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Volume 5, No. 11, December 2007
Features
American College of Obstetricians and Gynecologists
Use of Psychiatric Medications During Pregnancy and Lactation
Summary of Recommendations and Conclusions
The following recommendations and conclusions are based on good and consistent scientific evidence (Level A):
- Lithium exposure in pregnancy may be associated with a small increase in congenital cardiac malformations, with a risk ratio of 1.2–7.7.
- Valproate exposure in pregnancy is associated with an increased risk of fetal anomalies, including neural tube defects, fetal valproate syndrome, and long-term adverse neurocognitive effects. It should be avoided in pregnancy, if possible, especially during the first trimester.
- Carbamazepine exposure in pregnancy is associated with fetal carbamazepine syndrome. It should be avoided in pregnancy, if possible, especially during the first trimester.
- Maternal benzodiazepine use shortly before delivery is associated with floppy infant syndrome.
The following recommendations and conclusions are based on limited or inconsistent scientific evidence (Level B):
- Paroxetine use in pregnant women and women planning pregnancy should be avoided, if possible. Fetal echocardiography should be considered for women who are exposed to paroxetine in early pregnancy.
- Prenatal benzodiazepine exposure increased the risk of oral cleft, although the absolute risk increased by 0.01%.
- Lamotrigine is a potential maintenance therapy option for pregnant women with bipolar disorder because of its protective effects against bipolar depression, general tolerability, and a growing reproductive safety profile relative to alternative mood stabilizers.
- Maternal psychiatric illness, if inadequately treated or untreated, may result in poor compliance with prenatal care, inadequate nutrition, exposure to additional medication or herbal remedies, increased alcohol and tobacco use, deficits in mother–infant bonding, and disruptions within the family environment.
The following recommendations and conclusions are based primarily on consensus and expert opinion (Level C):
- Whenever possible, multidisciplinary management involving the patient’s obstetrician, mental health clinician, primary health care provider, and pediatrician is recommended to facilitate care.
- Use of a single medication at a higher dose is favored over the use of multiple medications for the treatment of psychiatric illness during pregnancy.
- The physiologic alterations of pregnancy may affect the absorption, distribution, metabolism, and elimination of lithium, and close monitoring of lithium levels during pregnancy and postpartum is recommended.
- For women who breastfeed, measuring serum levels in the neonate is not recommended.
- Treatment with all SSRIs or selective norepinephrine reuptake inhibitors or both during pregnancy should be individualized.
- Fetal assessment with fetal echocardiogram should be considered in pregnant women exposed to lithium in the first trimester.
Use of Psychiatric Medications During Pregnancy and Lactation. ACOG Practice Bulletin No. 87. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007; 110:1179-98
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17978143
Cesarean Delivery on Maternal Request
ABSTRACT: Cesarean delivery on maternal request is defined as a primary cesarean delivery at maternal request in the absence of any medical or obstetric indication. A potential benefit of cesarean delivery on maternal request is a decreased risk of hemorrhage for the mother. Potential risks of cesarean delivery on maternal request include a longer maternal hospital stay, an increased risk of respiratory problems for the baby, and greater complications in subsequent pregnancies, including uterine rupture and placental implantation problems. Cesarean delivery on maternal request should not be performed before 39 weeks of gestation or without verification of lung maturity. Cesarean delivery on maternal request should not be motivated by the unavailability of effective pain management. Cesarean delivery on maternal request is not recommended for women desiring several children, given that the risks of placenta previa, placenta accreta, and the need for gravid hysterectomy increase with each cesarean delivery.
Cesarean Delivery on Maternal Request ACOG Committee Opinion no. 386. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;110:1209-12.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17978146
Colonoscopy and Colorectal Cancer Screening and Prevention
ABSTRACT: Most colorectal cancer can be detected by screening modalities and treated at a preinvasive or early invasive stage, before it has developed to a fully invasive and potentially fatal disease. Obstetrician–gynecologists should counsel all patients aged 50 years and older about the benefits of colorectal cancer screening and should encourage colonoscopy as the preferred method of screening for women at either average risk or high risk. The advantages and limitations of other appropriate colorectal cancer screening methods also should be discussed so that women may choose to be tested by whichever method they are most likely to accept and complete.
Colonoscopy and Colorectal Cancer Screening and Prevention. ACOG Committee Opinion No. 384. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;110:1199-1202.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17978144
The Limits of Conscientious Refusal in Reproductive Medicine
ABSTRACT: Health care providers occasionally may find that providing indicated, even standard, care would present for them a personal moral problem—a conflict of conscience—particularly in the field of reproductive medicine. Although respect for conscience is important, conscientious refusals should be limited if they constitute an imposition of religious or moral beliefs on patients, negatively affect a patient’s health, are based on scientific misinformation, or create or reinforce racial or socioeconomic inequalities. Conscientious refusals that conflict with patient well-being should be accommodated only if the primary duty to the patient can be fulfilled. All health care providers must provide accurate and unbiased information so that patients can make informed decisions. Where conscience implores physicians to deviate from standard practices, they must provide potential patients with accurate and prior notice of their personal moral commitments. Physicians and other health care providers have the duty to refer patients in a timely manner to other providers if they do not feel that they can in conscience provide the standard reproductive services that patients request. In resource-poor areas, access to safe and legal reproductive services should be maintained. Providers with moral or religious objections should either practice in proximity to individuals who do not share their views or ensure that referral processes are in place. In an emergency in which referral is not possible or might negatively have an impact on a patient’s physical or mental health, providers have an obligation to provide medically indicated and requested care.
The Limits of Conscientious Refusal in Reproductive Medicine ACOG Committee Opinion no. 385. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;110:1203-8.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17978145
Supracervical Hysterectomy
ABSTRACT: Women with known or suspected gynecologic cancer, current or recent cervical dysplasia, or endometrial hyperplasia are not candidates for a supracervical procedure. Patients electing supracervical hysterectomy should be carefully screened preoperatively to exclude cervical or uterine neoplasm and should be counseled about the need for long-term follow-up, the possibility of future trachelectomy, and the lack of data demonstrating clear benefits over total hysterectomy. The supracervical approach should not be recommended by the surgeon as a superior technique for hysterectomy for benign disease
Supracervical Hysterectomy. ACOG Committee Opinion no. 388. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;110:1215-7.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17978148
Pharmaceutical Compounding
ABSTRACT: Compounding is the preparation of an individualized drug product in response to a physician’s prescription to create a medication tailored to the specialized needs of an individual patient. There are currently no specific prohibitions by the U.S. Food and Drug Administration on what constitutes a legitimate claim for compounded drug products, even if there is no efficacy, risk, or safety evidence to support an advertised claim. Physicians and patients should exercise caution in prescribing and using products that are largely untested for safety and efficacy.
Pharmaceutical Compounding. ACOG Committee Opinion no. 387. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;110:1213-4 .
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17978147
American Family Physician**
Predicting the Likelihood of Successful Vaginal Birth After Cesarean Delivery
Clinical Question
Which patients are likely to have a successful vaginal birth after a previous cesarean delivery?
Evidence Summary
The American College of Obstetricians and Gynecologists and the American Academy of Family Physicians recommend that pregnant women with a single previous cesarean delivery and a low-transverse incision be offered a trial of labor. Although the rate of vaginal birth after cesarean delivery (VBAC) increased from 19 percent of all deliveries in 1989 to a peak of 28 percent in 1996, the rate decreased to only 9.2 percent of all deliveries in 2004. The decline has been partially driven by concerns about the small but measurable risk of uterine rupture with VBAC, particularly when labor is induced or augmented.
At the same time, the total number of cesarean deliveries has been increasing, largely because of an increase in primary cesarean deliveries. A screening tool to help predict whether a woman will have a successful VBAC may help patients and their physicians make more informed shared decisions.
A 2003 evidence review by the Agency for Healthcare Research and Quality found overall VBAC success rates between 60 and 82 percent in published studies, with an estimated overall success rate of 75 percent at teaching institutions and tertiary medical centers. The risks of perinatal death or hysterectomy from uterine scar rupture were low (1.5 and 4.8 per 10,000 births, respectively). The review identified factors associated with an increased likelihood of vaginal delivery (i.e., maternal age younger than 40 years, previous successful vaginal delivery, and favorable cervical factors). The review also identified factors that decreased the likelihood of vaginal birth (i.e., more than one previous cesarean delivery; induction of labor; birth weight greater than 4,000 g [8 lb, 13 oz]; and gestational age greater than 40 weeks).
A number of researchers have attempted to develop clinical decision rules to predict the likelihood of a successful trial of labor after a previous cesarean delivery. A 2004 systematic review identified six of these clinical decision rules, two of which were validated (i.e., tested in a new population to confirm accuracy of the rule). Three subsequent rules were developed and validated. These five validated rules are summarized in Table 1 (see link below)
Although the Troyer rule was validated, the number of patients in the validation group was small. The Hashima rule was also prospectively validated; however, only three out of 5,414 women had a score of 0, and only 101 had a score of 1 (low probability of success). The remaining 5,310 women had scores of 2 (53 percent success rate) or 3 (67 percent success rate), which provides little useful information for decision making.
The remaining three scores were well validated and were shown to be accurate in a large, representative population. The Flamm rule (Table 2) (see link below) is the simplest to use, although it is limited by its age (data were gathered between 1990 and 1992) and by the requirement of cervical effacement information, which makes it unhelpful for antepartum planning.
The Smith rule is well validated but is based on a multivariate equation, making it too complex for practical use at the point of care. Although the Grobman rule is also based on a complex multivariate equation, a nomogram (Figure 1) (see link below) is provided for use at the point of care.
The Grobman rule has been well validated and all of the needed variables are available to the patient and physician before the onset of labor.)
Applying the Evidence
A 25-year-old, non-Hispanic, white woman with a body mass index (BMI) of 25 kg per m2 is in labor. Her cervix is 3 cm dilated and about 30 to 40 percent effaced. She has had one previous pregnancy, which resulted in cesarean delivery because of failure to progress. She wonders how likely it is that a trial of labor will be successful.
Answer:
Using the Flamm rule (Table 2) (see link below) the patient receives two points for age and one for cervical effacement. The total score of 3 gives her a 60 percent probability of vaginal delivery. Using the Grobman nomogram (Figure 1), (see link below) the patient receives 10 points for age, 30 for body mass index, points each for being non-African American and non-Hispanic, and 0 for no history of vaginal birth or recurrent primary indication. The total score of 54 points gives her a 68 percent probability of vaginal delivery. You advise the patient that her chance of a successful trial of labor is about two out of three. http://www.aafp.org/afp/20071015/poc.html Point-of-Care Guides
Effectiveness of Insulin Sensitizing Drugs for Polycystic Ovary Syndrome
Clinical Question
Do insulin sensitizing drugs with or without oral contraceptive pills improve clinical outcomes in women with polycystic ovary syndrome (PCOS)?
Evidence-Based Answer
Insulin sensitizing drugs are more effective than oral contraceptives alone at improving fasting insulin levels in patients with PCOS. Compared with metformin (Glucophage) alone, oral contraceptives alone better control irregular menstrual cycles and reduce androgen levels. There is insufficient evidence to recommend insulin sensitizing drugs alone or in combination with oral contraceptives to decrease the risk of diabetes, cardiovascular disease, or endometrial cancer.
Practice Pointers
PCOS is defined by the presence of two of the following criteria: oligomenorrhea or amenorrhea, clinical or biochemical hyperandrogenism, or polycystic ovaries visible on ultrasonography. Family physicians routinely treat symptoms of irregular menstrual cycles and excessive androgen levels with combination oral contraceptives. The benefit of using insulin sensitizing drugs is unclear. Ideally, treatment of PCOS would improve clinical symptoms such as hirsutism and infertility and decrease the risk of type 2 diabetes, cardiovascular disease, or endometrial cancer.
In this Cochrane review, the authors searched the literature for randomized controlled trials (RCTs) comparing treatment of PCOS with insulin sensitizing drugs with or without oral contraceptives. They found six RCTs that included 226 total patients, 20 to 52 years of age. Patients were followed for four to 12 months, with a median study duration of six months. Metformin, 500 mg orally three times per day, was the only insulin sensitizing drug studied.
Oral contraceptives were more effective at improving menstrual cycle regularity and lowering androgen levels compared with metformin. Although these findings were statistically significant, only 104 participants in three trials were analyzed for these outcomes. Metformin lowered fasting insulin levels and did not impact triglyceride levels compared with oral contraceptives. However, metformin did not lower fasting glucose levels in patients without impaired glucose tolerance and did not reduce the risk of type 2 diabetes when used alone. Combined therapy improved hirsutism in a single RCT with 34 participants.
No combined RCTs with acne as primary outcome were available. None of the trials analyzed the primary outcomes of stroke, myocardial infarction, or endometrial cancer.
This review was limited by small study sizes. Because outcomes addressed chronic disease, the studies may not have followed patients long enough to show prevention benefits. No studies were available comparing alternative insulin sensitizing drugs such as rosiglitazone (Avandia) or pioglitazone (Actos). There was insufficient evidence on the outcomes of hirsutism, acne, body mass index, blood pressure, and other cholesterol parameters.
Evaluating fertility rates as a primary outcome could provide practice-modifying information for many physicians. Expert consensus by the American Association of Clinical Endocrinologists states that metformin should be considered in the initial treatment of PCOS, especially for patients who are overweight or obese. The 2002 American College of Obstetricians and Gynecologists guideline recommends metformin as one measure to improve ovulatory frequency and to treat risk factors for diabetes and cardiovascular disease. Cochrane Briefs
Costello M, Shrestha B, Eden J, Sjoblom P, Johnson N. Insulin-sensitising drugs versus the combined oral contraceptive pill for hirsutism, acne and risk of diabetes, cardiovascular disease, and endometrial cancer in polycystic ovary syndrome. Cochrane Database Syst Rev 2007(1):CD005552.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17253562
Second Trimester Pregnancy Loss (See also Patient Education)
Second trimester pregnancy loss is uncommon, but it should be regarded as an important event in a woman's obstetric history. Fetal abnormalities, including chromosomal problems, and maternal anatomic factors, immunologic factors, infection, and thrombophilia should be considered; however, a cause-and-effect relationship may be difficult to establish. A thorough history and physical examination should include inquiries about previous pregnancy loss. Laboratory tests may identify treatable etiologies. Although there is limited evidence that specific interventions improve outcomes, management of contributing maternal factors (e.g., smoking, substance abuse) is essential. Preventive measures, including vaccination and folic acid supplementation, are recommended regardless of risk. Management of associated chromosomal factors requires consultation with a genetic counselor or obstetrician. The family physician can play an important role in helping the patient and her family cope with the emotional aspects of pregnancy loss. (Am Fam Physician 2007;76:1341-6, 1347-8.
http://www.aafp.org/afp/20071101/1341.html
AAFP and ACP Publish Recommendations on Diagnosis and Management of VTE
There are 600,000 cases of venous thromboembolism (VTE) in the United States every year. Of all persons with undetected or untreated pulmonary embolism, 26 percent will have a fatal embolic event, and another 26 percent will have a recurrent embolic event that could become fatal. Therefore, an early diagnosis of VTE is important to prevent mortality and morbidity in this population.
This guideline summarizes the current approaches for the diagnosis of venous thromboembolism. The importance of early diagnosis to prevent mortality and morbidity associated with venous thromboembolism cannot be overstressed. This field is highly dynamic, however, and new evidence is emerging periodically that may change the recommendations. The purpose of this guideline is to present recommendations based on current evidence to clinicians to aid in the diagnosis of lower extremity deep venous thrombosis and pulmonary embolism.
Qaseem A, et al Current diagnosis of venous thromboembolism in primary care: a clinical practice guideline from the American Academy of Family Physicians and the American College of Physicians. Ann Fam Med. 2007 Jan-Feb;5(1):57-62.
