic screening during pregnancy is not mandatory. They deem routine use reasonable when requested by a patient. Most women in the United States undergo at least 1 or 2 ultrasounds during pregnancy; this level of exposure has never been associated with significant risk and use may provide significant benefits. However, some expectant couples have followed the lead of actors Tom Cruise and Katie Holmes and purchased (for costs ranging between $15,000 and $200,000) their own ultrasound machines, which they use daily.
There are some data (mostly from other vertebrates) suggesting that prolonged and frequent use of fetal ultrasound can cause abnormalities in fetal brain development, behavior, and body weight. Even though such findings have not been substantiated in humans, the US Food and Drug Administration (FDA) considers promotion, selling or leasing of ultrasound equipment for the purpose of making "keepsake fetal videos" an unapproved use of a medical device. Such use may also violate state laws and regulations.
Risks of Unnecessary Testing
Before considering a full-body scan or other non-proven screening test, individuals should be made aware of the potential risks. False-positive test results are extremely common among individuals with no signs or symptoms of disease; multiple tests increase the likelihood of false-positive results. Such alarming, yet incorrect test results, can lead to further unnecessary investigations, additional patient costs, heightened anxiety, and risk to future insurability. Conversely, true positive results can lead to the over diagnosis of conditions that would not have become clinically significant, thus leading to further risky interventions.
Examples of potentially harmful screening methods and possible outcomes include:
- Pelvic ultrasounds on asymptomatic women to search for ovarian cancer could lead to unnecessary laparoscopies and biopsies, with attendant complications; and
- Screening all current and former smokers in the United States for lung cancer with a CT scan would identify more than 180 million lung nodules, the vast majority of which would be benign. Millions of patients with nodules could needlessly undergo invasive needle lung biopsies and/or removal of parts of their lungs, resulting in many cases of impaired breathing, pneumothorax, hemorrhage, infection, and even death.
Even commonly recommended tests carry a sometimes large risk of a false-positive result. For example, among women in their early 40s with abnormal mammograms, it was shown that approximately 57 women without cancer underwent further diagnostic workup for every 1 woman found to have a malignancy.
On the other hand….Evidence-based Screening
Space limitation precludes a thorough discussion of an evidence-based approach to screening tests, but this section provides a brief overview of criteria for appropriate screening. Tests to screen for disease in the pre-symptomatic stages should meet certain criteria before being recommended. These criteria include:
- The disease being screened for must be reasonably common and have a significant effect on either duration or quality of life;
- Acceptable, effective treatment must exist, and the condition must have an asymptomatic period during which detection and treatment can improve outcome;
- Treatment during the asymptomatic period must be superior to treatment once symptoms occur; and
- The screening test must be safe, affordable, and have adequate sensitivity (i.e., the test is usually positive in those with disease) and specificity (the test is usually negative in those without disease).
Examples of gynecologic- or obstetrically-related screening tests meeting these criteria include Pap smears, mammography, oral glucose tolerance testing during pregnancy, and universal testing of newborns for certain congenital disorders. Other general tests of proven value include blood pressure monitoring for those older than 21 years of age, cholesterol tests for those 35 to 65 years of age, and abdominal ultrasounds for persons (especially men) with coronary risk factors and/or positive family history to screen for abdominal aortic aneurysms.
Regrettably, many well-established screening tests are underused, especially among nonwhites, those of lower socioeconomic status (SES), and those with inadequate or no health insurance. Such underuse has been clearly linked with increased risk for adverse outcome. For example, SES differences in access to and use of screening mammography have been associated with advanced stage at time of breast cancer diagnosis and lower survival rates, especially among African-Americans. SES differences in the use of prenatal testing for trisomy 21 have also been associated with disparities in the live-birth prevalence of Down syndrome. Because incidence of this disease does not vary according to SES, it has been demonstrated that early prenatal diagnosis leads to a higher rate of elective termination of pregnancy by individuals of higher SES
Causes and Consequences of the Unwarranted Use of Costly and Unscientific (Yet Profitable) Screening Modalities?
http://www.medscape.com/viewarticle/552964?src=mp
Indian Child Health Notes - Steve Holve, Pediatrics Chief Clinical Consultant
June / July 2007
Acute pain relief in children
Pertussis: Secular Trends in the United States
Persistence of racial disparities in fatal injuries to very young children
http://www.ihs.gov/MedicalPrograms/MCH/M/ChPedNotes.cfm
Information Technology
Brigg Reilley / John Redd, HQW
How can we improve HIV screening in pregnancy? Preliminary GPRA Related Results
As you read the following, think about the classic ‘3 things you should take away from a presentation,’
1.) Prenatal HIV screening is the responsibility of all clinics whether we like it or not
2.) Most service units have a prenatal HIV screening problem, but we are not aware of it
3.) There are gaps that that staff can identify and fix, improving both actual screening rates and reported screening rates.
In some clinics, there can be a ‘not my job’ syndrome.
People say things along the lines of: 1) We refer the women out anyway; 2) We don’t have an HIV counselor, and it’s not my role to counsel and 3) What if it IS positive? We can’t do anything about it anyway.
All of these reasons are essentially irrelevant – and, as noted below, the successful small clinics assume responsibility for the first few PN visits, which includes getting the lab panels done, even if the woman will eventually be referred out.
Background
Current national standards of care for prenatal care specifically recommend that all pregnant women be routinely screened for a variety of diseases for which early detection is beneficial to the mother or child. Routine infectious disease screening includes tests for HIV, syphilis, gonorrhea, chlamydia, and hepatitis B surface antigen. Early detection of HIV is critical because it can reduce the risk of mother-to-child transmission from approximately 25% with no intervention to less than 1% with intervention.
National IHS policy is that prenatal HIV screening in IHS should be conducted on all women in IHS through “opt-out” testing. The IHS 2005 Executive Summary states “The Indian Health Service has issued guidance recommending universal prenatal HIV testing using the “opt-out” approach. In “opt-out” testing, HIV tests are included in the standard battery of prenatal tests and women are informed that an HIV test is being conducted and that they have a right to refuse it. Information regarding HIV is included as part of a patient’s prenatal education. As more practitioners adopt opt-out testing, prenatal HIV screening rates should increase.”
IHS considers prenatal HIV screening an important indicator of the quality of care provided by the Agency. As a result, HIV screening during prenatal care is one of the core Government Performance and Results Act (GPRA) measurements, with the IHS goal being to reach 100%. GPRA considers a service unit ‘responsible’ for HIV screening if there is >1 visit during the time frame of pregnancy.
For the most recent year, GPRA statistics show that percentage of IHS prenatal patients tested during pregnancy for HIV varies considerably by IHS Area, from 17% to 84%. The national IHS rate is about 65%.
Clearly, these rates can and should improve.
The IHS Division of Epidemiology & Disease Prevention Prenatal HIV Screening Project
In response to these results, IHS, through the Minority AIDS Initiative and the IHS Division of Epidemiology & Disease Prevention, has funded the ongoing IHS Prenatal HIV Screening Project. In brief, this is the methodology of this phase of the project:
Charts that were considered ‘misses’ by GPRA (i.e. prenatal care but no HIV screening) are being reviewed in 20 IHS sites (thus far, charts have been reviewed at 12 sites) across the country. The misses were identified by running a simple logic (a set of commands that we can give to any service unit that is interested).
In general, most service units have said they are sure that they have tested every prenatal patient for HIV, and usually express surprise at their low GPRA scores.
Results
These results are part of an ongoing study and are considered preliminary.
The two main categories of ‘misses’ as 1) data and 2) clinical. Sites that have < 80% reported HIV screening rates generally have some sort of data or clinical gap in screening, or often both.
On the clinical side, the main misses were:
not using opt-out, including still using a consent form
not testing at all, mainly among women who are late presenters, or skip appointments, or have otherwise ‘non-routine’ prenatal care, although it is arguable that this group is actually at highest risk
a provider determining that an HIV test is not needed because there are ‘no risk factors’ or -carrying over an HIV test from a previous pregnancy
assuming that the test was done (or will be done) at the previous (or next) service unit to see the patient.
In the data category, the main errors were:
not entering HIV tests results from a contract lab into the facility’s computer
not entering HIV tests results done by an another facility
not entering HIV test refusals into the facility’s computer
(note: to enter refusals in the EHR takes a couple extra steps, which should be fixed in the next version).
Preliminary Recommendations to IHS Service Units
Review the policy of universal prenatal HIV testing via “opt-out” with all clinicians, whether or not they usually see prenatal patients.
Run the SU’s patient list to find charts that are misses and ‘diagnose’ the SU’s gaps.
Bundle HIV and the other routine prenatal ID serum tests into a “prenatal panel” that can be ordered in one step by clinicians. Tests done ‘a la carte’ result in greater misses for HIV and other IDs, especially in patients with complications and missed appointments.
Perform prenatal testing before transferring to a higher level of care. Small facilities should remember that GPRA will consider them responsible for prenatal HIV testing if the patient is seen by them. Transfers out with no lab tests done, and with no follow up to obtain results on test done elsewhere, result in low scores.
Make prenatal opt-out HIV screening absolutely routine, both in policy and in practice. Sites with lower scores tend to ‘bottleneck’ testing in a way that makes it an exceptional event rather than the rule. For example, a provider may be unable to test without a specific consent form (and the form isn’t easily available), and without using a specific person to obtain consent (and that person isn’t in clinic today). These reasons for low testing rates are no longer acceptable in the world of universal prenatal opt-out HIV screening.
OB/GYN CCC Editorial comment:
Act now: Make HIV screening a routine test in pregnancy
Brigg Reilley and John Redd emphasize that the above results are just part of an ongoing investigation, but felt strongly in the importance of this data to allow a preliminary release. The full analysis will follow.
In the meantime, there are clear ‘provider related’ and ‘system related’ obstacles to routine prenatal HIV screening and documentation that can be addressed now. Pending the final results, these simple statements are true:
All pregnant patients should be educated about and offered HIV screening in pregnancy
HIV screening in pregnancy is your responsibility. Don’t wait for the next provider or facility to do perform the screening
HIV screening in pregnancy is a routine part of care. It does not need a separate written consent and can be ‘bundled’ in with the other initial prenatal labs
Many of the patients who miss the initial screen, e.g., due to missed appointments etc… are those patients at highest risk. Please continue to try to obtain the HIV screen right up to and including the time of delivery.
Other Resources:
Division of Epidemiology and Disease Prevention
http://www.ihs.gov/medicalprograms/epi/index.cfm
International Health Update: Claire Wendland, Madison, WI
Social context of maternal deaths and morbidity
Fair warning: the three pieces I’m recommending here are not freely available online. But all should be available through your librarian, and for providers who are interested in the social context of maternal deaths and morbidity, they are well worth seeking out.
