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Volume 6, No. 1, January 2008
Features
American College of Obstetricians and Gynecologists
Human Immunodeficiency Virus
ABSTRACT: Because human immunodeficiency virus (HIV) infection often is detected through prenatal and sexually transmitted disease testing, an obstetrician–gynecologist may be the first health professional to provide care for a woman infected with HIV. Universal testing with patient notification and right of refusal ("opt-out" testing) is recommended by most national organizations and federal agencies. Although opt-out and "opt-in" testing (but not mandatory testing) are both ethically acceptable, the former approach may identify more women who are eligible for therapy and may have public health advantages. It is unethical for an obstetrician–gynecologist to refuse to accept a patient or to refuse to continue providing health care for a patient solely because she is, or is thought to be, seropositive for HIV. Health care professionals who are infected with HIV should adhere to the fundamental professional obligation to avoid harm to patients. Physicians who believe that they have been at significant risk of being infected should be tested voluntarily for HIV.
Human immunodeficiency virus. ACOG Committee Opinion no. 389. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;110:1473-8.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=18055751
Ethical Decision Making in Obstetrics and Gynecology
ABSTRACT: Physicians vary widely in their familiarity with ethical theories and methods and their sensitivity toward ethical issues. It is important for physicians to improve their skills in addressing ethical questions. Obstetrician–gynecologists who are familiar with the concepts of medical ethics will be better able to approach complex ethical situations in a clear and structured way. By considering the ethical frameworks involving principles, virtues, care and feminist perspectives, concern for community, and case precedents, they can enhance their ability to make ethically justifiable clinical decisions. Guidelines, consisting of several logical steps, are offered to aid the practitioner in analyzing and resolving ethical problems.
Ethical Decision Making in Obstetrics and Gynecology*. ACOG Committee Opinion no. 390. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;110:1479-87.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=18055752
Invasive Prenatal Testing for Aneuploidy
Summary of Recommendations and Conclusions
The following recommendation is based on good and consistent scientific evidence (Level A):
- Early amniocentesis (at less than 15 weeks of gestation) should not be performed because of the higher risk of pregnancy loss and complications compared with traditional amniocentesis (15 weeks of gestation or later)
The following conclusions are based on limited or inconsistent scientific evidence (Level B):
- Amniocentesis at 15 weeks of gestation or later is a safe procedure. The procedure-related loss rate after midtrimester amniocentesis is less than 1 in 300–500.
- In experienced individuals and centers, CVS procedure-related loss rates may be the same as those for amniocentesis.
The following recommendation and conclusions are based primarily on consensus and expert opinion (Level C):
- Invasive diagnostic testing for aneuploidy should be available to all women, regardless of maternal age.
- Patients with an increased risk of fetal aneuploidy include women with a previous fetus or child with an autosomal trisomy or sex chromosome abnormality, one major or at least two minor fetal structural defects identified by ultrasonography, either parent with a chromosomal translocation or chromosomal inversion, or parental aneuploidy.
- Nondirective counseling before prenatal diagnostic testing does not require a patient to commit to pregnancy termination if the result is abnormal.
Invasive Prenatal Testing for Aneuploidy. ACOG Practice Bulletin No. 88. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007; 110:1179-98.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=18055749
American Family Physician**
Patient-Controlled Analgesia for Postoperative Pain: Cochrane Briefs
Clinical Question
Is patient-controlled opioid analgesia more effective than conventional analgesia for postoperative pain?
Evidence-Based Answer
Patient-controlled opioid analgesia is safe and provides a statistically significant improvement in analgesia in postoperative patients, but the clinical significance of the improvement is marginal.
Practice Pointers
Patient-controlled analgesia (PCA) using opioids (e.g., morphine) has become the standard of care at many institutions for the management of postoperative pain. However, previous systematic reviews in 1992 and 2001 found conflicting results regarding the effectiveness of this approach compared with traditional analgesia.1,2 The authors of this Cochrane review identified 55 studies with a total of 3,861 patients, and they compared these studies with the 16 studies1 and 33 studies2 found in the previous systematic reviews. None of the studies were double-blinded and, in general, the studies were of poor quality.
Most studies measured pain on a visual analog scale (e.g., a scale with zero meaning the patient had no pain, and 100 meaning that the patient had severe pain) at various points in time. A change of 10 to 15 points on a 100-point visual analog scale is generally considered to be clinically significant and detectable by patients as an improvement.3 In these studies, the average pain intensity during a time period or the final pain intensity at the end of a time period was measured. The study durations generally ranged from 24 to 72 hours.
Pain intensity during the first 24 hours was eight points lower in the PCA group than in a group receiving conventional analgesia (95% CI, -12 to -4 points), nine points lower between 25 and 48 hours (95% CI, -14 to -5 points), and 13 points lower between 49 and 72 hours (95% CI, -20 to -6 points).3 Patients in the PCA group used more opioids than those in the control group over 72 hours; however, with the exception of a small increase in pruritus, there was no difference in other adverse effects such as nausea, vomiting, sedation, or urinary retention. Overall, more patients were more satisfied with the mode of analgesia in the PCA group (84 versus 65 percent; number needed to treat = 5.3).
Hudcova J, McNicol E, Quah C, Lau J, Carr DB. Patient controlled opioid analgesia versus conventional opioid analgesia for postoperative pain. Cochrane Database Syst Rev 2006;(4):CD003348.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17054167
Aspirin Combined With Clopidogrel (Plavix) Decreases Cardiovascular Events in Patients with Acute Coronary Syndrome
Clinical Scenario
A 65-year-old man with a history of myocardial infarction is on low-dose aspirin. His peripheral vascular disease has worsened over the past year.
Clinical Question
Should physicians combine aspirin with clopidogrel (Plavix) in patients with a high risk of cardiovascular disease or in patients with acute coronary syndrome?
Evidence-Based Answer
A combination of aspirin and clopidogrel decreased cardiovascular events in patients at high risk of cardiovascular disease and in those with acute coronary syndrome. However, the risk of major bleeding events outweighed the benefits in all high-risk patients except those with acute coronary syndrome.
Keller TT, Squizzato A, Middeldorp S. Clopidogrel plus aspirin versus aspirin alone for preventing cardiovascular disease. Cochrane Database Syst Rev 2007;(3):CD005158.
Cochrane for Clinicians Putting Evidence into Practice
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17636787
AHRQ
Women leaving the hospital against medical advice after delivering a baby should be targeted for more services http://www.ahrq.gov/research/dec07/1207RA11.htm
Full disclosure of medical errors to patients is becoming more and more transparent
http://www.ahrq.gov/research/dec07/1207RA7.htm
Colorectal cancer screening can be improved at primary care practices
http://www.ahrq.gov/research/dec07/1207RA21.htm
Family-centered, high quality primary care is linked to fewer nonurgent emergency department visits by children
http://www.ahrq.gov/research/dec07/1207RA4.htm
Ask A Librarian: Diane Cooper, M.S.L.S. / NIH
Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity
In February 2004, the American Medical Association convened a second expert committee to guide the development of 3 articles that would explore current evidence-based science and form the basis of new recommendations on the assessment, prevention, and treatment of child and adolescent overweight and obesity. Representatives from 15 national organizations
formed the second expert committee. The committee used a multidisciplinary model and integrated approaches across disciplines. The conceptual framework is the chronic care model with the goal of achieving family/self-management of childhood obesity.
The product was 4 articles, 1 on each of the aforementioned overview areas of the management of obesity and 1 overarching support document. The articles were written by national experts in the field of childhood obesity who were nominated jointly by the members of the expert and steering committees.
-Barlow SE and the Expert Committee Expert Committee. Recommendations Regarding the
Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity:
Summary Report PEDIATRICS Volume 120, Supplement 4, December 2007 S164 - S192
-Krebs NF et al Assessment of Child and Adolescent Overweight and Obesity. PEDIATRICS Volume 120, Supplement 4, December 2007: S193 - S228
- Davis MM Recommendations for Prevention of Childhood Obesity PEDIATRICS Volume 120, Supplement 4, December 2007 S229 - S253
-Spear BA et al Recommendations for Treatment of Child and Adolescent Overweight and Obesity PEDIATRICS Volume 120, Supplement 4, December 2007 S254 - S288
http://pediatrics.aappublications.org/content/vol120/Supplement_4/index.shtml
or
The Healthy Heart Handbook for Women '07 - 20th Anniversary Edition
This newly revised handbook, with a special message from First Lady Laura Bush, provides new information on women’s heart disease and practical suggestions for reducing your own personal risk of heart-related problems. The handbook presents the latest information on how to live a healthier and longer life, by taking action steps to prevent and control heart disease risk factors.
You’ll also find new tips on following a nutritious eating plan, tailoring your physical activity program to your particular goals, quitting smoking, and getting your whole family involved in heart healthy living. The Healthy Heart Handbook for Women is part of The Heart Truth for Women, a national public awareness campaign for women about heart disease sponsored by the National Heart, Lung and Blood Institute (NHLBI) and many other groups.
http://www.nhlbi.nih.gov/health/public/heart/other/hhw/hdbk_wmn.pdf
Behavioral Health Insights, Peter Stuart, IHS Psychiatry Consultant
Teens, Depression, Black Box Warnings and Suicide
After a substantial period of gradually decreasing rates of suicide in adolescents including AI/AN adolescents , recent 2004 data documenting increased suicide rates for adolescents suggests more attention will be coming to adolescent mood problems. The increase in suicides was most dramatic in female populations with rates rising dramatically in younger female populations ages 10-14 (75.9%) and significantly so in older adolescent females ages 15-19 (32.3%) and males ages 15-19 (9%). The increases coincide with the FDA’s black box requirement for many antidepressants that is likely responsible for an overall reduction in the prescription of antidepressants for teenagers. Does this mean decreased antidepressant prescription was causally related to the increase in suicides? We don’t know but the temporal association is suggestive.
Our adolescents are unfortunately at the forefront of the suicide curve. Indian country has received significant attention recently due to increasing concern about suicide clusters in adolescent populations and more generally young adults. Theories abound as to why this is occurring – and given the low base rates of the event and the high frequency of conditions and behaviors associated with increased risk real understanding is still some time away.
There is a general consensus, however, that part of the solution lies in identifying and treating depression in Primary Care. The American Academy of Pediatrics recently released GLAD-PC (Guidelines for Adolescent Depression in Primary Care) I and II which include excellent resources for developing primary care based approaches to management. The full documents can be found at www.glad-pc.org and include screening and assessment instruments as well as treatment tracking tools.
The recent publication of further results from the TADS (Treatment of Adolescent Depression Study) is also encouraging as it suggests that risks related to antidepressant treatment can be mitigated with appropriate therapy and management.
Combined Depression Regimen Appears to Reduce Suicidality.Psychiatr News, Mar 2007; 42: 28 – 35
Some basic recommendations for tackling adolescent depression:
- Screen using a systematic assessment (screening tool) – for those of you familiar with the PHQ-9 there is a slightly modified instrument for adolescents available on
www.glad-pc.org Other instruments with established psychometric properties are also
available for use and several are free.
- Develop relationships with your local BH system – you can treat and manage many patients successfully with fairly limited consultative support,
- Take adequate time – pediatric and primary care schedules are often crazy and packed – this is for better or for worse one of those occasions where time up front reduces emergencies and time later. If you have the opportunity to integrate BH care into your primary care services your schedule interruptions can be minimized.
- Treatment works – and while there may be issues with the relative strength of psychotherapy vs. medications both have demonstrated efficacy over placebo or treatment as usual approaches. Keys to successful treatment include having a plan, reassessing progress frequently particularly in the early stages of treatment, and getting help if there is no improvement or improvement plateaus before full resolution.
- Access to lethal means restriction counseling may reduce risk of self-injury (see http://www.sprc.org/featured_resources/bpr/ebpp_PDF/emer_dept.pdf).
- The “Medical Home” is an encompassing model that if applied properly in conjunction with developmentally appropriate preventive counseling provides maximum opportunity to identify, intervene and mitigate at least some of the risk for self-destructive behaviors in adolescence – whether that behavior be self-injury, smoking, unprotected sex or drug and alcohol use.
