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Maternal Child

Volume 6, No. 5, May 2008

Features

American College of Obstetricians and Gynecologists

ACOG Practice Bulletin: Use of Psychiatric Medications During Pregnancy and Lactation

Summary of Recommendations and Conclusions:

The following recommendations and conclusions are based on good and consistent scientific evidence (Level A):

• Lithium exposure in pregnancy may be associated with a small increase in congenital cardiac malformations, with a risk ratio of 1.2–7.7.
• Valproate exposure in pregnancy is associated with an increased risk of fetal anomalies, including neural tube defects, fetal valproate syndrome, and longterm adverse neurocognitive effects. It should be avoided in pregnancy, if possible, especially during the first trimester.
• Carbamazepine exposure in pregnancy is associated with fetal carbamazepine syndrome. It should be avoided in pregnancy, if possible, especially during the first trimester.
• Maternal benzodiazepine use shortly before delivery is associated with floppy infant syndrome.

The following recommendations and conclusions are based on limited or inconsistent scientific evidence (Level B):

• Paroxetine use in pregnant women and women planning pregnancy should be avoided, if possible. Fetal echocardiography should be considered for women who are exposed to paroxetine in early pregnancy.
• Prenatal benzodiazepine exposure increased the risk of oral cleft, although the absolute risk increased by 0.01%.
• Lamotrigine is a potential maintenance therapy option for pregnant women with bipolar disorder because of its protective effects against bipolar depression, general tolerability, and a growing reproductive safety profile relative to alternative mood stabilizers.
• Maternal psychiatric illness, if inadequately treated or untreated, may result in poor compliance with prenatal care, inadequate nutrition, exposure to additional medication or herbal remedies, increased alcohol and tobacco use, deficits in mother–infant bonding, and disruptions within the family environment.

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

• Whenever possible, multidisciplinary management involving the patient’s obstetrician, mental health clinician, primary health care provider, and pediatrician is recommended to facilitate care.
• Use of a single medication at a higher dose is favored over the use of multiple medications for the treatment of psychiatric illness during pregnancy.
• The physiologic alterations of pregnancy may affect the absorption, distribution, metabolism, and elimination of lithium, and close monitoring of lithium levels during pregnancy and postpartum is recommended.
• For women who breastfeed, measuring serum levels in the neonate is not recommended.
• Treatment with all SSRIs or selective norepinephrine reuptake inhibitors or both during pregnancy should be individualized.
• Fetal assessment with fetal echocardiogram should be considered in pregnant women exposed to lithium in the first trimester.

ACOG Practice Bulletin No. 92: Use of Psychiatric Medications During Pregnancy and Lactation. Obstet Gynecol. 2008 Apr;111(4):1001-20. http://www.ncbi.nlm.nih.gov/pubmed/18378767

ACOG Committee Opinion: End-of-Life Decision Making

ABSTRACT: The purpose of this Committee Opinion is to discuss issues related to end-of-life care, including terms and definitions, ethical principles, legal constructs, physician–patient communication, and educational opportunities pertinent for specialists in obstetrics and gynecology. Assumptions about the objectives of care—which may be understood differently by the patient and her caregivers—inevitably shape perceptions about appropriate treatment. Because unarticulated commitments to certain goals may lead to misunderstanding and conflict, the goals of care should be identified through shared communication and decision making and should be reexamined periodically. A good opportunity to initiate the discussion of caregiving goals, including end-of-life care, is during well-patient care. Physicians must be careful not to impose their own conception of benefit or burden on a patient. End-of-life care is particularly challenging for pregnant women, whose autonomy is limited in many states. Many apparent conflicts will be averted by recognizing the shared interests of the woman and her fetus. When interests diverge, however, pregnant women’s autonomous decisions should be respected.

ACOG Committee Opinion No. 403: End-of-Life Decision Making. Obstet Gynecol. 2008 Apr;111(4):1021-7. http://www.ncbi.nlm.nih.gov/pubmed/18378768

ACOG Committee Opinion: Late-Preterm Infants

ABSTRACT: Late-preterm infants (defined as infants born between 34 0⁄7 weeks and 36 6⁄7 weeks of gestation) often are mistakenly believed to be as physiologically and metabolically mature as term infants. However, compared with term infants, late-preterm infants are at higher risk than term infants of developing medical complications, resulting in higher rates of infant mortality, higher rates of morbidity before initial hospital discharge, and higher rates of hospital readmission in the first months of life. Preterm delivery should occur only when an accepted maternal or fetal indication for delivery exists. Collaborative counseling by both obstetric and neonatal clinicians about the outcomes of late-preterm births is warranted unless precluded by emergent conditions.

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American Family Physician**

Abstinence- Plus Programs for Prevention of HIV - Cochrane Briefs

Clinical Question

Do abstinence-plus programs prevent human immunodeficiency virus (HIV) infection?

Evidence-Based Answer

Abstinence-plus is sex education that includes information on abstinence, condom use, and contraception. Compared with a variety of controls-including usual care, no intervention, or other programs-there is no evidence of increased rates of pregnancy or sexually transmitted infection (STI). Based on limited data, abstinence-plus programs increase knowledge, reduce pregnancy rates, and decrease incidence of unprotected sex and frequency of sex.

Practice Pointers

Abstinence-plus interventions are designed to prevent, stop, or decrease sexual activity while promoting safer sex practices for persons who choose to engage in sex. In contrast, abstinence-only interventions promote abstinence as the only way to prevent HIV infection.

In this Cochrane review of randomized and quasi-randomized controlled trials of abstinence-plus interventions, the authors identified 39 studies with a total of 37,724 participants. All studies were conducted on adolescents or young adults in North America, and 37 studies were conducted in the United States. Most of the studies took place in urban schools or community centers, and the participants were primarily of ethnic minorities. Active parental consent was required by 28 of the studies. Interventions varied considerably, but they all promoted abstinence as the best choice and condom or contraception use for those who have sex. Control interventions also varied considerably. All interventions included information on HIV, STI prevention, sexual risks, and strategies for HIV prevention. Interventions ranged from a single session to programs that were three years in duration. Results were self-reported.

Because of methodologic differences, meta-analysis was not possible. There was no evidence that abstinence-plus programs increased the risk of HIV infection, and there were no adverse effects reported. Abstinence-plus education improved participants' knowledge of HIV across trials. Only two studies (with 1,700 participants, total) included STI screening as an outcome. No statistical differences were found among interventions. Limited evidence suggests that abstinence-plus programs reduce the incidence of pregnancy. Limited data also demonstrate a reduction in the incidence of unprotected intercourse and a reduced frequency of vaginal and anal sex.

In a previous review, the authors evaluated 13 trials of abstinence-only programs with a total of 15,940 U.S. adolescent participants.1 Compared with various controls, the abstinence-only programs did not reduce self-reported biologic (e.g., STIs) or behavioral (e.g., unprotected vaginal sex) outcomes in participants. One study in the review found increases in short- and long-term incidences of STIs, an increased rate of pregnancy, and an increased frequency of vaginal sex (4,652 participants).1 However, these findings of harm were limited to that one study.

Underhill K, Montgomery P, Operario D. Abstinence-plus programs for HIV infection prevention in high-income countries. Cochrane Database Syst Rev. 2008;(1):CD007006.

http://www.ncbi.nlm.nih.gov/pubmed/18254124

Evaluation of Acute Abdominal Pain in Adults

Acute abdominal pain can represent a spectrum of conditions from benign and self-limited disease to surgical emergencies. Evaluating abdominal pain requires an approach that relies on the likelihood of disease, patient history, physical examination, laboratory tests, and imaging studies. The location of pain is a useful starting point and will guide further evaluation. For example, right lower quadrant pain strongly suggests appendicitis. Certain elements of the history and physical examination are helpful (e.g., constipation and abdominal distension strongly suggest bowel obstruction), whereas others are of little value (e.g., anorexia has little predictive value for appendicitis). The American College of Radiology has recommended different imaging studies for assessing abdominal pain based on pain location. Ultrasonography is recommended to assess right upper quadrant pain, and computed tomography is recommended for right and left lower quadrant pain. It is also important to consider special populations such as women, who are at risk of genitourinary disease, which may cause abdominal pain; and the elderly, who may present with atypical symptoms of a disease. Am Fam Physician. 2008;77(7):971-978

http://www.aafp.org/afp/20080401/971.html

Expanded Newborn Screening: Information and Resources

Family physicians treat an increasing number of children with metabolic disorders identified through newborn screening, and they are often the first line of defense in responding to an abnormal screening result. How the family physician chooses to interpret information from the screening and what he or she chooses to tell the family affects the parent-child relationship, as well as the infant's medical and developmental outcomes. Family physicians must, therefore, be familiar with the current state of expanded newborn screening to effectively communicate results and formulate interventions. They also must recognize signs of metabolic disorders that may not be detected by newborn screening or that may not be a part of newborn screening in their state. For every infant identified with a metabolic disorder, 12 to 60 additional infants will receive a false-positive screening result. One recommendation for communicating results to parents is to explain what the initial and follow-up findings mean, even if the diagnosis is not confirmed. For infants with true-positive results, long-term follow-up involves regular medical examinations, communication with a metabolic treatment center, and developmental and neuropsychological testing to detect possible associated disorders in time for early intervention. This article provides a description of metabolic disorders included in expanded newborn screening programs; a list of disorders screened for in each state; and resources for obtaining ACTion sheets (guidelines for responding to newborn screening results), fact sheets, and emergency and acute illness protocols. Am Fam Physician. 2008;77(7):987-994.

http://www.aafp.org/afp/20080401/987.html

Subclinical Hypothyroidism

Clinical Scenario

A 65-year-old woman with a history of poorly controlled hypertension and mild, untreated depression presents with an elevated thyroid-stimulating hormone (TSH) level and normal free thyroxine (T4) and free triiodothyronine (T3) levels. She denies any symptoms related to hypothyroidism, but is wondering if she should start thyroid replacement therapy.

