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Volume 4, No. 10, October 2006
Features
American Family Physician**
Patient-Oriented Evidence that Matters (POEMS)*
Postcoital Bleeding and Cervical Cancer Risk
Clinical Question: Does bleeding after intercourse indicate cervical cancer?
Study Design: Systematic review
Synopsis: The authors systematically reviewed several databases for English-language studies that reported or provided sufficient data to estimate the incidence or prevalence of postcoital bleeding. The authors do not report searching for unpublished data, independent and paired application of inclusion criteria, or paired data abstraction. Ultimately, they included 38 articles.
They found no studies that determined how often women presenting with post-coital bleeding were subsequently found to have cervical cancer. One mass screening study from Finland identified 2,648 women with postcoital bleeding, of whom 12 (0.45 percent) had invasive cancer at the time of presentation. Eight of the studies (including hundreds of thousands of women) evaluated women in community settings. The overall rate of complaints about postcoital bleeding is highly variable (0.7 to 9.0 percent); however, the large population-based studies report the prevalence at approximately 1 percent. It is not known how many women who experience postcoital bleeding seek medical care.
Sixteen studies reported the prevalence of postcoital bleeding in more than 47,000 women with invasive cervical cancer. The range of prevalence in these studies was 0.7 to 39.0 percent.
Bottom Line : In this systematic review, the rate of postcoital bleeding is highly variable and of uncertain significance. The best estimate is that approximately one out of 220 women with postcoital bleeding has invasive cervical cancer.
(Level of evidence: 3a-)
Shapley M, et al. A systematic review of postcoital bleeding and risk of cervical cancer. Br J Gen Pract June 2006;56:453-60.
Metformin May Help Children Lose Weight
Clinical Question: Does metformin (Glucophage) lead to weight loss for obese children and adolescents?
Study Design: Crossover trial (randomized)
Synopsis: Participants were obese patients from nine to 18 years of age (13 boys, 15 girls) who were treated in an endocrine clinic. All had clinical evidence of insulin resistance but did not meet the criteria for diabetes. Patients were randomized (double-blinded) to metformin 1 g twice daily or placebo for six months. This was followed by a six-month crossover period to the other treatment, with a two-week washout period in between.
There were equal numbers of children at Tanner stages 1 and 2 and at Tanner stages 3 to 5 at study entry. Mean body mass index (BMI) was 35 kg per m2. Standardized information on exercise and healthy eating was given to all patients. Four patients dropped out during the study, but not because of medication side effects. At the end of the active treatment period, significant benefits were observed for weight, BMI, abdominal circumference, and fasting insulin levels. The mean treatment effects after six months of active therapy compared with placebo were weight loss of 9.6 lb (4.4 kg), BMI decrease of 1.3 kg per m2, waist circumference decrease of 1.1 inches (2.8 cm), and fasting insulin decrease of 2 mIU per L (14 pmol per L). Data to calculate a number needed to treat were not presented.
Bottom Line: For obese patients nine to 18 years of age, six months of metformin (1 g twice daily) treatment resulted in a mean weight loss of approximately 10 lb (4.5 kg). Larger and longer studies are needed to support the effectiveness and safety of this regimen.
(Level of evidence: 1b-)
Srinivasan S, et al. Randomized, controlled trial of metformin for obesity and insulin resistance in children and adolescents: improvement in body composition and fasting insulin. J Clin Endocrinol Metab June 2006;91:2074-80.
Lubiprostone (Amitiza) for Chronic Idiopathic Constipation (STEPS)
Lubiprostone (Amitiza) is a prostaglandin derivative that reduces constipation and improves stool consistency by activating specific chloride channels (ClC-2) in the small intestine to increase intestinal fluid secretion and accelerate small intestine and colonic transit time.1-3 It is labeled for the treatment of chronic idiopathic constipation lasting at least 12 weeks.4 Lubiprostone also is being studied for use in constipation-predominant irritable bowel syndrome and postoperative ileus.