If you decide to use medications, keep in mind the following:
- Medications should be used to treat full MH disorders and generally avoided in sub-syndromic states in children and adolescents,
- Fluoxetine remains the best option to start with for adolescents – it has the best risk profile and is indicated for treatment of adolescent depression.
- Educate the patient and parents/guardians/family members about use of the medication, including the possible development of agitation, restlessness, and anxiety – these symptoms may portend the development of medication-induced suicidal thinking. The FDA and AACAP guidelines suggest initial weekly face-to-face visits – while this is desirable it is often not feasible or practical but the pearl here is to plan regular weekly contact whether in person, by phone or through other means, with the patient and family and identify this in your documentation. Follow-up may actually need to be more frequent if there is any significant suicidal ideation or self-harm concerns.
- Screen for history of bipolar symptoms both in the patient and through the family history – be very cautious using medications without consultation where there is a history of mania-like symptoms or family bipolar disorder.
- Stop medications gradually – risk periods for increased suicidal thinking appear to be both around the initial time of initiation of antidepressant therapy AND AFTER sudden discontinuation.
- Limit refills. Keep dispensed amounts to only slightly more than necessary to get to the next contact or appointment for the first three months of treatment.
Resources / References:
Academy of Child and Adolescent Psychiatry Practice Parameters
http://www.aacap.org/galleries/PracticeParameters/InPress_2007_DepressiveDisorders.pdf
CDC suicide rate increase article focusing on 10-19 year olds
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5635a2.htm
Breastfeeding - Suzan Murphy, PIMC
Breastfeeding, it is not just about the baby
According to a 2005 meta-analysis by the Agency for Healthcare Research and Quality (AHRQ), postpartum depression (PPD) is a major depressive disorder that effects between 5-25% of women in developed nations. Compared to men, women are twice as likely to experience depression in their lifetime.
Risk factors for PPD include:
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For many reasons, PPD is often undiagnosed. PPD left untreated can be devastating for new mothers and their families..
A recent study by Mancini et al (cited below), described using the Postpartum Depression Screening Scale (PDSS) developed by Beck et al to screen women in large midwifery and obstetric practice in Albuquerque, New Mexico. The practice saw approximately 2000 deliveries per year, 40% enrolled in the Medicaid program. The goals of the study were to look at prevalence of positive PDSS screen at 6 weeks, determine the benefits and challenges of using the PDSS screening tool and find demographic and clinical characteristics that were related to positive screens.
In a 12 month period, 755 women were screened, 740 with complete data sets. Data was collected on PDSS score, age, parity, race/ethnicity, education, marital status, infant feeding, type of delivery, and history of depression. The prevalence of a positive screen at 6 weeks was 16% with major PPD and 20% with symptoms suggesting potential PPD risk. The PDSS was integrated into the patient care routine ultimately with positive feed back by the staff and patients. A total of 75% of the providers participated, 6 of 11 obstetricians, all of 9 CNMs. They reported a sense of providing more comprehensive care and the opportunity to gently educate about mental illness. Patients reported appreciating the chance to talk about mental wellness issues.
The study found that women who had a positive screen at 6 weeks postpartum were more likely to not have completed high school, not be partnered, be exclusively bottle feeding, and have a history of depression. The 2 characteristics that were statistically significant as predictors of a positive PDSS screen were history of depression (risk ratio, 4.8; 95% CI, 4.4-5.2) and exclusive bottle feeding (risk ratio, 2.0; CI, 1.6-2.4). The possible reasons suggested for breastfeeding reducing risk of PPD included decreased maternal stress sensitivity, and enhanced response/action of the parasympathetic nervous system.
Like many other articles about PPD, the authors reiterated the need for more research and attention to timely screening and early intervention.
A side note: Other possible reasons for reduced PPD risk with breastfeeding mothers include increased levels of prolactin and oxytocin, shortened duration of post partum bleeding with enhanced involution, possible delayed return to menses – and so less risk of PMS symptoms, possible weight loss, reduced stress due to less infant illness, and likely increase in maternal self-esteem.
Mancini F, Carlson C, Albers L; Use of the Postpartum Depression Screening Scale in a collaborative obstetric practice, Journal of Midwifery & Women’s Health 2007;52:429-434.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17826704
Driscoll JW; Postpartum depression, How nurses can identify and care for women grappling with this disorder, AWHONN Lifelines, 2006 Oct-Nov;10(5):400-9.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17069572
Other
Milk pollution due to alcohol
RESULTS: The elimination of alcohol and time-to-zero levels in breast milk are described in a nomogram as a function of the amount of alcohol consumed and the body weight of the woman. CONCLUSIONS: Careful planning of a breast feeding schedule, by storing milk before drinking and/or waiting for complete alcohol elimination from the breast milk, can ensure women that their babies are not exposed to any alcohol.
Ho E et al Alcohol and Breast Feeding: Calculation of Time to Zero Level in Milk Alcohol and breast feeding: calculation of time to zero level in milk. Biol Neonate. 2001;80(3):219-22
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=11585986
Special journal issue offers guidance on promoting and supporting breastfeeding
The November-December 2007 issue of the Journal of Midwifery and Women's Health is dedicated to lactation and reflects a commitment of the American College of Nurse-Midwives to promote breastfeeding and improve the clinical practice of midwives and other women's health professionals. The issue provides recent research about the science of lactation, including new information about breast anatomy and the physiology of lactation. Topics include new information about the best way to bring the infant to the breast and help the infant latch, how to assess breastfeeding and how to assist mothers with specific breastfeeding problems, how to appropriately counsel women about the benefits of breastfeeding, and what can be done during labor and birth to minimize the impact of birth practices on breastfeeding. The issue is available at http://www.sciencedirect.com/science/journal/15269523
Lactation complicated by overweight and obesity: Many challenges
Research shows that mothers who are obese (with a BMI >30) are less likely to initiate lactation, have delayed lactogenesis II, and are prone to early cessation of breastfeeding. Black women, with the highest rates of American obesity, have the lowest rates and shortest duration of breastfeeding compared to Hispanic and white women. Women who are overweight and obese have lowered prolactin responses to suckling. Women who are obese are at risk for prolonged labors, excessive labor stress, and cesarean birth, all of which delay lactogenesis II. Lactation has a small but significant role in preventing future obesity in the mother and child. Midwifery management of obesity-related lactation problems begins with education about optimal prenatal weight gain and regular weight assessment to avoid excessive gain. Support of physiologic birth processes to avoid stress, prolonged labor, and surgical birth and limit maternal-newborn separation enhances the onset of lactogenesis II. Massage or pumping may soften and extend the obese nipple for easier latch. Infants of lactating women with prior bariatric surgery are at risk for B12 deficiency and require regular nutrition and growth assessment. Five hundred calorie per day restriction paired with aerobic exercise for intentional postpartum weight loss does not affect milk quality or infant growth.
Jevitt C et al Lactation complicated by overweight and obesity: supporting the mother and newborn. J Midwifery Womens Health. 2007 Nov-Dec;52(6):606-13
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17983998
CCC Corner Digest
Nicely laid out hard copy - A compact digest of last month’s CCC Corner
December Highlights include
- 30 minute rule not a requirement and ‘immediately available’ defined locally
- Random glucose test would have missed 5 of 6 women with GDM
- Cesarean delivery in Native American women: Low rates explained by practice style?
- HPV test beats Pap in detecting cancer - Use new ASCCP Consensus Guidelines
- Long-term prognosis for infants after massive fetomaternal hemorrhage
- Heart Disease Kills More Younger Women
- Use of Psychiatric Medications During Pregnancy and Lactation
- Predicting the Likelihood of Successful Vaginal Birth After Cesarean Delivery
- The Healthy Heart Handbook for Women '07 - 20th Anniversary Edition
- Breastfeeding Promotion: Good Public Health Policy: Part 2 of 2
- Adolescent primary prevention programs for DV which are school based
- New module: Lack of VZIG and new prenatal assessment of varicella immunity
- Special Global Issue - Obstetrics and Gynecology
- Tightening the "holes" in the Swiss cheese model of patient safety in obstetrics
- Frequently Asked Questions about Infant Feeding Choice
- What is the presenting part?
-Vaginal birth after cesarean (VBAC) in rural hospitals - Counterpoint
- Which caused more deaths in the United States in 2005, MRSA or HIV?
- 2008 Long Term IHS Training– NURSE ANESTHESIA – Apply Soon
- Cancer in American Indians and Alaska Natives
- Methicillin-resistant Staphylococcus aureus in women’s health
- A cost decision analysis of 4 tocolytic drugs
- Traditional AI/AN Medicine: Incorporating Into I/T/U Clinical Practice
- Prevention of Mother-to-Child HIV Transmission in Resource-Limited Settings
- Hypertension Triples Womens’ Risk for Diabetes
- Alaska Native FASD and Suicidality in a Healthcare setting
If you want a copy of the CCC Digest mailed to you each month, please contact nmurphy@scf.cc
Domestic Violence
Improving Domestic Violence Law Enforcement Response on the Tohono O'odham Nation
The IHS Office of Emergency Services is happy to share with you that Emerging Leader, Michelle Begay's, article "Improving Domestic Violence Law Enforcement Response on the Tohono O'odham Nation" has been published in The IHS Primary Care Provider.
It was published in the October edition - October being DV Awareness Month.
Thanks
Denise
Improving Domestic Violence Law Enforcement Response on the Tohono O'odham Nation
Vol. 32 #10 Oct 2007 Issue.
http://www.ihs.gov/PublicInfo/Publications/HealthProvider/issues/PROV1007.pdf
Child abuse funding offered: CCTV / Recording Technology Grant Program
The American Bar Association/Center on Children and the Law has recently announced a second round of funding for the CCTV/Recording Technology Grant Program. This program provides funds to states and local units of government (including Indian tribes and Alaska Native villages) to purchase and/or upgrade CCTV and recording equipment for use in child abuse cases. One exciting feature of the program is that Indian tribes are exempt from the 25% match requirement.
Applications are due February 15, 2008. A 30-minute web-based information session on December 18, 2007, at 1:00 p.m. EST. Please register for the information session by sending your name, email address and phone number to : cctv@staff.abanet.org
More information - including the full text of the request for proposals, FAQs and a sample application — can be found online at http://www.abanet.org/child/videotape.shtml
You can also contact Molly Hicks by email or phone if you have any questions.
Molly A. Hicks, MPA
Phone/Fax: 703-451-5468
Email : mhicks@keenemillconsulting.com
2008 NICWA Annual Conference
Early Bird Registration Ends March 28, 2008! Be a part of the largest national conference that focuses on American Indian children’s issues. The 2008 NICWA Annual Conference will be located at the Sheraton Bloomington Hotel at 7800 Normandale Boulevard, Bloomington, MN 55439, (866) 837-4728 at http://www.starwoodhotels.com/sheraton/property/overview/index.html?propertyID=1493
The government per diem room rate is $121.00 per night, plus taxes. Registration form and conference information is available at www.nicwa.org/conference Questions about registration, please contact Tileah (Tia) Begay at (503) 222-4044 ext. 157 or by e-mail at tbegay@nicwa.org
Family violence in health care and public health settings: Accepting Manuscripts
The Family Violence Prevention and Health Practice e-journal invites you to submit manuscripts on addressing family violence in health care and public health settings. The next issue will look at the relationship between childhood and adult sexual and physical violence and obesity. For information on submission guidelines go to the “info for contributors” tab of the journal: http://www.endabuse.org/health/ejournal/
Elder Care News
Training in Palliative and End of Life Care - SAVE THE DATE
March 25 -27, 2008 - Minneapolis, MN
and
April 22-24, 2008 – Flagstaff, AZ
The Education in End of Life and Palliative Care – Oncology (EPEC-O) for Indian Health is a 3 day training program designed to improve knowledge in pain and symptom management and end-of-life care. The format includes formal presentations and small group discussions and will provide those who attend with a modular curriculum to bring home for training and program development at their home facilities.
This training, using the NCI EPEC-O with AI/AN Cultural Considerations curriculum, is designed to provide a basic introduction to palliative and end-of-life care and familiarity with the modular EPEC-O curriculum.Those attending last year’s session in Window Rock were able to take home the curriculum to use for local training and program development.
The target audience includes IHS, Tribal, and Urban physicians, nurses, PAs and APNs, behavioral health providers, and pharmacists.