A northern Nigerian proverb tells us “the world is a pregnant woman” – suggesting that life, like pregnancy, is uncertain and perilous. But why is it so much more perilous in some places than others? Biomedical and public health perspectives on the problem have tended to identify shortfalls in clinical care, and have led to interventions designed to improve skills training: not long ago the training of TBAs was the flavor of the day, and more recently the focus has shifted to the improvement of emergency obstetric care in health centers. Anthropologists Craig Janes and Lewis Wall (also an Ob/Gyn) bring a different perspective to their studies of pregnancy-related mortality in the disparate settings of Nigeria and Mongolia, both arguing that rising maternal death rates reflect not just health sector deficiencies, but larger social upheavals and overarching economic structures.
In Mongolia, for example, herders have been organized since the 13th century into collective structures – first feudal, then socialist – that regulated access to valued resources including land, livestock and water (and under the socialists, health care and education). These collective structures were rapidly dismantled when Mongolia initiated the so-called “shock therapy” program of economic reforms in 1990. Food shortages, widespread unemployment and localized famine, growing inequality, and deterioration of the public health sector rapidly followed. Though this initial shock has now stabilized, reproductive health and maternal mortality statistics continue to be poorer than they were under socialism. Women, Janes suggests, appear to be particularly vulnerable to the economic stresses occasioned by de-collectivization, household food insecurity, and migration, in part because the deconstruction of the collective has isolated women – economically and socially – at the single-household level.
Nigeria has had similar problems with a deteriorating public health sector and economy. Wall’s article demonstrates how highly patriarchal social and religious structures compound these national problems, resulting in rising rates of maternal death, obstetric fistula disease and perhaps even peripartum cardiomyopathy. Where women depend on powerful men for both the social permission and the economic resources required to travel to the hospital, tragedy can all too easily follow.
For a more intimate narrative take on issues of gender, maternity and risk in North Africa, consider Kris Holloway’s new book Monique and the Mango Rains. Holloway was a Peace Corps volunteer in Mali 1989-1991, where she worked closely with Monique Dembele, a Malian community health worker and midwife. Monique had minimal training and even more minimal facilities but a burning drive to improve health care -- and particularly childbirth safety -- in a rural village. This nicely written, extremely accessible book (requiring no clinical background to enjoy) neither pathologizes nor romanticizes Malian village life, and deals in a fair and approachable way with issues of sexuality and patriarchy.
All three of these readings challenge conventional medical wisdom by suggesting that a narrow focus on improving one or another aspect of formal health sector care -- absent an understanding of and attention to the larger social and political contexts of women’s lives -- will not be enough to substantially reduce maternal deaths in the Third World.
Resources
Holloway K. Monique and the Mango Rains: Two Years with a Midwife in Mali. Longview, IL: Waveland Press, 2007
Wall LL. Dead mothers and injured wives: the social context of maternal morbidity and mortality among the Hausa of northern Nigeria. Studies in Family Planning 29(4):341-359, 1998
Janes CR, Chuluundorj O. Free markets and dead mothers: the social ecology of maternal mortality in post-socialist Mongolia. Medical Anthropology Quarterly 18(2):230-257, 2004
MCH Alert
Progress toward meeting Healthy People 2010 Maternal, Infant, and Child objectives
Healthy People 2010 Midcourse Review: Maternal, Infant and Child Health highlights results from an assessment of progress toward achieving the Healthy People (HP) 2010 maternal, infant, and child health goals and objectives through the first half of the decade. The purpose of the midcourse review, which was led by the Centers for Disease Control and Prevention and the Health Resources and Services Administration, is to assess data trends; consider new science and available data; and, if appropriate, revise the objectives to ensure that HP 2010 remains current, accurate, and relevant to public health priorities. Topics include modifications to objectives and sub-objectives, progress toward Healthy People 2010 targets, progress toward elimination of health disparities, opportunities and challenges, and emerging issues.
http://www.healthypeople.gov/data/midcourse/pdf/FA16.pdf
Mental disorders and nicotine dependence among pregnant women
These data suggest that cigarette use and nicotine dependence are not uncommon among women who are pregnant in the United States, with more than one in four pregnant women using cigarettes during pregnancy, and approximately one in ten having a diagnosis of nicotine dependence. The authors found that
* Among pregnant women in the United States, 21.7% reported that they smoked cigarettes and 12.4% met criteria for nicotine dependence.
* Among pregnant women who smoked cigarettes, 45.1% met criteria for at least one mental disorder; among pregnant women with nicotine dependence, 57.5% met criteria for at least one mental disorder.
* After adjustment for differences in demographic characteristics and co-morbid mental disorders, the associations between major depressive disorder, dysthymia, and panic disorder remained significantly associated with nicotine dependence among pregnant women.
Results suggest an urgent need for smoking cessation and nicotine dependence treatment and that mental health outreach programs might be indicated in conjunction with prenatal care, especially in underserved areas.
Goodwin RD, Keyes K, Simuro N. 2007. Mental disorders and nicotine dependence among pregnant women in the United States. Obstetrics and Gynecology 109(4):875-883. http://www.greenjournal.org/cgi/content/abstract/109/4/875
MCH Headlines: Judy Thierry HQE
Improve the system - Improve the care: Underpinnings
The title of the American Native Women’s Health and Maternity Care Conference to be held August 15 - 17, 2007 at the Marriott - Louisiana, Blvd., Albuquerque, NM has as one of its three objectives to “outline the underpinnings of an optimal WH and MCH health care system /environment in the ITU”.
Underpinnings like a foundation, like the joists in a floor are about strength and unity.
Underpinnings like the lining of a coat or jacket provide durability, form and fit.
The 18.5 credit 2.5 day conference is YOUR conference. Workgroups, professional reports and updates, state of the art practice across ITU’s and plenary discussions from national leaders and women’s health advocates are designed to ‘fit’ your practice and the community you serve.
Wanda Jones, Deputy Assistant Secretary, Office for Women’s Health (OWH) Department of Health and Human Services will identify the challenges for Women’s Health in 2007 and the strategies for addressing those issues. She will describe OWH mission and initiatives impacting on AIAN women (underserved, women of color, health disparities and citizens of sovereign nations). http://www.4women.gov/owh/about/welcome.cfm
Ms. Stacy Bohlen, Executive Director National Indian Health Board will provide remarks on NIHB’s educational and advocacy role, the key partnerships and collaborations that support American Indian and Alaska Native women and their families and communities. Recent testimony by a board member requested increased support for diabetes and chronic disease. http://www.nihb.org/index.php
Empowering women is a precept of Centering Pregnancy R. Evidence based group prenatal care taken up by Zuni, Chinle, Kayenta and Tuba, among other practice communities will present a paradigm shift in care that is client centered, founded on building trust among the women. http://www.centeringpregnancy.com/
A pre-meeting training on Monday and Tuesday will take place at the Marriot – please contact judith.thierry@ihs.gov if you are interested.
Special Care Program at PIMC presented by Judy Whitecrane, CNM serves A/OD at risk pregnant women ‘where they are at’ in a sensitive, confidential and behaviorally integrated health care approach.
Provider Self Care? Terese Grant from the Center on Human Development and Disability, University of Washington will engage participants in appreciating the importance of a system that values self-care, respite, retreats, networking and day-to-day support of staff who work with high-risk women.
“Improve the System – Improve the Care” planning committee has designed many workshops and plenary objectives to address the effects of violence on AIAN women and the clinical and community response. Domestic Violence and Sexual Assault strategies and potential alternatives for serving victims of sexual assault in direct Tribal and urban Indian locations will be addressed by - Connie Monahan, New Mexico Statewide Sexual Assault Nurse Examiner (SANE) Coordinator.
Please join us
Native Women’s Health and MCH Conference, 2007
http://www.ihs.gov/MedicalPrograms/MCH/F/CN01.cfm#Aug07
Drive It Right Kits
Talking to teens about safe driving to 19,000 high schools across the country. Drive it Right, Talking to teens about safe driving is arriving at schools across the country just in time to incorporate them into National Youth Traffic Safety Month projects.
Allstate Insurance Company has a limited amount of Drive it Right, Talking to teens about safe driving kits available to NOYS member organizations on a first request basis.
These materials include Educator Resource Materials, a poster, and a supporting video. NOYS has previewed this resource and supports the content and use of the materials to address youth traffic safety.
16 page work book with questionnaires divided into:
# LICENSE TO TEACH – FOR teachers
# LICENSE TO DRIVE - STUDENTS
• It’s Your Road
Introduction and background information on driving issues
that affect teens.
• Crash Test
A list of questions to gauge teens pre-existing knowledge and
attitudes about teen driving issues and to spark genuine dialogue.
• What’s It Worth?
Checklist of what teens could lose by driving carelessly.
• Split-second Decision
Real world, driving-related scenarios to make teens think about
how they would react.
• Simple Tips to Stay Alive
Quick tips to help students improve their driving habits.
• What Are You Going to Do About It?
Ideas for teen-directed initiatives they could implement during
your Teen Safe Driving Campaign.
• Tips for Creating a Drive It Right Pledge
Culminating pledge that students will create and sign, promising
to keep themselves and their friends safe.
www.discoveryschool.com/100days Contact Sandy Spavone atsspavone@noys.org
Have you heard of: “oral health risk assessment”…“fluoride varnish”…“early childhood caries”…“the Baby bottle tooth decay germ -aka Streptococcus mutans?
While most of these terms are part of our clinical vocabulary we still have long way to go to reduce and prevent caries in infants and young children. In the coming months ten American Indian and Alaska Native communities will be getting an oral health check-up – training that is!
Dentists from academic and private practice will be supporting pediatricians, dentists, dental hygienists, and oral health community stakeholders who submitted applications on how they wanted to work with their communities in early childhood oral health. Sites will receive $2,000 in free in-kind consultation services for onsite technical assistance.
The American Academy of Pediatrics’ Oral Health Initiative along with the Bright Futures Educational Center is providing these awards in partnership with the Indian Health Service Maternal and Child Health Program and the Division of Oral Health. Preceptors will be making their way for a one-day training designed by the individual sites. Proposed plans include updates with WIC, Head Start Programs, primary care providers, oral health providers and community dental consultants to refresh their early childhood oral health knowledge and skills. Components of the one-day preceptorship will include how to: conduct oral health risk assessments, oral health exams, apply varnish and learn how to expand community and parent participation in this number one infectious disease. The preceptorships will build upon existing activities bringing up-to-date information on infant and toddlers oral health.
The ten awardees’ coordinating the preceptorships and visiting preceptors are:
- Chinle Comprehensive Health Care Facility, Chinle, AZ - Kristi Nix, MD - Jay Shirley, DMD Marietta, Georgia
- Consolidated Tribal Health Project, Inc. Redwood Valley, CA - Mary Ann Gonzalez, DDS - Leslee Singleton Huggins, BS, DDS, MS , Tyler, TX
- Fort Defiance Indian Hospital: Fort Defiance, AZ – Michael Bartholomew, MD - Ronald Winder, DDS, Tulsa, Oklahoma
- Gallup Indian Medical Center, Gallup, NM - Kevin Sweeney, MD - Adriana Segura-Donly DDS, MS, San Antonio, Texas
- Oneida Dental Clinic: Oneida, WI - Barb Ayres, RDH - Kavita Kohli, DDS, New York, N.Y.
