MCH - OB/GYN Chief Clinical Coordinator's Corner

Maternal Child Health ‹ CCC Corner ‹ June 2008

OB/GYN CCC Corner - Maternal Child Health for American Indians and Alaska Natives

Volume 6, No. 6, June 2008

Features

American College of Obstetricians and Gynecologists

ACOG Practice Bulletin: Diagnosis and Management of Vulvar Skin Disorders

Summary of Recommendations:

The following recommendation is based on limited or inconsistent scientific evidence (Level B):

The recommended treatment for lichen sclerosus is an ultrapotent topical corticosteroid, such as clobetasol propionate.

The following recommendations are based primarily on consensus and expert opinion (Level C):

Biopsy of hyperpigmented or exophytic lesions, lesions with changes in vascular patterns, or unresolving lesions is particularly important and should be performed to rule out carcinoma.
For patients with biopsy-confirmed Paget disease, further evaluation of the breast, genitourinary tract, and gastrointestinal tract should be undertaken.

ACOG Practice Bulletin No. 93: Diagnosis and Management of Vulvar Skin Disorders. Obstet Gynecol. 2008 May;111(5):1243-54. http://www.ncbi.nlm.nih.gov/pubmed/18448767

ACOG Committee Opinion: Low Bone Mass (Osteopenia) and Fracture Risk

ABSTRACT: Diagnosis of low bone mass or osteopenia, defined by measures of bone mineral density (BMD), has generated much confusion. Because BMD alone is not sufficient to describe risk of fracture, clinicians face challenges in interpreting BMD and clinical risk factors, counseling patients on absolute risk of fracture, and determining the need for pharmacologic intervention. For fracture risk assessment, the most valuable risk factors appear to be BMD, age, prior fracture history, and risk of falling. Until better models of fracture risk exist, postmenopausal women in their 50s with T scores in the osteopenia range and without risk factors may well benefit from counseling on calcium and vitamin D intake and risk factor reduction to delay the initiation of pharmacologic intervention.

ACOG Committee Opinion No. 407: Low Bone Mass (Osteopenia) and Fracture Risk. Obstet Gynecol. 2008 May;111(5):1259-61. http://www.ncbi.nlm.nih.gov/pubmed/18448770

ACOG Committee Opinion: Ovarian Tissue and Oocyte Cryopreservation

ABSTRACT: As more young women are cured of cancer with chemotherapy and radiotherapy, which can be gonadotoxic, interest is growing in treatments that may preserve fertility. In vitro fertilization with cryopreservation of embryos is currently the best option for fertility preservation when treatment for cancer is anticipated. Ovarian tissue cryopreservation and oocyte cryopreservation are two options with the potential to preserve fertility. Although these methods are developing rapidly, their use as a means to have a child after cancer treatment must be considered investigational and offered only with appropriate informed consent in a research setting and under the auspices of an institutional review board.

ACOG Committee Opinion No. 405: Ovarian Tissue and Oocyte Cryopreservation. Obstet Gynecol. 2008 May;111(5):1255-6. http://www.ncbi.nlm.nih.gov/pubmed/18448768

ACOG Committee Opinion: Coping With the Stress of Medical Professional Liability Litigation

ABSTRACT: Obstetrician–gynecologists should recognize that being a defendant in a medical professional liability lawsuit can be one of life’s most stressful experiences. Coping with the stress of medical professional liability litigation is an ongoing, complex process in which physicians often must struggle to regain a sense of personal identity and professional mastery, as well as control of their clinical practices. Open communication with family members will assist in reducing emotional isolation and self-blame; however, legal and clinical aspects of a case must be kept confidential. Peer support and individual professional counseling can be of great benefit. Rapid intervention facilitates healthier coping strategies and can restore a sense of equilibrium and self-esteem during an unpredictable time.

ACOG Committee Opinion No. 406: Coping With the Stress of Medical Professional Liability Litigation. Obstet Gynecol. 2008 May;111(5):1257-8. http://www.ncbi.nlm.nih.gov/pubmed/18448769

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American Family Physician**

A Practical Approach to Neonatal Jaundice

ABSTRACT: Kernicterus and neurologic sequelae caused by severe neonatal hyperbilirubinemia are preventable conditions. A structured and practical approach to the identification and care of infants with jaundice can facilitate prevention, thus decreasing rates of morbidity and mortality. Primary prevention includes ensuring adequate feeding, with breastfed infants having eight to 12 feedings per 24 hours. Secondary prevention is achieved by vigilant monitoring of neonatal jaundice, identifying infants at risk of severe hyperbilirubinemia, and ensuring timely outpatient follow-up within 24 to 72 hours of discharge. Total serum bilirubin or transcutaneous bilirubin levels should be routinely monitored in all newborns, and these measurements must be plotted on a nomogram according to the infant's age in hours. The resultant low-, intermediate-, or high-risk zones, in addition to the infant's risk factors, can guide timing of post-discharge follow-up. Another nomogram that consists of age in hours, risk factors, and total bilirubin levels can provide guidance on when to initiate phototherapy. If the infant requires phototherapy or if the bilirubin level is increasing rapidly, further work-up is indicated.

Moerschel SK , Cianciaruso LB, Tracy, LR, A Practical Approach to Neonatal Jaundice, American Family Physician. Leawood: May 1, 2008. Vol. 77, Iss. 9; pg. 1255-62.

http://www.aafp.org/afp/20080501/1255.html

Physical Activity Counseling

ABSTRACT: Every year in the United States, at least 250,000 deaths are attributed to lack of physical activity. Because of the health benefits of physical activity, national guidelines recommend participation in 30 minutes of accumulated moderate-intensity physical activity such as walking fast on five or more days of the week. However, most Americans fail to achieve this goal and report that their physicians have not counseled them to increase physical activity. Because 84 percent of Americans consult a physician each year, even brief physician counseling that leads to modest activity changes could affect the population's health. Some physicians report that they do not deliver physical activity counseling because of limitations in time, reimbursement, knowledge, confidence, and practical tools. The five A's (Assess, Advise, Agree, Assist, Arrange) model can help physicians deliver brief, individually tailored physical activity messages to patients.

Rebecca A Meriwether RA, et al., Physical Activity Counseling, American Family Physician. Leawood: Apr 15, 2008. Vol. 77, Iss. 8; pg. 1129, 8 pgs

http://www.aafp.org/afp/20080415/1129.html

Oral Health During Pregnancy

ABSTRACT: Oral health care in pregnancy is often avoided and misunderstood by physicians, dentists, and patients. Evidence-based practice guidelines are still being developed. Research suggests that some prenatal oral conditions may have adverse consequences for the child. Periodontitis is associated with preterm birth and low birth weight, and high levels of cariogenic bacteria in mothers can lead to increased dental caries in the infant. Other oral lesions, such as gingivitis and pregnancy tumors, are benign and require only reassurance and monitoring. Every pregnant woman should be screened for oral risks, counseled on proper oral hygiene, and referred for dental treatment when necessary. Dental procedures such as diagnostic radiography, periodontal treatment, restorations, and extractions are safe and are best performed during the second trimester. Xylitol and chlorhexidine may be used as adjuvant therapy for high-risk mothers in the early postpartum period to reduce transmission of cariogenic bacteria to their infants. Appropriate dental care and prevention during pregnancy may reduce poor prenatal outcomes and decrease infant caries.

Silk H, et al., Oral Health During Pregnancy, American Family Physician. Leawood: Apr 15, 2008. Vol. 77, Iss. 8; pg. 1139-45. http://www.aafp.org/afp/20080415/1139.html

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AHRQ

Outcomes of Maternal Weight Gain

A new AHRQ evidence report, Outcomes of Maternal Weight Gain, finds that women who gain more or less than recommended amounts of weight during pregnancy are likely to increase the risk of problems for both themselves and their child. However, researchers concluded that the existing body of research is inadequate to permit objective assessments of the range of harms and benefits that would arise from providing all women—irrespective of age, race or ethnicity, or their body mass index before they became pregnant—with the same recommendations for weight gain in pregnancy.

http://www.ahrq.gov/clinic/tp/admattp.htm

Helping Smokers Quit; A Guide for Clinicians

The following is excerpted from the press release on the ARHQ website:

An updated clinical practice guideline released by the U.S. Public Health Service has identified new counseling and medication treatments that are effective for helping people quit smoking.

Treating Tobacco Use and Dependence: 2008 Update was developed by a 24-member, private-sector panel of leading national tobacco treatment experts that reviewed more than 8,700 research articles published between 1975 and 2007. The review found that there are now seven medications approved by the Food and Drug Administration as smoking cessation treatments that dramatically increase the success of quitting. The medications are: bupropion SR, nicotine gum, nicotine inhaler, nicotine lozenge, nicotine nasal spray, nicotine patch, and varenicline.

The 2008 PHS guideline update also found evidence that counseling by itself or especially in conjunction with medication can greatly increase a person's success in quitting. In particular, quitlines were found to be effective and can reach a large number of people; 1-800-QUIT-NOW, a national quitline, is an access number that connects people to their State-based quitline. It also provides broad access to cessation counseling for diverse populations and is easy for clinicians and patients to use.

Other recommendations issued in the 2008 PHS guideline update include the following:

Clinicians, in their offices and in the hospital, should ask their patients if they smoke and offer counseling and other treatments to help them quit. According to AHRQ's 2007 National Healthcare Quality Report, the percentage of hospitalized heart attack patients who were counseled to quit smoking has increased from 42.7 percent in 2000-2001 to 90.9 percent in 2005. Moreover, 48 States, Puerto Rico, and the District of Columbia all performed above 80 percent on this measure in 2005.
If tobacco users are unwilling to make an attempt to quit, clinicians should use the motivational treatments that have been shown effective in promoting future attempts to quit.
Individual, group and telephone counseling are effective, and their effectiveness increases with treatment intensity. Counseling should include two components: practical counseling and social support.
Tobacco cessation treatments also are highly cost-effective relative to other clinical interventions. Providing coverage for these treatments increases quit rates. Insurers and purchasers should ensure that all insurance plans include the counseling and medication treatments that have been found to be effective in the 2008 PHS guideline update.
Counseling treatments have been shown to be effective for adolescent smokers and are now recommended. Additional effective interventions and options for use with children, adolescents, and young adults need to be determined.

The 2008 PHS guideline update and its companion products, which include a consumer guide and a pocket guide for clinicians, are available online at http://www.surgeongeneral.gov/tobacco/default.htm . Copies of the 2008 PHS guideline update products are also available by calling 1-800-358-9295.

The press release is at http://www.ahrq.gov/news/press/pr2008/tobupdatepr.htm.

The ARHQ Guide for Clinicians is at http://www.ahrq.gov/clinic/tobacco/clinhlpsmksqt.htm.

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Ask A Librarian - Diane Cooper, M.S.L.S. / NIH

Women's Health Resources

A new Web resource providing scientists and consumers with the latest information on significant topics in women's health research from scientific journals and other peer-reviewed sources is now available through the National Library of Medicine (NLM). The NLM Division of Specialized Information Services, Office of Outreach and Special Populations has partnered with the NIH Office of Research on Women's Health (ORWH) to create this one-stop resource.

The 2008 National Institutes of Health (NIH) Research Priorities for Women's Health were used to identify overarching themes, specific health topics, and research initiatives in women's health. Within each section of the Web site are topics with links to relevant and authoritative resources and research initiatives for women's health.

Women's Health Resources from the NLM Web site can be found at:

http://sis.nlm.nih.gov/outreach/womenshealthoverview.html

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Behavioral Health Insights - Peter Stuart, IHS Psychiatry Consultant

Cutters – Understanding Intentional Self-Injury

The guest editor is Dr. Robert Beasley, MD, Oklahoma Area Family Psychiatrist, Clinical Professor, University of Oklahoma Health Sciences and long-standing member of the IHS Suicide Prevention Committee.

The cutting of ones own skin seems a modern-day phenomenon although descriptions of a Spartan leader cutting his skin go back to the 5 th century B.C. But no matter how ancient, it is still quite alarming to see those self-inflicted wounds marring the limbs or abdomen of anyone, especially a young adolescent. Parents, teachers, peers, and clinicians are often stunned and surprised and therefore reactive. Sorting this phenomenon out in a clinical setting is the task.

“Cutting” as it is popularly known (as well as “cutters”) has been lumped with other behaviors as self-mutilation which as an older term has a rather harsh implication (as in a mutilated body) and dictionarily does not fit with “cutting off or destroying an essential part.” Other terms less maiming such as self injury, non-suicidal self injury, and self-injurious behaviors are more in vogue.

