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Volume 6, No. 4, April 2008
Features
American College of Obstetricians and Gynecologists
Treatment of Urinary Infections in Nonpregnant Women
Summary of Recommendations and Conclusions:
The following recommendations and conclusions are based on good and consistent scientific evidence (Level A):
- Screening for and treatment of asymptomatic bacteriuria is not recommended in nonpregnant, premenopausal women.
- Resistance rates higher than 15–20% necessitate a change in antibiotic class.
- In all cases of acute pyelonephritis, whether treatment is on an inpatient or outpatient basis, 14 days of total antimicrobial therapy should be completed.
- A 3-day antimicrobial regimen is the preferred treatment duration for uncomplicated acute bacterial cystitis in women, including women aged 65 years and older.
The following conclusion is based on limited or inconsistent evidence (Level B):
- The initial treatment of a symptomatic lower UTI with pyuria or bacteriuria or both does not require a urine culture.
The following conclusions are based primarily on consensus and expert opinion (Level C):
- Beta-lactams, such as first-generation cephalosporins and amoxicillin, are less effective in the treatment of acute uncomplicated cystitis than those antimicrobials listed in Table 1
- To diagnose bacteriuria, decreasing the colony count to 1,000–10,000 bacteria per milliliter in symptomatic patients will improve the sensitivity without significantly compromising specificity
ACOG Practice Bulletin No. 91: Treatment of Urinary Tract Infections in Nonpregnant Women.
Obstet Gynecol. 2008 Mar;111(3):785-94. http://www.ncbi.nlm.nih.gov/pubmed/18310389
Technologic Advances to Reduce Medication-Related Errors
ABSTRACT:The Institute of Medicine estimates that up to 7,000 individuals die each year as a result of medication errors. Despite the significant national attention medical errors are receiving, they continue to pervade the U.S. health care system. Medication-related errors consistently rank at the top of all medical errors, accounting for thousands of deaths annually in the United States. Many new technologies are available that, when integrated into the various medication-related processes, can significantly reduce the incidence of preventable medication errors. Practicing obstetrician–gynecologists should be familiar with these technologies and the evidence supporting their use.
ACOG Committee Opinion No. 400: Technologic Advances to Reduce Medication-Related Errors. Obstet Gynecol. 2008 Mar;111(3):795-8. http://www.ncbi.nlm.nih.gov/pubmed/18310390
Relationships With Industry
ABSTRACT: Although physicians and their professional organizations have routinely accepted gifts from the health care industry, evidence now indicates that such gifts may misdirect physicians from their primary responsibility to act in the best interests of their patients. The American College of Obstetricians and Gynecologists’ Committee on Ethics offers revised recommendations for relationships with industry. Physicians should understand the potential for influence when considering accepting gifts, including those of apparently nominal value. If any gifts are accepted, they should primarily entail benefit to patients or be related to the physician’s work and should not be of substantial value. Sample drugs (or vouchers) may be dispensed but preferably as a full course of therapy on the basis of true need. Physicians are obligated to seek the most accurate, up-to-date, evidence-based, and balanced source of information about products. Neither patient referral nor industry support of institutions should be contingent on physician use or advocacy of a product. Physicians should disclose their financial interests to patients and colleagues. Support from industry for continuing medical education and professional meetings may be accepted, but subsidies should be disclosed and should not be accepted directly by physicians. Speakers may receive reasonable honoraria. Reimbursement for research should not exceed reasonable direct and indirect costs, and reasonable compensation for subsequent consulting and lecturing is permissible. Investigators who are or may become involved in a company’s research may not buy or sell its stock until their involvement ends and the research is published or disseminated.
ACOG Committee Opinion No. 401: Relationships With Industry. Obstet Gynecol. 2008 Mar;111(3):799-804. http://www.ncbi.nlm.nih.gov/pubmed/18310391
Antenatal Corticosteroid Therapy for Fetal Maturation
ABSTRACT: A single course of corticosteroids is recommended for all pregnant women between 24 and 34 weeks of gestation who are at risk of preterm delivery within 7 days. A single course of antenatal corticosteroids should be administered to women with premature rupture of membranes (PROM) before 32 weeks of gestation to reduce the risks of respiratory distress syndrome, perinatal mortality, and other morbidities. The efficacy of corticosteroid use at 32–33 completed weeks of gestation for preterm PROM is unclear based on available evidence, but treatment may be beneficial, particularly if pulmonary immaturity is documented. No data exist on the efficacy of corticosteroid use before viability, and such use is not recommended at this time. Because of insufficient scientific evidence, repeat corticosteroid courses, including so-called “rescue therapy,” should not be used routinely but should be reserved for women enrolled in clinical trials.
ACOG Committee Opinion No. 402: Antenatal Corticosteroid Therapy for Fetal Maturation. Obstet Gynecol. 2008 Mar;111(3):805-7. http://www.ncbi.nlm.nih.gov/pubmed/18310392
ACOG Supports Effort to Encourage Electronic Prescribing
As of January 1, 2009 all computer generated prescriptions for Medicare Part D patients must comply with the NCPDP script standard and thus be transmitted electronically and not by computer-generated fax. If not, prescriptions must be printed and then manually faxed – a time consuming process. The Medicaid requirement for using tamper resistant prescription pads, effective October 1, 2008, also allows an exception for electronic prescribing. It is likely that other state and national regulations will soon require or encourage electronic prescribing.
More importantly to most ob/gyns, an electronic connection with pharmacies can improve the efficiency of a practice and the overall quality of a patient’s prescription information, improving patient care.
With this in mind, the American College of Obstetricians and Gynecologists is collaborating with the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Cardiology, the Medical Group Management Association and several other medical organizations to launch a nationwide program to assist physician practices with electronic subscribing, called the Get Connected program. The heart of the program is the www.GetRxConnected.com web portal, which helps assess a practice’s readiness for electronic prescribing, and guides users through the steps that they need to take to use e-prescribing.
Many EMR users are unaware that they are generating faxes that arrive on paper at the pharmacy’s fax machine. These computer-generated, faxed prescriptions will not be in compliance with the new regulations, and they fail to achieve the patient safety improvements that true e-prescribing offers. The www.GetRxConnected.com web site will help physicians that currently have EMRs that fax or print prescriptions, as well as those without EMRs.
A visit to www.GetRxConnected.com can provide you with more detail on these benefits and other valuable information including:
·Information on the benefits of e-prescribing/pharmacy connectivity, including the business case and social case for e-prescribing.
·An estimate of the value of the time your practice spends annually managing prescription renewal requests by phone/fax – time better spent on patient care, or other reimbursable activity.
·A listing of pharmacies in your area that can exchange prescription information with your practice electronically.
·The value of e-prescribing for your patients.
http://www.acog.org/departments/dept_notice.cfm?recno=19&bulletin=4479
American Family Physician**
Pharmacologic Management of Adult Depression (Also See Patient Education)
Major depression is a common and treatable disease. Many patients benefit from pharmacologic treatment and, because there is little variation in antidepressant effectiveness, medication choices should be made based on patient characteristics, safety, and anticipated side effects. Most patients respond favorably to treatment, but many do not have complete symptom relief. Changing medications or augmenting with a second medication is helpful for some partial or nonresponders. All antidepressants are capable of producing harmful side effects, and some are particularly prone to dangerous drug-drug interactions. The risk of suicide is always a concern in depression and this risk is not necessarily reduced by the use of antidepressants. Some persons may have an increase in suicidal thoughts with antidepressant treatment. Close follow-up is required when initiating therapy and adjusting dosages.
Stephen M. Adams , MD; Karl E. Miller, MD; and Robert G. Zylstra, EdD, LCSW, Pharmacologic Management of Adult Depression, Am Fam Physician. 2008;77(6):785-792, 795-796.
http://www.aafp.org/afp/20080315/785.html
Diagnosis and Treatment of Female Sexual Dysfunction
Female sexual complaints are common, occurring in approximately 40 percent of women. Decreased desire is the most common complaint. Normal versus abnormal sexual functioning in women is poorly understood, although the concept of normal female sexual function continues to develop. A complete history combined with a physical examination is warranted for the evaluation of women with sexual complaints or concerns. Although laboratory evaluation is rarely helpful in guiding diagnosis or treatment, it may be indicated in women with abnormal physical examination findings or suspected comorbidities. The PLISSIT (Permission, Limited Information, Specific Suggestions, Intensive Therapy) or ALLOW (Ask, Legitimize, Limitations, Open up, Work together) method can be used to facilitate discussions about sexual concerns and initiation of treatment. Developments in the treatment of male erectile dysfunction have led to investigation of pharmacotherapy for the treatment of female sexual dysfunction. Although sexual therapy and education (e.g., cognitive behavior therapy, individual and couple therapy, physiotherapy) form the basis of treatment, there is limited research demonstrating the benefit of hormonal and nonhormonal drugs. Testosterone improves sexual function in postmenopausal women with hypoactive sexual desire disorder, although data on its long-term safety and effectiveness are lacking. Estrogen improves dyspareunia associated with vulvovaginal atrophy in postmenopausal women. Phosphodiesterase inhibitors have been shown to have limited benefit in small subsets of women with sexual dysfunction.
Am Fam Physician 2008;77(5):635-642. http://www.aafp.org/afp/20080301/635.html
AHRQ
Care quality is not necessarily better with electronic health records
Electronic health records (EHR) do not automatically guarantee higher quality care in medical settings, a new study finds. Researchers from Harvard and Stanford looked at the effect EHRs had on 17 indicators of quality, including disease management, antibiotic use, preventive counseling, screening tests, and drugs prescribed for elderly patients. They found EHRs improved performance for 2 indicators, worsened performance for 1, and offered no real advantage for the remaining 14.
Physicians using EHRs scored well in not prescribing sedatives (benzodiazepines) to depressed patients and avoiding routine urinalyses at general medical visits. In addition, when researchers limited the study sample to primary care and heart physicians, those who employed EHRs more often counseled smokers to quit. Yet, doctors who had EHR systems didn't do as good a job in prescribing medication for patients with high cholesterol as those who didn't use EHR systems, notes Jeffrey A. Linder, M.D., M.P.H.
Dr. Linder and colleagues used 2003 to 2004 data from more than 50,000 patient records collected by the National Ambulatory Medical Care Survey of patient visits to U.S. physician practices. Electronic health records were used in 18 percent of about 1.8 million ambulatory medical visits during the study period.
The authors note that performance for both groups—with and without EHRs—was below par, indicating there is room for improvement across the board. They stress that no one should assume that quality improves as EHR use widens. Earlier studies conducted by the Agency for Healthcare Research and Quality, however, found that EHRs can boost the amount of care that meets with guidelines, improve care through clinical monitoring, and curtail medical errors.
The authors recommend that physicians adopting EHR systems consider ones that include clinical decision support and use that feature to improve care.
This study was funded in part by the Agency for Healthcare Research and Quality (HS14563 and HS11313).
See "Electronic health record use and the quality of ambulatory care in the United States," by Dr. Linder, Jun Ma, M.D., R.D., Ph.D., David W. Bates, M.D., M.Sc., and others, in the July 9, 2007, Archives of Internal Medicine; pp. 1400-1405. http://www.ncbi.nlm.nih.gov/pubmed/17620534
OB/GYN CCC Editorial comment :
Seek improvement in record documentation, but be aware of patient outcomes
This AHRQ study raises some excellent questions which we should all be aware of. In the meantime EHR implementation is with us, regardless. It is incumbent on us to follow patient outcomes closely and be willing to modify the EHR, or shut it down if patient safety is endangered.
The Primary Care Discussion Forum had a thoughtful discussion on this topic which is available here:
http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForumMod.cfm#ehr
Patients with diabetes and depression tend to skip self-care behaviors that would help keep their diabetes in check
http://www.ahrq.gov/research/mar08/0308RA13.htm
Rural emergency departments have a high rate of medication errors with the potential to harm children
http://www.ahrq.gov/research/mar08/0308RA16.htm
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
Behavioral Health Insights - Peter Stuart, IHS Psychiatry Consultant
School Refusal
By Elise Fatimi, MD*
It is estimated that up to 4% of children refuse school because of anxiety. Ten- to 14-year-olds are especially prone to school refusal. These children may go on to be less likely to ever marry or have children, and are at increased risk for future anxiety disorders and depression. Because anxiety is strongly hereditary, a parent may be too fearful to set firm limits in the face of their child’s panic. With each day’s unexcused absence it grows harder to reestablish regular school attendance.
