Acrobat
MS Word
PowerPoint
Volume 6, No. 3, March 2008
Features
American College of Obstetricians and Gynecologists
Fatigue and Patient Safety
ABSTRACT: It has long been recognized that fatigue can affect human cognitive and physical function. Although there are limited published data on the effects of fatigue on health care providers, including full-time practicing physicians, there is increasing awareness within the patient safety movement that fatigue, even partial sleep deprivation, impairs performance. Most of the current literature reviews resident function after recent work reform changes. However, the information available from many studies in health care and other occupations can be applied to the work habits of practicing obstetrician–gynecologists.
Fatigue and Patient Safety. ACOG Committee Opinion No. 398. American College of Obstetricians and Gynecologists. Obstet Gynecol 2008;111:471–3
http://www.ncbi.nlm.nih.gov/pubmed/18238990
ACOG Statement on Home Births
The American College of Obstetricians and Gynecologists (ACOG) reiterates its long-standing opposition to home births. While childbirth is a normal physiologic process that most women experience without problems, monitoring of both the woman and the fetus during labor and delivery in a hospital or accredited birthing center is essential because complications can arise with little or no warning even among women with low-risk pregnancies.
ACOG acknowledges a woman's right to make informed decisions regarding her delivery and to have a choice in choosing her health care provider, but ACOG does not support programs that advocate for, or individuals who provide, home births. Nor does ACOG support the provision of care by midwives who are not certified by the American College of Nurse-Midwives (ACNM) or the American Midwifery Certification Board (AMCB).
Childbirth decisions should not be dictated or influenced by what's fashionable, trendy, or the latest cause célèbre. Despite the rosy picture painted by home birth advocates, a seemingly normal labor and delivery can quickly become life-threatening for both the mother and baby. Attempting a vaginal birth after cesarean (VBAC) at home is especially dangerous because if the uterus ruptures during labor, both the mother and baby face an emergency situation with potentially catastrophic consequences, including death. Unless a woman is in a hospital, an accredited freestanding birthing center, or a birthing center within a hospital complex, with physicians ready to intervene quickly if necessary, she puts herself and her baby's health and life at unnecessary risk.
Advocates cite the high US cesarean rate as one justification for promoting home births. The cesarean delivery rate has concerned ACOG for the past several decades and ACOG remains committed to reducing it, but there is no scientific way to recommend an 'ideal' national cesarean rate as a target goal. In 2000, ACOG issued its Task Force Report Evaluation of Cesarean Delivery to assist physicians and institutions in assessing and reducing, if necessary, their cesarean delivery rates. Multiple factors are responsible for the current cesarean rate, but emerging contributors include maternal choice and the rising tide of high-risk pregnancies due to maternal age, overweight, obesity and diabetes.
The availability of an obstetrician-gynecologist to provide expertise and intervention in an emergency during labor and/or delivery may be life-saving for the mother or newborn and lower the likelihood of a bad outcome. ACOG believes that the safest setting for labor, delivery, and the immediate postpartum period is in the hospital, or a birthing center within a hospital complex, that meets the standards jointly outlined by the American Academy of Pediatrics (AAP) and ACOG, or in a freestanding birthing center that meets the standards of the Accreditation Association for Ambulatory Health Care, The Joint Commission, or the American Association of Birth Centers.
It should be emphasized that studies comparing the safety and outcome of births in hospitals with those occurring in other settings in the US are limited and have not been scientifically rigorous. Moreover, lay or other midwives attending to home births are unable to perform live-saving emergency cesarean deliveries and other surgical and medical procedures that would best safeguard the mother and child.
ACOG encourages all pregnant women to get prenatal care and to make a birth plan. The main goal should be a healthy and safe outcome for both mother and baby. Choosing to deliver a baby at home, however, is to place the process of giving birth over the goal of having a healthy baby. For women who choose a midwife to help deliver their baby, it is critical that they choose only ACNM-certified or AMCB-certified midwives that collaborate with a physician to deliver their baby in a hospital, hospital-based birthing center, or properly accredited freestanding birth center.
http://www.acog.com/from_home/publications/press_releases/nr02-06-08-2.cfm
Alcohol and Pregnancy: Know the Facts
Washington, DC -- The recent news story "Can Pregnant Women Drink Alcohol in Moderation?", which aired on ABC's Good Morning America Weekend, has created tremendous confusion among women about the safety of drinking alcohol during pregnancy. The American College of Obstetricians and Gynecologists (ACOG) strongly urges women not to ignore the public health warnings associated with consuming alcohol while pregnant.
ACOG is concerned that this television segment disseminated a potentially dangerous and mixed message to pregnant women. According to ACOG, patients who saw the show are asking their ob-gyns for clarification about whether moderate—or even light—drinking will impact the health of their baby. Therefore, ACOG reiterates its long-standing position that no amount of alcohol consumption can be considered safe during pregnancy.
Maternal alcohol use is the leading known cause of mental retardation and is a preventable cause of birth defects. Children exposed to alcohol in utero are at risk for growth deficiencies, facial deformities, central nervous impairment, behavioral disorders, and impaired intellectual development. Consuming alcohol during pregnancy also increases the risk of miscarriage, low birth weight, and stillbirth.
The bottom line according to ACOG: Women should avoid alcohol entirely while pregnant or trying to conceive because damage can occur in the earliest weeks of pregnancy, even before a woman knows that she is pregnant.
http://www.acog.com/from_home/publications/press_releases/nr02-06-08-1.cfm
ACOG Patient Education Pamphlet, Alcohol and Pregnancy
www.acog.org/publications/patient_education/bp132.cfm
Asthma in Pregnancy
Summary of Recommendations and Conclusions
The following recommendations and conclusions are based on limited or inconsistent scientific evidence (Level B):
- It is safer for pregnant women with asthma to be treated with asthma medications than it is for them to have asthma symptoms and exacerbations.
- Clinical evaluation of asthma includes subjective assessments and pulmonary function tests.
- The ultimate goal of asthma therapy in pregnancy is maintaining adequate oxygenation of the fetus by preventing hypoxic episodes in the mother.
- The step-care therapeutic approach increases the number and dosage of medications with increasing asthma severity.
- Inhaled corticosteroids are first-line controller therapy for persistent asthma during pregnancy.
- Budesonide is the preferred inhaled corticosteroid for use during pregnancy.
- Inhaled albuterol is recommended rescue therapy for pregnant women with asthma.
- Identifying and controlling or avoiding factors such as allergens and irritants, particularly tobacco smoke, can lead to improved maternal well-being with less need for medication.
- Continuation of immunotherapy is recommended in patients who are at or near a maintenance dose, not experiencing adverse reactions to the injections, and apparently deriving clinical benefit.
- Use of prednisone, theophylline, antihistamines, inhaled corticosteroids, b2-agonists, and cromolyn is not contraindicated for breastfeeding.
The following recommendations and conclusions are based primarily on consensus and expert opinion (Level C):
- Asthma self-management skills, including self-monitoring, correct use of inhalers, and following a plan for long-term management of asthma and promptly handling signs of worsening asthma, enhance asthma control.
- For pulmonary function assessment of patients during outpatient visits, spirometry is preferable, but peak expiratory flow measurement with a peak flow meter also is sufficient.
- Ultrasound examinations and antenatal fetal testing should be considered for women who have moderate or severe asthma during pregnancy.
- Pregnant patients with asthma, even those with mild or well-controlled disease, need to be monitored with PEFR and FEV1 testing as well as by observing their symptoms during pregnancy.
- Routine evaluation of pulmonary function in pregnant women with persistent asthma is recommended.
- Because pulmonary function and asthma severity may change during the course of pregnancy, routine evaluation of pulmonary function in pregnant women with persistent asthma is recommended
Asthma in Pregnancy. ACOG Practice Bulletin No. 90. American College of Obstetricians and Gynecologists. Obstet Gynecol 2008; 111:457–64. http://www.ncbi.nlm.nih.gov/pubmed/18238988
Surrogate Motherhood
ABSTRACT: Ethical responsibilities are described for obstetrician–gynecologists who choose to participate in surrogacy arrangements by 1) advising couples who are considering surrogacy, 2) counseling potential surrogate mothers, 3) providing obstetric services for pregnant women participating in surrogacy, or 4) offering assisted reproductive technologies related to surrogacy. Although the obligations of physicians will vary depending on the type and level of their involvement, in all cases physicians should carefully examine all relevant issues related to surrogacy, including medical, ethical, legal, and psychologic aspects.
Surrogate Motherhood. ACOG Committee Opinion No. 397. American College of Obstetricians and Gynecologists. Obstet Gynecol 2008;111:465–70.
http://www.ncbi.nlm.nih.gov/pubmed/18238989
American Family Physician**
Treating Eating Disorders in Primary Care (also see Patient Information)
Binge-eating disorder, bulimia nervosa, and anorexia nervosa are potentially life-threatening disorders that involve complex psychosocial issues. A strong therapeutic relationship between the physician and patient is necessary for assessing the psychosocial and medical factors used to determine the appropriate level of care. Most patients can be effectively treated in the outpatient setting by a health care team that includes a physician, a registered dietitian, and a therapist. Psychiatric consultation may be beneficial. Patients may require inpatient care if they are suicidal or have life-threatening medical complications, such as marked bradycardia, hypotension, hypothermia, severe electrolyte disturbances, end-organ compromise, or weight below 85 percent of their healthy body weight. For the treatment of binge-eating disorder and bulimia nervosa, good evidence supports the use of interpersonal and cognitive behavior therapies, as well as antidepressants. Limited evidence supports the use of guided self-help programs as a first step in a stepped-care approach to these disorders. For patients with anorexia nervosa, the effectiveness of behavioral or pharmacologic treatments remains unclear. Am Fam Physician. 2008;77(2):187-195, 196-197. http://www.aafp.org/afp/20080115/187.html
End-of-Life Care: Guidelines for Patient-Centered Communication
When patients are diagnosed with cancer, primary care physicians often must deliver the bad news, discuss the prognosis, and make appropriate referrals. When delivering bad news, it is important to prioritize the key points that the patient should retain. Physicians should assess the patient's emotional state, readiness to engage in the discussion, and level of understanding about the condition. The discussion should be tailored according to these assessments. Often, multiple visits are needed. When discussing prognosis, physicians should be sensitive to variations in how much information patients want to know. The challenge for physicians is to communicate prognosis accurately without giving false hope. All physicians involved in the patient's care should coordinate their key prognosis points to avoid giving the patient mixed messages. As the disease progresses, physicians must reassess treatment effectiveness and discuss the values, goals, and preferences of the patient and family. It is important to initiate conversations about palliative care early in the disease course when the patient is still feeling well. There are innovative hospice programs that allow for simultaneous curative and palliative care. When physicians discuss the transition from curative to palliative care, they should avoid phrases that may convey to the patient a sense of failure or abandonment. Physicians also must be cognizant of how cultural factors may affect end-of-life discussions. Sensitivity to a patient's cultural and individual preferences will help the physician avoid stereotyping and making incorrect assumptions. Am Fam Physician. 2008;77(2):167-174.
http://www.aafp.org/afp/20080115/167.html
CDC Reports on Lead Exposure in Women of Childbearing Age
Evidence on the adverse health effects of moderate- and low-level blood lead concentrations is mounting. Public health authorities use higher levels to define blood lead levels of concern in nonpregnant women (>= 25 µg per dL [1.20 µmol per L]) than in pregnant women (>= 5 µg per dL [0.25 µmol per L]), in whom maternal and fetal levels are nearly identical because lead crosses the placenta unencumbered. The difference in blood lead levels for nonpregnant and pregnant women has received attention because of the recognition that a proportion of nonpregnant women with blood lead levels greater than 5 µg per dL may become pregnant and potentially expose their infants to the adverse health effects from lead. The Centers for Disease Control and Prevention (CDC) summarized 2004 surveillance data on elevated blood lead levels among women of childbearing age (i.e., 16 to 44 years) in 37 states participating in the CDC's Adult Blood Lead Epidemiology and Surveillance (ABLES) program, and emphasized the need for necessary surveillance measures to prevent lead exposure in women of childbearing age.
Adverse health effects in infants born to women with moderately elevated blood lead levels (i.e., 10 to 15 µg per dL [0.50 to 0.70 µmol per L]) include preterm birth, decreased gestational maturity, lower birth weight, reduced postnatal growth, increased incidence of minor congenital anomalies, and early neurologic or neurobehavioral deficits. Some evidence documents associations between prenatal elevated blood lead levels and decreased intelligence when those children are three to seven years of age. Estimates have varied widely concerning the number and rate of women of childbearing age with elevated blood lead levels; however, conducting surveillance of elevated blood lead levels in this population is important because approximately one third to one half of U.S. pregnancies are unplanned. Primary and secondary prevention of lead exposure among women of childbearing age, which includes identifying and counseling women who might become pregnant and expose their infant to lead in utero, is needed to lessen the risk of possible neurobehavioral and cognitive defects in their children.
Rates of elevated blood lead levels detected in the ABLES program among women who worked in the manufacturing sector, especially in the industry that includes battery manufacturing, were much higher than those of the general population for all lead exposures. These increased rates suggest that the workplace remains a substantial source of lead exposure, and physicians should consider work history when determining whether to measure blood lead levels.