- Pine Ridge Indian Hospital - Delores Starr - Hakan Koymen, DDS, MS, Perry Hall, MD
- Port Gamble S’Klallam Health Department: Kingston, WA - Dorie Salem-Soule, RDH - Rama Oskouian, DMD, Woodville, WA
- Seminole Tribe of Florida: Hollywood. FL - Kerri Cook-Descheene, Dental Prevention Coordinator - Jonathan Shenkin, DDS, MPH , Bangor, ME
- Tulalip Indian Health Clinic: Tulalip, WA - Marion Fulkomer, MD - Rama Oskouian, DMD, Woodville, WA
- White Earth Health: Ogema, MN - Karry Cassidy, Hygiene Supervisor - TBA
Interested in applying for the second round?
Contact Wendy Nelson at Wnelson@aap.org for an application.
Newly completed Pregnancy and Postpartum Quitline Toolkit
For a one per person hard copy of the Quitline Toolkit sent to you (include your mailing address) Email Lauren DiBiaseldibiase@schsr.unc.edu
Online availability at http://www.helppregnantsmokersquit.org/
K-12 Oral Health Education Curriculum
The Missouri Dept. of Health and Senior Services has completed a K-12 Oral Health Education Curriculum power point presentation series. The presentations can be downloaded free-of-charge by clicking on the grade(s) specific icons. These presentations can be used by school health nurses or teachers, as well as by other health care/child care professionals, in conjunction with their health curriculum. The presentations are available online at: http://www.dhss.mo.gov/oralhealth/OralHealthEducation.html
American Academy of Pediatrics on state mandated benefits for childhood vaccinations
AI/AN CHILDREN are covered under VACCINES FOR CHILDREN (VFC). THIS CHART IS HELPFUL TO SEE THE Larger SAFTY NET
http://cme.kff.org/Key=12433.7c.F.C.PFdksq
2005 - State by state AIAN % population breakout State ranking http://factfinder.census.gov/servlet/GRTTable?_bm=y&-geo_id=01000US&
-_box_head_nbr=R0203&-ds_name=ACS_2005_EST_G00_&-_lang=en&-format=US-30&-_sse=on
National Children's Study - by county: It is Pregnant
women who are enrolled and their offspring followed for 2 decades
http://www.nationalchildrensstudy.gov/about/locations/
Infant Mortality Statistics from the 2004 Period Linked Birth/Infant Death Data Set
Objectives—This report presents 2004 period infant mortality statistics from the linked birth/infant death data file by a variety of maternal and infant characteristics. The linked file differs from the mortality file, which is based entirely on death certificate data.
Methods—Descriptive tabulations of data are presented and interpreted. Excluding rates by cause of death, the infant mortality rate is now published with two decimal places.
Results—The U.S. infant mortality rate was 6.78 infant deaths per 1,000 live births in 2004 compared with 6.84 in 2003. Infant mortality rates ranged from 4.67 per 1,000 live births for Asian and Pacific Islander mothers to 13.60 for non-Hispanic black mothers. Among Hispanics, rates ranged from 4.55 for Cuban mothers to 7.82 for Puerto Rican mothers. Infant mortality rates were higher for those infants whose mothers were born in the 50 States and the District of Columbia, were unmarried, or were born in multiple births. Infant mortality was also higher for male infants and infants born preterm or at low birth weight. The neonatal mortality rate declined from 4.63 in 2003 to 4.52 in 2004 while the postneonatal mortality rate was essentially unchanged. Infants born at the lowest gestational ages and birth weights have a large impact on overall U.S. infant mortality. More than one-half (55 percent) of all infant deaths in the United States in 2004 occurred to the 2 National Vital Statistics Reports, Vol. 55, No. 14, May 2, 2007 2 percent of infants born at less than 32 weeks of gestation. Still, infant mortality rates for late preterm (34–36 weeks of gestation) infants were three times those for term (37–41 week) infants. The three leading causes of infant death—Congenital malformations, low birthweight, and SIDS—taken together accounted for 45 percent all infant deaths. Results from a new analysis of preterm-related causes of death show that 36.1 percent of infant deaths in 2004 were due to preterm-related causes. The preterm-related infant mortality rate for non-Hispanic black mothers was 3.3 times higher, and the rate for Puerto Rican mothers was 75 percent higher than for non-Hispanic white mothers.
Infant Mortality Statistics from the 2004 Period Linked Birth/Infant Death Data Set by T.J. Mathews, M.S., and Marian F. MacDorman, Ph.D., Division of Vital Statistics
http://www.cdc.gov/nchs/data/nvsr/nvsr55/nvsr55_14.pdf
Trends in Preterm-Related Infant Mortality by Race and Ethnicity: United States, 1999-2004 Objectives—This report examines trends in preterm-related causes of infant death in the United States by maternal race and ethnicity.
Methods—A grouping of preterm-related causes of infant death was created by identifying causes of death that were a direct cause or consequence of preterm birth.
Cause-of-death categories were considered to be preterm-related when 75% or more of total infant deaths attributed to that cause were born preterm, and the cause was
considered to be a direct consequence of preterm birth based on a clinical evaluation and review of the literature. Trends in preterm-related causes of death were
examined by maternal race and ethnicity.
Results—In 2004, 36.1% of all infant deaths in the United States were preterm related, up from 34.5% in 1999. The preterm-related infant mortality rate for non-
Hispanic black mothers was 3.3 times higher and the rate for Puerto Rican mothers was 75% higher than for non-Hispanic white mothers. The preterm-related infant
mortality rate for non-Hispanic black mothers was higher than the total infant mortality rate for non-Hispanic white, Mexican, and Asian or Pacific Islander (API)
mothers.
Discussion—The leveling off of the U.S. infant mortality decline since 2000 has been attributed in part to an increase in preterm and low birthweight (LBW) births.
Continued tracking of this group of preterm-related causes of infant death will improve our understanding of trends in infant mortality and perinatal health in the
United States .
Trends in Preterm-Related Infant Mortality by Race and Ethnicity: United States, 1999-2004 by Marian F. MacDorman, Ph.D., Division of Vital Statistics; William M. Callaghan, M.D., M.P.H., Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion; T.J. Mathews, M.S.; Donna L. Hoyert, Ph.D.; and Kenneth D. Kochanek, M.A., Division of Vital Statistics, National Center for Health Statistics
http://www.cdc.gov/nchs/products/pubs/pubd/hestats/infantmort99-04/infantmort99-04.htm
Kids Count Tables: Child and youth demographics – by race, by state, health, economic
Annie E. Casey Foundation has launched a new and improved website
IF YOU ARE DRAFTING ANY PROPOSAL YOU WANT TO REFERENCE THIS WEBSITE FOR COMPARISON DATA.
- CHILD WELFARE - National Foster Care Month focuses national attention on the needs of children and youth in foster care. The campaign encourages more citizens to get involved -- whether as their foster parents, volunteers, mentors, or employers, or in other ways. The Annie E. Casey Foundation and its direct services agency, Casey Family Services, are among the partner organizations involved in promoting stable and permanent family connections for children.
- COMMUNITY CHANGE
- ECONOMIC SECURITY
- EDUCATION
- HEALTH
- JUVENILE JUSTICE
- SPECIAL INTEREST AREAS.
New Resource for Children’s Health Information
SCHIP and child health coverage by state, with state to state comparisons, state to US comparisons lacks AIAN specifics. Statehealthfacts.org now includes a children’s health section that offers customized fact sheets for each state, a directory of all children’s health topics on the site, and the latest children’s health research from KCMU and headlines from kaisernetwork.org
http://cme.kff.org/Key=12433.7c.P.C.Mzc7Px
Definitions: Persons of Hispanic origin may be of any race; all other racial/ethnic groups are non-Hispanic.
"Other" includes Asian-Americans, Pacific Islanders, American Indians, Aleutians, Eskimos and persons of "Two or More Races".
These groups have been combined due to their small populations in many states which prevent meaningful statistical analyses of the groups individually.
The distribution of the U.S. population by Race/Ethnicity is: White, 195,289,747 (66.7%), Black, 35,539,912 (12.1%), Hispanic, 43,077,106 (14.7%), American Indian, 1,654,861 (0.6%), Asian-Americans and Pacific Islanders, 12,915,910 (4.4%), and Two or More Races, 4,469,902 (1.5%).
Two charts from fact sheet:
http://www.kff.org/medicaid/upload/7610.pdf
Link to the AAP Government Affairs “state by state” LEGISLATION REPORT
TOC FOR your specific interests. When sessions convene / adjourn / governor / state budgets /… to booster seats to guns to helmets to…tobacco.
http://www.aap.org/advocacy/statelegrpt.pdf
Birth characteristics single and multirace women
Medical Mystery Tour
Which Indian Health facilities lead the entire U.S. in national obstetric benchmarks?
You saw the above question last month in the May CCC Corner.
Here is the rest of the story…
First, let me tell you two characteristics common to both facilities. Both have strong certified nurse midwife programs and both are 638 facilities, e.g., operated by tribal Boards under Self Determination legislation.
….and now the envelope please….the winners are… the Tuba City obstetrical care unit and the Alaska Native Medical Center obstetrical care unit.
Tuba City was recognized for cesarean delivery rate just under 14 percent – lowest in the State of Arizona for Arizona Perinatal Trust Level II Nurseries
and
Alaska Native Medical Center was recognized for best practice in five categories of the American College of Nurse- Midwives (ACNM) 2005 Benchmarking Program for facilities its size.
The categories included:
Successful vaginal after cesarean rate 84.1% (63 attempted VBACs)
Intact perineum 84.1% (1352 vaginal births)
Patients with prenatal care by 12 weeks 86.9% (1488 births)
Lowest pitocin induction rate 5.4% (1488 births)
Cesarean delivery rate 9.1% (1488 births)
As no one staff category can accomplish the above in isolation, so I would like to offer congratulations to the entire staffs at both facilities for a job well done.
Now, how can we translate that success to other Indian Health sites?
The easiest way to start that process is to hear directly from the staff themselves. We have arranged to have members of their staff present at the upcoming 2007 National Indian Women’s Health and MCH Conference in Albuquerque, NM August 15- 17, 2007 so you can hear for yourselves.
The theme of the 2007 National Indian Women’s Health and MCH Conferenceis “Improve the System: Improve the Outcome” so it will explore how we can all work together to raise the AI/AN health status to the highest possible status.
There will be national benchmark organizations (Institute for Healthcare Improvement, American College of Nurse- Midwives, American College of Obstetricians and Gynecologists, Kaiser Family Foundation, etc…), internationally known speakers, and a rather extensive clinical Program.
The meeting is only every 3 years, so you and a team from your facility should try your best to attend. You can either use your local facility funds, because there is a program review function, or use your CME /CEU funds. In addition, limited scholarships are available.