Sometimes the goal of returning to full attendance is abandoned, and a child may be home-schooled, or provided home-based instruction by the school. This may maintain academic achievement, but social confidence and age-appropriate friendships often suffer. It takes a strong commitment of time and social networking for a parent to engage with other home-schooling families. For working parents, or those with anxiety problems of their own, this is a tall order.
A child who refuses school may have a real illness or a good reason to worry (e.g. a depressed parent, a bully in the playground). But when these have been ruled out with reasonable confidence, explore for anxiety symptoms. Have other separations been difficult? Is the child a ‘worrier’? Have there been past attempts at school refusal after holiday breaks or illnesses? Is there a family history of anxiety?
There are many “flavors” of anxiety. Children who refuse school may have Separation Anxiety Disorder. A child may also have Generalized Anxiety Disorder, with worries about illness, worst-case scenarios, or far-off events, and physical symptoms such as headaches and stomachaches. In Social Anxiety Disorder, children are fearful of embarrassment, scrutiny, or interacting with unfamiliar people.
I consider school refusal to be a genuine psychiatric emergency, much like heavy bleeding. A child’s confidence in his ability to “make it” is, in a sense, hemorrhaging. Time is of the essence. Here are some elements of an effective treatment plan:
- Educate the whole family . Explain clearly that the goal is a return to full attendance, but that you will work hard to make this tolerable. Avoid bargaining (“let’s wait until after Spring break, it’s only another week”) or granting of retroactive medical excuses. Get permission to contact school staff. Refer for therapy as needed to develop and follow a plan for reintroduction to school- children with more severe problems may start with a class period and increase steadily to a full day.
- Work with school staff . Most principals will allow a child to use a ‘time-out’ in the nurse’s office is he/she is too upset to stay in class. Ask the nurse not to send the child home before the agreed time unless there is objective evidence of illness. Devise a specific strategy for morning drop off at school. Parents should keep goodbyes brief. Avoid parent-child phone contact during the school day, as it tends to exacerbate anxiety.
- Medication may be indicated when a child is severely anxious. Short-term use of benzodiazepines (e.g. clonazepam at bedtime before a school day) can help with anticipatory anxiety and insomnia. If the child is sleepy in the morning, reassure parents and teachers that “asleep at school is better than awake at home” at the start of treatment. Ongoing treatment of anxiety disorders is best achieved with SSRI medications (e.g. fluoxetine, sertraline). Self-injurious or aggressive behavior may (rarely) require inpatient management.
Most children can resume full school attendance within days to weeks, and many seem to forget the episode in a little while. In overcoming this challenge, the whole family will build confidence and skills for the future.
Here’s a link to the American Academy of Child and Adolescent Psychiatry that has information on this topic as well as a large range of other psychosocial/mental health related ones :
http://www.aacap.org/cs/root/facts_for_families/children_who_wont_go_to_school_separation_anxiety
*This month’s column is provided by Elise Fatimi, MD, a child and adolescent psychiatrist with long experience in IHS in the Southwest. She currently presides over the Greater Phoenix Chapter of the Academy of Child and Adolescent Psychiatry. She mixes clinical acumen and patient advocacy exceedingly well.Breastfeeding - Suzan Murphy, PIMC
What makes a good idea work?
The concept of supporting breastfeeding is agreeable to most of us. The immunological impact and long term health benefits for both mom and baby make breastfeeding a sound and reasonable behavior to encourage. However, when the findings that breastfeeding can also significantly reduce risk of obesity/overweight and type 2 diabetes are added to the rationale, supporting breastfeeding becomes important tool in tackling a daunting and far reaching public health problem.
So, what will increase initiation and duration?
Baby Friendly Hospital Initiative, ( USA ) and Baby Friendly, UNICEF/WHO have similar steps that promote breastfeeding perinatally. Generally they are:
- Maintain a written, well-communicated hospital breastfeeding policy.
- Train clinical staff to effectively implement policy.
- Inform all pregnant women about benefits and management of breastfeeding.
- Help mother initiate breastfeeding ½ hour (UNICEF/WHO)/1 hour ( USA) after birth.
- Show mothers how to continue breastfeeding, even if they are separated from their babies.
- Do not supplement babies unless medically indicated.
- Practice rooming in – mother and infants remain together 24 hours/day.
- Encourage unrestricted breastfeeding.
- Give no pacifiers or artificial nipples to breastfeeding infants
- Foster the establishment of breastfeeding support groups and refer mothers to them at discharge.
Research indicates that when the steps are implemented, breastfeeding initiation can increase by as much as 400%. Federal agencies surveyed women who planned to breastfeed and experienced five of the ten steps – early breastfeeding initiation (step 4), no supplementation unless medically indicated (step 6), rooming in (step 7), unrestricted breastfeeding encouraged (step) 8, and no pacifiers or artificial nipples used (step 9). Families who did not experience any of the steps were 8 times more likely to stop breastfeeding before 6 weeks. The more steps experienced, the more likely the family was to continue breastfeeding to 6 weeks and beyond. The strongest risk factors for stopping breastfeeding early were late breastfeeding initiation (missing step 4) and supplementing the baby (missing step 6). For more information, please see DiGirolamo AM, LM Grummer-Strawn, S Fein. 2001. Maternity care practices: implications for breastfeeding. Birth 28:94-100.
National goals help support breastfeeding. Watch for upcoming information about Healthy People 2020 goals that enlist the community at large. New points of focus include:
Increasing the number of:
- Women who take family medical leave
- Employers with workplace lactation programs
- Baby Friendly hospitals
- Mothers who see lactation consultants in hospital
- Maternity staff receiving 18 hours of lactation training
- Mothers seen by appropriately trained lactation care providers post discharge
- Third party payers and employers who cover lactation care and services
- Number of hospitals that make donor human milk available
And reducing the number of breastfed neonates receiving supplemental formula that is not medically indicated.
Supporting breastfeeding is sometimes about a paradigm shift – big and little changes that may not be easy. It is also about education and choice. For our families it is about improving wellness now and later. www.babyfriendlyusa.org
CCC Corner Digest
Nicely laid out hard copy - A compact digest of last month’s CCC Corner
March 2008 highlights include:
- Minorities underrepresented in umbilical cord blood banking
- HPV brochure for AI/AN: available for broad dissemination
- Evidence Favors Late Cord Clamping in Infants
- Biofeedback Reduces Psychological Burden in Older Women With Urge Incontinence
- Sex education: Providers need to fill gaps in adolescent knowledge
- Diuretics most effective blood pressure medicine for people with metabolic syndrome
- Treating Eating Disorders in Primary
- PTSD: A technique that works for me
- Report cites high rate of violence against Native women
- Exciting opportunity to develop new resources in geriatrics
- Ringing Endorsement: Women Prefer Contraceptive Ring Over Patch
- Meeting notes now online: 2007 Native Women’s Health and MCH Conference
- How can we actually reduce infant mortality in AI/AN?
- Good intentions and unintended consequences
- Maternal depression as a risk factor affecting child readiness and school readiness
- Findings from the National Survey of Children's Health includes Native Americans
- St. John's wort for depression in a young woman: The Answers
- Perineal warm packs reduce 3rd and 4th degree lacerations, pain, urinary incontinence
- Adnexal Masses during Pregnancy
- Integrating Nursing and Behavioral Health
- SSRI Use and Bone Loss in Older Women
- Assuring Quality Care for People With Limited Health Literacy
- Usefulness of middle cerebral artery Doppler of the fetus at risk for anemia
- Mental health issues in children and adolescents –Starts March 3rd
- Diabetes A Stronger Risk Factor For Death In Women than In Men
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/CCCC_v6_03.pdf
If you want a copy of the CCC Digest mailed to you each month, please contact nmurphy@scf.ccDomestic Violence - Denise Grenier, Tucson / Rachel Locker, Warm Springs
Teen dating violence: 3 articles
Teens, dating violence, and media use
Dating violence is highly prevalent among adolescents. Of importance, dating violence has been associated with negative physical and mental health outcomes for teens and high-risk behaviors such as unsafe sex practices. Although a growing body of research has examined the extent and nature of this problem, little research has considered aspects of the media that might be associated with risk for teen dating violence, such as time spent using media and effects of media content. This article provides an overview of the prevalence of teen dating violence, describes the potential for assessing media use as a risk factor, offers a conceptual model, and suggests ideas for future research.
Manganello JA . Teens, dating violence, and media use: a review of the literature and conceptual model for future research. Trauma Violence Abuse. 2008 Jan;9(1):3-18. http://www.ncbi.nlm.nih.gov/pubmed/18182628
Linking dating violence, peer violence, and suicidal behaviors among high-risk youth
CONCLUSIONS: There is a substantial overlap among different forms of violent behavior, suggesting that additional research is needed to better understand the factors that contribute to involvement in multiple forms of violence.
Swahn MH et al Linking dating violence, peer violence, and suicidal behaviors among high-risk youth. Am J Prev Med. 2008 Jan;34(1):30-8. http://www.ncbi.nlm.nih.gov/pubmed/18083448
Non-condom use among young adolescent male perpetrators of dating violence
These results indicate that non-use of condoms is occurring among adolescent male perpetrators of dating violence, particularly in the context of their steady relationships and despite reports of very high risk sexual activity including sexual infidelity, involvement in 'trains' and multiple sex partners. Sexual health interventions integrated with dating violence and sexual assault prevention efforts and tailored to adolescents are needed.
Raj A et al Contexts of condom use and non-condom use among young adolescent male perpetrators of dating violence. AIDS Care. 2007 Sep;19(8):970-3. http://www.ncbi.nlm.nih.gov/pubmed/17851992
Domestic Violence Resources
Two domestic violence resources have been forwarded by Carolyn Aoyama. For the first one, open the link below then scroll down to the DV section:
http://www.cdc.gov/ncipc/pub-res/pubs.htm
One link of particular use is http://www.cdc.gov/ncipc/dvp/IPV/ipv-SViolence.htm
This manual surveys several different screening tools for use by healthcare providers.
The second link is: http://www.chooserespect.org/scripts/index.asp
Also please note, The S urgeon General’s Women's Mental Health Workshop Report has been posted to the SG's website: http://www.surgeongeneral.gov/topics/womensmentalhealth/
American Psychological Association’s Violence Summit
I am passing the following web addresses to you courtesy of Rose Weahkee from the American Psychological Association’s Violence Summit.
Click on the first site from CDC and scroll down to violence for info on DV.
http://www.cdc.gov/ncipc/pub-res/pubs.htm
This is a successful CDC resource called “Choose Respect” which also provides useful information.
http://www.chooserespect.org/scripts/index.asp
(From Carolyn Aoyama Carolyn.Aoyama@ihs.gov )
Elder Care News - Bruce Finke, Elder Care Initiative
Training in Palliative and End of Life Care
- April 22-24, 2008
- Flagstaff , AZ
- Contact Tim Domer, MD tim.domer@ihs.gov
Few nursing home residents receive medications and supplements for osteoporosis
http://www.ahrq.gov/research/mar08/0308RA10.htm
Family Planning
Increasing contraceptive use and adherence in adolescents
Tony Ogburn MD presented a lecture at the 2007 Native Women’s Health and MCH Conference entitled ‘ Contraception for teens: What’s new?’ which can be found at the link below.
The lecture notes are posted in alphabetical order
http://www.ihs.gov/MedicalPrograms/MCH/F/lecNotes.cfm#wHealthConf
In addition, below is an excerpt from the UpToDate discussion entitled ‘Issues concerning the use of hormonal contraception by adolescents’ for which the link is available at the end of this posting. Please refer to the full chapter for complete details.
Background
Oral contraceptive pills (OCPs) are the most popular prescriptive contraceptive method used by adolescents (44 percent), followed by condoms (37 percent), and depot medroxyprogesterone acetate (DMPA) (10 percent).