Morbidity and Mortality Weekly Report, April 27, 2007
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5616a4.htm
Dietary Supplements for Osteoarthritis
A large number of dietary supplements are promoted to patients with osteoarthritis and as many as one third of those patients have used a supplement to treat their condition. Glucosamine-containing supplements are among the most commonly used products for osteoarthritis. Although the evidence is not entirely consistent, most research suggests that glucosamine sulfate can improve symptoms of pain related to osteoarthritis, as well as slow disease progression in patients with osteoarthritis of the knee. Chondroitin sulfate also appears to reduce osteoarthritis symptoms and is often combined with glucosamine, but there is no reliable evidence that the combination is more effective than either agent alone. S-adenosylmethionine may reduce pain but high costs and product quality issues limit its use. Several other supplements are promoted for treating osteoarthritis, such as methylsulfonylmethane, Harpagophytum procumbens (devil's claw), Curcuma longa (turmeric), and Zingiber officinale (ginger), but there is insufficient reliable evidence regarding long-term safety or effectiveness. Am Fam Physician. 2008;77(2):177-184.
http://www.aafp.org/afp/20080115/177.html
AHRQ
Physicians want to learn from medical mistakes but say current error-reporting systems are inadequate
http://www.ahrq.gov/research/feb08/0208RA1.htm
A combination of maternal, baby, and episiotomy factors contribute to high rates of maternal birth trauma in Iowa
http://www.ahrq.gov/research/feb08/0208RA11.htm
Comparative Effectiveness of Second-Generation Antidepressants in the Pharmacologic Treatment of Adult Depression: AHRQ Executive Summary
http://www.medscape.com/viewprogram/7793?src=sr
Nurse midwives deliver more babies in hospitals than homes in Washington State
http://www.ahrq.gov/research/feb08/0208RA10.htm
Study of young Head Start children links overweight to worsened asthma
http://www.ahrq.gov/research/feb08/0208RA6.htm
Ask A Librarian: Diane Cooper, M.S.L.S. / NIH
Cervical Cancer Community-Based Research Project in a Native American Community
The Messengers for Health on the Apsáalooke Reservation project uses a community-based participatory research (CBPR) approach and lay health advisors (LHAs) to generate knowledge and awareness about cervical cancer prevention among community members in a culturally competent manner. Northern Plains Native Americans, of whom Apsáalooke women are a part, continue to be disproportionately affected by cervical cancer. This article examines quantitative and qualitative changes that occurred in the community since the inception of the Messengers for Health program. Paired sample t tests are used to evaluate the one-group pretest and posttest interviews of 83 Apsáalooke women in knowledge, comfort, and cancer awareness levels. Results reveal cervical cancer knowledge gains, gains in participants' comfort discussing cancer issues, and gains in awareness of cervical cancer and the Messengers program. Field notes, meeting minutes, and community perceptions are used to qualitatively evaluate the effectiveness of the Messengers program. Practice implications are discussed.
Christopher S et al A Cervical Cancer Community-Based Participatory Research Project in a Native American Community. Health Educ Behav. 2007 Dec 12
http://www.ncbi.nlm.nih.gov/pubmed/18077653
Behavioral Health Insights, Peter Stuart, IHS Psychiatry Consultant
PTSD: A technique that works for me
by Dr. James Lagattuta*
I would like to share with you a technique I use routinely to work with client experiencing trauma. “TIR, or Traumatic Incident Reduction, is a systematic method of locating, reviewing, and resolving traumatic events” link below.
With its roots in psychoanalytic as well as desensitization/exposure literature, it is highly “person-centered, non-judgmental, and non-evaluative” in its treatment of the client. The provider becomes a very active listener gently only asking the client to state when, where, how long, and what the initial feeling was about the “incident” that happened, followed by asking that it be first viewed in mind, and then told to the provider … and then repeated and repeated. At a certain point the client is asked if they feel “heavier (H)” or “lighter (L).” If lighter, then this incident is “the” root trauma and work on it continues. If “heavier,” than “is there and earlier, similar incident” which seems to immediately come to mind, and one goes there and work continues, with the “H” v “L” question continuing to search out “the” root incident to which the other trauma, including the presenting one, is linked. Once this incident is located and neutralized, energy involved with subsequent trauma is freed. This would occur if the presenting trauma involved a battle incident, or the case I shall describe. Some details have been altered to ensure confidentiality.
After the Christmas holidays a mother asked if I would see her 18 y.o. son for a severe depression. The depression started after a multiple car fender-bender with no physical injuries on an icy road. It had been over a month since the incident and the beginning of the second semester of his HS senior year. He had stopped driving, had not returned to school, was missing assignments, and was having difficulty with his role as Captain of the wrestling team. He had already gotten early selection to a prestigious college. I explained what I would do during our session to mother, asking her to explain it to her son and seek his permission to work together.
When the son arrived, I reviewed the procedure and asked him to select an incident to work on. He chose the recent accident. We proceeded in the TIR manner and I asked the “H” v “L” question and his response was “H.” He then jumped to a fender-bender in which he was involved as he was driving with his mother with a learner permit at 14.
I asked, “Heavy or Light?”
He responded, “Heavier.”
He jumped to another fender-bender at age 9 when his mother was driving.
As I was getting to a time when I would have asked the “H” v “L” question he suddenly said, “and I was curled up in a ball and watched the car run over me.”
I responded, “How old were you?”
He said, “Three.”
I stated “Go there to the beginning.”
Instead of responding directly he immediately replied with the following story, “My brother and I were in the back seat of the car ... it was parked at an incline facing down the hill leading to our house … dad went into the house for something … I jumped out and went to the front of the car … was told later my brother jumped into the driver seat, released the emergency brake and pretended to drive … I saw the car rolling toward me, curled up into a ball and looked up watching the car roll over me.”
Then he suddenly said, “That SOB!!! Dad came out of the house yelling at us, blaming us for what was happening and then punished us … and when I was 9 he said nearly the same things, and at 14 and last month, too!!! I never realized how angry I’ve been at him all these years. “
I asked, “Heavy or Light?”
He said, “Very light!”
He returned the next week, having driven himself to the appointment, went back to school and activities, caught up with all work. He had a direct talk with dad about his feelings that he had held in over the years. He felt he had completed his work and did not need further assistance, and went on to graduate with honors.
Though simple compared with some more seemingly more painful and complex trauma, this procedure can at times deal with significant traumas in as little as one viewing session.
Traumatic Incident Reduction http://www.healing-arts.org/tir/
*Dr. Jim Lagattuta is a long-time therapist in Indian country and has been a pioneer in adapting exposure-based therapies for helping AI/AN patients recover from traumatic incidents. The following tale highlights how he approaches this complicated issue and demonstrates how it is not always “talking” about traumatic life events that takes the sting out. Readers should also note that not all therapy requires multiple sessions – in this particular case a good outcome was achieved with one session of focused work.
Breastfeeding - Suzan Murphy, PIMC
Promoting, Protecting, Supporting
2001 HRSA USBC Strategic Plan brochure stresses 6 major areas that since 1984 have withstood the test of time:
- Improving professional education in human lactation and breastfeeding
- develop public education and promotion efforts
- strengthen the support for breastfeeding in the health care system
- develop a broad range of support services in the community
- initiate a national breastfeeding promotion effort directed at working women; and
- expand research on human lactation and data collection on breastfeeding.
Mission and Vision, IV Strategic goals and objectives developed around the 2010 goals are quite details. For your review and use.
This will be posted on the IHS breastfeeding web page.
Contact Judith.Thierry@ihs.gov to review the strategic plan
CCC Corner Digest
Nicely laid out hard copy - A compact digest of last month’s CCC Corner
February 2008 highlights include:
- Concern for rising Cesarean rates in Native American populations
- Save the Dates!! Earn up to 28 hours of CME/CE specific to Indian Health
- Knowledge of cervical length / fetal fibronectin: Shorter evaluation and PTB
- Misoprostol is as effective as manual vacuum aspiration in SAB of <12 weeks
- Secondhand smoke during infancy linked in dose-response fashion with allergies
- 'Awake' during surgery: Examining intraoperative awareness
- Elective and risk–reducing salpingo-oophorectomy
- Prevention and Treatment of Sexually Transmitted Diseases: An Update
- Cervical Cancer Community-Based Research Project in a Native American Community
- Breast Pumps: The good, the bad, and the ugly
- National Report: National Indian Child Welfare
- Palliative / End of Life Care Training- SAVE THE DATES – March and April Courses
- Continuous Oral Contraception May Not Reduce Bleeding Days but May Improve Sx
- New and Improved MCH Conferences page - More user friendly
- Multiple Chlamydia species pose an unexpected challenge for blindness prevention
- Insights on Implementing Cultural and Linguistic Competence in MCH
- Announcing the 2008 PREVENT Child Maltreatment Institute
- St. John's wort for depression in a young woman
- Smoking Status as a Predictor of Hip Fracture Risk in Postmenopausal Women
- AI / AN women - successful at this; Evidence supports this; Women benefit from this
- Judy Whitecrane: Tireless Improvement of Care for Native American women
- Biliary Gallstone Disease and Pregnancy
- AWHONN – numerous on line courses – materials and fees listed
- Cesarean Delivery: What are the risks and benefits?
- Patients Prefer "Tell Back- Collaborative Inquiry" Method to Assess Understanding
- Women with cardiovascular risk factors may be predisposed to pre-eclampsia
- Mental health issues in children and adolescents –Starts in March
- The cervical cancer risk is still increased 25 years after treatment for CIN 3
- Resolving to Lose Weight in the New Year?
- Women's Leadership Scholarship
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/CCCC_v6_02.pdf
If you want a copy of the CCC Digest mailed to you each month, please contact nmurphy@scf.cc
Domestic Violence
IHS-sponsored training in sexual assault forensic examination
My office will be sponsoring training in sexual assault forensic examination for IHS and Tribal physicians, nurses and Advanced Practice Nurses. In order to plan the training I need an idea of the number of people interested in attending.
Please email me if you might be interested in attending. The training is 40 hours long (either 4-10 hour days or 5-8 hour days) and will be held in either Phoenix or Albuquerque this summer – June or July. I will not be able to provide travel support. Carolyn.Aoyama@ihs.gov
Report cites high rate of violence against Native women
American Indian and Alaska Native women suffer from the highest rates of domestic violence, according to a new Centers for Disease Control and Prevention report.
In the largest-ever survey of its kind, 39 percent of Native women said they were victims of intimate-partner violence. This was by far the highest rate among women of all racial and ethnic groups.
The survey also showed that nearly 19 percent of Native men were victims of intimate-partner violence. This was the second-highest rate, behind African-American men.
Government studies have long shown that Native women suffer from high rates of domestic violence. But the data published in the current issue of Morbidity and Mortality Weekly Report provides the most up to date information about an issue that is gaining national and international attention.
"In Alaska, an Alaska Native woman has a likelihood of rape that is four times higher than a nonnative woman in the state," said Sen. Lisa Murkowski (R-Alaska), the vice chair of the Senate Indian Affairs Committee, said on January 23 during debate of the Indian Health Care Improvement Act.
"But we know it is not only in Alaska that there is this danger of violence that faces our Native women," she said. "Statistics show that Native women around the country are two to three times more likely to be raped than women from other populations in the United States."
The CDC report ties domestic violence to the high rates of chronic diseases and conditions found in Indian Country. According to the survey, people who are victimized by their current or former partner are more likely to suffer from asthma, stroke and heart disease, all common among Native Americans.
Intimate-partner violence, or IPV, is also linked to health risk behaviors like smoking and binge drinking, according to the CDC. With the exception of diabetes, high blood pressure and being overweight, "reporting of health conditions and risk behaviors was significantly higher among women who had experienced IPV during their lifetimes compared with women who had never experienced IPV," the report said.
In an editorial note, the authors of the CDC study said the data doesn't prove that adverse health outcomes are directly caused by domestic violence. They recommend that health care professionals assess whether intimate-partner violence is a factor in treating patients.
Resources
Adverse Health Conditions and Health Risk Behaviors Associated with Intimate Partner Violence --- United States, 2005 (February 8, 2008)
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5705a1.htm
and
http://www.indianz.com/Health/
Resource for interrupting the cycle violence
Online victim assistance training - VAT Online – is available through the Office for Victims of Crime. www.ovcttac.org/vatonline
For fact sheets go to: www.ojp.usdoj.gov/ovc/assist/pdftxt/VAtraining_options_fs.pdf
Affects of cueing on providers discussion of intimate partner violence
This study identified potentially important differences in provider behaviors [related to discussing intimate partner violence (IPV) with pregnant women] as a result of cueing based upon pre-visit assessments.
The intervention included a summary cueing sheet for health professionals, all of whom received a brief orientation to the use of the cueing sheets. The authors found that
* Between June 2006 and June 2007, 286 pregnant women completed a risk assessment. Most women (223; 78%) reported no risks and were not randomized; 63 women (22%) reported one or more risks and were assigned to intervention or control groups.
* IPV was the most frequently reported risk, followed by smoking. Only three participants reported drug use, and one reported alcohol use.
* Of the 37 women who reported IPV, 20 were randomized to the intervention group. Seventeen intervention participants (85%) reported having a discussion about IPV with their health professional. Of the 17 participants randomized to the control group, four (23.5%) reported having a discussion about IPV.
* Smoking was identified as a risk in 34 participants, and 19 were randomized to the intervention group. All 19 intervention participants
(100%) reported having a discussion about smoking with their health professional. Of the 15 participants randomized to the control group, 9
(60%) reported having a discussion about smoking.
The authors conclude that "risk assessment with provider cueing is a promising adjunct to prenatal providers' efforts to address IPV."
Calderon SH, Gilbert P, Jackson R, et al. 2008. Cueing prenatal providers: Effects on discussions of intimate partner violence. American Journal of Preventive Medicine 34(2)134-137. http://www.ajpm-online.net/article/PIIS0749379707006496/abstract
Women who have had physical abuse during pregnancy: risk of preterm delivery
Conclusion: Women who have had physical abuse during pregnancy present a large increase in the risk of preterm delivery, independently from a large set of sociodemographic and behavioral characteristics usually recognized as determinants of preterm birth.
Rodrigues T et al Physical abuse during pregnancy and preterm delivery. Am J Obstet Gynecol. 2008 Feb;198(2):171.e1-6. http://www.ncbi.nlm.nih.gov/pubmed/17905171Elder Care News
Exciting opportunity to develop new resources in geriatrics
An exciting opportunity to develop new resources in geriatrics in the Indian Health system.