Methamphetamine Abuse (See also Patient Education)
Methamphetamine is a stimulant commonly abused in many parts of the United States. Most methamphetamine users are white men 18 to 25 years of age, but the highest usage rates have been found in native Hawaiians, persons of more than one race, Native Americans, and men who have sex with men. Methamphetamine use produces a rapid, pleasurable rush followed by euphoria, heightened attention, and increased energy. Possible adverse effects include myocardial infarction, stroke, seizures, rhabdomyolysis, cardiomyopathy, psychosis, and death. Chronic methamphetamine use is associated with neurologic and psychiatric symptoms and changes in physical appearance. High-risk sexual activity and transmission of human immunodeficiency virus are also associated with methamphetamine use. Use of methamphetamine in women who are pregnant can cause placental abruption, intrauterine growth retardation, and preterm birth, and there can be adverse consequences in children exposed to the drug. Treatment of methamphetamine intoxication is primarily supportive. Treatment of methamphetamine abuse is behavioral; cognitive behavior therapy, contingency management, and the Matrix Model may be effective. Pharmacologic treatments are under investigation. Am Fam Physician 2007;76:1169-74, 1175-6
http://www.aafp.org/afp/20071015/1169.html
Outpatient Care of the Premature Infant (See also Patient Education)
An increasing number of infants in the United States are born prematurely, with current statistics estimating about 13 percent of all births. Although survival rates and outcomes for premature infants have dramatically improved in recent decades, morbidity and mortality are still significant. Infants born prematurely are at increased risk of growth problems, developmental delays, and complex medical problems. To account for prematurity, growth and development monitoring should be done according to adjusted age (age in months from term due date). Premature infants should gain 20 to 30 g (0.71 to 1.06 oz) per day after discharge from the hospital. Growth parameters may be improved in the short term with the use of enriched preterm formula or breast milk fortifier. Each well-child examination should include developmental surveillance so that early intervention can be initiated if a developmental delay is diagnosed. Routine vaccination should proceed according to chronologic age with minor exceptions, and respiratory syncytial virus immune globulin is indicated in preterm infants who meet the criteria. Am Fam Physician 2007;76:1159-64, 1165-6. http://www.aafp.org/afp/20071015/1159.html
Somatoform Disorders (See also Patient Education)
The somatoform disorders are a group of psychiatric disorders that cause unexplained physical symptoms. They include somatization disorder (involving multisystem physical symptoms), undifferentiated somatoform disorder (fewer symptoms than somatization disorder), conversion disorder (voluntary motor or sensory function symptoms), pain disorder (pain with strong psychological involvement), hypochondriasis (fear of having a life-threatening illness or condition), body dysmorphic disorder (preoccupation with a real or imagined physical defect), and somatoform disorder not otherwise specified (used when criteria are not clearly met for one of the other somatoform disorders). These disorders should be considered early in the evaluation of patients with unexplained symptoms to prevent unnecessary interventions and testing. Treatment success can be enhanced by discussing the possibility of a somatoform disorder with the patient early in the evaluation process, limiting unnecessary diagnostic and medical treatments, focusing on the management of the disorder rather than its cure, using appropriate medications and psychotherapy for comorbidities, maintaining a psychoeducational and collaborative relationship with patients, and referring patients to mental health professionals when appropriate. Am Fam Physician 2007;76:1333-8 http://www.aafp.org/afp/20071101/1333.html
Mind-Body Therapies for Headache (See also Patient Education)
Headache is one of the most common and enigmatic problems encountered by family physicians. Headache is not a singular entity, and different pathologic mechanisms are involved in distinct types of headache. Most types of headache involve dysfunction of peripheral or central nociceptive mechanisms. Mind-body therapies such as biofeedback, cognitive behavior therapy, hypnosis, meditation, and relaxation training can affect neural substrates and have been shown to be effective treatments for various types of headache. Meta-analyses of randomized controlled trials show that the use of mind-body therapies, alone or in combination, significantly reduces symptoms of migraine, tension, and mixed-type headaches. Side effects generally are minimal and transient. Am Fam Physician 2007;76:1518-22, 1523-4.
http://www.aafp.org/afp/20071115/1518.html
Ulcerative Colitis: Diagnosis and Treatment (See also Patient Education)
Ulcerative colitis is a chronic disease with recurrent symptoms and significant morbidity. The precise etiology is still unknown. As many as 25 percent of patients with ulcerative colitis have extraintestinal manifestations. The diagnosis is made endoscopically. Tests such as perinuclear antineutrophilic cytoplasmic antibodies and anti-Saccharomyces cerevisiae antibodies are promising, but not yet recommended for routine use. Treatment is based on the extent and severity of the disease. Rectal therapy with 5-aminosalicylic acid compounds is used for proctitis. More extensive disease requires treatment with oral 5-aminosalicylic acid compounds and oral corticosteroids. The side effects of steroids limit their usefulness for chronic therapy. Patients who do not respond to treatment with oral corticosteroids require hospitalization and intravenous steroids. Refractory symptoms may be treated with azathioprine or infliximab. Surgical treatment of ulcerative colitis is reserved for patients who fail medical therapy or who develop severe hemorrhage, perforation, or cancer. Longstanding ulcerative colitis is associated with an increased risk of colon cancer. Patients should receive an initial screening colonoscopy eight years after the onset of pancolitis and 12 to 15 years after the onset of left-sided disease; follow-up colonoscopy should be repeated every two to three years. Am Fam Physician 2007;76:1323-30, 1331. http://www.aafp.org/afp/20071101/1323.html
Nonspecific Low Back Pain and Return to Work (See also Patient Education)
As many as 90 percent of persons with occupational nonspecific low back pain are able to return to work in a relatively short period of time. As long as no "red flags" exist, the patient should be encouraged to remain as active as possible, minimize bed rest, use ice or heat compresses, take anti-inflammatory or analgesic medications if desired, participate in home exercises, and return to work as soon as possible. Medical and surgical intervention should be minimized when abnormalities on physical examination are lacking and the patient is having difficulty returning to work after four to six weeks. Personal and occupational psychosocial factors should be addressed thoroughly, and a multidisciplinary rehabilitation program should be strongly considered to prevent delayed recovery and chronic disability. Patient advocacy should include preventing unnecessary and ineffective medical and surgical interventions, prolonged work loss, joblessness, and chronic disability. Am Fam Physician 2007;76:1497-1502, 1504.
http://www.aafp.org/afp/20071115/1497.html
AHRQ
Study documents the health costs of being a woman
http://www.ahrq.gov/research/nov07/1107RA2.htm
Death and complications after breast cancer surgery are rare, with
wound infection the most common problem
http://www.ahrq.gov/research/nov07/1107RA3.htm
Women suffer fewer postoperative problems after vascular surgery
at Veterans Administration than at private hospitals
http://www.ahrq.gov/research/nov07/1107RA4.htm
A skin condition may identify young patients at risk for developing
type 2 diabetes
http://www.ahrq.gov/research/nov07/1107RA8.htm
Ask A Librarian: Diane Cooper, M.S.L.S. / NIH
The Healthy Heart Handbook for Women '07 - 20th Anniversary Edition
This newly revised handbook, with a special message from First Lady Laura Bush, provides new information on women’s heart disease and practical suggestions for reducing your own personal risk of heart-related problems. The handbook presents the latest information on how to live a healthier and longer life, by taking action steps to prevent and control heart disease risk factors.
You’ll also find new tips on following a nutritious eating plan, tailoring your physical activity program to your particular goals, quitting smoking, and getting your whole family involved in heart healthy living. The Healthy Heart Handbook for Women is part of The Heart Truth for Women, a national public awareness campaign for women about heart disease sponsored by the National Heart, Lung and Blood Institute (NHLBI) and many other groups.
http://www.nhlbi.nih.gov/health/public/heart/other/hhw/hdbk_wmn.pdf
Breastfeeding - Amy Patterson, California Area Indian Health Service
Getting it Right
Breastfeeding Promotion: Good Public Health Policy (Part 2 of 2)
During pregnancy, the mother’s body changes to prepare itself for lactation so that she can successfully nurse her infant. There are truly very few cases in which a mother is physically unable to breastfeed.
Breastfeeding is natural, but it takes some time to learn to do it correctly. With few exceptions-discussed below- all pregnant women should be encouraged to breastfeed, and to learn about breastfeeding through classes run by hospitals or lactation consultants. Hospital policies can also make a difference; in particular, “rooming-in” and encouraging nursing within the first hour of birth both increase the chance of breastfeeding success. After birth, nursing mothers should receive help from their hospital’s lactation consultant to make sure they and their babies are getting off to the right start. If a nursing mother is having problems with latching or is concerned about milk supply, a lactation consultant can evaluate and help. An IBCLC (International Board Certified Lactation Consultant) credential represents the “gold standard” for lactation counseling. IBCLCs are certified after hundreds of hours of consulting and academic training; they must also pass a rigorous, comprehensive exam. To find a certified consultant, go to www.ilca.org , and click on “Find a Lactation Consultant in Your Area.”
Newborn babies who are breastfed need to eat frequently; it is not uncommon for them to wake many times a night to nurse. Providers can let new parents know that while this will interrupt their normal sleep cycles for a while, it is temporary; as a baby gets older they go longer in between feedings. Night waking is a normal feature of newborns; even formula-fed babies wake at night to eat. There are also special advantages to breastfeeding; although a nursing baby may wake a bit more frequently than a formula-fed baby, the nursing mother has no bottles to prepare in the middle of the night and can comfort her infant immediately. Remind mothers that this is also true during the day when they are out of the house, and means they will not have to carry bottles or formula around. California law also protects the rights of mothers to nurse in public.
Also, remind new mothers that there are significant health benefits from nursing. Nursing infants also get sick less often, which means fewer trips to the doctor, and fewer nights spent caring for a sick baby. The longer a woman nurses, the greater the health benefits for her baby. Breastfeeding can continue as long as it is beneficial for both mother and child- there is no time limit on how many months or years a woman should nurse.
Nursing can also continue after a mother returns to work. A nursing mother can nurse her baby in the evenings, overnight, and in the mornings. Then, she can pump her milk while at work and store it for caregivers to give to her baby while she is at work. Nursing mothers have rights under California State Law for break time and privacy to pump milk while at work.
However, there are some women for whom breastfeeding is not advised. Women who are HIV positive should not breastfeed because of the risk of transmitting the virus to the baby. Also, women with active, untreated TB (tuberculosis) or who are receiving any kind of chemotherapy should not breastfeed.
Women who are breastfeeding should not take illegal drugs. Some drugs, such as methamphetamine, cocaine and PCP, can affect the baby and cause serious side effects. Other drugs, such as heroin and marijuana can cause irritability, poor sleeping patterns, tremors, and vomiting. Babies can become addicted to these drugs. If a mother is addicted and can not get off these drugs, she should not breastfeed. However, mothers undergoing methadone treatment may breastfeed.
Mothers who smoke should be encouraged to quit as soon as possible. However, even if they cannot, it is still better to breastfeed, as long as they do not smoke near their infants.
Most common illnesses, such as colds, flu, or diarrhea, can not be passed through breast milk. In fact, when a mother is sick, her breast milk will have antibodies in it that will help protect infants from getting the same sickness.
GPRA
The Indian Health Service has a developmental GPRA measure on exclusive and near exclusive breastfeeding rates among 2 month old infants, with the goal of increasing breastfeeding rates among these and older infants. RPMS users can use a PCC Infant Feeding Tool to record infant feeding status; this information is captured in RPMS and extracted by the Clinical Reporting System (CRS). Sites using PCC, RPMS and CRS can monitor the feeding status of their infant population by running CRS reports.
The Indian Health Service uses Healthy People 2010 objectives whenever possible for its GPRA targets. The Healthy People 2010 goal is to have at least 75 percent of mothers breastfeeding during the early postpartum period and 50 and 25 percent breastfeeding at 6 months and 1 year, respectively. In 1998, 64 percent of all mothers breastfed their infants during the early postpartum period. 29 and 16 percent of mothers breastfed their infants at 6 months and 1 year, respectively. This data is for all races; no comprehensive national data on breastfeeding rates among American Indians and Alaska Natives yet exists.
For More Information:
Indian Health Service Breastfeeding Page
http://www.ihs.gov/MedicalPrograms/MCH/M/bf.cfm
California State Breastfeeding Program
http://www.mch.dhs.ca.gov/programs/bfp/
LaLeche League International
http://www.lalecheleague.org/
Centers for Disease Control Breastfeeding Page
http://www.cdc.gov/breastfeeding/
National Women’s Health Information Center (DHHS Breastfeeding resources
page)
http://www.4woman.gov/Breastfeeding/index.cfm?page=227
International Lactation Consultant Association
http://www.ilca.org/
World Alliance for Breastfeeding Action
http://worldbreastfeedingweek.org/downloads.htm
Other
Rare Side-Effect of Codeine in Nursing Mothers: Ultra-rapid metabolizers
FDA is alerting healthcare professionals about a very rare but serious side effect that can affect the babies of nursing mothers who are taking drugs that contain codeine. The problem affects mothers who are "ultra-rapid metabolizers" of codeine. Ultra-rapid metabolizers have a specific genotype that causes them to convert codeine to its active metabolite, morphine, more rapidly and completely than other people. This can result in the mother having unusually high morphine levels in her serum and breast milk, and this can put her nursing infant at risk of morphine overdose.
A recent report in the literature described a healthy, 13-day-old breast-feeding baby who died of a morphine overdose. His mother was taking codeine at less than the usual analgesic dose.
The prevalence of the ultra-rapid metabolizers of codeine varies for different populations. Among Caucasians, the figure is about 1 to 10 percent. Among African-Americans, about 3 percent are ultra-rapid metabolizers of codeine, and among Asians and Hispanics, about 1 percent. The highest prevalence is among some groups of North Africans, Ethiopians and Saudis, where it can be as high as 28 percent.
It is important to note that nursing mothers have used codeine safely for many years. Many women are sent home after having a baby with analgesics such as acetaminophen with codeine to relieve episiotomy pain or abdominal cramping and many of these women are also breast feeding. Despite this widespread use, FDA was able to find only the one case where the baby clearly died as a result of morphine overdose from breast milk. This means that many breast fed babies born to mothers who are ultra-rapid metabolizers and who are taking codeine will not have a problem, but some babies may.
FDA has cleared a genetic test that can determine whether someone is a rapid metabolizer of a number of drugs, but there's only limited information on using it for codeine. Which means at this point, the test result alone may not correctly predict whether the mother is an ultra-rapid metabolizer of codeine. In other words, the test is not a substitute for a doctor's judgment.
FDA recommends that clinicians who prescribe codeine for a nursing mother do so in the lowest dose for the shortest period of time in order to relieve pain. Clinicians should also educate nursing mothers who may be taking codeine about the signs of morphine overdose in themselves or their infants.
Mothers should understand that they don't need to go without pain relief if they're breast feeding, but they should know what to look for if there's a morphine overdose. For the mother herself, the signs include extreme sleepiness and constipation. The mother should also watch for increased sleepiness in her baby, keeping in mind that breastfed babies usually nurse every two to three hours and shouldn't sleep more than four hours at a time. She should also watch for trouble breast feeding, breathing difficulties and limpness. Mothers should also be aware that morphine may remain in the infant's body for up to several days after the last codeine dose.
Finally, in order to help the FDA understand and quantify this problem, it's important to report possible cases of morphine overdose in mothers and infants. To report an adverse event to the FDA please see the below link.
Additional Information :
FDA MedWatch Safety Alert. Codeine Products Used By Nursing Mothers. August
17, 2007
http://www.fda.gov/medwatch/safety/2007/safety07.htm#Codeine
FDA MedWatch. Reporting Adverse Events to FDA. April 19, 2007
http://www.fda.gov/medwatch/how.htm
Nicotine In Breast Milk Disrupts Infants’ Sleep Patterns
Infants spent less time sleeping overall and woke up from naps sooner when their mothers smoked prior to breastfeeding,
CONCLUSIONS: An acute episode of smoking by lactating mothers altered infants' sleep/wake patterning. Perhaps concerns that their milk would taste like cigarettes and their infants' sleep patterning would be disrupted would motivate lactating mothers to abstain from smoking and to breastfeed longer.