Although a variety of hormonal contraceptive methods are available, this discussion will focus on those commonly used by adolescents: OCPs and DMPA. In addition, the transdermal patch will be discussed since it appears to be increasing in popularity among adolescents. Use of the vaginal ring is increasing among older adolescents who are comfortable inserting it. There also appears to be an emerging interest in the intrauterine device by some practitioners.
Emergency contraception, which is discussed in detail separately, is available by prescription and should be mentioned to all sexually active adolescents.
Motivating factors - The sexually active adolescent is more likely to seek contraception in the following situations:
-Perceiving pregnancy as a negative outcome
-Having long-term educational goals
-Being of older age
-Experiencing a pregnancy scare or actual pregnancy
-Having family, friends, and/or a clinician who sanction the use of contraception
Adolescents are more likely to use condoms if they understand condoms can prevent HIV/AIDS, if they carry condoms and are not embarrassed to use them, and if they are worried about getting AIDS.
Initiating contraception - Adolescents vary in their readiness to initiate contraception. From a developmental perspective, sexually active girls in early adolescence have difficulty planning events and activities; they often live for the moment. Therefore, implementing a contraceptive method that requires planning and forethought is difficult at this age without monitoring and adult support. Girls in middle and late adolescence are more capable of higher-level planning, decision making, and problem solving, skills essential to effective contraceptive behavior.
Education - Several points should be discussed at the time of initiating a contraceptive:
Selecting the best method
Risk of side effects
Tips on adherence
Use of condoms to protect against STIs
Practical suggestions to promote use, such as keeping condoms in a purse
The availability of and indications for emergency contraception
Sometimes an adolescent is sexually active and does not desire a pregnancy but is undecided about starting a method. In these cases, the discussion should raise her awareness of her risk of pregnancy and STIs. Reviewing stories of her sister(s), friends, or peers at school who are teen mothers may be helpful. Girls who are not engaging in sexual activity also should be educated about the use of condoms and emergency contraception, in case their status changes.
Selecting the best method - A careful history should be obtained prior to beginning the counseling process. This step will help the clinician facilitate counseling regarding any possible absolute or relative contraindications to starting an estrogen-progesterone product.
Anticipated adverse effects - The anticipated side effects from hormonal contraception should be reviewed. Breakthrough bleeding or amenorrhea from OCPs, DMPA, and the transdermal patch can be very upsetting. These methods are likely to be discontinued unless the adolescent has been counseled about potential problems and their treatment. As an example, in one study of women treated with DMPA, women who were told about the possibility of amenorrhea were 2.5 times more likely to continue DMPA than those not given this information.
A rash and itching at the application site may be of concern to adolescents using the transdermal patch. Partial or complete detachment of the transdermal patch was reported in 35 percent of adolescents in one study, compared with less than 5 percent in adults. Of note, no detachments were reported when the patch was worn on the arm. The likely explanation may be inadequate care in application and increased activity among teenagers compared with adults.
Noncontraceptive benefits - Reviewing the noncontraceptive benefits of OCPs, DMPA, and the transdermal patch with adolescents also is important. Benefits of OCPs and the transdermal patch include improved bone density and protection against ovarian cancer, endometrial cancer, salpingitis, ectopic pregnancy, benign breast disease, dysmenorrhea, and iron deficiency. The same benefits, with the exception of improved bone density, are provided by DMPA.
Informed consent - Although it is not necessary to obtain written informed consent before the initiation of hormonal contraception in adolescents, the use of a structured informed consent form can ensure that the risks and benefits are adequately discussed. The form used by Texas Children's Hospital for combination hormonal contraceptives is an example.
Barriers to use and adherence - Barriers to the use of hormonal contraception by adolescents include fear of side effects, some of which are not substantiated by evidence.
Fear of side effects - A fear of side effects from OCPs and DMPA injections is a common barrier to the use of hormonal methods. As an example, in one review, adolescents in a private practice setting were overwhelmingly more concerned about weight gain from OCPs and those in an urban hospital-based adolescent clinic were concerned about weight gain, blood clots, birth defects, and infertility .
Weight gain - Many adolescents are concerned that oral contraceptives cause weight gain. However, available data suggest this is not the case. In the review described above, adolescents who did not adhere to their OCPs were more likely to feel they had gained weight, although actual weight often was unchanged . Most young women did not gain more than 2.3 kg while using OCPs or 3.6 kg while using DMPA during a two-year period.
In another study, the effect of OCP use on body weight and fat distribution was assessed in 49 healthy young women initiating treatment with a low-dose OCPs (30 microgram ethinyl estradiol plus 75 microgram gestodene); anthropometric measurements before and after the initiation of OCP use were compared with those in 31 age-and-weight matched women not using OCPs. Baseline body mass index (BMI), percent fat, percent water, and waist-to-hip ratio (WHR) did not change significantly after six cycles in the OCP users. A similar number of women gained weight in both groups (30.6 percent of users, 35.4 percent of controls); the typical weight gain in the OCP group was only 0.5 kg. The weight gain in these women was caused by accumulation of fat, not body water. Approximately 20 percent of women in both groups lost weight. Thus, adolescents should be reassured that OCP use does not result in an increase in body weight or percent body fat over that seen in nonusers.
Adolescents also are increasingly concerned about weight gain from DMPA. Although weight gain and DMPA use may be concomitant events, a causal relationship has not been established. Factors other than DMPA may be playing a role. As an example, in one study, after six months of DMPA use, weight gain was greater among black than white subjects (4.2 versus 1.2 percent increase or mean weight gain of 2.9 versus 0.9 kg). A higher baseline weight, eating restraint, eating disinhibition, and other medications were predictive for weight gain in the black adolescents. In contrast, the only predictive factor for weight gain in white adolescents was a higher baseline weight. Thus, weight gain while using DMPA appears to occur in adolescents with a propensity for weight gain
Bone density - DMPA and ultra low-dose estrogen (20 microgram) pills may interfere with achieving optimal peak bone mass in very young women by causing loss in bone density or interference with the increase during a time of expected bone accretion
Rare cases of osteoporosis, including osteoporotic fractures, have been reported postmarketing in patients taking DMPA. For this reason, the United States Food and Drug Administration has a labeling change to include a warning that DMPA be used as a long-term birth control method (eg, longer than two years) only if other birth control methods are inadequate.
It is important to review information regarding DMPA and bone density with adolescents. The general opinion is that, if possible, DMPA should be avoided in a girl during early adolescence. However, the data are not sufficient to limit the use of the transdermal patch in adolescents; nor are they sufficient to limit the use of DMPA in older adolescents. In fact, some experts argue that for adolescents in whom DMPA is the only acceptable contraceptive option, the benefit of pregnancy prevention outweighs the potential risk to bone health. This conclusion is based upon the following points :
-Pregnancy also appears to decrease BMD
-Most adolescents who use DMPA do so for less than two years
-There is at least partial recovery of bone density after discontinuation of DMPA
The adolescent can modify other lifestyle factors to maximize bone health (ie, calcium intake, exercise, avoidance of tobacco use).
Estrogen supplementation may provide additional bone protection and may be warranted for girls in whom BMD may already be decreased (eg, family history of osteoporosis, anorexia nervosa, chronic renal disease). The optimal dose and route for estrogen supplementation is not known; (0.625 mg equine estrogen per day is the only oral dose that has been tested).
Spinal bone mineral density can be monitored with dual energy absorptiometry (DXA) and compared with normative data to determine whether DMPA should be continued or discontinued. DXA should be obtained in all young women who use DMPA continuously for two years.
The Society for Adolescent Medicine has published a position paper regarding the black box warning for DMPA. The position paper suggests that:
-With adequate explanation of benefits and potential risks, DMPA may continue to be prescribed to adolescent girls who need contraception
-Decisions regarding bone density monitoring of adolescents using DMPA for contraception should be individualized; the decisions should be made by the clinician in concert with the adolescent, and potentially the adolescent's guardian
-Duration of use of DMPA need not be restricted to two years
-Adolescents using DMPA should be encouraged to take 1300 mg and 400 IU vitamin D and to exercise each day. Calcium and vitamin D supplements are available separately in tablet form or combined in a single tablet.
Estrogen supplementation should be considered for girls who are doing well on DMPA and have osteopenia or are at risk for osteopenia and who have no contraindications to estrogen
The effects of DMPA on bone density are discussed separately.
Pelvic inflammatory disease — The relationship between OCPs pelvic inflammatory disease (PID) is complex. Whereas some studies indicate that the use of OCPs increases the risk of PID, others suggest that OCPs increase the risk for cervicitis and endometritis, but not salpingitis, thereby decreasing the severity of PID.
No association between DMPA and risk of PID has been reported. The intrauterine device (IUD) itself does not increase the risk for PID. However, the presence of the IUD may increase the severity of PID in an adolescent due to their increased risk for STIs.
Venous thromboembolism - The association between OCPs and risk of venous thromboembolism (VTE) appears to be related to estrogen dose and type of progestin. Even low-dose OCPs (30 to 50 microgram estrogen pills) can be associated with a modest increase (three- to sixfold) in the risk of VTE. OCPs containing third-generation progestins also may be associated with a slight increase in risk of VTE.
The risk of VTE with OCPs or the transdermal patch should be considered in relation to the risk of VTE during pregnancy. The risk of VTE may be 3- to 10-fold higher in pregnant than nonpregnant women.
Many adolescents and their parents also have raised questions about the reports of increased risk of VTE from the transdermal patch. The FDA has required the label for the transdermal patch to contain a warning regarding the possible increased risk of thrombotic events related to a higher-than-average circulating estrogen level. This warning is controversial because it is unclear whether the increased circulating estrogen level will in fact be associated with a higher frequency of adverse events.
Nonetheless, it is important to take a careful personal and family history of deep venous thrombosis to identify those adolescent women who might be at high risk before prescribing an OCP or the patch (eg, those who have antiphospholipid antibodies or nephrotic syndrome).
Other effects - Other side effects from OCPs of concern to adolescents include blood clots (22 percent), birth defects (11 percent), and infertility (10 percent). Many adolescents hear about these effects from an adult who may have used higher-dose OCPs in the 1960s and 1970s or is otherwise misinformed. This situation underscores the importance of dispelling misconceptions about the adverse effects of OCPs, as well as DMPA, especially in adolescent women. There is no evidence to support an association between OCPs and either birth defects or infertility.
Summary - The perceived adverse effects of hormonal contraception is a real barrier to the use of this method among some adolescents.
Weight gain is a common concern. However, there is no evidence to suggest OCP use results in an increased body weight or percentage of body fat beyond that seen in nonusers. Among users of DMPA, weight gain appears to occur in those who have an underlying propensity for weight gain.
DMPA and low-dose estrogen OCPs may interfere with the achievement of peak bone mass in very young adolescent women. The general opinion is that, if possible, DMPA should be avoided in girls during early adolescence. The data are not sufficient to limit the use of the transdermal patch in adolescents; nor are they sufficient to limit the use of DMPA in older adolescents.
Low-dose OCPs are associated with a modest increase in the risk of venous thromboembolism.
Inadvertent OCP administration during early pregnancy has not been associated with an increase in risk of congenital anomalies.
OCPs do not increase the risk of infertility; in fact, the risk of primary infertility may be reduced in women who have taken an OCP.
Issues concerning the use of hormonal contraception by adolescents, UpToDate
Featured Website - David Gahn, IHS MCH Portal Web Site Content Coordinator
More lecture notes added daily
-Lectures listed in alphabetical order by author
Kelly Acton, M.D.
Gail Bolan MD
Karen Carey CNM MS
Peter Cherouny, MD
Donald Coustan, M.D.
Scott Deasy, M.D.
Willeen Druley, RN, MS, BC, FNP
Denise Findlay, RN BSN
- Using the Feeding & Teaching Scales to Plan Effective Interventions
- Promoting Maternal Mental Health During Pregnancy
Terry Friend, CNM
Cindy Gebremariam, RN
Scott Giberson, Ph.C, PharmD, MPH
George Gilson, M.D.