EPEC –O for Indian Health is a collaboration between the IHS and the National Cancer Institute (NCI), with funding provided for travel and per diem. Location and application information coming soon. For questions, contact Tim Domer MD attim.domer@ihs.gov
A pharmacy alert system plus physician-pharmacist collaboration can reduce inappropriate drug prescribing among elderly outpatients
http://www.ahrq.gov/research/dec07/1207RA16.htm
Family Planning
Intrauterine Device and Adolescents, ACOG Committee Opinion
ABSTRACT: The intrauterine device (IUD) is highly effective and widely used by women throughout the world. Data support the safety of IUDs for most women, including adolescents. This document addresses the major benefits of IUD use in adolescents, a population at particular risk of unintended pregnancy.
Intrauterine Device and Adolescents. ACOG Committee Opinion no. 392. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;110:1493-5.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=18055754
Prescription contraceptive use increased reflecting state mandates on private insurers
CONCLUSION: Prescription contraceptive use increased most significantly among privately insured women between 1995 and 2002, potentially reflecting state mandates enacted during that period requiring contraceptive coverage by private insurers. It is important for clinicians to understand these differences and address issues of insurance coverage with patients when discussing contraceptive options. LEVEL OF EVIDENCE: III.
Culwell KR et al Changes in prescription contraceptive use, 1995 2002: the effect of insurance status. Obstet Gynecol. 2007 Dec;110(6):1371-8.
Advance provision of EC does not reduce pregnancy rates, nor affect sexual behavior
CONCLUSION: Advance provision of emergency contraception did not reduce pregnancy rates and did not negatively affect sexual and reproductive health behaviors and outcomes compared with conventional provision. LEVEL OF EVIDENCE: III
Polis CB et al Advance Provision of Emergency Contraception for Pregnancy Prevention: A Meta-Analysis. Obstet Gynecol. 2007 Dec;110(6):1379-1388.
Ethinyl Estradiol/Drospirenone for the Symptoms of Premenstrual Dysphoric Disorder
A combined oral contraceptive pill containing 20 µg of ethinyl estradiol and 3 mg of the progestin drospirenone in a novel dose regimen (24 active pills followed by 4 placebo pills), has demonstrated efficacy for the symptoms of premenstrual dysphoric disorder, a severe form of premenstrual syndrome, with an emphasis on the affective symptoms. Drospirenone has progestagenic, anti-androgenic and anti-aldosterone properties, which differ from earlier generations of progestins, and reducing the hormone pill-free interval allows for better suppression of ovarian steroid production.
Rapkin AJ, McDonald M, Winer SA. Ethinyl Estradiol/Drospirenone for the Treatment of the Emotional and Physical Symptoms of Premenstrual Dysphoric Disorder. Women's Health. 2007;3(4):395-408.
http://www.medscape.com/viewarticle/561680?sssdmh=dm1.324491&src=journalnl
Featured Website David Gahn, IHS Women’s Health Web Site Content Coordinator
Preconception Counseling for Women with Diabetes and Hypertension: New module
This is a new module in the Perinatology Corner Series
This particular topic is coming up a lot more frequently in our patients.
What can you treat with and not endanger the fetus?
What you can’t treat with?
This module offers good advice on these and many other issues, plus lots of resources, even if you don’t want the free CME
http://www.ihs.gov/MedicalPrograms/MCH/M/PNC/PreconCouns01.cfm
and
It was low hanging fruit before: Now it is even easier - Perinatology Corner
The Perinatology Corner, a great Indian Health resource on many obstetric topics, plus free CME, has just gotten easier to use. Once you create an IHS login username and password (which takes about 30 seconds) the system will remember you and make it easier each time you want to take another module.
Submitting a Posttest
To take a posttest, log in with an IHS login now
The link to log in is in the leftside menu of each module's posttest page. (You will only need to log in once to any page that provides the link in the IHS site.) Once you fill in the registration information on the posttest page of one module, the demographics will self populate all future modules, thereby saving you time and effort.
You can take and retake any posttest. Any time you take a posttest, an email will sent to you with answers. You only get credit for the first time you take a module's posttest.
You can change your contact information (except their email address, through this system) in the form of any module's posttest once you've submitted your contact information in the first posttest you take.
You can update your contact information on the form when you're submitting a new posttest, when retaking a test with or without retaking the posttest.
Here is how to complete the Posttest and Evaluation
It is easy. Ptease log in and the Posttest page will become available
-If you have logged into the to the Indian Health registration before, then go directly to Login (choose the "Login" link):
Hit Login or Register
-If haven't completed the Registration process before, it is easy, secure, and relatively quick.
-It will also allow you to take future modules without having to repeat your contact information each time.
Choose the "Register" link:
Once you have successfully logged into your web account, then hit the Return button on the
Successful Login page and it will take you to the Posttest and Evaluation
Perinatology Corner
http://www.ihs.gov/MedicalPrograms/MCH/M/perCrnr.cfm
Frequently Asked Questions
Q. How should we manage a patient with a previous abruptio placenta?
A. There are significant risks after 2 previous abruptions or if fetal death resulted
(See details)
Short take
In the vast majority of cases no change in management is required in subsequent pregancies. Reversible risk factors can be modified (eg, avoid cigarette smoking or cocaine use) and women with nonrecurrent risk factors (eg, trauma) may be reassured.
In selected patients, such as those with two or more prior perinatal deaths or one perinatal death with persistent nonmodifiable risk factors for abruption, offering patients the option of preterm delivery upon documentation of fetal lung maturity is reasonable.
Background
The risk of recurrence has been reported as 5 to 15 percent, compared to a baseline incidence of 0.4 to 1.3 percent in the general population. After two consecutive abruptions, the risk of a third rises to 25 percent. ( Clark) When the abruption is severe enough to kill the fetus, there is a 7 percent incidence of the same outcome in a future pregnancy.( Pritchard)
Placental abruption may also predict a greater likelihood of other problems in subsequent pregnancies. A cohort study that examined pregnancy outcome in the pregnancy immediately following a placental abruption found higher rates of small for gestational age infants, spontaneous preterm birth, and preeclampsia, even in the absence of recurrent abruption.
Management in subsequent pregnancy — There are no data on which to base a recommendation for management of women with a history of abruptio placenta in a previous pregnancy. Risk factors for abruption should be identified (Table below). Reversible risk factors can be modified (eg, avoid cigarette smoking or cocaine use) and women with nonrecurrent risk factors (eg, trauma) may be reassured. It is not known whether thromboprophylaxis is effective in reducing the risk of recurrent abruption in women with inherited thrombophilias, but we treat such women.
In women who smoke, smoking cessation reduces the risk of recurrent abruption by 50 percent and to the same level as nonsmokers with a history of abruption, but their risk is still higher than in women with no history of abruption.
A cohort study based upon data from the Medical Birth Registry of Norway calculated gestational age-specific risks of complicated placental abruption (preterm, small for gestational age, or perinatal death) in a second pregnancy: 7 per 1000 for an initial event and 33 per 1000 for a first recurrence. During the subsequent pregnancy, special surveillance and delivery six weeks prior to the gestational age of the initial abruption would be necessary to reduce the risk of recurrent abruption to the baseline rate.
We do not use antepartum fetal monitoring tests in women with a history of abruption since these tests are not predictive of acute placental insufficiency. We typically await spontaneous labor until the estimated date of confinement or perform a repeat cesarean delivery at 39 to 40 weeks of gestation. In selected patients, such as those with two or more prior perinatal deaths or one perinatal death with persistent nonmodifiable risk factors for abruption, offering patients the option of preterm delivery upon documentation of fetal lung maturity is reasonable.
Risk factors for abruptio placenta
|
Trauma |
|
Rapid uterine decompression |
|
Hypertension |
|
Cigarette smoking |
|
Cocaine abuse |
|
Increasing parity |
|
Preterm premature rupture of membranes |
|
Inherited thrombophilia |
|
Multifetal gestation |
|
Uterine leiomyoma |
|
Previous abruption |
|
Uterine or placental anomalies |
Resources
How should we manage a patient with a previous abruptio placenta?
MCH FAQ site
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/AbruptioRec12907.doc
Management and outcome of abruptio placentae , UpToDate Software
http://www.uptodateonline.com/utd/content/topic.do?topicKey=pregcomp/31354
Clark , SL. Placentae Previa and Abruptio Placentae. In: Maternal Fetal Medicine, 4th ed, Creasy, RK, Resnik, R, (Eds), WB Saunders Company, Philadelphia, Pennsylvania 1999. p.623.
Pritchard, JA, Mason, R, Corley, M, Pritchard, SA. Genesis of severe placental abruption. Am J Obstet Gynecol 1970; 108:22.
Other
Frequently Asked Questions about Infant Feeding Choice
BACKGROUND INFORMATION
Why collect this data? Because it is used in the clinical performance measure called Breastfeeding Rates that is reported in the RPMS Clinical Reporting System (CRS). While this measure is currently not a GPRA measure (one reported to Congress and OMB) it is used in support of the GPRA measure Childhood Weight Control with the goal of lowering the incidence of childhood obesity in the IHS patient population. Additionally, facilities can use this data to track infant feeding patterns and breastfeeding rates within their own patient population.
Research indicates that children who were breastfed have lower incidences of overweight or obesity. For additional information, please click the link below to review the article in the March 2007 IHS Primary Care Provider.
http://www.ihs.gov/PublicInfo/Publications/HealthProvider/issues/PROV0307.pdf
How is this data used? It is used in the CRS Breastfeeding Rates topic in several measures that report:
- How many patients approximately 2 months through 1 year of age were ever screened for infant feeding choice.
- How many patients were screened at the approximate ages of 2 months, 6 months, 9 months, and 1 year.
- How many patients who were screened were either exclusively or mostly breastfed at those age ranges.
Users may run the CRS Selected Measures (Local) Reports to view all of the breastfeeding performance measures. The report also provides the option to include a list of patients and identifies the dates and ages they were screened and their infant feeding choice values. Click the link below to learn how to run this report in CRS, starting on page 206 (as numbered in the document itself, not in Adobe).
http://www.ihs.gov/misc/links_gateway/download.cfm?doc_
id=10716&app_dir_id=4&doc_file=bgp_070u.pdf
Is Infant Feeding Choice data the same as the data included in the Birth Measurements section of the EHR and with the PIF (Infant Feeding Patient Data) mnemonic in PCC? No, it is different. The information collected in these sections are intended for one-time collection of birth weight, birth order, age when formula was started, breastfeeding was stopped and solid foods started, and linking to mother/guardian. Shown below is a screen shot of this section from EHR. While this information is important, none of it is used in the logic for the CRS Breastfeeding Rates measure; only the Infant Feeding Choice data is used.
What are the definitions for the Infant Feeding Choices? The definitions are shown below and are the same definitions used in both EHR and PCC.
- Exclusive Breastfeeding: Formula supplementing less than 3 times per week (<3x per week)
- Mostly Breastfeeding: Formula supplementing 3 or more times per week (>3x per week) but otherwise mostly breastfeeding
- ½ Breastfeeding, ½ Formula Feeding: Half the time breastfeeding, half the time formula feeding
- Mostly Formula: The baby is mostly formula fed, but breastfeeds at least once a week
- Formula Only: Baby receives only formula
Who should be collecting this information and how often? It depends on how your facility is set up but any provider can collect this information. At a minimum, all providers in Well Child and Pediatric clinics should be collecting this information for patients 45-394 days old at all visits occurring during that age range. Public Health Nurses should also be collecting this information. This data can be entered in EHR or PCC/PCC+, as described below.
ENTERING INFANT FEEDING CHOICE DATA IN EHR
In which version of EHR is Infant Feeding Choice data able to be entered? EHR Version 1.1, which was deployed nationally on October 3, 2007.
How do I enter Infant Feeding Choice in EHR?
- After you have selected the patient and the visit, go to the Personal Health section. For some EHR sites, this may be included on the Wellness tab.
From the Personal Health dropdown list, select Infant Feeding, then click the Add button.
NOTE: The age of the patient must be five years or less to be able to select Infant Feeding; otherwise, Infant Feeding will not be listed in the dropdown list.