Mennella JA, et al Breastfeeding and smoking: short-term effects on infant feeding and sleep. Pediatrics. 2007 Sep;120(3):497-502
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17766521
Formula free zone - Sion Baby Friendly Hospital
The Sion municipal hospital in Mumbai, which featured in the Yorkshire TV film "Bottle Feeding in India" (contact Baby Milk Action for copies of this), broadcast in the UK in 1995, is of more than 900 Baby Friendly Hospitals in India. The Sion hospital caters for some of the poorest families in Mumbai, including residents of Asia's largest slum, Dharavi. Approximately 6,000 babies are born in the Sion every year, 30 - 40% of them premature or low-birth weight. Between 1979 1986, the Sion used invasive medical techniques such as prelacteal and supplementary bottle feeds, assisted ventilation devices, frequent blood investigations, etc. However, these practices have changed and the hospital has not used any baby milk for the last 10 years. Breastfeeding has been as one of the key factors in a reduction in infant morbidity. When bottle feeding was routine 7 out of 10 premature babies died, now at least 8 out of 10 survive. Like all hospitals, the Sion Hospital is badly in need of cash - but any suggestion that they take money from the baby food or drug industry was dismissed by the staff as unthinkable.
Indian doctors reject baby food sponsorship
Aware that parents are receiving confusing messages from doctors; a number of professional organizations in India are tackling the issue of commercial sponsorship head on. After a thorough debate at its annual conference in January 1997, the Indian Academy of Pediatrics overwhelmingly passed a Resolution saying: "The IAP shall not accept the sponsorship in any form from any industry connected directly or indirectly with the products covered by the [Indian] Act."
The Federation of Obstetrics and Gynecological Societies of India (FOGSI), with 12,000 members throughout India, also rejects baby food sponsorship, even though massive amounts have been offered. The Federation has declared 1997 to be the FOGSI Breastfeeding Year.
J & J apologizes and withdraws
The Indian Act includes all the articles of the International Code and one of its most unique and innovative aspects is its authorization of voluntary organizations to bring criminal complaints for prosecution. Over the last few years the ACASH has filed criminal complaints against Nestle, Johnson and Johnson and more recently, Wockhardt. The company reaction to these charges has been revealing: As Update readers will know, Nestle has so far refused to apologize and has challenged the validity of the Indian Act.
Johnson & Johnson, in contrast, has submitted a letter of apology to ACASH and has stated that because bottle feeding may not be appropriate in the Indian context it is withdrawing from the market. The Wockhardt case involves its labeling of Dexolac, and the company has issued an apology to ACASH and to the courts. Judith.Thierry@ihs.gov
The yeast connection: is Candida linked to breastfeeding associated pain?
CONCLUSION: C. albicans is found more often in breastfeeding mothers who report pain as compared with asymptomatic breastfeeding mothers. Further studies, including treatment trials, are needed to determine whether Candida plays an etiologic role in breastfeeding associated pain.
Andrews JI, The yeast connection: is Candida linked to breastfeeding associated pain?
Am J Obstet Gynecol. 2007 Oct;197(4):424.e1-4.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17904988
CCC Corner Digest
Nicely laid out hard copy - A compact digest of last month’s CCC Corner
- Hospital brought rapid cesarean delivery times into range of 10.9 minutes: Can you?
- Let’s clear up any confusion over the availability of the HPV vaccine
- SBE prophylaxis not recommended for cesarean delivery and other GU procedures
- 2006 consensus guidelines for the management of abnormal cervical cancer screening
- Traumatic events and alcohol use disorders among American Indian adolescents
- Aging and prevalence of CVD risk factors in American Indians: the Strong Heart Study
- Viral Hepatitis in Pregnancy
- The HSR Library- a branch of the NIH Library Provides Access to Many Online Journals
- Breastfeeding Promotion: Good Public Health Policy
- Coaching Boys Into Men AI/AN Poster
- Transdermal hormonal contraception: benefits and risks
- EHR graphical user interface (GUI) application, version 1.1. – National Release
- Treating schizophrenia in poorer countries: Old dilemmas and new directions
- Having more family meals during adolescence is associated with improved diet quality
- Child passengers are exposed to secondhand smoke
-Endometriosis: Where is the real truth? It’s here
- Hormone therapy had no effect on memory, but increases sexual interest
- If you have to use something, nitrous oxide might be better than narcotics and epidurals
- Acute Appendicitis and Pregnancy
- Nurses and physicians have different perspectives in medical decisions
- Training for Shoulder Dystocia
- Ordinary Doses of Vitamin D Linked to Lower Mortality
- No, I don’t mean THAT Dating Game
- Magic Pill Improves Glycemic Control and Decreases Death by 25% for Type 2's
- Planning Group - conference on midwifery models of care
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/CCCC_v5_10.pdf
If you want a copy of the CCC Digest mailed to you each month, please contact nmurphy@scf.cc
Domestic Violence - Denise Grenier, Tucson / Rachel Locker, Warm Springs
Adolescent primary prevention programs for domestic violence which are school based
I have put together some slides that while not the clearest will have you looking at the html versions. I adapted this chart into a ppt slide “Breastfeeding, TV viewing and smoking in household by race and ethnicity” And many more files. recent years, a number of evaluations of primary prevention programs targeting partner violence have been published. This article presents a systematic review of recent interventions for primary prevention of partner violence. A total of 11 programs met inclusion criteria for the review. All 11 studies used some combination of feminist theory and social learning theory as a basis for the intervention.
- All targeted middle- or high-school aged students, and all but one were set in a school setting and were universal interventions (i.e., were not targeted to an at risk group).
- Interventions tended to be brief, with only two using interventions totaling more than 5 h in duration.
Although a majority of studies were randomized trials, study quality was generally poor due to relatively short follow-up periods, high attrition rates, and poor measurement. Of the four studies that measured behavior, two found a positive intervention impact. Those two studies had the most comprehensive interventions, using both individual-level curricula and other community-based interventions. Both also employed rigorous designs.
Conclusions about the overall efficacy of dating violence interventions are premature, but such programs are promising. We discuss recommendations regarding the content and evaluation of dating violence prevention programs. Judith.Thierry@ihs.gov
Elder Care News
Postdischarge care management that integrates medical and social
care can improve outcomes of the low-income elderly
http://www.ahrq.gov/research/nov07/1107RA10.htm
Principles of Effective Pain Management at the End of Life
http://www.medscape.com/viewarticle/545562
Family Planning
A novel acid buffering gel is safe and acceptable and has contraceptive efficacy
CONCLUSION: An acid buffering gel used with a diaphragm is a safe, acceptable contraceptive with efficacy comparable to that of a common commercial spermicide with diaphragm. LEVEL OF EVIDENCE: I.
Barnhart KT et al Contraceptive efficacy of a novel spermicidal microbicide used with a diaphragm: a randomized controlled trial. Obstet Gynecol. 2007 Sep;110(3):577-86.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17766603
Featured Website - David Gahn, IHS MCH Portal Web Site Content Coordinator
Lack of VZIG and new prenatal assessment of varicella immunity addressed: New module
New Perinatology Corner Module: Varicella (Chickenpox) in Pregnancy
-Unfortunately, the manufacturer has discontinued production, so the availability of VZIG is rapidly declining, since the only manufacturer of this product has ceased production.
What should you do about the lack of available VZIG?
-The CDC has recommended the use of “VariZIG”, a purified lyophilized
human immune globulin preparation prepared from plasma with high levels of anti-varicella
antibodies. It is only available however under an “investigational new
drug application expanded access protocol” from the sole U.S. distributor.
And informed consent must be obtained prior to use. Turn around time for your
laboratory is obviously critical to stay within the 4-day window.
How readily available is VariZIG at your service unit?
Where will you obtain it ad how quickly can it arrive?
-Prenatal assessment of women for evidence of varicella immunity is recommended. Birth before 1980 is not considered evidence of immunity for pregnant women because of potential severe consequences of varicella infection during pregnancy, including infection of the fetus.
How should that be implemented?
Go to this link. Get the free CME or just use the many resources
http://www.ihs.gov/MedicalPrograms/MCH/M/PNC/VC01.cfm
and
It was low hanging fruit before: Now it is even easier - Perinatology Corner
The Perinatology Corner, a great Indian Health resource on many obstetric topics, plus free CME, has just gotten easier to use. Once you create an IHS login username and password (which takes about 30 seconds) the system will remember you and make it easier each time you want to take another module.
Submitting a Posttest
To take a posttest, log in with an IHS login now
The link to log in is in the leftside menu of each module's posttest page. (You will only need to log in once to any page that provides the link in the IHS site.) Once you fill in the registration information on the posttest page of one module, the demographics will self populate all future modules, thereby saving you time and effort.
You can take and retake any posttest. Any time you take a posttest, an email will sent to you with answers. You only get credit for the first time you take a module's posttest.
You can change your contact information (except their email address, through this system) in the form of any module's posttest once you've submitted your contact information in the first posttest you take.
You can update your contact information on the form when you're submitting a new posttest, when retaking a test with or without retaking the posttest.
Here is how to complete the Posttest and Evaluation
It is easy. Ptease log in and the Posttest page will become available
-If you have logged into the to the Indian Health registration before, then go directly to Login (choose the "Login" link):
Hit Login or Register
-If haven't completed the Registration process before, it is easy, secure,
and relatively quick.
-It will also allow you to take future modules without having to repeat your
contact information each time.
Choose the "Register" link:
Once you have successfully logged into your web account, then hit the Return
button on the
Successful Login page and it will take you to the Posttest and Evaluation
Perinatology Corner
http://www.ihs.gov/MedicalPrograms/MCH/M/perCrnr.cfm
Frequently asked questions
Q. Where can I get copies of the lecture notes from the 2007 Women’s Health and MCH
Conference that was held in Albuquerque on August 15-17 th ?
A. The lecture notes are posted on the MCH Meeting Notes web site, as are the professional group reports. Go here http://www.ihs.gov/MedicalPrograms/MCH/F/lecNotes.cfm
Indian Child Health Notes - Steve Holve, Pediatrics Chief Clinical Consultant
December 2007
- No more cough syrup says the FDA
- No more cavities says Dr. Esposito
- Not enough Hib vaccine says Dr. Singleton
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ICHN1207b.doc
Information Technology
Patient-Physician Email Communication May Be Effective
CONCLUSIONS: Patient-physician e-mail is a service that patients will use given the opportunity. The e-mail service enables physicians to answer medical questions with less time spent compared with telephone messaging. In our experience in an academic pediatric subspecialty practice, patients reported enhanced communication and access with the e-mail service.
Rosen P, Kwoh CK. Patient-physician e-mail: an opportunity to transform pediatric health care delivery. Pediatrics. 2007 Oct;120(4):701-6.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17908755
Frequently Asked Questions: Clinical Performance Measurement, GPRA and CRS
-How does GPRA performance affect IHS and Tribal Programs
-What is clinical performance measurement?
-How does the Government Performance and Results Act (GPRA) relate to clinical performance measurement
-These and many other questions are answered and are available
Contact: Francis.frazier@ihs.gov or Stephanie.klepacki@ihs.gov
Is more information available? Yes, CRS has its own web site and contains a variety of information, such as the CRS User Manual, Fact Sheet, and past training presentations.
The web site is: www.ihs.gov/cio/crs
Medicine Dish - Broadcast Schedule
Rodger Goodacre, Tribal Affairs Group/ CMS
Please note that the Medicine Dish broadcasts are routinely scheduled for the second Wednesday of every month at 1:30 Eastern.
Broadcast Schedule
Note: Broadcast topics are subject to change. Please review the individual Program Announcement prior to each broadcast for the most recent program information
|
Date |
Topic |
Presenters |
|
October 10, 2007 |
Maximizing reimbursement for Medicare Part D |
|
|
November 14, 2007 |
Medicare 101 for Tribes |
|
|
December 12, 2007 |
Medicaid 101 for Tribes |
|
|
January 9, 2008 |
Survey and Certification 101 for Tribes |
|
|
February 13, 2008 |
Coding and Billing for M/M, including the All Inclusive Rate |
|
|
March 12, 2008 |
How to access CMS tribal health care resources |
|
|
April 9, 2008 |
Medicare Part B: requirements, processes for enrollment & participation |
|
|
May 14, 2008 |
Cost reports for I/T/U: how to do them, what is in them, how they are used |
|
|
June 11, 2008 |
Electronic medical records |
|
|
July 9, 2008 |
CMS website: a tour and how to use it |
|
|
August 13, 2008 |
Federally-Qualified Health Centers (FQHC) billing basics |
|
|
September 10, 2008 |
Information about the treatment of specific diseases |
|
If you have any questions, please contact Rodger Goodacre, Tribal Affairs Group/ CMS at Rodger.goodacre@cms.hhs.gov
International Health Update - Claire Wendland, Madison, WI
I wanted to draw some attention to the Special Global Issue of Obstetrics and Gynecology, 11/07
Ghana postgraduate training program: 37 or 38 OB/GYNs remained in the country
The Safe Motherhood Initiative has highlighted the need for improved health services with skilled attendants at delivery and the provision of emergency obstetric care. "Brain drain" has hampered this process and has been particularly prevalent in Ghana. Between 1993 and 2000, 68% of Ghanaian trained medical school graduates left the country. In 1989, postgraduate training in obstetrics and gynecology was established in Ghana, and as of November 2006, 37 of the 38 specialists who have completed the program have stayed in the country, most working in the public sector providing health care and serving as faculty. Interviews with graduates in 2002 found that the first and single-most important factor related to retention was the actual presence of a training program leading to specialty qualification in obstetrics and gynecology by the West African College of Surgeons. Economic and social factors also played major roles in a graduates' decision to stay in Ghana to practice. This model deserves replication in other countries that have a commitment to sustainable development, human resource and health services capacity building, and maternal mortality reduction. A network of University partnerships between departments of obstetrics and gynecology in developed and developing countries throughout the world sharing internet resources, clinical information, training curriculum and assessment techniques could be created. Grand rounds could be shared through teleconferencing, and faculty exchanges would build capacity for all faculty and enrich both institutions. Through new partnerships, creating opportunity for medical school graduates to become obstetrician-gynecologists may reduce brain drain and maternal mortality.
Anderson FW, et al Who Will be There When Women Deliver?: Assuring Retention of Obstetric Providers. Obstet Gynecol. 2007 Nov;110(5):1012-1016.
Traditional birth attendant training for improving health behavior and pregnancy outcomes
AUTHORS' CONCLUSIONS: The potential of TBA training to reduce peri-neonatal mortality is promising when combined with improved health services. However, the number of studies meeting the inclusion criteria is insufficient to provide the evidence base needed to establish training effectiveness. - COCHRANE UPDATE
Traditional birth attendant training for improving health behaviours and pregnancy outcomes. Obstet Gynecol. 2007 Nov;110(5):1017-8.
Vaginal and neonatal chlorhexidine wipes applied in home settings are well tolerated
CONCLUSION: Use of 0.6% chlorhexidine vaginal and neonatal wipes for the prevention of neonatal infection is well-tolerated and seems safe. A trial of this intervention by traditional birth attendants in a home-delivery setting is feasible. LEVEL OF EVIDENCE: I.
Saleem S, et al Chlorhexidine Vaginal and Neonatal Wipes in Home Births in Pakistan: A Randomized Controlled Trial. Obstet Gynecol. 2007 Nov;110(5):977-985.
Everybody has a story
Women's struggles in Malawi, Africa, lead to unacceptably high levels of maternal morbidity and mortality. Everybody has a story. Every woman in Malawi has her version of the common theme of struggling to survive, raise her children, and keep them alive. This spring, I had the privilege to care for many Malawian women as they sought help at their local hospital. I was able to bear witness to the myriad challenges they face and capture pieces of their stories along the way….