2007 National Indian Women’s Health and MCH Conference
http://www.ihs.gov/MedicalPrograms/MCH/F/CN01.cfm#Aug07
Background
About Benchmarking
Benchmarking is a method for comparing your facilities care processes to those of the practices in the field that demonstrate the best outcomes. Identifying "best practices" through benchmarking allows all who participate in the process to improve and adapt the care they provide in order to obtain superior outcomes: high satisfaction, patient safety, effectiveness and efficiency.
One Example: ACNM
The purpose of the American College of Nurse- Midwives (ACNM) Benchmarking Program is to provide a midwifery-specific mechanism to improve and maintain the superior quality of midwifery care provided to women and children by promoting member awareness of "best practices." To facilitate this, members are encouraged to participate in benchmarking their practice against other midwifery practices in the country.
ACNM Benchmarking Program
http://www.acnm.org/education.cfm?id=842
Another Example:
Tuba City Regional Health Care Corporation leads the way with healthy childbirth model Tuba City Regional Health Care Corporation birth by cesarean delivery is just under 14 percent – lowest in the State of Arizona for Arizona Perinatal Trust Level II Nurseries, according to latest data. Certified nurse mid-wife/obstetrician model practiced is favored by the World Health Organization Citing its collaborative certified nurse mid-wife/obstetrician model for childbirth, Tuba City Regional Health Care Corporation reported the lowest birth by cesarean delivery rate in Arizona among Arizona Perinatal Trust Level II Nurseries for the year 2005 – just 13.9 percent. The national average is approximately 33%. For most mothers in labor arriving at the Tuba City obstetrical care unit (OCU), everything is considered normal, healthy and natural until signs show otherwise. Midwives care for patients in the OCU 24 hours per day. Obstetricians are always available when anything abnormal begins to occur during labor, or for high-risk pregnancies. The World Health Organization recommends the certified nurse mid-wife/obstetrician model utilized at Tuba City Hospital. A cesarean delivery is the birth of a baby by surgery. The doctor makes an incision in the belly and uterus and then removes the baby. A c-section is usually performed when a vaginal delivery would lead to medical complications; although nationwide it is becoming increasingly more common to have an elective c-section when there is no contra-indication to having a vaginal birth. While sometimes necessary, a c-section is major abdominal surgery, carrying with it a considerable list of risks, such as bleeding, infection, damage to nearby organs such as the bowel or the bladder, scar tissue formation, and a higher risk in future pregnancies. When a c-section is necessary, it can be a life saving technique for both mother and infant. Another factor increasing the rates of c-section births is the belief that ‘once a c-section, always a c-section.’ Often, pregnant women who have had a previous c-section aren’t necessarily aware that in some facilities they can still choose to have a natural vaginal birth. The risks from Vaginal Birth After C-section (VBAC) delivery are low, but are slightly higher than for a repeat c-section delivery – this finding is from a study by the National Institute of Child Health and Human Development of the National Institutes of Health. “We are strong advocates for VBAC at this facility for appropriate candidates, and we have an excellent success rate with no known uterine ruptures over the last 10 years,” said Dr. Amanda Leib, TCRHCC OB/GYN Chief. In 2006, among 28 mothers who chose to try to have VBACs at Tuba City Hospital, there was an 82% success rate. 24 women had successful vaginal births, and 4 underwent c-sections. “The decision for c-section is usually made between the doctor, certified nurse mid-wife and patient. There are many reasons why women wind up having c-sections, and the events leading to such a decision vary depending on the situation,” said Dr. Leib. Some reasons the c-section rate is low at Tuba City Hospital are that we offer VBACs, we have a certified nurse mid-wife/obstetrician model which allows more one-on-one attention during labor and delivery than at other facilities, and that we are very involved with our high risk patients. We believe in active management before fetal problems occur.” Barbara Orcutt, CNM, MSN, Director of Nurse Mid-wives at Tuba City Hospital has been a certified nurse mid-wife for 29 years. She remarked, “I’ve been associated with numerous practices and hospitals in various parts of the country, and the acceptance of certified nurse mid-wifery here is wonderful. We have a close working relationship with our obstetricians and we are valued.” Certified nurse mid-wives deliver all of the vaginally born babies at Tuba City Hospital, and are involved in the labor of women who eventually do have c-sections. There are 5 certified nurse mid-wives currently practicing at Tuba City Hospital. In addition to following traditional ways, the OB/Gyn Department is scheduled and run in such a manner that both patient and provider will very often see a familiar face when a woman is in labor. Certified nurse mid-wives staff the OCU 24 hours a day, and they work 12-hour shifts so there is continuity with any one patient with a large block of time.
Our schedules are structured as such that we don’t think in terms of ‘It’s Friday afternoon and I’d better get her delivered before the weekend,’” said Orcutt. Dr. Leib continued, “We regularly review our c-section rate and individual c-sections as a department, looking for ways we can improve and offer even better patient care.”
Pregnant women considering a c-section, with no clear medical reason for it, should know that the procedure is not without risk, Canadian doctors caution in a report in February 2007. Dr. Shiliang Liu with the Public Health Agency in Ottawa, Canada, and colleagues, report that the rate of severe complications, such as major bleeding, infection and blood clots, is three times higher overall in women having a planned c-section compared with women who have a natural birth. The researchers used a Canadian database to look at the outcomes of 46,766 women who underwent what doctors deemed to be a low-risk, c-section delivery and nearly 2.3 million women who underwent planned vaginal delivery between April 1991 and March 2005. Liu’s team found that the rate of severe complications in the planned cesarean group was 27.3 cases per 1,000 deliveries, compared with 9.0 per 1,000 deliveries in the planned vaginal delivery group. This data adds to a growing body of evidence suggesting that primary elective c-section birth may place both the mother and newborn at greater risk for complications. In 2005 there were 546 live births at Tuba City Hospital, of which 471 were vaginal deliveries. Of the 546, 75 were c-section deliveries – 40 of which were primary c-sections (first time c-sections), and 35 of which were repeat c-sections. “We have some really fine doctors and providers at Tuba City Hospital and in the Indian Health Service,” remarked Orcutt. “We provide excellent maternity care that is based on sound medical evidence and do not engage in the legal protective thinking that pervades obstetrics elsewhere.” “It’s a wonderful way to practice,” Orcutt continued, “just doing the natural thing, the right thing.” “Here on the Navajo Reservation, there is still a cultural acceptance of labor and birth as a natural function of the body, and great stoicism in labor. All of this decreases interventions. All of these things factor into our low c-section rate at TCRHCC.” TCRHCC Mission Tuba City Regional Health Care Corporation is a community focused non-profit, health care organization offering a 73-bed acute care referral hospital and a broad range of outpatient care services. It serves a patient population of approximately 75,000 Navajo, Hopi and San Juan Piute, in a 4,400 square mile area. Its mission is to provide accessible, quality, culturally sensitive health care. Arizona Perinatal Trust Mission The Arizona Perinatal Trust is created to be an independent source of energy and resources to focus efforts on the continuing improvement of the health of Arizona’s mothers and babies. Arizona Perinatal Trust Purpose Based in Casa Grande, Arizona, the Arizona Perinatal Trust (Trust) is a non-profit organization, working to continually improve the quality of care for Arizona’s mothers and babies. • Promote, develop and coordinate Arizona’s regional perinatal system • Provide, facilitate and support perinatal education • Collaborate with the diverse community of perinatal healthcare providers, • Arizona Health Care Cost Containment System (AHCCCS), and the Arizona Department of
Health Services/Office of Women’s and Children’s Health • Increase public awareness of perinatal health.
Tuba City Regional Health Care Corporation Press Release
http://www.tchealth.org/news_033007.html
Other Resources
Collins-Fulea C, et al Improving midwifery practice: the American College of Nurse- Midwives' benchmarking project. J Midwifery Womens Health. 2005 Nov-Dec;50(6):461-71.
or
http://download.journals.elsevierhealth.com/pdfs/journals/
1526-9523/PIIS1526952305003302.pdf
Medscape*
Urinary Tract Infections: A Primer for Clinicians (CME)
http://www.medscape.com/viewarticle/556040
Management of Breast Cysts Revisited (CME)
http://www.medscape.com/viewarticle/555606
CDC Issues New Treatment Recommendations for Gonorrhea (CME)
http://www.medscape.com/viewarticle/555228?sssdmh=dm1.269355&src=top10#
http://www.medscape.com/viewarticle/532220
Ask the Experts topics in Women's Health and OB/GYN Index, by specialty,
Medscape
http://www.medscape.com/pages/editorial/public/ate/index-womenshealth
OB GYN & Women's Health Clinical Discussion Board Index, Medscape
http://boards.medscape.com/forums?14@@.ee6e57b
Clinical Discussion Board Index, Medscape
Hundreds of ongoing
clinical discussions available
http://boards.medscape.com/forums?14@@.ee6e57b
Free CME: MedScape CME Index by specialty
http://www.medscape.com/cmecenterdirectory/Default
*NB: Medscape is free to all, but registration is required. It can be accessed from anywhere with Internet access. You just need to create a personal username and password.
Menopause Management
Earlier hormone therapy closer to menopause tended to have reduced CHD risk
CONCLUSIONS: Women who initiated hormone therapy closer to menopause tended to have reduced CHD risk compared with the increase in CHD risk among women more distant from menopause, but this trend test did not meet our criterion for statistical significance. A similar nonsignificant trend was observed for total mortality but the risk of stroke was elevated regardless of years since menopause. These data should be considered in regard to the short-term treatment of menopausal symptoms.
Rossouw JE, et al Postmenopausal hormone therapy and risk of cardiovascular disease by age and years since menopause JAMA. 2007 Apr 4;297(13):1465-77
Low dose transdermal estradiol gel effective for postmenopausal symptoms
CONCLUSION: The 0.87 g/d dose of this new transdermal E2 gel, which delivers an estimated 0.0125 mg E2 daily, delivered the lowest effective dose for treatment of vasomotor symptoms and vulvovaginal atrophy in a population of postmenopausal women.
Simon JA, et al Low dose of transdermal estradiol gel for treatment of symptomatic postmenopausal women: a randomized controlled trial Obstet Gynecol. 2007 Mar;109(3):588-96
Updated Statement on Hormone Therapy (CME)
http://www.medscape.com/viewarticle/551565?src=0_nl_cme_8
Midwives Corner - Lisa Allee, CNM
Ultrasound affects mice brains in negative ways: First, do no harm
I was flipping through the November/December issue of Mothering magazine and found a citation of an interesting research article on the effects of ultrasound on mice brains. It has scary findings for an intervention that is often considered routine and benign by providers and patients.