Clinical Question

Should physicians recommend thyroid hormone therapy for any nonpregnant patient with subclinical hypothyroidism?

Evidence-Based Answer

Although there is evidence that thyroid hormone therapy in patients with subclinical hypothyroidism may improve lipid profiles, cognitive function, and echographic left ventricular function, there is no evidence that this will decrease morbidity or mortality.

Cochrane for Clinicians, Putting Evidence into Practice

http://www.cochrane.org/reviews/en/ab003419.html

Colonoscopy Surveillance After Polypectomy and Colorectal Cancer Resection

This article describes a joint update of guidelines by the American Cancer Society and the U.S. Multi-Society Task Force on Colorectal Cancer delineating evidence-based surveillance recommendations for patients after polypectomy and colorectal cancer resection. Although there are some qualifying conditions, the following general guidelines apply: after colonoscopic polypectomy, patients with hyperplastic polyps should be considered to have normal colonoscopies, and subsequent colonoscopy is recommended at 10 years. Patients with one or two small (less than 1 cm) tubular adenomas, including those with only low-grade dysplasia, should have their next colonoscopy in five to 10 years. Patients with three to 10 adenomas, any adenoma 1 cm or larger, or any adenoma with villous features or high-grade dysplasia should have their next colonoscopy in three years. Following curative resection of colorectal cancer, patients should undergo a colonoscopy at one year, with subsequent follow-up intervals determined by the results of this examination. Adoption of these guidelines will have a dramatic impact on the quality of care provided to patients after a colorectal cancer diagnosis, will assist in shifting available resources from intensive surveillance to screening, and will ultimately decrease suffering and death related to colorectal cancer. Am Fam Physician. 2008;77(7):995-1002, 1003-1004 http://www.aafp.org/afp/20080401/995.html

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AHRQ

Adolescents are willing to have chlamydial screening by pediatricians during urgent care visits

http://www.ahrq.gov/research/apr08/0408RA5.htm

Antidepressant use during pregnancy is linked to increases in preterm birth and potentially serious infant perinatal problems

http://www.ahrq.gov/research/may08/0508RA8.htm

Maternal asthma is associated with lower birth weight

http://www.ahrq.gov/research/apr08/0408RA7.htm

Noncancerous pelvic problems are linked to poor quality of life and sexual functioning for premenopausal women

http://www.ahrq.gov/research/may08/0508RA9.htm

Studies examine pediatricians' and parents' attitudes toward childhood obesity

http://www.ahrq.gov/research/may08/0508RA10.htm

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

Women's Health Resources

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

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

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

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

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Behavioral Health Insights - Peter Stuart, IHS Psychiatry Consultant

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.

3. 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.

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Breastfeeding - Kendra Carter, Northern Navajo Medical Center

What Do High Performance Cars and Near Term Neonates Have In Common?

Infants like high performance cars, require consistent care and unique fuel. Many people understand the car scenario when educated on the characteristics of near-term infants who by definition are of a gestational age between 34-37 weeks. These late premature infants are at higher risk for the following:

-hypothermia due to less body fat and low weight (may actually weigh 1-1.5 pounds less than full term infants.)

-hypoglycemia and even dehydration can occur if infants miss feedings.

-infection related to an immature immune system

-hyperbilirubinemia related to immature liver

-uncoordinated ability to feed due to suck, swallow, breathe pattern when breastfeeding adding to fatigue.

-become easily over stimulated, resulting in an unorganized state compounding feeding difficulty.

It is vital that the nursing plan reflect understanding of the above risks and sometimes subtle signs, especially if the infant rooms-in and is breastfeeding.

-Feed baby every three hours and be aware that these infants can rapidly move from a hyper-alert to a deep sleep state and may require waking up techniques to feed.

-Limit total feeding time to thirty minutes to allow infant to rest-

-Allow the mother time to pump afterward as baby sleeps on her lap.

-Teach mothers and family members to look for signs of an effective latch and feeding of the infants. Families can help, awaken infant, change infant’s diapers, and provide mothers with a snacks, water and uninterrupted time for breastfeeding.

-Vigorous, rhythmic sucking burst with brief pauses between sucking bursts is a sign of effective suck. No dimpling in baby’s cheeks should be seen during sucking. Audible swallows and listen for soft “k” sound

-Supplement five to ten ml of pumped breast milk using a special nurser or syringe feeding techniques.

-Mother is relaxed and comfortable. Like the car scenario, the pit crew is a mom’s lifeline. She may need to be reminded to take care of herself and accept help.

-Moms need to drink to thirst- keep healthy drinks, water, and natural juice, watch out for caffeinated drinks. Drink to thirst- keep healthy drinks, water, and natural juice, watch out for caffeinated drinks. Eat to hunger- keep healthy snacks of veggies and protein snacks. This is not the time to diet to lose weight. Let some else take care of the household chores for the first day or two at home. Nap when baby nap, do not forget sleep is important to you as well.

-Lactation consultants brought in early can anticipate discharge instructions and home follow-ups.

-Use of infant feeding records can reassure and be used for emphasis.

-Baby is having adequate numbers of wet and soiled diapers

-Baby regains birth weight between days ten and fourteen of life.

Resources:

The AWHONN Late Preterm Infant Initiative, launched in 2005, a multi-year endeavor, addresses the special needs of infants born between 34 and 36 completed weeks of gestation. www.awhonn.org.

Meek, Joan, Tippins, Sherill. American Academy of Pediatrics, New Mother’s Guide to Breastfeeding. Bantam Books. 2002.

Shannon, Teresa, O’Donnell, Mary Jane, Skinner, Kristen. Breastfeeding in the 21st Century, Overcoming Barriers to Help Women and Infants. Nursing for Women’s Health. AWHONN 11: 6, pp570-575. 2008

Submitted by LTJG Kendra A. Carter RN BSN USPHS

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CCC Corner Digest

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

April 2008 highlights include:

- High prevalence of multiple HPV subtypes in AI women of the Northern Plains

- Afghanistan Update: You can make a huge difference

- Cesarean delivery during nursing change of shift: Increased complications

- The Evolution of Midurethral Slings 

- Maternal grandmothers’ alcohol use linked to FAS in the Northern Plains

- Low-dose aspirin: Lower risk for all-cause mortality, especially older women

- Treatment of Urinary Infections in Nonpregnant Women

- Care quality is not necessarily better with electronic health records

- School Refusal

- What makes a good idea work?

- Teen dating violence: 3 articles

- Training in Palliative and End of Life Care, April 22-24, 2008, Flagstaff , AZ

- How to Increase contraceptive use and adherence in adolescents

- Meeting notes now online: 2007 Native Women’s Health and MCH Conference

- Does anyone have an Indian Health EHR template for obstetrical patients?

- Seeking input from the field - Clinician’s Information Management

- Routes to TB treatment in rural Nepal

- New Bullying-Prevention Toolkit Released

- Maternal, Infant and Child Health Capacity Needs Assessment

- You know how to treat yeast infections, right?

- What Happened to Women in WHI study 3 years after stopping HRT?

- Midwives Keep Birth Normal, and Midwife-Provided Acupuncture Helps With PROM

- Sexual Assault Nurse Examiner (SANE) Training Course, June 9 – 13, 2008

- Call for nominations of nurses working in Indian health: Deadlines looming

- Prenatal Care in Oklahoma

- Look at all the drugs that affect bone metabolism

- Treating Depression: What You Should Know

- What is this all about the ‘minor markers’ for Down Syndrome?

- USPSTF Recommendations for STI Screening

- Link between type 2 DM in adults: Diabetes in pregnancy or type 1 DM in their mothers

- Have the Disparities Between AI/ANs and Caucasians Narrowed?

http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm#apr08

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

Intimate Partner Violence and Sexual Violence Victimization Assessment Instruments for Use in Healthcare Settings

Intimate Partner Violence and Sexual Violence Victimization Assessment Instruments for Use in Healthcare Settings is a compilation of existing tools for assessing intimate partner violence (IPV) and sexual violence (SV) victimization in clinical/healthcare settings. The purpose of this compilation is to provide practitioners and clinicians with the most current inventory of assessment tools for determining IPV and/or SV victimization and to inform decisions about which instruments are most appropriate for use with a given population.

This document will aid in the selection of assessment instruments to identify victims requiring additional services. This can help practitioners make appropriate referrals for both victims and perpetrators . www.cdc.gov/ncipc/dvp/IPV/IPVandSV-Screening.pdf

Other resources

Below is the link to CDC’s Injury publications that also has some useful resources.

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

Male Partner Violence Hurts Women's Health Worldwide

Women who are victims of male partner violence suffer a wide range of physical and mental health problems, says a World Health Organization study that included 25,000 women in 11 countries. INTERPRETATION: In addition to being a breach of human rights, intimate partner violence is associated with serious public-health consequences that should be addressed in national and global health policies and programmes.

Ellsberg M et al Intimate partner violence and women's physical and mental health in the WHO multi-country study on women's health and domestic violence: an observational study. Lancet. 2008 Apr 5;371(9619):1165-72. http://www.ncbi.nlm.nih.gov/pubmed/18395577

IHS-ACF DV Project: dental and reconstructive surgery for DV survivors

Give Back a Smile:

This program was developed to address a need in the communities of the members of the AACD. Volunteer members of the AACD agree to restore the broken and damaged teeth of survivors of domestic violence. Survivors know that bruises and scars will fade but broken and missing teeth will not. Our generous dentists erase that memory by restoring the smiles at no cost to the survivor thereby restoring their lives.