Applications are being accepted until April 2 for the Practice Change Fellows Program. This program, sponsored by The Atlantic Philanthropies and The John A. Hartford Foundation, is designed to expand the number of health care leaders who can effectively promote high quality care to older adults in a wide range of health and health care organizations. The short-term goal of this program is to transform health care professionals working within the broadly defined delivery system into effective leaders. These leaders will have strong management skills and content expertise to effectuate practice improvement within their organizations to better meet the needs of older adults. The long-term goal is to establish a vigorous network of health care practice change specialists with the capacity to influence care for this population on a national scale.
The Practice Change Fellowship is open to nursing, social workers and physician leaders. Leaders in local health systems (Tribal, Federal, or Urban), and those working at an Area or regional Tribal level as well as those working at a national level would be eligible. The fellowship comes with funding to support the leadership and improvement activities ($45,000 per year for two years) and requires a strong commitment of support from leadership of the home organization.
You can find the details on the fellowship at http://www.practicechangefellows.org/
I know that the Advisory Board for the Fellowship Program is very interested in supporting improvement in geriatric care in the Indian Health system and I believe that they would look favorably on strong proposals from IHS, Tribal, and Urban applicants.
Dr. Robert Schreiber, a geriatrician who has volunteered for a number of years at Rosebud and has helped Rosebud develop a strong clinical geriatrics program, is involved with the Practice Change Fellowship program and has offered to provide guidance and advice to potential applicants.
Please let me know if you have interest or have a candidate at your facility, Office, or Tribal program who might have interest and who you see as an effective leader who can help build your geriatric program. And feel free to contact me with questions
Bruce Finke, MD
IHS / Nashville Area Elder Health Consultant
Chronic Care Initiative
(413) 584-0790
(615) 417-4915 cell
2008 End-of-Life Nursing Education Consortium Schedule announced
The End-of-Life Nursing Education Consortium (ELNEC) project is a national education initiative to improve end-of-life care in the United States. Launched in February 2000, the ELNEC provides nurses and nurse educators with essential training in end of life / palliative care and provides participants with the knowledge and resources to share this knowledge with other nursing colleagues.
ELNEC - 2008 Course Schedule - American Association of Colleges of Nursing
http://www.aacn.nche.edu/elnec/CourseSchedule.htm
or
http://www.aacn.nche.edu/elnec/
End-of-Life Care in the Setting of Cancer: Withdrawing Nutrition and Hydration
http://www.medscape.com/viewarticle/569277
Family Planning
Ringing Endorsement: Women Prefer Contraceptive Ring Over Patch
In the first study to directly compare a contraceptive vaginal ring and skin patch, more women indicated overall satisfaction with the vaginal ring, researchers report
CONCLUSION: Women satisfied with combined oral contraceptives and interested in a nondaily method are more likely to continue using the contraceptive ring than the contraceptive patch. LEVEL OF EVIDENCE: I.
Creinin MD, et al Multicenter Comparison of the Contraceptive Ring and Patch: A Randomized Controlled Trial. Obstet Gynecol. 2008 Feb;111(2):267-277 .
http://www.ncbi.nlm.nih.gov/pubmed/18238962?dopt=Abstract
Misconceptions About Oral Contraception Pills Among Adolescents and Physicians
RESULTS: The prevalence of incorrect beliefs was exceedingly high in the whole adolescent study group and relatively high among the physicians. The prevalence of incorrect beliefs was comparable between COCP users and non-users, regarding the 10 misconceptions investigated. The duration of COCP use did not influence the prevalence of misconceptions about the pill. Age did not serve as a confounding factor for all misconceptions.
CONCLUSIONS: Lack of informative communication between COCP-prescribing physicians and users and mistaken knowledge of the caring physicians may contribute to adolescent ignorance of the COCP. Focusing on adolescent-specific disbeliefs could lead to construction of better educational programs in schools and clinics
Hamani Y et al Misconceptions about oral contraception pills among adolescents and physicians. Hum Reprod. 2007 Dec;22(12):3078-83.
http://www.ncbi.nlm.nih.gov/pubmed/17905749
Copper containing IUDs are more effective for contraception than other IUDs: Cochrane
AUTHORS' CONCLUSIONS: TCu380A or TCu380S appear to be more effective than other IUDs. No IUD showed consistently lower removal rates for bleeding and pain in comparison to other IUDs. There is no evidence that any particular framed copper device is better suited to women who have not had children.
Kulier R, et al Copper containing, framed intra-uterine devices for contraception. Cochrane Database Syst Rev. 2007 Oct 17;(4):CD005347. http://www.ncbi.nlm.nih.gov/pubmed/17943851
Ortho Evra Contraceptive Transdermal Patch: Higher risk of serious blood clots
A modified the prescribing information for the Ortho Evra Contraceptive Transdermal (Skin) Patch to include the results of a new epidemiology study that found that users of the birth control patch were at higher risk of developing serious blood clots, also known as venous thromboembolism (VTE), than women using birth control pills. VTE can lead to pulmonary embolism. The label changes are based on a study conducted by the Boston Collaborative Drug Surveillance Program on behalf of Johnson and Johnson. The patch was studied in women aged 15-44. These findings support an earlier study that also said women in this group were at higher risk for VTE.
FDA believes that Ortho Evra is a safe and effective method of contraception when used according to the labeling, which recommends that women with concerns or risk factors for serious blood clots talk with their health care provider about using Ortho Evra versus other contraceptive options. http://www.fda.gov/medwatch/safety/2008/safety08.htm#orthoevrapatch
Levonorgestrel / Ethinyl Estradiol (Lybrel) for Continuous Contraception
Bottom Line: Lybrel appears to be as safe and effective as other combined oral contraceptives; however, at this time, there is little published data about this specific product. Other combined monophasic oral contraceptives, some of which cost less than Lybrel, can be used continuously and have been shown to produce similar results. Patients who choose to take contraceptives continuously should be advised that they may experience spotting or irregular menses at any time. http://www.aafp.org/afp/20080115/steps.html
Featured Website David Gahn, IHS Women’s Health Web Site Content Coordinator
Meeting notes now online: 2007 Native Women’s Health and MCH Conference*
Kelly Acton, M.D.
Gail Bolan MD
Karen Carey CNM MS
Peter Cherouny, MD
Donald Coustan, M.D.
Scott Deasy, M.D.
Willeen Druley, RN, MS, BC, FNP
Denise Findlay , RN BSN
Terry Friend, CNM
Cindy Gebremariam, RN
Scott Giberson, Ph. C, Pharm D, MPH
George Gilson, M.D.
Amy Groom, MPH
Howard Hays, M.D.
Mary Henrikson MN, RNC
Stephen W. Heath, MD, MPH
Lynn Hoefer, DV Advocate
Diane Jeanotte RN
Wanda K. Jones, Dr. P.H.
Favian Kennedy, MSW
Nancy Knapp MPH & Brenda Isaacs
- Integrating Brief Motivation Enhancing Interventions into the Primary Care Setting Integrating Brief Motivation Enhancing Interventions into the Primary Care Setting: Handout
Michele R. Lauria, MD, MS
Rachel Locker, M.D.
Tami McBride, CNM, MS, RNC
Richard McClain, MD
Paul Melinkovich, M.D.
Connie Monahan, MPH
Neil Murphy MD
Sue Murphy, RD, MPH, CDE, CLE
Tony Ogburn MD
Sharon Phelan MD
Marilyn Pierce Bulger
- Community Approaches to Reducing Infant Mortality: Nutaqsiivik Program
- Approaches To Reducing Infant Mortality- Nutaqsiivik Program
Usha Ranji, M.S.
Brigg Reilley
Sharon Schindler Rising, MSN, CNM
Greg Shorr, M.D.
Melanie Taylor MD, MPH
Judy Thierry, DO MPH
Shelley Thorkelson , CNM MSN CDE
Sheila Warren, MPH, RN, CPHQ
Judy Whitecrane MSN, CNM
Nancy Whitney, MS, LMHC
* http://www.ihs.gov/MedicalPrograms/MCH/F/lecNotes.cfm#wHealthConf
Frequently Asked Questions
How can we actually reduce infant mortality in AI/AN?
Marilyn Pierce-Bulger present information on a successful program in Anchorage
http://www.ihs.gov/MedicalPrograms/MCH/F/documents/Community%20Approaches%20To%20Reducing%20IM%20Nutaq.ppt
Indian Child Health Notes - Steve Holve, Pediatrics Chief Clinical Consultant
March 2008
- If cough is the question is honey the answer?
- Dr. Esposito’s final column don’t miss it
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ICHN308.doc
Information Technology
iCare Training
The IHS Office of Information Technology (OIT) and the IHS Clinical Support Center (Accredited Sponsor) present WebEx training sessions for the iCare (Population Management) software application. You will be able to participate in the training from the comfort of your office or conference room and will not be required to travel to obtain this training.
iCare is a tool with multiple uses for a wide variety of providers that presents diverse RPMS data through an easy to use graphical user interface (GUI).
We will continue to offer a brief intro session that will just introduce the software to participants. This session does not offer any training and CEUs will not be given for this session
1. A Brief Introduction to iCare 30 minutes
The 2 standard training sessions are again offered and we are now offering CEUs for these classes. We recommend these 2 classes be taken sequentially.
- iCare - Nuts and Bolts 2.0 hours
- the Practical Use of iCare 1.5 hours
The target audience is any provider who cares for patients (e.g. physicians, mid-level providers, nurses, case managers, public health personnel, pharmacists etc.)
NOTE:You must register for these classes. They are NOT limited to participants in a particular Area; they are open to all. Below are the agendas and date/times for both classes.
You can choose to register individually or as a group. If you register individually, all you need is your computer, the ability to sign on to the internet and a telephone. If you'd like to attend as a group, one person will need to register and then sign in at the designated time. You will need a conference room, conference phone, computer and projector. Please ensure someone at your facility is responsible for taking care of these arrangements.
Please note that these are live, internet-based trainings, not recorded sessions, and people will be able to ask questions and actively participate in the class.
NOTE: All training times shown above are for the Mountain Standard Time ( Arizona Time) zone. Please ensure you adjust the time for your particular time zone.
ACCREDITATION:
The Indian Health Service (IHS) Clinical Support Center is accredited by the Accreditation Council for Continuing Medical Education to sponsor continuing medical education for physicians.
The IHS Clinical Support Center designates this continuing medical education as Category 1 credit toward the Physician’s Recognition Award of the American Medical Association. Each physician should claim only those hours of credit he or she actually spent in the educational activity.
This Category 1 credit is accepted by the American Academy of Physician Assistants and the American College of Nurse Midwives.
The Indian Health Service Clinical Support Center is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
Training Schedule
- iCare – Nuts and Bolts
Target Audience – Patient Care Providers (e.g. physicians, mid-level providers, nurses, case managers, public health personnel, pharmacists etc.)
Agenda
- Introductions and Context
- Set Up
- Background Processes
- Establishing and Changing User Preferences
- Panel Creation
- Panel Modification
- Patient Record
Session Date and Time Reg Password
iCare Nuts and Bolts Tues 03/11/2008 08:00-10:00 MST coyote
Mon 03/24/2008 11:00-13:00 MST coyote
- The Practical Use of iCare
Target Audience – Patient Care Providers (e.g. physicians, mid-level providers, nurses, case managers, public health personnel, pharmacists etc.)
Agenda
- Introductions and Context
- Scenarios
- Tips
- Using the Performance Measure views to improve outcomes
Session Date and Time Reg Password
The Practical Use of iCare Tues 03/18/2008 08:30-10:00 MST coyote
Wed 03/26/2008 14:00-15:30 MST coyote
- A Brief Introduction to iCare
Target Audience – Patient Care Providers (e.g. physicians, mid-level providers, nurses, case managers, public health personnel, pharmacists etc.) who don't have time to attend a longer session.
Agenda
- Highlights
- Background Processes
- Panel Creation and Modification
Session Date and Time Reg Password
A Brief Introduction to iCare Thurs 03/13/2008 14:00-14:30 MST coyote
Registration Information
- Click this link:
- In the Search box, type in "iCare" (do not type in the quotation marks) and click the Search button. NOTE: If you do not see the Search For box, ensure the Training Center tab is selected at the top of the WebEx window.
- All of the scheduled sessions will then be displayed in the window below. Choose the one you want to attend and click “Registration” in the Status column.
- Enter the Registration password that is shown above that corresponds to the class you want to attend.
- Click the OK button.
- Complete the registration form.
- Click the Register button.
- A Registration confirmation is displayed that contains all of the information for the training session, including the link for the session and the password to enter when you are ready to attend the session. Click the OK button to finish.
Setup (Software Install) Information:
You must have the WebEx software installed on your computer prior to attending the WebEx session. You should setup the software at least a day before the training session. You should not need anyone such as the Site Manager to install it for you. Below are the instructions.
- Click this link:
- On the left side of the window, locate Set Up
- Click Training Manager
- A message is displaying giving you information about the setup process. Click the Set Up button
- After the software is installed, click the OK button.
Attending the Session:
On the day of the scheduled training, you will receive a confirmation email. When you are ready to attend the session, connect to the WebEx session by clicking on the link in that email. You will then need to connect to the conference line. The dial information for the conference line is shown below and is also included in your registration confirmation message.
Phone Number: (877) 781-4791
Passcode: 135963#
International Health Update: Claire Wendland, Madison, WI
Good intentions and unintended consequences
At the turn of the twenty-first century, activists, politicians, and academics pushed hard for a major increase in international funding to solve seemingly intractable health problems in the Third World. Two results are the GAVI Alliance, formed in 2000 to expand mass vaccination programs (particularly for children), and the Global Fund, created in 2002 to tackle HIV/AIDS, tuberculosis and malaria. Most observers agree that both organizations have been very successful at bringing together government, industry and other private funds – at a scale larger than imagined possible in the past – and directing them to programs, private or governmental, that address these pressing health issues in poor countries. Two recent analyses, however, raise concerns about some unintended side effects.