Eugenius, et al*, found that when fetal mice are exposed to 30 minutes or more of ultrasound that “a small but statistically significant number of neurons fail to acquire their proper position and remain scattered within inappropriate cortical layers and/or in the subjacent white matter. The magnitude of dispersion of labeled neurons was variable but systematically increased with duration of exposure to USW.” Yikes! This means that cells in the brain are not all in the right place. Okay, you’re saying these are mice, not humans. In their discussion the authors discuss this—it might not apply to humans, but then again it might in a big way:
First it may not be applicable because “..the distance between the
exposed cells and transducer in our experiments is shorter than in human. Furthermore,
the duration of neuronal production and the migratory phase of cortical neurons
in the human fetus lasts 
18
times longer than in mice (between 6 and 24 weeks of gestation, with the peak
occurring between 11 and 15 weeks), compared with the duration of only 
1
week (between E11 and E18) in the mouse. Thus, an exposure of 30 min represents
a much smaller proportion of the time dedicated to development of the cerebral
cortex in human than in mouse and, thus, could have a lesser overall effect,
making human corticogenesis less vulnerable to USW” (ultrasound mwaves.)
But on the other hand, “There are also some reasons to think that the USW may have a similar or even greater impact on neuronal migration in the human fetal brain. First, migrating neurons in the human forebrain are only slightly larger than in the mouse, and, with the acoustic absorption provided by the tissue stand-off pad, the amount of energy absorbed within a comparable small volume of tissue during the USW exposure was in the same general range. Second, the migratory pathway in the convoluted human cerebrum is curvilinear and at least an order of magnitude longer. Thus, the number of neurons migrating along the same radial glial fascicle, particularly at the later stages of corticoneurogenesis, is much larger and their routes are more complex, increasing the chance of a cell going astray from its proper migratory course. Third, the inside-to-outside settling pattern of isochronously generated neurons in primates is more precise than in rodents and thus, the tolerance for malpositioning may be smaller. In addition, different functional areas in the primate cortex are generated by different schedules so that exposure to USW may potentially affect selective cortical areas and different layers, depending on the time of exposure, potentially causing a variety of symptoms.”
These effects of ultrasound are hard to study in humans because the testing to find ectopic cells in the brain cannot be done in humans according to the authors. There are some things that are known and are concerning: “even a small number of ectopic cells might, as a result of specific position and inappropriate connectivity, be a source of epileptic discharge or abnormal behavior. Although we have not as yet generated behavioral data, previous studies in rodents and primates indicate that prenatal exposure to USW may affect higher brain function of the offspring. Furthermore, there are numerous human neuropsychiatric disorders that are thought to be the result of misplacement of cells as a consequence of abnormal neuronal migration.” The authors go on to say that their research supports the recommendation by the FDA that medically non-indicated commercial ultrasound videos should not be done.
I find this research concerning for more than just ultrasound videos offered in malls. I wonder about repeated ultrasounds for medical indications, dating ultrasounds during the most vulnerable periods of cell migration in the brain, antenatal testing that has never been shown to improve outcomes, and, the biggest of all, continuous fetal monitoring during labor for hours on end. Remember: the ultrasound to create pictures is pulsed—only 1/100th of the time is actual exposure to ultrasound—whereas the fetal monitor on L & D is a continuous deluge of ultrasound—it is not pulsed, the whole time is exposure to ultrasound and the effects these researchers found increased with time. Yes, most monitoring is after the time of migration of neurons cited above, but we do know that the human brain continues to develop in a big way for the rest of intrauterine life and a long time after, so there may be are other effects on the brain cells. Anyone heard tell of increased rates of autism, depression, bipolar disease, behavioral problems, etc. in the current crop of young ‘ens?? Food for thought
Other Resources:
Physics and safety of diagnostic ultrasound in obstetrics and gynecology, UpToDate
Indications for diagnostic obstetrical ultrasound examination , UpToDate
*Eugenius, et al citation available from Lisa.Allee@ihs.gov
Navajo News, John Heusinkveld, Shiprock
Adjustable Urethral Slings Offer Hope for Patients with Complex Incontinence Problems
This month's Navajo News comes from Northern Navajo Medical Center, which has the highest gynecology surgery volume of the Navajo Area IHS facilities.
Over the past 10 years, various versions of the mid-urethral sling operation have dramatically improved the surgical treatment of urodynamic stress incontinence. The vast majority of patients, whose incontinence results from urethral hypermobility, can now be cured by a simple, minimally invasive procedure, preferably in combination with pelvic floor physical therapy.
Treatment of stress incontinence resulting from problems such as instrinsic sphincteric deficiency (ISD) and other neuromuscular problems remains more problematic. Urethral bulking procedures such as collagen or carbon bead injection can provide temporary relief, but have to be repeated at intervals in order maintain their effect. Mid-urethral slings placed via the suprapubic approach appear to be moderately effective for ISD; however, in order to be effective for this indication, a sling generally needs to be placed under greater tension than one placed for urethral hypermobility, and the difference between continence and retention can be quite small.
A new modification of the suprapubic sling technique appears to be well-suited for patients with complex problems such as ISD or recurrent incontinence after previous surgery. In this procedure, a small sling of mesh is placed under the mid-urethra and attached to 2 polypropylene threads which pass behind the pubic symphysis and through the lower extent of the abdominal wall, where they are attached to a small prosthesis, implanted directly above the rectus fascia via a two to three centimeter incision in the skin above the symphysis pubis. This prosthesis contains a tiny spool around which the traction threads are wound; rotating the spool to the right or left increases or decreases the level of tension on the threads, which correspondingly adjust the level of support for the urethra. A small plastic arm attached to the prosthesis containing the spool is left in place, protruding slightly through a small gap in the suprapubic incision. On postoperative day one or two, the bladder is filled, the indwelling catheter is removed, and the adjustment arm is rotated to the right, increasing support for the urethra until no leakage is observed with coughing. The cough test is then repeated with the patient standing, and the level of tension can be increased if necessary. The patient then voids and the tension can be reduced if retention occurs. Finally, the adjustment arm is removed and the gap in the incision is closed.
If a patient with an adjustable sling ever experiences recurrent leakage or retention, the level of urethral support can be adjusted via a simple procedure done under local anesthesia, in which the suprapubic incision is reopened and the adjustment arm is reattached to the prosthesis, allowing the spool to be turned to the right or left as needed to increase or decrease the level of urethral support. This procedure can be repeated as many times as needed throughout the patient's life.
In addition to patients with sphincter deficiency, adjustable slings appear well-suited for patients who have failed a conventional continence operation, or who present with recurrent leakage after previous surgical procedures. They can also be used with caution in patients who are not candidates for other surgical techniques due to neuromuscular problems affecting the detrusor muscle. These patients typically utilize the Valsalva maneuver during voiding, and are at high risk for retention using conventional surgical techniques. An adjustable sling allows the surgeon to find a level of support that balances continence with retention.
To our knowledge there are two adjustable sling products currently approved by the FDA, only one of which is actively being marketed in the United States. The system described here was developed by the Neomedic corporation in Spain and is marketed in the US by Tri-Anim under the brand name Remeex ™ (Regulacion Mecanica Externa). A somewhat different system using a trans-obturator route, Safyre-t ™, manufactured by the South American company Promedon, has received FDA approval but is not yet being marketed in the US. The Neomedic product has been in widespread use in Europe since 1999 with an excellent safety record and good results.
Our early experience with the adjustable sling in Shiprock has been positive. The surgical technique is virtually identical to placement of a conventional mid-urethral sling via the suprapubic route. As expected, adjustable sling placement involves significantly more effort for the surgeon and the patient than a conventional sling, typically requiring several days hospitalization in order to implant and adjust the sling. Although we would not advocate the adjustable sling as a first-line treatment for most stress incontinence patients, we believe that it is an excellent option for patients with certain conditions.
Here is a link to a commercial website which contains abstracts from a group in Spain which has been evaluating the Neomedic product in long-term trials.
http://remeex.com/index.php?id_seccio_menu=37&cnv_idioma=1&idioma_seleccionat=1
Nurses Corner - Sandra Haldane, HQE
Personal Digital Assistants: Practical Advice for Nurses in 2007
http://www.medscape.com/viewarticle/553563?sssdmh=dm1.264275&src=0_tp_nl_0
Office of Women's Health, CDC
CDC’s Pregnancy Information Center
If you're pregnant or planning to get pregnant, you probably have a lot of questions. This website will help you learn how to be healthy (before, during, and after pregnancy) and give your baby a healthy start to life.
http://www.cdc.gov/ncbddd/pregnancy_gateway/default.htm
Lead Exposure Among Females of Childbearing Age - United States , 2004
This report summarizes 2004 surveillance data regarding elevated blood lead levels (BLLs) among females of childbearing age (i.e., aged 16-44 years) in 37 states participating in CDC's Adult Blood Lead Epidemiology and Surveillance program. The results indicated that rates of elevated BLLs ranged from 0.06 per 100,000 females of childbearing age at BLLs of >40 µg/dL to 10.9 per 100,000 females at BLLs of >5 µg/dL. Primary and secondary prevention of lead exposure among females of childbearing age is needed to avert neurobehavioral and cognitive deficits in their offspring.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5616a4.htm
Oklahoma Perspective Greggory Woitte – Hastings Indian Medical Center
Cesarean Delivery on Maternal Request
It was in June of last year when I last wrote about the NIH Consensus conference on Cesarean Delivery on Maternal Request (CDMR). Over the past year there has been several articles written on the subject. The most recent of which is published in the New England Journal of Medicine by Ecker and Frigoletto (excerpted below).
Here at Hasting’s Indian Medical Center, we are beginning to explore this issue through journal clubs and dialogue. We have had more patients recently requesting Cesarean Delivery over the past year. A review of the NIH Consensus conference points out that most of the evidence is weak or non-existent to support planned vaginal or cesarean delivery. Moderate quality evidence is available for only three outcome variables (postpartum hemorrhage, maternal length of stay, and neonatal respiratory morbidity). .
ACOG sent out a news release on May 9, 2006 after the NIH consensus conference. In it they point out that more research is needed and that CDMR is not recommended for women planning on having several children due to the risks of placenta previa and placenta accreta increasing with each cesarean delivery. In addition, Dr. Zinberg, Deputy Executive Vice President of ACOG states “ACOG continues to review all of the issues surrounding maternal-request cesarean, but at this time our position is that cesareans should be performed for medical reasons.”
A number of the articles written have pointed out ACOG’s position that a cesarean delivery on maternal request can be ethically justified at times. In ACOG’s “Surgery and Patient Choice: The Ethics of Decision Making,” ACOG states that “In the absence of significant data on the risks and benefits of cesarean delivery, the burden of proof should fall on those who are advocates for a change in policy in support of elective cesarean delivery (i.e., the replacement of a natural process with a major surgical procedure.”
As many of the articles and editorials written over the past year have pointed out, caution should be used when a patient requests a cesarean delivery. Moving slowly in the absence of good evidence is a prudent option. While support for a women’s choice is without question of paramount importance, performing cesarean deliveries on maternal request may ultimately lead to a violation of the Hippocratic Oath to do no harm.