Self cutting or repetitive skin cutting is the most common form of self injury (70% plus) and most people who self injure only do this once or a few times. Those who chronically self injure experience frequent urges and frequent attempts to resist them.

Like other understudied behaviors estimating prevalence is still a guess–like 4% in adults but adolescents report higher rates of self injury. In one study 46% of ninth and tenth graders reported a self-injurious behavior and 14% reported cutting behaviors. Rates are said to be much higher in mental health settings with 40% to 80% study rates in adolescent patients. Thus self-injurious behavior especially in adolescents and especially cutting should not be so surprising or seen as uncommon.

Self-injurious behavior also might be viewed as a developmental phenomenon as it arises in early adolescence. Girls are more prone to cutting while boys are more likely to be hitting things or burning themselves. No doubt puberty with its physical growth, hormonal change, and menstrual cycling sets the stage of this development. Ethnic differences have not been explored adequately but are said to be higher in Caucasians. No studies addressing native populations appear in the literature.

Before looking at psychological characteristics of people who self injure it is important to view this phenomenon through a spectrum in order to spread out the colors and shades and avoid reducing a symptom into a stereotype. Developmental and experienced vision helps. A 14-year-old who self injures may have much different dynamics than a 19-year-old or a 30-year-old. Also going back a decade or two ago the literature and the daily clinical practice connected self-injurious behavior to fairly serious characterlogic pathology usually ascribed to “the borderline personality.” Perhaps this in part, was related to a population who were older, more symptomatic, and more difficult to treat.

As a medical student in the late 60's, I recall how the head of the surgery department was fascinated with the tattoos of prison inmates on the ward as if tattoos were confirmation of sociopathy. Certainly that is not the case today. So it is with cutting or other self-injurious behavior. The symptom does not make a diagnosis and the symptom has evolved and became more widespread and appears earlier with the fluxes of adolescent development.

However, there are some generally shared characteristics with the most common being negative emotionality, i.e. more frequent and more intense negative emotions. Also the ability to identify, express and regulate emotions is problematic. There is often a strong element of self-critical, self-derogatory, and self-punitive thought that fuels the negativity. These characteristics are a part of normal development that usually are managed by the maturation process but certainly reappear when one experiences depression.

It seems unclear what the role of past trauma has in self-injurious behavior. We have passed the time when we would automatically suspect child abuse especially sexual abuse in the background. There may be a relationship in some instances, but this is not the expected connection. Also, the relationship between self-injurious behavior and suicidal behavior does not consummate a marriage. They are two different phenomena but a clinician cannot afford to not assess the intent of the self-injurious behavior and evaluate any suicidality.

The obvious question of “why would one do that to oneself?” does have explanations, some clinical reasoned, some theoretical and some just guesses. Certainly many report that self injury stops (displaces) the intensity of the emotional storm and is seen as calming. It gives some control over intense emotional distress. There is also a sense of atonement from punishing oneself. In others who think they have lost the ability to feel, it confirms that they are not numb, not emotionally dead. It may also be tied to relationships, seeking the care or attention of others or bonding with someone who has self injured. It can have a protective function to keep one from suicidal ideation or actions. For some it may have a “daredevil” or thrill seeking manifest explanation and for others no explanation is pronounced – “I don’t know why.”

Clinical assessment therefore, should begin with the knowledge that self-injurious behavior is not uncommon especially in adolescence, that cutting is the predominant method, that the behavior is different phenomenologically from suicide and, that it serves a function. When first encountering a patient with a self injury, who is medically stabilized, analyzing one’s own reaction to the self injury is very significant. Negative reactions such as shock, disgust, distancing, moral judging, fear, and especially anger, impede an evaluation and may impede treatment. They discourage a patient from getting help and may interfere with a referral process. A low-key dispassionate demeanor to self injury is the recommended path or as stated in the book, Skin Game: A Cutters Memoir by Kettlewell, one should approach self injury with “respectful curiosity.” With this demeanor one can then begin to gather the history of self injury with the details of the recent self injury, the antecedents and the consequences and aftermath.

When evaluating adolescents, my own background in family systems generally leads me to include the parents or parenting system from the start and it puts the family in the focus as the unit of concern. Although this can be awkward and chaotic initially, much can be gained for therapeutic planning. Also the adolescent may feel some relief from the emotional burden of the behavior. The parents at the same time realize that they are a part of the treatment process.

Specific treatment is as diverse as there are therapists and depends on how the self-injurious behavior is conceptualized in the greater scheme of things. Certainly in this day of symptom-focused, pharmacologically driven insurer-capitalistic controlled, research-based best practice, an algorithm will be delivered to clear up this bloody problem. In the mean time, I would recommend a respectfully curious, non-judgmental family-based therapist who is a bit slow on the drug trigger.

In researching this article I recommend three authors. Armando Favazza has written extensively on the subject (even a book) and has traced the history. David Klonsky and Jennifer Muelenkamp have a good research review for the practioner and Barrent Walsh has an excellent article on clinical assessment.

Favazza AR, The coming of age of self-mutilation, J Nerv Ment Dis. 1998 May;186(5):259-68. http://www.ncbi.nlm.nih.gov/pubmed/9612442

Klonsky ED, Muehlenkamp JJ, Self-injury: a research review for the practitioner. J Clin Psychol. 2007 Nov;63(11):1045-56. http://www.ncbi.nlm.nih.gov/pubmed/17932985

Walsh B, Clinical assessment of self-injury: a practical guide. J Clin Psychol. 2007 Nov;63(11):1057-68. http://www.ncbi.nlm.nih.gov/pubmed/17932980

Kettlewell, C. (1999) Skin Game: A Cutters Memoir. New York, NY St. Martin’s Press.

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Breastfeeding - Suzan Murphy

Supporting breastfeeding without money or a lot of time

Since obesity and its complications including type 2 diabetes have reached epidemic rates, health care planners are very eager for ways to reduce risk. At the moment, there are no promises of cure, but there are many different ways to reduce risk. Breastfeeding is one way.

But making breastfeeding work is not always easy. There are many distractions and barriers. Extra use of plastic nipples, pacifiers, and formula can slow down the lactation start up process. Painful latch, ineffective suck, jaundice, poor infant weight gain, engorgement, cracked and bleeding nipples, and well-meant-but-inaccurate-information can end the best intentions to breastfeed. Reassuring anxious dads, friends and relatives that “yes, the baby is getting enough and yes, the milk is good” can be overwhelming for new moms and challenging for providers. Managing breastfeeding, childcare, and work/school can be exhausting for new families. Keeping track of how breastfeeding support interventions are working can be time consuming and frustrating for health care planners and providers.

But – there is hope. Thanks to technology and the internet, there are more resources and reliable answers available than ever before. There are free materials available via Indian Health Service on-line resources like the MCH Breastfeeding page ( www.ihs.gov/MedicalPrograms/MCH/M/bf.cfm ). There are downloadable patient education materials (under Staff Resources), and a direct link to the amazing I.H.S. Diabetes Education on-line catalog (click on the Indian Health Service link by the picture of the pink/salmon Easy Guide to Breastfeeding) – TONS of free, helpful, culturally appropriate materials, including the Easy Guide (under pregnancy). The materials can be ordered on line and are shipped promptly and for free. A free NIH/I.H.S.video, “Close to the Heart: Breastfeeding our Children Honoring our Values” can be requested at 1-877-868-9473. The video is also part of a DVD that has other diabetes wellness/prevention stories – the DVD is 45 minutes long and looped so it can play over and over in the waiting room. Examples of other web pages that are especially helpful are the Centers for Disease Control ( www.cdc.gov ) – great for the latest on diseases/issues that impact lactation, American Academy of Pediatrics ( www.aap.org ) – helpful policies, DHHS/Office of Women’s Health ( www.4women.gov ) – excellent resources for new moms, WIC (www.fns.usda.gov/wic/benefitsandservices/) - wonderful family friendly resources for breastfeeding, NIH Lactation and Medication search engine at http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT - quick, reliable, current research on maternal medication and breast milk.

Getting data? Electronic Health Records (E.H.R.) can make it easy. When a baby is seen, click on visit data (visit element tab), at Personal Health click on “To add, select”, then from the pull down menu – select infant feeding, push “add” – and the big work is done. Feeding choice can be done at each visit. RPMS will track feeding choice by visit date. If it looks like last month’s info disappeared, don’t worry, it really didn’t. The other variables – such as birth order, birth weight, mother’s name, age of introduction of solids, and age of starting formula/stopping breastfeeding can be added at using the pull down menu and picking birth measurement. It is a short learning curve.

Need a report? CRS can report your progress of exclusively and mostly breastfeeding at predetermined ages. You can also do customized progress checks by using a vgen or qman search. For more details, please check with your IT or E.H.R. Department – or call us at 1-877-868-9473.

So, when you have a minute, see what you can do, then click on E.H.R and see what makes a difference.

Grummer-Strawn LM, Mei Z; Centers for Disease Control and Prevention Pediatric Nutrition Surveillance System, Does breastfeeding protect against pediatric overweight? Analysis of longitudinal data from the Centers for Disease Control and Prevention Pediatric Nutrition Surveillance System, Pediatrics. 2004 Feb;113(2):e81-6. http://www.ncbi.nlm.nih.gov/pubmed/14754976

Ip S, et al., Breastfeeding and maternal and infant health outcomes in developed countries.

Evid Rep Technol Assess (Full Rep). 2007 Apr;(153):1-186. http://www.ncbi.nlm.nih.gov/pubmed/17764214

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CCC Corner Digest

Nicely laid out hard copy - A compact digest of last month’s CCC Corner

If you want a copy of the CCC Digest mailed to you each month, please contact nmurphy@scf.cc

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Domestic Violence - Denise Grenier, Tucson / Rachel Locker, Warm Springs

“Keeping the Circle Strong: Celebrating Native Women’s Health and Well-Being”

2008 Conference

The National Indian Women's Health Resource Center will be hosting a two and a half day national conference in Albuquerque, NM June 9-11, 2008. Topics include Violence Against Native Women, HIV/AIDS, Diabetes, Cardiovascular Health, Advocacy for Elders, Spirituality and the Healing Process, Suicide Among Native Women, Methamphetamine Abuse Among the American Indian Population, Health Literacy, and Mentoring Native Youth.

For more information visit the “Keeping the Circle Strong: Celebrating Native Women’s Health and Well-Being” 2008 conference registration website: http://www.niwhrc.org/2008%20conference.htm

For more information about the National Indian Women’s Health Resource Center visit:

http://www.niwhrc.org/

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Elder Care News - Bruce Finke, Elder Care Initiative

Landmark Study on Treatment of Hypertension in the Very Old

This international randomized controlled trial addresses the important unanswered question of the value of treatment for hypertension in men and women aged 80 and older. Although treatment of elevated systolic and diastolic blood pressure has clearly been shown to benefit younger elders, prior to this study the data in the older elderly has been inconclusive.

Nearly 4000 elders aged 80 and older with systolic blood pressures of 160mm Hg or higher were randomized to receive either placebo or a diuretic similar to HCTZ. An ACE-I was added to the diuretic as needed to reach the target blood pressure of 150/80.

Over a 2 year study period active treatment was associated with a 30% reduction of stroke (fatal and nonfatal), a 39% reduction in death from stroke, a 21% reduction in death from any causes, a 23% reduction in death from cardiovascular causes, and a 64% reduction in heart failure. There were fewer serious adverse events in the active treatment group than in the placebo group.

Elder Care Initiative Editorial comment:

This is a landmark study that makes clear the benefit of treatment of hypertension, diastolic and systolic, in the very old. I was especially interested in the marked reduction in stroke and heart failure, two conditions with huge implications for the function and quality of life of older people. Treatment of high blood pressure is not just about preventing death, but also about preserving quality of life.

Beckett NS, et al. Treatment of Hypertension in Patients 80 Years of Age or Older.

N Engl J Med. 2008 Mar 31 http://www.ncbi.nlm.nih.gov/pubmed/18378519

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Family Planning

Fact Sheet Examines States' Efforts To Safeguard Adolescents' Confidentiality

State Policies Affecting the Assurance of Confidential Care for Adolescents provides an overview of states' minor consent laws and new information on the use of explanation-of-benefit (EOB) statements by state Medicaid agencies and their contracting managed care organizations. The fact sheet, published by Incenter Strategies, The National Alliance to Advance Adolescent Health, explains how and why EOBs are used and addresses the implications of state policies for
adolescents and for health professionals. Conclusions and data on state protections for sensitive services are included. The fact sheet is available at http://www.incenterstrategies.org/jan07/factsheet5.pdf.