- HIV Infection in Pregnancy: 2007 Update
- Prenatal Testing Update 2007
- THE OB-PEDS INTERFACE:“GOT ISSUES?”
Amy Groom, MPH
Kathleen Harner, M.D.
Howard Hays, M.D.
Mary Henrikson MN, RNC
Stephen W. Heath, MD, MPH
Lynn Hoefer, DV Advocate
- Ketchikan Indian Clinic Domestic Violence Project: Take Home Tips
- Take Home Tips from Alaska IPV/DV Screening Project: Linking Culture and Community to Action
Diane Jeanotte RN
Wanda K. Jones, Dr.P.H.
- Optimizing Women’s Health in the United States: Deaths
- Optimizing Women’s Health in the United States: URLs
Favian Kennedy, MSW
Nancy Knapp MPH & Brenda Isaacs
- Integrating Brief Motivation Enhancing Interventions into the Primary Care Setting
- Integrating Brief Motivation Enhancing Interventions into the Primary Care Setting: Handout
Michele R. Lauria, MD, MS
- Optimizing Care Through Simulations and Structured Communication: Plenary
- Vaginal Birth after Cesarean: Still a Viable Option? Workshop
Rachel Locker, M.D.
Tami McBride, CNM, MS, RNC
Richard McClain, MD
Paul Melinkovich, M.D.
Connie Monahan, MPH
- Challenges of SANE in the Clinical Setting (Plenary)
- Making SANE Work: Operational Details (Workshop)
Neil Murphy MD
- 2007 Data Tally
- 2007 Birth Statistics by Facility
- 2007 Narrative Tally
- Human Papilloma Virus Vaccine 2007
- Save the World
- How to keep current
Sue Murphy, RD, MPH, CDE, CLE
Tony Ogburn MD
Sharon Phelan MD
Marilyn Pierce Bulger
- Community Approaches to Reducing Infant Mortality: Nutaqsiivik Program
- Approaches To Reducing Infant Mortality- Nutaqsiivik Program
Usha Ranji, M.S.
Brigg Reilley
- Prenatal HIV Screening: Workshop
- Sharon Schindler Rising, MSN, CNM
- Essential Elements of the Centering Model
Greg Shorr, M.D.
Melanie Taylor MD, MPH
Judy Thierry, DO MPH
Shelley Thorkelson , CNM MSN CDE
- Case Tracking Strategies Using RPMS , CMS, DMS and Hard Copy
- Diabetes in Pregnancy: Case Tracking Strategies
- DM & Pregnancy Program Flowsheet
Sheila Warren, MPH, RN, CPHQ
Judy Whitecrane MSN, CNM
Nancy Whitney, MS, LMHC
- Intervention as Prevention: Working Effectively with Mothers Who Abuse Alcohol and Drugs During Pregnancy
- Parent-Child Assistance Program (PCAP)
2007 Native Women’s Health and MCH Conference
http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NWHMCH51507.pdf
*Web link http://www.ihs.gov/MedicalPrograms/MCH/F/lecNotes.cfm#wHealthConfFrequently Asked Questions
Does anyone have an EHR template that is IHS approved for obstetrical patients?
Question:
I am new to IHS, but does anyone have an EHR template
that is IHS approved for obstetrical patients?
From Maureen Sullivan CNM,
WHNP, MS, Rosebud
Answer:
We have a template that we use just for the initial
intake visit.
Please contact Mary Morphet-Brown Mary.Morphet-Brown@IHS.GOV
Yakama
Indian Health Center Public Health Nursing
If you have other resources to offer, please let me know nmurphy@scf.cc
How to Strengthen Your Pelvic Floor Muscles?
Indian Child Health Notes - Steve Holve, Pediatrics Chief Clinical Consultant
April 2008 - Highlights
- Does scoliosis screening work?
- What are the newest updates in immunizations?
- Meet our new editors for review of published articles relating to AI/AN health?
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ICHN408.doc
Information Technology
Seeking input from the field - Clinician’s Information Management Technology Advisory Council
What do you see as the most important issues or needs at this time?
What do you see as our future needs?
CIMTAC has been in existence for a number of years. We have been the clinicians (doctors and nurses) PSG - Professional Specialty Group. Requests for RPMS packages and enhancements filter through us for approval and/or prioritization. We are going to be taking a more active role in strategic planning for RPMS. We would appreciate your input.
Contact Kathy Ray at Kathy.Ray@IHS.GOV with your suggestions and input.
HIMSS Davies is proud to announce a new recognition opportunity
Since 1994, the Nicholas E. Davies Awards have rewarded excellence in the implementation and value derived from the use of electronic health records (EHRs) by provider organizations, private practices and public health systems. HIMSS proudly announces the expansion of this prestigious national award to recognize Community Health Organizations (CHOs), that are uniquely characterized as providing direct patient care and health services to safety-net underserved and vulnerable populations.
Why Apply?
“For me personally, the Davies Award started me down a very exciting path of opportunity in healthcare, a chance to make a difference on a larger scale, and to ultimately influence the healthcare of those who I could have never reached without this recognition."
~ Jim Morrow, MD, North Fulton Family Practice, 2004 Davies Ambulatory
Award
-Learn from the application process itself as it serves as an introspective
self-assessment that is valuable for planning and optimizing use of EHR technologies
in practice .
-Be recognized for effective adoption of technology and your expertise and achievements
in providing primary care and associated health services to safety-net underserved
and vulnerable populations, while maintaining an open door policy.
-Be an inspiration to your peers, professional associations, patients and communities,
who aspire to better patient safety, quality, effectiveness and efficiency.
-Have an impact by providing education to the larger health care community to
testify before congressional committees making a difference on a larger scale,
sharing model practices, innovative approaches, and lessons learned.
How to Apply:
Written applications are due May 30, 2008 and site visits for qualified applicants will be scheduled during the summer. Visit www.himss.org/davies to learn more about the Davies award, view the application pre-requisites, and download the application.
For more information, e-mail HIMSS, Davies Awards Manager, dcollins@himss.org
If you have any questions or problems please contact us at techsupport@himss.org
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 now 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
- Tthe 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 | Reg Password |
| What's New with iCare? | Thurs 04/03/2008 11:00-12:30 PDT | coyote |
| Tues 04/22/2008 13:00-14:30 PDT | coyote | |
| Thurs 05/08/2008 12:30-14:00 PDT | coyote | |
| Wed 05/28/2008 09:30-11:00 PDT | coyote |
- iCare – Nuts and Bolts
Target Audience – Patient Care Providers (e.g. physicians, mid-level providers, nurses, case managers, public health personnel, pharmacists etc.)
Agenda
- Introductions and Context
- Set Up
- Background Processes
- Establishing and Changing User Preferences
- Panel Creation
- Panel Modification
- Patient Record
| Session | Date and Time | Reg Password |
| iCare Nuts and Bolts | Mon 03/24/2008 11:00-13:00 PDT | coyote |
| Wed 04/16/2008 09:30-11:30 PDT | coyote | |
| Mon 05/19/2008 13:00-15:00 PDT | coyote |
- The Practical Use of iCare
Target Audience – Patient Care Providers (e.g. physicians, mid-level providers, nurses, case managers, public health personnel, pharmacists etc.)
Agenda
- Introductions and Context
- Scenarios
- Tips
- Using the Performance Measure views to improve outcomes
| Session | Date and Time | Reg Password |
| The Practical Use of iCare | Wed 03/26/2008 14:00-15:30 PDT | coyote |
| Tues 04/01/2008 08:00-09:30 PDT | coyote | |
| Thurs 04/17/2008 12:00-13:30 PDT | coyote | |
| Wed 05/21/2008 09:30-11:00 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 Reg Password
A Brief Introduction to iCare Mon 04/07/2008 10:00-10:30 PDT coyote
Wed 05/07/2008 09:30-10:00 PDT coyote
Registration Information
- Click this link:
- In the Search box, type in "iCare" (do not type in the quotation marks) and click the Search button. NOTE: If you do not see the Search For box, ensure the Training Center tab is selected at the top of the WebEx window.
- All of the scheduled sessions will then be displayed in the window below. Choose the one you want to attend and click “Registration” in the Status column.
- Enter the Registration password that is shown above that corresponds to the class you want to attend.
- Click the OK button.
- Complete the registration form.
- Click the Register button.
- A Registration confirmation is displayed that contains all of the information for the training session, including the link for the session and the password to enter when you are ready to attend the session. Click the OK button to finish.
Setup (Software Install) Information:
You must have the WebEx software installed on your computer prior to attending the WebEx session. You should setup the software at least a day before the training session. You should not need anyone such as the Site Manager to install it for you. Below are the instructions.
- Click this link:
- On the left side of the window, locate Set Up
- Click Training Manager
- A message is displaying giving you information about the setup process. Click the Set Up button
- After the software is installed, click the OK button.
Attending the Session:
On the day of the scheduled training, you will receive a confirmation email. When you are ready to attend the session, connect to the WebEx session by clicking on the link in that email. You will then need to connect to the conference line. The dial information for the conference line is shown below and is also included in your registration confirmation message.
Phone Number: (877) 781-4791
Passcode: 135963#International Health Update - Claire Wendland, Madison, WI
Routes to TB treatment in rural Nepal
Tuberculosis remains a serious problem in many low and middle-income countries, and as readers of this newsletter well know, it can also be an issue in impoverished parts of wealthy countries. Several factors associated with poverty make TB more likely: overcrowded living conditions, immune suppression (for instance due to HIV or substance abuse), chronic malnutrition. Besides increasing the chances of acquiring TB, poverty affects the likelihood of getting it properly diagnosed and treated.
A new qualitative study from Nepal explores just how people who develop symptoms from TB find their way to diagnosis and therapy. A team of Dutch and Nepalese researchers interviewed a convenience sample of twenty-six patients undergoing TB treatment at various public health centers – some remote, some more central – in lowland Nepal. They found that all of these patients had consulted more than one provider before beginning therapy. When patients decided where to seek help, their decisions were based on a combination of economic factors, their perceptions of whether the symptoms were serious or not, and the reputations and perceived quality of the providers. The opinions of family members or friends influenced their choices as well. Most patients reported that they began their journeys at a private practitioner’s facility. Lines were long at the free public clinics, these clinics were often far away, and they were known to run short on medications. Patients knew they could get quicker care at nearby private clinics. Many of these places were “medical shops,” places where one can buy drugs with no medical consultation or physical exam. Others were staffed by providers (sometimes medically trained, sometimes not) who offered consultation for a fee.
Unfortunately, only one of these private providers referred a patient to someone more qualified, a problem the authors suggest may relate to financial incentives to keep patients. Most patients self-referred elsewhere only when treatment failed or they lost trust in the competence of their providers. The delay introduced by this chain of referrals lasted an average of seven months before a TB diagnosis was made. (The one positive finding was that once anyone entertained the possibility of TB, appropriate referral for diagnosis and initiation of treatment was quite prompt.)
This article has significant limitations. Chief among these: the sampling strategy means we cannot know what is happening to those who do not find their way to the national treatment program. Nonetheless, these researchers uncovered several practical and counter-intuitive findings for health system planners. First, reputation of the public clinics deterred many people from seeking care there, at least initially – even though the care was free. Second, educational strategies intended to improve TB case-finding will probably need to involve private practitioners. Third, not one person interviewed mentioned anything that could be considered a “cultural barrier” to care, though these are often assumed to be significant in public health programs targeting the underserved.
Ten Asbroek AH, Bijlsma MW, Malla P, Shrestha B, Delnoij DM. . 2008 The road to tuberculosis treatment in Nepal: a qualitative assessment of 26 journeys. BMC Health Serv Res. 2008 Jan 11;8:7.
http://www.ncbi.nlm.nih.gov/pubmed/18190698
Unite For Sight Volunteer Abroad Opportunities
Volunteer Abroad in Summer, Fall, Winter, or Spring:
WITH THE ASSISTANCE OF VOLUNTEERS LIKE YOU, UNITE FOR SIGHT RESTORED SIGHT TO 10,062 PATIENTS AND PROVIDED EYE CARE TO 300,000 IN 2006 AND 2007
How Do I Apply? The application as well as complete details about Unite For
Sight's international opportunities are available at http://www.uniteforsight.org/intl_volunteer/
Who Is Eligible To Volunteer Abroad?: Volunteers are 18 years
and older, and there is no upper age limit. Volunteers range from undergraduate/college
students to medical and optometry students, public health students and professionals,
business students, filmmakers and photographers, nurses and nursing students,
social workers, physician's assistants, teachers and educators, opticians, optometrists
and ophthalmologists.