At issue is a shift in the concept of sustainability. Conventional ideas of sustainability meant that recipient countries would need to gradually take over any internationally funded health intervention. Because the cost of vaccines and AIDS drugs is so high, programs involving treatment of AIDS or prevention of childhood infections were clearly not going to be sustainable by this definition anytime soon. An innovation of the new funders was to consider programs “sustainable” if they could be paid for indefinitely at the international level. If wealthy countries made long-term pledges to buy drugs and vaccines, the poorest recipients would only have to be sustainably responsible for provision of basic health-system needs like transport, nutritional support, and health care staffing. And therein lies the rub.
The “vertical” programs (those targeted toward a specific problem rather than general primary health care) funded through these new mechanisms keep their staff lean and their programs efficient by refusing to integrate other kinds of care. Where transport is difficult, as in much of the Third World, villagers may walk for hours to bring a sick or starving child in for a mass vaccination campaign, but be unable to speak to anyone about their child’s malnutrition, seizure disorder, or diarrhea – not to mention the mother’s new pregnancy. These primary health tasks shift downward to untrained laypeople, or to no one at all, and health systems become more fragmented.
Perhaps even more problematic are the effects on public health sector staffing. When vertical programs such as those providing antiretrovirals are part of the public health system, donors pay for the drugs but not the new staff needed to distribute them and monitor patients. When these programs are non-governmental, they hire qualified nurses and doctors away from the public sector, because they can afford to pay more than the local salary. Most of the time, both types of programs are funded in any given country. A ministry of health must train, recruit, and pay salaries for new staff even as existing doctors and nurses are being hired away by better-funded employers. But governments are required by the international financial institutions from which they borrow to keep civil service salaries at a pre-specified cap. Ministries of health are left with two ugly choices. They can violate the salary cap to recruit and retain health workers, but lose all development loans (which may amount to half a country’s total budget), or they can keep salaries low and risk ongoing hemorrhage of qualified health professionals into the non-governmental sector – not to mention the strikes, retirements, and emigration that take their toll on the well-being of patients in public hospitals and clinics.
The jury is still out on the actual impact of these big new funding programs on the health problems they target. (Expect early reports for the Global Fund by later this year.) But it’s already clear that in some of the most heavily targeted areas, maternal and child health indicators are deteriorating even as vaccination rates rise and deaths from AIDS begin to plateau. As a doctor in Malawi told me flatly, talking about hospital staffing and maternal deaths in that country, “these NGOs are killing us.” It may be time to think again about what sustainability really means, and whose responsibility it really is.
Ooms G. et al. 2007 Medicines Without Doctors: Why the Global Fund Must Fund Salaries of Health Workers to Expand AIDS Treatment. PLoS Medicine 4(4):e128.
http://www.ncbi.nlm.nih.gov/pubmed/17439295
Piller C. and D. Smith 2007 Unintended victims of Gates Foundation generosity. Los Angeles Times 16 December.
Peanuts +Vegetable oil +milk powder+vitamins + minerals = Plumpynut
We estimated that stunting, severe wasting, and intrauterine growth restriction together were responsible for 2·2 million deaths and 21% of disability-adjusted life-years (DALYs) for children younger than 5 years. Deficiencies of vitamin A and zinc were estimated to be responsible for 0·6 million and 0·4 million deaths, respectively, and a combined 9% of global childhood DALYs. Iron and iodine deficiencies resulted in few child deaths, and combined were responsible for about 0·2% of global childhood DALYs.
-Iron deficiency as a risk factor for maternal mortality added 115
000
deaths and 0·4% of global total DALYs.
-Suboptimum breastfeeding was estimated to be responsible for 1·4 million child deaths and 44 million DALYs (10% of DALYs in children younger than 5 years).
In an analysis that accounted for co-exposure of these nutrition-related factors, they were together responsible for about 35% of child deaths and 11% of the total global disease burden.”
Peanuts +Vegetable oil +milk powder+vitamins + minerals = Plumpynut
Peanuts contain mono-unsaturated fats, which are easy to digest. They are also very high in calories, which means that a child will get a lot of energy from just small amounts (important because their stomachs have shrunk). They are rich in zinc and protein — both good for the immune system. Protein is also needed for muscle development. Peanuts are a good source of vitamin E, a powerful antioxidant that helps to convert food into energy. Peanuts are a wonder food, really — the problem that we in the West have is that there is such a high incidence of peanut allergy ...Another theory is that developed countries introduce nuts relatively late compared with other cultures.
Plumpy'nut was created by André Briend, who spent years working in humanitarian crises. He realised that a ready-to-eat supplement that needs no cooking or added water, and is cheap to produce, could help to save millions of lives in remote and under-developed areas. Plumpy'nut is now produced in Normandy by a company that specialises in food relief, in partnership with Unicef, the United Nation's children's organisation.
The UN says that 150,000 children under 5 are severely malnourished in Niger and a further 650,000 are moderately malnourished. This translates into ankles and wrists barely wider than a man's thumb www.plump ynutinthe field.com/eng/index-eng.php
Black RE Maternal and child undernutrition: global and regional exposures and health consequences The Lancet, Volume 371, Number 9608, 19 January 2008
http://www.thelancet.com/journals/lancet/article/PIIS0140673607616900/fulltext
CCGHE Launches Online HIV Training Course in Zambia
The need for in-depth clinical training about HIV care and treatment in Zambia is Zambia widely recognized. The CCGHE and JHPIEGO, a Johns Hopkins affiliate with a country office in Lusaka, Zambia have worked together to bring a new online course, Management of Adult HIV in Zambia. The course contains 22 lectures by experts at Johns Hopkins, JHPIEGO, University Teaching Hospital in Lusaka and Ministry of Health. Topics include Epidemiology and Infection Prevention, Diagnosing and Initial Management, Clinical Manifestations of HIV Infection, and Antiretroviral Therapy. Support for this course was provided in part by Northwater Foundation.
More than 120 physicians, nurses, pharmacists, program managers, and researchers have signed up to take the course, which runs from January 16 - February 20, 2008. Course participants will receive CD-ROMS of the lectures, and take pre and post-tests online toward a Certificate of Achievement.
Featured Case
6yo female presented to ED with fever of 103°F, change in MS ...
Infectious Disease Grand Rounds Recently Posted
-35 yo female with untreated AIDS who developed a painful, pruritic rash...
-31 yo male with AIDS (CD4 = 4) presented with 1 mo h/o SOB, fatigue...
-34 yo female,1 mo post delivery by C-section, who developed sepsis...
-17 mo male who developed a 3 day onset of rhinorrhea, fever, low appetite...
-9 wk old female who presented with 1d h/o decreased po intake & urine output...
http://www.ccghe.jhmi.edu/assets/CCGHE/Documents/ADVANCE_Health_Information_Executives.pdf
Stunting In First Two Years Of Life Leads To Huge Negative Consequences In Later Life
Poor fetal growth or stunting in the first two years of life leads to irreversible damage, including shorter adult height, lower attained schooling, reduced adult income and decreased offspring birthweight for women.
We conclude that damage suffered in early life leads to permanent impairment, and might also affect future generations. Its prevention will probably bring about important health, educational, and economic benefits. Chronic diseases are especially common in undernourished children who experience rapid weight gain after infancy.
Victora CG, et al Maternal and child undernutrition: consequences for adult health and human capital. Lancet. 2008 Jan 16 http://www.ncbi.nlm.nih.gov/pubmed/18206223
Editorial
1 of 3 Child Deaths And 11% Of Global Disease Due To Maternal And Child Undernutrition
More than one third of child deaths and 11% of the total disease burden worldwide are due to maternal and child undernutrition. By doing an analysis that accounted for co-exposure of nutrition-related factors, the authors found that they were together responsible for 35% of child deaths globally and 11% of the total global disease burden. The authors conclude: "The high mortality and disease burden resulting from these nutrition-related factors make a compelling case for the urgent implementation of interventions, to reduce their occurrence or ameliorate their consequences.
Black RE et al Maternal and child undernutrition: global and regional exposures and health consequences. Lancet. 2008 Jan 19;371(9608):243-60.
http://www.ncbi.nlm.nih.gov/pubmed/18207566
MCH Alert
Maternal depression as a risk factor affecting child readiness and school readiness
Reducing Maternal Depression and Its Impact On Young Children: Toward a Responsive Early Childhood Policy Framework provides an overview of why it is important to address maternal depression as a central part of the effort to ensure that all young children enter school ready to succeed.
The issue brief is jointly published by Project THRIVE and Pathways to Early School Success at the National Center for Children in Poverty (NCCP). Project THRIVE serves as a resource to the Maternal and Child Health Bureau-funded State Early Childhood Comprehensive Systems program. Pathways to Early School Success is NCCP's ongoing project to help policymakers, program administrators, and practitioners reduce barriers to achievement for young children from families with low incomes. The brief is based on a meeting to identify and promote solutions to emerging issues that impact young children's healthy development and school readiness. Topics include how depression affects parenting and child outcomes, particularly for young children; how often it occurs in combination with other parental risks, like post-traumatic stress disorders; and what kinds of strategies can prevent negative consequences for parents, for their parenting, and for their young children. State and federal policy responses, recommendations, and a conclusion are also presented. http://www.nccp.org/publications/pub_791.html
Role of nurses in oral health of children and women
The January-February 2008 issue of MCN: The American Journal of Maternal-Child Nursing focuses on the role of nurses in promoting oral health in children, adolescents, and women. One of the articles in the issue presents a Nurse's Call to Action to help improve oral health in women. Another article provides an overview of early childhood caries and suggestions for actions that nurses can take to improve children's oral health. Other topics addressed in the issue include the health risks associated with adolescent's oral behaviors of adolescents; gaps in practice and research on pregnancy and oral health and recommendations to close these gaps; nursing care and management of pathological oral conditions in women and children; maternal periodontal disease, pregnancy, and neonatal outcomes; and how nurses can help women and children with HIV and AIDS who have oral complications. Additional content focuses on nurse-dentist collaboration, infant nutrition and oral health, and global oral health in women and children. The journal is available at http://www.mcnjournal.com
Relationship between air pollution and postneonatal infant mortality
A recent review of air pollution and children’s health in Europe by the World Health Organization concludes that 'the evidence is sufficient to infer a causal relationship between particulate air pollution and respiratory deaths in the post-neonatal period' (World Health Organization 2005).
The authors found that
* The relationship between course particulate matter and respiratory-related postneonatal mortality was elevated and significant in both the single- and the multi-pollutant models.
* For SIDS, ozone was associated with a significant increased risk in the single-pollutant models.
The authors conclude that this study provides further support for PM air pollution as a risk factor for respiratory-related postneonatal infant mortality and suggests that [ozone] may play a role in SIDS.
Woodruff TJ, Darrow LA, Parker JD. 2008. Air pollution and postneonatal infant mortality in the United States, 1999-2002. Environmental Health Perspectives 116(1):110-115. Full text available at http://www.ehponline.org/members/2007/10370/10370.pdf
Influence of multiple social risk factors on children’s health
Social risk factors threaten children's health in a cumulative manner across physical health, oral health, and mental heath domains. The authors found that
* Approximately 40% of the children were from families with low incomes, 32% lived in a household where no resident had an education beyond high school, 55% had two or more social risk factors, and 24% had four or more.
* Low maternal mental health, black race or Hispanic ethnicity, family income less than 200% of the FPL, low household education, unsafe neighborhoods, and lack of health insurance increased the odds for less than very good child health.
* Low maternal mental health, black race or Hispanic ethnicity, family income less than 200% of the FPL, low household education, unsafe neighborhoods, lack of health insurance, and family conflict increased the odds for less than very good oral health.
* For child socioemotional problems, low maternal mental health, not residing in a two-parent household, and family conflict were strong independent correlates, along with unsafe neighborhoods and family income less than 200% of the FPL.
* All the risk factors except lack of insurance increased the odds for overweight.
* When risks were combined into a social risk index, controlling for child age, gender, and number of children in the household, there was a 17-fold increase in the odds for less than very good health and an almost 11-fold increase in the odds for less than very good oral health for children with six or more vs. zero social risks; the respective figure for child socioemotional well-being and overweight status was about four.
"The cumulative impact of multiple risks is much greater than the effect of any one risk acting alone. Programs and policies that address multiple domains of social risk offer the best hope for achieving improvements in child health.
Larson K, Russ SA, Crall, JJ, et al. 2008. Influence of multiple social risks on children's health. Pediatrics 121(2):337-344. http://pediatrics.aappublications.org/cgi/content/abstract/121/2/337MCH Headlines - Judy Thierry HQE
Findings from the National Survey of Children's Health includes Native Americans
The authors set out to examine racial/ethnic disparities in medical and oral health, access to care, and use of services in a national sample.
They used the National Survey of Children's Health which was a telephone survey in 2003-2004 of a national random sample of parents and guardians of 102,353 children 0 to 17 years old. Disparities in selected medical and oral health and health care measures were examined for white, African American, Latino, Asian/Pacific Islander, Native American, and multiracial children. The authors found many significant disparities were noted; for example:
-Uninsurance rates were 6% for whites, 21% for Latinos, 15% for Native Americans, 7% for African Americans, and 4% for Asians or Pacific
Islanders,
-The proportions of children with a usual source of care were as follows: whites, 90%; Native Americans, 61%; Latinos, 68%; African Americans, 77%; and Asians or Pacific Islanders, 87%.
-Many disparities persisted for one minority group in multivariate analyses, including increased odds of suboptimal health status, overweight, asthma, activity limitations, behavioral and speech
problems, emotional difficulties, uninsurance, suboptimal dental health,no usual source of care, unmet medical and dental needs, transportation barriers to care, problems getting specialty care, no medical or dental visit in the past year, emergency department visits, not receiving mental health care, and not receiving prescription medications.
-Certain disparities were particularly marked for specific racial/ethnic groups: for Latinos, suboptimal health status and teeth condition, uninsurance, and problems getting specialty care; for African Americans, asthma, behavior problems, skin allergies, speech problems, and unmet prescription needs; for Native Americans, hearing or vision problems, no usual source of care, emergency department visits, and unmet medical and dental needs; and for Asians or Pacific Islanders, problems getting specialty care and not seeing a doctor in the past year.