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Featured Website - David Gahn, IHS MCH Portal Web Site Content Coordinator

Donald Coustan: Gestational Diabetes

Donald Coustan: Use of Oral Antidiabetic Agents in Obstetrics: Workshop

Diabetes and Pregnancy Online Resources

A patient education tool about diabetes and pregnancy is available online from the National Center on Birth Defects and Developmental Disabilities. The website answers common questions and presents general information about diabetes:
http://www.cdc.gov/features/diabetespregnancy/

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Frequently Asked Questions

First Trimester Down Syndrome Testing

Q.Who should be offered first trimester Down syndrome (DS) screening?
A. Women presenting for prenatal care at less than 14 weeks gestation.
Q. Should only high-risk women (over 35 y/o) be offered 1st trimester DS screening?
A. No, all women who desire the testing are candidates.
Q. At what gestational age should first trimester DS screening be scheduled?
A. Between 11 weeks 0 days and 13 weeks 6 days (by ultrasound).
Q. What are the components of the 1 st trimester DS screen?
A. Ultrasound measurement of the nuchal translucency (NT) + blood for PAPP-A (pregnancy-associated plasma protein-A) and free beta HCG. (Most ultrasound exams at ANMC will also include the fetal heart rate, nasal bone, and ductus venosus or tricuspid waveform, if able to be obtained, which increase the sensitivity and reduce the false positives.)
Q. I’m pretty good at office ultrasound. Can I do my own NT measurements?
A. Without certification, unfortunately no. Accurate NT measurements are difficult to obtain without special training. A lot is riding on the results. NT measurement requires a certificate of competency which can be obtained by attending a one-day didactic course, taking a written examination, and submitting 10 ultrasound images for critique and/or acceptance. Following certification, annual certification of competency needs to be accomplished by submitting more images. If interested, the certification process can be initiated at this website: www.ntqr.org.
Q. I’m happy with our usual 2 nd trimester screening. What’s the advantage to offering first trimester DS screening?
A. The advantages are earlier diagnosis, increased sensitivity (91%), and fewer false positives (4%). (This is compared to 2 nd trimester screening that has a 78% sensitivity and a 5% FPR for screening in younger women (<35 y/o), and an 85% sensitivity but an 11% FPR in women >35 y/o. Many women will present too late for 1 st trimester screening, so 2 nd trimester screening will continue to be an appropriate option.)
Q. What is “integrated screening”?
A. Integrated screening is a screening strategy which relies on the results of both the 1 st and 2 nd trimester testing to give a final risk assessment. (The ANMC contract with our reference lab, NTD Laboratories, is currently not set up to do integrated screening. Also, we felt that most women would want to have the results of an abnormal 1 st trimester screen divulged to them right away, and not wait for another several weeks.)
Q. What is “sequential contingent screening”?
A. Sequential contingent screening is the strategy that we are currently using at ANMC. If women have an abnormal 1 st trimester result, they are informed, and offered the option of immediate invasive testing, or subsequent 2 nd trimester testing. If they have a normal result, their DS screening is considered to have been completed.
Q. What are the cut-off values used for 1 st trimester screening?
A. A 1 st trimester cut-off of 1:50 or higher is used to counsel about immediate invasive testing, if the woman so desires.
-A 1 st trimester cut-off of 1:300 or higher is used to recommend a detailed 2 nd trimester anatomic ultrasound, and/or possible amniocentesis.
-According to our current ANMC protocol, women with a screening result of less than 1:300 have completed DS screening. (If the pregnancy is 13 weeks or less, ANMC patients may be referred to Seattle for chorionic villus sampling [CVS], if they so desire. If a woman is beyond 13 weeks, or does not wish CVS, or would prefer amniocentesis, she will need to wait 2 weeks and be referred for amnio after 15 weeks. “Early amnio”, between 12-15 weeks, has a high [2.6%] pregnancy loss rate, and is not recommended.)
Q. If my client’s 1 st trimester DS screen is negative, is any further testing necessary?
A. If the woman’s 1 st trimester DS screen is less than 1:300, our strategy of contingent sequential screening does not require any further testing for fetal aneuploidy. However, testing for fetal open neural tube defects (ONTD) still needs to be carried out. (In the current ANMC system, it is unfortunately currently not possible to order a maternal serum alpha fetoprotein (MSAFP) for ONTD screening alone, apart from a quad screen. Following negative 1 st trimester screening, 2 nd trimester serum screening, if not “integrated”, has an unacceptably high false positive rate (17%) for fetal Down syndrome, and is not recommended. However, we are fortunate to be able to order routine fetal anatomic surveys at 16-20 weeks, which have a high sensitivity (96%) for fetal ONTD and fetal abdominal wall defects. MSAFP screening only has an 80% sensitivity for ONTD in ultrasound-dated pregnancies (only 65% in LMP-dated pregnancies), so ultrasound is superior in this regard. In order to follow ACOG guidelines, some sort of ONTD screening needs to be done.)
Q. At 12 weeks 2 days, a woman undergoes 1 st trimester screening and has a nuchal translucency (NT) of 2.9 mm, which is >95 th percentile for this crown rump length. How should she be counseled?
A. The NT alone does not determine the screening result. It needs to be combined with the PAPP-A and free beta HCG for a final risk assessment. The NT alone only has a sensitivity for fetal DS of 72%, with a (high) false positive rate of 19%. The NT combined with the biochemistries has a sensitivity of 91% and a FPR of 4%. The full screen result requires both, and it is not prudent to act on the NT measurement alone. (Important exception: If the NT measurement is over 3.5 mm (+3 SD), it is considered a cystic hygroma, and the woman may be counseled about having invasive testing right away, if she so desires. A cystic hygroma raises the risk of aneuploidy to as high as 1:2.)
Q. I’ve heard that an enlarged NT can also signal fetal heart defects. How large does the NT have to be to be considered a marker for potential heart defects?
A. About 1% of patients have an NT >3.5 mm (>99 th percentile), which is used as the cutoff for making a referral for fetal echocardiography after 20 weeks. Even if the fetus is found to have a normal karyotype, it should still be screened for cardiac defects. (The sensitivity of a NT >3.5 mm for congenital heart disease is about 40%, but the positive predictive value is only about 4%.)
Q. What about multiple gestations? Can they undergo 1 st trimester screening?
A. Twins can be screened for fetal aneuploidy in the 1 st trimester since nomograms are available to calculate their overall risk. Higher order multiples however are not able to be accurately screened at present, although an NT >3.5 mm should always raise suspicion.
Q. Does 1 st trimester screening only screen for fetal Down syndrome, or can other fetal trisomies also be detected?
A. First trimester combined screening tests screen for trisomy 21 (Down syndrome) and trisomy 18. Trisomy 13 and sex chromosome aneuploidies (Turner syndrome, XO, and Klinefelter syndrome, XXY, etc.) are not efficiently screened with this test. (However, remember, over 50% of fetuses with Turner syndrome will have a cystic hygroma, i.e., NT>3.5 mm.)
Q. My client has a negative 1st trimester DS screening result, and a normal 2 nd trimester ultrasound, but she still desires amniocentesis. Is that indicated?
A. Both 1st and 2nd trimester screening is just that, screening, not diagnostic. Screening is able to lower risks, but only an invasive diagnostic test can definitively diagnose fetal aneuploidy. If a woman still wishes invasive testing and understands the risks of pregnancy loss following testing (which are quoted in the literature as ranging from 1:200 to 1:1600), that is her choice. (It would have been more cost-effective if she had decided that earlier and been referred before having any screening!)

OB/GYN CCC Editorial comment:

First trimester screening is a reality

Though first trimester screening a reality, please note that these comments are from George Gilson, MFM, at the Alaska Native Medical Center so are based on the resources available in tertiary care center. You may wish to do something different in your service unit, but it is helpful to be aware which direction your clinical care will be heading when the resources are available.

REFERENCES

Malone FD, D’Alton ME. First trimester sonographic screening for Down syndrome. Obstet Gynecol 2003; 102:1066-79.
Malone FD, et al. First trimester or second trimester screening, or both, for Down syndrome (FASTER Study). N Eng J Med 2005; 353:2001-11.
Wald NJ, Rodeck C, et al. First and second trimester antenatal screening for Down syndrome (SURUSS Study). J Med Screen 2003; 10:56-104.
Wapner R, et al. First trimester screening for trisomies 21 and 18. NEJM 2003; 349:1405-13.
Reddy UM, Mennuti MT. Incorporating first trimester Down syndrome studies into prenatal screening (NICHD Workshop). OG 2006; 107:167-73.
Berkowitz RL, et al. Aneuploidy screening: What test should I use? OG 2006; 107:715-8.
Chervenak FA, McCullough LB. Implementation of first trimester risk assessment for trisomy 21: Ethical considerations. Am J Obstet Gynecol 2005; 192:1777 -81.
Odibo AO, et al. A cost-effectiveness analysis of prenatal screening strategies for Down syndrome. OG 2005; 106:562-8.
ACOG. First trimester for fetal aneuploidy. ACOG Committee Opinion No.296. ACOG July 2004

ACOG. First trimester for fetal aneuploidy. ACOG Committee Opinion No.296. ACOG July 2004.

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Indian Child Health Notes - Steve Holve, Pediatrics Chief Clinical Consultant

Autism Articles of Interest

Identification and Evaluation of Children with Autism Spectrum Disorders. Pediatrics 120: 5; 1183-215 November 2007 http://www.ncbi.nlm.nih.gov/pubmed/17967920

Management of Children with Autism Spectrum Disorders. Pediatrics 120:5; 1161-1182 November 2007 http://www.ncbi.nlm.nih.gov/pubmed/17967921

These two clinical reports published in Pediatrics in November 2007 provide a complete summary for the clinician on autism spectrum disorders (ASDs). The review last month highlighted the identification and evaluation of children with autism spectrum disorders. The review this month will describe management strategies.

Summary

Autism Spectrum Disorders (ASDs) are not rare with an estimated frequency in Europe and North America of 1/150 births. Given this frequency most primary care providers will care for several patients with this disorder.

ASDs, like other neurodevelopmental disorders are generally not curable but can benefit from management like other chronic diseases. The goal is to minimize the deficits associated with ASD such as speech impairment and social interactivity while maximizing the potential of patients to function independently.

There are a variety of modalities used to treat ASDs. Relatively few of these have been rigorously evaluated. The most work has been done with applied behavior analysis, a form of behavior modification. Studies have shown improvement in IQ measurements, academic performance, and social adaptiveness. For interventions to be effective they need to be intensive and sustained which is defined as one on one teaching for a minimum of 25 hours/week.

Medical management is also discussed. Seizures occur in 20-40% of children with autism and treatment is based on the same principles used to treat other children with epilepsy. Challenging behavior, especially behaviors that include aggression or self-injurious may benefit from a trial of medications. SSRIs have been used for the past decade. Recently Risperidone® has been licensed by the FDA for use for symptoms of irritability and aggression in children with ASDs.

Lastly, a large number of biological and non-biological treatments have been offered for treatment of ASDs. Appropriately designed trials have show no benefit for treatment for the following; dimethlyglycine, vitamin B6, magnesium, secretin, auditory integrative training and facilitated communication. Many other treatments have not been rigorously evaluated but are offered to patients; these include immunotherapy, chelation, anti-fungals, various elimination diets and complementary and alternative medicines. The physician’s job is to help families use the best evidence to choose therapies with proven benefit and avoid therapies with potential risks.

Editorial Comment from Dr. Holve

There is no cure for ASDs. Medical therapies for ASDs are limited but may be of benefit for specific indications. Educational interventions have the most potential but require personnel who are familiar with ASDs and can devote intensive time treatment. There is good evidence that children need intervention as soon as the diagnosis of ASD is entertained and that the intervention needs to be intensive with a minimum of 25/hours a week. This kind of expertise and intensive treatment could be made available through Head Start or public schools. The reality in many rural settings is that these patients may struggle to get the services they need. The physician’s job is to be an advocate at the school for needed services.

Indian Child Health Infectious Disease Updates .

Rosalyn Singleton, MD, MPH

Recent literature on American Indian/Alaskan Native Health

Michael L. Bartholomew, MD

In a moment of unconscious communication Drs. Singleton and Bartholomew both submitted reviews on the same article. This study below demonstrates that the persistence of substandard housing and plumbing accounts for at least some of the continuing disparity in infectious disease burden for AI/AN children. As physicians we often focus on medical determinants, such as vaccines and antibiotics, and may overlook many of the other important factors in health.