FACE TO FACE is a program that was started in 1994 by the Educational and Research Foundation for the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS). The FACE TO FACE Program offers facial plastic and reconstructive surgery to domestic violence survivors to repair injuries on the face, head and neck caused by an intimate partner or spouse. The toll-free number for the FACE TO FACE Program is 1-800-842-4546.

The American Society for Dermatologic Surgery (ASDS) was formally known as the Skin Care Outreach Empowers Survivors or S.C.O.R.E.S. Program and was started in 1999. This program is no longer recognized by ASDS as of 2004 although they still provide volunteers from their membership that offer dermatologic surgery to domestic violence survivors to repair skin injuries (scars, burns, tattoos) on the body caused by an intimate partner or spouse. The toll-free number for the program formally known as S.C.O.R.E.S. is 1-888-892-6702.

http://www.aacd.com/foundation/( 800) 773-4227

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Elder Care News - Bruce Finke, Elder Care Initiative

Landmark Study on Treatment of Hypertension in the Very Old

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

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

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

Elder Care Initiative Editorial comment:

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

Beckett NS, Peters R, Fletcher AE, Staessen JA, Liu L, Dumitrascu D, Stoyanovsky V, Antikainen RL, Nikitin Y, Anderson C, Belhani A, Forette F, Rajkumar C, Thijs L, Banya W, Bulpitt CJ; the HYVET Study Group. Treatment of Hypertension in Patients 80 Years of Age or Older.

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

2008 IHS Long-Term Care Grants Program Is Now Open For Applications

The IHS Long Term Care Grants program is intended to support Tribes, Tribal organizations, and Urban Indian Health programs to plan and implement long-term care services. This program will award 8 – 10 grants for the purpose of Assessment and Planning (up to $50,000 per year for 2 years) or Implementation (up to $75,000 per year for 2 years) of long-term care services.

Key dates :

May 2 is the deadline for the mandatory Letter of Intent to Apply (LOI).

June 20 is the closing date for the RFA

The Federal Register Announcement can be found at http://edocket.access.gpo.gov/2008/pdf/E8-6409.pdf

Look for the Grant Announcement at www.grants.gov. You will find it listed under the Funding Announcement Number: HHS-2008-IHS-EHC-0001.

Please spread the word about this funding opportunity

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Family Planning

Contraceptive agents when initiating breastfeeding

Nonhormonal methods of contraception (barrier contraception, copper intrauterine device) are preferred in nursing mothers because hormonal contraception may interfere with lactation and transfer of hormones into milk poses a theoretical risk to the infant.

Progestin only - If hormonal methods are to be used, progestin-only contraceptives are the preferred method for breastfeeding women, although timing of initiation of therapy is somewhat controversial. Because falling progesterone levels trigger lactogenesis, early initiation of progestin-containing contraceptives theoretically could interfere with this process, particularly if injection contraception is given in the first 72 hours after delivery. The immature metabolism of neonates theoretically could lead to accumulation of progesterone and its metabolites in the infant.

Due to these concerns, manufacturers' package inserts recommend starting progesterone-containing oral contraceptives six weeks postpartum if the mother is exclusively breastfeeding, and three weeks postpartum if she is supplementing with formula. However, there are no data on the impact of earlier initiation of progestin-only contraception. The American College of Obstetricians and Gynecologists (ACOG) recommends that breastfeeding women initiate progestin-only oral contraceptives at two to three weeks postpartum, and depot medroxyprogesterone acetate at six weeks postpartum. In certain clinical situations, such as concern about patient follow-up, ACOG states that it may be appropriate to start progesterone-containing contraception earlier.

The levonorgestrel releasing intrauterine device is recommended for insertion six weeks postpartum in breastfeeding women.

Combined estrogen-progestin - Combined estrogen-progestin contraceptives are known to

suppress milk production in the early post-partum period, and have even been used to treat

engorgement. Clinical trials examining the effect of combined oral contraceptives on milk

supply and infant growth have reported mixed results. A large review of the literature concluded

that the data were of such poor quality that no evidence-based recommendation could be made

regarding use of combined contraceptives in lactating women.

Expert recommendations vary:

- ACOG recommends delaying the initiation of combined estrogen-progestin contraceptives until at least six weeks postpartum, and then only if lactation is well-established and the infant's nutritional status can be closely monitored.

- The World Health Organization (WHO) recommends delaying the initiation of combined contraceptives until six months postpartum. Between six weeks and six months, WHO states that the theoretical or proven risks usually outweigh the advantages.

Helpful resources

Combined hormonal versus nonhormonal versus progestin-only contraception in lactation: Cochrane Review

http://www.cochrane.org/reviews/en/ab003988.html

National Guidelines Clearinghouse

http://www.guidelines.gov/summary/summary.aspx?ss=15&doc_id=7098&nbr=004270&string
=contraceptive+AND+choices+AND+breastfeeding+AND+women

Faculty of Family Planning & Reproductive Health Care. Contraceptive choices for breastfeeding women. J Fam Plann Reprod Health Care 2004 Jul;30(3):181-9

http://www.ncbi.nlm.nih.gov/pubmed/15222930?dopt=Abstract

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

Meeting notes now online: 2007 Native Women’s Health and MCH Conference*

- More lecture notes added daily

- Lectures listed in alphabetical order by author

Kelly Acton, M.D.

• Diabetes in American Indian & Alaska Native Women

Gail Bolan MD

• Current Issues in STD Management: Implications for Improving Women’s Reproductive Health Outcomes

Karen Carey CNM MS

• Obstetric Drills

Peter Cherouny, MD

• Idealized Design of Perinatal Care: Plenary
• Quality Care in Obstetrics-Clinical Bundles: Workshop

Donald Coustan, M.D.

• GESTATIONAL DIABETES
• Gestational Diabetes
• Use of Oral Antidiabetic Agents in Obstetrics: Workshop

Scott Deasy, M.D.

• Navajo Nation Breast & Cervical Cancer Prevention Program

Willeen Druley, RN, MS, BC, FNP

• Mobile Women’s Health Unit

Denise Findlay, RN BSN

• Using the Feeding & Teaching Scales to Plan Effective Interventions
• Promoting Maternal Mental Health During Pregnancy

Terry Friend, CNM

• SCHOOL-BASED HEALTH (BY ACCIDENT)

Cindy Gebremariam, RN

• iCare: A population management tool )

Scott Giberson, Ph.C, PharmD, MPH

• IHS HIV Program: Risk and Response

George Gilson, M.D.

• HIV Infection in Pregnancy: 2007 Update
• Prenatal Testing Update 2007
• THE OB-PEDS INTERFACE:“GOT ISSUES?”

Amy Groom, MPH

• HPV Vaccine Implementation

Kathleen Harner, M.D.

• Balancing Motherhood: Helping Moms Stay Drug Free

Howard Hays, M.D.

• Women’s Health Software Application V 3.0

Mary Henrikson MN, RNC

• Us versus Them and Being in the Middle

Stephen W. Heath, MD, MPH

• Risk Management in Maternal Child Health

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

• Billings Area SIDS / Infant Mortality Reduction

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

• Northern Plains Smoke-Free Homes Campaign

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.

• Domestic Violence: Screening and Documentation

Tami McBride, CNM, MS, RNC

• Obstetric Emergency Drills
• Obstetric Drill De-Brief Form

Richard McClain, MD

• MONARC vs. Paravaginal wall Repair: A system and surgeon perspective

Paul Melinkovich, M.D.

• Denver School-Based Health Centers

Connie Monahan, MPH

• Challenges of SANE in the Clinical Setting (Plenary)
• Making SANE Work: Operational Details (Workshop)

• Challenges of SANE in the Clinical Setting

• Challenges of SANE in the Clinical Setting: Handout

• Making SANE Work: Operational Details

• Appendices: Making SANE work

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

• Breastfeeding Update

Tony Ogburn MD

• Contraception for teens: What’s new?

Sharon Phelan MD

• Obesity: A weighty problem

Marilyn Pierce Bulger

• Community Approaches to Reducing Infant Mortality: Nutaqsiivik Program
• Approaches To Reducing Infant Mortality- Nutaqsiivik Program

Usha Ranji, M.S.

• Health Coverage and Access to Care: Key Issues for Native Women

Brigg Reilley

• Prenatal HIV Screening: Workshop
• Sharon Schindler Rising, MSN, CNM
• Essential Elements of the Centering Model

Greg Shorr, M.D.

• PCC+ Obstetric Care Module

Melanie Taylor MD, MPH

• Chlamydia Among AI/AN Adolescents: The Stop Chlamydia Project

Judy Thierry, DO MPH

• Improve the System, Improve the Outcome
• PCC+ Obstetric Care Module

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

• Patient Safety in Maternal Child Health

Judy Whitecrane MSN, CNM

• What We Did About Prenatal Substance Abuse

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

Conference Brochure

http://www.ihs.gov/MedicalPrograms/MCH/F/documents/NWHMCH51507.pdf

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Frequently Asked Questions

First Trimester Down Syndrome Testing

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

OB/GYN CCC Editorial comment:

First trimester screening is a reality

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

REFERENCES

1. Malone FD, D’Alton ME. First trimester sonographic screening for Down syndrome. Obstet Gynecol 2003; 102:1066-79.
2. Malone FD, et al. First trimester or second trimester screening, or both, for Down syndrome (FASTER Study). N Eng J Med 2005; 353:2001-11.
3. Wald NJ, Rodeck C, et al. First and second trimester antenatal screening for Down syndrome (SURUSS Study). J Med Screen 2003; 10:56-104.
4. Wapner R, et al. First trimester screening for trisomies 21 and 18. NEJM 2003; 349:1405-13.
5. Reddy UM, Mennuti MT. Incorporating first trimester Down syndrome studies into prenatal screening (NICHD Workshop). OG 2006; 107:167-73.
6. Berkowitz RL, et al. Aneuploidy screening: What test should I use? OG 2006; 107:715-8.
7. Chervenak FA, McCullough LB. Implementation of first trimester risk assessment for trisomy 21: Ethical considerations. Am J Obstet Gynecol 2005; 192:1777=81.
8. Odibo AO, et al. A cost-effectiveness analysis of prenatal screening strategies for Down syndrome. OG 2005; 106:562-8.