-Multiracial children also experienced many disparities.
The authors conclude that minority children experience multiple disparities in medical and oral health, access to care, and use of services. Certain disparities are particularly marked for specific racial/ethnic groups, and multiracial children experience many
Flores G and Tomany-Korman SC. Racial and Ethnic Disparities in Medical and Dental Health, Access to Care, and Use of Services in US Children PEDIATRICS Vol. 121 No. 2 February 2008, pp. e286-e298 http://www.ncbi.nlm.nih.gov/pubmed/18195000
Medicaid Reimbursement for Car Seats Is Cost-Effective Health Policy
A
study from The Children's Hospital of Philadelphia (CHOP) shows that distributing car
safety seats among economically disadvantaged children could be as cost-effective
as long-established federal vaccination programs. The research, published
this week in the journal Ambulatory Pediatrics, offers insights for state and
national lawmakers involved in setting future healthcare policy, particularly
for those interested in exploring programs with a greater focus on preventive
care for children.
The Vaccines for Children (VFC) program proved to be a smart investment of public
funds to prevent illness and disease, says Flaura Winston, M.D., Ph.D., an author
on the paper and the co-scientific director of the Center for Injury Research
and Prevention at The Children's Hospital of Philadelphia. With this study, we
show that similar public commitment to reduce the incidence of motor
vehicle crash injury - the leading cause of death and permanent disability among
children - would also result in significant cost savings and health
benefits to society and affected children.
The proposed Child Restraint Systems (CRS) Program would provide access
to child restraints and education via a physicians prescription. Assuming enrollment
in a Medicaid-based CRS program at birth, every child would receive a convertible
child safety seat (combined infant and toddler seat) along with pertinent education
when discharged from the hospital. At age four the child would receive
a belt-positioning booster seat to be used to about age 8 [reaches 4 feet 9 inches].
The net cost per beneficiary of the 8-year program would be $32.
Including all medical and relevant societal costs, a program in which physicians
write prescriptions for car seats for Medicaid-eligible children would achieve
the following yearly cost savings per 100,000 children:
Reduce medical costs by $1 million
Regain $100,000 in the cost of parental work loss
Reduce future victim productivity costs by $2.7 million.
According to the researchers, without the proposed Medicaid CRS program in place,
injuries to children from vehicle crashes (per 100,000 children) would result
in an estimated $4.2 million in medical costs, $350,000 in parental work loss,
and $8.3 million in reduced future victim productivity. The programs break-even
point for society could be reached after three years. At that time, program costs
would balance savings from averted medical expenses, parental work loss, and
victim future productivity losses.
Until now, the economic benefit of Medicaid providing child restraint systems
to low-income children through physician prescriptions had not been explored.
Moreover, this study compared the cost-effectiveness of such a program with one
that has been proven successful, the VFC program.
When researchers looked at comparative effectiveness between their theoretical
program and seven vaccines, they found that only Haemophilus Influenzae B and
Measles/Mumps/Rubella vaccinations were more cost-effective than the CRS disbursement
and education program.
Car crashes are the biggest threat to our children’s health and well-being,
and economically disadvantaged children are disproportionately at risk, says
Dr. Winston. "The program we explored in our study would address the most
significant common barriers in public health issues: access and education.
Limited pilot testing of the Medicaid CRS program at the state or community
level is the recommended next step in evaluating its real world applicability,
effectiveness, and cost savings.
The researchers also call for a policy shift. At a time when policymakers
are considering an overhaul of the health care system in the U.S., this paper
should generate interest in health care policies that consider prevention as
a primary clinical strategy and allow medical expenses for proven prevention
strategies, says Dr. Winston.
The study utilized several data sources including Partners for Child Passenger
Safety (PCPS), a child-focused crash surveillance system with State Farm Insurance
Company's and the National Highway Traffic Safety Administration's Fatality Analysis
Reporting System, as well as sources for standard research methods such as the
Task Force on Community Preventive Services review and the Panel on Cost-Effectiveness
in Health and Medicine.
Goldstein
JA, et al Medicaid-Based Child Restraint System Disbursement and Education
and the Vaccines for Children Program: Comparative Cost-effectiveness. Ambul
Pediatr. 2008 Jan;8(1):58-65. http://www.ncbi.nlm.nih.gov/pubmed/18191783
For more information about how to protect children in crashes, visit http://www.chop.edu/carseat
For more information contact Dana Mortensen, 267-426-6092 , mortensen@email.chop.edu
2008 MCH EPI Grand Rounds Schedule 7 one-hour calls
*Please note that speakers and topics/titles are subject to change and announcements will be sent when necessary.
March 5, 2008 from 2-3 p.m. ET
Title: Fetal Death Case Ascertainment in Iowa
Presenter: Kimberly Noble Piper, RNC, BS, CPH
Iowa Department of Public Health
April 2, 2008 from 2-3 p.m. ET
Title: Low Contraceptive Use among Florida Women – Explanations
and Recommendations
Presenter: Lauren B. Zapata, PhD, MSPH
Centers for Disease Control and Prevention (CDC)
May 7, 2008 from 2-3 p.m. ET
Topic: TBD
Presenter: TBD
September 3, 2008 from 2-3 p.m. ET
Topic Area: Miscarriage
Presenter: Kathryn S. Oths, PhD
The University of Alabama
October 1, 2008 from 2-3 p.m. ET
Title: Analysis, Professional Reward, and Integrity: How
MCH Epi Research Can Harm the Health of Women and Children
Presenter: Paul H. Wise, MD, MPH
Stanford University, Center for Health Policy/Center for Primary Care and Outcomes
Research
November 5, 2008 from 2-3 p.m. ET
Title: Trends in Chronic Disease among Iowans
Presenters: Catherine J. Lillehoj, PhD and Joann Muldoon, MS,
MA
Iowa Department of Public Health
Webcast Requirements:
To join the webcast, you must register at least a day ahead of time at: http://www.uic.edu/sph/cade/mchepi/
Tips for Webcast Audience:
1. Register using the same computer that you will use to attend
the webcast - this guarantees, once you have passed the technical check, that
the computer meets the minimum requirements.
2. Register well in advance of the event - this gives you time to troubleshoot and remedy problems in advance of the webcast.
3. Use the online technical support at http://www.uic.edu/sph/cade/mchepi, or contact CADE (The Center for the Advancement of Distance Education at the University of Illinois at Chicago School of Public Health), if you can't resolve technical problems.
4. Connect to the live webcast 20 minutes before the scheduled start time - this allows your computer to connect and download the presentation slides in advance of the event.
5. Link for technical requirements: http://www.uic.edu/sph/cade/mchepi/techreqs.htm.
Thanks!
-MCH EPI Program http://www.cdc.gov/reproductivehealth/MCHEpi/index.htmMedical Mystery Tour
St. John's wort for depression in a young woman
You may recall last month when we posted this question…
A 28-year-old female with severe major depression has achieved partial symptom remission with a selective serotonin reuptake inhibitor ( SSRI) but complains of persistent diarrhea and loss of libido. She asks you about using St. John's wort to treat her depression
Appropriate advice would include which of the following? (Select all that are true.)
- St. John's wort may be effective in milder forms of major depression
- St. John's wort is more effective than placebo in patients with severe major depression
- St. John's wort is better tolerated than prescription antidepressants
-The combination of St. John's wort and SSRIs is safe and effective for major depression.
- St. John's wort may reduce the efficacy of combined oral contraceptives
The answers are:
- St. John's wort may be effective in milder forms of major depression
- St. John's wort is better tolerated than prescription antidepressants
- St. John's wort may reduce the efficacy of combined oral contraceptives
Here is some background
The data on efficacy of St. John's wort in treating depression are confusing, mixed, and subject to criticism over concerns about lack of standardized preparations, adequacy of blinding of patients, short study duration, and inclusion of patients not meeting criteria for major depression. Most studies show benefit compared with placebo for mild depressive syndromes (including many patients without major depressive disorder who may not require treatment with medication). However, evidence is mixed when analyses of St. John's wort compared to placebo are restricted to patients with major depressive disorder. Some studies, however, do suggest that St. John's wort is as effective as SSRIs and low-dose tricyclic antidepressants for patients with mild to moderate major depression. Most head-to-head studies show that patients are less likely to discontinue St. John's wort because of side effects, compared with standard antidepressants. The combination of St. John's wort and SSRIs has not been studied; combining them poses an increased theoretical risk for serotonin syndrome. St. John's wort may induce the metabolism of oral contraceptives containing ethinyl estradiol, possibly resulting in an unplanned pregnancy.
Medscape*
A Rational Approach to Constipation
http://www.medscape.com/viewarticle/567681?src=sr
Turning Adverse Drug Events Into Better Patient Care
http://www.medscape.com/viewarticle/569872
Angiogenesis as a Strategic Target for Ovarian Cancer Therapy
http://www.medscape.com/viewpublication/1166_index
Premenstrual Dysphoric Disorder Resource Center Update
http://www.medscape.com/resource/pmdd?src=rcupdate#1
Ask the Experts topics in Women's Health and OB/GYN Index, by specialty, Medscape
http://www.medscape.com/pages/editorial/public/ate/index-womenshealth
OB GYN & Women's Health Clinical Discussion Board Index, Medscape
http://boards.medscape.com/forums?14@@.ee6e57b
Clinical Discussion Board Index, Medscape
Hundreds of ongoing clinical discussions available
http://boards.medscape.com/forums?14@@.ee6e57b
Free CME: MedScape CME Index by specialty
http://www.medscape.com/cmecenterdirectory/Default
*NB: Medscape is free to all, but registration is required. It can be accessed from anywhere with Internet access. You just need to create a personal username and password.Menopause Management
Calcium supplements may increase heart attacks in older women
Research suggests that calcium supplements may increase the risk of heart attack in healthy postmenopausal women
CONCLUSION: Calcium supplementation in healthy postmenopausal women is associated with upward trends in cardiovascular event rates. This potentially detrimental effect should be balanced against the likely benefits of calcium on bone. TRIAL REGISTRATION: Australian Clinical Trials Registry ACTRN 012605000242628.
Bolland MJ et al Vascular events in healthy older women receiving calcium supplementation: randomised controlled trial. BMJ. 2008 Feb 2;336(7638):262-6
http://www.ncbi.nlm.nih.gov/pubmed/18198394
Postmenopausal Systemic Hormone Therapy: Putting Risks Into Perspective
http://www.medscape.com/viewarticle/569399
Black Cohosh and Menopausal Symptoms
http://www.medscape.com/viewarticle/569485Midwives Corner - Lisa Allee, CNM
Perineal warm packs reduce 3 rd and 4 th degree lacerations, pain and urinary incontinence
CONCLUSIONS: The application of perineal warm packs in late second stage does not reduce the likelihood of nulliparous women requiring perineal suturing but significantly reduces third- and fourth-degree lacerations, pain during the birth and on days 1 and 2, and urinary incontinence. This simple, inexpensive practice should be incorporated into second stage labor care.
Dahlen HG et al Perineal outcomes and maternal comfort related to the application of perineal warm packs in the second stage of labor: a randomized controlled trial. Birth. 2007 Dec;34(4):282-90.
http://www.ncbi.nlm.nih.gov/pubmed/18021143
The Business of Being Born
The American College of Nurse-Midwives (ACNM) congratulates Executive Producer Ricki Lake and Director Abby Epstein on the release of their documentary The Business of Being Born, a critique of the medicalization of childbirth in the U.S. and a celebration of normal birth and midwifery care.
The film interlaces intimate birth stories with shocking statistics about the U.S. maternity care system. The film encourages childbearing women to embrace birth as a powerful—and empowering—life event rather than view it as an illness in need of medical treatment.
Certified nurse-midwives (CNMs) are featured prominently in the film, attending hospital, birth center, and home births. CNMs and certified midwives (CMs) attend 11% of the vaginal births in the U.S., 97% of which are in hospitals. While midwife-attended births in the U.S. have more than doubled since 1990, midwives attend 70% or more of the births in Western Europe, Britain and Japan, with better outcomes and lower cost of care.
“ Lake and Epstein spotlight the high quality care offered by CNMs,” says Lorrie Kline Kaplan, ACNM executive director. “The U.S. cesarean section rate is rising dramatically. Our infant mortality rates are climbing, and there are indications that maternal mortality is rising as well. It’s time to sit up and take notice—and work to turn these trends around.”
“The vast majority of women in the U.S. and other developed countries are at low-risk for complications in childbirth, and under the midwifery model of supportive care, are capable of delivering a baby vaginally and participating fully in this experience,” says ACNM President Eunice K.M. Ernst, CNM, MPH, DSc (Hon), FACNM.
ACNM urges midwifery proponents to support efforts to improve access to midwifery care. Congress is considering the “Midwifery Care Access and Reimbursement Equity Act of 2007,” (S.507/H.R.864) which would lead to improved reimbursement for midwives. In many states, CNMs and CMs can’t attend home births or provide services without a written agreement with a physician. Many hospitals have restrictive rules that make it difficult for midwives to practice.
“We can’t all be filmmakers,” quips Kaplan. “But if we are in the fortunate minority who has delivered a baby with the support of a midwife, we can spread the word by sharing our stories, encouraging other women to see this uniquely beautiful film, and advocate for increased access to midwifery care.”
More facts about midwifery:
- There are many types of midwives, so pay attention to credentials. The vast majority of midwives are Certified Nurse-Midwives and Certified Midwives and ACNM urges consumers to choose a CNM or CM.
- CNMs and CMs are highly educated. Most have a master’s degree or higher. Schools of midwifery reside in such prestigious universities as Yale, Georgetown, and Columbia.
- CNMs and CMs also provide well-woman and primary health care for women in all stages of life.
- Most insurers cover midwifery services, including Medicare and Medicaid.
- CNMs practice in all 50 states and the District of Columbia.
- Help us win our battle for fair reimbursement.
For more information about the film, visitwww.thebusinessofbeingborn.