Hennessy TW, Ritter T, Holman RC, Bruden DL, Yorita KL, Bulkow L, Cheek JE, Singleton RJ, Smith J. The Relationship Between In-Home Water Service and the Risk of Respiratory Tract, Skin, and Gastrointestinal Tract Infections Among Rural Alaska Natives. American Journal of Public Health May 2008 Vol 98 No. 5 http://www.ncbi.nlm.nih.gov/pubmed/18382002

Modern water and sanitation services have long been known to be important in improving health and reducing the transmission of infectious diseases. During the first half of the 20 th century, multiple surveys attempting to assess the health status of American Indians and Alaska Natives (AI/AN) cited a lack of water and waste disposal services as significant causal factors to the high rates of infectious diseases among AIs and ANs. 1 In 1959, The Indian Sanitation Facilities Act (P.L. 86-121) authorized the Indian Health Service to provide water and sanitation services to homes and communities. Since its inception, the impact on Native Health has been dramatic with reductions in morbidity and mortality from infectious diseases among AI/ANs.

This study investigates the relationship between modern sanitation services (in-home water services and wastewater disposal services) and hospitalization rates for respiratory, skin, and gastrointestinal tract infections in rural Alaska villages. Between 2000 and 2004, in-home water and waste disposal services were surveyed and analyzed in rural villages within defined regions in Alaska. Water service data for one region (Region A) was further examined on a village level. Additionally, regional and village level (Region A) hospitalization rates for infectious gastroenteritis, pneumonia or influenza, RSV among children less than 5 years, skin or soft tissue infection, and methicillin resistant Staphylococcus aureus (MRSA) infections were obtained and compared.

Overall, in-home water service was present in 73% (range 57%-100%) of homes while 71 %( range 55%-100%) of homes had wastewater services. This is in comparison to the 99.4% of homes in the United States with modern sanitation services. Unevenly distributed, 61% of homes had in-home water service within Region A (designated a low service area). Thirty percent of the population (less than 10% of homes) within Region A lived in homes that lacked modern sanitation. The largest town had 99.5% of homes with in home water service, accounting for 23% of the Region A’s population.

Regional hospitalization rates differed by water service level. Children less than 5 years of age living in low service regions were 3.4 times more likely to be hospitalized for RSV than children living in high service regions (95%CI=3.0,3.8). This trend can also be seen in all ages with pneumonia or influenza (RR=2.5; 95% CI= 2.4, 2.7)), skin or soft tissue infections (RR=1.9; 95% CI=1.8, 2.1)), and MRSA infections (RR=4.5; 95% CI=3.6, 5.7)). Hospitalization rates between high and low service regions for infectious gastroenteritis showed no difference. This may be related to the adequate availability of safe drinking water to all homes, low temperature of the water and nutritional status of the population. Within Region A, hospitalization rates for lower respiratory tract infections (LRTI), pneumonia, and RSV among infants were the highest in villages where less 10% of homes had in-home water service. Significant trends of decreasing rates of hospitalizations of infants with LRTI and LRTI with pneumonia, skin and soft tissue infections, Staphylococcus aureus infections and MRSA infections were seen with increase proportions of homes with in-home water service.

Despite the inability to draw casual conclusions, the results strongly suggest an association between water service and infectious disease. In-home water service is an important public health intervention. The authors conclude from the results of this study that the simple intervention of providing modern water and sanitation to all homes in rural Alaska villages would significantly improve health of Alaska native children. The same can be said for all homes on tribal lands.

Reference:

Galloway JM, Goldberg BW, Alpert JS. 1999. Primary Care of Native American Patients: Diagnosis, Therapy, and Epidemiology. Boston: Butterworth-Heinemann

Editorial Comment by Dr Singleton:

The study, published American Journal of Public Health, demonstrated that RSV hospitalization rates (Relative Rate [RR] = 3.4 in children <5 years), pneumonia and influenza hospitalization rates (RR=2.5), and skin or soft tissue infection rates (RR=1.9) were higher in Alaska regions with low levels of water service than those with high levels of service. Diarrheal disease hospitalizations were uncommon and rates were similar throughout Alaska; each village has a supply of potable water.

Lack of clean water and wastewater disposal may contribute to respiratory and skin infections by making hand washing and body hygiene more difficult because families are conserving water for cooking and drinking. In many other parts of Indian Country, the lack of in-home water service is similar to rural Alaska. This study highlights the importance of addressing non-medical household determinants of health through construction of in-home sanitation services. Providing these basic services has the potential to reduce respiratory, skin and diarrheal diseases, through availability of adequate amounts of potable water for consumption and hygiene.

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Information Technology

iCare Training

The IHS Office of Information Technology (OIT) and the IHS Clinical Support Center (Accredited Sponsor) present WebEx training sessions 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).

NEW! We are offering a new training that will address the additions in the next version of iCare. At this time, we will not be offering CEUs for this class

What's New with iCare? 1.5 hours

We will continue to offer a brief intro session that will just introduce the software to participants. This session does not offer any training and CEUs will not be given for this session

A Brief Introduction to iCare 30 minutes

We will continue to off the 2 standard training sessions and are offering CEUs for these classes. We recommend these 2 classes be taken sequentially. These sessions will be updated to include the new functionality.

iCare - Nuts and Bolts 2.0 hours
The Practical Use of iCare 1.5 hours

The target audience is any provider who cares for patients (e.g. physicians, mid-level providers, nurses, case managers, public health personnel, pharmacists etc.)

NOTE:You must register for these classes. They are NOT limited to participants in a particular Area; they are open to all. 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 in the Pacific Daylight Time ( California) zone. Please ensure you adjust the time for your particular time zone.

ACCREDITATION:

The Indian Health Service (IHS) Clinical Support Center is accredited by the Accreditation Council for Continuing Medical Education to sponsor continuing medical education for physicians.

The IHS Clinical Support Center designates this continuing medical education as Category 1 credit toward the Physician’s Recognition Award of the American Medical Association. Each physician should claim only those hours of credit he or she actually spent in the educational activity.

This Category 1 credit is accepted by the American Academy of Physician Assistants and the American College of Nurse Midwives.

The Indian Health Service Clinical Support Center is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

Training Schedule

What's New with iCare?

Target Audience – Patient Care Providers (e.g. physicians, mid-level providers, nurses, case managers, public health personnel, pharmacists etc.)

Agenda

New Panel Definitions
Panel Reminders
Aggregate Reminders
PCC Tab
Adding Historical Events

Session	Date and Time
What's New with iCare?	Wed: 05/28/2008 09:30-11:00 PDT
	Mon: 06/16/2008 10:00-11:30 PDT
	Tues: 07/15/2008 14:00-15:30 PDT
	Thurs: 08/14/2008 13:00-14:30 PDT

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
iCare Nuts and Bolts	Mon 05/19/2008 13:00-15:00 PDT
	Wed 06/11/2008 09:00-11:00 PDT
	Tues 07/01/2008 13:00-15:00 PDT
	Fri 08/08/2008 12:00-14:00 PDT

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
The Practical Use of iCare	Wed 05/21/2008 09:30-11:00 PDT
	Fri 06/13/2008 13:00-14:30 PDT
	Tues 07/02/2008 09:00-10:30 PDT
	Tues 08/12/2008 14:00-15:30 PDT

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
A Brief Introduction to iCare	Tues 06/03/2008 09:00-09:30 PDT
	Wed 06/18/2008 09:30-10:00 PDT
	Mon 07/14/2008 15:00-15:30 PDT
	Fri 08/22/2008 14:00-14:30 PDT

For more information: You may visit the iCare website http://www.ihs.gov/CIO/ca/icare/index.asp

or contact Cindy Gebremariam at: Cynthia.Gebremariam@ihs.gov; (520) 670-4697

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International Health Update - Claire Wendland, Madison, WI

Fistulas and Ethics

When the tissues between a woman’s bladder (or rectum or urethra) and vagina erode as a result of labor complications, she is said to have obstetric fistula disease. Fistulas are very rare in the wealthy world, and when they do occur, are usually a result of cancer surgery or radiation therapy. In the Third World, they are all too common. One often-cited estimate is that two million women worldwide suffer from obstetric fistula, the majority of these in Africa. Women are at risk when they have limited access to good-quality emergency obstetric care, when they are poor, when they are malnourished or of short stature (sometimes associated with teen parenthood, usually associated with chronic malnutrition), or when gender inequalities mean they do not have permission or funds to get help in labor. All of these increase the risk of obstructed labor, in which prolonged pressure from the fetal head against maternal soft tissues sets the stage for fistula – and nearly always for a stillbirth as well. (Female genital mutilation is often cited as leading to fistula too, but while FGM is a matter for serious concern, the data suggests it does not significantly contribute either to obstructed labor or to obstetric fistula.) It’s a socially devastating disorder. Leaking urine or stool or both, women usually are separated from their husbands, often divorced, sometimes considered ritually impure, and sometimes driven out of their communities.

Two articles this month provide hope and caution about obstetric fistula. Wairagala Wakabi updates us on Ethiopia’s efforts to reduce and treat the problem. Ethiopia probably has the world’s best treatment system. Addis Ababa Fistula Hospital, dedicated to this single problem, has been functioning now for over thirty years. With surgeons at work there and in three new branches of the hospital, over 1000 patients are having repairs yearly. But public health officials estimate that for every operated case, nine new cases of fistula appear, many in rural areas where women cannot hope to access treatment. The Ethiopian government, collaborating with transnational funders, is moving more aggressively toward prevention. The focus is improving emergency obstetric care, increasing numbers of midwives trained to ensure that women have the chance to have births attended by someone skilled, and encouraging labor attendants to use the partograph. (Partographs are simple tools used to assess normal and problem labor – if you haven’t seen one, look at http://www.who.int/reproductive-health/impac/Clinical_Principles/figureC10.html.)

Lewis Wall, writing with coauthors including I.H.S. veteran Jeff Wilkinson, adds a note of caution. The plight of women with fistulas is so terrible that many first-world surgeons and gynecologists have done short-term surgery missions to try to address the backlog of untreated cases. Wall and colleagues worry about the ethics of these missions, which may fall short in postoperative care, in treatment of the associated psychosocial problems, and even in the training and operative techniques of the doctors involved. They argue for a code of ethics that puts the best interests of the patient at heart, embeds surgery in programs that treat the whole patient, and – probably most controversially – commits physicians who engage in such missions to work for social justice and the eradication of the inequalities that lead to fistulas in the first place. It’s food for thought.

Wakabi W. Ethiopia steps up fight against fistula. Lancet 371:1493-4, 2008

http://www.ncbi.nlm.nih.gov/pubmed/18459187

Wall LL et al. A Code of Ethics for the fistula surgeon. Int J Gyn Obs 101(1):84-7, 2008

http://www.ncbi.nlm.nih.gov/pubmed/18068168

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MCH Alert

Brief Highlights Key Findings On Breastfeeding in the United States

"Breastfeeding rates in the United States have increased significantly among infants born between 1993-1994 and 2005-2006," state the authors of an April 2008 data brief published by the National Center for Health Statistics. The report summarizes information on breastfeeding rates in the United States based on data from the 1999-2006 National Health and Nutrition Examination Surveys. Results are reported for the total U.S. population and three race-and-ethnicity groups by birth-year cohort.

Overall, the authors found that

In 2005-2006, breastfeeding rates exceeded the Healthy People 2010
goals of 75%
Breastfeeding rates at age 6 months did not achieve the Healthy People
2010 target goal of 50%
Breastfeeding rates were associated with race and ethnicity, maternal
age, and family income status

"These findings underscore the need to continue breastfeeding promotion and intervention activities that target diverse populations," conclude the authors.

McDowell MM, Wang C, Kennedy-Stephenson J. 2008. Breastfeeding in the United States: Findings from the National Health and Nutrition Examination Surveys, 1999-2006. NCHS data briefs, no. 5. Hyattsville, MD: National Center for Health Statistics. http://www.cdc.gov/nchs/data/databriefs/db05.htm .