Lathrop E. Everybody has a story. Obstet Gynecol. 2007 Nov;110(5):986-8.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17978108
Investment in family planning reduces global poverty and improves both maternal and child health
Family planning plays a pivotal role in population growth, poverty reduction, and human development. Evidence from the United Nations and other governmental and nongovernmental organizations supports this conclusion. Failure to sustain family planning programs, both domestically and abroad, will lead to increased population growth and poorer health worldwide, especially among the poor. However, robust family planning services have a range of benefits, including maternal and infant survival, nutrition, educational attainment, the status of girls and women at home and in society, human immunodeficiency virus (HIV) prevention, and environmental conservation efforts. Family planning is a prerequisite for achievement of the United Nations' Millennium Development Goals and for realizing the human right of reproductive choice. Despite this well-documented need, the U.S. contribution to global family planning has declined in recent years.
Allen RH. The role of family planning in poverty reduction. Obstet Gynecol.
2007 Nov;110(5):999-1002. http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db
=pubmed&list_uids=17978110&dopt=AbstractPlus
The 12-month probability of pregnancy for injectable and pill users is 0.6% and 9.5%
CONCLUSION: The overall risk of pregnancy for injectable contraceptive users was substantially lower than for oral contraceptive pill users. However, Thai participants had similarly low cumulative pregnancy probabilities for both methods. Women receiving contraceptive counseling should be informed that their experience with a given method may differ from the average or typical-use pregnancy rates often discussed during contraceptive counseling. Tailored counseling is necessary for women to make informed choices. LEVEL OF EVIDENCE: II.
Steiner
MJ, Pregnancy Risk Among Oral Contraceptive Pill, Injectable Contraceptive,
and Condom Users in Uganda, Zimbabwe, and Thailand. Obstet Gynecol. 2007 Nov;110(5):1003-1009. http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db
=pubmed&list_uids=17978111&dopt=AbstractPlus
Safe motherhood strategies should include evidence of effectiveness
After two decades of the Safe Motherhood Initiative, meaningful reductions in maternal mortality and disability during pregnancy and childbirth in developing countries have not been realized. Herein, we present an overview of the Initiative and review the reasons for this lack of impact, focusing on the issue of strategic effectiveness. An appraisal of strategies that are currently recommended reveals a lack of strong evidence to support their effectiveness. Drawing from the Initiative's history, we propose that, among essential elements to achieve safe motherhood, recommended public health strategies should be supported by good evidence of effectiveness, through (cluster) randomized trials when feasible, before their widespread implementation.
Tita AT, et al Two Decades of the Safe Motherhood Initiative: Time for Another Wooden Spoon Award? Obstet Gynecol. 2007 Nov;110(5):972-976.
A Skirt for a Life?
Julia was a beautiful, young Ugandan woman, straight and graceful as she walked along the dusty road, balancing a load of bananas on her head.
Her steps were light these days. She had recently met the man of her dreams. He was from a far off town called Hoima. He came from a different tribe than hers, but she felt she could live with that. And her mother would soon stop grumbling about it.
Froese JC. A skirt for a life? Obstet Gynecol. 2007 Nov;110(5):1010-1.
HIV infection was not associated with increased stillbirth risk in a large African cohort
CONCLUSION: In this large cohort, HIV infection was not associated with increased stillbirth risk. Further work is needed to elucidate the relationship between chorioamnionitis and stillbirth in African populations.
Chi
BH, et al Predictors of Stillbirth in Sub-Saharan Africa. Obstet Gynecol.
2007 Nov;110(5):989-997 http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db
=pubmed&list_uids=17978109&dopt=AbstractPlus
MCH Alert
Tightening the "holes" in the Swiss cheese model of patient safety in obstetrics
Most health care professionals who are involved in efforts to improve patient safety are aware of James Reason’s "Swiss cheese" model of how accidents occur. Some elements and pressures of current obstetric practice may weaken defenses and safeguards against perinatal injury. Several components of obstetric care in labor and delivery units can be used as targets for tightening the "holes" in the Swiss cheese model. These include improving communications, preparing for rare critical events through simulation training, developing protocols for administration of important medications used in labor and delivery (oxytocin, misoprostol, and magnesium sulfate), increasing the in-house presence of obstetricians, developing an effective departmental infrastructure that includes effective peer review, providing risk management education about high-risk clinical areas that have the potential to result in catastrophic injury, and staffing the unit for all contingencies during all hours, day and night. Acceptance by the obstetric medical staff is critical to the implementation of these patient safety elements.
Veltman LL. Getting to havarti: moving toward patient safety in obstetrics. Obstet Gynecol. 2007 Nov;110(5):1146-50.
Electronic resource updates state action on HPV Vaccine
HPV Vaccine Legislation 2007 presents information on the June 2006 recommendation by the national Advisory Committee on Immunization Practices (ACIP) for routine vaccination against Human Papillomavirus
(HPV) for girls ages 11-12, as well as on state activity to require, fund, or educate the public about the HPV vaccine. The electronic resource, produced by the National Conference of State Legislatures (NCSL), addresses key issues such as school vaccine requirements and financing. A table provides a state-by-state summary of 2007 legislation introduced to date. Related resources from NCSL, the Centers for Disease Control and Prevention, the Journal of the American Medical Association, and the Kaiser Family Foundation are included. http://www.ncsl.org/programs/health/HPVvaccine.htm
Improving the health of women and children benefits an employer’s bottom line
Investing in Maternal and Child Health: An Employer's Toolkit provides information
and resources employers can use to improve the health of employees and their
families. The toolkit, published by the National Business Group on Health with
support from the Maternal and Child Health Bureau, outlines the unique opportunity
that employers' have to improve the health of women and children through health
benefit design, beneficiary education and engagement, and health promotion programs.
The toolkit is divided into seven sections. Topics include recommendations on
evidence-informed, comprehensive health benefits to support child, adolescent,
and pregnancy health; cost-impact assessments of recommended benefit changes;
data on the cost of maternal and child health (MCH) care services; the business
case for investing in child and adolescent health, healthy pregnancies, and primary
care services for all beneficiaries; tools employers can use to develop an MCH
strategy, communicate the value of their MCH benefits, and link MCH outcomes
to organizational performance; strategies employers can use to effectively communicate
with beneficiaries and to tailor existing health programs and policies to the
unique needs of children, adolescents, and pregnant women; and health education
information specifically developed for beneficiaries. http://www.businessgrouphealth.org/healthtopics/maternalchild
/investing/docs/mch_toolkit.pdf
Lower socioeconomic status and poor perinatal outcomes: Even with universal access
INTERPRETATION: Lower family income is associated with increased rates of gestational diabetes, small-for-gestational-age live birth and postneonatal death despite health care services being widely available at no out-of-pocket expense
Joseph KS et al Socioeconomic status and perinatal outcomes in a setting with universal access to essential health care services. CMAJ. 2007 Sep 11;177(6):583-90.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17846440
MCH Headlines - Judy Thierry HQE
Frequently Asked Questions about Infant Feeding Choice
BACKGROUND INFORMATION
Why collect this data? Because it is used in the clinical performance measure called Breastfeeding Rates that is reported in the RPMS Clinical Reporting System (CRS). While this measure is currently not a GPRA measure (one reported to Congress and OMB) it is used in support of the GPRA measure Childhood Weight Control with the goal of lowering the incidence of childhood obesity in the IHS patient population. Additionally, facilities can use this data to track infant feeding patterns and breastfeeding rates within their own patient population.
Research indicates that children who were breastfed have lower incidences of overweight or obesity. For additional information, please click the link below to review the article in the March 2007 IHS Primary Care Provider.
http://www.ihs.gov/PublicInfo/Publications/HealthProvider/issues/PROV0307.pdf
How is this data used? It is used in the CRS Breastfeeding Rates topic in several measures that report:
- How many patients approximately 2 months through 1 year of age were ever screened for infant feeding choice.
- How many patients were screened at the approximate ages of 2 months, 6 months, 9 months, and 1 year.
- How many patients who were screened were either exclusively or mostly breastfed at those age ranges.
Users may run the CRS Selected Measures (Local) Reports to view all of the breastfeeding performance measures. The report also provides the option to include a list of patients and identifies the dates and ages they were screened and their infant feeding choice values. Click the link below to learn how to run this report in CRS, starting on page 206 (as numbered in the document itself, not in Adobe).
http://www.ihs.gov/misc/links_gateway/download.cfm?doc
_id=10716&app_dir_id=4&doc_file=bgp_070u.pdf
Is Infant Feeding Choice data the same as the data included in the Birth Measurements section of the EHR and with the PIF (Infant Feeding Patient Data) mnemonic in PCC? No, it is different. The information collected in these sections are intended for one-time collection of birth weight, birth order, age when formula was started, breastfeeding was stopped and solid foods started, and linking to mother/guardian. Shown below is a screen shot of this section from EHR. While this information is important, none of it is used in the logic for the CRS Breastfeeding Rates measure; only the Infant Feeding Choice data is used.
What are the definitions for the Infant Feeding Choices? The definitions are shown below and are the same definitions used in both EHR and PCC.
- Exclusive Breastfeeding: Formula supplementing less than 3 times per week (<3x per week)
- Mostly Breastfeeding: Formula supplementing 3 or more times per week (>3x per week) but otherwise mostly breastfeeding
- ½ Breastfeeding, ½ Formula Feeding: Half the time breastfeeding, half the time formula feeding
- Mostly Formula: The baby is mostly formula fed, but breastfeeds at least once a week
- Formula Only: Baby receives only formula
Who should be collecting this information and how often? It depends on how your facility is set up but any provider can collect this information. At a minimum, all providers in Well Child and Pediatric clinics should be collecting this information for patients 45-394 days old at all visits occurring during that age range. Public Health Nurses should also be collecting this information. This data can be entered in EHR or PCC/PCC+, as described below.
ENTERING INFANT FEEDING CHOICE DATA IN EHR
In which version of EHR is Infant Feeding Choice data able to be entered? EHR Version 1.1, which was deployed nationally on October 3, 2007.
How do I enter Infant Feeding Choice in EHR?
- After you have selected the patient and the visit, go to the Personal Health section. For some EHR sites, this may be included on the Wellness tab.
- From the Personal Health dropdown list, select Infant Feeding, then click the Add button.
NOTE: The age of the patient must be five years or less to be able to select Infant Feeding; otherwise, Infant Feeding will not be listed in the dropdown list.
- At the Add Infant Feeding Record window, click the appropriate checkbox to select the type of infant feeding, and then click the OK button to save the value.
- The patient’s value for Infant Feeding Choice for this visit is now displayed in the Personal Health section, as shown below.
ENTERING INFANT FEEDING CHOICE DATA IN PCC/PCC+
Which data entry patch do I need? You will need to have data entry patch 8 (apcd0200.08k) installed, which was released on October 19, 2005.
How do I enter Infant Feeding Choice in PCC?
- Create a new visit or select an existing visit to append.
- At the Mnemonic prompt, type “IF” (Infant Feeding Choices) and press Enter.
- Type the number corresponding to the type of feeding and press Enter. If you do not know the number, type “??” and press Enter to see a list of choices.
- You are returned to the Mnemonic prompt. Continue with data entry of other items.
Stephanie Klepacki
CRS Project Manager/Lead Analyst
November 2, 2007
MCH Coordinator Editorial comment:
The infant feeding choice functionality is supported in the newly released EHR 1.1
The clinical performance measure called Breastfeeding Rates reported in the RPMS Clinical Reporting System (CRS) is a measure of interest. We wish to emphasize that while this measure is currently not a GPRA measure (one reported to Congress and OMB) it is used in support of the GPRA measure Childhood Weight Control with the goal of lowering the incidence of childhood obesity in the IHS patient population. Additionally, facilities can use this data to track infant feeding patterns and breastfeeding rates within their own patient population in the first year of life.
To capture this data Stephanie Klepacki, the CRS Project Manager/ Lead Analyst has developed: Frequently Asked Questions: Infant Feeding Choice in EHR. A team of analysts and clinicians have been involved in developing and testing this functionality. Kudos go to Phoenix Indian Medical Center’s Department of Pediatrics, to Sherry Allison, Information Processing Supervisor and her staff for getting the data entered pre EHR, and the ever diligent and nurturing Suzan Murphy, RD, IBLCE who have done the lion’s share of the clinical testing.
From an MCH standpoint expanding this functionality into toddler and early childhood feeding choices seems a natural next step as later versions are developed.
We look forward to your feedback, comments and use of this functionality in the universal documentation of feeding choice during the first year of life for our American Indian and Alaska Native families.
Lastly, new to the Indian Health Breastfeeding page* is the Lactation Support in the Workplace Toolkit. This document includes information on: how to get started, drafting local policy, evaluation tools, resources available on the Indian Health Breastfeeding page, as well as FAQs.
Lactation Support Policy in the Workplace
*Indian Health Breastfeeding page
http://www.ihs.gov/MedicalPrograms/MCH/M/bf.cfm
First Nations and Inuit Health Health Canada HHS and Indian Health Service MOU
A signing ceremony between HHS Secretary Mike Leavitt and the Canadian Minister of Health, Tony Clement, is scheduled for November 1, 2007 in the HHS Humphrey Building Great Hall. The signing of a Memorandum of Understanding (MOU) is to improve the health status of indigenous communities in the U.S. and Canada. Mr. Robert McSwain, Acting Director of the Indian Health Service (IHS), will deliver a speech at the ceremony. The MOU will foster enhanced international collaborations, identification and reinforcement of best practices, and innovative approaches to learning opportunities. The MOU, which continues the work of a similar five-year MOU signed in 2002 and completed this year, will focus on improving health care delivery and access to health services for American Indians and Alaska Natives of the U.S. and the First Nation and Inuit people of Canada.- Verna N. Miller, Office of the Director, Public Affairs, Indian Health Service , (301) 443-3593
A focused collaboration on midwifery training, practice, traditions and community awareness and outreach is being planned for year I.
IHS Behavioral Health with First Nations and Inuit Health Branch (FNIHB) collaborated on a FASD work group under the 2002 MOU. Contact Judith.Thierry@ihs.gov
New Guidelines on Fish Consumption for Females of Childbearing Age,
Young Children
Alaska State health officials released new guidelines on the amount of local
fish women and girls of childbearing age, and young children should consume,
the Anchorage
Daily News reports. According to the recommendations, these groups can eat
salmon from local waters in unlimited amounts without risking overexposure to
mercury but should limit consumption of large halibut, shark, large lingcod,
yelloweye rockfish and spiny dogfish because of mercury levels found in the fish.
The state previously said that females of childbearing age and young children could eat an unlimited amount of local fish but changed its guidelines because of mercury levels reported this year in certain fish that never had been tested and in larger specimens of previously tested fish, according to the Daily News. The state's fish tissue testing program, which began in 2001, shows that most of Alaska's five species of salmon and pollock contain safe levels of mercury, based on the state's health standards. According to the Daily News, the state has tested the hair of 359 pregnant women for mercury since 2002 and has extended the studies to all females ages 15 to 45. The tests found that hair mercury levels in all of the women were well below 14 parts per million, which the World Health Organization says can cause harm to the health of a fetus.
Differing Guidelines
Alaska's guidelines on fish consumption differ from FDA and Environmental
Protection Agency guidelines, the Daily News reports (Bluemink, Anchorage
Daily News, 10/17). FDA and EPA in 2005 issued warnings that advise young children,
pregnant women, nursing women and women of childbearing age to avoid consuming
swordfish, king mackerel, shark and tilefish because of high mercury levels.
The warnings also recommend that those groups eat no more than 12 ounces of fish
weekly and no more than six ounces of canned albacore tuna weekly (Kaiser
Daily Women's Health Policy Report, 10/11). Alaska officials said that fish
from local waters are less contaminated than fish from other areas and may be
consumed in greater amounts. According to the Daily News, the state on Monday
also unveiled a "fish diet calculator" Attached to help families
gauge how much of the riskier fish they may consume weekly without health risk. http://www.epi.hss.state.ak.us/eh/fish/FishDietCalculator.pdf
26th Annual “Protecting Our Children”
- April 20-23, 2008
- Minneapolis , MN
- National American Indian Conference on Child Abuse and Neglect
- http://www.nicwa.org/
Early child health caries reduction tool kit
Into the Mouths of Babe’s Oral Health Tool Kit
(Scroll to bottom)
http://www.communityhealth.dhhs.state.nc.us/dental/
Child-Oriented Clinical Practice in Process
-Call new mothers at home 1-2 days after they leave the hospital. (designate person(s), have simple script or prompts, make a chart note)
-Check immunizations at every patient visit
http://www.cdc.gov/vaccines/recs/schedules/child-schedule.htm#printable
- Plot accurate heights & weights on an appropriate growth chart http://www.cdc.gov/nchs/about/major/nhanes/growthcharts/clinical_charts.htm
Solicit feedback and acknowledge a parent’s effort at all visits.