It is currently slated for limited release in theaters in January and February 2008 but supporters can host their own screenings.
http://www.midwife.org/siteFiles/news/The_Business_of_Being_Born_Jan_08.pdf
Factors for the fear of childbirth in first-time mothers (see next article, too)
This study is interesting as it demonstrates how the fear of childbirth can have an affect on some women during pregnancy. These fears are not irrational and have a social and/or psychological root. Knowing what factors make some women more prone to this type of fear helps doctors and midwives to identify those most in need of extra support.
CONCLUSIONS: The prevalence of fear of childbirth among healthy nulliparous women with singleton pregnancies did not increase during the study period. Fear of childbirth among nulliparous women was most often seen in individuals with few social and psychological resources. Testing the women twice, we found the same prevalence of fear in early and late pregnancy, but found that half the women who expressed fear during early pregnancy had no fear later in pregnancy, an effect that was counterbalanced by a similar number of women who became fearful between the two interviews.
Laursen M, Hedegaard M, Johansen C. Fear of childbirth: predictors and temporal changes among nulliparous women in the Danish National Birth Cohort. BJOG 2008;115:354-360
http://www.ncbi.nlm.nih.gov/pubmed/18190372
Women’s fear of childbirth boosts cesareans
Women suffering from significant childbirth fear indicate that they are less self-confident, unhappy, afraid that the child will be injured and don’t long for the child. This clearly emphasises the need for pre and postnatal support.
For each women requesting to have a caesarean, as doctors, we provide them with a consultation on the advantages and disadvantages of the procedure.
The overall c-section rate in the UK is high but comparable to other western countries. If we are to lower the numbers, we need to understand sympathetically why some women, with no medical reasons, are choosing to have caesareans.
Healthy women are sometimes criticized for choosing a c-section over a normal delivery. This study reveals that a psychological reason may be behind elective caesareans. Some women may be too scared, rather than too posh, to push.
CONCLUSIONS: Women requesting caesarean section did not always suffer from clinically significant fear of childbirth. The finding that women subjected to complicated deliveries had a negative birth experience emphasizes the importance of postnatal support
Wiklund I, Edman G, Ryding E, Andolf E. Expectation and experiences of childbirth in primiparae with caesarean section. BJOG 2008;115:324-331. http://www.ncbi.nlm.nih.gov/pubmed/18190368Navajo News - John Balintona, Shiprock
Adnexal Masses during Pregnancy
The presence of adnexal masses during pregnancy is not uncommon at 0.5% to 2%. Discovery of an adnexal mass during pregnancy can prove to be a management dilemma for the obstetric provider. The clinician must develop and communicate a plan of expectant management versus intervention that exposes the patient to the least amount of morbidity.
Prior to the routine use of ultrasound in early pregnancy, most masses were found incidentally or were symptomatic and this often led to prompt surgical intervention. Now with the near universal prenatal ultrasound, the majority of masses are found earlier allowing for more conservative management.
Diagnosis
Adnexal masses have nongynecologic causes, however most are gynecologic and benign in nature. The age of the patient, prior medical history, and gestational age may be useful in determining the likely etiology of the mass. The most common cause is leiomyoma, which may be uncovered in review of the past medical history. Corpus luteum cysts are common in the first trimester of gestation. Benign ovarian entities like functional cysts, benign teratomas, and serous cystadenomas are found in younger patients. The potential for ovarian malignancy does rise as the patient ages.
Ultrasound is the primary imaging technique used to detect adnexal masses and to assess the risk of malignancy. Some experts suggest the MRI may be useful in the evaluation, especially if the ultrasound diagnosis is uncertain. Various morphologic characteristics found on ultrasound may be useful in determining the risk of malignancy in adnexal masses.
Low Risk Moderate - High Risk
Cystic, unilocular Cystic, multilocular
Size; 5 cm or smaller Size; greater than 5 cm
Complex mass
Solid mass
Thick septations
Nodules
Persists past 16 weeks EGA
Laboratory tests are of limited use in the evaluation of adnexal masses as many of the tumor markers, e.g. CA-125, AFP, BHCG; etc may be elevated in normal pregnancy.
Occasionally the patient will present with signs and symptoms due to the mass. These patients may have abdominal pain, back or flank pain, digestive disorders, furthermore, the patient may appear to have a gestational size greater than expected due date. The rate of torsion can be up to 20% and rupture rate can be as high as 10%. Some suggest that the risk of torsion is increased in masses between 6 cm and 10 cm in size.
Management
The main management option for the clinician is in choosing expectant management versus intervention. Expectant management decreases the potential for invasive procedures, however, can expose the patient for potential torsion, mass rupture, or obstruction of labor. Surgical intervention carries its own inherent risks of adverse outcome for mother and fetus. A rational decision can be made based on natural history, malignancy risk, and presence of symptoms.
Most ovarian cysts discovered during pregnancy will resolve spontaneously prior to 16 weeks EGA. This is especially true if the cyst is less than 5 cm. Observation for small cysts is recommended. It is reasonable for the obstetric provider to recommend surgical intervention for cysts that persist after 16 weeks EGA and surgery be indicated for any adnexal mass that may be causing symptoms such as pain or digestive difficulties.
Adnexal masses that have morphologic characteristics that are consistent with a low risk of malignancy may be observed throughout pregnancy. Less than 1% of adnexal masses found in pregnancy prove to be malignant and even in these cases, the majority is of low-grade disease. Nevertheless, any mass that is deemed moderate or high risk should be surgically removed. If the clinician has strong evidence that malignancy is likely, it may be prudent to transfer the patient to a facility that can provide the proper staging surgery and expedient histologic diagnosis.
Adverse fetal outcome is typically associated with abdominal catastrophe from ovarian torsion or mass rupture during surgery. Uncomplicated surgery for adnexal masses has not been shown to increase the risk for fetal loss or preterm delivery. Laparotomy is generally used, but in certain cases, i.e. early first trimester, benign appearing small cyst, expertise of the surgeon, laparoscopy may be entertained. Regardless of the approach, efforts should be made to perform the most conservative procedure possible.
The following is a summary of scenarios that the author advises surgical intervention.
Strong suspicion for malignancy
Large (> 8-10cm) masses
Symptomatic complaints
Persistent masses (after 16 weeks EGA)
References
- Leiserowitz G. Managing Ovarian Masses During Pregnancy. Obstetrical and Gynecologic Survey. 2006. Vol 61. 463-470
- Giuntoli R, et al. Evaluation and Management of Adnexal Masses During Pregnancy. Clinical Obstetrics and Gynecology. 2006. Vol 49. 492-505
- Ribic-Pucelj M, et al. Surgical Treatment of Adnexal Masses in Pregnancy. Journal of Reproductive Medicine. 2007. Vol 52. 273-279
Questions John.Balintona@ihs.gov
Nurses Corner - Sandra Haldane, HQE
Integrating Nursing and Behavioral Health
Wyatt Massi, PsyD, Chief of Behavioral Health Services, is developing an integrated behavioral health approach for the Fort Peck primary care clinic and is recruiting for a psych-mental health NP or an APN who is interested in going back to school for a post-masters psych-mental health certificate.
Dr. Massi has “integrated” the behavioral health consultant duties into a traditional psychiatric nurse practitioner position. The most common model for the BHC is using a counselor or psychologist in the position. Dr. Massi elected to go with a Psych NP because it was part of the “deal” that I brokered with my service unit to get the funds for the position. At first Dr. Massi thought he was making compromises, but Dr. Massi came to the conclusion that a NP dedicated to integration is an ideal person to bridge the gap b/w Primary Care, Health Promotion, and Behavioral Health. As a primary care provider, who has come up through the nursing education system, and has a place as a Behavioral Health staff member, Dr. Massi thinks this individual will be able to facilitate a cultural change in the health care environment. And hopefully Dr. Massi will save some money on my psychiatrist contracts while revolutionizing the world of IHS !
Dr Massi is happy to describe the position and the model of care. This is a very exciting opportunity. If you have questions please contact Dr. Massi directly.
MassI Wyatt, PsyD
Chief, Behavioral Health Services
Ft. Peck IHS
Poplar, Montana
406-768-3491
UCLA post-doc program for nurses
We have extended the deadline - please help to widely disseminate.
Many thanks. Felicia
Felicia Schanche Hodge, Dr.P.H.
Professor, School of Nursing
Chair, American Indian Studies
700 Tiverton Ave., RM 5-940 Factor Bldg.
Los Angeles, CA 90095-1702
(310) 267-2255 fhodge@sonnet.ucla.edu
New Report on American Indian/Alaskan Native Disparity & Strengths from RWJ
http://www.rwjf.org/programareas/resources/product.jsp?id=23193&pid=1142
Creating a Healing Community: Partnerships to Improve the Care of Indian People
NANAINA SUMMIT XIV
October 26-29-2008
Radisson Hotel
120 S. Wildwood Dr .
Branson, MO 65616
1-888-566-5290
National Alaska Native American Indian Nurses Association
Fraud - SPAM
Just wanted to alert you to this SPAM that is being selectively sent to nurses.
For those of you who may not know, as an HHS employee or employee under the umbrella of HHS, and you get email SPAM, you can forward it to SPAM@HHS.GOV
Office of Women's Health, CDC
Cervical Cancer Awareness
Getting regular Pap tests can save a woman's life. Six out of ten cervical cancers occur in women who have never had a Pap test or have not been screened in the past five years. Regular Pap tests lower a woman's risk of cervical cancer because they can find early problems before cancer ever develops. http://www.cdc.gov/Features/CervicalCancer/
United States Life Tables, 2004
This report presents period life tables for the United States based on age-specific death rates in 2004. Both males and females in each race group experienced increases in life expectancy between 2003 and 2004. The greatest increase was experienced by black males with an increase of 0.6 year (from 68.9 to 69.5). Life expectancy increased by 0.4 year for black females (from 75.9 to 76.3), for white females (from 80.4 to 80.8), and for white males (from 75.3 to 75.7).
http://www.cdc.gov/nchs/data/nvsr/nvsr56/nvsr56_09.pdfOklahoma Perspective Greggory Woitte – Hastings Indian Medical Center
Cesarean Delivery: What are the risks and benefits?
Here are a few of the recent articles that describe the risks and benefits of cesarean delivery.
Elective Cesarean Delivery Linked to Higher Risk for Infant Respiratory Morbidity
CONCLUSION: Compared with newborns delivered vaginally or by emergency caesarean sections, those delivered by elective caesarean section around term have an increased risk of overall and serious respiratory morbidity. The relative risk increased with decreasing gestational age.
Hansen AK et al Risk of respiratory morbidity in term infants delivered by elective caesarean section: cohort study. BMJ. 2008 Jan 12;336(7635):85-7
http://www.ncbi.nlm.nih.gov/pubmed/18077440
Cesarean delivery can be reduced: Identification of barriers to change is key to success
CONCLUSIONS: The cesarean delivery rate can be safely reduced by interventions that involve health workers in analyzing and modifying their practice. Our results suggest that multifaceted strategies, based on audit and detailed feedback, are advised to improve clinical practice and effectively reduce cesarean delivery rates. Moreover, these findings support the assumption that identification of barriers to change is a major key to success.
Chaillet N et al Evidence-based strategies for reducing cesarean section rates: a meta-analysis. Birth. 2007 Mar;34(1):53-64 http://www.ncbi.nlm.nih.gov/pubmed/17324180
Cesarean delivery increases the risk of maternal and neonatal morbidity and mortality CONCLUSIONS: Caesarean delivery independently reduces overall risk in breech presentations and risk of intrapartum fetal death in cephalic presentations but increases the risk of severe maternal and neonatal morbidity and mortality in cephalic presentations.
Villar J et al Maternal and neonatal individual risks and benefits associated with caesarean delivery: multicentre prospective study. BMJ. 2007 Nov 17;335(7628):1025.
http://www.ncbi.nlm.nih.gov/pubmed/17977819
The Indian Health system strongly encourages vaginal birth whenever possible and we have some of the highest VBAC rates in the country. In fact an Indian Health facility won the ACNM benchmark program award for highest VBAC rate in the US
http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0607_Feat.cfm#mmtour
Overall the Indian Health system has performed VBAC at that high rate consistently
Here is the data from our recent national meeting. It gives the VBAC rates around the whole Indian Health system
http://www.ihs.gov/MedicalPrograms/MCH/F/documents/DataTally81107.doc
If done under existing guidelines and within the standard of care, VBAC is fully covered by the Federal Tort Claim system
We should look closely at the NNEPQIN system, as it works with small rural facilities. In fact, Dr. Lauria presented similar lectures at our meetings in 2004 and again in 2007. For her 2004 presentation go to this link and scroll down to her name (in alpha order)
http://www.ihs.gov/MedicalPrograms/MCH/F/lecNotes.cfm
Here are just a few of the recent articles that have highlighted on this topic in the CCC Corner in recent months. There are many others
Can a 29% Cesarean Delivery Rate Possibly Be Justified?
http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_HT.cfm#ob
Vermont , New Hampshire Sections Recognized for
Effort
Project Focuses on VBAC
http://www.ihs.gov/MedicalPrograms/MCH/F/ACOG01_vbac.cfm#vbac
(Dr. Cherouny was a lecturer at out meeting in ABQ)
(Small hospitals in New England have the same problems we have)
Trial of Labor After Cesarean: Evidence based guidelines
http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0805_HT.cfm#ob
VBAC: Is There Such a Thing as Low Risk?
http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/NewMexico.ppt
Here is our free Indian Health CME Module on this topic
Vaginal Birth After Cesarean
http://www.ihs.gov/MedicalPrograms/MCH/M/VB01.cfm
Another approach is to look at the morbidity imposed on our AI/AN women due to all the repeat cesareans
Placental problems with previous caesarean delivery: Abruptio, previa
http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0607_HT.cfm#ob
Postcesarean delivery adhesions associated with delayed delivery of infant
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17466702
More stillbirths after previous cesarean delivery
http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0507_HT.cfm#ob
First delivery by cesarean begins cascade of risks - obstetric and perinatal outcomes
Here are some things on risks
Is vaginal birth after cesarean (VBAC) or elective repeat cesarean safer in women with a prior vaginal delivery?