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

May 2008 –

-Autism Spectrum Disorders – Guidelines for Identification and Diagnosis

-Vaccines and Autism – The Courts weigh in – wrongly

-Child Safety Seats for AI/AN children – how can we get children in safety seats – and more

importantly how can we keep them in them

http://www.ihs.gov/MedicalPrograms/MCH/M/ChPedNotes.cfm#may08

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Information Technology

RPMS Immunization Package

Patch Release Announcement

The Indian Health Service Office of Information Technology and the Immunization Program announce the following application patch release:

• Patch 1 of Immunization Package v8.2 (RPMS namespace: BI)

A patch release notice from the IHS Office of Information Technology have been sent to all RPMS site managers. Site managers are advised to notify users once the patch has been installed. Complete details of the modifications included in these patches are included in the official patch release notices.  The beta sites for this patch were:

• Alaska Native Medical Center
• Chinle Service Unit
• Sells Service Unit

The patch is available for download at http://www.ihs.gov/Cio/RPMS/index.cfm?module=home&option=software.   When the patch is loaded, the version number for the Immunization Package should change to 8.2*1.

The following changes are included in Patch 1: 

1. The Vaccine Table has been updated and all Vaccine Group, Related Contraindications, and other default fields are included in the update. 
2. The Menactra forecasting option was updated to forecast for 11 – 18 year olds.
3. The Adolescent report now excludes immunizations given after the Quarter Ending Date.
4. Lot Number validity is now checked before a visit is filed.
5. PNE, VAR, and HEPA are no longer included in the Minimum Needs when the Quarterly Report is queued.
6. A Facility field filter on the Imm Lot file was created to help limit inappropriate lot choices.
7. Restricted DEFAULT Lot Numbers will no longer appear to users logged onto other facilities.
8. State immunization data with longer Other Locations field lengths can now be imported.
9. Additional code was added to support IHS sites running 64-bit environments.
10. A new error trap was added and the error code table was updated.
11. Pre-installation routine was updated to preserve local templates.
12. New public entry point was added for EHR compatibility.
13. New code was added to allow imported data strings larger than 32K.
14. Updated access to ICD and CPT codes to comply with Code Set Versioning requirement.

For user support please contact the RPMS help desk at RPMSHelp@ihs.gov or call (888) 830-7280.

American Indian health advocates can learn to develop multimedia health projects for rural communities

The development and dissemination of culturally relevant health care information has traditionally taken a "top-down" approach. Governmental funding agencies and research institutions have too often dictated the importance and focus of health-related research and information dissemination. In addition, the digital divide has affected rural communities in such a way that their members often do not possess the knowledge or experience necessary to use technological resources. And, even when they do, their skills may be limited, adequate only for implementing applications and programs designed by others who live and work outside of these communities. This need became the driving force in the creation of the Native Telehealth Outreach and Technical Assistance Program. The goal of the program is to equip Native community members, at both the lay and professional levels, with the means to use technology to address tribal health care needs. The transfer of relevant technical knowledge and skills enables participants to develop projects which enhance the community-wide dissemination of health care information. Nine community health advocates and professionals participated in the initial cohort. Eight of the participants successfully developed multimedia-based projects including Web sites, interactive CD-ROMs, and video focusing on a variety of health concerns. At the conclusion of the 18-month program period, projects were disseminated throughout rural communities. The NTOTAP staff continues to evaluate the use of these projects and their benefits within the rural communities.

Dick RW et al The Native Telehealth Outreach and Technical Assistance Program: a community-based approach to the development of multimedia-focused health care information. Am Indian Alsk Native Ment Health Res. 2007;14(2):49-66. http://www.ncbi.nlm.nih.gov/pubmed/17874365

Release of BGP Clinical Reporting System, Version 8.0

We are pleased to announce the release of BGP Clinical Reporting System, Version 8.0 on April 1, 2008.

The BGP Clinical Reporting System v8.0 package was tested at: Rapid City Service Unit, Red Lake Hospital, Cherokee Indian Hospital, Fort Defiance Indian Hospital, Choctaw Nation Health Services, Hastings Indian Medical Center, Pawnee Service Unit, Portland Area Office and Warm Springs Health and Wellness Center.

The key changes that are included in this version are listed below. For a full list of changes, please refer to the CRS 2008 v.8.0 User Manual.

- Split the National GPRA Report and all related reports and patient lists into separate reports: National GPRA Report and a new Other National Measures (ONM) Report. NOTE: The Breastfeeding Rates topic is now included in the ONM Report. There is also a new Other National Measures Report Patient List that provides the user with lists of patients either meeting or not meeting an ONM Report measure(s).

- New GPRA Measure Forecast Patient List: Created to allow users to run a GPRA-measure forecast for individual patients, a clinic or facility's scheduled patients, or for any patient regardless of appointment status.

This list uses modified National GPRA logic and indicates the GPRA measures will be due for during the GPRA year. It also includes information for the provider on how the measure can be met. This is included on the National GPRA Reports menu as option FOR. There is also an accompanying denominator definitions page (menu option FORD from National GPRA Reports menu) users can run to see how the denominators are defined for the Forecast list.

- 4 new non-GPRA performance topics:

- Alcohol Screening and Brief Intervention (ASBI) in the ER

- Heart Failure and Evaluation of LVS Function

- Sexually Transmitted Infection (STI) Screening

- Palliative Care

- Updated CRS GUI: Includes updated functionality to match all functionality available in the CRS roll-and-scroll version.

- CMS Report: Complete redesign of the report and new choices for running lists of patients for each of the 4 topics of AMI, Heart Failure, Pneumonia, and Surgical Infection Prevention (SIP). Also added

4 new measures (2-Pneumonia, 2-SIP).

• Logic Changes to both GPRA and Non-GPRA Measures: See CRS 2008 v.8.0 User Manual, section 1.1 for detailed list of logic changes.

Theresa.Cullen@ihs.gov

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International Health Update - Claire Wendland, Madison, WI

Is health a human right?

In the arena of international development and health, the use of human-rights language to advocate for the health of the poor is increasingly popular. This language raises many serious questions, yet it also historically and morally powerful. The two articles referenced at the end of this column give those who are interested a place to start with this rights-and-ethics discussion.

What can a “right to health” possibly mean? If we interpret the phrase as “a right to be healthy,” it’s a difficult proposition to swallow. Everyone dies, and nearly everyone contracts a serious disease at some point in life: in that light, a right to be healthy seems positively nonsensical. In practice, though, the phrase “right to health” usually serves as a shorthand for a right to the conditions necessary to produce the best attainable standard of health – conditions including basic education and access to information, adequate health care, food security, a safe environment, protection from severe poverty, decent sanitation and clean water. Public health research has consistently shown these factors to be strong social determinants of health; many have been enshrined in the Millenium Development Goals as keys to world human development.

In fact, the right to the conditions necessary for health has been part of the Universal Declaration of Human Rights (to which the US is one of many signatories) since 1948. An expanded version became international law in the 1970s. Though a US ambassador to the United Nations derided this law as a “letter to Santa Claus” the decade after that, soon a terrible epidemic was to draw the world’s attention to the conjunction of health and human rights. In the 1990s, the devastating spread of HIV/AIDS exposed to the view of wealthy countries the links between inequality and disease, marginalization and disease, poverty and disease, lack of adequate health care and disease. In this context, the work of Jonathan Mann called for human rights to be the foundation of public health ethics, an idea that has spread widely in the new millennium.

This framework is not without problems. First, it does not address the issue of competing priorities. Why is health a priority over all other communal values, or is it? What happens in situations of extreme scarcity? What about when one country’s priorities (for national security, for instance, or for intellectual property rights) cause damaged health in other countries? Second, it carries an ambiguity between judicial and moral claims. Rights in the legal sense are things a person may reasonably expect to have satisfied by the force of the law. Is a decent standard of living really this kind of right? Is access to health care? If so, how much health care? (Those in the Indian Health Service, where treaty rights really did establish legal claims to health care and education, will recognize some of these debates.) Even if the “right to health” is not thought of as a legal right, but a moral one, whose responsibility is it? Finally, what about transnational or supra-national institutions? Mechanisms of international accountability remain fairly thin. If the World Bank’s policies, or Chevron’s, or Pfizer’s, hurt the health of the Third-World poor, who holds them accountable and how?

Despite these serious concerns, thinking about health as a human right does have an impact in the international health arena. I see it as having two major functions. It creates a right to assistance – and a duty to intervene – in the name of health. This right and duty have been established for decades in humanitarian conflicts (though they are not completely without controversy); what’s new here is their use in the setting of severe disease. Again, the HIV/AIDS epidemic, especially in Africa, was paramount in shifting this discussion. More broadly, health as a human right rhetorically establishes a framework of ethics, a language of moral urgency that does not depend on religious creed and therefore opens the way to international consensus on public health issues. In this sense, it is an important counter-discourse to the dominant argument of neo-liberal economics: that the invisible hand of the market, working through economic growth, is alone enough to improve human well being. In this realm human rights as a framework for public health ethics meets social justice movements. The powerful language of rights moves the disciplines of medicine and public health away from narrow disease-specific intervention programs, away from a preoccupation with individual genetics and behavioral choices and into the realm of social determinants of health.