More information is available from the following MCH Library resource:
http://www.mchlibrary.info/guides/breastfeeding.html

New Edition of Overweight and Obesity Knowledge Path Available

Overweight and Obesity -- Knowledge Path is an electronic guide to recent resources about the prevention, identification, management, and treatment of overweight and obesity in children and adolescents in homes, schools, and communities. The knowledge path, produced by the MCH
Library, contains information on Web sites, publications, databases, and newsletters and online discussion lists. Separate sections identify resources for families, schools and after-school programs, and child care settings. Another section presents resources about the impact of
media use. The knowledge path is available at http://www.mchlibrary.info/KnowledgePaths/kp_overweight.html

MCH Library knowledge paths on other maternal and child health topics
are available at http://www.mchlibrary.info/KnowledgePaths/index.html

Continuing Education Activity Focuses on Cultural and Linguistic Competence in the Diagnosis and Treatment of Depression

Incorporating Cultural and Linguistic Competence in the Diagnosis and Treatment of Depression is an online continuing medical education (CME) activity designed to help primary care physicians improve care for clients from a wide range of racial and ethnic groups who experience depression. The CME activity was developed by the National Center for Cultural Competence with partial support from the Praxis Partnership program, Initiative for Decreasing Disparities in Depression, and the activity is jointly sponsored by the Georgetown University Hospital and
the Georgetown University Center for Child and Human Development. The course provides an opportunity for physicians and other health professionals to assess their awareness, knowledge, and skills in the following six domains: (1) values and belief systems, (2) cultural influences on illness and related problems, (3) depression and health, (4) clinical management, (5) cross-cultural communication, and (6) promotion of cultural and linguistic competence in systems of care and communities. The activity also allows users to develop a personalized plan for future learning. More information is available at http://www.gucchdgeorgetown.net/I3D

To subscribe to MCH Alert, send an e-mail message to MCHAlert-request@list.ncemch.org with SUBSCRIBE in the subject line. You do not need to enter any text in the body of the message.

Web site: http://www.MCHLibrary.info/Alert/default.html

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MCH Headlines - Judy Thierry HQE

New Lead Screening Requirements from CMS

CMS has required for its covered population (and that includes a majority of Native American children) that lead screening is to be completed at 1 year of age and again at 2 years of age. Health literacy materials for professional, child care and lay public can be found at the EPA site.

http://www.epa.gov/lead/pubs/leadpbed.htm

Test your knowledge about lead at http://www.rivcoph.org/cms/leadquiz.htm

If you would like slides or other materials please call upon your area MCH coordinator, Steve Holve (Peds CCC), or Judy Thierry (National MCH Coordinator). We can put you in contact with the EPA who is holding several tribal conferences on child environmental health and lead awareness workshops. Montana Wyoming Tribal Leaders are also conducting a training in May and a conference in June.

The following are excerpts from a monthly newsletter of Children and Youth Programs:
Preventing Youth Suicide in Rural America: Recommendations to States; April 2008

Prepared by the Rural Youth Suicide Prevention Workgroup Convened by the Suicide Prevention Resource Center (SPRC), Education Development Center (EDC), and the State & Territorial Injury Prevention Directors Association (STIPDA) Even after two decades of decreasing youth suicide rates, suicide remains the third leading cause of death among youth between the ages of 10 and 24. Moreover, declines are not evenly distributed; in 15 states, youth suicide rates remain as high as or even higher than the 20-year peak of 9.36 suicides per 100,000. Western and mountain states consistently have higher suicide rates than the rest of the country, and all of the states with the highest suicide rates have many counties that would meet most definitions of “rural” – that is, with very low population density and residents living in relatively small communities, separated by vast landscapes. Small rural communities may be better prepared to launch prevention efforts because their social and economic infrastructures are well integrated and community members are linked to one another in ways that may be less common in urban areas. However, these same strengths can turn into barriers when small communities lack the resources, access to care, and privacy or anonymity that larger communities may offer. This report presents recommendations that approach youth suicide prevention through the lens of America’s rural communities, so that both the strengths and limitations of rural settings can be taken into account to design and implement more effective prevention strategies. The report is available at: http://www.sprc.org/library/ruralyouth.pdf .

Suicide Prevention Program Planning and Evaluation Resources

Suicide Prevention Resource Center (SPRC)

The Suicide Prevention Resource Center (SPRC) has developed a number of suicide prevention program planning and evaluation resources, including the following:

Taking Action: Resources for Effective Suicide Prevention Programs http://www.sprc.org/taking_action/index.asp
Plan Your Strategy: Planning and Implementing Your Program

http://www.sprc.org/taking_action/plan.asp

Planning and Evaluation for Youth Suicide Prevention (free online workshop)

http://training.sprc.org/

Evaluating Your Program

http://www.sprc.org/taking_action/evaluate.asp

Native HOPE (Helping Our People Endure) Youth Training Manual (Suicide Prevention)

Suicide Prevention Resource Center (SPRC)

This curriculum is based on the theory that suicide prevention can be successful in Indian Country by native youth being committed to breaking the “Code of Silence” prevalent among all youth. This program is also premised on the foundation of increasing “strengths” as well as warning-signs awareness of suicide among native youth. The program supports the full inclusion of Native Culture, traditions, spirituality, and humor.

The cover & index may be viewed at: http://www.oneskycenter.org/education/documents/NativeHOPEYouthTrainingManualCoverandIndex.pdf .

The complete youth training manual is available at: http://www.oneskycenter.org/education/documents/NativeHope3-DayManual_000.pdf .

A facilitators’ training manual is available at:

http://www.oneskycenter.org/education/documents/NativeHOPETOF2-DayM98D_002.pdf /

Free Anti-Meth Training Through Lamar Associates

Lamar Associates will offer free training opportunities in each of the six geographical regions used by the Bureau of Indian Affairs Office of Justice Services in addition to an in-depth online training program. The training will reflect cultural understanding and sensitivity and equip course participants with the critical organizational skills they need to respond to meth use in their communities. Lamar Associates is a 100 percent American Indian-owned small business with an intimate understanding of the challenges facing Indian Country. The company has been awarded a grant by the U.S. Department of Justice (DOJ) to provide onsite and online training.

Upcoming Training Dates :
June 9-10, 2008 - Reno, NV
July 21-22, 2008 - Spokane, WA
August 18-19, 2008 - San Diego, CA
October 27-28, 2008 - Minneapolis, MN
January 12-13, 2009 - Oklahoma City, OK
February 9-10, 2009 - Hollywood, FL

Further information about this program is available at:

http://indiancountryanti-meth.webexone.com/login.asp?loc=&link=

Surveillance for Violent Deaths – National Violent Death Reporting System, 16 States, 2005 (April 2008)

An estimated 50,000 persons die annually in the United States as a result of violence-related injuries. This report summarizes data from CDC's National Violent Death Reporting System (NVDRS) regarding violent deaths from 16 U.S. states for 2005. Results are reported by sex, age group, race/ethnicity, marital status, location of injury, method of injury, circumstances of injury, and other selected characteristics. For 2005, a total of 15,495 fatal incidents involving 15,962 violent deaths occurred in the 16 NVDRS states included in this report. The majority (56.1%) of deaths were suicides, followed by homicides and deaths involving legal interventions (29.6%), violent deaths of undetermined intent (13.3%), and unintentional firearm deaths (0.7%). Fatal injury rates varied by sex, race/ethnicity, age group, and method of injury. Rates were substantially higher for males than for females and for American Indians/Alaska Natives (AI/ANs) and blacks than for whites and Hispanics. Rates were highest for persons aged 20--24 years. For method of injury, the three highest rates were reported for firearms, poisonings, and hanging/strangulation/suffocation. Suicides occurred at higher rates among males, AI/ANs, whites, and older persons and most often involved the use of firearms in the home. Suicides were precipitated primarily by mental illness, intimate partner or physical health problems, or a crisis during the previous 2 weeks. Homicides occurred at higher rates among males and young adult blacks and most often involved the use of firearms in the home or on a street/highway. Homicides were precipitated primarily by an argument over something other than money or property or in conjunction with another crime. Similar variation was reported among the other manners of death and special situations or populations highlighted in this report. For more information, see: http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5703a1.htm

For further information about receiving this full newsletter, please contact Judy Thierry at judith.thierry@ihs.gov

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Medical Mystery Tour

A diabetic patient who is finally losing weight

A 21 year old G1 P0 presents with persistent nausea and vomiting for 7 weeks. The patient was diagnosed with type 2 diabetes 4 years ago and has had fair control with and an oral hypoglycemic agent. She stopped her hypoglycemic when she learned she was pregnant. Her glucose has been well controlled with diet and exercise during her pregnancy. The patient has a history of migraine that often presents with concomitant nausea.

Exam reveals a 7 % loss from her pre-pregnancy body weight which she states was without trying to lose weight. Otherwise the patient’s fundus is palpable 3 fingers breath below her umbilicus.

Laboratory evaluation reveals no evidence of urinary tract infection, but she does have ketonuria.

Ultrasound confirms a single 16 week female fetus with normal amniotic fluid and a Grade I anterior fundal placenta.

A diabetic losing is a good thing, right?

Pregnancy is not an ideal time for weight loss. Significant weight loss should be confined to the preconception and postpartum periods. Ketosis is associated with a high fetal mortality rate. Ketonemia may have adverse developmental effects as well.

What do you think is happening? How can you help this patient?

Morning sickness and hyperemesis gravidarum are terms used to describe mild versus severe nausea and vomiting induced by pregnancy.

Morning sickness - Some degree of nausea with or without vomiting occurs in 50 to 90 percent of all pregnancies. The mean onset of symptoms is at five to six weeks of gestation, peaking at nine weeks, and usually abating by 16 to 18 weeks of gestation; however, symptoms continue until the third trimester in 15 to 20 percent of gravida and until delivery in 5 percent. Although the lay term for mild pregnancy-related nausea and vomiting is "morning sickness," the symptoms may occur at any time of day and often (80 percent) persist throughout the day. Interestingly, women with mild nausea and vomiting during pregnancy experience fewer miscarriages and stillbirths than women without these symptoms. In one meta-analysis, the odds of miscarriage in women with nausea and vomiting in the first 20 weeks of pregnancy was OR 0.36 (95% CI 0.2-0.42).

Hyperemesis gravidarum - Hyperemesis gravidarum is considered the severe end of the spectrum of nausea and vomiting, although there is no clear demarcation between common pregnancy-related "morning sickness" and the infrequent pathologic disorder. An objective definition of hyperemesis that is often used is persistent vomiting accompanied by weight loss exceeding 5 percent of pre-pregnancy body weight and ketonuria unrelated to other causes. The incidence of woman with severe symptoms is not well-documented; reports vary from 0.3 to 2 percent. Ethnic differences and differences in the definition of the disease may account, in part, for this variability. Hyperemesis tends to improve in the last half of pregnancy, but may persist until delivery. If vomiting persists beyond a few days postpartum, other etiologies should be investigated.

The pathogenesis of hyperemesis is unknown. The predominant theories that have been proposed are described below.

Psychologic factors - Two general theories are that hyperemesis reflects (1) a conversion or somatization disorder or (2) a response to stress. In particular, a feeling of ambivalence about the pregnancy has been offered as an etiologic or contributing factor. However, no study has definitively demonstrated that the psychologic makeup of patients with hyperemesis gravidarum differs from those without the disorder, although the psychological response to persistent nausea and vomiting may exacerbate symptoms.

Hormonal changes - No single hormonal profile can accurately predict the presence of hyperemesis gravidarum. Elevated serum concentrations of estrogen and progesterone have long been implicated in the pathogenesis of this disorder. Although several lines of evidence support a role, especially for estrogen, the fact that sex hormone levels peak in the third trimester, long after symptoms of hyperemesis gravidarum have typically resolved, is inconsistent with this theory.

By comparison, serum concentrations of human chorionic gonadotropin (hCG) peak during the first trimester, the time when hyperemesis gravidarum is typically seen. The observation that serum hCG concentration is higher in women with hyperemesis than in other pregnant women also supports a possible etiologic role for this hormone. In addition, their hCG has more thyroid-stimulating activity because more of it is desialyated. An increased prevalence of hyperemesis in women with gestational trophoblastic disease, which is characterized by very high hCG levels, has been well-described. Nevertheless, an association between hCG levels and hyperemesis gravidarum has not been firmly established.

-Abnormal gastric motility - Gastric motility may be abnormal (delayed or dysrhythmic) in hyperemesis gravidarum. Studies addressing motility disturbances have shown conflicting results, suggesting that these abnormalities are not highly predictive of the disease.

Women with diabetes may have gastroparesis.

-Other - Several other theories to explain hyperemesis have been suggested, including specific nutrient deficiencies (e.g., zinc), alterations in lipid levels, changes in the autonomic nervous system, genetic factors, and infection with Helicobacter pylori . None is consistently associated with or highly predictive of the disease.

Risk Factors - Studies of risk factors for hyperemesis gravidarum have generally included only a small number of affected women, and results have not been definitive. Non-pregnant women who experience nausea and vomiting after estrogen exposure, from motion sickness, with migraine, or with exposure to certain tastes (supertasters) are more likely to have pregnancy-related nausea and vomiting. In contrast, anosmic women appear to be at low risk for this disorder. Psychiatric illness and pregestational diabetes are other purported risk factors, but these are controversial. Interestingly, studies have consistently shown a preponderance of female fetuses among pregnancies complicated by hyperemesis.

Advanced maternal age (age >35) and cigarette smoking (perhaps due to the effect of nicotine) appear to be protective.