Unite For Sight welcomes volunteers who may not have previous health or eye
care experience. Volunteers receive all necessary training from Unite For Sight
so that they are able to assist eye doctors with community eye outreach programs.
Unite For Sight also welcomes volunteers to participate as photographers and
filmmakers.
What is Unite For Sight's Mission? Unite For Sight is a 501(c)(3)
nonprofit organization that empowers communities worldwide to improve eye health
and eliminate preventable blindness.
Unite For Sight's work to prevent blindness and restore sight is featured
weekly on CNN INTERNATIONAL from September 2007-August 2008.
What Do Volunteers Do?: Volunteers receive hands-on clinical
experience while assisting doctors in remote, rural villages. Volunteers learn
about international health and eye care, learn clinical skills while working
with patients and doctors, and, in one program location, have an opportunity
to practice cataract surgery on a goat's eye.
The goal of Unite For Sight and its partner eye clinics and communities is to create eye disease-free communities. Unite For Sight’s volunteers (local and visiting) work with partner eye clinics to provide eye care in communities without previous access. The eye clinic’s eye doctors and Unite For Sight volunteers jointly provide community-based screening programs in rural villages. The clinic’s eye doctors diagnose and treat eye disease in the field, and surgical patients are brought to the eye clinic for surgery. Patients receive free surgery funded by Unite For Sight so that no patient remains blind due to lack of funds. Volunteers immediately see the joy on patients' faces when their sight is restored after years of blindness. These memories last a lifetime.
While helping the community, volunteers are in a position to witness and draw their own conclusions about the failures and inequities of global health systems. It broadens their view of what works, and what role they can have to insure a health system that works for everyone and that leaves no person blind in the future.
What Do Volunteers Say?
“During my volunteering experience, I realized that Unite for Sight’s
service is a campaign for the salvation of humanity that allows the light of
compassion to shine through each of us. I believe it is this display of altruism
and commitment that makes the organization’s service so virtuous and treasured
by both volunteers and patients. After all, making a difference in the world
is not so difficult if only one would care enough to sacrifice a part of oneself
in order to change the world for the better. My experience as a Unite for Sight
volunteer has inspired me to dedicate my future career to serving underprivileged
communities around the world.”—Chiwing “Jessica” Qu,
Yale University Undergraduate Student, Unite For Sight Volunteer in Chennai,
India
"I can honestly say that everything I learned in 3 years of medical school paled in comparison to the 3 week experience I had in Accra ( Ghana) in October 2007 as part of Unite For Sight. The program provides volunteers with a unique and hands-on involvement – being able to help out to the level of your training and comfort. My experience taught me that Ghanaian people are the friendliest people I have interacted with anywhere in the world, that ordinary people involved with Unite For Sight are making extraordinary differences, and that sitting in a classroom receiving a world-class education cannot match real life experiences while volunteering."--Varun Verma, UMDNJ Medical Student, Unite For Sight Volunteer in Accra, Ghana
"While in Ghana, I worked with an ophthalmologist (Dr. James Clarke), two eye nurses (Robert Dolo, Kartee Karloweah), an assistant (Bismark Boryor), and a coordinator (Seth). Working with the Unite for Sight team on these outreaches in service to these wonderful people of Ghana was the single most rewarding work I've done in my life. The people of Ghana are some of the friendliest and most thankful of anyone I have ever met. Overall, the experience has changed the way I view the world, my own country, and my role in the world forever. The only way to understand the way 4/5 of the world lives is to go yourself and get involved. The staff I worked with that are the heart and soul of Unite for Sight in Accra were some of the brightest and hard working individuals I have ever met. They are accomplishing feats few ever accomplish in their lives, and I am truly blessed to have had the opportunity to work with them and now call them my friends. I look forward to future work with Unite for Sight as an Ophthalmologist. The task at hand in Ghana, and I'm sure in all of Unite for Sight's locations throughout the world, is enormous. The more people that get involved, the more accessible services will be to these wonderful people. Plain and simple, the more we help, the more people can see the world they live in!”—Brian Fowler, Medical Student at University of Virginia, Unite For Sight Volunteer in Accra, Ghana
Hundreds of volunteer narratives, volunteer diaries, as well as videos of alumni volunteers and partner eye doctors are available on the Unite For Sight website: http://www.uniteforsight.org/intl_volunteer
Also, Unite For Sight's Fifth Annual International Health Conference is coming up at Yale on April 12-13, 2008. Keynote addresses by Dr. Jeffrey Sachs, Dr. Sonia Sachs, Dr. Jim Yong Kim, Dr. Allan Rosenfield, and Dr. Susan Blumenthal. Plus 180 Speakers and 2,000+ conference attendees. Register for the conference at http://www.uniteforsight.org/conference
From Jennifer Staple Jennifer.Staple@AYA.YALE.EDU via Advanced Practice Nurses LISTSERV
MCH Alert
New Bullying-Prevention Toolkit Released
Eyes on Bullying . . . What Can You Do? A Toolkit to Prevent Bullying In Children's Lives offers a variety of tools to help parents and other caregivers understand bullying in a new way, reexamine their knowledge and beliefs about bullying, and shape the beliefs and behaviors of the children in their care. The toolkit, created at Education Development Center, is designed especially for parents and other caregivers of preschool- and school-age children and adolescents to use in child care programs, after-school programs, and camps. Topics include (1) the issue of bullying; (2) why bullying can sometimes be difficult to see; (3) the concepts of bully, victim, and bystander; (4) recommendations and strategies for addressing bullying when it occurs; (5) a strategic approach to creating an environment where everyone takes responsibility for preventing bullying; and (6) resources and references on bullying prevention. The toolkit is available at http://www.eyesonbullying.org/pdfs/toolkit.pdf
All the content from the toolkit and additional information, materials, and resources are available from the Eyes on Bullying Web site at http://www.eyesonbullying.org
Chartbook Reports Findings From National Survey of Children with Special
Health Care Needs
The National Survey of Children with Special Health Care Needs Chartbook 2005-2006
highlights major findings on the prevalence of special health care needs among
children, both nationally and within each state, and on access to and satisfaction
with health care among children with special health care needs (CSHCN) and their
families. The survey, sponsored by the Maternal and Child Health Bureau and carried
out by the National Center for Health Statistics, provides information about
six core outcomes used to measure progress toward the Healthy People 2010
objectives to increase the proportion of states that have integrated service
systems for CSHCN. The chartbook is available at http://mchb.hrsa.gov/cshcn05/index.htm
Breastfeeding Improves Prevalence of Metabolic Syndrome Among Women in Midlife
We have found that duration of lactation is associated with prevalence of MetSyn [metabolic syndrome] in parous midlife women in a dose-response manner.
The authors found that
- There were 536 prevalent cases of MetSyn (21.3%).
- Among women who breast fed, 297 (18.3%) met the criteria for MetSyn, compared with 239 among those who did not (26.7%).
- Women who developed MetSyn were more likely to have a higher body mass index (BMI) at time of interview and at completion of high school, to be African American, to smoke, and to be of lower socioeconomic status. They also breast fed for shorter periods of time.
- Duration of lactation was inversely correlated with current BMI, waist circumference, systolic blood pressure, diastolic blood pressure, fasting levels of glucose, insulin, triglycerides, total cholesterol, and low-density lipoprotein cholesterol. There was a positive correlation with fasting high-density lipoprotein levels.
- After adjusting for age, current smoking, parity, ethnicity, socioeconomic status, study site, physical activity, caloric intake, and high-school BMI, parous women who had ever breast fed had a significantly lower prevalence of MetSyn.
- The rate of MetSyn was significantly lower with increasing duration of lactation, suggesting a dose-response relationship.
The authors conclude that "in addition to the pediatric benefits of breast-feeding, these findings of maternal benefit may encourage more women to initiate and maintain breast-feeding behavior."
Ram
KT, Bobby P, Hailpern S. 2008. Duration of lactation is associated with lower
prevalence of the metabolic syndrome in midlife -- SWAN, the Study of Women's
Health Across the Nation. American Journal of Obstetrics and Gynecology 198(3):268.e1-268e6.
http://www.ajog.org/article/S0002-9378(07)02226-0/abstract
MCH Headlines - Judy Thierry HQE
Maternal, Infant and Child Health Capacity Needs Assessment
In an effort to better understand the maternal, infant and child health (MICH) services available to urban American Indians and Alaska Natives (AI/AN); the Urban Indian Health Institute (www.uihi.org) conducted a Maternal, Infant and Child Health Capacity Needs Assessmentwith 34 urban Indian health organizations (UIHO) funded through Title V of the Health Care Improvement Act. The purpose of the assessment was to assist in identifying specific assets, limitations or gaps in the urban Indian health program as a whole.
The findings of this capacity needs assessment highlight current areas of strength and need in providing MICH care to urban AI/AN. Findings document a need for additional pregnancy and infant health services at many sites. Increased resources to support MCH services offered by UIHOs may effectively reduce observed MCH disparities among urban AI/AN in the risk of adverse birth outcomes and infant mortality.
For a link to the report: http://www.uihi.org/publications/reports/ . Please contact the Project Coordinator with any questions or comments: Shira Rutman, shirar@uihi.org or 415-374-7868.
Key Findings:
Pregnancy and Infant Health Services
- The majority of sites provide immunizations, well-child visits and parenting support. However, around one-third of sites does not offer or refer clients for maternity case management, childbirth classes, home visits/public health nurse visits and SIDS counseling. Slightly more sites offer or refer for newborn screening and lactation support.
- The need for pregnancy and infant health services is also seen in the large number of sites reporting shortages of providers/services and resources/funding for MICH services.
- The specific need for OBGYN providers and services was a theme repeated throughout the survey.
- Limited funding for an OB provider was also reported as a barrier to care for pregnant women.
Dental Care
- The need for dental and prenatal dental care providers was mentioned specifically by site representatives and was reported as an unmet need by both clients and providers.
Child Care and Transportation
- Most sites provide transportation assistance to their sites, but only one of the participating sites offers childcare, and only on an informal basis.
- The need for child care and transportation was mentioned expressly by clients and may be an important barrier to the provision of health services for UIHO.
GHSA and State Farm Partner to Keep 'Tweens and Teens Safe age 8 to 18
- Leading cause of death for children 3 and older, but … low support for programs for 5 to 16 year olds.
- Training courses by/for educators not readily available. [i.e. see emails on drive it right curriculum]
- The strong and well informed constituency of early childhood safety ‘falls away’ as children get older.
Assessment tool for state highway safety offices to examine their OPC programs and focus their resources where they are most needed.
Five priority areas for which the respondents
requested additional information:
- programs for “tweens”,
- funding and resources,
- marketing strategies,
- data and evaluation, and
- law enforcement.
- The Manual highlights programs that are designed to address the needs of children who fall between a booster seat program and traditional driver education programs.
- Ages of eight and 16.
- data-driven and research-based program.
- various program components that be replicated throughout the country.
- PDF document online
- advisory team led by GHSA Executive Director Barbara Harsha and made up of representatives from GHSA, NHTSA, The Children's Hospital of Philadelphia, and State Farm provided direction and leadership for the project.
Medical Mystery Tour
You know how to treat yeast infections, right? Which of these are true about vulvar pruritus ?
1.) It is important to ask patients presenting with vulvar pruritus if symptoms vary with their cycles
True
False
2.) Candida glabrata tends to respond to intravaginal boric acid therapy
True
False
3.) Nystatin successfully treats the majority of patients with tinea cruris.
True
False
4.) Topical steroid ointments at the correct treatment for lichen sclerosus
True
False
5.) Classic psoriasis occurs often on the vulva
True
False
Please think about the above scenarios.