Bottom Line
Although bulk or osmotic laxatives are less expensive first options for treating patients with chronic idiopathic constipation, lubiprostone is an alternative for those who do not tolerate or respond to these agents, or in patients older than 65 years in whom tegaserod use is not recommended.
http://www.aafp.org/afp/20061015/steps.html
STEPS drug updates cover Safety, Tolerability, Effectiveness, Price, and Simplicity. Each update provides an independent review of a new medication by authors who have no financial association with the drug manufacturer.
* POEM Rating system : http://www.infopoems.com/levels.html POEM Definition: http://www.aafp.org/x19976.xml
** The AFP sites will sometimes ask for a username and password. Instead just ‘hit; cancel on the pop up password screen, and the page you are requesting will come up without having to enter a username and password.
American College of Obstetricians and Gynecologists
Amnioinfusion Does Not Prevent Meconium Aspiration Syndrome
ABSTRACT: Amnioinfusion has been advocated as a technique to reduce the incidence of meconium aspiration and to improve neonatal outcome. However, a large proportion of women with meconium-stained amniotic fluid have infants who have taken in meconium within the trachea or bronchioles before meconium passage has been noted and before amnioinfusion can be performed by the obstetrician; meconium passage may predate labor. Based on current literature, routine prophylactic amnioinfusion for the dilution of meconium-stained amniotic fluid is not recommended. Prophylactic use of amnioinfusion for meconium-stained amniotic fluid should be done only in the setting of additional clinical trials. However, amnioinfusion remains a reasonable approach in the treatment of repetitive variable decelerations, regardless of amniotic fluid meconium status.
Amnioinfusion does not prevent meconium aspiration syndrome. ACOG Committee Opinion No. 346. American College of Obstetricians and Gynecologists. Obstet Gynecol 2006;108:1053–5.
http://www.acog.org/publications/committee_opinions/co346.cfm
Postpartum Hemorrhage
ACOG Practice Bulletin No. 76
Summary of Recommendations and Conclusions
The following recommendations and conclusions are based primarily on consensus and expert opinion (Level C):
- Uterotonic agents should be the first-line treatment for postpartum hemorrhage due to uterine atony.
- Management may vary greatly among patients, depending on etiology and available treatment options, and often a multidisciplinary approach is required.
- When uterotonics fail following vaginal delivery, exploratory laparotomy is the next step.
- In the presence of conditions known to be associated with placenta accreta, the obstetric care provider must have a high clinical suspicion and take appropriate precautions.
Postpartum hemorrhage. ACOG Practice Bulletin No. 76. American College of Obstetricians and Gynecologists. Obstet Gynecol 2006 ;108:1039–47.
Vulvodynia
ABSTRACT: Vulvodynia is a complex disorder that can be difficult to treat. It is described by most patients as burning, stinging, irritation, or rawness. Many treatment options have been used, including vulvar care measures, medication, biofeedback training, physical therapy, dietary modifications, sexual counseling, and surgery. A cotton swab test is used to distinguish generalized disease from localized disease. No one treatment is effective for all patients. A number of measures can be taken to prevent irritation, and several medications can be used to treat the condition.
Vulvodynia. ACOG Committee Opinion No. 345. American College of Obstetricians and Gynecologists. Obstet Gynecol 2006;108:1049–52.
AHRQ
What processes are in place for same last name awareness?