OB/GYN CCC Editorial comment:
Looking for sanity in the ever increasing cesarean delivery rate
Ecker and Frigoletto state the key question centers on both the number needed to treat to avoid one adverse neonatal outcome and the level of risk that is currently considered acceptable. As practicing obstetricians, we find that the risk that women are now willing to assume in exchange for a measure of potential benefit, especially for the neonate, has changed: for many, the level of risk of an adverse outcome that was tolerated in the past to avoid cesarean delivery is no longer acceptable, and the threshold number needed to treat has thus been reset.
In the face of the resulting continued increase in cesarean deliveries, our obligation as providers is to educate patients about the trade-offs entailed in choosing a particular course or intervention and to ensure that their choices are congruent with their own philosophy, plans, and tolerance of risk. In areas in which there is still uncertainty, we must organize clinical trials that will produce the data we require for counseling patients. For the moment, however, few of the relevant factors seem likely to change, and the cesarean rate can be predicted to continue its climb.
The March 2006 National Institutes of Health (NIH) State-of-the-Science Conference report concluded that there was a need for research that explicitly compared outcomes of planned cesarean delivery with outcomes of planned vaginal delivery. Declercq et al examines 6 years of data from a population-based linked data system to create a refined measure identifying women with planned cesareans and planned vaginal births and comparing maternal outcomes and costs associated with these two options.
1.) planned cesarean increases complications and re-hospitalizations and
2.) planned cesarean increases cost
Declercq et al document a small, but consistent growth in planned primary cesareans, but higher costs, longer hospital stays, and substantially greater risks of maternal re-hospitalization associated with these deliveries.
The authors found that
* The rate of re-admission to a hospital (per 1,000) within 1 month of delivery for planned vaginal births was significantly lower than that for planned primary cesarean births (7.5 vs. 19.2). Adjusting for age, race or ethnicity, and parity, a woman who had a planned primary cesarean birth was 2.3 times as likely as a woman who had a planned vaginal birth to be re-admitted in the first month after the birth.
* The leading reason for re-admission associated with planned primary cesarean births in the first 30 days after birth was surgical wound complications. Postpartum infections were a major cause of re-admission for both groups, with the rate of re-admission for infection after planned primary cesarean births almost twice as high as that of infection after planned vaginal births.
* The average initial maternal (excluding infant) hospital costs in 2003 dollars for a planned primary cesarean birth were 76% higher than the average initial costs for a planned vaginal birth ($4,372 vs. $2,487).
* Women who had a planned primary cesarean birth averaged 4.3 days in their initial stay and 4.4 days in cases of re-admission, compared with
2.4 and 3.9 days, respectively, for those with a planned vaginal birth.
* Costs associated with a planned primary cesarean birth, compared with costs associated with a planned vaginal birth, were higher for both delivery (65%) and postpartum re-admission (11%).
Kennare R, et al just reported that after the first cesarean, the risks increase in next pregnancy. Specifically, cesarean delivery is associated with increased risks for adverse obstetric and perinatal outcomes in the subsequent birth. However, some risks may be due to confounding factors related to the indication for the first cesarean.
Dr. Woitte reminds us to do no harm. Declercq et al and Kennare R, et al findings suggest that planned primary cesareans are not without immediate health consequences for mothers and financial implications for society. Clinicians should be aware of the increased risk for maternal re-hospitalization after cesarean deliveries to low-risk mothers when counseling women about their choices.
Reference:
Declercq E, Barger M, Cabral HJ, et al. 2007. Maternal outcomes associated with planned primary cesarean births compared with planned vaginal births. Obstetrics and Gynecology 109(3):669-677. http://www.greenjournal.org/cgi/content/abstract/109/3/669?etoc or
Ecker
JL, Frigoletto
FD Jr. Cesarean delivery and the risk-benefit calculus. N Engl J Med. 2007
Mar 1;356(9):885-8. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db
=pubmed&list_uids=17329693&dopt=Abstract
Or http://content.nejm.org/cgi/content/full/356/9/885
Kennare R, et al Risks of adverse outcomes in the next birth after a first cesarean delivery. Obstet Gynecol. 2007 Feb;109(2 Pt 1):270-6
NIH Consensus Conference Report
http://consensus.nih.gov/2006 /2006CesareanSOS027html.htm
Patient-Requested Cesarean Update, ACOG Press Release
http://www.acog.org/from_home/publications/press_releases/nr05-09-06-1.cfm
Surgery and Patient Choice: The Ethics of Decision Making
http://www.acog.org/from_home/publications/ethics/ethics021.pdf
Osteoporosis
Let’s put DEXA and other radiation risks into perspective
Average Radiation Doses Associated With Common Imaging Studies
|
Diagnostic Examination |
Effective Dose (mSv) |
|
X-rays |
|
|
Chest (PA film) |
0.02 |
|
Head |
0.07 |
|
Cervical spine |
0.3 |
|
Thoracic spine |
1.4 |
|
Lumbar spine |
1.8 |
|
Abdomen |
0.53 |
|
Pelvis/hip |
0.83 |
|
Limbs/joints |
0.06 |
|
Upper GI |
3.6 |
|
Lower GI |
6.4 |
|
Screening mammogram |
0.13 |
|
CT |
|
|
Head |
2.0 |
|
Abdomen |
10.0 |
|
Chest |
20-40 |
|
Pulmonary angiography |
20-40 |
|
PET - CT |
25 |
http://www.medscape.com/viewarticle/523000_3
DEXA radiation safety and comparison
As in the above table of other imaging procedures and their exposure
http://homepage.mac.com/kieranmaher/digrad/DRPapers/DEXA_Dosimetry.html#BMD
Health Risks from Exposure to Low Levels of Ionizing Radiation: BEIR VII Phase 2 (2006)
http://books.nap.edu/books/030909156X/html
Patient education
Nice patient education piece for health education public information Web site developed and funded by the American College of Radiology (ACR) and the Radiological Society of North America (RSNA). It was established to inform and educate the public about radiologic procedures and the role of radiologists in healthcare, and to improve communications between physicians and their patients.” http://www.radiologyinfo.org/en/info.cfm?pg=dexa&bhcp=1
Relation of Cortisol Levels and Bone Mineral Density Among Premenopausal Women With Major Depression
http://www.medscape.com/viewarticle/555892
Patient Information
Hypertriglyceridemia: What You Should Know
http://www.aafp.org/afp/20070501/1372ph.html
Low Back Pain
http://www.aafp.org/afp/20070415/1190ph.html
Perinatology Picks - George Gilson, Maternal Fetal Medicine, ANMC
Placental cultures and histology poor predictors of infectious status of the amniotic fluid
RESULTS: Ninety-two percent of women with positive amniotic fluid cultures tested with at least one positive placenta culture. Eighty percent of women who had negative amniotic fluid cultures also tested with a positive placenta culture. The accuracy of placental cultures in predicting amniotic fluid infection varied from 44% to 57%. Placental pathology showed an accuracy of only 58% in diagnosing intraamniotic inflammation.
CONCLUSION: Placental microbiologic and histologic studies poorly reflect the infectious and inflammatory status of the amniotic fluid. Results of such studies should be interpreted with caution in the management and future counseling of women with preterm labor or preterm premature rupture of membranes
Pettker CM, et al Value of placental microbial evaluation in diagnosing intra-amniotic infection. Obstet Gynecol. 2007 Mar;109(3):739-49
Free beta-HCG outperforms intact HCG in a multimarker protocol
CONCLUSION: The results of our analysis suggest that in a first-trimester Down syndrome screening protocol free beta-human chorionic gonadotropin achieves higher sensitivity and lower false-positive results than intact human chorionic gonadotropin . Moreover, intact human chorionic gonadotropin does not add substantially to screening performance until the end of the first trimester.
Evans MI, et al Meta-analysis of first trimester Down syndrome screening studies: free beta-human chorionic gonadotropin significantly outperforms intact human chorionic gonadotropin in a multimarker protocol Am J Obstet Gynecol. 2007 Mar;196(3):198-205
Forum: Periodontal Health and Birth Outcomes - HRSA MCHB
Research to Policy and Practice Forum: Periodontal Health and Birth Outcomes—Summary of a Meeting of Maternal, Child, and Oral Health Experts explores the oral health requirements of pregnant women as a promising strategy for improving maternal and infant health. The report summarizes presentations of commissioned background papers and other topics, as well as workgroup discussions from a forum convened by the Health Resources and Services Administration's (HRSA's) Maternal and Child Health Bureau, held on December 11-12, 2006, in Washington, DC. http://www.mchoralhealth.org/PDFs/PeriodontalSummary.pdf
PREMAG inconclusive, but improvements of outcome are of potential significance
CONCLUSION: Although our results are inconclusive, improvements of neonatal outcome obtained with MgSO(4) are of potential clinical significance. More research is needed to assess the protective effect of MgSO(4) alone or in combination with other neuroprotective molecules.
Marret S, et al Magnesium sulphate given before very-preterm birth to protect infant brain: the randomized controlled PREMAG trial BJOG. 2007 Mar;114(3):310-8
Insulin Glargine Use During Pregnancy Not Linked to Fetal Morbidity
CONCLUSIONS: The results of this pilot study indicate that insulin glargine treatment during pregnancy does not appear to be associated with increased fetal macrosomia or neonatal morbidity.
Price, N et al Use of insulin glargine during pregnancy: a case-control pilot study. BJOG. 2007 Apr;114(4):453-7
Proposal for the Reconsideration of the Definition of Gestational Diabetes
In 1997, the American Diabetes Association (ADA) announced a new diagnostic criterion for diabetes and set the definition of gestational diabetes mellitus (GDM). Before 1991, GDM was defined as "a transient abnormality of glucose tolerance during pregnancy". However, the 1997 definition of GDM by the ADA includes diabetes diagnosed during pregnancy. This definition ignores the added risks to the mother and to the fetus when the mother has undiagnosed type 2 diabetes. We propose reconsideration of the definition, which would separate diabetes and slight abnormal carbohydrate, so-called GDM, to provide a better model of care for type 2 diabetic pregnant women.
There are three problems concerning an undiagnosed type 2 diabetic woman that are not major issues in pregnant women who are first diagnosed with abnormal glucose tolerance in pregnancy that resolves after pregnancy. First, the entire pregnancy is associated with abnormal carbohydrate metabolism, not just the second half. The second problem is related to the rate of congenital malformations of newborns from these pregnant women. The third is concerned with undiagnosed diabetic retinopathy.
In our Japanese cohort, we observed the results of 75-g oral glucose tolerance tests (OGTTs) ( Japan criteria: two or more values above fasting glucose >100 mg/dl, 1-h glucose >180 mg/dl, and 2-h glucose >150 mg/dl) for 1,416 pregnant women who had risk factors for GDM. We found the frequency of GDM in the first trimester is the highest (33/250 [13.2%]), followed by the second (32/417 [7.7%]) and third trimesters (37/749 [4.9%]). Similarly, the frequency of type 2 diabetes is the highest in the first trimester at 6.0%, with 2.6% in the second trimester and 1.3% in the third trimester. Thus, in women with positive OGTT, GDM accounts for 7.2% and type 2 diabetes diagnosed during pregnancy accounts for 2.5% of the total pregnant population. In other words, 35% of women with a positive OGTT have type 2 diabetes diagnosed for the first time in pregnancy.