- At the Add Infant Feeding Record window, click the appropriate checkbox to select the type of infant feeding, and then click the OK button to save the value.
- The patient’s value for Infant Feeding Choice for this visit is now displayed in the Personal Health section, as shown below.
ENTERING INFANT FEEDING CHOICE DATA IN PCC/PCC+
Which data entry patch do I need? You will need to have data entry patch 8 (apcd0200.08k) installed, which was released on October 19, 2005.
How do I enter Infant Feeding Choice in PCC?
- Create a new visit or select an existing visit to append.
- At the Mnemonic prompt, type “IF” (Infant Feeding Choices) and press Enter.
- Type the number corresponding to the type of feeding and press Enter. If you do not know the number, type “??” and press Enter to see a list of choices.
- You are returned to the Mnemonic prompt. Continue with data entry of other items.
Stephanie Klepacki
CRS Project Manager/Lead Analyst
November 2, 2007
MCH Coordinator Editorial comment:
The infant feeding choice functionality is supported in the newly released EHR 1.1
The clinical performance measure called Breastfeeding Rates reported in the RPMS Clinical Reporting System (CRS) is a measure of interest. We wish to emphasize that while this measure is currently not a GPRA measure (one reported to Congress and OMB) it is used in support of the GPRA measure Childhood Weight Control with the goal of lowering the incidence of childhood obesity in the IHS patient population. Additionally, facilities can use this data to track infant feeding patterns and breastfeeding rates within their own patient population in the first year of life.
To capture this data Stephanie Klepacki, the CRS Project Manager/ Lead Analyst has developed: Frequently Asked Questions: Infant Feeding Choice in EHR. A team of analysts and clinicians have been involved in developing and testing this functionality. Kudos go to Phoenix Indian Medical Center’s Department of Pediatrics, to Sherry Allison, Information Processing Supervisor and her staff for getting the data entered pre EHR, and the ever diligent and nurturing Suzan Murphy, RD, IBLCE who have done the lion’s share of the clinical testing.
From an MCH standpoint expanding this functionality into toddler and early childhood feeding choices seems a natural next step as later versions are developed.
We look forward to your feedback, comments and use of this functionality in the universal documentation of feeding choice during the first year of life for our American Indian and Alaska Native families.
Lastly, new to the Indian Health Breastfeeding page* is the Lactation Support in the Workplace Toolkit. This document includes information on: how to get started, drafting local policy, evaluation tools, resources available on the Indian Health Breastfeeding page, as well as FAQs.
Lactation Support Policy in the Workplace
*Indian Health Breastfeeding page
http://www.ihs.gov/MedicalPrograms/MCH/M/bf.cfm
Indian Child Health Notes - Steve Holve, Pediatrics Chief Clinical Consultant
January 2008
- Birth weight and lifetime illness – bad news from Europe
- The immunization schedule for 2008
- Diarrheal illness in American Indians/Alaska Natives
http://www.ihs.gov/MedicalPrograms/MCH/M/ChPedNotes.cfm
Information Technology
iCare Training
The IHS Office of Information Technology continues to offer WebEx training for the iCare (Population Management) software application. You will be able to participate in the training from the comfort of your office or conference room and will not be required to travel to obtain this training.
iCare is a tool with multiple uses for a wide variety of providers that presents diverse RPMS data through an easy to use graphical user interface (GUI).
We will continue to offer a brief intro session that will just introduce the software to participants. This session does not offer any training.
1. A Brief Introduction to iCare 30 minutes
The 2 standard training sessions are again offered and we recommend they be taken sequentially.
- iCare - Nuts and Bolts 2.0 hours
- the Practical Use of iCare 1.5 hours
Coming Soon!!!!
We will be adding a new training session called "What's New in iCare?". This session will cover the new functionality that will be delivered in the next version of iCare. The dates for this training are yet to be decided so stay tuned for this new session.
The target audience for all of these sessions is any provider who cares for patients (e.g. physicians, mid-level providers, nurses, case managers, public health personnel, pharmacists etc.)
NOTE:You must register for these classes. They are NOT limited to participants in a particular Area; they are open to all. Below are the agendas and date/times for both classes.
You can choose to register individually or as a group. If you register individually, all you need is your computer, the ability to sign on to the internet and a telephone. If you'd like to attend as a group, one person will need to register and then sign in at the designated time. You will need a conference room, conference phone, computer and projector. Please ensure someone at your facility is responsible for taking care of these arrangements.
Please note that these are live, internet-based trainings, not recorded sessions, and people will be able to ask questions and actively participate in the class.
NOTE: All training times shown above are for the Mountain Standard Time ( Arizona Time) zone. Please ensure you adjust the time for your particular time zone.
Training Schedule
- iCare – Nuts and Bolts
Target Audience – Patient Care Providers (e.g. physicians, mid-level providers, nurses, case managers, public health personnel, pharmacists etc.)
Agenda
- Introductions and Context
- Set Up
- Background Processes
- Establishing and Changing User Preferences
- Panel Creation
- Panel Modification
- Patient Record
Session Date and Time Reg Password
iCare Nuts and Bolts Thur 12/13/2007 11:00-13:00 MST coyote
Tues 01/08/2008 13:00-15:00 MST coyote
- The Practical Use of iCare
Target Audience – Patient Care Providers (e.g. physicians, mid-level providers, nurses, case managers, public health personnel, pharmacists etc.)
Agenda
- Introductions and Context
- Scenarios
- Tips
- Using the Performance Measure views to improve outcomes
Session Date and Time Reg Password
The Practical Use of iCare Mon 12/17/2007 14:00-15:30 MST coyote
Thur 01/10/2008 10:00-11:30 MST coyote
- A Brief Introduction to iCare
Target Audience – Patient Care Providers (e.g. physicians, mid-level providers, nurses, case managers, public health personnel, pharmacists etc.) who don't have time to attend a longer session.
Agenda
- Highlights
- Background Processes
- Panel Creation and Modification
Session Date and Time Reg Password
A Brief Introduction to iCare Wed 12/12/2007 11:00-11:30 MST coyote
Mon 01/14/2008 14:00-14:30 MST coyote
Registration Information
- Click this link:
- In the Search box, type in "iCare" (do not type in the quotation marks) and click the Search button. NOTE: If you do not see the Search For box, ensure the Training Center tab is selected at the top of the WebEx window.
- All of the scheduled sessions will then be displayed in the window below. Choose the one you want to attend and click “Registration” in the Status column.
- Enter the Registration password that is shown above that corresponds to the class you want to attend.
- Click the OK button.
- Complete the registration form.
- Click the Register button.
- A Registration confirmation is displayed that contains all of the information for the training session, including the link for the session and the password to enter when you are ready to attend the session. Click the OK button to finish.
Setup (Software Install) Information:
You must have the WebEx software installed on your computer prior to attending the WebEx session. You should setup the software at least a day before the training session. You should not need anyone such as the Site Manager to install it for you. Below are the instructions.
- Click this link:
- On the left side of the window, locate Set Up
- Click Training Manager
- A message is displaying giving you information about the setup process. Click the Set Up button
- After the software is installed, click the OK button.
Attending the Session:
On the day of the scheduled training, you will receive a confirmation email. When you are ready to attend the session, connect to the WebEx session by clicking on the link in that email. You will then need to connect to the conference line. The dial information for the conference line is shown below and is also included in your registration confirmation message.
Phone Number: (877) 781-4791
Passcode: 135963#
International Health Update: Claire Wendland, Madison, WI
Disparities, Inequalities, or Inequities?
Everyone knows that the average health status of people living in poor countries is generally worse than that of people living in wealthier ones. When health outcomes differ among different population groups, are they health disparities or inequalities? Or, in the only term that implies a moral wrong, are they health inequities? Inequities based on differential access to a society’s resources are difficult to detect without some sort of assessment of wealth. Because of technical problems with the measurement of wealth, and perhaps because of a lack of political will, we’ve had a real dearth of information on inequality within countries – especially poor countries – until recently. Now a new World Bank report focuses on the correlations between economic status and health within fifty-six poor countries in Africa, Asia, the former Soviet Union, and Latin America. The authors made female-male and rural-urban comparisons as well, but their focus is primarily on economics.
Why is this data so late to the scene? Economic status was neglected in most of the earlier studies of health disparities because it is very hard to measure. Household income may not be in cash at all, especially where unemployment is high; people may be much more reluctant to estimate family income for analysts than to check a box revealing gender or race; and proxy measures like education or occupation did not prove to be good analogues for wealth. All of these problems were magnified in poor countries. In the late 1990s, researchers realized that various assets (for instance bicycles, radios, piped water, or corrugated iron roofing rather than thatch) could be compiled into an “asset index” that worked very well to rank economic status. It’s only been in the last decade, therefore, that researchers were able to correlate economic status and health with reasonable accuracy.
I urge you to check out the report itself. For those of us interested in maternal and child health, it includes detailed tables on child and infant health, basic fertility indicators and STD prevalence, and some maternal health indicators (such as deliveries attended by skilled staff). The results are sobering, though preliminary. Infant and child mortality, fertility, and malnutrition are all much greater among the poor than the rich. Immunization, antenatal care, medical treatment of respiratory infections, oral rehydration for diarrhea and other basic health interventions are all less likely to be used (or available) the poorer the household. Even primary health care offers greater benefits to the better-off than to the poor – 12% of benefits accrue to the poorest 20% of the population, 29% to the richest 20% – though it isn’t as skewed in this regard as hospital care, where 10% of benefits go to the poorest quintile and over forty percent to the richest. The only indicator in which the poor do better is breastfeeding: in nearly every country surveyed, the poorest were more likely to breastfeed their infants. (Other studies have shown that the richer are also more likely to get unnecessary operations like excess Cesarean sections, and to suffer the associated morbidity. That particular issue is not addressed in this report.)
Most sobering of all, the authors predict that as new health improvements find their way into poor countries, inequalities are likely to worsen. Whether it is antiretrovirals for HIV or surfactant for prematurity, the rich have means to learn about these improvements and to access them long before the poor do. Average health status may improve even as inequalities – and inequities – worsen. As the authors conclude, “Much more will be needed if the global health community is to move beyond platitudes about improving the health of the poor to effective action that can do so.”
Gwatkin DR, Rutstein S, Johnson K et al. 2007 Socio-economic differences in health, nutrition, and population within developing countries: an overview. Washington DC: World Bank. http://go.worldbank.org/XJK7WKSE40
MCH Alert
Insights on Implementing Cultural and Linguistic Competence in MCH
And the Journey Continues: Achieving Cultural and Linguistic Competence in Systems Serving Children and Youth with Special Health Care Needs and Their Families highlights experiences in infusing cultural and linguistic competence into the policies, structures, and practices of selected state programs. The monograph, developed by the National Center for Cultural Competence (NCCC) at Georgetown University with support from the Maternal and Child Health Bureau, presents stories collected from 23 Title V Children with Special Health Care Needs programs. Also included are key lessons that NCCC faculty, staff, and consultants have learned about providing program guidance, as well as an analysis of the various aspects of linguistic and cultural competence described in each state's story. A list of references and state and territorial contacts is included. http://www.gucchdgeorgetown.net/NCCC/journey
MCH Headlines - Judy Thierry HQE
Oral Health for Head Start Children: Best Practices
This 12 page document provides evidence-based approaches and interventions to improve the oral health of Head Start children and their families. The Best Practices are divided into three key points of intervention;
- pregnancy,
- birth through two years, and
- two years through five years of age.
Readership should include: Head Start administration and staff, medical, dental, and community health staff who will need to work together to effectively improve the future oral health of American Indian and Alaska Native children.