Are patient encounter environment(s) infant, child and teen appropriate? (mobiles, toys, games, books, posters, Audio/visuals, passive referral information and health literacy for 0 – 20 year olds, oriented staff)
-Address age appropriate prevention measures at each visit. http://www.aap.org/bst/showprod.cfm?DID=15&CATID=132&ObjectGroup_ID=812
-Address a child or teen directly, appropriately and as soon as possible during the encounter.
-All parental phone calls are returned no matter how trivial. Obtain a pediatric telephone advise reference such as : http://worldcat.org/wcpa/oclc/36470676
-Ask about parent forms at the start of the visit and complete the forms before the patient leaves. (saves time, reduces lost forms, saves mailing, customer service, what you would want to have happen in a visit)
-Discuss confidentiality with the patient and parent at the 11 or 12 year old visit; then consider seeing the patient alone for at least part of every health visit thereafter.
MCH's favorite website for referencing all things related to child maltreatment
I have sent this out previously and want to call your attention once again to this child maltreatment tool kit / web site. IHS HQ will be updating its child neglect / CMT / child sexual abuse policy. If you are interested in participating please contact me. Thanks Judy
Ann S. Botash, MD at Upstate New York and colleagues have developed a comprehensive web site, cross referenced, appended, and up to date---consider this your go-to reference for all things related to child maltreatment and child sexual abuse.
http://www.childabusemd.com/index.shtml
The CPT code tells the insurer "what" was done (i.e. type of visit), and the ICD-9 tells "why" or the diagnosis. In most office settings, the patient who presents with a child abuse issue or diagnosis is an "established patient." However, occasionally the suspected abuse patient may present as a "new patient" or even as a referral for consultation. Depending on whether the patient is new, established, or a consultation, separate CPT codes are used. In addition, when determining the level of evaluation and management (E&M level for CPT codes), the key components include the history, examination, and medical decision. However, if counseling and coordination of care drive 50% or more of the encounter, time determines the code for the visit.
The CPT codes for new patients (99201-99205) and for established patients (99211-99215) are usually at a level 4 or 5 for child abuse encounters. Document each level in order to support the code. Using a template that triggers coding for detailed or comprehensive histories and physicals may assist in the documentation process.
Prolonged Visit
Preventive medicine codes are those commonly used to bill for the annual well-patient
visit. Because child abuse encounters often require additional time, use modifiers
with appropriate supporting documentation. To capture billing on prolonged visits,
add a two digit modifier to the five digit CPT code. For example, add -21(visit
takes longer than the usual for well child care) or -25 (dealing with a medical
problem or child abuse issue at the same time as the well child exam).
Counseling
The series 99401-99405 is used for individual counseling. Each incremental increase
in code equals 15 minutes of time. Parent-only counseling can be coded as counseling
time. Only mental health clinicians can use the psychiatric CPT codes.
Chart Review
If the medical provider is reviewing a chart for Child Protective Service, these
can be billed as 99358 (60 minutes) and 99359 (each additional 30 minutes). This
is used for prolonged physician service without direct face-to-face patient contact.
Conference or Meeting
A team conference or meeting with Child Protective Services, police, rape crisis
counselors, etc. can be coded as 99361 for 30 minutes and 99362 for 60 minutes.
For these conferences, document time spent, people present, content of discussion,
and plans for the patient.
Continuing Oversight
When there needs to be continuing oversight to ensure that the patient follows
through and is protected, the bill should reflect 99374 (less than 30 minutes
per month) or 99375 (more than 30 minutes per month).
Telephone Calls
Telephone calls are generally not reimbursed, but can be billed as 99371-99373.
If the calls are over 60 minutes, use the 99359 prolonged physician service code.
Table of Contents includes:
Triage
history
physical exam
laboratory
radiology
diagnosis
treatment & follow-up
documentation – sub section: billing excerpt see below!!!
reporting
foster care
children and adolescents with disabilities
juvenile sexualized behavior
MDT’s (multi-disciplinary teams)
legal issues
Under the documentation section you will find sub-headings including: “In order to correctly code and bill pediatric child abuse cases, you need to understand the Current Procedural Terminology (CPT) published by the American Medical Association and the International Classification of Disease, Clinical Modification, 9th Edition (ICD-9 CM) published by the World Health Organization.” http://www.childabusemd.com/documentation/coding-billing.shtml#cpt
The 2006 National PedNSS report data tables are now online! WIC data
Of the 33,489 > 2 year olds – AIAN - 20% were in the 85th to <95th% for weight and 19.4 % were in the > 95th% for weight
The CDC web site has a robust 2006 data set on WIC pediatric and prenatal indicators PEDNSS and PNS.
- Weight
- Breastfeeding
- Anemia
- Health risk behaviors – TV and smoking
http://www.cdc.gov/pednss/pednss_tables/index.htm
Half of U.S. Kids Skip Annual Dental Exam
Dentists recommend a checkup every six months. But many kids, particularly poor ones, aren't seeing the dentist even once a year. A study has found that about half of children ages 2 to 17 do not get annual dental checkups.
The study was called the Medical Expenditure Panel Survey. It showed that 38% of low-income children (ages 2 to 17) had a dental checkup in 2003. Among higher-income children, 60% had a checkup that year. The study included 8,983 U.S. children. Among middle- and high-income children, those with other health problems were less likely to visit the dentist. Researchers found that other health care professionals, such as doctors and nurses, are just as likely to recommend a dental visit to lower-income families as to higher-income families. But fewer poor children actually make it to the dentist.
Like the more recent research, the NSCH study found that poor children and younger children were less likely to visit the dentist. It also found that children who did not have a regular doctor were less likely to visit a dentist. That study was published in the March 2007 issue of the journal Pediatrics.
The current study appears in the October issue of the Journal of the American Dental Association. Access article online at:
An educational must! Tribal School Zone Safety video & toolkit
Tribal School Zone Safety: Videos & Toolkit – “look left, right, left”…”walk with a partner”…”face the traffic”…”eyes ears and then feet”…”make eye contact with the driver before moving”…”youth as role models for younger peers” – “watch the younger kids”…”buckle up!”...”flashlights, reflective materials and glow sticks at dusk and night”…”Be seen”…”be aware”…”know your way”…”look and listen”
Many tribes contributed to this production: Eastern Band of Cherokee, Osage Pawhuska Elementary, Indian Camp School Lummi Nation, Lummi School
“Native Americans have the highest rates of pedestrian injury and death of any other group in the United States. In fact, adult pedestrian death rates for Native Americans are almost 3.5 times that of the general population. For Native American children, the pedestrian death rate is almost four times that of the overall population of the United States.”
“The need to educate younger road users (including drivers, riders, and pedestrians) never ends. To address this need, this DVD contains the following elements (you can preview the videos):”
Kelsey Falling Leaf engages kids in this 7.5 minute video on young pedestrian awareness as
they negotiate the world of adult drivers, backing out vehicles, distractions, weather, dusk and nighttime in tribal land settings. Realistic attention getting, filled with messages for and by kids this should run well in any outpatient clinic, pediatric waiting room and in school classrooms or PTSA. Safety Doesn´t Happen by Accident (Windows Media) – Video designed for school-aged children.*
Tribal Leaders direct attention to role of tribal leadership and child safety; use of the built environment to protect and reduce injuries; attention to traffic patterns; the importance of parental responsibilities in this mix; as well as the roles of teachers in modeling safe choices; while reinforcing attention to safe practices as stressed in the first video. Pedestrian Safety: A New Tradition (Windows Media)
– Video for parents, guardians, transportation coordinators, and tribal leaders.*
“Tribal School Zones Safety Video Toolkit” – (PDF document) Complement to the above videos
as it provides additional educational materials, promotional tips, and resource information.
“Tribal School Zones Safety Literature Review” – (PDF document) Comprehensive review that
shows facts and statistics and was used, in part, as the basis for development of the above
materials.
Video clips and photos for making your own pedestrian safety materials.
DVD Videos are Closed Captioned.
To obtain the free DVD, please contact:
- Chimai Ngo 202.366.1231 or Monica Gourdine 202.366.1872
Medical Mystery Tour
What is the presenting part?
A 20 year old gravida 4 para 1,0,2,1 presented at 40 2/7 weeks in active labor. The patient had had a 39 pound weight gain throughout her otherwise unremarkable prenatal care. The patient’s obstetric history was significant for one previous vaginal delivery of a term 9 pound 15 ounce infant. Laboratory testing was essentially unremarkable. On admission the patient’s exam was cephalic presentation, 4 cm dilation, -1 station. The cervix was soft and in a mid position. External fetal monitoring was reassuring. Sixty second contractions were noted every 5 minutes.
At 01:30 the CNM noted that patient had progressed nicely in labor to 7 cm dilated and 100% effaced. The presenting part was still at -1 station. The membranes were intact. The CNM was unable to completely identifiy the presenting part. The FHR tracing was reassuring. The CNM noted that a suture line and fontanelle were palpable, but other tissue may have been present. The MD on call was asked to perform a bedside ultrasound to confirm the presenting part.
The bedside ultrasound confirmed a cephalic presentation which was slightly oblique. The physician proceeded to perform a digital exam.
What did the physician find on digital exam?
Stay tuned till next issue to learn the rest of the story
Trivia fact from Abstract of the Month
What is another classic line from the Pirates of the Caribbean: The Curse of the Black Pearl,, beside the Rule of Parlay line?
Commodore Norrington (Jack Davenport), an officer in the Royal Navy who is in love with Elizabeth Swann (Keira Knightley), also has a deep-seated dislike for pirates.
He mentions to Captian Jack Sparrow (Johnny Depp) that Sparrow is "the worst pirate I have ever heard of".
As Jack Sparrow runs fingers his less than hygeinic beard he retorts, “Ahh, but you have heard of me”
*If this is not amusing as presented here, then I suggest you consult Pirates of the Caribbean: The Curse of the Black Pearl, directly. (Needless to say, I have no financial conflict of interest.)
Pirates of the Caribbean: The Curse of the Black Pearl
http://en.wikipedia.org/wiki/Pirates_of_the_Caribbean:_The_Curse_of_the_Black_PearlMedscape*
Recognizing and Treating Excessive Sleepiness in Primary Care: Circadian Rhythm Sleep Disorders
What happens when the "circadian pacemaker" skips a few beats?
Can you reset the rhythm? Plus: narcolepsy, PMS, migraine, and sleep.
http://www.medscape.com/viewprogram/7994?src=mp
Small Steps and Practical Approaches to the Treatment of Obesity
http://www.medscape.com/viewarticle/565822
Challenges of Treating Tobacco Users in High-Risk Populations
http://www.medscape.com/viewarticle/565309
Newly Diagnosed Breast Cancer: Moving Toward Individualized Treatment
Planning
http://www.medscape.com/viewprogram/8054?src=nlcmealert
Ageing in Marfan Syndrome
http://www.medscape.com/viewarticle/564064
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
Lowest effective transdermal 17beta-estradiol dose for relief of hot flushes: RCT
CONCLUSION: Micro-dose E2 (0.014 mg/d) was clinically and statistically significantly more effective than placebo in reducing the number of moderate and severe hot flushes, with a 41% responder rate, supporting the concept of the lowest effective dose.
Bachmann GA, et al Lowest effective transdermal 17beta-estradiol dose for relief of hot flushes in postmenopausal women: a randomized controlled trial.
Obstet Gynecol. 2007 Oct;110(4):771-9.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17906008
Low-Fat Diet May Reduce Incidence of Ovarian Cancer in Postmenopausal Women
CONCLUSIONS: A low-fat dietary pattern may reduce the incidence of ovarian cancer among postmenopausal women
Prentice RL et al Low-fat dietary pattern and cancer incidence in the Women's Health Initiative Dietary Modification Randomized Controlled Trial.
J Natl Cancer Inst. 2007 Oct 17;99(20):1534-43.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17925539
Hormones and heart disease in women: the timing hypothesis
Largely on the basis of results from meta-analyses of observational studies, postmenopausal estrogen was widely prescribed to prevent coronary heart disease. However, epidemiologic studies, no matter how consistent and coherent, are not sufficient to recommend mass preventive therapy to healthy women. In fact, all three large clinical trials failed to confirm estrogen's expected cardiac protection. The most persistent explanatory hypothesis for the "trial failure" was the age of the participants, based on the thesis that estrogen in recently menopausal women could prevent the development of coronary artery plaque but, given to older women with vulnerable plaque, would have a null or even harmful effect. The timing hypothesis is plausible, but the prespecified subgroup analyses in both Women's Health Initiative trials showed no significant interaction with age or years since menopause. The best opportunity to test the timing hypothesis was lost when 1,000 Women's Health Initiative women younger than 60 years had coronary artery calcium scans to evaluate the effect of estrogen on plaque burden, but no women 60 years or over were similarly examined. Therefore, this ancillary study can examine the effect of estrogen treatment on coronary calcium in women younger than 60 years but will not be able to determine if the effect is different in older women. In the meantime, publicized statements in multiple venues have promoted the timing hypothesis as fact, confusing patients and physicians who do not realize that the hypothesis is stronger than the evidence.
Barrett-Connor E. Hormones and heart disease in women: the timing hypothesis.
Am J Epidemiol. 2007 Sep 1;166(5):506-10.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17849510
Midwives Corner
Vaginal birth after cesarean (VBAC) in rural hospitals
Counterpoint: David Gahn, M.D.
At Hastings Indian Medical Center, the Ob/Gyn Department decided to stop offering VBAC's routinely. None of the physicians or midwives is “anti-TOLAC/VBAC” but we considered several factors:
1) Our anesthesia department refuses to participate in a management plan to facilitate VBAC despite any data we may present. If we request them to be in house during a VBAC, they will refuse. Then I have to document in the chart that I requested anesthesia and they would not come in. That is a terrible way to do business. Our anesthesia department does provide excellent care to our laboring patients and are pros at emergent cesarean deliveries. They are skilled professionals, but the department is not staffed well enough to provide a CRNA or anesthesiologist dedicated solely to L&D.
2) Even though our Med Staff Rules and Regulations require on call personnel to able to present themselves within 20 minutes, this is not reliable. Also, we have only one OR crew and only one anesthesia person available in the evening. We have a protocol for an emergency c/s when the OR crew is already operating, but nothing is workable to do a cesarean hysterectomy with no anesthesia or OR crew. If you have ever done an emergent c/s under local with a CNM and an L&D nurse, you will appreciate this.
3) We also considered the local standard of practice. The one insurance company that covers physicians in the entire state of Oklahoma will not cover a physician who performs TOLAC/VBAC's. Therefore, there are no physicians other than federally employed physicians and Oklahoma University in Oklahoma City 3 hours away (they are self-insured) who will allow TOLAC. While this doesn't apply to the Federal Tort Claims Act, it does apply to the physician tort database, our licensing authorities, the physician's reputation, and the hospitals reputation. (Tort claims are printed in our local newspaper.)
4) In order for us to offer TOLAC, all 6 of our Ob/Gyn's need to be on board with the plan and they are not, mainly because anesthesia is not in house. There is data that supports VBAC without anesthesia present in the hospital, but you don't know our anesthesia department or how busy we are in the evenings.
5) Unfortunately, the national data on c/s rates is usually 2-3 years behind, and our hospital has matched those rates. We deliver about 975 babies per year, and our c/s rate to date for CY 2007 is 37%. Should we be ashamed of the number or proud of the good outcomes? The balance between risks and benefits in this regard in tenuous.