Here’s how I see Jonathan Mann’s project, Paul Farmer’s project, the project of those who work within this model: they are calling us to a passion for social justice. They are getting public health up beside them on the soapbox in defense of a set of values embedded in human rights talk. Their language has echoes of Mandela and Gandhi, Jefferson and Lincoln, Tiananmen Square, Birmingham and Martin Luther King. They marshal deep history and moral force to move us forward – with genuine partnerships and a shared vision of the future – into a struggle for the human commonwealth.

Sounds good, doesn’t it?

Buchanan, DR. Autonomy, paternalism, and justice: ethical priorities in public health. American

Journal of Public Health 98(1):15-21, 2008. http://www.ncbi.nlm.nih.gov/pubmed/18048780

Mann, JM. Medicine and public health, ethics and human rights. Hastings Center Report 27(3):6-

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MCH Alert

Adverse Drug Events in Pediatrics

This study is the first to develop and evaluate a trigger tool to detect ADEs [adverse drug events] in an inpatient pediatric population.

The authors found that

* A total of 960 randomly selected charts reflecting a total of 6,806 patient days were evaluated. A total of 2,388 triggers were detected (mean rate of 2.49 triggers per patient) and a total of 107 ADEs were identified (mean rates of 11.1 ADEs per 1,000 patients, 15.7 ADEs per 1,000 patient days, and 1.23 ADEs per 1,000 medication doses).

* Of the 107 ADEs identified in the study, 104 (97.2%) contributed to or resulted in temporary harm to the patient and required intervention; 22% percent were preventable, 17.8% could have been identified earlier, 16.8% could have been mitigated more effectively, and only 3.7% had a voluntary hospital occurrence report associated with the event.

* The medication-management stage during which a medication error was most likely to occur (resulting in a preventable ADE) was the monitoring phase (62.5%; defined as failure to review a prescribed regimen for appropriateness and detection of problems or failure to use appropriate clinical or laboratory data for adequate assessment of patient response to prescribed therapy).

* The medication class most frequently associated with an ADE was analgesics or opioids.

* The most frequent type of ADE was pruritis (severe itching).

These data should provide the groundwork for aggressive, evidence-based prevention strategies to decrease the substantial risk for medication-related harm to our pediatric inpatient population.

Takata GS, Mason W, Taketomo C, et al. 2008. Development, testing, and findings of a pediatric-focused trigger tool to identify medication-related harm in US children's hospitals. Pediatrics 121(4):e927-e935. Abstract available at http://pediatrics.aappublications.org/cgi/content/abstract/121/4/e927

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MCH Headlines - Judy Thierry HQE

CDC Releases Study on Abuse & Neglect of Infants

CDC released a study today entitled "Nonfatal Maltreatment of Infants -- United States, October 2005–September 2006." The study, published in CDC’s Morbidity and Mortality Weekly Report, found that in the year studied, there were 91,278 babies less than 1 year old who were documented victims of child abuse or neglect. Of those, 29,881 were victims of abuse or neglect before they were 1 week old.

Almost 70% of babies less than 1 week old were reported for neglect and 13.2% were reported for physical abuse. The study also found that medical professionals, such as doctors, nurses, and other hospital staff were most likely to report child abuse and neglect of babies. The study was authored by researchers from CDC’s National Center for Injury Prevention & Control and the Administration for Children & Families (ACF).

The study is available at http://www.cdc.gov/mmwr.

Child maltreatment is a huge problem throughout the United States, and it disproportionately affects the youngest members of our society. The few cases of abuse or neglect we see in the news are only a small part of the problem. Many cases are not reported to police or social services. What we do know is that approximately 1,530 children died in the United States in 2006 from abuse and neglect. In addition, the legal and health care costs for child maltreatment exceed $24 billion each year.

April was National Child Abuse Prevention Month, an observance intended to increase awareness of child maltreatment and encourage individuals and communities to support children and families. CDC defines child maltreatment as any act or series of acts of commission or omission by a parent or other caregiver that results in harm, potential for harm, or threat of harm to a child. During April, CDC and ACF will highlight a range of child maltreatment prevention measures at the national, state, and local levels, including promotion of safe, stable, and nurturing relationships (SSNR) between children and caregivers.

More information on child maltreatment and the SSNR framework can be found in the following publications, available online:

• The Effects of Childhood Stress on Health Across the Lifespan
• Preventing Child Sexual Abuse within Youth Serving Organizations: Getting Started on Policies and Procedures
• Child Maltreatment Surveillance, Uniform Definitions for Public Health and Recommended Data Elements

The MMWR article is available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5713a2.htm

Additional CDC information on child maltreatment can be found at http://www.cdc.gov/ncipc/dvp/CMP/default.htm.

Additional information from ACF is available at http://www.acf.hhs.gov , and from the Child Welfare Information Gateway at http://www.childwelfare.gov.

Unique status of vaccines as disease prevention “tools”

There are several distinctions that I have selected below from the 10 page – article.

The online article is well written if you do not want to hop through my bulleted excerpts.

·If thresholds fall below certain levels (90 – 95%) the protective herd immunity is lost. 

(A simplistic animation on herd immunity from the WHO can be found at: http://www.immunisation.nhs.uk/About_Immunisation/Science/Herd_immunity_-_animation  )

·“Natural infection may provide life long immunity but with risk of complications of pneumonia, brain damage, and birth defects.  These consequences including death are unlikely with immunizations.”

·“Research shows that infants are fully capable of responding safely and effectively to multiple vaccines” – Antigenic load

·“…5200 families have filed autism injury claims with the federal government, a collective action known as the Omnibus Autism Proceeding…” Vaccine Program/Office of Special Masters  The combination theory, the basis of 3 of the collective actions attempts to link the vaccine with the mercury containing preservative.

·“Adverse Reaction (AR) classified into 3 groups:

1. Vaccine-induced (eg, pain at the injection site, allergic reactions);

2. Programmatic error (eg, administering an intramuscular vaccine by the subcutaneous route); or

3. Coincidental (having a temporal association with the vaccine but would have occurred even in the absence of vaccination).”

·“The nation's voluntary reporting system for adverse events following vaccine administration confirms that vaccine side effects are surprisingly uncommon. Vaccine Adverse Event Reporting System (VAERS) data reveal that 11.4 adverse events occur per 100,000 vaccine doses distributed. Adverse events often depend upon the nature of the vaccine itself. The events and the frequency of events are similar to those that occur with placebo injections in controlled trials and include pain, swelling, and redness at the injection site.”

·“The National Childhood Vaccine Injury Act of 1986 established the Vaccine Injury Compensation Program (VICP). The VICP went into effect on October 1, 1988 and is a federal "no-fault" system designed to compensate individuals or families of individuals who have been injured by covered vaccines, whether administered in the private or public sector. Since its inception, the VICP has helped stabilize the US vaccine market by providing liability protection to vaccine manufacturers and providers, encouraged research and development of new and safer vaccines, and provided a more streamlined and less adversarial way to resolve vaccine injury claims.”

·Custodian/parent education includes receiving a Vaccine Information Statement (VIS) on the vaccines being administered.  Us of the VIS is required by law. “ The VIS lists both the risks and benefits of the vaccine. On page 2 of every VIS, the potential serious injuries that can occur with the vaccine are described, and the telephone number and Web site of the VICP are provided.” 

·Underreporting of AR’s in general and for post-immunization events is well known.  Physicians and nurse need training in reporting any kind of significant event and anyone can report to VAERS by calling 1-800-822-7967 or directly on the VAERS Web site.

·“VAERS is not a vaccine injury compensation program. That is an entirely separate process; it is important to realize that submitting a report to VAERS does not initiate the process to compensate an individual or family for a potential vaccine injury.”

·“The DTaP vaccine is an example that "lets the numbers do the talking." If a child gets diphtheria, the risk of death is 1 in 20; for tetanus, it is 1 in 5. Pertussis leads to pneumonia in 1 of 8 individuals, to encephalitis in 1 of 20, and death in 1 of 1500. These figures must be contrasted to the risks of adverse outcomes of the DTaP vaccine. Only 1 in 14,000 may experience seizures or shock with full recovery, perhaps 10 in 1,000,000 suffer acute encephalopathy, and none have been known to die as a result of the DTaP vaccine. Clearly, children are far more likely to be injured as a result of contracting one of these diseases than from the vaccine given to protect them.

Summary:

 “Vaccines remain the most powerful tools we have for disease prevention today. However, their benefits can only be realized when the necessary high coverage levels are achieved. The development of new, safer, and more effective vaccines, as well as novel ways to administer these vaccines, is one of the most important public health missions of the new millennium.”

http://www.medscape.com/viewarticle/568534_2

CDC funding 4.4 million to 15 awards oral health HPDP due May 27

CDC -"State-Based Oral Disease Prevention Program"

• $4,400,000 in FY 2008 to fund up to
• 15 awards to states and/or territories.
• assist state or territorial health departments to establish, strengthen, and enhance the infrastructure and capacity of states/territories to plan, implement, and evaluate population-based oral disease prevention and promotion programs, prioritizing populations based on oral disease burden. 
• application due date is May 27, 2008. 
• Anticipated award date is July 31, 2008.

*Technical assistance and other information pertinent to this FOA/cooperative agreement application, including reference information, reporting requirements, future funding information, and guidelines, will be provided on the Web-based CDC Sitescape.  To become a user, please send an e-mail requesting Sitescape link information to Bridgette Smith at bsn0@cdc.gov. 

*CDC is planning two telephone conference calls to provide additional technical assistance related to this FOA.  These calls will be scheduled during April.  Information for accessing the conference calls will be sent as soon as it is available.