VBAC: Smaller attributable risk than previously reported
http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_HT.cfm#ob
As obesity increases in our population, so does the risk of cesarean complications
Linear association between maternal pre-pregnancy body mass index and risk of caesarean section in term deliveries.
http://www.ncbi.nlm.nih.gov/pubmed/16972860
The costs to the system are higher too
Significantly higher rehospitalization rates and costs with planned cesareans
So there is precedent, ongoing successful outcomes, and extensive other literature to support VBAC in the Indian Health system.
Should VBAC be offered at your facility?
Please see the following for help with that answer:
February 2008 Abstract of the Month
http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08aom
and
February 2008 Midwives Corner
http://www.ihs.gov/MedicalPrograms/MCH/M/ob.cfm?module=2_08ft#midwOsteoporosis
SSRI Use and Bone Loss in Older Women
Background : Antidepressants are one of the most commonly used medication classes in the United States. The recent introduction of selective serotonin reuptake inhibitors (SSRIs) has resulted in a dramatic increase in the prescribing of antidepressants in older patients. The SSRIs work by inhibiting serotonin transport. The older tricyclic antidepressants (TCAs) work by inhibiting the reuptake of norepinephrine and serotonin. Recent developments have shown that serotonin transporters, and medications that affect these transporters, may play a role in bone metabolism. Concerns have been raised about the impact of increased use of SSRIs in older patients because this group has an increased risk of osteoporosis and fractures. Diem and associates evaluated bone mineral density (BMD) in women 65 years or older to determine if SSRI use has any effect on bone metabolism.
Conclusion: The authors conclude that the use of SSRIs in older women is associated with an increase in the rate of bone loss: this association does not occur with the use of TCAs. The authors add that these results should be further investigated with more follow-up to determine the long-term effect of SSRI use on bone metabolism.
Diem SJ, et al. Use of antidepressants and rates of hip bone loss in older women: the study of osteoporotic fractures. Arch Intern Med. June 25, 2007;167(12):1240-1245.
http://www.ncbi.nlm.nih.gov/pubmed/17592096
Nonpharmacologic Management of Osteoporosis to Minimize Fracture Risk
http://www.medscape.com/viewarticle/567334
Supplementation With Calcium and Vitamin D: Efficacy Against Fracture and Total Mortality: A Best Evidence Review
http://www.medscape.com/viewarticle/569488
The Impact of Adherence and Persistence in the Pharmacological Management of Osteoporosis
http://www.medsitecme.com/(vq1wqn55rky2xdysygicd43d)/IDetail/Default_Campaign/Default_Program//302//sponsor.aspx
Patient Information
Assuring Quality Care for People With Limited Health Literacy
http://www.medscape.com/viewarticle/569201
Knowing Importance of Prenatal Folic Acid May Affect Neural Tube Defect Incidence
In 1998, the Food and Drug Administration mandated that folic acid be added to cereal grain products. A 26% decline in the NTD rate in the United States was observed from the period before (1995--1996) to the period after (1999--2000) fortification. However, racial/ethnic disparities persisted, with Hispanic women having the highest rate of NTDs and the lowest reported consumption of folic acid. A statewide survey conducted annually in California during the period 2002--2006 indicated that Hispanic women had the lowest use of supplements containing folic acid. In addition to the racial/ethnic disparities, differences of supplement use by age have been reported.
Although year-to-year variation has been observed over time, the percentage of women of childbearing age who reported consumption of a daily supplement containing folic acid increased overall from 28% in 1995 to 32% in 2003 (6) and to 40% in 2004 and 2007. One of the Healthy People 2010 objectives is to increase to 80% the proportion of all women of childbearing age who consume 400 µg of folic acid daily to reduce their risk for serious birth defects (objective no. 16-16a) . Thus, although progress has been made toward this goal, approximately 60% of women of childbearing age surveyed in 2007 were still not consuming a daily supplement containing folic acid. Women aged 18--24 years have the highest rate of unintended pregnancies in the United States but remain the least aware of and knowledgeable about folic acid and the least likely to report consuming a supplement containing folic acid. These findings warrant the continued promotion of folic acid consumption among all women of childbearing age and especially among women aged 18--24 years. Folic acid education that promotes consumption of folic acid from various sources (e.g., supplements containing folic acid and fortified foods), in addition to foods rich in folate, can increase the possibility of all women consuming the recommended daily amount of 400 µg.
The findings in this report are subject to at least two limitations. First, the low response rate of 32% increases the risk that response bias might have affected the results. Results should be interpreted with caution and in the context of other surveys. For certain questions, recall bias also might have affected results. Second, the survey was limited to households with landline telephones, and the results might not be representative of all households. Whether this limitation would result in overestimates or underestimates in various results is not predictable.
The findings in this report indicate that women aged 18--24 years identified schools or colleges and magazines or newspapers as their primary sources for folic acid information, so these two channels might provide important opportunities to reach this population. Research has indicated that women in this age group are more likely to respond to folic acid messages that do not focus on pregnancy or infants. Innovative and effective messages tailored to women aged 18--24 years are needed to help change behaviors, increase awareness and knowledge regarding folic acid consumption, and ultimately reduce the incidence of NTDs.
Summary: Knowledge of the importance of taking folic acid prenatally may be linked to incidence of infant neural tube defects.
Use of Supplements Containing Folic Acid Among Women of Childbearing Age --- United States, 2007 MMWR January 11, 2008 / 57(01);5-8 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5701a3.htm
Anorexia and Bulimia: What You Should Know
http://www.aafp.org/afp/20080115/196ph.html
Perinatology Picks - George Gilson, Maternal Fetal Medicine, ANMC
Usefulness of middle cerebral artery Doppler of the fetus at risk for anemia
The use of Doppler ultrasound evaluation to measure the peak systolic velocity of the fetal middle cerebral artery (MCA) has been a major breakthrough in the noninvasive detection of fetal anemia. An elevated peak MCA velocity of >1.5 multiples of the median is useful in the timing of the initial intrauterine transfusion (IUT) in the red cell–alloimmunized pregnancies. Data reported to date suggest that a threshold of 1.32 multiples of the median can be used to time the second IUT; the MCA Doppler evaluation does not appear sensitive for the timing of subsequent IUTs in these pregnancies. The peak MCA velocity has also proved useful in the detection of other anemic states that include Kell alloimmunization, fetal parvovirus infection, fetomaternal hemorrhage, alphathalassemia, and after-laser therapy for twin-twin transfusion.
Moise KJ Jr. The usefulness of middle cerebral artery Doppler assessment in the treatment of the fetus at risk for anemia. Am J Obstet Gynecol. 2008 Feb;198(2):161.e1-4.
http://www.ncbi.nlm.nih.gov/pubmed/18226612
Results indicate the presence of dyslipidemia in women with spontaneous preterm birth
RESULTS: High cholesterol or triglycerides <or=15 weeks were associated with a 2.8-fold (1.0-7.9) and 2.0-fold (1.0-3.9) increased risk for preterm birth <34 weeks and >or=34-<37 weeks, respectively. Overweight women who delivered <34 weeks had particularly elevated early pregnancy concentrations of cholesterol and low-density lipoprotein; lean women with moderate preterm birth had elevated triglycerides. There was a reduced triglyceride response in the first half of pregnancy among women who delivered <34 weeks. CONCLUSION: Our results indicate the presence of dyslipidemia in women with spontaneous preterm birth.
Catov JM et al Early pregnancy lipid concentrations and spontaneous preterm birth. Am J Obstet Gynecol. 2007 Dec;197(6):610.e1-7. http://www.ncbi.nlm.nih.gov/pubmed/18060950
High maternal weight increases risk of neonatal mortality, especially after preterm PROM
CONCLUSION: High maternal weight seems to increase the risk of neonatal mortality, especially in infants born after preterm PROM. Inflammation or infection related to obesity may be part of the causal pathway. LEVEL OF EVIDENCE: II.
Nohr EA, Maternal obesity and neonatal mortality according to subtypes of preterm birth. Obstet Gynecol. 2007 Nov;110(5):1083-90.
http://www.ncbi.nlm.nih.gov/pubmed/17978123
Caffeine intake during pregnancy increases the risk of miscarriage
RESULTS: An increasing dose of daily caffeine intake during pregnancy was associated with an increased risk of miscarriage, compared with no caffeine intake, with an adjusted hazard ratio (aHR) of 1.42 (95% confidence interval 0.93 to 2.15) for caffeine intake of less than 200 mg/day, and aHR of 2.23 (1.34 to 3.69) for intake of 200 or more mg/day, respectively. Nausea or vomiting during pregnancy did not materially affect this observed association, nor did the change in intake pattern of caffeine during pregnancy. In addition, the magnitude of the association appeared to be stronger among women without a history of miscarriage (aHR 2.33, 1.48 to 3.67) than that among women with such a history (aHR 0.81, 0.34 to 1.94). CONCLUSION: Our results demonstrated that high doses of caffeine intake during pregnancy increase the risk of miscarriage, independent of pregnancy-related symptoms.
Weng X et al Maternal caffeine consumption during pregnancy and the risk of miscarriage: a prospective cohort study. Am J Obstet Gynecol. 2008 Jan 24
http://www.ncbi.nlm.nih.gov/pubmed/18221932
Prognosis of fetal cystic hygroma detected during the first trimester is poor, NT is crucial
RESULTS: Some 72 fetuses had cystic hygroma. The mean size of the cystic hygroma was 7.9 mm. Chromosomal abnormalities were present in 52.7% of cases (38/72), including 14 cases (36.8%) of Down syndrome. A total of 34 chromosomally normal pregnancies gave rise to 18 live births (52.9%), with no visible serious structural abnormalities. The outcome of pregnancy was unfavourable (miscarriage, elective termination, serious structural abnormalities) in 77.7% of cases (56/72). The 18 live-born infants were followed up for 17-98 months. Sixteen infants developed normally, while 1 developed Noonan's syndrome and 1 had a urinary tract abnormality (pyelo-ureteral junction; PUJ). CONCLUSION: These data suggest that the prognosis of fetal cystic hygroma detected during the first trimester is poor, and show that sonographic evaluation of fetal nuchal translucency thickness in the first trimester is crucial.
Graesslin O et al Characteristics and outcome of fetal cystic hygroma diagnosed in the first trimester. Acta Obstet Gynecol Scand. 2007;86(12):1442-6. Epub 2007 Sep 6 .
http://www.ncbi.nlm.nih.gov/pubmed/17851808Primary Care Discussion Forum - Ann Bullock, Cherokee, NC
Topic:Mental health issues in children and adolescents
When: March 2008
Moderator : Dr. Frank Armao, Psychiatry staff at Winslow
Salient points for discussion
-The complex influence of early life stress and trauma in shaping development.
-The increased burden of developmental stress as it pertains to Native Americans.
-How to distinguish teens with relatively normal perturbation in development from those needing more intensive management and/or referral to behavioral health.
-What constitutes a significant mood disorder in an adolescent, and what are the options for management.
-The serious limitations of DSM-IV and current nosology in “diagnosing” adolescent behavioral health conditions .
Primary Care Discussion Forum website
http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForum.cfm
How to subscribe / unsubscribe to the Primary Care Discussion Forum?
Subscribe to the Primary Care listserv
http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=51
Unsubscribe from the Primary Care listserv
http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=51
Questions on how to subscribe, contact ANNBULL@nc-cherokee.com
directly
STD Corner - Lori de Ravello, National IHS STD Program
Routine HIV Screening in the Emergency Department Using the New US Centers for Disease Control and Prevention Guidelines: Results From a High-Prevalence Area
http://mp.medscape.com/cgi-bin1/DM/y/hBgpH0Ou5N60Jdl0JDLV0EV
New Updates to U.S. HIV Treatment Guidelines
On January 29, 2008, the U.S. Food and drug Administration (FDA) announced new updates to the Department of Health and Human Services (DHHS) Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents. These updates supplement the last major revision of the guidelines, issued December 1, 2007. A summary of the latest changes is presented below.
Initial Combination Regimens for the Antiretroviral-Naive Patients
- Abacavir
(Ziagen) + 3TC
(lamivudine; Epivir) -- also available together in the Epzicom combination
pill -- has been upgraded from an “alternative” to a “preferred” nucleoside/nucleotide
reverse transcriptase inhibitor (NRTI) backbone for patients who test negative
for HLA-B*5701, a genetic marker for susceptibility to abacavir hypersensitivity
reactions.
- AZT
(zidovudine; Retrovir) + 3TC has been downgraded from “preferred” to
an “alternative” NRTI background due to potential toxicities.
- Ritonavir-boosted saquinavir
(Invirase) was changed from “acceptable…but inferior to preferred
or alternative components” to an “alternative” protease inhibitor
(PI).
- The PI nelfinavir
(Viracept), the 2-NRTI combination of d4T
(stavudine; Zerit) + 3TC, and the NRTI-only triple regimen of abacavir +
AZT + 3TC are no longer recommended for treatment-naive individuals.
- The panel added a section entitled “Other Treatment Options Under Investigation: Insufficient Data to Recommend,” which includes recent data from clinical trials of ritonavir-boosted darunavir (Prezista), the newly approved CCR5 antagonist maraviroc (Selzentry), and the new integrase inhibitor raltegravir (Isentress) in treatment-naive patients.
Treatment Interruption
- This section was updated with recent data on short-term and long-term treatment interruption. The panel reaffirmed that -- aside from unplanned or planned short-term interruption due to illnesses -- long-term treatment interruption is not recommended and should only be undertaken in a clinical trial.
Acute HIV Infection
- The new guidelines include a new table on “Identifying, diagnosing,
and managing acute HIV-1 infection,” replacing the old table of signs and
symptoms of acute retroviral syndrome.