IHS Head Start Program website: www.ihs.gov/nonmedicalprograms/headstart/
You can also find current information and bulletins on oral health as it relates to Head Start at the Head Start Bureau Learning Center at the following website: http://www.eclkc.ohs.acf.hhs.gov/hslc
Safer infant sleep environment through crib giveaways and education
Bedtime Basics for Babies is a national campaign designed to give families both the equipment and the information they need to ensure a safe sleep environment for infants. The Bedtime Basics campaign, initially launched by First Candle in April 2007, builds on the success of the national Back to Sleep campaign in reducing the risk of sudden infant death, while also emphasizing other aspects of infant sleep surroundings. In response to growing national concern about the number of infants dying in unsafe sleep conditions, the Bill and Melinda Gates Foundation recently awarded First Candle a multimillion-dollar grant to combine two components: (1) a crib-distribution component for families in need and at risk and (2) a public- and professional-education component. During the 7-year initiative, First Candle will work with public and private groups already involved with new parents and infant-mortality prevention in the target states of Indiana and Washington, as well as in the District of Columbia. A research team will track families who receive cribs, information, and support on safe sleep practices starting before their infant is born through the first year. The team will also follow infant death patterns in the targeted states. http://www.firstcandle.org/bedtimebasics
Alcohol Screening Brief Intervention: Cooperative Agreement announcement by SAMHSA
The IHS under the direction of Dr. David Boyd has disseminated ASBI information to the IHS-Tribal hospital and EMS system. Service Unit “Champions” are developing local hospital ASBI programs. Five Area Office ASBI Train-The-Trainers (TTT) Conferences and several other local and service unit TTT presentations have been conducted. A funding opportunity may open wide the door.
CSAT Grant: Cooperative Agreements for Screening, Brief Intervention, Referral, and Treatment (SBIRT)
Request for Applications (RFA) No. TI-08-001
Posting on Grants.gov: November 27, 2007
Receipt Date: January 31, 2008
Announcement Type: Initial
The Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment is accepting applications for fiscal year (FY) 2008 for Cooperative Agreements for Screening, Brief Intervention, Referral, and Treatment (SBIRT). The purpose of this program is to expand and enhance state/tribal substance abuse treatment service systems by:
Expanding the state’s/tribe’s continuum of care to include SBIRT in general medical and other community settings (e.g., community health centers, nursing homes, schools and student assistance programs, occupational health clinics, hospitals, and emergency departments);
Supporting clinically appropriate services for persons at risk for, or diagnosed with, a substance use disorder (i.e., substance abuse or dependence). (Note: for the purpose of this RFA, “at risk” is defined as persons who are using substances but who do not yet meet the criteria for a diagnosis of substance use disorders); and
Identifying systems and policy changes to increase access to treatment in generalist and specialist settings.
Proposals due 31 Jan 2008
Download the Complete Announcement No. TI-08-001:
http://www.samhsa.gov/Grants/2008/ti_08_001.pdf
Please contact David Boyd for more information AND if your tribe is planning to submit a proposal.
David R. Boyd MDCM, FACS
National Trauma Systems Coordinator
301-443-1557
Child abduction Amber Alert Article
A pdf version of the August 2007 article from The American Legion Magazine which provides much space in its publications and web site for its commitment to child issues is available upon request. Written by Marc Klaas whose daughter Polly was abducted and murdered in 1993 the nonprofit KlaasKids Foundation’s mission is to stop crimes against children. The 3 page article presents for a wide audience simple tips – what children can do, what custodians MUST do to responsibly protect their children. Readable, realistic and relevant in 2007 as in 1993 the article focuses on basic public health assurances that neighborhoods, parents, caregivers and providers can do. Legislation is chronicled in sufficient detail with clear examples – California “Three Strikes…,” Megan’s Law and the Walsh Act. There is no online version or link to the publication without subscription. Judith.Thierry@ihs.gov
Childhood Obesity: AMA expert committee recommendations released
The expert committee final papers on the assessment, prevention, and treatment of childhood obesity in clinical settings are now available in Pediatrics as supplements. I don't think the link is accessible outside CDC because we have an e-subscription through library resources. You should be able to access it here and if interested can download the PDF's for each article.
(See Ask a Librarian, above, for more details)
http://pediatrics.aappublications.org/content/vol120/Supplement_4/index.shtml
Medical Mystery Tour
What is the presenting part?
You may recall we presented the case of a 20 year old gravida 4 para 1,0,2,1 at 40 2/7 weeks in active labor. The patient had had a 39 pound weight gain throughout her otherwise unremarkable prenatal care. The patient’s obstetric history was significant for one previous vaginal delivery of a term 9 pound 15 ounce infant. Laboratory testing was essentially unremarkable. On admission the patient’s exam was cephalic presentation, 4 cm dilation, -1 station. The cervix was soft and in a mid position. External fetal monitoring was reassuring. Sixty second contractions were noted every 5 minutes.
At 01:30 the CNM noted that patient had progressed nicely in labor to 7 cm dilated and 100% effaced. The presenting part was still at -1 station. The membranes were intact. The CNM was unable to completely identify the presenting part. The FHR tracing was reassuring. The CNM noted that a suture line and fontanelle were palpable, but other tissue may have been present. The MD on call was asked to perform a bedside ultrasound to confirm the presenting part.
The bedside ultrasound confirmed a cephalic presentation which was slightly oblique. The physician proceeded to perform a digital exam.
What did the physician find on digital exam?
In the interim since the physician had been initially called, the patient’s membranes had ruptured and the FHR remained reassuring. The physician noted several long loops of umbilical cord presenting. Otherwise the fetus was in cephalic presentation with complete cervical dilation and effacement. The CNM then elevated the fetus’s head out of the pelvis with her hand and the patient was moved to the operative suite in an expeditious manner while in knee-chest position.
As the obstetric team reached the OR table before the anesthesia team was ready and the patient was completely dilated, an attempt was made at funic reduction. This manuever was only successful for part of the prolapsed cord, but loops remained distal to the fetal skull.
The maternal skin incision was made within 13 minutes of anesthesia’s notification and the fetus was delivered within one minute as a Joel-Cohen technique was used. The infant female was delivered from an occiput posterior position and weighed 3450 g with Apgars of 8 and 9. At the time of surgery the cord was felt to be clinically ‘long’ plus had a true, but loose, knot with no proximal edema. A generous section of umbilical cord was obtained for possible cord gases.
The arterial pH was 7.17 with a base excess of -5.4. The venous pH was 7.23 with a base excess of -4.0. Of note, the arterial C02 was 70.5 (mmHg) (49.2 to 50.3) so some cord occlusion had begun shortly before delivery.
Examination of the placenta in the pathology department the next day revealed a somewhat eccentric umbilical cord insertion, 4 cm from the placental margin. Even after formalin fixation and not measuring the either portion of the umbilical cord sent for cord blood gases, nor the area remaining on the infant at surgery, the cord was still 53 cm. There was a true knot at 17 cm from the insertion. As you will see below the most accurate measurement of cord is actually done in the delivery suite, not after formalin fixation and other incisions for cord gases, etc...
Both the patient and her new daughter had unremarkable hospital courses for two days prior to discharge.
So, what was the presentation the CNM had noted?
The patient had a funic presentation prior to SROM.
In this case there was so much cord that it essentially filled the pelvic outlet. By the time the physician performed a digital exam after SROM and the ultrasound exam, the patient had been in an unrecognized cord prolapse with reassuring FHRs for approximately 10-15 minutes.
Long umbilical cord
Cord length increases with advancing gestational age. The average length at term is 55 cm (22 inches), with a wide normal range (35 to 80 cm) (14 – 32 inches) (Rayburn). The length should be noted and compared with published standards (Table below). Umbilical cord accidents were most frequent in the presence of a long cord (20 of 32 cases, 62%). In addition, mothers with a history of an excessively long umbilical cords are at increased risk of a second long cord.
The length measurement should include the portion of cord on the infant after cord transection at delivery as well as the part remaining with the placenta, thus it is best determined in the delivery room.
Cord length is determined in part by hereditary factors, but also by the tension the fetus places on the cord when it moves. For this reason, short cords are associated with fetal inactivity related to fetal malformations, myopathic and neuropathic diseases, and oligohydramnios. Long cords may be caused by a hyperactive fetus and have been associated with cord accidents, such as entanglement, knotting, and prolapse (Rayburn). Long cords are also associated with placental lesions indicative of intrauterine hypoxia, as well as fetal death, fetal growth restriction, and long term adverse neurologic outcome (Baergen)
Normal umbilical cord length
|
Gestation, weeks |
Length, cm |
|
20 |
32 +/- 9 |
|
24 |
40 +/- 10 |
|
28 |
45 +/- 10 |
|
32 |
50 +/- 12 |
|
36 |
56 +/- 13 |
|
38 |
57 +/- 13 |
|
40 |
60 +/- 13 |
Fetal malpresentation — Abnormal fetal presentation (breech, transverse, or oblique lie) is consistently associated with a high risk of UCP. In one review, the overall frequency of UCP in vertex, breech, and transverse lies was 0.24, 3.5, and 9.6 percent, respectively. Footling breech presentations carry a higher risk of UCP than other types of breech presentation. However, the majority of UCPs occur with vertex presentations because of the relatively low incidence of noncephalic presentation.
Knots — False knots are tortuosities of the umbilical vessels that form bulges; they are not associated with any adverse outcome.
True knots occur in 1 percent of births and are generally single and loose. However, tight or multiple true knots and knots associated with coiling or twisting of the cord increase the risk of intrauterine demise, particularly if the cord is long and during the second trimester when the fetus has a lot of room to move. The medical record should document the presence of a true knot, the tightness or laxity of the knot, the presence of unilateral edema of the cord relative to the knot, and whether there are thrombi in the vessels. A pathologist should obtain a section through the knot for histologic examination. The appropriate management of true knots identified by ultrasound examination antepartum is unclear.
MANAGEMENT : Umbilical cord prolapse
Standard obstetric management of Umbilical cord prolapse (UCP) requires prompt delivery to avoid fetal compromise or death from compression of the cord between the presenting fetal part and the margin of the pelvic inlet. We suggest cesarean delivery as the safest clinical course of management for the viable fetus, especially in the first and early second stages of labor. There are no data from prospective or randomized studies on which to base recommendations because of the infrequent and urgent nature of this problem.
Various preoperative maneuvers can be helpful to reduce pressure on the cord:
Funic decompression — This is the most common method to alleviate cord compression. After diagnosis of UCP, the examiner's hand is maintained in the vagina to elevate the presenting part off of the cord while preparations for an emergency cesarean delivery are being made. The patient can be placed in steep Trendelenburg or the knee-chest position to try to move the fetus and further alleviate cord occlusion. Manipulation of the cord and exposure to a cool environment may exacerbate poor perfusion by inducing spasm of the cord vessels.
Funic reduction — Funic reduction is a controversial approach to the management of cord prolapse. It is employed to alleviate pressure on the cord from the presenting part while preparations for cesarean delivery are being made. This procedure involves lifting the fetal head from the vagina and then digitally elevating the cord above the widest part of the vertex so as to place it in the nuchal area. Gentle suprapubic pressure can help with raising the fetal head and decreases the chance of creating an oblique or transverse lie.
Funic reduction had been considered an appropriate initial step in management of UCP, but was subsequently discarded in favor of cesarean delivery because the procedure appeared to be associated with an increase in intrapartum asphyxia and demise. However, this association was observed prior to the advent of continuous fetal monitoring. With use of continuous fetal monitoring, this technique may permit vaginal delivery and avoid emergent cesarean delivery in some patients. This was suggested by a small series of eight patients with UCP in which five vaginal deliveries were achieved 14 to 512 minutes after a successful funic reduction without anesthesia. The other three patients either delivered vaginally shortly after the diagnosis of UCP or were delivered by cesarean. All of the fetuses were in vertex presentation and had less than 25 cm of cord prolapsing. There was no morbidity or mortality reported. Thus, funic reduction in the setting of continuous fetal monitoring can be considered a viable approach if vaginal delivery is considered imminent or if cesarean delivery cannot be performed immediately.
Bladder filling — A temporizing technique involves insertion of a Foley catheter into the maternal bladder immediately upon diagnosis of UCP. The bladder is then rapidly filled with 500 to 700 milliliters of normal saline with the patient in Trendelenburg position. The distended bladder elevates the presenting part and keeps it off of the cord, thus relieving the compression and potentially obviating the need for prolonged vaginal digital decompression.
One series of 51 cases employed both a tocolytic (ritodrine) and bladder filling to relieve cord compression. The mean interval from diagnosis to delivery was 35 minutes and there were no fetal or neonatal deaths; the majority of infants had Apgar scores 
7 at five minutes. Tocolytic use in this series was not associated with postpartum uterine atony or hemorrhage. Thus, the technique of bladder filling may be a useful approach, particularly when immediate cesarean delivery is not possible.