This article reports on a case of mistaken identity that resulted in erroneous surgery, despite a "time out" before beginning the operation. http://psnet.ahrq.gov/resource.aspx?resourceID=4211
Here is an interesting DNR case from this month’s AHRQ Web M + M
An elderly woman who had a DNR in place took a fall that required her to have surgery. Discussion with the patient's health care proxy led to the DNR order being suspended during surgery, with the understanding that it would be reinstated postoperatively. Several days later, a nurse noticed that patient remained 'full code' because the DNR had not been restored. See the link below for the rest of the story
DNR in the OR and Afterwards
http://www.webmm.ahrq.gov/case.aspx?caseID=135
Prevalence, impact, and disclosure of domestic violence among women
http://www.ahrq.gov/research/aug06/0806RA4.htm
Moderately premature infants born at 30 to 34 weeks gestation tend to suffer substantial health problems
http://www.ahrq.gov/research/aug06/0806RA11.htm
Bariatric obesity surgery complication rates are higher over time
http://www.ahrq.gov/research/aug06/0806RA1.htm
Elderly women are more likely than men to die after coronary bypass surgery
http://www.ahrq.gov/research/aug06/0806RA5.htm
Minority women are nearly twice as likely as white women to not receive needed postoperative treatments for early-stage breast cancer
http://www.ahrq.gov/research/aug06/0806RA3.htm
Complications from chemotherapy in women with breast cancer are greater than previously estimated
http://www.ahrq.gov/research/aug06/0806RA2.htm
Ask A Librarian: Diane Cooper, M.S.L.S. / NIH
From your Library: Updated Cochrane Systematic Reviews
Aerobic Exercise and Pregnancy
A review of 11 trials involving 472 pregnant women suggested that pregnant women who engage in vigorous exercise at least two to three times per week improve or maintain their physical fitness, and there is some evidence that these women have pregnancies of the same length as those who maintain their usual activities. There is too little evidence to show whether there are other effects on the woman and her baby. The trials reviewed included non-contact exercise such as swimming, static cycling and general floor exercise programs. Most of the trials were small and of insufficient methodologic quality, and larger, better trials are needed before confident recommendations can be made about the benefits and risk of aerobic exercise in pregnancy. Aerobic exercise is physical activity that stimulates a person's breathing and blood circulation .
Kramer MS, McDonald SW. Aerobic exercise for women during pregnancy. Cochrane Database of Systematic Reviews 2006, Issue 3.
Calcium Supplementation Safe and Cheap
Calcium supplementation during pregnancy is a safe and relatively cheap means of reducing the risk of pre-eclampsia in women at increased risk, and women from communities with low dietary calcium, according to a recent review.. Preterm birth (birth before 37 weeks) is often caused by high blood pressure and is the leading cause of newborn deaths, particularly in low-income countries. No adverse effects have been found from calcium supplementation, but further research is needed into the ideal dosage.
Hofmeyr GJ, Atallah AN, Duley L. Calcium supplementation during pregnancy for preventing hypertensive disorders and related problems. Cochrane Database of Systematic Reviews 2006, Issue 3.
Preclampsia Drugs: No Clear Choice
A review of 24 trials including 2949 women found that while antihypertensive drugs lower blood pressure, there is not enough evidence to show which drug is the most effective when taken by pregnant women with hypertension. There is some evidence that diazoxide may result in the woman's blood pressure falling too quickly, and that ketanserin may not be as effective as hydralazine. Further research into the effects of antihypertensive drugs is needed.
Duley L, Henderson-Smart DJ, Meher S. Drugs for treatment of very high blood pressure during pregnancy. Cochrane Database of Systematic Reviews 2006, Issue 3.
OB/GYN CCC Editorial comment:
Cochrane Library :
Evidence based reviews of an array of clinical topics
Thanks to Diane Cooper at the NIH library, the link below will take you from
our Indian Health website to the NIH Health Services Research Library. The Cochrane
Library is the definitive evidence based medicine resource. It reviews only randomized
controlled trials.
Paste the link below into your browser. Click on the Cochrane Library link. This will take you to the NIH Library site. Scroll across the top menu to RESEARCH TOOLS. In the drop down box select DATABASES, and scroll down the list to COCHRANE.
http://www.ihs.gov/MedicalPrograms/CIR/index.cfm?module=cir_answering_clinical_questions
Contact Diane Cooper for questions: cooperd@ors.od.nih.gov
Breastfeeding - Suzan Murphy, PIMC
Do you have breastfeeding questions? The new Breast feeding site has the answers
The I.H.S MCH Breastfeeding webpage has been updated. To see the new look, go towww.ihs.gov, click on Medical Programs, then Maternal Child Health and then Breastfeeding.
Once on the Breastfeeding home page, you will find quick access to helpful resources like the Easy Guide to Breastfeeding for AI/AN Families, the new Lactation Support Policy in the Workplace, and list of topics designed to make breastfeeding support a reality.