6) I propose that every time a healthy mom walks out of the hospital with a healthy baby, we have succeeded in our mission. Is our cesarean delivery rate too high? Until I see the definition of "too high", I'll argue with you. I disagree with the argument that our rate is what it is because we take care of higher risk patients. I don't think that is a reason. We do have a high teen pregnancy rate, diabetes, massive obesity, hypertension, etc., but we haven't studied it that closely. We would love to decrease the c/s rate, but obstetrics is a treacherous business and each physician is held responsible for the health of patients, mom and baby. We have to face reality – if a patient does not have a perfect baby, the physician will suffer a tort claim. (And I do mean suffer.)
7) We can't and don't force women to have repeat cesarean deliveries, for that would be assault. We do recommend a repeat cesarean delivery and tell patients of our policy. We occasionally have a patient that refuses a recommended c/s (breech, previous c/s, macrosomia, history of shoulder dystocia with permanent injury) and we have them sign a consent form and take care of her very well. This is all well within the standard of care.
On a similar topic, we don't offer women elective primary cesarean delivery even if the patient should decide this is her preferred method of delivery. In this case, we do refuse to allow women to give birth the way they choose.
8) When we did offer TOLAC, we had about 2 per year. We take this to mean that the others, after being counseled by a physician, opted for repeat c/s. Considering this, our c/s rate would not appreciably change if we offered VBACs.
9) Please don't condemn us for a policy that does not recommend VBAC's. Recognize that the data and ACOG support both options, and also recognize that the data has to be applied to the hospital. Because of the number of deliveries we perform, we have reliable data on post-operative infections (half the national average), TTN, transfusions, IUFD's, etc. Also know that we have excellent collaboration between our 6 physicians, 7 midwives, and 1 nurse practitioner. We don't make policies like this lightly and we examine the data carefully and applied it to our current practice.
So the bottom line is we might be more aggressive with TOLAC/VBACs if we had additional support. None of the physicians in our department are concerned with our cesarean delivery rate. One quote I heard is, "My cesarean delivery rate is 100% for everyone who needs a cesarean delivery." While this a bit crass, it is germane - the decision to perform a c/s rests solely with the physician charged with the care of the patient and the patient. I would love for our cesarean delivery rate to be 15%, but not at the expensive of a single injured child or mother. I fully support TOLAC in the right environment. That environment does not exist at Hastings Indian Medical Center. David.Gahn@ihs.gov
Do you have another learned opinion?
If so, please share it with me by December 10th and we will continue this point / counterpoint discussion in the next issue. nmurphy@scf.cc
In the meantime the first 5 articles in the Obstetrics Section, above, reveal a few of the advantages/disadvantages to vaginal after cesarean and cesarean delivery.
Navajo News - Jean Howe, Chinle
Which caused more deaths in the United States in 2005, MRSA or HIV?
A JAMA article estimating rates of invasive Methicillin Resistant Staphylococcus Aureus (MRSA) associated death rates in the United States, as well as several widely publicized deaths of children and adolescents from invasive MRSA and subsequent school closures, have brought new attention to the increasingly widespread problem of antibiotic resistance. The JAMA article, by Klevens et al., uses active population-based surveillance data from 7/04 through 12/05 from nine sites in the United States to estimate national rates of invasive MRSA in 2005. The sites, ranging in size from the state of Connecticut to Ramsey County, Minnesota, also included several metropolitan areas. One site ( Baltimore) had exceptionally high rates and this outlier data was excluded from the final analysis. The majority of the 8987 cases identified were health care associated, with 58.4% of health care associated cases having a community onset and 26.6% having a hospital onset. Another 13.7% of the cases were not linked to health care and 1.3% could not be identified as conclusively hospital or community associated. 1598 in-hospital deaths of patients with invasive MRSA were recorded. The overall rate of invasive infection was 31.8/100,000 and the mortality rate 6.3 per 100,000. The highest rates of invasive infection were noted in those over 65 years old, African Americans, and males.
Using this standardized rate of 31.8 per 100,000 for invasive MRSA, the authors estimate that the national burden invasive MRSA infection was 94,360 cases in 2005 with 18,650 associated deaths. As an accompanying editorial by Bancroft points out, if this projection is accurate, these deaths would exceed the total number of deaths attributable to HIV/AIDS in the United States in 2005. The editorial also points to several effective interventions that would decrease spread of these pathogens but are imperfectly implemented. These include thorough hand washing, careful use of antibiotics, limiting invasive devices, decolonization, and environmental cleaning. Clearly we can all do more to control the spread of this pathogen and limit the ongoing development of antibiotic resistance. A patient education sheet was also included in the same issue.
MRSA infections of the skin and soft tissue have become a widespread problem across the United States and have become quite common in many Native American communities. For example, at the Annual Navajo Area Women’s Health Provider Meeting in September, Dr. Iralu, the Infectious Disease Consultant for Navajo Area, discussed the fact that fully 50% of staph isolates in Navajo Area are methcillin-resistant, leaving only a few drugs that are effective for treatment when antibiotics are needed. Incision and drainage is the foundation of management of local infections suspicious for MRSA and cultures should be collected to guide further treatment and for ongoing surveillance. Bactrim is one of the few oral antibiotics still widely effective for MRSA skin and soft-tissue infections; and Vancomycin is often used to treat invasive disease.
For non-invasive disease, antibiotics are not always necessary and incision and drainage with local wound care is often sufficient for treatment. The proper technique for incision and drainage is reviewed in the latest installment of the “Videos in Clinical Medicine” series from the New England Journal of Medicine. This useful resource also includes such topics as “Orotracheal Intubation”, “Basic Laceration Repair”, and “Pelvic Examination” with new videos being added periodically. These videos can be accessed from the NIH library web site with the access codes available to IHS employees from the librarian, Diane Cooper. Simply follow the online journal link to the New England Journal of Medicine and look for the “Procedure Videos” link on the NEJM home page.
Oh, and don’t forget to wash your hands!
Klevens RM, Invasive methicillin-resistant Staphylococcus aureus infections in the United States, JAMA 2007 Oct 17;298 (15): 1763-1771.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17940231
Bancroft, EA, Antimicrobial Resistance, It’s not just for hospitals, JAMA 2007 Oct 17;298(15):1803-1804.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17940239
Zeller, JL, JAMA Patient Page; MRSA Infections, JAMA 2007 Oct 17;298(15)1826.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17940240
Fitch MT, Manthey DE, McGinnis HD, Nicks BA, Pariyadath M., Videos in clinical medicine. Abscess incision and drainage. N Engl J Med. 2007 Nov 8;357(19):e20.
http://content.nejm.org/cgi/content/video_preview/357/19/e20
Nurses Corner - Sandra Haldane, HQE
2008 LONG TERM TRAINING – NURSE ANESTHESIA – Apply Soon
To All IHS Nurse Commissioned Officers:
The Indian Health Service (IHS) Headquarters Division of Nursing (DNS), Rockville, Maryland, will sponsor one (1) Nurse Commissioned Officers in 30 months of Long-Term Training (LTT) in Nurse Anesthesia to begin in June 2008 at the Uniformed Services University of Health Sciences (USUHS) in Bethesda, MD. Nurse Anesthesia Students will complete Phase I, 12 months of didactic, at USUHS in Bethesda, MD, followed by Phase II, 18 months of clinical, at the Alaska Native Medical Center (ANMC) in Anchorage, AK. The intent of this process is to supply the IHS with Certified Registered Nurse Anesthetists (CRNAs). Upon completion of the LTT, these CRNAs will serve their payback obligation as a CRNA in an Operating Room (OR) at a tribal facility that has left its Tribal Shares in the Headquarter’s Nurse Initiatives, NECI Section 118, COSTEP, and Continuing Education program budgets, or as a CRNA in an OR in an IHS facility. In addition to providing anesthesia services to patients undergoing surgical procedures, CRNA obligees will act as a resource for staff development, policy formulation, and consultation in the provision of anesthesia services to their local and Area facilities as well as nationally as requested.
IMPORTANT NOTE:
- Placement of nurses into this training and after training will be in accordance with the Indian Preference Act (Title 25 U.S. Code Section 472 and 473) in which absolute preference will be given to qualified Indian candidates.
- Selection for this Long Term Training position is subject to acceptance into USUHS Graduate School of Nursing (GSN) Nurse Anesthesia Program that leads to certification eligibility
- Sponsorship of this training is subject to the availability of Fiscal Year 2008 funds.
The solicitation of applications for the training cycle begins immediately, November 5, 2007 and ceases at 5 PM Eastern Time December 15, 2007 and in accordance with the following:
- One (1) original and two (2) copies of the IHS DNS application materials must be submitted and include copies of the full USUHS application materials
- Incomplete applications will not be accepted.
- Faxed applications will not be accepted
- Late applications will not be accepted
- Only applications meeting the following minimum criteria of the IHS/DNS will be considered.
Individuals must possess all the following minimum criteria in order to apply.
1) Must be a USPHS CO and have completed two years of service as a registered nurse (RN) in any IHS, Tribal, or urban facility but have no more than 12 years of creditable service toward retirement at the time training begins (June 1, 2008).
2) Must possess and maintain a current, active, and unrestricted registered nurse license in a State, District of Columbia, the Commonwealth of Puerto Rico, or a territory of the United States.
3) Must have been recommended for promotion on last two Commissioned Officers’ Effectiveness Reports (COERs).
a. At least an overall rating of "D" on each of their last two COERs.
4) Must meet the Surgeon General/Office of Force Readiness’ requirements for Basic Ready Qualified.
5) Must meet USUHS special extended application deadline of December 15, 2007 and minimum application requirements to USUHS found at the following link:
http://cim.usuhs.mil/gsn/admissions/requirements.htm
6) Must meet the IHS DNS LTT application deadline of 5 PM Eastern, December 21, 2007.
Applicant must meet the application deadline for USUHS and in addition, must submit the following application materials by close of business on December 15, 2007. All application materials must be submitted as an entire package. Incomplete applications will not be accepted. Submit info to:
Sandra L. Haldane, BSN, RN, MS
Chief Nurse, Indian Health Service
OCPS/Division of Nursing
801 Thompson Ave., STE 300
Rockville , Maryland 20852
Admission Requirements for USUHS Masters Level Programs
http://cim.usuhs.mil/gsn/admissions/requirements.htm
Scope of Practice and the Nurse Practitioner: Regulation, Competency, Expansion, and Evolution
"I'm an NP -- can I work as an RN? As an acute care NP, can I work in primary care? I'm prepared as an adult NP -- can I see children too?" Learn the answers to these questions and many more. http://www.medscape.com/viewarticle/506277
Overweight Children and Adolescents - National Association of School Nurses
POSITION STATEMENT:
Abstract. The fastest rising public health problem in our nation is obesity,
second only to tobacco use. Over the last two decades the percentage of overweight
children has almost doubled and the percentage of overweight adolescents has
almost tripled. Currently, in the United States, 13% of children 6 to 11 years
of age and 14% of teens 12 to 19 years of age are categorized as overweight (NCHS,
CDC 2001; USDHHS, 2000).
Healthy People 2010 (USDHHS, 2000) identifies specific goals to reduce the prevalence of overweight and obesity. Since most children spend a large portion of their day at school, the school can become a key setting in which to implement strategies to address this issue. The school nurse has the capacity to reach a large number of youth from varied backgrounds. The school can provide a healthy environment that supports balanced nutrition and activity.
ACTIONS:
• assisting students in developing good decision-making skills related to nutrition and in establishing activity patterns to maintain normal body mass indices throughout their lives
• educating students, faculty, and parents on the following:
• the importance of positive role modeling
• dietary guidelines that promote balanced meals low in dietary fat
• the need for 60 minutes of physical activity daily
• the potential negative influence of inactivity
• reading and interpreting dietary information on food products
• relating dietary guidelines to food preparation
• educating coaches on the importance of proper nutrition on the athletes’ peak performance
• initiating school policies that provide for a healthy school environment, policies that relate to:
• school breakfast and lunch programs
• vending machines
• prevention of discrimination or abuse toward overweight youth
• school-based counseling
• health promotion for school staff
• supporting families as they assist their children to achieve and/ or maintain a healthy BMI
• encouraging acceptance of body type that has been inherited, individual diversity, and a positive self-image
• identifying students who are overweight and educating and encouraging these students to find and use acceptable weight loss programs
• implementing and managing school-based weight reduction programs
• providing community-based referral sources, as appropriate
• supporting students in understanding that once weight loss is achieved, the changes must be continued throughout their lives to maintain their healthier weight
• advocating for daily physical education for all grades
http://www.nasn.org/Portals/0/positions/2002psoverweight.pdf
Office of Women's Health, CDC
Cancer in American Indians and Alaska Natives
Annual Report to the Nation on the Status of Cancer, 1975-2004
A new report, Annual Report to the Nation on the Status of Cancer, 1975-2004, Featuring Cancer in American Indians and Alaska Natives, shows cancer death rates decreased on average 2.1 percent per year from 2002 through 2004, nearly twice the annual decrease of 1.1 percent per year from 1993 through 2002. Declines were observed in the incidence of lung cancer in men, colorectal cancer in men and women, and in breast cancer incidence in women from 2001 through 2004. For women, incidence rates for all cancers combined stabilized from 1999 through 2004 after years of increases. Death rates among women decreased for 10 of the 15 most common cancers. The American Cancer Society, the National Cancer Institute, CDC, and the North American Association of Central Cancer Registries collaborate to provide this annual update on cancer occurrence and trends in the United States.
http://www.cdc.gov/Features/CancerReport/
Vaccination of Pregnant Women (2007 Update)
Risk to a developing fetus from vaccination of the mother during pregnancy is primarily theoretical. No evidence exists of risk from vaccinating pregnant women with inactivated virus or bacterial vaccines or toxoids. Live vaccines pose a theoretical risk to the fetus. Benefits of vaccinating pregnant women usually outweigh potential risks when the likelihood of disease exposure is high, when infection would pose a risk to the mother or fetus, and when the vaccine is unlikely to cause harm. http://www.cdc.gov/vaccines/pubs/preg-guide.htm
ACIP Releases 2007-08 Adult Immunization Schedule
Morbidity and Mortality Weekly Report, October 19, 2007
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5641-Immunizationa1.htm
Oklahoma Perspective Greggory Woitte – Hastings Indian Medical Center
Methicillin-resistant Staphylococcus aureus in women’s health
Methicillin-resistant Staphylococcus aureus (MRSA) has become a hot topic in the media recently. In October, the CDC released a report that there was 18,650 deaths from MRSA in 2005. This was more than the number of deaths due to AIDS in the same year. MRSA has been a well known superbug in Hospitals for years. MRSA has been a growing problem due to its resistance to many common antibiotics including beta lactam antibiotics including methicillin. While most invansive MRSA infections can still be traced to hospital exposure, approximately 15% of invasive infections are occurring in individuals with no known health care risk. These infections are primarily occurring in people over the age of 65 and 2/3 of infections that can be traced back to a health care exposure occur in patients that are no longer hospitalized.
http://www.webmd.com/news/20071016/more-us-deaths
-from-mrsa-than-aids?src=rss_psychtoday
As I am sitting her writing this and watching the football game, a report came on the TV about two High School students who are recovering from the Superbug. What can we as women’s health providers do? Start with the basics that we learned in medical school. Wash your hands, Wash your hands, Wash your hands. The use of appropriate hand washing or the use of alcohol based rubs have been shown to decrease hospital infections, but compliance rates are rarely 100%. Next, use the right antibiotic for the appropriate infection. The days of shot gunning antibiotics can no longer be tolerated. The use of prophylactic antibiotics for surgeries or obstetrical procedures should comply with ACOG recommendations.
Even with diligent hand washing, and appropriate use of antibiotics, there will still be MRSA infections. Here at Hastings Indian Medical Center, we are fortunate to have Dr. Greg Felzien, a board certified Infectious Disease specialist, however I have included a list of treatment recommendations that was July 2006 ACOG Green Journal and reprinted from The Medical Letter for community acquired MRSA infections. In addition, a high index of suspicion is important, culture all wounds that open or that you opened. This includes all seromas, hematomas, as well as all obvious infected wounds.