Delivery — There are few data regarding attempted vaginal delivery in the setting of UCP. Successful operative vaginal delivery with vacuum or forceps has been reported when cesarean delivery could not be performed immediately.
Despite these case reports, immediate cesarean delivery remains the optimal mode of delivery. While preparations are being made for cesarean delivery, it is important to ensure adequate intrauterine resuscitation by changing maternal position, cord decompression by funic decompression or bladder distention, and tocolysis, where appropriate.
Resources:
Rayburn WF; Beynen A; Brinkman DL Umbilical cord length and intrapartum complications. Obstet Gynecol. 1981 Apr;57(4):450-2.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=7243092
Baergen RN; Malicki D; Behling C; Benirschke K Morbidity, mortality, and placental pathology in excessively long umbilical cords: retrospective study.Pediatr Dev Pathol. 2001 Mar-Apr;4(2):144-53 . http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=11178630
Umbilical cord prolapse, UpToDate software
http://www.uptodateonline.com/utd/content/topic.do?topicKey
=labordel/2191&selectedTitle=2~150&source=search_result
Gross examination of the placenta, UpToDate software
http://www.uptodateonline.com/utd/content/topic.do?topicKey=fet_phys/2144
Umbilical cord blood acid-base analysis, UpToDate software
http://www.uptodateonline.com/utd/content/topic.do?topicKey
=labordel/11115&selectedTitle=2~150&source=search_result
Medscape*
Making Sense of the Complex: A Point of Care Approach to Managing Chronic Pelvic Pain / Interstitial Cystitis http://www.medscape.com/viewarticle/566953
Management of Premenstrual Dysphoric Disorder Throughout the Ages: A Series of Interactive Cases http://www.medscape.com/viewarticle/558957
Commonly Administered Vaccines and Associated Illnesses
http://www.medscape.com/viewarticle/566528
Understanding Triglycerides: Beyond LDL Cholesterol
http://www.medscape.com/viewarticle/566766
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
Treating Sexual Difficulties in Menopause
Background: Women often experience changes in sexual function after menopause. Although changes in desire are not inevitable, postmenopausal women consistently experience a decrease in arousal, manifested by decreases in genital perfusion, engorgement, vaginal lubrication, and response to touch and vibration. Many also experience a decrease in the intensity of orgasm.
In addition to the physiologic changes that occur during menopause (most likely because of a drop in estrogen), psychological factors and expectations may also play a role in sexual satisfaction. Iatrogenically, surgical treatment of stress incontinence and hysterectomy have variable effects on sexual function, depending on preoperative factors and surgical technique. Atherosclerosis and hyperglycemia can impair sexual function in women, as can certain medications, such as selective serotonin reuptake inhibitors and dopamine receptor blockers.
Recommendations: Evaluation should include a comprehensive medical, sexual, and psychosocial history. A genital examination should include evaluation of resting pelvic floor muscle tone and voluntary vaginal and anal sphincter tone. Laboratory testing such as testosterone measurement is not indicated. However, targeted testing is appropriate for suspected disorders.
Treatment addressing sexual complaints should take into account the importance of sex to the patient. Other treatment recommendations include addressing unrealistic expectations, using lubricants, and creating romantic environments. Sex therapy can be helpful for psychological problems.
Estrogen improves vaginal lubrication and may improve orgasm. Although high doses of estrogen can achieve central effects that are more broadly beneficial to sexual function, the progesterone required for endometrial protection negates many of these benefits. If estrogens are used in patients who have an intact uterus and no risk factors, transdermal formulations should be prescribed, because oral estrogens increase sex-hormone binding globulin and decrease desire. Vaginal estrogen increases lubrication, may increase vasocongestion, and is safer than systemic estrogen, but long-term use should be avoided. Combination estrogen/testosterone increases sexual desire and responsiveness but lowers high-density lipoprotein cholesterol levels. Using a testosterone patch may avoid this adverse effect and, in combination with systemic estrogen, may improve the number of satisfying sexual episodes.
Other medications that may be helpful include bupropion (Wellbutrin) and phosphodiesterase inhibitors. Bupropion may increase arousal and orgasm completion. Phosphodiesterase inhibitors increase genital perfusion but have no significant effect on arousal. A subgroup of women taking phosphodiesterase inhibitors had improved overall satisfaction with changes in vaginal lubrication, genital sensation, and ability to achieve orgasm. The same cautions that apply to men in the use of these agents are relevant to women.
Several mechanical devices are available. Vibrators supply high-intensity, direct clitoral stimulation. A hand-held vacuum pump also increases clitoral blood flow and has been shown to increase sexual satisfaction. Some data suggest that pelvic floor exercises can be beneficial and can decrease sexual incontinence. New products to improve desire-including androgen delivery systems and dopamine agonists-as well as agents targeting genital arousal are currently in development.
Potter JE. Clinical crossroads. A 60-year-old woman with sexual difficulties. JAMA February 14, 2007;297:620-33. http://www.aafp.org/afp/20071201/tips/3.html
Midwives Corner - Lisa Allee, CNM
ACNM seeks Midwifery Expertise on an as-needed basis
Dear Colleague,
As the ACNM grows in size and stature, we receive an increasing number of invitations to be present at meetings and events. For instance, the ACNM was recently asked to send a representative to a meeting organized by the Gynecologic Cancer Foundation to discuss a public education campaign regarding HPV and the new vaccines.
These meetings vary in length from an hour or two to a couple of days, usually on weekdays, and are generally held in DC and the surrounding area. Sometimes we merely gather information and write a brief report; at other meetings, we provide basic information about midwives and midwifery practice; sometimes our goal is to advance a particular agenda.
With limited CNM staff in Professional Services, we cannot always have a staff member attend. We have been fortunate to have a cadre of willing and able local midwives on whom we can call. (Many of you responded to a similar call for help 10 years ago!) We know, however, that the growing pool of local midwives must contain other willing and able members on whom we have not yet called.
So, we are asking your help. If you are willing to represent ACNM at a meeting or event, probably not more than once per year, please complete the online form. When were offered a seat at the table, and need a CNM to fill it, we will use the information to contact you. We will provide whatever background material, ACNM Position Statements, etc. that might be relevant and, depending on the event, there may be reimbursement for expenses.
If you have represented the ACNM in the past, please accept our thanks. If you wish to continue to be available, please provide updated information by using the online form. If you have questions, you can reach us at 240-485-1840 or via e-mail.
Sincerely,
Lisa Summers, CNM, DrPH, FACNM
Director of Professional Services
lsummers@acnm.org
Navajo News - Jean Howe, Chinle
Informed Refusal, Leaving Against Medical Advice, and Asking Questions
A recent article in the “Clinical Practice” series of the New England Journal of Medicine addresses the assessment of patient’s competence to consent to (and decline) treatment. This series uses a case vignette and discussion to address common clinical problems. In this case, a 75 year old woman with type II diabetes, peripheral vascular disease, and a gangrenous foot ulcer who refuses a recommended amputation is described. The patient states that she “prefers to die with her body intact” and the provider is concerned about apparent increasing confusion and possible depression limiting her ability to provide informed consent. Legally relevant criteria for evaluating decision-making capacity are outlined for the patient’s tasks of communicating a choice, understanding the relevant information, appreciating the situation and its consequences, and reasoning about treatment options. Approaches to assessment and the consequences of a finding of incompetence are reviewed. The lack of formal practice guidelines for assessment of competence to consent is highlighted.
Refusal of treatment is also the focus of an overview of hospital discharge “against medical advice” in this month’s American Journal of Public Health. This database audit of over 3 million discharges from U.S. non-federal acute care hospitals identified a rate of 1 in 70 (1.44%) of “self-discharges”. Higher rates were associated with young age, male gender, African American race, and low socio-economic status. Because this study is a database review only, no information is available on the reasons for AMA discharge. The authors discuss possible reasons, including frustration with administrative delays in the discharge process, pressing domestic or social concerns, and disagreement with their physician’s assessment of their health status. They also discuss the public health significance of these discharges and the importance of addressing shortcomings of the health care system that may place underserved patients at higher risk for this event.
Meanwhile, the Agency for HealthCare Research and Quality is launching a campaign called “Questions are the Answer” encouraging patients to ask questions about their healthcare as a safety measure and in an effort to improve overall health through greater understanding and ownership of health care decisions. Their sample questions for patients and more information about this campaign, including video clips of singing and dancing health care workers are available at the AHRQ website.
I happened to encounter all three of these articles/information on the same day and was struck by the increased attention to patient autonomy and recognition that medical advice may be rejected, ignored, or poorly understood. We, as healthcare providers, have an ongoing duty to encourage our patients’ understanding and ownership of their health and their right to make informed decisions about their care. Vulnerable groups may benefit from additional attention to their needs, whether for respectful assessment of decision-making capacity or for culturally appropriate hospital care that minimizes the risks of “self-discharge”. I’m not sure if the singing health care workers in the AHRQ videos will help but we must continue our efforts to welcome, encourage, and respect our patients’ efforts to make truly informed health care decisions.
Resources:
Paul S. Appelbaum, Clinical practice. Assessment of patients' competence to consent to treatment, N Engl J Med. 2007 Nov 1;357(18):1834-40
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17978292
Said A. Ibrahim, C. Kent Kwoh, and Eswar Krishnan, Factors Associated With Patients Who Leave Acute-Care Hospitals Against Medical Advice, Am J Public Health 2007 97: 2204-2208, 10.2105/AJPH.2006.100164
http://www.ajph.org/cgi/content/abstract/97/12/2204
AHRQ
http://www.ahrq.gov/questionsaretheanswer/index.html
CCC Editorial comment:
What are the elements of a patient decision making?
This is a very timely topic as ACOG has just released the three Committee Opinions below that relate to a patient’s decision making process. We need to have made all efforts possible to assure that the decision is informed, on the patient’s actual educational level, as well as ethical. Please also note this month’s Abstact of the Month and Dr. Weiss’s comments on Health Literacy, above.
ACOG
Health Literacy. ACOG Committee Opinion no. 391. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;110:1489-91.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=18055753
The Limits of Conscientious Refusal in Reproductive Medicine ACOG Committee Opinion no. 385. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;110:1203-8.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=18055753
Ethical Decision Making in Obstetrics and Gynecology*. ACOG Committee Opinion no. 390. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;110:1479-87 .
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=18055752
Nurses Corner - Sandra Haldane, HQE
Scope of Practice and the Nurse Practitioner: Regulation, Competency, Expansion, and Evolution
"I'm an NP -- can I work as an RN? As an acute care NP, can I work in primary care? I'm prepared as an adult NP -- can I see children too?" Learn the answers to these questions and many more. http://www.medscape.com/viewarticle/506277
Overweight Children and Adolescents - National Association of School Nurses
POSITION STATEMENT:
Abstract. The fastest rising public health problem in our nation is obesity, second only to tobacco use. Over the last two decades the percentage of overweight children has almost doubled and the percentage of overweight adolescents has almost tripled. Currently, in the United States, 13% of children 6 to 11 years of age and 14% of teens 12 to 19 years of age are categorized as overweight (NCHS, CDC 2001; USDHHS, 2000).
Healthy People 2010 (USDHHS, 2000) identifies specific goals to reduce the prevalence of overweight and obesity. Since most children spend a large portion of their day at school, the school can become a key setting in which to implement strategies to address this issue. The school nurse has the capacity to reach a large number of youth from varied backgrounds. The school can provide a healthy environment that supports balanced nutrition and activity.