The answers, with discussion and references, will be available in next month’s CCC Corner Medical Mystery Tour.
Stay tuned to next issueMedscape*
Overactive Bladder: Diagnosis and Treatment in Primary Care, CME/CE
http://www.medscape.com/viewprogram/8987
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 passwordMenopause Management
What Happened to Women in WHI study 3 years after stopping HRT?
RESULTS: The risk of cardiovascular events after the intervention was comparable by initial randomized assignments, 1.97% (annualized rate) in the CEE plus MPA (343 events) and 1.91% in the placebo group (323 events). A greater risk of malignancies occurred in the CEE plus MPA than in the placebo group (1.56% [n = 281] vs 1.26% [n = 218]; hazard ratio [HR], 1.24; 95% confidence interval [CI], 1.04-1.48). More breast cancers were diagnosed in women who had been randomly assigned to receive CEE plus MPA vs placebo (0.42% [n = 79] vs 0.33% [n = 60]; HR, 1.27; 95% CI, 0.91-1.78) with a modest trend toward a lower HR during the follow-up after the intervention. All-cause mortality was somewhat higher in the CEE plus MPA than in the placebo group (1.20% [n = 233] vs 1.06% [n = 196]; HR, 1.15; 95% CI, 0.95-1.39). The global index of risks and benefits was unchanged from randomization through March 31, 2005 (HR, 1.12; 95% CI, 1.03-1.21), indicating that the risks of CEE plus MPA exceed the benefits for chronic disease prevention.
CONCLUSIONS: The increased cardiovascular risks in the women assigned to CEE plus MPA during the intervention period were not observed after the intervention. A greater risk of fatal and nonfatal malignancies occurred after the intervention in the CEE plus MPA group and the global risk index was 12% higher in women randomly assigned to receive CEE plus MPA compared with placebo.
Heiss G , Wallace R , Anderson GL , Aragaki A , Beresford SA , Brzyski R , Chlebowski RT , Gass M , LaCroix A , Manson JE , Prentice RL , Rossouw J , Stefanick ML ; WHI Investigators . Health risks and benefits 3 years after stopping randomized treatment with estrogen and progestin. JAMA. 2008 Mar 5;299(9):1036-45. http://www.ncbi.nlm.nih.gov/pubmed/18319414
Associations between subjective night sweats and sleep study findings
CONCLUSIONS: Subjective night sweats are associated with a variety of other sleep-related symptoms, but we could find no evidence for an association between subjective night sweats and objective evidence of specific sleep disorders.
Mold JW et al Associations between subjective night sweats and sleep study findings. J Am Board Fam Med. 2008 Mar-Apr;21(2):96-100. http://www.ncbi.nlm.nih.gov/pubmed/18343856?dopt=Abstract
The Beneficial Effect of Hormone Therapy on Mortality and Coronary Heart Disease in Younger versus Older Postmenopausal Women
http://www.medscape.com/viewarticle/569935?src=mp
Black Cohosh and Menopausal Symptoms: Cases in CAM
What's the evidence regarding black cohosh? Your older female patients may be using it.
http://www.medscape.com/viewarticle/569485
FDA Goes After 'Natural' HRT Claims
Federal regulators warned several pharmacy companies Wednesday to stop marketing so-called "natural" hormone replacement therapy, calling their sales to women "false and misleading."
http://www.medscape.com/viewarticle/568648?src=srMidwives Corner - Lisa Allee, CNM, 4 Corners Regional Health Center, Red Mesa, AZ
Midwives Excel at Keeping Birth Normal, and Midwife-Provided Acupuncture Helps With PROM
Amy Romano, CNM with the Lamaze Institute for Normal Birth presents four fabulous studies in a review of research that further support the extensive benefits of normal birth.
The first study convincingly shows that midwifery care is more effective in keeping birth normal and, thus, women healthier. The study focused on care for women at moderate obstetrical risk. This prospective cohort study made use of an intriguing new tool called the “Optimality Index-US” which assesses care processes as well as outcomes giving better information than just mortality and morbidity. The study found provider type to be predictive of optimality with midwifery care having higher scores. For example: “The cesarean-section rate was 13% among women in the midwife group versus 34% in the physician group, a difference that also was not explained by health status alone. (The rates were 5.6% and 15.6%, respectively, after excluding women with preexisting chronic medical conditions.) In various statistical analyses, only type of provider accurately predicted cesarean rates in the two groups.” As to why this may have been true some of the processes of care looked at included: “Compared to women in the physician group, women in the midwife group were more likely to drink or eat (95% vs. 80%); maintain mobility in labor (68% vs. 28%); and use nonpharmacologic methods of pain relief (88% vs. 51%). Epidural use was lower in the midwife group than in the physician group (31% vs. 51%), as was use of any pharmacologic pain-relief methods (64% vs. 82%).” Romano concludes her review with the following: “In this and other studies, midwifery care has been associated with high optimality, demonstrating appropriate use of interventions and good outcomes given the individual women's clinical situations. Midwives are often assumed to care for only low-risk women, but many midwives also care for women at moderate or high risk. This study finds that midwifery may be optimal for a moderate-risk population by promoting good outcomes with less reliance on technological and surgical intervention and greater attention to the care practices that support normal birth.” This certainly rings very true for midwifery in the Indian Health Service—we care for women of all risk levels and have impressive outcomes and I would bet “optimality” scores as well. Anyone ready to do the research with this new tool?
The second study looked at third and forth degree perineal tears and again found the less interventionist path to be the preferred route. They looked at six modifiable factors-- forceps, vacuum, episiotomy, prolonged second-stage labor, fetal occiput posterior position during crowning, and epidural—and found that avoiding these individually and definitely in combination helped prevent third and forth degree tears. In her assessment of this study in regards to normal birth Romano says: “Third- and fourth-degree anal tears are highly associated with pain and incontinence in the postpartum period and contribute to long-term pelvic floor dysfunction. Unfortunately, this argument has fueled the debate about the rights of women to choose medically unnecessary cesarean surgeries rather than prompting examination of the obstetric management practices that contribute to excess risk of anal sphincter damage in vaginal births. This study provides evidence of a strong link between modifiable obstetric practices such as episiotomy, epidural use, and instrumental vaginal birth and anal sphincter tears. This study also reinforces that, when instrumental vaginal birth becomes necessary, episiotomy should be avoided and vacuum extraction is less likely to injure the anal sphincter than forceps birth. Although some instances will always occur when these interventions are necessary for fetal or maternal well-being, their overuse contributes to excess maternal morbidity with long-term consequences. Care practices such as avoiding routine interventions, promoting comfort in labor through mobility and nonpharmacologic techniques, and encouraging physiologic, spontaneous pushing in nonsupine positions (none of which were assessed in this study) minimize the risk of severe lacerations both directly in the case of spontaneous nonsupine pushing and indirectly, by reducing the need for epidural, promoting optimal positioning of the fetus, and reducing forceps and vacuum use.” Again these are all aspects of the midwifery model of care.
The third study looked at midwives providing a 20-minute acupuncture treatment to women with PROM. The women in the treatment group had significantly shorter active labor—4.4 hours vs. 6.1 hours—and the relationship was even stronger when they controlled for parity, epidural use, and infant birth weight. For women who were induced the active phase in the control group was twice as long as in the acupuncture group and acupuncture was associated with less augmentation of labor as well. This study was small but the results are impressive. Romano makes some very meaningful conclusions as to the relevance of this to the promotion of normal birth: “Although the majority of women will go into labor on their own after membranes rupture at term, many providers encourage pharmacologic induction out of concern about infection. Minimal evidence suggests that a policy of routine induction for PROM prevents infection, and several studies report an increase in cesarean rates with induction for PROM versus expectant management. Furthermore, pharmacologic induction always requires other interventions such as intravenous lines, electronic fetal monitoring, and restrictions on mobility in labor, transforming a normal birth into a medicalized one and introducing potentially unnecessary risks. Low-risk techniques to encourage labor to start may be beneficial in preventing complications of both prolonged membrane rupture` and aggressive induction protocols. This small but well-designed study suggests that acupuncture treatment influences labor initiation and progress in women with PROM. A larger trial may be able to confirm an effect on mode of birth, rates of induction, and likelihood of infection. However, in the meantime, the fact that acupuncture has not been shown to be harmful to birthing women or their newborns suggests that it is an optimal first-line approach when the option of encouraging labor to start is desirable.” Some IHS sites are providing acupuncture services (finally!) for patients. I think it behooves midwives to work with acupuncture providers in IHS and/or outside IHS to get trained in this technique of promoting labor.
The forth study was published in the ACNM journal and looked at the experience of women in early labor. The study’s results and Romano’s comments are very encouraging for all of us to examine how we prepare and care for women in early labor. Romano says: “For women who choose hospital birth, mounting evidence suggests that their likelihood of achieving vaginal birth is strongly influenced by how long they stay home. However, simply advising women to stay home until active labor is well established may contribute to anxiety and confusion if they are not equipped with appropriate information, support, and anticipatory guidance. This small study suggests that women spend energy and time in early labor sorting out their expectations, devising new plans, managing mixed emotions, and second-guessing decisions. Providing women with strategies to anticipate and deal with gaps between expectations and experiences may help them adapt better to early labor and have confidence in their management strategies. Reassessing how childbirth educators teach women to self-diagnose labor—or introducing models that include home visitation or outpatient early-labor assessment and support, as proposed by the study authors—may help women who choose hospital birth to optimize the timing of hospitalization to achieve normal births.” I highly recommend that each midwifery service in IHS read this study, examine how early labor is talked about with patients in classes, groups, or clinic, and how early labor triaging and care is provided for in the labor and birthing areas.
Romano, A., Research Summaries for Normal Birth, J Perinat Educ. 2007 Spring; 16(2): 47–50.
http://www.ncbi.nlm.nih.gov/pubmed/18311339
Women given sterile water injection experience less labor pain compared to acupuncture
RESULTS: The main results of this study were that sterile water injections yielded greater pain relief (p<0.001) during childbirth compared to acupuncture. The secondary outcome showed that women in the sterile water group had a higher degree of relaxation (p<0.001) compared to the acupuncture group. The women's own assessment of the effects also favoured sterile water injections (p<0.001). There were no significant differences regarding requirements for additional pain relief after treatment between the 2 groups. CONCLUSIONS: Women given sterile water injection experience less labour pain compared to women given acupuncture.
Mårtensson L et al Acupuncture versus subcutaneous injections of sterile water as treatment for labour pain. Acta Obstet Gynecol Scand. 2008;87(2):171-7. http://www.ncbi.nlm.nih.gov/pubmed/18231884
Irrespective of treatment, pelvic girdle pain regresses in majority by 12 weeks after delivery
RESULTS: Approximately three-quarters of all the women were free of pain 3 weeks after delivery. There were no differences in recovery between the 3 treatment groups. According to the detailed physical examination, pelvic girdle pain had resolved in 99% of the women 12 weeks after delivery. CONCLUSIONS: This study shows that irrespective of treatment modality, regression of pelvic girdle pain occurs in the great majority of women within 12 weeks after delivery.
Elden H et al Regression of pelvic girdle pain after delivery: follow-up of a randomised single blind controlled trial with different treatment modalities. Acta Obstet Gynecol Scand. 2008;87(2):201-8.
http://www.ncbi.nlm.nih.gov/pubmed/18231889
Cervical Cancer Screening Practices of Certified Nurse-Midwives in the United States
Many nurse-midwives initiate cervical cancer screening earlier than guidelines recommend; 72% would initiate screening in an 18-year-old within 1 month of coitarche, while 36% would begin screening virginal girls at age 18, and many continue cervical cancer screening after guidelines recommend cessation. More than 60% of the respondents would continue screening a woman who had undergone total hysterectomy for symptomatic fibroids who had no history of dysplasia, and half would continue to screen a 70-year-old woman with a 30-year history of previous normal Pap tests. In addition, despite guidelines which recommend less frequent screening, more than one-quarter (28%) would continue annual screening in a 35-year-old woman with three or more normal tests. Certified nurse-midwives are performing cervical cancer screening more frequently than current guidelines recommend. Comparisons to the practice of other providers are offered. Education to limit unnecessary testing is needed.