Clinical Course : Hyperemesis gravidarum is a clinical diagnosis, without uniform criteria. As discussed above, the diagnosis can be made in a woman with persistent vomiting, weight loss exceeding 5 percent of pre-pregnancy body weight, and ketonuria beginning in the first trimester, after other causes have been excluded. The onset of symptoms is typically at 4 to 10 weeks of gestation. Hospitalization rates peak at about nine weeks, then fall, plateauing at around 20 weeks of gestation. Abdominal pain is infrequent.

Laboratory abnormalities - Laboratory abnormalities may or may not be present:

Electrolyte derangements, such as hypokalemia and metabolic alkalosis.

An increase in hematocrit, indicating hemoconcentration due to plasma volume depletion. The degree of hemoconcentration may be underestimated unless the physiologic decline in hematocrit seen in normal pregnancies is considered.

Abnormal liver enzyme values occur in approximately 50 percent of patients who are hospitalized with hyperemesis. The most striking abnormality is an increase in serum aminotransferases. Alanine aminotransferase (ALT) is typically elevated to a greater degree than aspartate aminotransferase (AST). Values for both are typically only mildly elevated, e.g. in the low hundreds, and rarely as high as 1000 U/L. Hyperbilirubinemia also can occur, but rarely exceeds 4 mg/dL. Serum amylase and lipase may increase as much as five-fold (as opposed to a 5 to 10-fold increase in acute pancreatitis) and are of salivary rather than pancreatic origin. The degree of abnormality in liver tests correlates with the vomiting; the highest elevations are seen in patients with the most severe or protracted vomiting. Abnormal liver biochemical tests resolve promptly upon resolution of the vomiting.

Mild hyperthyroidism, possibly due to high serum concentrations of human chorionic gonadotropin which has thyroid-stimulating activity. One report noted low serum TSH concentrations more often in women with hyperemesis gravidarum than in normal pregnant women; TSH was suppressed in 60 percent of hyperemesis patients versus 9 percent of controls. Some of these women had elevated serum free T4 concentrations and therefore met the definition of hyperthyroidism.

Features that distinguish the transient hyperthyroidism of hyperemesis gravidarum from hyperthyroidism of other causes (which in a pregnant woman is most likely to be due to Graves' disease) are the vomiting, absence of goiter and ophthalmopathy, and absence of the common symptoms and signs of hyperthyroidism (heat intolerance, muscle weakness, tremor). In addition, serum free T4 concentrations are only minimally elevated and serum T3 concentrations are not elevated in women with hyperemesis gravidarum, whereas both are usually unequivocally elevated in pregnant women with true hyperthyroidism. Treatment of hyperthyroidism should not be undertaken without clear evidence of a primary thyroid disorder (e.g., goiter, elevated free thyroid hormone or elevated TSH receptor antibody levels).

Hypercalcemia due to hyperparathyroidism. This is uncommon, but should be considered as hypercalcemia may contribute to the vomiting.

DIAGNOSTIC EVALUATION - The standard initial evaluation of pregnant women with persistent vomiting includes measurement of weight, orthostatic blood pressures, serum free T4 concentration, serum electrolytes, and urine ketones. An ultrasound examination is performed to exclude gestational trophoblastic disease and multiple gestation, both of which are associated with hyperemesis.

Given the characteristic clinical manifestations of hyperemesis gravidarum, a liver biopsy is not needed in women with abnormal liver function tests to exclude other causes for the laboratory findings. When a liver biopsy has been performed, it was either normal or showed nonspecific findings. Inflammation was absent, but necrosis with cell drop out, steatosis centrilobular vacuolization, and rare bile plugs have been seen. These changes help to explain the mechanism for the liver test abnormalities.

Differential diagnosis - Hyperemesis is generally a diagnosis of exclusion, based on its first occurrence in early in pregnancy, with gradual resolution over weeks to months. Nausea and vomiting that develop after 10 weeks of gestation are not likely due to hyperemesis gravidarum. The presence of associated symptoms, such as abdominal pain, fever, headache, goiter, abnormal neurologic findings, diarrhea, constipation, or hypertension, also suggests another diagnosis is likely; many conditions unrelated to pregnancy can cause persistent nausea and vomiting.

Preeclampsia, HELLP syndrome (Hemolysis, Elevated Liver function tests, Low Platelets), and fatty liver of pregnancy are also causes of pregnancy-related nausea and vomiting, but onset is typically in the latter half of pregnancy.

What are some of the treatment options for this patient?

If conservative measures are successful, does a PICC line facilitate treatment of hyperemesis gravidarum?

See next month’s Medical Mystery Tour for the answers

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Medscape*

Guidelines Issued for Medical Care of Pregnant Women With Preexisting Diabetes, CME/CE
http://www.medscape.com/viewarticle/573917

APHA 2007: Focus on Women's Health CME/CE
http://www.medscape.com/viewprogram/12595

The Skinny on Weight Loss Supplements: Fact or Fantasy? CME/CE
http://www.medscape.com/viewarticle/574182

Cultural Competency in Healthcare: A Clinical Review and Video Vignettes from the National Medical Association CME/CE
http://www.medscape.com/viewprogram/12540

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.

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Menopause Management

Gabapentin for the treatment of menopausal hot flashes: a randomized controlled trial

OBJECTIVE: To compare the effectiveness and tolerability of gabapentin with placebo for the treatment of hot flashes in women who enter menopause naturally.
DESIGN: A randomized, double-blind, placebo-controlled trial was conducted across the greater Toronto area between March 2004 and April 2006 in the community and primary care settings. Eligible participants were 200 women in natural menopause, aged 45 to 65 years, having at least 14 hot flashes per week. Study participants were randomized to receive gabapentin 300 mg oral capsules or placebo three times daily for 4 weeks. The primary outcome measure was the mean percentage change from baseline to week 4 in daily hot flash score, determined from participant diaries. Secondary outcome measures included changes in weekly mean hot flash scores and frequencies, quality of life, and adverse events.
RESULTS: Of the 197 participants, 193 (98%) completed the study. Analysis was by intention to treat. Hot flash scores decreased by 51% (95% CI: 43%-58%) in the gabapentin group, compared with 26% (95% CI: 18%-35%) on placebo, from baseline to week 4. This twofold improvement was statistically significant (P < 0.001). The Menopause-Specific Quality-of-Life vasomotor score decreased by 1.7 (95% CI: 1.3-2.1; P < 0.001) in the gabapentin group. These women reported greater dizziness (18%), unsteadiness (14%), and drowsiness (12%) at week 1 compared with those taking placebo; however, these symptoms improved by week 2 and returned to baseline levels by week 4.

CONCLUSION: Gabapentin at 900 mg/day is an effective and well-tolerated treatment for hot flashes.

Butt DA et al. Gabapentin for the treatment of menopausal hot flashes: a randomized controlled trial, Menopause. 15(2):310-318, March/April 2008.

http://www.ncbi.nlm.nih.gov/pubmed/17917611

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Midwives Corner - Lisa Allee, CNM, 4 Corners Regional Health Center, Red Mesa, AZ

Midwives Gathering: Historical, Momentous, and Amazing

Wow, wow, wow! The Invitational Gathering on North American Indigenous Birthing and Midwifery happened this past week, May 5-8, in Rockville, MD at IHS headquarters and the ripple effects of this gathering are going to fan out in an ever widening wave that is going to rock our world! Aspects of various movements—women reclaiming birth, midwifery, honoring of elders, awakening to remember and honor ancient ways, rising up of indigenous peoples--that have been going on for years intersected at this gathering and the energy of this merging is going to move us onwards at an ever increasing pace. There were representatives from Canada, the US, and Mexico. There were two of the Grandmothers from The International Council of Thirteen Indigenous Grandmothers (www.grandmotherscouncil.com). There were icons of midwifery and natural birthing—Ina May Gaskin and Robbie Davis-Floyd. There were representatives of the variety of routes to midwifery in all three countries—apprentice, midwifery school, and nurse midwifery. There were policy makers, researchers, educators and advocates. The group was dynamic, enthusiastic, and strong. The message was loud and clear: midwifery is an essential and integral part of quality health care and increasing the number of indigenous midwives and the number of midwives with knowledge of indigenous midwifery will serve to take that quality higher and higher. Here are some tidbits from the gathering:

Where we are now:

Canada : Federal Government gives open, explicit support to midwifery being an integral part of health care. Not all provinces have legislation for midwifery yet. There are several indigenous midwifery training programs that effectively combine ancient knowing and modernity. There is great acceptance of a variety of birth settings and midwives have to demonstrate competence in all of them—home, birth centre, and hospital. There has been a realization that the policy of “evacuation” of northern pregnant women to southern cities has been detrimental to women, babies, families and communities. Some northern communities have or are beginning to reclaim birth.
Mexico : The Ministry of Health has begun to realize the value of the indigenous midwives of Mexico and has begun a program of certification. There have been educational exchanges between indigenous midwives and obstetricians/ministry of health personnel and a program focusing on the value of birthing in vertical positions. This has been called the intercultural model.
US: The number of midwives and midwife-attended births continue to steadily grow. Midwives are integral to IHS in most areas, but not all. There are a variety of routes to becoming a midwife in this country from no degree to a PhD and many midwifery training programs, but none that have indigenous midwifery as an integral part of the curriculum, yet.

Ideas for the future:

Canada : Continue and expand the work of “Bringing Birth Closer to Home” so northern women can return to birthing closer to family and community. Create more indigenous midwifery training programs. Midwifery legislation for every province and addressing indigenous midwifery effectively in that legislation.
Mexico : Continue the process of recognizing indigenous midwives and moving towards supporting them financially. Continue to spread the intercultural model and the humanization of health care during pregnancy, birth and postpartum.
US: Expand the types of midwives employed by IHS to include CMs, CPMs, and other direct-entry prepared midwives. Then Native women and men interested in becoming midwives would have the option of all the routes to midwifery and be assured of employment as midwives in their communities. This will make midwifery education and practice more accessible to more Native people both as midwives and as patients. Start “grow your own” indigenous midwifery training programs in various areas that would gestate midwives in the traditional midwifery paradigms of the people of that area combined with the current art and science of midwifery. Expand the birth setting options provided by IHS to include birth centers and home—these settings have been shown to be as safe as and have advantages over hospital and Native Americans deserve to have the birth setting options available to the rest of the US population.

Collaborative ideas between the countries of North America:

Professional and educational exchanges.
Development of a common minimum data set to collect data regarding indigenous midwifery and birthing, May be based on the Optimality Index.
Continuing the wonderfully effective networking that was begun this week.
Support, help, and encourage each other to provide exceptional midwifery care to indigenous women and families, spread the wisdom and knowing of indigenous midwifery and increase the numbers of indigenous midwives.

Some impressive numbers:

90% of midwife attended births in Quebec are out of hospital.
There are 24 US states with direct entry midwifery legislation already and 11 are working on it this year.
The CPM (certified professional midwife) study showed 92% of the births were at home or in a birth center, there was an 8% transfer rate and only 2% were emergencies, planned home births had no added risk.
At Six Nations Birthing Centre ( Canada) they have a medicine person on staff who sees 90% of the patients.
The Farm Midwifery Center (US) had a 0.5% C-section rate in the first 400 births and their current rate is 2%. Breastfeeding initiation is 99% and 98% at 6 months.
Nunavik Birth Centre (northern Canada) has had a 1.3% c-section rate for the last 5-6 years and no maternal deaths.

A few of the many pearls spoken at the gathering:

Nothing comes to you for no reason. Whatever you do, do your best.
Take out the boundaries between our countries they weren’t there to begin with.
Pregnancy is not an illness.
Midwives are normal childbirth experts and facilitate normal birth.
We must be ourselves wherever we go.
Train the youth—train the future grandmothers, train the future midwives.
Be aware of colonization mentality—it affects us all and can be very subtle and so ingrained that it is easy to miss….if we doubt and mistrust each other we can never come together.

For further information about this conference, please contact judith.thierry@ihs.gov

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Navajo News - Jean Howe, Chinle

Sexual Assault Nurse Examiner (SANE) Training Course, June 9 – 13, 2008, Navajo Nation Museum, Window Rock, Arizona.

This 5-day intensive training course will focus on the basic forensic medical examination techniques and issues in providing care for adult and adolescent victims of sexual assault. It will provide nurses and other licensed healthcare professionals with the didactic training necessary for certification as a Sexual Assault Nurse Examiner (SANE) or a Sexual Assault Forensic Examiner ( SAFE) and discuss next steps after training. Strategies for developing a multi-disciplinary Sexual Assault Response Team (SART) will also be reviewed.