ACTIONS:
- assisting students in developing good decision-making skills related to nutrition and in establishing activity patterns to maintain normal body mass indices throughout their lives
- educating students, faculty, and parents on the following:
- the importance of positive role modeling
- dietary guidelines that promote balanced meals low in dietary fat
- the need for 60 minutes of physical activity daily
- the potential negative influence of inactivity
- reading and interpreting dietary information on food products
- relating dietary guidelines to food preparation
- educating coaches on the importance of proper nutrition on the athletes’ peak performance
- initiating school policies that provide for a healthy school environment, policies that relate to:
- school breakfast and lunch programs
- vending machines
- prevention of discrimination or abuse toward overweight youth
- school-based counseling
- health promotion for school staff
- supporting families as they assist their children to achieve and/ or maintain a healthy BMI
- encouraging acceptance of body type that has been inherited, individual diversity, and a positive self-image
- identifying students who are overweight and educating and encouraging these students to find and use acceptable weight loss programs
- implementing and managing school-based weight reduction programs
- providing community-based referral sources, as appropriate
- supporting students in understanding that once weight loss is achieved, the changes must be continued throughout their lives to maintain their healthier weight
- advocating for daily physical education for all grades
http://www.nasn.org/Portals/0/positions/2002psoverweight.pdf
Office of Women's Health, CDC
Cancer in American Indians and Alaska Natives
Annual Report to the Nation on the Status of Cancer, 1975-2004
A new report, Annual Report to the Nation on the Status of Cancer, 1975-2004, Featuring Cancer in American Indians and Alaska Natives, shows cancer death rates decreased on average 2.1 percent per year from 2002 through 2004, nearly twice the annual decrease of 1.1 percent per year from 1993 through 2002. Declines were observed in the incidence of lung cancer in men, colorectal cancer in men and women, and in breast cancer incidence in women from 2001 through 2004. For women, incidence rates for all cancers combined stabilized from 1999 through 2004 after years of increases. Death rates among women decreased for 10 of the 15 most common cancers. The American Cancer Society, the National Cancer Institute, CDC, and the North American Association of Central Cancer Registries collaborate to provide this annual update on cancer occurrence and trends in the United States.
http://www.cdc.gov/Features/CancerReport/
Vaccination of Pregnant Women (2007 Update)
Risk to a developing fetus from vaccination of the mother during pregnancy is primarily theoretical. No evidence exists of risk from vaccinating pregnant women with inactivated virus or bacterial vaccines or toxoids. Live vaccines pose a theoretical risk to the fetus. Benefits of vaccinating pregnant women usually outweigh potential risks when the likelihood of disease exposure is high, when infection would pose a risk to the mother or fetus, and when the vaccine is unlikely to cause harm. http://www.cdc.gov/vaccines/pubs/preg-guide.htm
ACIP Releases 2007-08 Adult Immunization Schedule
Morbidity and Mortality Weekly Report, October 19, 2007
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5641-Immunizationa1.htm
Oklahoma Perspective Greggory Woitte – Hastings Indian Medical Center
Methicillin-resistant Staphylococcus aureus in women’s health
Methicillin-resistant Staphylococcus aureus (MRSA) has become a hot topic in the media recently. In October, the CDC released a report that there was 18,650 deaths from MRSA in 2005. This was more than the number of deaths due to AIDS in the same year. MRSA has been a well known superbug in Hospitals for years. MRSA has been a growing problem due to its resistance to many common antibiotics including beta lactam antibiotics including methicillin. While most invansive MRSA infections can still be traced to hospital exposure, approximately 15% of invasive infections are occurring in individuals with no known health care risk. These infections are primarily occurring in people over the age of 65 and 2/3 of infections that can be traced back to a health care exposure occur in patients that are no longer hospitalized.
http://www.webmd.com/news/20071016/more-us-deaths
-from-mrsa-than-aids?src=rss_psychtoday
As I am sitting her writing this and watching the football game, a report came on the TV about two High School students who are recovering from the Superbug. What can we as women’s health providers do? Start with the basics that we learned in medical school. Wash your hands, Wash your hands, Wash your hands. The use of appropriate hand washing or the use of alcohol based rubs have been shown to decrease hospital infections, but compliance rates are rarely 100%. Next, use the right antibiotic for the appropriate infection. The days of shot gunning antibiotics can no longer be tolerated. The use of prophylactic antibiotics for surgeries or obstetrical procedures should comply with ACOG recommendations.
Even with diligent hand washing, and appropriate use of antibiotics, there will still be MRSA infections. Here at Hastings Indian Medical Center, we are fortunate to have Dr. Greg Felzien, a board certified Infectious Disease specialist, however I have included a list of treatment recommendations that was July 2006 ACOG Green Journal and reprinted from The Medical Letter for community acquired MRSA infections. In addition, a high index of suspicion is important, culture all wounds that open or that you opened. This includes all seromas, hematomas, as well as all obvious infected wounds.
As the media continues to pick up and publicize MRSA infections, you can educate your patients with handouts from the CDC at this website: http://www.cdc.gov/ncidod/dhqp/ar_mrsa_ca_posters.html
Treatment Recommendations
http://www.greenjournal.org/cgi/reprint/108/1/198
ACOG Practice Bulletin #47 October 2003 - Prophylactic Antibiotics in Labor and Delivery
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=14551023
ACOG Practice Bulletin No. 80: Premature Rupture of Membranes. Clinical management guidelines for obstetrician-gynecologists
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17400872
ACOG Practice Bulletin #74 July 2006 –Prophylactic Antibiotics in Gynecological Procedures
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=16816087
Osteoporosis
Effects of Steroidal and Nonsteroidal Aromatase Inhibitors on Markers of Bone Turnover in Healthy Postmenopausal Women
CONCLUSION: Exemestane increased serum levels of the bone-formation marker PINP after 24 weeks, suggesting a specific bone-formation effect related to its androgenic structure. Potential effects on cortical bone and reduced fracture risk must be verified in a comparative clinical trial.
Goss PE, et al Effects of steroidal and nonsteroidal aromatase inhibitors on markers of bone turnover in healthy postmenopausal women.
Breast Cancer Res. 2007 Aug 10;9(4):R52
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17692126
Patient Information
Assessing Health Literacy in Clinical Practice
http://www.medscape.com/viewarticle/566053
Pregnant or Thinking About Getting Pregnant?
These tips can help you prevent infections that could harm your unborn baby. You won’t always know if you have an infection - sometimes you won’t even feel sick. If you think you might have an infection or think you are at risk, see your doctor.
http://www.cdc.gov/ncbddd/pregnancy_gateway/infection.htm
Pregnancy Loss: What You Should Know
http://www.aafp.org/afp/20071101/1347ph.html
Caring for Your Premature Baby
http://www.aafp.org/afp/20071015/1165ph.html
Meth Abuse: What You Should Know
http://www.aafp.org/afp/20071015/1175ph.html
Perinatology Picks - George Gilson, Maternal Fetal Medicine, ANMC
Less errors with more standardization of corticosteroid regimens
Repeat doses of corticosteroids reduces neonatal morbidity at 2 years of age
CONCLUSIONS: Administration of repeat doses of antenatal corticosteroids reduces neonatal morbidity without changing either survival free of major neurosensory disability or body size at 2 years of age
Crowther CA et al Outcomes at 2 years of age after repeat doses of antenatal corticosteroids. N Engl J Med. 2007 Sep 20;357(12):1179 -89
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17881750
and
Repeat vs single dose corticosteroids did not differ significantly, except NS cerebral palsy
CONCLUSIONS: Children who had been exposed to repeat as compared with single courses of antenatal corticosteroids did not differ significantly in physical or neurocognitive measures. Although the difference was not statistically significant, the higher rate of cerebral palsy among children who had been exposed to repeat doses of corticosteroids is of concern and warrants further study.
Wapner RJ et al Long-term outcomes after repeat doses of antenatal corticosteroids.
N Engl J Med. 2007 Sep 20;357(12):1190-8.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17881751
Editorial comment: George Gilson, MFM
Less errors with more standardization of corticosteroid regimens
It would probably be good if we all standardized our use of antenatal corticosteroids for fetal lung maturation. I have seen various regimens being used, but the one below is the one recommended by ACOG on the basis of the available evidence. Steroids are given over a 48 hour interval. Their maximum effect is maintained for 7 days, although a lesser, but still significant, effect is seen for a considerably longer interval. Giving the doses at closer intervals will not speed up the fetal lung maturation process, even though you think the baby needs to deliver sooner than later!
Betamethasone 12 mg IM x2 at 24 hour intervals -or-
Dexamethasone 6 mg IM x4 at 12 hour intervals
Steroids are appropriate between 24 and 34 weeks gestation (some authorities would restrict their use to 32 weeks or less in women with PPROM). There is no consensus on whether betamethasone or dexamethasone is better, so either regimen is fine. Steroids should ideally only be given once, so you should carefully consider if they are really needed at the time. (One "rescue" dose later, while not recommended, has not been associated with significant adverse neonatal effects, and is also acceptable on an individualized basis.)
Reference:
Antenatal corticosteroid therapy for fetal maturation. ACOG Committee Opinion No. 273. American College of Obstetricians and Gynecologists. Obstet Gynecol 2002;99:871-873
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=12197491
NEJM Comment
Stiles AD. Prenatal corticosteroids--early gain, long-term questions. N Engl J Med. 2007 Sep 20;357(12):1248-50
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17881757
Conservative checklist protocol for oxytocin: improves maternal and newborn outcomes
CONCLUSION: Implementation of a specific and conservative checklist-based protocol for oxytocin infusion based on maternal and fetal response results in a significant reduction in maximum infusion rates of oxytocin without lengthening labor or increasing operative intervention. Cesarean delivery rate declined system-wide following implementation of this protocol. Newborn outcome also appears to be improved.
Clark S et al Implementation of a conservative checklist-based protocol for oxytocin administration: maternal and newborn outcomes. Am J Obstet Gynecol. 2007 Nov;197(5):480
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17980181
Does the dose of oxytocin affect uterine rupture in candidates for VBAC?
Results
Of the 13,523 patients who elected a VBAC trial, 128 women experienced a uterine rupture; 80 of these ruptures were in women who received oxytocin (62.5%). There was evidence of “dose response” for maximum oxytocin amount and uterine rupture, with a uterine rupture rate of 2.07 % (adjusted odds ratio, 2.98; 95% CI 1.51-5.90) at the highest dosages.
Conclusion
In VBAC attempts, a dose-response relationship of maximum oxytocin and uterine rupture exists. These results provide evidence for vigilance when higher doses of oxytocin are given to patients who attempt VBAC.
Cahill AG et al Does a maximum dose of oxytocin affect risk for uterine rupture in candidates for vaginal birth after cesarean delivery? Am J Obstet Gynecol. 2007 Nov;197(5):495
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17714683
Terbutaline provided more tocolysis with less impact on BP than NTG in resuscitation
CONCLUSION: Although terbutaline provided more effective tocolysis with less impact on maternal blood pressure, no difference was noted between nitroglycerin and terbutaline in successful acute intrapartum fetal resuscitation.
Pullen KM et al Randomized comparison of intravenous terbutaline vs nitroglycerin for acute intrapartum fetal resuscitation. Am J Obstet Gynecol. 2007 Oct;197(4):414
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17904983
Exam-indicated cerclage prolongs gestation / improves survival vs expectant management
CONCLUSION: In this study, the largest cohort reported to date, physical examination-indicated cerclage appears to prolong gestation and improve neonatal survival, compared with expectant management in selected women with cervical dilation between 14(0/7) and 25(6/7) weeks. A randomized, controlled trial should be conducted to determine whether these potential benefits outweigh the risks of cerclage placement in this population.
Pereira L et al Expectant management compared with physical examination-indicated cerclage (EM-PEC) in selected women with a dilated cervix at 14(0/7)-25(6/7) weeks: results from the EM-PEC international cohort study. Am J Obstet Gynecol. 2007 Nov;197(5):483
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17980182
Mid-pregnancy cytokines in predicting spontaneous preterm delivery appears limited
CONCLUSION: Elevated mid-pregnancy plasma IL-2, TNF-alpha, and GM-CSF did not appear to be associated with an increased risk of spontaneous preterm delivery, while elevated IFN-gamma and IL-6 levels were weakly associated with moderate and late spontaneous preterm delivery. The value of using mid-pregnancy cytokines in predicting spontaneous preterm delivery appears limited.
Curry AE et al Mid-pregnancy maternal plasma levels of interleukin 2, 6, and 12, tumor necrosis factor-alpha, interferon-gamma, and granulocyte-macrophage colony-stimulating factor and spontaneous preterm delivery. Acta Obstet Gynecol Scand. 2007;86(9):1103-10
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17712652
Colonization with specific microbes interacted with antibiotics to increase preterm birth
CONCLUSION: Neither baseline endometrial microbial colonization nor plasma cell endometritis were risk factors for adverse pregnancy outcome. However, colonization with specific microbes interacted with antibiotics to increase adverse outcomes.