In this cohort, the congenital malformation rate from GDM patients was 1.9% and was no different from the rate in the general Japanese population. In contrast, the congenital malformation rate in infants of type 2 diabetic mothers diagnosed during pregnancy was higher than that of children from pregestational diabetic mothers treated during pregnancy, 12.7 vs. 4%, respectively.
There were no GDM patients with retinopathy. However, the rate of background retinopathy was 12.7% and proliferative retinopathy was 4.2% in the type 2 diabetic women diagnosed for the first time during pregnancy.
Similar rates and complications were seen in a cohort of pregnant women in Santa Barbara, California, where a total of 49,861 pregnancies occurred in our Mexican-American population from 1997 to 2004. A total of 4,133 (8.3%) had a positive OGTT based on the ADA criteria. However, 40% of the GDM women had type 2 diabetes first diagnosed during pregnancy based on our criteria: acanthosis nicgrans, requiring insulin before the 12th week of gestation, because they failed to maintain goals with dietary intervention alone. Five percent of the type 2 women had retinopathy, and 7% had significant proteinuria at time of diagnosis.
O’Sullivan defined GDM as "a transient abnormality of glucose tolerance during pregnancy." We should return to this time-honored definition. If type 2 diabetes is first detected during pregnancy, then it should be named as such. Data presented here underscores that this is a worldwide problem.
Omori Y, Jovanovic L. Proposal for the reconsideration of the definition of gestational diabetes. Diabetes Care. 2005 Oct;28(10):2592-3
Level of angiogenic factors from first to second trimester as predictors of preeclampsia
CONCLUSION: Low placenta growth factor and high soluble fms-like tyrosine kinase-1 increase from first to second trimester are strong predictors of preeclampsia.
Vatten LJ, et al Changes in circulating level of angiogenic factors from the first to second trimester as predictors of preeclampsia Am J Obstet Gynecol. 2007 Mar;196(3):239.e1-6.
Primary Care Discussion Forum
Electronic Health Record (EHR) Implementation: Worth the effort?
Ongoing at this time. You still can join in
Moderator: David Johnson, MD
Anticipated benefits of an EHR: Demonstrated through experience?
What are the real costs: Decreased efficiency, IT support requirements, etc…
Effect on the provider – patient relationship
How to subscribe / unsubscribe to the Primary Care Discussion Forum?
Subscribe to the Primary Care listserv
http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=26
Unsubscribe from the Primary Care listserv
http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=26
STD Corner - Lori de Ravello, National IHS STD Program
Guidelines for School-Based STD Screening in Indian Country
I’m pleased to announce that our office has just released “Guidelines for School-Based STD Screening in Indian Country”. A PDF of the document or hard copies are available, so please let me know if you would like one. Also, the link will be up on our website soon, url below.
Thanks so much to everyone who helped to put these together. We look forward to your feedback. Also, please let us know if you need our technical assistance to implement school-based STD screening in your area. Lori
Table of Contents Page
1 Introduction
2 Getting Started
3 Forming a Team
4 Making a Plan
5 Making the Pitch
6 Making it Happen
7 Making it Stick
Tel: 505-248-4202 or lori.deravello@ihs.gov
http://www.ihs.gov/medicalprograms/epi/index.cfm
Fluoroquinolones No Longer Recommended for Treatment of Gonococcal Infections
In the United States, gonorrhea is the second most commonly reported notifiable disease, with 339,593 cases documented in 2005. Since 1993, fluoroquinolones (i.e., ciprofloxacin, ofloxacin, or levofloxacin) have been used frequently in the treatment of gonorrhea because of their high efficacy, ready availability, and convenience as a single-dose, oral therapy. However, prevalence of fluoroquinolone resistance in Neisseria gonorrhoeae has been increasing and is becoming widespread in the United States, necessitating changes in treatment regimens.
Beginning in 2000, fluoroquinolones were no longer recommended for gonorrhea treatment in persons who acquired their infections in Asia or the Pacific Islands (including Hawaii); in 2002, this recommendation was extended to California. In 2004, CDC recommended that fluoroquinolones not be used in the United States to treat gonorrhea in men who have sex with men (MSM). This report, based on data from the Gonococcal Isolate Surveillance Project (GISP), summarizes data on fluoroquinolone-resistant N. gonorrhoeae (QRNG) in heterosexual males and in MSM throughout the United States. This report also updates CDC's Sexually Transmitted Diseases Treatment Guidelines, 2006 regarding the treatment of infections caused by N. gonorrhoeae. On the basis of the most recent evidence, CDC no longer recommends the use of fluoroquinolones for the treatment of gonococcal infections and associated conditions such as pelvic inflammatory disease (PID). Consequently, only one class of drugs, the cephalosporins, is still recommended and available for the treatment of gonorrhea.
Update to CDC's Sexually Transmitted Diseases Treatment Guidelines, 2006: Fluoroquinolones No Longer Recommended for Treatment of Gonococcal Infections. MMWR Morb Mortal Wkly Rep. 2007 Apr 13;56(14):332-336.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5614a3.htm
Let's talk about HIV counseling and testing – New Facilitators' guide
To download PDF of 70 page guide “Tools to build NGO/CBO capacity to mobilize communities for HIV counseling and testing to help non-governmental organizations (NGOs), community based organizations (CBOs) and other civil society organizations in developing countries help mobilize communities for HIV counseling and testing (HCT).
The guide covers different aspects of HCT and includes participatory activities to carry out with NGO/CBO staff. The resource starts out by providing basic information about testing, and then tries to get participants to think critically about the advantages of and barriers to HIV counseling and testing; issues around stigma, discrimination, and confidentiality; the different medical, social, psychological and economic needs of people who test either negative or positive for HIV.
http://www.aidsalliance.org/graphics/secretariat/publications/VCT_Manual.pdf or http://www.aidsalliance.org/sw37361.asp
Does your lab have capacity to culture N gonorrhoeae for treatment failures?
Share with your lab staff and infection control staff!!!
Excerpts:
The US Centers for Disease Control and Prevention (CDC) have issued new treatment recommendations for gonorrhea, which are published in the April 13 issue of the Morbidity and Mortality Weekly Report. The new guidelines recommending cephalosporin treatment are in response to gonorrhea resistance to fluoroquinolones, which is now widespread in the United States among heterosexuals and men who have sex with men.”
Treat QRNC with Ceftriaxone 125 mg IM x1
Threshold for change of drugs is 5% resistance rates.” (said another way 95% treatment effectiveness for a drug is sought)
Resistance seen in Asia (2000), Hawaii (2000), California (2002), MSM (2004), UK (~2003) and NOW broadly across US.
Fluoroquinolone-resistant N. gonorrhoeae (QRNG)
Men who have sex with men (MSM)
Gonococcal Isolate Surveillance Project (GISP)
ARG = Antibiotic Resistant Gonorrhea
Gonorrhea is under diagnosed and underreported, and we estimate that about twice that number of people were affected. Incubation period usually 2 to 7 days. – Red Book
“Because gonorrhea resistance to penicillin, sulfa drugs, and tetracycline is already widespread, this limits available options for gonorrhea treatment to drugs in the cephalosporin class.”
"We are running out of options to treat this serious disease. Increased vigilance in monitoring for resistance to all available drugs is essential."
“…gonorrhea is largely diagnosed by a convenient DNA test, many laboratories and providers no longer have the capability of culturing N gonorrhoeae for drug resistance testing. The CDC is urging health departments to maintain or develop this capacity and to evaluate any gonorrhea treatment failures for possible resistance.”
“…persistent symptoms of gonococcal infection or whose symptoms recur shortly after treatment with a recommended or alternative regimen should be reevaluated by culture for N gonorrhoeae.”
“Most cases of gonorrhea in women are asymptomatic and untreated. However, failure to treat gonorrhea aggressively and early may result in pelvic inflammatory disease with associated infertility, chronic pelvic pain, and/or ectopic pregnancy. In men, rare complications of untreated gonorrhea may include epididymitis, rarely associated with infertility.”
“Increase susceptibility to HIV due to inflammation.”
“Alternative regimens for uncomplicated gonococcal infections of the cervix, urethra, and rectum are 2 g of spectinomycin (not available in the United States) in a single IM dose or cephalosporin single-dose regimens (ceftizoxime, 500 mg IM; or cefoxitin, 2 g IM, administered with probenecid, 1 g orally; or cefotaxime, 500 mg IM).”
“Positive isolates should be tested for antimicrobial susceptibility, and clinicians and laboratories should report treatment failures or resistant gonococcal isolates to the CDC at the telephone number: 1-404-639-8373, through state and local public health authorities.”
Persons in whom gonococcal infection is diagnosed should be treated for possible coinfection with Chlamydia trachomatis with a single dose of azithromycin 1 g by mouth or with doxycycline 100 mg twice a day, by mouth for 7 days, if chlamydial infection has not been ruled out.
http://www.cdc.gov/std/gonorrhea/arg/
http://www.medscape.com/viewarticle/555228?src=mp
Urinary symptoms in adolescent females: STI or UTI?
RESULTS: In the full sample, prevalence of UTI and STI were 17% and 33%, respectively. Neither urinary symptoms nor UTI was significantly associated with STI. Further analyses are reported for the 154 (51%) with urinary symptoms: Positive urine leukocytes, more than one partner in the last three months and history of STI predicted STI. Urinalysis results identified four groups: (1) Normal urinalysis-67% had no infection; (2) Positive nitrites or protein-55% had UTI; (3) Positive leukocytes or blood-62% had STI; and (4) Both nitrites/protein and leukocytes/blood positive-28% had STI and 65% had UTI. Those without a documented UTI were more likely to have trichomoniasis than those with a UTI, and 65% of those with sterile pyuria had STI, mainly trichomoniasis or gonorrhea.
CONCLUSIONS: Adolescent females with urinary symptoms should be tested for both UTI and STIs. Urinalysis results may be helpful to direct initial therapy.
Huppert JS, Biro F, Lan D, Mortensen JE, Reed J, Slap GB. Urinary symptoms in adolescent females: STI or UTI? J Adolesc Health. 2007 May;40(5):418-24. Epub 2007 Mar 9.
http://www.jahonline.org/article/PIIS1054139X06006112/abstract
Sexually transmitted infections in preadolescent children
Pediatric nurse practitioners may be called on to conduct an assessment for sexual abuse of a young child. Depending on the type of sexual contact, a decision may have to be made to obtain cultures for sexually transmitted infections (STIs). Recognizing the symptoms of STIs in preadolescent children, along with having knowledge of the modes of transmission, diagnostics, and treatment, are part of the clinical decision. The impact of STI in preadolescent children has physical and emotional consequences for the child and family, along with legal consequences for an accused perpetrator. Knowledge about types of sexual contact that necessitate STI cultures, incubation periods, and symptomatology is essential. Accurate techniques and appropriate selection of culture materials are necessary. Proper positioning of the child for obtaining cultures can decrease the potential for discomfort during the examination. Gonorrhea, Chlamydia trachomatis, herpes simplex virus, human papillomavirus virus, syphilis, Trichomonas vaginalis, hepatitis B, and HIV are reviewed.