*Instructions for locating this announcement on www.grants.gov are as follows:

Select apply for grants

Select step 1: download grant application

Insert the Funding Opportunity Number:  CDC-RFA-DP08-802

Select Download Package

Again, select the download link on the bottom right

Pull up the Synopsis, Full Announcement, and electronic application (under, "How to Apply") by selecting the buttons across the top of the page.

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Medical Mystery Tour

You know how to treat yeast infections, right? Which of these are true about vulvar pruritus?

Here are the answers to last month’s questions

1.) It is important to ask patients presenting with vulvar pruritus if symptoms vary with their cycles

True

Discussion:

When did the symptoms start in relation to menses? Candida vulvovaginitis often occurs in the premenstrual period, while trichomoniasis often occurs during or immediately after the menstrual period.

2.) Candida glabrata tends to respond to intravaginal boric acid therapy

True

Discussion:

C. glabrata has low vaginal virulence and rarely causes symptoms, even when identified by culture. Every effort should be made to exclude other co-existent causes of symptoms and only then treat for yeast vaginitis. Treatment failure with azoles is not uncommon (around 50 percent) in patients with C. glabrata vaginitis. Moderate success (65 to 70 percent) in women infected with this organism can be achieved with intravaginal boric acid (600 mg capsule once daily at night for two weeks). Better results (>90 percent cure) have been achieved with intravaginal flucytosine cream (5 g nightly for two weeks); however, flucytosine cream is not readily available and must be made by a compounding pharmacy. There are no good data regarding use of oral voriconazole for C. glabrata vaginitis. Anecdotal reports suggest poor response and rare if any success, and the potential for toxicity.

Sobel JD; Chaim W Treatment of Torulopsis glabrata vaginitis: retrospective review of boric acid therapy. Clin Infect Dis 1997 Apr;24(4):649-52. http://www.ncbi.nlm.nih.gov/pubmed/9145739

3.) Nystatin successfully treats the majority of patients with tinea cruris.

False

Discussion:

Tinea cruris (jock itch) is a special form of tinea corporis involving the crural fold. It is a specific fungal infection, but it’s a dermatophyte infection, unlike Candida, which is a yeast form. In North America the most common cause is T rubrum. A few cases are caused by E floccosum and occasionally T mentagrophytes.

Tinea cruris is far more common in men than women. The disease often begins after physical activity that results in copious sweating, and the source of the infecting fungus is usually the patient's own tinea pedis. Obesity predisposes to tinea cruris.

Topical antifungal treatment will suffice for the ordinary case. Failure to treat concomitant tinea pedis usually results in prompt recurrence. Lesions resistant to topical medications can be treated with griseofulvin by mouth, 250 mg three times daily for 14 days, or any of the other systemic agents.

Daily application of talcum or other desiccant powders to keep the area dry will help prevent recurrences. Itching can be alleviated by over the counter preparations such as Sarna or Prax, although these can be irritating if applied to inflamed or excoriated skin. Patients should also be advised to avoid hot baths and tight-fitting clothing, and to wear boxer shorts rather than briefs.

4.) Topical steroid ointments at the correct treatment for lichen sclerosus

True

Discussion:

The treatment with the best evidence of efficacy from randomized trials is superpotent topical corticosteroid ointment. Approximately 95 percent of women will achieve complete or partial relief of symptoms. No specific superpotent steroid or regimen has been shown to be superior to another. We use clobetasol or halobetasol propionate 0.05 percent ointment daily at night for 6 to 12 weeks and then one to three times per week for maintenance. The ointment is applied sparingly in a thin film over the affected area. A 15 g tube of ointment should be prescribed.

Diakomanolis ES et al Vulvar lichen sclerosus in postmenopausal women: a comparative study for treating advanced disease with clobetasol propionate 0.05%. Eur J Gynaecol Oncol. 2002;23(6):519-22. http://www.ncbi.nlm.nih.gov/pubmed/12556095

5.) Classic psoriasis occurs often on the vulva

False

Discussion:

Classic psoriasis rarely presents primarily on the vulva. If it does present on the vulva, it is usually in patients with psoriasis primarily present in the classic psoriasis positions elsewhere on the body.

Patients with plaque type psoriasis usually present as young adults with symmetrically distributed plaques involving the scalp, extensor elbows, knees, and back. The plaques are erythematous with sharply defined margins that are raised above the surrounding normal skin. A thick silvery scale is usually present, although recent bathing may remove the scale. The lesions can range from less than 1 to more than 10 cm in diameter. The plaques typically are asymptomatic, although some patients complain of pruritus. Close inspection may reveal pitting of the nail plates and involvement of intertriginous areas such as the umbilicus and intergluteal cleft.

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Medscape*

Expanded HIV Testing in Primary Care: Implementing the CDC Recommendations

http://www.medscape.com/viewarticle/572204

HIV Opt-out Testing and Primary Care Practice

http://www.medscape.com/viewarticle/572205

New Guidelines for Management of Urinary Tract Infection in Nonpregnant Women

http://cme.medscape.com/viewarticle/571545?src=mp&uac=77433SY

Hirsutism, CME/CE

http://www.medscape.com/viewprogram/9101

Ask the Experts topics in Women's Health and OB/GYN Index, by specialty, Medscape

http://www.medscape.com/pages/editorial/public/ate/index-womenshealth

OB GYN & Women's Health Clinical Discussion Board Index, Medscape

http://boards.medscape.com/forums?14@@.ee6e57b

Clinical Discussion Board Index, Medscape

Hundreds of ongoing clinical discussions available

http://boards.medscape.com/forums?14@@.ee6e57b

Free CME: MedScape CME Index by specialty

http://www.medscape.com/cmecenterdirectory/Default

*NB: Medscape is free to all, but registration is required. It can be accessed from anywhere with Internet access. You just need to create a personal username and password.

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Menopause Management

Estrogen therapy doubles rate of benign breast lumps

The concern not only because of the extra biopsies and worry those lumps cause, but benign proliferative breast disease may be associated with cancer development in approximately 10 years.

CONCLUSION: Use of 0.625 mg/d of CEE was associated with a statistically significant increased risk of benign proliferative breast disease

Rohan TE et al Conjugated equine estrogen and risk of benign proliferative breast disease: a randomized controlled trial. J Natl Cancer Inst. 2008 Apr 16;100(8):563-71
http://www.ncbi.nlm.nih.gov/pubmed/18398105

Postmenopausal Systemic Hormone Therapy: Putting Risks Into Perspective CME/CE
http://www.medscape.com/viewarticle/569399

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Midwives 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.

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Navajo News - Jean Howe, Chinle

Sexual Assault Nurse Examiner (SANE) Training Course, June 9 – 13, 2008

Navajo Nation Museum, Window Rock, Arizona.

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

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

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

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

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Nurses Corner - Sandra Haldane, HQE

Staff education and performance feedback only slightly improve fracture prevention among nursing home residents

http://www.ahrq.gov/research/may08/0508RA12.htm

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Office of Women's Health, CDC

Factors Associated with Elevated Risk of Postneonatal Mortality Among Alaska Native

Objective Compared to non-Natives in Alaska, the Alaska Native population has a postneonatal mortality rate 2.3 times higher (95% CI 1.9, 2.7). The objective of the study was to identify variables that account for this elevated risk.

Methods The dataset used included birth and death certificate records for all Alaska-resident live births and infant deaths occurring during 1992-2004. Race was defined as Alaska Native or non-Native. The association between race and postneonatal mortality was examined using univariate, stratified and regression analyses. Variables were considered confounding if they resulted in a change of at least 10% in the odds ratio between race and postneonatal mortality when added to a bivariate model, or when removed from a multivariate model.

Results In stratified analysis, race remained associated with postneonatal mortality within most categories of marital status, maternal education, maternal age, prenatal tobacco or alcohol use, prenatal care utilization, parity and residence. The odds ratio between race and postneonatal mortality was reduced to 1.3 (95% CI 1.0, 1.6) by controlling for education, a composite variable of marital status and the presence of father's name on the birth certificate, and prenatal tobacco or alcohol use.

Conclusions A small number of potentially modifiable factors explain most of the postneonatal mortality disparity between Alaska Natives and non-Natives, leaving a relatively small increase in risk. These findings suggest that by targeting Alaska Native women who display these characteristics, the postneonatal mortality gap may be reduced.

Blabey MH, Gessner BD.Three Maternal Risk Factors Associated with Elevated Risk of Postneonatal Mortality Among Alaska Native Population. Matern Child Health J. 2008 Apr 4

http://www.ncbi.nlm.nih.gov/pubmed/18389352

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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_hAnew76523

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Osteoporosis

Drug Insight: Choosing a Drug Treatment Strategy for Women With Osteoporosis--An Evidence-Based Clinical Perspective 

http://www.medscape.com/viewarticle/572416

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Patient Information

Colon Cancer Screening: What You Should Know

http://www.aafp.org/afp/20080401/1003ph.html

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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 from the April Perinatology Picks story 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.

If you have further questions, please contact Neil Murphy at nmurphy@scf.cc

What is this all about the ‘minor markers’ for Down Syndrome? April 2008 CCC Corner

http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=4_08ft#peri

Do We Need to do MSAFP Testing after First Trimester Down Syndrome Screening?

A recent Fetal Medicine Foundation newsletter (Vol.2, Issue 3, July 2006) discussed this topic and reached some interesting conclusions that may be pertinent to our practices. The current standard of care in the United States has been in place since the early 1980’s, and is to offer maternal serum alpha fetoprotein (MSAFP) testing to all pregnant women in order to screen for fetal open neural tube defects (ONTD), including anencephaly and meningomyelocele. Other important abnormalities suggested by an elevated MSAFP are the abdominal wall defects, including gastroschisis and omphalocele. Most MSAFP determinations are done between 15 and 20 weeks gestation, and are now part of either the “triple” or “quad” screens, which are also done to screen for fetal Down syndrome (DS). Unfortunately, MSAFP has less than optimal sensitivity and specificity for ONTD, with a detection rate of about 80% (MSAFP >2.5 MoM) at a fixed false positive rate of 5%.