This course provides the classroom curriculum portion of SANE/ SAFE training. For nurses or other healthcare professionals who do not routinely perform pelvic examinations, practical experience to acquire pelvic examination skills should be arranged outside of this course. It would be beneficial to begin this process prior to attending the course if possible. After completion of the course, proctoring is also strongly recommended for the initial forensic examinations performed.

This course is open to Indian Health Service healthcare professionals, including nurses, advanced practice nurses, PAs, and physicians. A brochure and registration forms will be available soon, as well as information on lodging. There is no fee to attend the course. Transportation, lodging, and per diem are the responsibility of the home health system or individual.

This course is being co-sponsored by Carolyn Aoyama, Senior Consultant for Women’s Health and Advanced Practice Nursing Program at IHS Headquarters and by the Chinle Family Violence Prevention Task Force and the Navajo-Hopi-Zuni SANE/SART Work Group. For questions about content, please contact Sharon Jackson (Sharon.jackson@ihs.gov) or Sandra Dodge (Sandra.dodge@ihs.gov). For questions about registration or logistics, please contact Alberta Gorman (Alberta.gorman@ihs.gov).

IHS and Tribal sites throughout the Four Corners area are working with the Northern Arizona Center Against Sexual Assault to formulate an integrated approach to sexual assault. This training is a part of that effort. The goal is to have SANE and SART services available throughout the Four Corners area.

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Nurses Corner - Sandra Haldane, HQE

Medscape: No Relief for U.S. Nursing Shortage
http://www.medscape.com/viewarticle/574501

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Office of Women's Health, CDC

Availability of Cefixime 400 mg Tablets - United States , April 2008

Availability of cefixime (for the treatment of N. gonorrhoeae infections) had been limited since July 2002, when Wyeth Pharmaceuticals ( Collegeville, Pennsylvania) discontinued manufacturing cefixime tablets in the United States. Beginning in April 2008, cefixime (Suprax ®) 400 mg tablets are again available in the United States.

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5716a5.htm?s_cid=mm5716a5_e

Information on obtaining cefixime is available from Lupin by telephone (866-587-4617). Guidance on treatment of N. gonorrhoeae infections and updates on the availability of recommended antimicrobials are available from CDC at http://www.cdc.gov/std/treatment

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Oklahoma Perspective Greggory Woitte – Hastings Indian Medical Center

Meet Dr. George Chiarchiaro, Oklahoma MCH Coordinator

Dr. George Chiarchiaro attended the University of California at Long Beach and graduated from Georgetown University School of Dentistry in 1978. He spent a brief time in the private practice of dentistry and entered the Indian Health Service in 1980. After serving four years as dental chief, clinical director, and health systems administrator on the Rocky Boys Reservation, Dr. Chiarchiaro transferred to Gallup Indian Medical Center to enter a Dental Advanced General Practice Residency. In 1997 Dr. Chiarchiaro received his Master of Health Administration from the University of Oklahoma Health Sciences Center.

George Chiarchiaro, DDS, MHA
Consultant for Dental, Medical Imaging, and MCH
Division of Health Care Systems
Oklahoma City Area IHS
Five Corporate Plaza,
3625 NW 56th Street,
Oklahoma City, OK 73112

Phone: (405) 951-3818
Fax: (405) 951-3916
Cell: (405) 204-7664

George.Chiarchiaro@ihs.gov

Oklahoma MCH Coordinator Website

http://www.ihs.gov/MedicalPrograms/MCH/F/MCHC07.cfm

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Osteoporosis

Screening for osteoporosis in men: a systematic review for an American College of Physicians guideline.

BACKGROUND: Screening for low bone mineral density (BMD) by dual-energy x-ray absorptiometry (DXA) is the primary way to identify asymptomatic men who might benefit from osteoporosis treatment. Identifying men at risk for low BMD and fracture can help clinicians determine which men should be tested.

PURPOSE: To identify which asymptomatic men should receive DXA BMD testing, this systematic review evaluates 1) risk factors for osteoporotic fracture in men that may be mediated through low BMD and 2) the performance of non-DXA tests in identifying men with low BMD. DATA SOURCES: Studies identified through the MEDLINE database (1990 to July 2007). STUDY SELECTION: Articles that assessed risk factors for osteoporotic fracture in men or evaluated a non-DXA screening test against a gold standard of DXA.

DATA EXTRACTION: Researchers performed independent dual abstractions for each article, determined performance characteristics of screening tests, and assessed the quality of included articles.

DATA SYNTHESIS: A published meta-analysis of 167 studies evaluating risk factors for low BMD-related fracture in men and women found high-risk factors to be increased age (>70 years), low body weight (body mass index <20 to 25 kg/m2), weight loss (>10%), physical inactivity, prolonged corticosteroid use, and previous osteoporotic fracture. An additional 102 studies assessing 15 other proposed risk factors were reviewed; most had insufficient evidence in men to draw conclusions. Twenty diagnostic study articles were reviewed. At a T-score threshold of -1.0, calcaneal ultrasonography had a sensitivity of 75% and specificity of 66% for identifying DXA-determined osteoporosis (DXA T-score, -2.5). At a risk score threshold of -1, the Osteoporosis Self-Assessment Screening Tool had a sensitivity of 81% and specificity of 68% to identify DXA-determined osteoporosis.

LIMITATION: Data on other screening tests, including radiography, and bone geometry variables, were sparse.

CONCLUSION: Key risk factors for low BMD-mediated fracture include increased age, low body weight, weight loss, physical inactivity, prolonged corticosteroid use, previous osteoporotic fracture, and androgen deprivation therapy. Non-DXA tests either are too insensitive or have insufficient data to reach conclusions.

Liu H, et al, Screening for osteoporosis in men: a systematic review for an American College of Physicians guideline. Ann Intern Med. 2008 May 6;148(9):685-701.

http://www.ncbi.nlm.nih.gov/pubmed/18458282

Guidelines Issued for Screening Men for Osteoporosis, CME

http://www.medscape.com/viewarticle/573982

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Patient Information

Physical Activity: What You Should Know

American Family Physician . Leawood: Apr 15, 2008. Vol. 77, Iss. 8; pg. 1138

http://www.aafp.org/afp/20080415/1138ph.html

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Perinatology Picks - George Gilson, Maternal Fetal Medicine, ANMC

Who returns for postpartum glucose screening following gestational diabetes mellitus?

OBJECTIVE: The objective of the study was to determine the prevalence of postpartum impaired glucose regulation (IGR) and factors associated with glucose screening following gestational diabetes mellitus (GDM)

STUDY DESIGN: This was a prospective cohort study of 707 women with GDM who delivered at the University Hospital ( San Antonio, TX).

RESULTS: A total of 35.5% of 400 women with any postpartum glucose testing had IGR postpartum, and 40.6% of 288 women who completed an oral glucose tolerance test had IGR, one-third of whom had isolated elevated 2-hour glucose levels. Women who failed to return for postpartum glucose testing (n = 307) were more likely to report prior GDM, have higher diagnostic glucose levels, and require insulin during pregnancy than women who returned for postpartum glucose testing.

CONCLUSION: Women who returned for postpartum glucose testing had less severe GDM than women who failed to return, suggesting that the true prevalence of postpartum IGR may be even higher than identified in our population.

Hunt KJ, Conway DL. Who returns for postpartum glucose screening following gestational diabetes mellitus? Am J Obstet Gynecol 2008;198:404.e1-404.e6.

http://www.ncbi.nlm.nih.gov/pubmed/18241820

Body mass index and weight gain prior to pregnancy and risk of gestational diabetes mellitus

OBJECTIVE: The objective of the study was to evaluate obesity and rate of weight change during the 5 years before pregnancy and risk of gestational diabetes mellitus (GDM) in a nested case-control study.

STUDY DESIGN: GDM cases (n = 251) and controls (n = 204) were selected from a multiethnic cohort of 14,235 women who delivered a live birth between 1996 and 1998. Women who gained or lost weight were compared with those with a stable weight (± 1.0 kg/year).

RESULTS: Women who gained weight at a rate of 1.1 to 2.2 kg/year had a small increased risk of GDM (odds ratio [OR] 1.63 [95% confidence interval (CI) 0.95 to 2.81]) and women who gained weight at a rate of 2.3 to 10.0 kg/year had a 2.5-fold increased risk of GDM (OR 2.61 [95% CI, 1.50 to 4.57]), compared with women with stable weight (after adjusting for age, race-ethnicity, parity, and baseline body mass index).

CONCLUSION: Weight gain in the 5 years before pregnancy may increase the risk of GDM.

Hedderson MM, Williams MA, Holt VL, et al. Body mass index and weight gain prior to pregnancy and risk of gestational diabetes mellitus. Am J Obstet Gynecol 2008;198:409.e1-409.e7.

http://www.ncbi.nlm.nih.gov/pubmed/18068138

Fetal outcome in motor-vehicle crashes: effects of crash characteristics and maternal restraint

OBJECTIVE: This project was undertaken to improve understanding of factors associated with adverse fetal outcomes of pregnant occupants involved in motor-vehicle crashes.

STUDY DESIGN: In-depth investigations of crashes involving 57 pregnant occupants were performed. Maternal and fetal injuries, restraint information, measures of external and internal vehicle damage, and details about the crash circumstances were collected. Crash severity was calculated using vehicle crush measurements. Chi-square analysis and logistic regression models were used to determine factors with a significant association with fetal outcome.

RESULTS: Fetal outcome is most strongly associated with crash severity (P < .001) and maternal injury (P = .002). Proper maternal belt-restraint use (with or without airbag deployment) is associated with acceptable fetal outcome (odds ratio = 4.5, P = .033). Approximately half of fetal losses in motor-vehicle crashes could be prevented if all pregnant women properly wore seat belts.

CONCLUSION: Higher crash severity, more severe maternal injury, and lack of proper seat belt use are associated with a higher risk of adverse fetal outcome. These results strongly support recommendations that pregnant women use properly positioned seatbelts.

Klinich KD, Flannagan CAC, Rupp JD, et al. Fetal outcome in motor-vehicle crashes: effects of crash characteristics and maternal restraint. Am J Obstet Gynecol 2008;198:450.e1-450.e9.

http://www.ncbi.nlm.nih.gov/pubmed/18395036

Vaginal birth after cesarean: clinical risk factors associated with adverse outcome

OBJECTIVE: The objective of the study was to identify vaginal birth after cesarean (VBAC) success rates and maternal and neonatal complication rates for selected antenatal conditions.

STUDY DESIGN: This was a population-based cohort study using administrative discharge data for women delivering in California hospitals during 2002.

RESULTS: Among 41,450 women, 29.72% (12,320 of 41,450) had maternal, fetal, or placental conditions complicating pregnancy. Attempted VBAC rates and VBAC success rates varied widely by these clinical condition, ranging from 10% to 73%. The VBAC success rate for low-risk women (no conditions) was 73.76% vs 50.31% for high-risk women (at least 1 condition), P < .0001. Absolute rates of maternal and neonatal complications were low (less than 1-2%), and the rate of adverse events was higher in the high-risk clinical group as compared with the low-risk clinical group.

CONCLUSION: Variation in rates of VBAC success and childbirth morbidities can be partially attributed to clinical factors complicating pregnancy. Women without such conditions show improved VBAC success and fewer maternal and neonatal complications.

Gregory KD, Korst LM, Fridman M, et al. Vaginal birth after cesarean: clinical risk factors associated with adverse outcome. Am J Obstet Gynecol 2008;198:452.e1-452.e12.

http://www.ncbi.nlm.nih.gov/pubmed/18395037

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Primary Care Discussion Forum - Ann Bullock, Cherokee, NC

The conclusion of the adolescent behavioral health on-line discussion:

This month’s discussion on adolescent behavioral health will be terminated prematurely due to the non-negotiable demands of Spring Break – certainly an imperative that all self-respecting adolescents would endorse enthusiastically.

I hope that the case discussed shed at least some light on issues bearing on the diagnosis and management of behavioral health disorders in adolescents. Precision in psychiatric diagnosis of children and teens is problematic to say the least. A major proportion of drug prescriptions in this population are off-label, which is perhaps appropriate, as I am not sure we have an exact label for many struggling kids. Many DSM diagnoses are derived from adult criteria, and often fail to encompass the nuances of child and adolescent disorders. No better example exists than the diagnosis of PTSD, which works pretty well when applied to an adult after a discrete trauma, but doesn’t capture the wide spectrum of behavioral and emotional responses we see in children exposed to early life stress, whether chronic or acute. Adult derived criteria for bipolar disorder, major depression, and even substance abuse all leave room for “diagnostic orphans”, and conversely, can stretch-to-fit some youth who may not meet the classic definition, but need help nevertheless.