Lewin LC.Sexually transmitted infections in preadolescent children. J Pediatr Health Care. 2007 May-Jun;21(3):153-61.
Adjustments in opthalmia neonatorum (ON): Gonorrhea in pregnancy
Redbook- For routine prophylaxis of infants immediately after birth, a 1% solution of silver nitrate, or 1% tetracycline or 0.5% erythromycin ophthalmic ointment, OU with subsequent irrigation. Prophylaxis delay for up to 1 hour for bonding. Term Infants born to GC infected mom 125mg IV or IM ceftriaxone. The 1993 Pediatrics article (below) suggests that for women receiving PN care: Silver nitrate eye prophylaxis caused no sustained deleterious effects and even provided some benefit to infants born to women without Neisseria gonorrhoeae. However, the effect was modest and against microorganisms of low virulence. The results suggest that parental choice of a prophylaxis agent including no prophylaxis is reasonable for women receiving prenatal care and who are screened for sexually transmitted diseases during pregnancy (cited online April 25, 2007)
Of interest is the WHO Bulletin 2000 – Iodine cost effective and clinically effective in developing countries for prophylaxis of ON
‘Redbook’ article
http://pediatrics.aappublications.org/cgi/content/abstract/92/6/755
Barbara Stillwater, Alaska State Diabetes Program
High rate of diabetes among indigenous people not due to thrifty gene according to study
High rates of diabetes among indigenous people across the globe are rooted in social disadvantage rather than a genetic pre-disposition specific to indigenous populations.
This article examines one of the oldest gene-based theories of complex disease causation: the thrifty genotype hypothesis (THG). This hypothesis is emblematic of the way in which genetic research into complex disease attracts a high investment of scientific resources while contributing little to our capacity to understand these diseases and perpetuating problematic conceptions of human variation. Although there are compelling reasons to regard the high prevalence of type 2 diabetes mellitus as a by-product of our biological incapacity to cope with modern affluent and sedentary lifestyles, there is at present no consistent evidence to suggest that minority populations are especially genetically susceptible. Nor is it clear why such genetic differences would be expected, given the original pan-species orientation of the TGH. The limitations inherent in current applications of the TGH demonstrate that genetic research into complex disease demands careful attention to key environmental, social, and genetic risk factors operating within and between groups, not the simplistic attribution of between-group differences to racialized genetics. A robust interdisciplinary approach to genetic epidemiological research is proposed.
Paradies YC, et al Racialized genetics and the study of complex diseases: the thrifty genotype revisited Perspect Biol Med. 2007 Spring;50(2):203-27
Aspirin may be less effective heart treatment for women than men
A new study shows that aspirin therapy for coronary artery disease is four times more likely to be ineffective in women compared to men with the same medical history.
CONCLUSIONS: Additional large studies are required to understand whether biologically defined aspirin resistance is associated with increased risk for cardiovascular events, with special attention paid to sex differences.
Dorsch MP, et al Aspirin resistance in patients with stable coronary artery disease with and without a history of myocardial infarction. Ann Pharmacother. 2007 May;41(5):737-41
Cholesterol Could be Key to Treating Fetal Alcohol Syndrome
Consumption of alcohol by pregnant women can cause fetal alcohol spectrum defects (FASD), a congenital disease, which is characterized by an array of developmental defects that include neurological, craniofacial, cardiac, and limb malformations, as well as generalized growth retardation. FASD remains a significant clinical challenge and an important social problem. Although there has been great progress in delineating the mechanisms contributing to alcohol-induced birth defects, gaps in our knowledge still remain; for instance, why does alcohol preferentially induce a spectrum of defects in specific organs and why is the spectrum of defects reproducible and predictable. In this study, we show that exposure of zebrafish embryos to low levels of alcohol during gastrulation blocks covalent modification of Sonic hedgehog by cholesterol. This leads to impaired Hh signal transduction and results in a dose-dependent spectrum of permanent developmental defects that closely resemble FASD. Furthermore, supplementing alcohol-exposed embryos with cholesterol rescues the loss of Shh signal transduction, and prevents embryos from developing FASD-like morphologic defects. Overall, we have shown that a simple post-translational modification defect in a key morphogen may contribute to an environmentally induced complex congenital syndrome. This insight into FASD pathogenesis may suggest novel strategies for preventing these common congenital defects.
Li YX, et al Fetal alcohol exposure impairs Hedgehog cholesterol modification and signaling. Lab Invest. 2007 Mar;87(3):231-40
Apples during pregnancy could reduce asthma risk in offspring
Women who eat apples during pregnancy may reduce the chances of their children developing asthma by the age of five, according to research funded by Asthma UK.
Researchers discovered that the children of mothers who ate the most apples during pregnancy were 50% less likely to be diagnosed with asthma by the age of five. The study also determined that mothers who ate more fish during pregnancy reduce the likelihood of their child developing eczema during early life, and those mothers eating more oily fish during pregnancy reduce the likelihood of their child developing hay fever by the age of five.
The researchers suggest that the beneficial ‘apple-specific’ effect could come from powerful antioxidants called flavanoids, which have previously been associated with improved lung function in adults. The study also noted that apple consumption in the UK has fallen to around 173g per person per day, compared to 207g in 1974. However, more research is needed to establish the exact association between the development of early-life asthma and consumption of these individual foods before recommendations can be made regarding the amount of apples or fish eaten during pregnancy. Dr Victoria King, Asthma UK’s Research Development Manager said: 'Eating a healthy, balanced diet during pregnancy is advisable and this study suggests simple modifications to a pregnant mother’s diet that may help protect her child from developing asthma before the age of five. One in ten children in the UK has asthma, therefore, we are pleased to have funded research that could provide a natural way to help reduce the incidence of childhood asthma.'
http://www.asthma.org.uk/news_media/news/apples_during.html
Women's Health Headlines, Carolyn Aoyama, HQE
Women’s Early Drinking Problems More Likely to Escape Diagnosis
Men are more likely than women to experience many of the problems commonly associated with nondependent drinking, according to a new study. But the authors suggest women are prone to different alcohol-related problems that are less likely to be diagnosed.
CONCLUSIONS: Significant gender differences were found in approximately one-third of the symptoms assessed and in the overall scale. Further examination of the nature of gender differences in alcohol problem symptoms should be undertaken to investigate whether a gender-neutral scale should be created or if men and women should be assessed with separate criteria for alcohol dependence and abuse.
Nichol PE, Krueger RF, Iacono WG. Investigating gender differences in alcohol problems: a latent trait modeling approach Alcoholism: Clinical and Experimental Research 31(5), 2007.
Women and Health Coverage: The Affordability Gap
Although both men and women in the U.S. have a similar risk of being uninsured, women are more likely to have problems accessing health care because of costs, a new Commonwealth Fund issue brief finds. Conducted by researchers Elizabeth M. Patchias and Judith G. Waxman of the National Women's Law Center, the study finds that the high cost of health care services and premiums is forcing many women, even those with health insurance, to go without needed care. In fact, 33 percent of insured women and 68 percent of uninsured women don't get the health care they need because they can't afford it. Moreover, a higher proportion of women than men struggle to pay medical bills.
Women and Health Coverage: The Affordability Gap finds that women are at a disadvantage because they have greater health care needs and lower incomes than men. "Women are more likely than men to go without needed health care services because of costs, yet they still have higher out-of-pocket expenses," said Waxman. "As policymakers and advocates explore how to expand and improve health coverage, they should ensure that any proposal provides comprehensive benefits and low cost-sharing.
E. M. Patchias and J. Waxman, Women and Health Coverage: The Affordability Gap, The Commonwealth Fund, April 2007
http://www.cmwf.org/publications/publications_show.htm?
doc_id=478513&#doc478513
WomenHeart Symposium 2007
I writing you to ask you to do a two things. First, help us identify women with heart disease who might be good candidates for the Sixth Annual, "Science and Leadership Symposium for Women with Heart Disease" to be held in Rochester October 6-10, 2007. Second, help spread the word about this course to potential applicants via your network of colleagues, website, media and professional associations.
Mayo Clinic and WomenHeart: The National Coalition for Women with Heart Disease, are again co-hosting this course, with the goal of developing a national network of informed and activated women heart patients who will go back to their communities to educate others and advocate for better recognition and care for women with heart disease. Each year since 2002, 60 geographically and ethnically diverse women with heart disease have been taught basic information about cardiovascular disease, treatments, and research, and received training in advocacy, community education and public speaking. In return for their participation they are required to perform at least 24 hours of community education and outreach activities in the first six months after the course. We have trained more than 300 women from 42 states now, and last year's class was made up of more than 25% women of color. Virtually all past participants have met their required "give back" and most have done far more, seeking out venues and media to reach and teach other women and developing a growing number of support networks nationwide to help the 8 million other women living with heart disease.
Participants will be chosen in a competitive process based on their responses to the essay questions in the application with an emphasis on experience, passion and the likelihood that they will be effective in their communities, with some consideration of ethnic and geographic diversity. You can help this program by encouraging qualified women with heart disease, particularly women of color and those from medically underserved areas, who you think might be good candidates, to apply for the program. A copy of the application can be accessed from the main page on the WomenHeart website www.womenheart.org. If accepted, there is no cost to the participants except for transportation to Rochester (and there is a scholarship fund for those whom this would be a hardship)
Please spread the word and this forward this to those who would be good candidates. Sara Sandel at WomenHeart and I are available to discuss any questions that you or potential applicants might have about the Symposium or the application process. This is a fairly intense 4 1/2 day program aimed mainly at those who are at a stage in life and in good enough health that they wish to move on and give back to other women their communities.
For those of you who are health care providers, I have attached a generic introductory letter to send to your eligible patients explaining the course (personalize as you see fit). I've also enclosed an electronic copy of the application. For those of you with media connections, please help us by spreading the word and encouraging applications and involvement with WomenHeart. Contact me if you would be interested in featuring this program via your media outlet. Thanks for your help in this endeavor. I'd very much appreciate you forwarding this to colleagues at other institutions if you could, as we are trying to achieve a very diverse group of participants.
Hayes, Sharonne N. M.D.
What's new on the ITU MCH web pages?
Implementation and Use of an Electronic Health Record within the Indian Health Service
J Am Med Inform Assoc. 2007 March-April
http://www.ihs.gov/MedicalPrograms/MCH/F/documents/Sequist4207.doc
There are several upcoming Conferences
and Online CME/CEU resources, etc….
and the latest Perinatology Corners (free online CME from IHS)
…or just take a look at the What’s New page
Save the dates
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
Did you miss something in the last OB/GYN Chief Clinical Consultant Corner?
The May 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.
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