Second trimester ultrasound on the other hand has sensitivity and specificity for ONTD that are >95%. The diagnosis of anencephaly is usually immediate. The diagnosis of spinal defects is also excellent. In addition to vertebral column defects, the cranial findings of an abnormal cerebellum, the “banana” sign (Chiari type II malformation), and the resultant cranial deformity of the “lemon” sign, have been well described for several decades. Fetal abdominal wall defects are usually also easily diagnosed with ultrasound. The more rare fetal problems, such as the genitourinary abnormalities, bowel obstruction, and teratomas, which are also associated with elevated MSAFP, are also usually apparent on ultrasound.

If your patient has chosen first trimester “combined” screening for Down syndrome (measurement of the fetal nuchal translucency (NT) and determinations of pregnancy associated plasma protein A [PAPP-A] and free beta HCG between 11 and 13 weeks), does she also need to undergo MSAFP screening in the second trimester? Does she need a second trimester anatomic survey to look for the abnormalities detailed above? Ultrasound at 11-13 weeks should easily be able to diagnose anencephaly, as well as abdominal wall defects. At the present time however, there are no studies that have looked at the accuracy of screening for spinal defects at this gestational age.

In our system in Alaska, those women who have had negative first trimester screening for fetal DS receive a second trimester sonographic anatomic survey, and are thus screened for ONTD with the modality with the best detection rate. If a woman has had a negative first trimester screen, we have elected not to do “integrated” DS screening with a quad screen in the second trimester, and thus we do not get an MSAFP. Women who present after 13 weeks can elect multiple marker screening, with MSAFP, and may also require second trimester ultrasound as indicated. However, this scheme may not be most cost-effective in your setting, especially if “level II” ultrasound services are not readily available. Likewise, remember that ACOG guidelines continue to recommend MSAFP screening for women who have had first trimester screening, despite the above evidence. As this is a continuously evolving field, remember to “stay tuned for further details….”

References

1. Nadel et al. NEJM 1990; 323:557-61.
2. Nadel et al. Obstet Gynecol 1997; 89:660-5.
3. Lennon et al. Obstet Gynecol 1999; 94:562-6.
4. Johnson et al. Ultrasound Obstet Gynecol 1997; 9:14-6.
5. Nicolaides et al. Lancet 1986; 2:72-4.
6. Palomaki et al. Obstet Gynecol 1988; 71:906-9.

Physiologic evidence to support levels of anomie* and hostility with risk of PTD

Underlying maternal vascular disease has been implicated as one of several pathways contributing to preterm delivery (PTD) and psychosocial factors such as hostility, anomie, effortful coping, and mastery may be associated with PTD by affecting maternal vascular health. Using data from the Pregnancy Outcomes and Community Health (POUCH) study, we included 2018 non-Hispanic White and 743 African American women from 52 clinics in five Michigan, USA communities. Women were interviewed at 15-27 weeks' gestation and followed to delivery. In a subset of 395 women monitored for blood pressure, anomie scores were positively associated with systolic blood pressure and heart rate and hostility scores were positively associated with systolic and diastolic blood pressure, heart rate and mean arterial pressure in models that included time, awake/asleep, race/ethnicity, and age as covariates. Further adjustment for body mass index and smoking attenuated the anomie-vascular relations but had little effect on the hostility-vascular relations. Overall this study of pregnant women provides some physiologic evidence to support findings linking levels of anomie and hostility with risk of PTD.

Tiedje L et al Hostility and anomie: links to preterm delivery subtypes and ambulatory blood pressure at mid-pregnancy. Soc Sci Med. 2008 Mar;66(6):1310-21.

http://www.ncbi.nlm.nih.gov/pubmed/18179853

* Dictionary: Anomie (ăn'e-mē)

1. Social instability caused by erosion of standards and values.
2. Alienation and purposelessness experienced by a person or a class as a result of a lack of standards, values, or ideals: “We must now brace ourselves for disquisitions on peer pressure, adolescent anomie and rage” (Charles Krauthammer).

[French, from Greek anomiā, lawlessness, from anomos, lawless : a-, without; + nomos, law.]

Higher risk of offspring schizophrenia following antenatal maternal exposure to severe adverse life events

CONCLUSIONS: Our population-based study suggests that severe stress to a mother during the first trimester may alter the risk of schizophrenia in offspring. This finding is consistent with ecological evidence from whole populations exposed to severe stressors and suggests that environment may influence neurodevelopment at the feto-placental-maternal interface.

Khashan AS et al Higher risk of offspring schizophrenia following antenatal maternal exposure to severe adverse life events. Arch Gen Psychiatry. 2008 Feb;65(2):146-52.

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Primary Care Discussion Forum - Ann Bullock, Cherokee, NC

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

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

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

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

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

Specific Criteria for Referrals (AACAP)
The referring practitioner should consider the following criteria when considering the decision to refer.

1. When a child or adolescent demonstrates an emotional or behavioral problem that constitutes a threat to the safety of the child/adolescent or the safety of those around him/her. (e.g. suicidal behavior, severe aggressive behavioral, an eating disorder that is out of control, other self-destructive behavior),
2. When a child or adolescent demonstrates a significant change in his/her emotional or behavioral functioning for which there is no obvious or recognized precipitant. (e.g. the sudden onset of school avoidance, a suicide attempt or gesture in a previously well functioning individual),
3. When a child or adolescent demonstrates emotional or behavioral problems (regardless of severity), and the primary caretaker has serious emotional impairment or substance abuse problem. (e.g. a child with emotional withdrawal, whose parent is significantly depressed, a child with behavioral difficulties whose parents are going through a “hostile” divorce),
4. When a child or adolescent demonstrates an emotional or behavioral problem in which there is evidence of significant disruption in day-to-day functioning or reality contact. (e.g. a child/adolescent who has repeated severe tantrums with no apparent reason, a child reports hallucinatory experiences without an identifiable physical cause),
5. When a child or adolescent is hospitalized for the treatment of a psychiatric illness,
6. When a child or adolescent with behavioral or emotional problems has had a course of treatment intervention for six to eight weeks without meaningful improvement,
7. When child or adolescent presents with complex diagnostic issues involving cognitive, psychological, and emotional components that may be related to an organic etiology or complex mental health/legal issues,
8. When a child or adolescent has a history of abuse, neglect and/or removal from home, with current significant symptoms as a result of these actions,
9. When a child or adolescent whose symptom picture and family psychiatric history suggests that treatment with psychotropic medication may result in an adverse response. (e.g. the prescription of stimulants for a hyperactive child with a family history of bipolar disorder or schizophrenia),
10. When a child or adolescent has had only a partial response to a course of psychotropic medication or when any child is being treated with more than two psychotropic medications,
11. When a child under the age of five experiences emotional or behavioral disturbances that are sufficiently severe or prolonged as to merit a recommendation for the ongoing use of a psychotropic medication, or
12. When a child or adolescent with a chronic medical condition demonstrates behavior that seriously interferes with the treatment of that condition.

http://www.aacap.org/cs/root/physicians_and_allied_professionals/when_
to_seek_referral_or_consultation_with_a_child_and_adolescent_psychiatrist 

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

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

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

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

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

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STD Corner - Lori de Ravello, National IHS STD Program

HIV Screening in Dental Clinics?

The 2006 Centers for Disease Control recommendations for routine HIV screening in all health care settings could include dental clinics an important testing venue. However, little is known about patients' attitudes regarding the routine use of rapid oral HIV screening at an urban free dental clinic. This pilot study seeks to evaluate the patient perspective on rapid HIV screening in this setting. In June 2007, patients at a free dental clinic in Kansas City, Missouri, were provided an attitude assessment survey prior to their dental visit. This dental clinic serves a diverse patient population consisting of approximately 37% white, 47% black, 6% Hispanic, 4% Asian, and 1% Native American uninsured patients. Results were analyzed for acceptance of testing and potential barriers. Of the 150 respondents, 73% reported they would be willing to take a free rapid HIV screening test during their dental visit. Overall, 91% of Hispanics, 79% of Caucasians, and 73% of African American patients reported they would be willing to be screened. Patients with a history of multiple prior screening tests for HIV      were more likely to agree to oral rapid HIV screening in the dental clinic. The majority (62%) reported that it did not matter who provided them with the screening result, although some (37%) preferred their dentist above any other provider. Low self-perception of risk (37%) and having already received screening elsewhere (24%) were the main reasons for not accepting a free, rapid HIV screening. Overall, dental clinic patients widely accepted the offer of rapid oral HIV screening. Rapid HIV screening in the dental clinic setting is a viable option to increase the number of individuals who know their HIV status.

Dietz CA , Ablah E, Reznik D, Robbins DK Patients' attitudes about rapid oral HIV screening in an urban, free dental clinic. AIDS Patient Care & STDs. 22(3):205-12, 2008 Mar.

http://www.liebertonline.com/doi/pdfplus/10.1089/apc.2007.0235

Racial Disparities Persist Across All Reportable STDs

Racial and ethnic minorities continue to be disproportionately affected by sexually transmitted diseases in the United States; data in CDC’s 2006 STD Surveillance Report show higher rates of all STDs among minority racial and ethnic populations when compared to whites, with the exception of Asians/Pacific Islanders. These disparities may be, in part, because racial and ethnic minorities are more likely to seek care in public health clinics that report STDs more completely than private providers. However, this reporting bias does not fully explain these differences. Other contributing factors include limited access to quality health care, poverty, and higher prevalence of disease in these populations.