Murphy PA et al Cervical cancer screening practices of certified nurse-midwives in the United States. J Midwifery Womens Health. 2008 Jan-Feb;53(1):11-8. http://www.ncbi.nlm.nih.gov/pubmed/18164429
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.Nurses Corner - Sandra Haldane, HQE
Call for nominations of nurses working in Indian health: Deadlines looming
The National Nurse Leadership Council (NNLC) is happy to call for award nominations of nurses working in Indian Health Service, Tribal, or Urban Indian Health Programs. Awards will be given in the following categories:
- Nurse Administrator
- Advanced Practice Nurse
- Clinical Nurse
- Public Health Nurse
- Ancillary Nurse Assistant
- Nursing Group
- Special Friend of Nursing
These Awards will be presented at the Nurse Leadership in Native Care (NLiNC) meeting, formerly NCONA, in Anchorage, AK, May 14, 2008. Please see the attached documents for the nominations form and criteria. Nomination deadline for these awards is ASAP. Travel costs to receive these awards, with the exception of the Chief Nurse Officer Awards, will be picked up by the IHS Headquarters Division of Nursing. Your assistance in disseminating this call for nominations as well as for nominating one or several of the outstanding nurses we have in the Indian health system is greatly appreciated.
Please consider nominating our incredible IHS (CO, CS, Tribal) nurses for the following awards
Deadline for submission is April 4.
Mabel May Wagner Award
This award, established in 1979, is open to all professional nurses in the PHS who are engaged in clinical nursing practice. The award consists of an engraved plaque and $1000 in cash. The award is presented annually at the COA Symposium to a professional nurse in the Public Health Service (Commissioned Corps, Tribal or Civil Service) who:
* Exemplifies resourcefulness and dedication in helping to accomplish the mission of the Public Health Service;
* Demonstrates professional and technical skills and competence raising the quality of nursing;
* Displays evidence of exceptional ability to apply nursing standards of practice;
* Remains involved in continuing education as a participant, organizer or sponsor of it;
* Is of such excellence as to merit Public Health Service recognition.
Nominations:
Nominations may be made by an HHS employee or employee where the nurse officer, tribal nurse or civil service nurse is detailed, in the form of a letter containing:
* Name, title and grade or rank of the nominee;
* Work experience and educational background of the nominee;
* A brief description of the nominee’s present duties and responsibilities including the scope of work;
* A narrative statement of how the person meets the criteria for the award including a description of the specific accomplishments and/or contributions on which the nomination is based as well as exploring current practice vs. lifetime achievement. The achievements for which the nurse is being recognized should be within the last three years.
* Must state, in writing, that the individual is in good standing and has an active RN license on file (for Commissioned Corps officers in must be on file with DCP); and
* An endorsement by the nominee’s supervisor (responsible for ensuring the candidate’s good standing and work performance) and the final verification (for the recommended award recipient) will be by the Chief Nurse Officer (who will check with DCP to ensure that there are no outstanding actions and that an active license is on file).
* Award nominations should be limited to two pages.
The deadline for receipt of nominations for the 27th annual Mabel May Wagner Nursing Award is April 4, 2008. Please send nominations via email to CDR Suzanne England, COA Team Leader, at suzieq@gwtc.net
Lucille Woodville Award
This award was established in the Public Health Service's (PHS) centennial year as a memorial to the professional career of Lucille Woodville, who began her illustrious career in the Indian Health Service (IHS) in 1956. As part of her work in IHS, Ms. Woodville established the first Nurse Midwifery Service in Bethel, Alaska. She retired in 1973, after serving as Assistant Chief (1964-1971) and Chief (1971-1973) of the Maternal Child Health Branch, Division of Indian Health, Health Resources Services Administration, of the PHS.
This award honors a nurse midwife or a maternal/child health nurse whose work has resulted in significant contribution to the health and well-being of mothers and newborns. Each nominee must demonstrate outstanding contributions in improving maternal/child health. This contribution may be the commitment of their time and skills in the clinical setting, or may be in the design, implementation and/or management of innovative maternal/child health programs. All registered nurses, Civil Service, Tribal and Commissioned Corps, are eligible for the award. Any employer or employee of the PHS or Associate of a PHS contract or grant program may nominate a PHS nurse for this award.
Nominations:
Nominations may be made by an HHS employee or employee where the nurse officer, tribal or civil service nurse is detailed, in the form of a letter containing:
* Name, title and grade or rank of the nominee;
* Work experience and educational background of the nominee;
* A brief description of the nominee’s present duties and responsibilities including the scope of work;
* A narrative statement of how the person meets the criteria for the award including a description of the specific accomplishments and/or contributions on which the nomination is based.
* Must state, in writing, that the individual is in good standing and has an active RN license on file (for Commissioned Corps officers in must be on file with DCP); and
* An endorsement by the nominee’s supervisor (responsible for ensuring the candidate’s good standing and work performance) and the final verification (for the recommended award recipient) will be by the Chief Nurse Officer (who will check with DCP to ensure that there are no outstanding actions and that an active license is on file).
* Award nominations should be limited to two pages.
The award is presented annually at the COA Symposium.
The deadline for receipt of nominations for the Lucille Woodville Nursing Award is April 4, 2008. Please send nominations via email to CDR Suzanne England, COA Team Leader, at suzieq@gwtc.net .Office of Women's Health, CDC
April 7 – 13 th is National Public Health Week
This year’s focus is on Climate Change and it’s effect on vulnerable populations.
More information on planning events for your community is available at: http://www.nphw.org/nphw08/08_pg_ideas.htm
Oklahoma Perspective Greggory Woitte – Hastings Indian Medical Center
Prenatal Care in Oklahoma
A study released last fall compared the state of Oklahoma statistics of Native American women receiving prenatal care versus White women. The study showed a significant increase in the numbers of Native American women receiving prenatal care since the previous study was done in 1994. Today 76.7% of Native American women receive prenatal care in the first trimester, not significantly different from White women (78.8%). This improvement is greatly attributed to the significant improvement in access to care through construction of new and expansion of existing Indian Health Service, Tribal and Urban Health facilities. Barriers to care included in decreasing order: Lack of pregnancy recognition (51.8%), inability to get an earlier appointment (21.2%) and no Medicaid card (16.7%).
Other Statistics
Native American women were more likely to have their first baby before 18 (24.5% versus 14.3%)
Number one barrier to obtaining prenatal care as early as desired for Native American mothers was “I didn’t know I was pregnant”.
http://www.ok.gov/health/documents/PRAMS_Native%20Am_2007.pdf
or
http://www.tulsaworld.com/news/article.aspx?articleID=071213_1_A24_hAnew76523Osteoporosis
Drugs that affect bone metabolism
Many drugs can affect bone metabolism. As an example, heparin , warfarin , cyclosporine , glucocorticoids , medroxyprogesterone acetate , cancer drugs and thyroid hormone can cause bone loss, while thiazide diuretics can minimize bone loss
http://www.uptodateonline.com/utd/content/topic.do?topicKey=minmetab/15467Patient Information
Treating Depression: What You Should Know
http://www.aafp.org/afp/20080315/785.html
Self-management: Taking Charge of Your Health
http://familydoctor.org/online/famdocen/home/healthy/prevention/785.html
Perinatology Picks - George Gilson, Maternal Fetal Medicine, ANMC
Maternal Fetal Medicine Editorial Comment
Clarification for What is this all about the ‘minor markers’ for Down Syndrome?
We would like to clarify a few points before you read the story below entitled: What is this all about the ‘minor markers’ for Down Syndrome?
If women undergo first trimester Down syndrome (DS), and the results are negative (risk <1:300), the system set up at ANMC, "contingent sequential screening", considers them as not requiring further second trimester screening for DS. This is because second trimester quadruple marker screening will increase the number of false positive results if first trimester results are not taken into account. Other screening systems, such as "integrated screening" do use both first and second results do compute a final risk estimate, but this is not the strategy we have chosen to use at ANMC. Despite negative first trimester DS screening, women still need to be screened for open neural tube defects (NTD). We accomplish this at ANMC by having all women undergo a comprehensive fetal anatomic survey at 16-20 weeks. Ultrasound has a 96% sensitivity for NTD, whereas quad screening with maternal alpha fetoprotein (AFP) only has an 80% sensitivity (only 65% in pregnancies not ultrasound dated!). If your service unit is unable to do routine second trimester ultrasounds however, you still must offer women NTD screening with AFP testing, even if they have had negative first trimester DS screening results.
What is this all about the ‘minor markers’ for Down Syndrome?
I just wanted to share some info with you (that you may already know) about sonographic 2nd trimester markers for fetal Down syndrome and their significance.
The minor markers: echogenic intraventricular focus (EIF), choroids plexus cyst (CPC), ‘sandal-gap’ toes, pyelectasis, clinodactyly, etc. are poor predictors of DS (but excellent predictors of overwhelming maternal anxiety!). They are found in about 1% of normal fetuses between 15-20 wks. Younger women (<35 y/o) with a negative quad screen are at very low risk if they have one of these minor markers; amnio is not recommended for this group.
An enlarged nuchal thickness (NT), echogenic bowel, more than one marker, or any anomaly, are stronger predictors. Older women (>35 y/o), with or without a positive quad screen, are at higher risk with even a minor marker however, and counseling about amnio may be appropriate for this group.
The EIF is often the most worrisome to women; they should be reassured that it is NOT a marker that something is wrong with the baby’s heart; and they do NOT need fetal echocardiography for follow up. They should also be reassured that a CPC does not mean there is something wrong with their baby’s brain! Nevertheless, if the patient is anxious about these findings, it would be appropriate to obtain a follow up scan to reassure the patient that the marker has resolved.
Attached is a chart of the relative risks of each of the markers. Notice that a negative ultrasound (no markers found) will actually lower the pt’s risk (RR = 0.6) and should be reassuring (although it can’t be 100% so…..).
Also, as more patients get 1st trimester testing (to include BOTH nuchal translucency and PAPP-A and free bHCG at 11-13 wks, not just NT), it is important to know that that’s all they need; 2nd trimester testing is NOT indicated. If the results of 1st trimester screening are negative, no further (noninvasive) testing is indicated, and 2nd trimester testing will then only increase the number of false positives.
Trisomy-21 (Down syndrome) Second Trimester Ultrasonographic Markers
| RR | |
| thickened nuchal fold* | 19.0 |
| short femur | 2.3 |
| short humerus | 2.5 |
| cardiac abnormality (VSD, AV canal, Tetralogy) | 25.0 |
| echogenic bowel | 5.5 |
| choroid plexus cyst | 1.5 |
| hypoplasia of the middle phalanx of the 5th finger (clinodactyly) | 1.5 |
| widened iliac wings | |
| echogenic intracardiac focus | 1.5 |
| pyelectasis | 1.5 |
| sandal gap toes | |
| double bubble sign of duodenal atresia (usually 3rd trimester) | |
| absent nasal bone | |
| 2-vessel umbilical cord | |
| normal scan/no markers | 0.6 |
* NF by GA
| Weeks | Mean | 95th% |
| 16 | 2.8 | 4 |
| 17 | 3.0 | 5 |
| 18 | 3.3 | 5 |
| 19 | 3.6 | 5 |
| 20 | 3.7 | 6 |
| 21 | 3.9 | 6 |
| Multiple markers increase the likelihood of DS: | LR |
| Two markers | 10 |
| > 3 markers | 115 |
In a meta-analysis of 2nd trimester ultrasound to detect fetuses with Down syndrome (Smith-Bindman R, et al. JAMA 2001 (N=132,295; DS incidence =1.5%) the following information was derived:
In the absence of a major anomaly, the US markers had the following diagnostic values: sensitivity: 69%; FPR: 8%; PPV 1.5%; NPV: 99%
Smith-Bindman R, et al. Second-trimester ultrasound to detect fetuses with Down syndrome: a meta-analysis. JAMA. 2001 Feb 28;285(8):1044-55 .
http://www.ncbi.nlm.nih.gov/pubmed/11209176
Tobacco use increases the risk of a SGA infant at term across maternal strata
CONCLUSION: Self-identified tobacco use increases the risk of a SGA infant at term across maternal strata.