Tita AT et al Clinical trial of interconceptional antibiotics to prevent preterm birth: subgroup analyses and possible adverse antibiotic-microbial interaction. Am J Obstet Gynecol. 2007 Oct;197(4):367
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17904962
Cardiotocography with ST-segment analysis not associated with less operative deliveries
CONCLUSION: In a population with abnormal cardiotocography in labor, cardiotocography combined with ST-segment analysis was not associated with a reduction in operative deliveries for nonreassuring fetal status. The proportion of infants without scalp pH sampling during labor increased substantially, however.
Vayssière C et al A French randomized controlled trial of ST-segment analysis in a population with abnormal cardiotocograms during labor. Am J Obstet Gynecol. 2007 Sep;197(3):299
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17826428
Primary Care Discussion Forum - Ann Bullock, Cherokee, NC
Traditional AI/AN Medicine: Incorporating Into I/T/U Clincial Practice
Ongoing now
Moderator: Theresa Maresca, M.D., University of Washington School of Medicine
- What are the pros and cons of asking my patients about their traditional medicine use?
- How do I learn more about what traditional practices are common in my area?
- What specific strategies can be used to ask my patients diplomatically about their traditional medicine views?
- Where can I find resources about plant medicine?
- Is there a "right way" to work collaboratively with a traditional healer?
- What if I do not agree with my patient's views of traditional medicine
How to subscribe / unsubscribe to the Primary Care Discussion Forum?
Subscribe to the Primary Care listserv
http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=26
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http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=26
Questions on how to subscribe, contact nmurphy@scf.cc directly
STD Corner - Lori de Ravello, National IHS STD Program
Screening for Chlamydial Infection: Recommendation Statement, USPSTF
Summary of Recommendations and Evidence
The USPSTF recommends screening for chlamydial infection in all sexually active, nonpregnant women 24 years or younger and in older nonpregnant women who are at increased risk. A recommendation.
The USPSTF recommends screening for chlamydial infection in all pregnant women 24 years or younger and in older pregnant women who are at increased risk. B recommendation.
The USPSTF recommends against routinely providing screening for chlamydial infection in women 25 years or older, whether or not they are pregnant, if they are not at increased risk. C recommendation.
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for chlamydial infection in men. I statement.
Meyers D, Halvorson H, Luckhaupt S. Screening for chlamydial infection: a focused evidence update for the U.S. Preventive Services Task Force. Evidence synthesis no. 48. Rockville, Md.: Agency for Healthcare Research and Quality.
http://www.ahrq.gov/clinic/uspstf07/chlamydia/chlamydiasyn.pdf
Barbara Stillwater, Alaska State Diabetes Program
Family History more relevant to risk of GDM in nulliparous women than in parous subjects
RESULTS: There were no significant differences between the two groups in ethnicity, prepregnancy BMI, the insulin-sensitizing protein adiponectin, glucose tolerance status and area-under-the-glucose-curve (AUC(gluc)). In women with Familial history of type 2 diabetes (FHD), a multiple linear regression model of established GDM risk factors reconciled 35% of the variance in AUC(gluc), with (i) previous GDM (t = 3.74, P = 0.0003) identified as a positive independent determinant and (ii) log adiponectin (t = -3.48, P = 0.0008) and, unexpectedly, parity (t = -3.19, P = 0.0021) emerging as negative independent covariates of AUC(gluc). In contrast, in women without FHD, the same multivariate model reconciled only 15% of the variance in AUC(gluc), with no significant variables identified. Interestingly, in the entire population (n = 173), parity significantly modified the relationship between FHD and AUC(gluc) (FHD-parity interaction: t = -2.29, P = 0.0235). Indeed, FHD was an independent determinant of AUC(gluc) in nulliparous women (n = 91), but not in parous women (n = 82).
CONCLUSION: Established risk factors for GDM are relevant in women with FHD but may not be the principal determinants of gestational hyperglycaemia in women without FHD. Moreover, FHD may be more relevant to risk of GDM in nulliparous women than in parous subjects. These findings highlight the complex relationship between FHD and gestational hyperglycaemia, and may hold implications for selective screening for GDM.
Retnakaran R et al The impact of family history of diabetes on risk factors for gestational diabetes. Clin Endocrinol (Oxf). 2007 Nov;67(5):754-60.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17608815
Hypertensive disorders of pregnancy are predictive of diabetes mellitus 21 years later
RESULTS: Of the women without hypertensive disorders of pregnancy (HDP), 7.4% reported a diagnosis of diabetes mellitus compared with 15.3% of the women with HDP (unadjusted odds ratio [OR], 2.03; 95% CI, 1.42, 2.91). After adjustment for all potentially explanatory variables, only prepregnancy body mass index (BMI) and BMI at 21 years after delivery resulted in attenuation of the association (fully adjusted OR, 1.76; 95% CI, 1.21, 2.56). In a smaller subgroup, waist circumference and BMI at 21 years had similar effects on point estimates (fully adjusted OR with BMI, 1.64 [95% CI, 1.11, 2.42]; fully adjusted OR with waist, 1.60 [95% CI, 1.08, 2.40]). CONCLUSION: Hypertensive disorders of pregnancy are associated with reported diagnosis of diabetes mellitus 21 years
Callaway LK et al Diabetes mellitus in the 21 years after a pregnancy that was complicated by hypertension: findings from a prospective cohort study.Am J Obstet Gynecol. 2007 Nov;197(5):492
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17980185
Continuous subcutaneous insulin: No improvement in pregnant diabetic outcomes
Pregnancy outcomes and glycemic control were not significantly different among treatment groups. Higher number of ketoacidotic episodes and diabetic retinopathy found in the CSII group did not reach statistical significance. This systematic review does not show any advantage or disadvantage of using CSII over MDI in pregnant diabetic women. Large multicenter, randomized, controlled trials addressing the quality of life/cost effectiveness are required.
Mukhopadhyay A et al Continuous subcutaneous insulin infusion vs intensive conventional insulin therapy in pregnant diabetic women: a systematic review and metaanalysis of randomized, controlled trials. Am J Obstet Gynecol. 2007 Nov;197(5):447-56
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17678864
A fetal weight estimation at 29-34 weeks in diabetic pregnancies: Can it predict LGA ?
RESULTS: The mean birthweight percentile at term was significantly higher than the estimated fetal weight percentile at 29-34 weeks' gestation in the women with poor glycemic control, but not the women with good control. On multivariate analysis, the estimated fetal weight, interval from ultrasound to delivery, hemoglobin A1C level, gestational age at ultrasound, and classification of glycemic control were independently associated with the birthweight. Both the estimated fetal weight and the calculated birthweight had a low sensitivity and a low positive predictive value for predicting large-for-gestational-age infants. CONCLUSION: Accelerated fetal growth is evident primarily in diabetic women with poor glycemic control. These fetuses cannot be identified by a single ultrasound examination at 29-34 weeks' gestation.
Ben-Haroush A et al Accuracy of a single fetal weight estimation at 29-34 weeks in diabetic pregnancies: can it predict large-for-gestational-age infants at term? Am J Obstet Gynecol. 2007 Nov;197(5):497
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17980186
The Reproductive Phenotype in Polycystic Ovary Syndrome
The symptoms of women with polycystic ovary syndrome (PCOS) include hirsutism and irregular menstrual bleeding due to ovarian androgen excess and chronic anovulation. Typically, these features emerge late in puberty or shortly thereafter. The proposed mechanism(s) responsible for increased ovarian androgen production include heightened theca cell responsiveness to gonadotropin stimulation, increased pituitary secretion of luteinizing hormone, and hyperinsulinemia. The cause of ovulatory dysfunction is not well understood, but is linked to abnormal follicle growth and development within the ovary. As a result, infertility is common among women with PCOS and, in many instances, is the initial presenting complaint. Insulin resistance and obesity are frequently associated with PCOS and probably contribute to the severity of symptoms. The polycystic ovary that accompanies the syndrome has recently been defined as having 12 or more follicles per ovary or an ovarian volume greater than 10 ml as determined by ultrasonography. In addition, there is an increased number of growing follicles in the polycystic ovary. Despite this distinctive appearance, the cause and development of the polycystic ovary are completely unknown.
Chang RJ. The Reproductive Phenotype in Polycystic Ovary Syndrome Nat Clin Pract Endocrinol Metab. 2007; 3(10):688-695.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17893687
Women's Health Headlines, Carolyn Aoyama, HQE
Making a business case for investing in Maternal and Child Health
Healthcare services for children and pregnant women account for $1 out of every $5 large employers spend on health care. A substantial proportion of employee’s lost work time can be attributed to children’s health problems, and pregnancy is a leading cause of short- and long-term disability and turnover for most companies. Yet most companies don’t have a strategy for promoting the health of mothers and children.
In November, the Business Group released a new toolkit aimed at improving employer-sponsored health benefits and programs for children, adolescents, and pregnant women. The core component of this toolkit is the Maternal and Child Health Plan Benefit Model, which outlines 34 evidence-informed health, pharmacy, vision, and dental benefits recommended by the Business Group.
This webinar provided an overview of the new toolkit. The speakers will also discuss:
* The business case for investing in healthy pregnancies and healthy children.
* Benefit design recommendations.
* Recommended cost-sharing strategies to promote appropriate utilization and incentive for prevention.
* Data on the cost-offsets associated with prevention.
* “Lessons learned” from Marriott on communicating health benefits and engaging beneficiaries in health promotion and disease prevention.
Speakers:
Kathryn Phillips Campbell, MPH, Manager, National Business Group on Health
Scott Rothermel, Consultant and member of the Benefits Advisory Board
Rebecca L. Main, Senior Manager, Benefits, Marriott International
To view Investing in Maternal and Child Health: An Employer’s Toolkit, visit:
http://www.businessgrouphealth.org/healthtopics/maternalchild/investing/index.cfm
The webinar recording will be posted for all members on the Business Group website at: http://www.businessgrouphealth.org/opportunities/webinars.cfm
Depression and Initiation of Cigarette, Alcohol, and Other Drug Use among Young Women
SAMHSA's Office of Applied Studies (OAS) has released the following report on the web:
The NSDUH Report: Depression and the Initiation of Cigarette, Alcohol, and Other Drug Use among Young Adults, a 3 page short report based on SAMHSA's National Survey on Drug Use and Health provides prevalences of the following among young adults in the past year: major depressive episode, initiation of alcohol or illicit drug use, and the association between such new alcohol and/or illicit drug use and major depressive episode by gender, racial group, and Hispanic status. The full report is athttp://oas.samhsa.gov/2k7/newUsers/depression.cfm
Save the dates
23nd Annual Midwinter Indian Health OB/PEDS Conference
- February 8 - 10, 2008
- For providers caring for Native women and children
- Telluride, CO
- Contact AWaxman@salud.unm.edu
Training in Palliative and End of Life Care
- March 25 -27, 2008
- Minneapolis , MN
- Contact Tim Domer MD at tim.domer@ihs.gov
Keeping Native Women & Families Healthy & Strong
- April 23-25, 2008
- Milwaukee , WI
- Great Lakes Tribal Epidemiology Center
- E-mail contact EpidemiologyCenter@gmail.com
IHS Basic Colposcopy Course
- April 9 - 11, 2008
- Albuquerque , NM
- Contact AWaxman@salud.unm.edu
IHS Colposcopy Update & Refresher Course
- April 9 - 11, 2008
- Albuquerque , NM
- Contact AWaxman@salud.unm.edu
Training in Palliative and End of Life Care
- April 22-24, 2008
- Flagstaff , AZ
- Contact Tim Domer MD at tim.domer@ihs.gov
What’s new on the ITU MCH web pages?
What's new on the ITU MCH web pages?
Preconception Counseling for Women with Diabetes and Hypertension: New Module
http://www.ihs.gov/MedicalPrograms/MCH/M/PNC/PreconCouns01.cfm
There are several upcoming Conferences
and Online CME/CEU resources, etc….
and the latest Perinatology Corners (free online CME from IHS)
…or just take a look at the What’s New page
Did you miss something in the last OB/GYN Chief Clinical Consultant Corner?
The December 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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