As the media continues to pick up and publicize MRSA infections, you can educate your patients with handouts from the CDC at this website: http://www.cdc.gov/ncidod/dhqp/ar_mrsa_ca_posters.html
Treatment Recommendations
http://www.greenjournal.org/cgi/reprint/108/1/198
ACOG Practice Bulletin #47 October 2003 - Prophylactic Antibiotics in Labor and Delivery
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=14551023
ACOG Practice Bulletin No. 80: Premature Rupture of Membranes. Clinical management guidelines for obstetrician-gynecologists
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17400872
ACOG Practice Bulletin #74 July 2006 –Prophylactic Antibiotics in Gynecological Procedures
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=16816087
Osteoporosis
Effects of Steroidal and Nonsteroidal Aromatase Inhibitors on Markers of Bone Turnover in Healthy Postmenopausal Women
CONCLUSION: Exemestane increased serum levels of the bone-formation marker PINP after 24 weeks, suggesting a specific bone-formation effect related to its androgenic structure. Potential effects on cortical bone and reduced fracture risk must be verified in a comparative clinical trial.
Goss PE, et al Effects of steroidal and nonsteroidal aromatase inhibitors on markers of bone turnover in healthy postmenopausal women.
Breast Cancer Res. 2007 Aug 10;9(4):R52
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17692126
Patient Information
Pregnant or Thinking About Getting Pregnant?
These tips can help you prevent infections that could harm your unborn baby. You won’t always know if you have an infection - sometimes you won’t even feel sick. If you think you might have an infection or think you are at risk, see your doctor.
http://www.cdc.gov/ncbddd/pregnancy_gateway/infection.htm
Pregnancy Loss: What You Should Know
http://www.aafp.org/afp/20071101/1347ph.html
Caring for Your Premature Baby
http://www.aafp.org/afp/20071015/1165ph.html
Meth Abuse: What You Should Know
http://www.aafp.org/afp/20071015/1175ph.html
Headaches and Mind-Body Therapy: What You Should Know
http://www.aafp.org/afp/20071115/1523ph.html
Somatoform Disorder: What It Is and How to Cope
http://familydoctor.org/online/famdocen/home/common/pain/disorders/162.html
Ulcerative Colitis: What You Should Know
http://www.aafp.org/afp/20071101/1331ph.html
Low Back Pain and Your Job: What You Can Do to Get Back to Work
http://www.aafp.org/afp/20071115/1504ph.html
Perinatology Picks - George Gilson, Maternal Fetal Medicine, ANMC
Detection of intraamniotic infection/inflammation at bedside: Predicts adverse outcomes
CONCLUSION: The MMP-8 PTD Check test is a rapid, simple, and sensitive bedside test to detect intraamniotic infection/inflammation and to predict adverse outcome that includes short latency, chorioamnionitis, and significant neonatal morbidity in patients with PPROM. The results of this study bring the rapid detection of intraamniotic infection/inflammation to the bedside in clinical obstetrics.
Kim KW et al A rapid matrix metalloproteinase-8 bedside test for the detection of intraamniotic inflammation in women with preterm premature rupture of membranes. Am J Obstet Gynecol. 2007 Sep;197(3):292.e1-5.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17826425
Ferric carboxymaltose IV corrects postpartum anemia faster than ferrous sulfate PO
CONCLUSION: Large-dose IV ferric carboxymaltose administration is a new iron agent that is effective for the treatment of postpartum anemia. When compared with oral ferrous sulfate, IV ferric carboxymaltose is better tolerated, prompts a more rapid Hb response, and corrects anemia more reliably. LEVEL OF EVIDENCE: I.
Van
Wyck DB, et al Intravenous ferric carboxymaltose compared with oral iron
in the treatment of postpartum anemia: a randomized controlled trial.
Obstet Gynecol. 2007 Aug;110(2 Pt 1):267-78.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17666600
Alloimmune thrombocytopenia fetus can be safely treated in utero, without cordocentesis
CONCLUSION: The outcomes of both treatment groups were excellent and comparable. Early cordocentesis is not necessary when treating alloimmune thrombocytopenia in patients who have not delivered an infant with an intracranial hemorrhage in a prior pregnancy. LEVEL OF EVIDENCE: I
Berkowitz RL et al Antepartum treatment without early cordocentesis for standard-risk alloimmune thrombocytopenia: a randomized controlled trial. Obstet Gynecol. 2007 Aug;110(2 Pt 1):249-55.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17666597
Adequate dietary calcium in before and in early pregnancy: Prevent pre-eclampsia
COMMENTARY: We present the hypothesis that adequate dietary calcium before and in early pregnancy may be needed to prevent the underlying pathology responsible for pre-eclampsia. We suggest that the research agenda be redirected towards calcium supplementation at a community level
Hofmeyr GJ et al Dietary calcium supplementation for prevention of pre-eclampsia and related problems: a systematic review and commentary. BJOG. 2007 Aug;114(8):933-43. Epub 2007 Jun 12. Review.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17565614
A cost decision analysis of 4 tocolytic drugs
CONCLUSION: If one elects a tocolytic, both nifedipine and indomethacin should be the agents of choice, based on a cost decision analysis.
Hayes E, et al A cost decision analysis of 4 tocolytic drugs. Am J Obstet Gynecol. 2007 Oct;197(4):383.e1-6.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17904969
Repeat dose(s) of prenatal corticosteroids reduce serious health problems
AUTHORS' CONCLUSIONS: Repeat dose(s) of prenatal corticosteroids reduce the occurrence and severity of neonatal lung disease and the risk of serious health problems in the first few weeks of life. These short-term benefits for babies support the use of repeat dose(s) of prenatal corticosteroids for women at risk of preterm birth. However, these benefits are associated with a reduction in some measures of weight, and head circumference at birth, and
Crowther CA, et al Repeat doses of prenatal corticosteroids for women at risk of preterm birth for preventing neonatal respiratory disease. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD003935. Review.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17636741
Does knowledge of cervical length and fetal fibronectin affect management: RCT CONCLUSION: The knowledge of CL and FFN was associated with reduction in length of evaluation in women with CL > or = 30 mm and in incidence of SPTB in all women with PTL.
Ness A, et al Does knowledge of cervical length and fetal fibronectin affect management of women with threatened preterm labor? A randomized trial. Am J Obstet Gynecol. 2007 Oct;197(4):426.e1-7.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17904989
Increases in prepregnancy BMI between pregnancies: Increased primary cesarean
CONCLUSION: Increases in prepregnancy BMI between first 2 pregnancies from normal to obese is associated with increased risk of indications for primary cesarean. The association between being overweight or obese or increases in prepregnancy BMI between pregnancies and primary cesarean in the second pregnancy suggests that counseling women with regard to their high BMI may be beneficial.
Getahun D, et al Changes in prepregnancy body mass index between pregnancies and risk of primary cesarean delivery. Am J Obstet Gynecol. 2007 Oct;197(4):376.e1-7.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17904966
Metabolic score as a novel approach to assessing preeclampsia risk.
CONCLUSION: Metabolic score appears to be associated independently with developing preeclampsia, particularly severe disease.
Mazar RM et al Metabolic score as a novel approach to assessing preeclampsia risk. Am J Obstet Gynecol. 2007 Oct;197(4):411.e1-5.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17904982
Placenta accreta : Prophylactic placement of intravascular balloon catheters
CONCLUSION: Prophylactic intravascular balloon catheters did not benefit women with placenta accreta undergoing cesarean hysterectomy.
Shrivastava V, et al Case-control comparison of cesarean hysterectomy with and without prophylactic placement of intravascular balloon catheters for placenta accreta. Am J Obstet Gynecol. 2007 Oct;197(4):402.e1-5.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17904978
Amnioreduction vs fetoscopic laser photocoagulation for twin-twin transfusion syndrome
CONCLUSION: The outcome of the trial did not conclusively determine whether serial amnioreduction or selective fetoscopic laser photocoagulation is a superior treatment modality. severe twin-twin transfusion Syndrome cardiomyopathy appears to be an important factor in recipient survival in severe twin-twin transfusion syndrome.
Crombleholme TM, et al A prospective, randomized, multicenter trial of amnioreduction vs selective fetoscopic laser photocoagulation for the treatment of severe twin-twin transfusion syndrome. Am J Obstet Gynecol. 2007 Oct;197(4):396.e1-9.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17904975
Addition of biochemistry may enhance first-trimester risk assessment in twin pregnancies
Results: Adding biochemistry resulted in 100% detection rates for both conditions.
CONCLUSION: The addition of biochemistry may enhance first-trimester risk assessment in twin pregnancies. Further studies with larger numbers of affected pregnancies are needed.
Chasen ST, et al First-trimester risk assessment for trisomies 21 and 18 in twin pregnancy.
Am J Obstet Gynecol. 2007 Oct;197(4):374.e1- 3.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17904965
Magnesium supplementation did not reduce the incidence of HIE
CONCLUSIONS: Magnesium supplementation did not reduce the incidence of HIE significantly, probably because the study was underpowered and compliance was relatively poor
Harrison V et al Magnesium supplementation and perinatal hypoxia: outcome of a parallel group randomised trial in pregnancy. BJOG. 2007 Aug;114(8):994-1002.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17578470
Primary Care Discussion Forum
Traditional AI/AN Medicine: Incorporating Into I/T/U Clincial Practice
December 3, 2007
Moderator: Theresa Maresca, M.D., University of Washington School of Medicine
- What are the pros and cons of asking my patients about their traditional medicine use?
- How do I learn more about what traditional practices are common in my area?
- What specific strategies can be used to ask my patients diplomatically about their traditional medicine views?
- Where can I find resources about plant medicine?
- Is there a "right way" to work collaboratively with a traditional healer?
- What if I do not agree with my patient's views of traditional medicine
How to subscribe / unsubscribe to the Primary Care Discussion Forum?
Subscribe to the Primary Care listserv
http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=26
Unsubscribe from the Primary Care listserv
http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=26
Questions on how to subscribe, contact nmurphy@scf.cc directly
STD Corner - Lori de Ravello, National IHS STD Program
Special issue of the American Journal of Obstetrics & Gynecology
I wanted to draw some attention to the special issue of the American Journal
of Obstetrics & Gynecology which focused on Achievements, Issues, and Challenges:
Prevention of Mother-to-Child HIV Transmission in the United States and in Resource-Limited
Settings.
Below is a list of the table of contents – many of these articles should
be of interest
S1 For whom the bell tolls
Howard Minkoff
S3 Reducing the risk of mother-to-child human immunodeficiency virus transmission: past successes, current progress and challenges, and future directions
Mary Glenn Fowler; Margaret A. Lampe; Denise J. Jamieson; Athena P. Kourtis; Martha F. Rogers
There have been major advances with the prevention of mother-to-child human immunodeficiency virus transmission, and this paper summarizes the successes and current challenges and provides suggestions for future directions.
S10 Recent trends in the incidence and morbidity that are associated with perinatal human immunodeficiency virus infection in the United States
Matthew T. McKenna; Xiaohong Hu
Population-based data sources regarding the incidence and morbidity that are associated with perinatal human immunodeficiency virus infection are improving and indicate that prevention efforts have been enormously successful.
S17 Utility of antenatal HIV surveillance data to evaluate prevention of mother-to-child HIV transmission programs in resource-limited
settings
Omotayo Bolu; Abhijeet Anand; Andrea Swartzendruber; Wolfgang Hladik; Lawrence H, Marum; Abdullahi Ahmed Sheikh; Aseged Woldu;
Shabbir Ismail; Agnes Mahomva; Stacie Greby; Keith Sabin
This paper describes the utility of antenatal surveillance for monitoring and evaluating prevention of mother-to-child human immunodeficiency virus (HIV) transmission programs in resource-limited countries with generalized HIV epidemics.
S26 Recommendations for human immunodeficiency virus screening, prophylaxis, and treatment for pregnant women in the United States
Denise J. Jamieson; Jill Clark; Athena P. Kourtis; Allan W. Taylor; Margaret A. Lampe; Mary Glenn Fowler; Lynne M. Mofenson
The 25 year history of US recommendations for human immunodeficiency virus screening, prophylaxis, and treatment of pregnant women is summarized, highlighting the relevance for practitioners.
S33 Use of enhanced perinatal human immunodeficiency virus surveillance methods to assess antiretroviral use and perinatal human
immunodeficiency virus transmission in the United States, 1999-2001
Norma S. Harris; Mary Glenn Fowler; Stephanie L. Sansom; Nan Ruffo; Margaret A. Lampe
The results of this study demonstrate that mother-infant pairs who received all 3 arms of antiretroviral therapy had the lowest infant human immunodeficiency virus infection rates.
S42 International recommendations on antiretroviral drugs for treatment of HIV-infected women and prevention of mother-to-child HIV
transmission in resource-limited settings: 2006 update
Halima Dao; Lynne M. Mofenson; Rene Ekpini; Charles F. Gilks; Matthew Barnhart; Omotayo Bolu; Nathan Shaffer
Wereviewed the evidence and summarized the new 2006 World Health Organization recommendations on antiretroviral drugs for the treatment of women who are infected
with the human immunodeficiency virus and for the prevention of the transmission of the human immunodeficiency virus from mother to child.
S56 Use of single-dose nevirapine for the prevention of mother-to-child transmission of HIV-1: does development of resistance matter?
Michelle S. McConnell; Jeffrey S. A. Stringer; Athena P. Kourtis; Paul J. Weidle; Susan H. Eshleman
Nevirapine resistance has been detected after single-dose nevirapine, and there is concern about the effectiveness of subsequent nevirapine-based treatment in HIV infected women; data on the impact of single-dose nevirapine on subsequent treatment and pregnancies are reviewed.
S64 Infant human immunodeficiency virus diagnosis in resource-limited settings: issues, technologies, and country experiences
Tracy L. Creek; Gayle G. Sherman; John Nkengasong; Lydia Lu; Thomas Finkbeiner; Mary Glenn Fowler; Emilia Rivadeneira; Nathan Shaffer
This paper provides a description of challenges, progress, and recommendations for infant human immunodeficiency virus (HIV) diagnosis in resource-limited settings with high HIV prevalence.
S72 Rapid human immunodeficiency virus-1 testing on labor and delivery in 17 US hospitals: the MIRIAD experience
Denise J. Jamieson; Mardge H. Cohen; Robert Maupin; Steven Nesheim; Susan P. Danner; Margaret A. Lampe; Mary Jo O’Sullivan; Mayris P. Webber; Jeffrey Wiener; Rosalind J. Carter; Yvette Rivero; Mary Glenn Fowler; Marc Bulterys
Routine rapid testing during labor provides a feasible, acceptable, and accurate way to identify human immunodeficiency virus–infected women before delivery.
S83 Approaches for scaling up human immunodeficiency virus testing and counseling in prevention of mother-to-child human immunodeficiency virus transmission settings in resource-limited countries
Omotayo O. Bolu; Virginia Allread; Tracy Creek; Elizabeth Stringer; Fatu Forna; Marc Bulterys; Nathan Shaffer
This paper provides a summary of approaches and recommendations for scaling up human immunodeficiency virus testing and counseling in prevention of mother-to child transmission settings in resource-limited countries.
S90 Toward elimination of perinatal human immunodeficiency virus transmission in the United States: effectiveness of funded prevention programs, 1999-2001
Stephanie L. Sansom; Norma S. Harris; Ramses Sadek; Margaret A. Lampe; Nan M. Ruffo; Mary Glenn Fowler
The number of new perinatal human immunodeficiency virus infections in funded states decreased by 56%, achieving Centers for Disease Control and Prevention goal of a 50% reduction in incidence by 2005.
S96 Cesarean delivery for HIV-infected women: recommendations and controversies
Denise J. Jamieson; Jennifer S. Read; Athena P. Kourtis; Tonji M. Durant; Margaret A. Lampe; Kenneth L. Dominguez
Cesarean delivery to prevent mother-to-child transmission of human immunodeficiency virus is safe, effective, and relatively cost-effective; accordingly, cesarean delivery rates among human immunodeficiency virus–infected women have increased dramatically.