Aagaard-Tillery KM et al In utero tobacco exposure is associated with modified effects of maternal factors on fetal growth. Am J Obstet Gynecol. 2008 Jan;198(1):66 http://www.ncbi.nlm.nih.gov/pubmed/18166310Primary Care Discussion Forum - Ann Bullock, Cherokee, NC
Topic: Mental health issues in children and adolescents
When: Discussion ongoing now. Still time to join in
Moderator: Dr. Frank Armao, Psychiatry staff at Winslow
Salient points for discussion
-The complex influence of early life stress and trauma in shaping development.
-The increased burden of developmental stress as it pertains to Native Americans.
-How to distinguish teens with relatively normal perturbation in development from those needing more intensive management and/or referral to behavioral health.
-What constitutes a significant mood disorder in an adolescent, and what are the options for management.
-The serious limitations of DSM-IV and current nosology in “diagnosing” adolescent behavioral health conditions.
Primary Care Discussion Forum website
http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForum.cfm
How to subscribe / unsubscribe to the Primary Care Discussion Forum?
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Questions on how to subscribe, contact ANNBULL@nc-cherokee.com directlySTD Corner - Lori de Ravello, National IHS STD Program
USPSTF Recommendations for STI Screening
Since 2000, the U.S. Preventive Services Task Force (USPSTF) has issued eight clinical recommendation statements on screening for sexually transmitted infections. This article, written on behalf of the USPSTF, is an overview of these recommendations. The USPSTF recommends that women at increased risk of infection be screened for chlamydia, gonorrhea, human immunodeficiency virus, and syphilis. Men at increased risk should be screened for human immunodeficiency virus and syphilis. All pregnant women should be screened for hepatitis B, human immunodeficiency virus, and syphilis; pregnant women at increased risk also should be screened for chlamydia and gonorrhea. Nonpregnant women and men not at increased risk do not require routine screening for sexually transmitted infections. Engaging in high-risk sexual behavior places persons at increased risk of sexually transmitted infections. The USPSTF recommends that all sexually active women younger than 25 years be considered at increased risk of chlamydia and gonorrhea. Because not all communities present equal risk of sexually transmitted infections, the USPSTF encourages physicians to consider expanding or limiting the routine sexually transmitted infection screening they provide based on the community and populations they serve.
Am Fam Physician. 2008;77(6):819-824. http://www.aafp.org/afp/20080315/819.html
ACS Releases Guidelines for HPV Vaccination
The American Cancer Society (ACS) guideline for the early detection of cervical cancer was last reviewed and updated in 2002. 1 Since then, two vaccines against the most common cancer-causing types of human papillomavirus (HPV) have been developed and tested in clinical trials (i.e., quadrivalent HPV vaccine [Gardasil] and bivalent HPV vaccine [Cervarix], not yet approved by the U.S. Food and Drug Administration [FDA]). 2-7 An expert panel was convened by the ACS to review the data on HPV vaccines and to develop recommendations for their use. 8 This group worked independently from the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention, but reviewed the same data sources. Recommendations from both groups for the use of the quadrivalent HPV vaccine were published in 2007 and are summarized in Table 1. 2-4,8-10 The ACIP recommendations, which the American Academy of Family Physicians endorses, apply specifically to the quadrivalent vaccine because it currently is the only FDA-approved HPV vaccine. The ACS recommendations are meant to include the quadrivalent vaccine and, pending FDA approval, the bivalent vaccine.
http://www.aafp.org/afp/20080315/practice.html
Management of HIV Infection in Special Populations
http://www.medscape.com/viewprogram/8951?src=nlcmealert&spon=1&uac=77433SYBarbara Stillwater, Alaska State Diabetes Program
Link between type 2 DM in adults and type 1 DM or pregnancy-related diabetes in their mothers
The rate of diabetes or pre-diabetes was 21 percent in subjects born to mothers who had pregnancy-related diabetes (termed gestational diabetes), 12 percent in those whose mothers had a genetic predisposition for diabetes, 11 percent when the mothers had type 1 diabetes, and 4 percent in subjects born to women with no history of gestational or other types of diabetes.
The findings support the idea that exposure to high blood sugar levels in the womb contributes to the development of type 2 diabetes in adulthood, the researchers conclude. Aiming for normal blood glucose levels in pregnant women "may reduce the risk of type 2 diabetes in future generations."
CONCLUSIONS: A hyperglycemic intrauterine environment appears to be involved in the pathogenesis of type 2 diabetes/pre-diabetes in adult offspring of primarily Caucasian women with either diet-treated GDM or type 1 diabetes during pregnancy.
Clausen TD et al High prevalence of type 2 diabetes and pre-diabetes in adult offspring of women with gestational diabetes mellitus or type 1 diabetes: the role of intrauterine hyperglycemia.
Diabetes Care. 2008 Feb;31(2):340-6. http://www.ncbi.nlm.nih.gov/pubmed/18000174
Joslin Study Finds Restricting Insulin Doses Increases Mortality Risk
Study highlights important women’s health issue in diabetes and says behavior occurs in context of eating disorder symptoms. A new study led by researchers at the Joslin Diabetes Center has found that women with type 1 diabetes who reported taking less insulin than prescribed had a three-fold increased risk of death and higher rates of disease complications than those who did not skip needed insulin shots.
CONCLUSIONS: Our data demonstrate that insulin restriction is associated with increased rates of diabetes complications and increased mortality risk. Mortality associated with insulin restriction appeared to occur in the context of eating disorder symptoms, rather than other psychological distress. We propose a screening question appropriate for routine diabetes care to improve detection of this problem.
Goebel-Fabbri AE , et al Insulin restriction and associated morbidity and mortality in women with type 1 diabetes. Diabetes Care. 2008 Mar;31(3):415-9.
http://www.ncbi.nlm.nih.gov/pubmed/18070998
Low vitamin B12 in the first trimester and high folate in the second predispose insulin resistance
Insulin resistance at 6 years of age was significantly more common in the offspring of mothers who had low B12 levels at 18 weeks and high folate levels at 28 weeks of pregnancy, and was highest among those with a combination of both.
Adiposity was greater among the offspring of mothers with higher folate levels,
they add.
Increased plasma levels of homocysteine and methylmalonic acid as a consequence
of low plasma B12 results in lipogenesis, reduced protein synthesis and reduced
lean body mass, and may be the precursor of insulin resistance, the researchers
postulate. Epigenetic regulation, involving DNA methylation, may be another mechanism
of nutritional programming.
An imbalance in the vitamin B12 and folic acid levels produces the "undesirable
effects.
Multigenerational vegetarianism means that vitamin B12 deficiency is common in
Indians, but folate deficiency is relatively rare. High folate intakes in vitamin
B12-deficient mothers could increase the risk of type 2 diabetes in the offspring.
The National Anemia Program recommends use of iron and folic acid in pregnancy but ignores vitamin B12. This needs to be reconsidered and due attention needs to be given to vitamin B12.
CONCLUSIONS / INTERPRETATION: Low maternal vitamin B(12) and high folate status may contribute to the epidemic of adiposity and type 2 diabetes in India.
Yajnik CS et al Vitamin B(12) and folate concentrations during pregnancy and insulin resistance in the offspring: the Pune Maternal Nutrition Study. Diabetologia. 2008 Jan;51(1):29-38.
http://www.ncbi.nlm.nih.gov/pubmed/17851649
Replacing sugar in diet sodas with reduced calorie sweeteners may make weight control harder
The data clearly indicate that consuming a food sweetened with no-calorie saccharin can lead to greater body-weight gain and adiposity than would consuming the same food sweetened with a higher-calorie sugar,” the authors wrote.
The authors acknowledge that this outcome may seem counterintuitive and might not come as welcome news to human clinical researchers and health-care practitioners, who have long recommended low- or no-calorie sweeteners. What’s more, the data come from rats, not humans. However, they noted that their findings match emerging evidence that people who drink more diet drinks are at higher risk for obesity and metabolic syndrome, a collection of medical problems such as abdominal fat, high blood pressure and insulin resistance that put people at risk for heart disease and diabetes.
Why would a sugar substitute backfire?
Swithers and Davidson wrote that sweet foods provide a “salient orosensory stimulus” that strongly predicts someone is about to take in a lot of calories. Ingestive and digestive reflexes gear up for that intake but when false sweetness isn’t followed by lots of calories, the system gets confused. Thus, people may eat more or expend less energy than they otherwise would.
The good news, Swithers says, is that people can still count calories to
regulate intake and body weight. However, she sympathizes with the dieter’s
lament that counting calories requires more conscious effort than consuming low-calorie
foods.
Swithers adds that based on the lab’s hypothesis, other artificial sweeteners
such as aspartame, sucralose and acesulfame K, which also taste sweet but do
not predict the delivery of calories, could have similar effects. Finally, although
the results are consistent with the idea that humans would show similar effects,
human study is required for further demonstration.
Conclusion
We found that reducing the correlation between sweet taste and the caloric content of foods using artificial sweeteners in rats resulted in increased caloric intake, increased body weight, and increased adiposity, as well as diminished caloric compensation and blunted thermic responses to sweet-tasting diets. These results suggest that consumption of products containing artificial sweeteners may lead to increased body weight and obesity by interfering with fundamental homeostatic, physiological processes. (PsycINFO Database Record (c) 2008 APA, all rights reserved).
Susan E. Swithers, PhD and Terry L. Davidson, PhD, “A Role for Sweet Taste: Calorie Predictive Relations in Energy Regulation by Rats,” Behav Neurosci. 2008 Feb;122(1):161-73.
http://www.ncbi.nlm.nih.gov/pubmed/18298259Women's Health Headlines, Carolyn Aoyama, HQE
National Trends in the Perinatal and Infant Health of Rural American Indians (AIs) and Alaska Natives (ANs): Have the Disparities Between AI/ANs and Caucasians Narrowed?
Major Findings:
- Rates of inadequate prenatal care decreased for both AI/ANs and whites (figure), but a sizeable disparity between the groups persisted. Only two-thirds of rural AI/AN women
received first-trimester prenatal care in 1995-1997.
- Rates of postneonatal death among rural AI/ANs decreased over time (figure), but again, a sizeable disparity between AI/ANs and whites persisted.
- Preventable causes of death, predominantly infectious disease and sudden infant death syndrome, were largely responsible for AI/AN-white differences.
http://depts.washington.edu/uwrhrc/uploads/RHRC_WP111_1Pager.pdf
Sacred Circle Handouts, Slides, and Training Materials available
The slides really condense and explain the effect of colonial power on indigenous culture and families.
The slides came from Sacred Circle and they were used in a presentation by Sarah Deer at the Tribal Law and Policy Institute.
Contact Carolyn Aoyama for copies Carolyn.Aoyama@ihs.govSave the dates
IHS Basic Colposcopy Course
- April 9-11, 2008
- Albuquerque , NM
- Contact Alan Waxman, MD awaxman@salud.unm.edu
IHS Colposcopy Update & Refresher Course
- April 9-11, 2008
- Albuquerque , NM
- Contact Alan Waxman, MD awaxman@salud.unm.edu
Keeping Native Women and Families Healthy and Strong
Bemidji Area MCH Conference
- April 23-24, 2008
- Milwaukee , WI
- Great Lakes Tribal Epidemiology Center
- E-mail contact EpidemiologyCenter@gmail.com
Advances in Indian Health (AIH) Conference
- April 29-May 2, 2008
- Albuquerque , NM
- 28 credits, Indian Country’s Primary Care Conference
http://www.ihs.gov/MedicalPrograms/MCH/F/CN01.cfm#top
Sexual Assault Nurse Examiner (SANE) Training Course
- June 9 – 13, 2008
- Navajo Nation Museum, Window Rock, Arizona
- 40 hour didactic portion of SANE/SAFE training
What's new on the ITU MCH web pages?
Breastfeeding: US Breastfeeding Committee Strategic Plan
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 March 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.