Chlamydia

In 2006, the rate of chlamydia among African Americans was more than eight times higher than the rate among whites (1275.0 vs. 153.1 per 100,000 population), with approximately 46 percent of all chlamydia cases reported among African Americans. Additionally, the rates among American Indians/Alaska Natives (797.3 per 100,000) and Hispanics (477.0 per 100,000), were five times and three times higher than whites, respectively. In 2006, chlamydia rates increased for all racial/ethnic groups, except for Asians/Pacific Islanders.

Gonorrhea

Racial disparities in gonorrhea rates are even greater and racial gaps in diagnosis of gonorrhea are more pronounced than any other disease. The gonorrhea rate among African Americans was 18 times greater than that for whites in 2006 (658.4 per 100,000 vs. 36.5 per 100,000). From 2005 to 2006, the gonorrhea rate among African Americans increased by 6.3 percent—the first increase since 1998. In 2006, African Americans accounted for 69 percent of reported cases of gonorrhea.

In that same year, American Indians/Alaska Natives had the second-highest gonorrhea rate (138.3 per 100,000), followed by Hispanics (77.4), whites (36.5), and Asians/Pacific Islanders (21.1). In 2006, there were increases in gonorrhea rates among all racial and ethnic groups, except Asians/Pacific Islanders.

Syphilis

Although racial gaps in syphilis rates are narrowing, disparities remain, with rates in 2006 approximately six times higher among blacks than among whites. This represents a substantial decline from 1999, when the rate among blacks was 29 times greater than among whites. It is important to note that this narrowing reflects both declining disease rates among African Americans as well as significant increases among white males in recent years.

Despite some progress, African Americans continue to remain disproportionately affected by syphilis with a rate of 11.3 cases per 100,000 population in 2006. This is more than three times the rate for Hispanics, who have the second highest rate (3.6 cases per 100,000) as well as American Indians/Alaska Natives (3.3 cases per 100,000).

In 2006, the P&S syphilis rate among blacks increased for the third consecutive year, following more than a decade of declines. Between 2005 and 2006, the rate among blacks increased 16.5 percent (from 9.7 to 11.3), with the largest increase among black males (15.5 to 18.3, an increase of 18.1 percent).

In 2006, the rate of P&S syphilis in black females was 16 times higher than in white females. In that same year, 43.2 percent of all reported P&S syphilis cases occurred among African Americans, while whites accounted for 38.4 percent. Syphilis rates increased for all races and ethnicities in 2006. http://www.cdc.gov/std/stats/default.htm

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.

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Barbara Stillwater, Alaska State Diabetes Program

Take the stairs and live longer

Researchers at the University of Missouri in Columbia, Mo., and the University of Copenhagen in Denmark, asked study participants to reduce the amount of steps they take to just 1,400 per day. Instead of walking or taking the stairs, they were instructed to use elevators, escalators and cars whenever possible. Many doctors recommend taking 10,000 steps a day for a healthy lifestyle, but the average American takes only 7,473 steps each day and inactive Americans -- just 2,100.

After two weeks, participants' glucose and fat levels increased greatly and their bodies took much longer than before to clear the substances from their blood streams. "When extra fats and sugars (glucose) don't clear the bloodstream, they go where we don't want them and cause problems for our bodies' typical metabolic functions," Frank Booth, Ph.D., a professor of biomedical sciences at the University of Missouri's College of Veterinary Medicine, was quoted as saying.

Researchers say study participants experienced accumulation of dangerous abdominal fat, elevated blood-lipids -- a sign of pre-diabetes -- and their total skeletal and muscle mass decreased.

“Previously, we thought that not exercising just wasn't healthy, but we didn't think that a lack of activity could cause disease. That assumption was wrong,“ Booth said.

Olsen RH et al Metabolic responses to reduced daily steps in healthy non-exercising men.

JAMA. 2008 Mar 19;299(11):1261-3. http://www.ncbi.nlm.nih.gov/pubmed/18349087

Possible Way to Detect Gestational Diabetes

This study showed that 7% of women diagnosed with gestational diabetes were already diabetic at the time of first visit and were misdiagnosed with gestational diabetes, when they had diabetes. They also found that, a HBA1C level at the first visit of less than 5.3 would not develop gestational diabetes during the entire course of pregnancy.

Balaji V et al A1C in gestational diabetes mellitus in Asian Indian women. Diabetes Care. 2007 Jul;30(7):1865-7 http://www.ncbi.nlm.nih.gov/pubmed/17416790

OB/GYN CCC Editorial comment:

HgbA1C not ready for prime time to diagnose gestational diabetes

We have all struggled with what to call those pts diagnosed in the first trimester for just the reasons outlined by Balaji et al. The article is of interest, but doing a HgbA1C on all pregnant women is probably not ready for prime time of clinical diagnosis.

We have settled on the simple designation of First Trimester GDM because it could represent pregestational DM, but using that term (pregestational DM) can be confusing because many will have a normal OGTT after they deliver. This concept has been discussed in the CCC Corner.

http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0607_AOM.cfm

or here in pdf

http://www.ihs.gov/MedicalPrograms/MCH/M/documents/CCCC_v5_06.pdf

In the trenches the clinical differences during the pregnancy are minimal as far as management goes….we still need to follow their fingersticks and then add hypoglycemics if diet and exercise aren’t enough

Periodontal pathogens and gestational diabetes mellitus

Study has found evidence that pregnant women with periodontal (gum) disease have an increased risk of developing gestational diabetes than pregnant women with healthy gums.

In previous cross-sectional or case-control studies, clinical periodontal disease has been associated with gestational diabetes mellitus. To test the hypothesis that, in comparison with women who do not develop gestational diabetes mellitus, those who do develop it will have had a greater exposure to clinical and other periodontal parameters, we measured clinical, bacteriological (in plaque and cervico-vaginal samples), immunological, and inflammatory mediator parameters 7 weeks before the diagnosis of gestational diabetes mellitus in 265 predominantly Hispanic (83%) women in New York. Twenty-two cases of gestational diabetes mellitus emerged from the cohort (8.3%). When the cases were compared with healthy control individuals, higher pre-pregnancy body mass index (p=0.004), vaginal levels of Tannerella forsythia (p=0.01), serum C-reactive protein (p=0.01), and prior gestational diabetes mellitus (p=0.006) emerged as risk factors, even though the clinical periodontal disease failed to reach statistical significance (50% in those with gestational diabetes mellitus vs. 37.3% in the healthy group; p=0.38).

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Women's Health Headlines, Carolyn Aoyama, HQE

Surgeon General's Conference on Women and Mental Health

A summary of this 2005 conference is now available. You will find in the report an entire section on trauma, violence, and abuse. Although the workshop was in December of 2005, the lessons in it are still relevant. http://www.surgeongeneral.gov/topics/womensmentalhealth/

After School Programs Can Increase Physical Activity of Adolescent Girls

After school programs can modestly increase the amount of physical activity among girls in middle school, according to new results from the Trial of Activity for Adolescent Girls, a multiple site, community-based study supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health. [National Institutes of Health]

http://public.nhlbi.nih.gov/newsroom/home/GetPressRelease.aspx?id=2558

Obesity: Pinn Point on Women’s Health

The Office of Research on Women’s Health (ORWH) is broadcasting the tenth in a series of podcasts, “Pinn Point on Women’s Health,” hosted by Dr. Vivian W. Pinn, Associate Director for Research on Women’s Health and the Director of the Office of Research on Women’s Health. The monthly podcast discusses the latest news in women’s health research and includes conversations with guests on a variety of subjects.

In her latest podcast, Dr. Pinn discusses obesity with Dr. Susan Yanovski, Co-Director, Office of Obesity Research, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health.  Dr. Yanovski discusses the high rates of obesity among Americans, and women, especially women of color. She also addresses recent research linking obesity and gestational diabetes in pregnant women to obesity and diabetes in children, and offers tips to women on how to manage weight and nutrition issues for themselves and their families in their already busy daily lives.

“Podcasting” is a relatively new method of distributing audio and video information via the Internet to iPods and other portable media players on demand, so that it can be listened to at the user’s convenience. The main benefit of podcasting is that listeners can sync content to their media player and take it with them to listen to whenever they want. Because podcasts are typically saved in MP3 format, they can also be listened to on nearly any computer.

To listen to Dr. Pinn’s podcast, visit the ORWH homepage at http://orwh.od.nih.gov/ and click on the Obesity podcast. If you need further assistance on how to use podcasts, go to http://videocast.nih.gov/faq/podcast/default.asp.

For questions, contact Marsha Love at the Office of Research on Women’s Health by calling (301) 496-9472 or e-mailing lovem@od.nih.gov.

Chronic Pelvic Pain

I wanted to share this article, "Frequency and Distribution of Multiple Diagnoses In Chronic Pelvic Pain Related to Previous Abuse Or Drug-Seeking Behavior", on chronic pelvic pain with you.

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Save the dates

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

Contacts: Sharon Jackson Sharon.jackson@ihs.gov, Sandra Dodge Sandra.dodge@ihs.gov, or Alberta Gorman ( Alberta.gorman@ihs.gov ).

Community Health Representative National Educational Meeting

• July 29-31 2008
• Las Vegas , Nevada
• 40th anniversary of the CHR Program. 

http://www.nachr.net/conferences/2008/

Postgraduate Course on Obstetric, Neonatal and Gynecologic Care

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

http://www.ihs.gov/MedicalPrograms/MCH/F/CN01.cfm?module=08&option=9#top

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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 April 2008 OB/GYN CCC Corner is available.

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OB/GYN

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