S101 Prevention of mother-to-child transmission services as a gateway to family-based human immunodeficiency virus care and treatment in resource-limited settings: rationale and international experiences
Elaine J. Abrams; Landon Myer; Allan Rosenfield; Wafaa M. El-Sadr
Viewing preventing the mother-to-child transmission as a gateway to family-based human immunodeficiency virus care and treatment will help strengthen ties between the 2 programs.
S107 Site-specific interventions to improve prevention of mother-to-child transmission of human immunodeficiency virus programs in less developed settings
Tabitha Sripipatana; Allison Spensley; Anna Miller; James McIntyre; Gloria Sangiwa; Frederick Sawe; David Jones; Catherine M. Wilfert
This article discusses site-specific interventions to increase the uptake of prevention of mother-to-child transmission programs based on experiences in sub-Saharan Africa. Lessons learned can apply to many resource-constrained settings.
S113 Prevention of human immunodeficiency virus-1 transmission to the infant through breastfeeding: new developments
Athena P. Kourtis; Denise J. Jamieson; Isabelle de Vincenzi; Allan Taylor; Michael C. Thigpen; Halima Dao; Timothy Farley; Mary Glenn Fowler
This paper focuses on current and planned research trials on strategies to prevent breastfeeding transmission of human immunodeficiency virus from mother to infant worldwide.
Edited by Margaret A. Lampe RN, MPH Denise J. Jamieson MD, MPH Nathan Shaffer MD Martha F. Rogers MD from CDC) - Volume 197, Issue 3, Supplement S (September 2007 )
http://journals.elsevierhealth.com/periodicals/ymob/issues/contents
Other
Racial Disparities Persist Across All Reportable STDs
Racial and ethnic minorities continue to be disproportionately affected by sexually transmitted diseases in the United States; data in CDC’s 2006 STD Surveillance Report show higher rates of all STDs among minority racial and ethnic populations when compared to whites, with the exception of Asians/Pacific Islanders. These disparities may be, in part, because racial and ethnic minorities are more likely to seek care in public health clinics that report STDs more completely than private providers. However, this reporting bias does not fully explain these differences. Other contributing factors include limited access to quality health care, poverty, and higher prevalence of disease in these populations.
Chlamydia
In 2006, the rate of chlamydia among African Americans was more than eight times higher than the rate among whites (1275.0 vs. 153.1 per 100,000 population), with approximately 46 percent of all chlamydia cases reported among African Americans. Additionally, the rates among American Indians/Alaska Natives (797.3 per 100,000) and Hispanics (477.0 per 100,000), were five times and three times higher than whites, respectively. In 2006, chlamydia rates increased for all racial/ethnic groups, except for Asians/Pacific Islanders.
Gonorrhea
Racial disparities in gonorrhea rates are even greater and racial gaps in diagnosis of gonorrhea are more pronounced than any other disease. The gonorrhea rate among African Americans was 18 times greater than that for whites in 2006 (658.4 per 100,000 vs. 36.5 per 100,000). From 2005 to 2006, the gonorrhea rate among African Americans increased by 6.3 percent—the first increase since 1998. In 2006, African Americans accounted for 69 percent of reported cases of gonorrhea.
In that same year, American Indians/Alaska Natives had the second-highest gonorrhea rate (138.3 per 100,000), followed by Hispanics (77.4), whites (36.5), and Asians/Pacific Islanders (21.1). In 2006, there were increases in gonorrhea rates among all racial and ethnic groups, except Asians/Pacific Islanders.
Syphilis
Although racial gaps in syphilis rates are narrowing, disparities remain, with rates in 2006 approximately six times higher among blacks than among whites. This represents a substantial decline from 1999, when the rate among blacks was 29 times greater than among whites. It is important to note that this narrowing reflects both declining disease rates among African Americans as well as significant increases among white males in recent years.
Despite some progress, African Americans continue to remain disproportionately affected by syphilis with a rate of 11.3 cases per 100,000 population in 2006. This is more than three times the rate for Hispanics, who have the second highest rate (3.6 cases per 100,000) as well as American Indians/Alaska Natives (3.3 cases per 100,000).
In 2006, the P&S syphilis rate among blacks increased for the third consecutive year, following more than a decade of declines. Between 2005 and 2006, the rate among blacks increased 16.5 percent (from 9.7 to 11.3), with the largest increase among black males (15.5 to 18.3, an increase of 18.1 percent).
In 2006, the rate of P&S syphilis in black females was 16 times higher than in white females. In that same year, 43.2 percent of all reported P&S syphilis cases occurred among African Americans, while whites accounted for 38.4 percent. Syphilis rates increased for all races and ethnicities in 2006 . http://www.cdc.gov/std/stats/default.htm
Barbara Stillwater, Alaska State Diabetes Program
Hypertension Triples Women's Risk for Diabetes
The link between high blood pressure and diabetes risk was independent of factors known to increase the odds of getting diabetes and cardiovascular disease.”
Conclusion Baseline BP and BP progression are strong and independent predictors of incident type 2 diabetes among initially healthy women.
Conen D et al Blood pressure and risk of developing type 2 diabetes mellitus: The Women's Health Study. Eur Heart J. 2007 Oct 9
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17925342
Prenatal programming of childhood overweight and obesity: opportunity for prevention
METHODS: A systematic review of observational studies examining the relationship between prenatal exposures and childhood overweight and obesity was conducted using MOOSE guidelines. RESULTS: Four of six included studies of prenatal exposure to maternal diabetes found higher prevalence of childhood overweight or obesity among offspring of diabetic mothers, with the highest quality study reporting an odds ratio of adolescent overweight of 1.4 (95% CI 1.0-1.9). The Dutch famine study found that exposure to maternal malnutrition in early, but not late, gestation was associated with increased odds of childhood obesity (OR 1.9, 95% CI 1.5-2.4). All eight included studies of prenatal exposure to maternal smoking showed significantly increased odds of childhood overweight and obesity, with most odds ratios clustering around 1.5 to 2.0. The biological mechanisms mediating these relationships are unknown but may be partially related to programming of insulin, leptin, and glucocorticoid resistance in utero.
CONCLUSION: Our review supports prenatal programming of childhood overweight and obesity. MCH research, practice, and policy need to consider the prenatal period a window of opportunity for obesity prevention.
Huang JS et al Prenatal programming of childhood overweight and obesity. Matern Child Health J. 2007 Sep;11(5):461-73.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17006770
American Dietetic Association: Nutrition and lifestyle for a health pregnancy outcome
http://www.eatright.org/ada/files/Pregnancynp.pdf
Researchers Shed Light On Black Box Of Gestational Diabetes
Transgenic expression of menin in maternal beta-cells prevented islet expansion and led to hyperglycemia and impaired glucose tolerance, hallmark features of gestational diabetes. Prolactin, a hormonal regulator of pregnancy, repressed islet menin levels and stimulated beta-cell proliferation. These results expand our understanding of mechanisms underlying diabetes pathogenesis and reveal potential targets for therapy in diabetes.
Karnik SK, et al Menin Controls Growth of Pancreatic {beta}-Cells in Pregnant Mice and Promotes Gestational Diabetes Mellitus. Science. 2007 Nov 2;318(5851):806-809.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17975067
Prenatal exposure to alcohol and conduct problems: A clearer link
An Indiana University study provides some of the strongest evidence yet that prenatal exposure to alcohol causes conduct problems in children, a finding that has been called into question in recent years.
CONCLUSION: These results are consistent with PAE exerting an environmentally mediated causal effect on childhood CPs, but the relation between PAE and AIPs is more likely to be caused by other factors correlated with maternal drinking during pregnancy.
Causal Inferences Regarding Prenatal Alcohol Exposure and Childhood Externalizing Problems," Archives of General Psychiatry, vol. 64, no. 11, Nov. 2007
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17984398
Women's Health Headlines, Carolyn Aoyama, HQE
Alaska Native Fetal Alcohol Spectrum Disorders and Suicidality in a Healthcare setting
Objectives. To present a clinical case report and provide a review of the available literature
on fetal alcohol syndrome and the fetal alcohol spectrum disorders and suicidality to highlight
important implications for providers.
Study design . A case report and literature review.
Results. Almost 6% of adolescents evaluated by the fetal alcohol spectrum disorders diagnostic
clinic at the Alaska Native Medical Center had been seen for self-harm related consultation.
Conclusions. Persons with the fetal alcohol syndrome and the fetal alcohol spectrum disorders,
as a result of their disability, demonstrate characteristics or features that are commonly thought
to be risk factors for suicide—such as mental illness, alcohol and other drug abuse, impulsivity,
history of trauma or abuse, and employment and relationship/social difficulties. These persons
may experience mental health problems, including suicidal ideation and attempts, over the course
of their life times.
Fetal Alcohol Spectrum Disorders and Suicidality in a Healthcare setting
Baldwin MR Int J Circumpolar Health 2007; 66(Suppl 1):54-60
http://www.ijch.fi/issues/66%20Suppl%201/IJCH%2066%20Suppl%201_Baldwin.pdf
ACNM and AWHONN nursing representation to site visit and educational activities involving women's health
I want to let you know that Indian Health Service now has a representative from the American College of Nurse Midwives (ACNM) and the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) representing the interests of nurse-midwives, labor and delivery nurses, women’s health and neonatal nurses on the annual site visits to facilities providing perinatal services, and to the annual OB-GYN, Neonatal and Women’s Health Course.
Marilyn Pierce-Bulger, CNM is our representative from ACNM. Marilyn practiced midwifery and was Chief of Midwifery at the Alaska Native Medical Center from 1981 in to the 1990’s. Marilyn was not only involved in building the midwifery practice at ANMC, she also worked to reduce the infant mortality rate in Alaska through a program she developed to provide close case management through public health nursing to the mothers at highest risk of loosing their infant. She has also worked with the State of Alaska and CDC on various other health issues such as FASD and SIDS.
Karen Peddicord , RN, MSN is our representative from AWHONN. Karen spent her career as a labor and delivery nurse, OB Nurse Manager, a Professor of Nursing and the OB-Neonatal Product Manager for a large hospital here in the DC area. Karen has been the Acting CEO for AWHONN and is currently the Director of Research for AWHONN. Karen has always loved labor and delivery nursing. She often cites the heroism that L&D nurses display as just a routine part of their job.
Marilyn and Karen are part of the Post Graduate Course in OB, Neonatal and Women’s Health; the so-called Denver Course. They both participate in the planning committee meetings. Karen will make a presentation on ‘Creating a Nurse-Friendly Culture’ and ‘Creating a Culture of Safety within Labor and Delivery’. Karen will also be a part of the yearly site visits to IHS facilities providing OB services and will be focusing on nursing related issues. Marilyn is also part of the planning process for the OB, Neonatal and Women’s Health Course. She will be making a presentation on FASD at the course. Marilyn also will participate in the site visits and will focus on midwifery. She knows many of the issues that midwives must deal with, such as the following:
1) CNM roles in various sites differ but are almost always KEY to the provision of a large percentage of health care to Native women, however the CNM voice is not always 'at the table' for planning/program development purposes. In addition, some sites do not have a sense of a ‘CNM team’ or of the larger ‘ OB team’ which would benefit both women being served and the CNM's themselves.
2) The CNM role in some locations is being supervised (and/or performance reviews are done) by non-CNM providers. Perhaps encouragement and training/technical assistance could be provided to sites that desire an enhanced understanding of the CNM role. In other words if the org charts can't change, maybe the 'reviewers' can be trained to do a more informed review.
IHS conducts site visits in one Area each year. This year we will be going to Phoenix. I am interested in improving the nursing and nurse-midwifery content of those reviews. I believe that we are moving in the right direction. I will continue to work towards having adequate midwifery and perinatal/L&D nursing on each of the site visit teams. Carolyn.Aoyama@ihs.gov
Report: State of Women's Health Poor Nationwide
The 2007 edition of "Making the Grade on Women 's Health: A National and State-by-State Report Card," which measured 27 benchmarks, found that the United States now fails to meet 12 of the benchmarks, three more than it did not meet in 2004. Two benchmarks—reducing obesity and providing Pap smears to women age 18 and up—were met in 2004, but are no longer met by any state, according the analysis .
Making the Grade on Women’s Health: A National and State-by-State Report Card is the first-ever report card to assess the overall health of women at the national and state levels. The Report Card is designed to promote the health and well-being of women in the United States by providing the most comprehensive assessment to date of women’s health.
Benchmark Disparities
The report found that several benchmarks -- including the percentage of women
receiving prenatal care, infant mortality and the percentage of uninsured women
-- varied significantly by race. American Indians and Alaska Native women were
twice as likely as white women to be uninsured, the report found. Among white
women, 16.9% were uninsured, compared with 22.7% of black women and 37.8% of
Hispanic women, according to the report. The percentage of uninsured women increased
by 1.7% since 2004, according to the report (CQ HealthBeat, 10/17). Minnesota
had the lowest percentage of uninsured with 9.1%, and Texas had the highest percentage
at 28.1%, the report said (Reuters, 10/17).
The report found 85.7% of white women received prenatal care, compared with 70.8%
of American Indians, 75.9% of blacks and 77.5% of Hispanics. According to the
report, the percentage of women nationwide who received prenatal care increased
by 5% since 2004 but is still unsatisfactory. The report found that white women
have an infant mortality rate of 5.7 deaths for every 1,000 live births, compared
with 13.5 deaths per 1,000 live births for blacks and 5.6 per 1,000 live births
for Hispanics. The overall infant mortality rate has remained the same since
2004
Advanced Practice Nursing Brochure Available
Hello APNs!
I am wondering if you would like copies of the Nurse Practitioner Brochure we have used in the past. If there is demand for it, I will print it again and send it out to the Area Offices for distribution.
Please let me know if there is demand for at least 1,000 per Area. If you think you need more than 1,000 in your Area, please let me know that too. Carolyn.Aoyama@ihs.gov
Women’s Health Data Book Available
The DRAFT Women’s Health 2008 Databook (WHUSA) is available now. Contact Teddra Penland (301-443-1028) and let her know how many copies of the Databook you would like – Teddra will be ordering them. Thanks. Carolyn.Aoyama@ihs.gov
What's new on the ITU MCH web pages?
Where can I get copies of the lecture notes from the 2007 Women’s
Health and MCH Conference that was held in Albuquerque on August
15-17th ?
http://www.ihs.gov/MedicalPrograms/MCH/F/lecNotes.cfm
New
Perinatology Corner Module - Varicella (Chickenpox) in Pregnancy
http://www.ihs.gov/MedicalPrograms/MCH/M/PNC/VC01.cfm
Frequently Asked Question about Capturing Infant Feeding Choice on RPMS and EHR
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
Save the dates
2007 National HIV Prevention Conference
- December 2-5, 2007
- Atlanta , Georgia
- Center for Disease Control and Prevention
- http://www.2007nhpc.org/conferenceinfo.asp
23nd Annual Midwinter Indian Health OB/PEDS Conference
- February 8 - 10, 2008
- For providers caring for Native women and children
- Telluride, CO
- Contact AWaxman@salud.unm.edu
Keeping Native Women & Families Healthy & Strong
- April 23-25, 2008
- Milwaukee , WI
- Great Lakes Tribal Epidemiology Center
- E-mail contact EpidemiologyCenter@gmail.com
Did you miss something in the last OB/GYN Chief Clinical Consultant Corner?
The November 2007 OB/GYN CCC Corner is available.
Hot Topics ‹ Previous
OB/GYN
Dr. Neil Murphy is the Obstetrics and Gynecology Chief Clinical Consultant (OB/GYN C.C.C.). Dr. Murphy is very interested in establishing a dialogue and/or networking with anyone involved in women's health or maternal child health, especially as it applies to Native or indigenous peoples around the world. Please don't hesitate to contact him by e-mail or phone at 907-729-3154.