As many of you know, the diagnosis of bipolar disorder in youth has increased dramatically in recent years – actually by 40-fold, according to the Archives of General Psychiatry. (1) This seems a bit excessive. I think we now have more kids in this country who are bipolar than bilingual, which is a sad indictment of both our educational system and our behavioral health care non-system. If you look at these pediatric bipolar cases, they are overwhelmingly boys, overwhelmingly young (median age in one study, 12.8), and overwhelmingly co-diagnosed with some classic non-zebra-like animals, such as ADHD, Oppositional Defiant Disorder, and Substance Use Disorders. Bipolar disorder is no longer a discrete diagnosis; it’s a right of passage for troubled youth. However much this trend may corrupt diagnostic purity while enhancing the ROI for pharmaceutical companies, I think it may be even more problematic in Indian Country. There is a fair amount of evidence from the research that Western/Caucasian-derived classification schemes for behavioral health don’t “fit” well at all with Native American conceptualizations of mental and emotional dysfunction. Add this factor to the difficulties with DSM criteria for youth in general, and throw in the reality that in psychiatry one would be hard pressed to declare one symptom, sign, or lab or imaging test as pathognomonic for any condition – well, it is easy to see how difficult it can be to achieve diagnostic clarity with Native American adolescents amidst such chaos.

We always need to remember that we in IHS are dealing with a population that has been subjected to massive amounts of psychosocial deprivation. It is well demonstrated that kids who grow up in such circumstances are far more likely to exhibit signs and symptoms of emotional dysregulation, disruptive behavior disorders, ADHD, substance use disorders, and the whole gamut of psychiatric disorders – whatever the formal diagnosis may entail. Given the complexities and controversies in medication management for these youth, the primary care provider needs to develop a feel for when and how to refer teens and their families to specialty care. And although child and adolescent psychiatrists are in extremely short supply in IHS, thankfully we have a few, and have attracted more in recent years. Most adult psychiatrists – particularly if they’ve been in IHS for a while – do the best we can, and inevitably acquire a lot of experience with youth. The American Academy of Child and Adolescent Psychiatry has published guidelines for referral (link below):

http://www.aacap.org/cs/root/physicians_and_allied_professionals
/when_to_seek_referral_or_consultation_with_a_child_and_adolescent_psychiatrist

At any rate, primary care providers do have a major therapeutic role to play beyond referral. As was discussed earlier this month, attachment deficits are central to traumatized youth. Building on family and other interpersonal relationships is key, and encouraging participation in community activities (Boys and Girls Clubs, Big Brothers, Big Sisters, athletic activities), or organizing, mentoring or participating ourselves in these programs helps rectify attachment deficits. Participation in school and community activities also helps youth attain a sense of mastery, and building competence and self-efficacy for kids is invaluable. Often, teens will respond dramatically if given an opportunity to be of service to others in need. And sometimes, it is just a matter of helping a teen realize a strength or special talent that might have gone unrecognized. It all sounds simplistic, but it is often surprising how little effective guidance kids get from families in a perpetual state of crisis. And the problems often go unrecognized at school, where teens can either blend in with the crowd or act out enough so that staff give up on them.

These therapeutic interventions depend on the fact that teens’ brains are the ultimate in plasticity – always developing in response to environmental demands and influences. This is not just a vague concept, but based on research that demonstrates changes in synapses and even gene expression for neurotrophic growth factors in response to psychosocial and pharmacological interventions.

Adolescents and their families can and do respond to our efforts, although of course, not uniformly. But much of the success is built on the foundation of our primary care providers who take the time, even when there is no time, to try and bring order out of chaos.

1 Moreno C et al. Natural trends in the outpatient diagnosis and treatment of bipolar disorder in youth. Archive General Psychiatry. 2007; 64:1032-1039.

http://www.ncbi.nlm.nih.gov/pubmed/17768268

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Questions on how to subscribe, contact ANNBULL@nc-cherokee.com

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STD Corner - Lori de Ravello, National IHS STD Program

Adolescent Sexual Risk: Factors Predicting Condom Use Across the Stages of Change

This study examined factors associated with high-risk adolescents' movement toward or away from adopting consistent condom use behavior using the Transtheoretical Model Stages of Change. Participants drawn from the inactive comparison condition of a randomized HIV prevention trial (Project SHIELD) responded to items assessing pros and cons of condom use, peer norms, condom communication, and perceived invulnerability to HIV. Participants were categorized based on their condom use behavior using the Transtheoretical Model. Multiple logistic regressions found that progression to consistent condom use was predicted by continuing to perceive more advantages to condom use, reporting greater condom use communication with partners, and less perceived invulnerability to HIV. Movement away from adopting consistent condom use was predicted by a decrease in perceived advantages to condom use, increased perceived condom disadvantages, and fewer condom discussions. Future interventions may be tailored to enhance these factors that were found to change over time.

Grossman C, et al., Adolescent Sexual Risk: Factors Predicting Condom Use Across the Stages of Change, AIDS Behav. 2008 Apr 22 [Epub ahead of print]

http://www.ncbi.nlm.nih.gov/pubmed/18427971

Missed Opportunities for Chlamydia Screening of Young Women in the United States

OBJECTIVE: To identify missed opportunities for chlamydia screening in ambulatory care offices.

METHODS: We analyzed data from the 2005 National Ambulatory Medical Care Survey to estimate the number of visits to obstetrician–gynecologists and primary care physicians (family and general practitioners, internists, and pediatricians) for preventive care, pelvic examinations, Pap tests, and urinalyses for nonpregnant women aged 15–25 years, and the proportion of these visits at which chlamydia tests were not performed.

RESULTS: Obstetrician–gynecologists provided care for nonpregnant women aged 15–25 years at 6.3 million office visits during 2005, and primary care physicians at 20.9 million visits. Although obstetrician–gynecologists conducted only 23.1% of visits made by young women, they conducted 68.8% of visits with pelvic examinations and 71.1% of visits with Pap tests. Primary care physicians conducted 77.5% of visits with urinalyses. Obstetrician–gynecologists did not perform a chlamydia test at 3.2 of 3.8 million (82.1%) visits with pelvic examinations and at 1.8 of 2.3 million (77.3%) visits with Pap tests. Primary care physicians did not perform a chlamydia test at 2.9 of 3.0 million (99.1%) visits with urinalyses.

CONCLUSION: There are many missed opportunities for chlamydia testing of young women in ambulatory care visits — during pelvic examinations, Pap tests, and urinalyses. Effective and simple interventions are needed to increase targeted chlamydia screening of women by physicians.

Hoover K, Missed Opportunities for Chlamydia Screening of Young Women in the United States, Obstetrics & Gynecology 2008;111:1097-1102. http://www.ncbi.nlm.nih.gov/pubmed/18448741

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Barbara Stillwater, Alaska State Diabetes Program

Trends in the prevalence of preexisting diabetes and gestational diabetes mellitus among a racially/ethnically diverse population of pregnant women, 1999-2005

OBJECTIVE: The purpose of this study was to assess changes in the prevalence of preexisting diabetes (diabetes antedating pregnancy) and gestational diabetes mellitus (GDM) from 1999 through 2005.

RESEARCH DESIGN AND METHODS: In this retrospective study of 175,249 women aged 13-58 years with 209,287 singleton deliveries of >or=20 weeks' gestation from 1999 through 2005 in all Kaiser Permanente hospitals in southern California, information from clinical databases and birth certificates was used to estimate the prevalence of preexisting diabetes and GDM.

RESULTS: Preexisting diabetes was identified in 2,784 (1.3%) of all pregnancies, rising from an age- and race/ethnicity-adjusted prevalence of 0.81 per 100 in 1999 to 1.82 per 100 in 2005 (P(trend) < 0.001). Significant increases were observed in all age-groups and all racial/ethnic groups. After women with preexisting diabetes were excluded, GDM was identified in 15,121 (7.6%) of 199,298 screened pregnancies. The age- and race/ethnicity-adjusted GDM prevalence remained constant at 7.5 per 100 in 1999 to 7.4 per 100 in 2005 (P(trend) = 0.07). Among all deliveries to women with either form of diabetes, 10% were due to preexisting diabetes in 1999, rising to 21% in 2005, with GDM accounting for the remainder.

CONCLUSIONS: The stable prevalence of GDM and increase in the prevalence of preexisting diabetes were independent of changes in the age and race/ethnicity of the population. The increase in preexisting diabetes, particularly among younger women early in their reproductive years, is of concern.

Lawrence JM, Contreras R, Chen W, Sacks DA, Trends in the prevalence of preexisting diabetes and gestational diabetes mellitus among a racially/ethnically diverse population of pregnant women, 1999-2005, Diabetes Care. 2008 May;31(5):899-904. Epub 2008 Jan 25.

http://www.ncbi.nlm.nih.gov/pubmed/18223030

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Women's Health Headlines, Carolyn Aoyama, HQE

Funding for DV programs

I realize that many of you are very familiar with the available federal DV funding streams, but for those of you who want further information, please see the links below and the attached report.

I have links for everything from NIH research grants to a PDF of an APHSA publication, "Funding the Work: Community Efforts to End Domestic Violence and Child Abuse." This report outlines some program already in operation and some that provide start-up funding.

http://www.aphsa.org/policy/Doc/fundingstreams.pdf

In addition, here are some links to funding:
http://www.allstate.com/citizenship/foundation/funding-guidelines.aspx

Rural Domestic Violence and Child Victimization Enforcement Grant Program
The Rural Domestic Violence and Child Victimization Enforcement Grants are designed to enhance services available to rural victims and children by encouraging community involvement in developing a coordinated response to domestic violence, dating violence and child abuse.

STOP Violence Against Indian Women Discretionary Grant Program
The STOP Violence Against Indian Women Grants are intended to develop and strengthen tribal law enforcement and prosecution efforts to combat violence against Native women and to develop and enhance services for victims of such crimes.

2008 Mary Kay Ash Shelter Grant Program
Grants to women's shelters for victims of domestic violence.

Amy's Courage Fund
Provides emergency financial assistance to victims of domestic violence and their children to meet their immediate needs after escaping an abusive home.

Grants to Tribes, Tribal Organizations, and Migrant Programs for Community-Based Child Abuse Prevention Programs
The goal of the programs and activities supported by these funds is to prevent the occurrence or recurrence of abuse or neglect within the Tribal and Migrant populations.

Helping Outreach Programs to Expand Grant Program
Funding to grassroots, nonprofit, community-and faith-based victim organizations and coalitions to improve outreach and services to victims of crime.

Target Community Giving Grants
Grants currently focus on the arts, family violence prevention and for support groups and abuse shelters.

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Save the dates

“Keeping the Circle Strong: Celebrating Native Women’s Health and Well-Being”

2008 Conference

June 9-11, 2008
Albuquerque , NM
Registration website: http://www.niwhrc.org/2008%20conference.htm

Sexual Assault Nurse Examiner/Forensic Examiner (SANE/SAFE) Training Course

June 9 – 13, 2008
Navajo Nation Museum, Window Rock, Arizona
40 hour didactic portion of SANE/ SAFE training
Contacts for information: Sharon Jackson Sharon.jackson@ihs.gov , Sandra Dodge Sandra.dodge@ihs.gov , or Alberta Gorman ( Alberta.gorman@ihs.gov ).

Sexual Assault Nurse Examiner/Forensic Examiner (SANE/SAFE) Training Course

July 21-25, 2008
Aberdeen , South Dakota
40 hour didactic portion of SANE/ SAFE training
For additional information contact Lisa Palucci, lisa.palucci@ihs.gov, at the IHS Clinical Support Center

Community Health Representative National Educational Meeting

July 29-31, 2008
Las Vegas , Nevada
40 th Anniversary of the CHR Program
www.nachr.net/conferences/2008/

Sexual Assault Nurse Examiner/Forensic Examiner (SANE/SAFE) Training Course

August 18-22 , 2008
Oklahoma City , Oklahoma
40 hour didactic portion of SANE/ SAFE training
For additional information contact Lisa Palucci, lisa.palucci@ihs.gov, at the IHS Clinical Support Center

Postgraduate Course on Obstetric, Neonatal and Gynecologic Care

September 14-18, 2008
Salt Lake City , Utah
Comprehensive Women’s Health Update for Nurses, Advanced Practice Nurses, and Physicians
NRP offered as pre-conference session
Contact Yvonne Malloy, ymalloy@acog.org, for more information

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What's new on the ITU MCH web pages?

2007 Native Women’s Health and MCH Conference Meeting Notes

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 May 2008 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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Volume 6, No. 6, June 2008

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Barbara Stillwater, Alaska State Diabetes Program

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Did you miss something in the last OB/GYN Chief Clinical Consultant Corner?

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