- The panel now recommends that treatment-naive patients who plan to start therapy before drug resistance test results are available should consider using a PI-based regimen, since non-nucleoside reverse transcriptase inhibitor (NNRTI) resistance is more common in newly infected individuals.
Tuberculosis
- The panel updated recommendations concerning the timing of antiretroviral therapy in patients with active tuberculosis (TB), emphasizing overlapping toxicities and possible interactions between TB and HIV drugs, and the potential for immune reconstitution inflammatory syndrome. They also recommend repeat testing for latent TB infection in people whose CD4 count rises above 200 cells/mm3.
Table Updates
- Various tables were updated to include information on the most recently
approved antiretroviral drug, the second generation NNRTI etravirine
(Intelence, formerly TMC125).
- Tables were changed to reflect new
recommendations for atazanavir
(Reyataz) dosing in combination with proton pump inhibitors or H2 receptor
antagonists.
- The table of “Antiretroviral components that are acceptable as initial antiretroviral components but are inferior to preferred or alternative components” has been removed.
The complete new version of the treatment guidelines is available on the federal government’s AIDSInfo Web site. The latest changes are highlighted in yellow.
Sources
R Klein and K Struble. Division of Antiviral Drug Products, U.S. Food and Drug Administration. Updated Adult and Adolescent Treatment Guidelines. Email announcement. January 29, 2008.
U.S. Department of Health and Human Services. Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents. January 29, 2008.
http://aidsinfo.nih.gov/contentfiles/AdultandAdolescentGL.pdf
SAMHSA releases opportunity for funding of cooperative agreements with community based organizations
The main purpose of this cooperative agreement program is to assist grantees in building solid foundations for delivering and sustaining cutting edge substance abuse and HIV/AIDS prevention services. This program aims at expanding the capacity of community-level domestic public and private nonprofit prevention service entities to prevent and reduce the onset of substance abuse and HIV transmission among at-risk racial/ethnic minority populations. While grantees will have substantial flexibility in designing their grant projects, all are required to base their projects on the five steps of SAMHSA’s Strategic Prevention Framework (SPF). Successful evidenced-based prevention approaches developed from these cooperative agreements will be shared with other community service groups throughout the country.
Additional Funding opportunities:
For more information about the following grants, please reply directly to the Contacts listed in the announcements.
Cable Positive Grant = http://www.cablepositive.org/programs-tonycox.html
Community Participation Research Targeting the Medically Underserved = http://grants.nih.gov/grants/guide/pa-files/PAR-08-075.html
Integration of Food and Nutrition into Prevention, Care, and Treatment of HIV Infection and AIDS = http://grants.nih.gov/grants/guide/rfa-files/RFA-HD-07-023.html
Nutrition and Prevention, Care and Treatment of HIV/AIDS = http://grants.nih.gov/grants/guide/rfa-files/RFA-HD-07-022.html
Research on Pathways Linking Environments, Behaviors and HIV/AIDS = http://grants.nih.gov/grants/guide/pa-files/PAR-07-143.html
The Indian Health Service HIV Program and SAMHSA sign Memorandum of Understanding (MOU) on Jan 16, 2008.
This MOU will assist us with sustaining an interagency collaboration over the next 3 years and will include the potential for multiple projects. In 2008, SAMHSA and IHS will work closely on HIV training initiatives and multiple HIV rapid testing/screening projects. As alluded to in our strategic planning efforts, collaboration between agencies will result in increased awareness and utilization of common resources, decreased duplication of effort and increased integration and quality of services to the American Indian and Alaska Native population. We are pleased to release this information and appreciate the continued support from both agencies. Scott.Giberson@ihs.gov
FDA Approves Etravirine (TMC125)
The FDA approved Intelence (TMC125, etravirine) on Jan 11, 2008, the latest drug in a class of non-nucleoside reverse transcriptase inhibitors (NNRTIs). It will be used in combination therapy with existing AIDS drugs in adult patients who are failing other therapies. Intelence is made by Johnson & Johnson. NNRTIs block an essential enzyme that the HIV virus needs in order to replicate within a host T-cell.FDA approved the drug based on 24-week studies that showed 60 percent of patients who took an Intelence-based drug cocktail achieved an undetectable viral load. In comparison, 40 percent of patients taking a placebo in an AIDS drug combination attained undetectable levels of HIV. Intelence can also be used in patients failing other NNRTIs or have shown resistance to other ARV therapies. Dose is two tablets twice a day. Side effects: FDA reports skin rashes and nausea. Long term effects are unknown at this time. http://www.thebodypro.com/content/news/art44832.html
Barbara Stillwater, Alaska State Diabetes Program
Diabetes A Stronger Risk Factor For Death In Women than In Men
Eighteen years of follow-up shows that men are twice as likely to die from heart disease as women. However, this gender gap is markedly reduced when only patients with diabetes are considered.
CONCLUSION: Diabetes is a stronger predictor for IHD mortality in women than in men, and diabetes attenuates the usual gender gap in IHD mortality. With both diabetes and established CVD present, the gender gap is fully attenuated.
Dale AC, et al Diabetes mellitus and risk of fatal ischaemic heart disease by gender: 18 years follow-up of 74,914 individuals in the HUNT 1 Study. Eur Heart J. 2007 Dec;28(23):2924-9
http://www.ncbi.nlm.nih.gov/pubmed/17947212
Pedometers help people lose weight even without changes in diet
People who participate in a pedometer-based walking program can be expected to lose a modest amount of weight even without changing their diet, with more weight loss the longer they stick with the program, according to a University of Michigan Health System analysis of nine studies.
CONCLUSION: Pedometer-based walking programs result in a modest amount of weight loss. Longer programs lead to more weight loss than shorter programs.
Richardson CR et al A meta-analysis of pedometer-based walking interventions and weight loss. Ann Fam Med. 2008 Jan-Feb;6(1):69-77
http://www.ncbi.nlm.nih.gov/pubmed/18195317
New Position Statement for Glucose Intolerance in PCOS
The new recommendations highlight the high risk for glucose intolerance in
women with PCOS.
Generally, screening for glucose intolerance is recommended in these women because
it is often asymptomatic. Recommendations have varied with regards to PCOS and
the method and timing of screening for impaired glucose tolerance. Therefore,
an expert panel was created to make evidence-based recommendations.
“[The position statement] provides evidence and rationale for the recommendation that women with PCOS be screened for glucose intolerance at the initial visit, using an oral glucose tolerance test and that the women be retested every two years,” said Nestler, William G. Blackard Professor of Medicine Chair and division of endocrinology and metabolism vice chair at Virginia Commonwealth University.
The panel recommended screening with a two-hour OGTT specifically. However, several panel members recommended alternate screening using an OGTT only in patients with BMI >30 or lean patients with other risk factors.
For high-risk patients, re-screening should occur every two years or more frequently. The panel members also suggested annual screening for women found to have IGT.
Intensive lifestyle modification and weight loss should be considered for
PCOS patients with IGT, as it can help delay progression to type 2 diabetes.
The panel recommended at least 30 minutes of moderate activity at least five
days a week. They also recommended a hypocaloric diet for overweight and obese
women, with a target weight loss of 5% to 7%.
Women with PCOS should be screened for glucose intolerance, regardless of age,
weight, BMI or ethnicity, even in the absence of additional risk factors and
a two-hour OGTT should be performed at the initial diagnosis.
The same screening method should be utilized for adolescents with PCOS at least once every two year or more frequently if they present with an abnormal screen.
The position statement was recently published in The Journal of Clinical Endocrinology & Metabolism, Jan.2008.
Sattar N, Nelson SM. Polycystic ovarian syndrome, biomarkers, and metformin: research, risk, and reality. J Clin Endocrinol Metab. 2008 Jan;93(1):34-6.
http://www.ncbi.nlm.nih.gov/pubmed/18178908
Low-Carbohydrate Diets Rich in Vegetable Sources of Fat and Protein: Reduce Diabetes
Results Women with the highest carbohydrate scores (lowest carbohydrate intakes) were 40% more likely to be diagnosed with diabetes than those with the lowest carbohydrate scores (highest carbohydrate intakes) (P < 0.0001). Importantly, this effect disappeared after adjustment for body mass index. Glycemic load and total carbohydrate intake were positively related to risk of type 2 diabetes (P < 0.001). When carbohydrate scores were calculated by using percentages of energy from only animal fat and protein, there was no relation between the score and risk of type 2 diabetes. Conversely, when the scores were calculated by using percentages of energy from only vegetable fat and protein, lower carbohydrate consumption was associated with an 18% reduction in diabetes risk.
Conclusions The data provide additional evidence that consumption of a low-carbohydrate diet that provides relatively high amounts of animal fat and protein does not increase the risk of type 2 diabetes in women. However, low-carbohydrate diets rich in vegetables sources of fat and protein may reduce the risk.
Reference Halton TL, Liu S, Manson JE, Hu FB. Low-carbohydrate-diet score and risk of type 2 diabetes in women. American Journal of Clinical Nutrition 2008;87:339-46.
http://www.ajcn.org/cgi/content/abstract/87/2/339Women's Health Headlines, Carolyn Aoyama, HQE
Women and HIV/AIDS
PINN POINT ON WOMEN’S HEALTH
The Office of Research on Women’s Health (ORWH) is broadcasting the eighth 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 the latest podcast, Dr. Pinn talks with Dr. Victoria Cargill, Director of Minority Research and Clinical Studies, Office of AIDS Research, Office of the Director, National Institutes of Health. Dr. Cargill discusses women and HIV/AIDS from the perspective of a researcher and practicing physician in the community. Dr. Cargill emphasized that AIDS continues to be a major health problem for women and that “African American and Hispanic women are almost 80 percent of AIDS cases reported in women.” This podcast also discusses differences in how AIDS affects men and women.
“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 Pinn Point on Women’s Health (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.
APN brochures
This is a status report on the APN brochures: First, let me apologize that the brochures have not already been sent. I requested that a secretary prepare the requisition to have them printed and sent out, but I have just discovered that the requisition was never done, and the brochures were never ordered: I am starting the process from scratch once again.
Last year we printed 10,000 brochures. This year I would like to print enough so you have enough for at least a year.
The number of brochures you need depends on the number of encounters you all have and the frequency with which you provide the brochure. I am going to estimate that each of you averages about 2500 to 3000 encounters per year. Believe it or not, I have no way of identifying the number of APNs by site, so I have no idea how many APNs there are by Area. I will estimate that there are an average of 20 APNs by Area, seeing 3000 patients per year. That’s 60,000 brochures. So using these assumptions, I would provide 60,000 brochures to each Area with IHS facilities (not Alaska or California), and I would order 600,000 brochures.
It will help me come up with a more precise number for each Area if the NNLC members please email me the following information:
- The number of CNMs at each site (hospital and clinic) in your Area;
- The number of NPs at each site (hospital and clinic) in your Area;
- The number of CRNAs.
Knowing What Works in Health Care: A Roadmap for the Nation
This IOM Report provides a blueprint for a national program to assess the effectiveness of clinical services and to provide credible, unbiased information about what really works in health care.
http://www.nap.edu/catalog.php?record_id=12038
SAMHSACompendium of primary mental health activities now online
The SAMHSA website address below will take you to a compendium of primary mental health activities that may be helpful to you in your efforts to improve access to behavioral health services in primary care. http://samhsa.gov/Matrix/matrix_mh.aspx
DV Announcements: Grants, trainings and resources shared by various project faculty
The following is information about open grants, trainings and resources shared by various project faculty. If you have announcements, or questions to send to the group, just send them directly to me and I’ll post to the group.
- Ma ny of you know Cheryl Neskahi Coan from her leadership with the Family Harmony Project and Crownpoint IHS DV Team . She now works with the Southwest Center for Law and Policy as their Director of Violence Against Women Training. SCLP has ongoing trainings covering issues such as child custody, advocates under subpoena and sexual assault, just to name a few…visit their website for their full schedule: www.swclap.org
- Violence Against Women Discretionary Grants for Indian Tribal Governments announcement (see below my signature for more info)
- New SAMHSA compendium of primary mental health activities that may be helpful to you in your efforts to improve access to behavioral health services in primary care. Visit: http://samhsa.gov/Matrix/matrix_mh.aspx
- Southwest Indigenous Women's Coalition in Phoenix, AZ is hiring (see attached job announcements).
- WHO Foundation: Women Helping Others Offers Support for Grassroots Charities Serving Women and Children. Visit: http://www.whofoundation.org/WHO_Funding.htm for more info.
Save the dates
Keeping Native Women & Families Healthy & Strong
- April 23-25, 2008
- Milwaukee , WI
- Great Lakes Tribal Epidemiology Center
- E-mail contact EpidemiologyCenter@gmail.com
IHS Basic Colposcopy Course
- April 9 - 11, 2008
- Albuquerque , NM
- Contact AWaxman@salud.unm.edu
IHS Colposcopy Update & Refresher Course
- April 9 - 11, 2008
- Albuquerque , NM
- Contact AWaxman@salud.unm.edu
Training in Palliative and End of Life Care
- April 22-24, 2008
- Flagstaff , AZ
- Contact Tim Domer MD at tim.domer@ihs.gov
Advances in Indian Health (AIH) Conference
- April 29 – May 2, 2008
- Albuquerque , New Mexico
- 28 credits, Indian Country’s Primary Care Conference
http://www.ihs.gov/MedicalPrograms/MCH/F/CN01.cfm?module=2008&option=may#top
What's new on the ITU MCH web pages?
Meeting notes now online: 2007 Native Women’s Health and MCH Conference
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 February 2008 OB/GYN CCC Corner is available.
Hot Topics ‹ Previous
OB/GYN
Dr. Neil Murphy is the Obstetrics and Gynecology Chief Clinical Consultant (OB/GYN C.C.C.). Dr. Murphy is very interested in establishing a dialogue and/or networking with anyone involved in women's health or maternal child health, especially as it applies to Native or indigenous peoples around the world. Please don't hesitate to contact him by e-mail or phone at 907-729-3154.