Curious about breastfeeding reducing risk of diabetes and obesity? – Look in the Breastfeeding, diabetes and obesity section for information and references.
Want to know what to tell a mom about commonly asked concerns – like sore nipples and how-do-I-know-that-my-baby-is-getting-enough-milk? Click on FAQs and scroll to the topic.
How about breastfeeding benefits? The Breastfeeding Benefits section has a quick list of benefits, plus a link to the American Academy of Pediatrics’ (AAP) most recent position paper on breastfeeding. The paper includes numerous, landmark studies about breastfeeding benefits with links to Pubmed for abstracts.
Need ideas for breastfeeding moms who work or go school ? – Take a look at the Going back to Work or School section. Also, look at the Home Page link to the NEW I.H.S Circular for Lactation Support Policy in the Workplace (July 2006). The new circular has the latest, most current information about supporting breastfeeding employees in the I.H.S. work environment.
Want to know about medications and breast milk? The section on Medications is the spot for you. Jim Bresette and his amazing I.H.S. Pharmacists have collaborated to create this section – there is even a link to the NIH Lactnet page where a medication can be typed in and the studies, issues, AAP reviews, possible alternative drugs, etc are listed – quickly and easily read.
What about the nitty, gritty stuff - the things that staff need to make the real work of patient care come together? Like patient education materials/videos/posters, ways to easily keep track of feeding choice rates, PCC templates, job descriptions, policy/procedure ideas, what other agencies/coalitions are doing, etc? Don’t recreate the wheel, go directly to Staff Resources, use what fits, edit what you need and send suggestions.
Weary of limiting breastfeeding karma to just mom and baby? Be in awe of the beautiful dad and child picture on the Dads and Family Page – and email us your pictures!
Want to know about what other groups are doing or what other resources are available for lactation support? Try out the Links & Contact info page.
Got a bone to pick or question to ask about lactation support? Put your thoughts on line with the ListServ/Discussion Forum. Lactation is an evolving science, practice and research change the fact of what we do, no one knows all the answers, together we are better.
What is next for the web page? Possible additions include updates, more links, conference announcements, and CEUs.
Please send pictures, ideas, suggestions, and thoughts to suzan.murphy@ihs.gov
A New Look for Lactation Support – The New Breastfeeding web page
http://www.ihs.gov/MedicalPrograms/MCH/M/bf.cfm
Other
Lactation Support in the Indian Health Workplace: New Circular
We are pleased to announce - the Issuance of Circular 2006-05 – Lactation Support Program.
Signed by the Director on July 7, 2006 the circular establishes policy to
allow women who are returning to work who choose to breastfeed their infant,
to express breast milk during their tour of duty, provided they have obtained
prior approval. The draft circular went out for review and comment in early
winter 2006 and now in its final form will be sent to all Area Offices. http://www.ihs.gov/PublicInfo/Publications/IHSManual
/Circulars/Circ06/Circ06_05/circ06_05/circ06_05.htm
Please note the circular includes ‘exhibits’ on FAQ’s for employees, supervisor and for management allowing for ease of implementation. An implementation tool kit is being planned and we will be seeking your input. Judith.Thierry@ihs.gov
Thank you! Judy
CCC Corner Digest
Nicely laid out hard copy - A compact digest of last month’s CCC Corner
September 2006 Highlights included:
-FDA OTC Access for Plan B for 18 and Older: A ‘Catch-22’ for AI/AN patients?
-USPSTF Best Practices - Breast and Cervical Cancer Screening, plus Helpful Tips
-Cesarean delivery: Increased risks versus vaginal delivery - 4 articles
-See and treat: HPV positive, HSIL cytology, and a HG impression at 2nd colposcopy
-Metformin Useful for Treating PCOS in Adolescents
-Varenicline was significantly more efficacious for smoking cessation
-Human Papillomavirus Vaccination: ACOG Committee Opinion
-Engorgement - It only feels like it is going to last forever
-Adolescent perception of sexual abstinence: A complete disconnect
-HIV Management System, v1.0 - National Release
-Health care and indigenous peoples: the other side of the planet
-First trimester screening: How would you counsel this patient?
-Postpartum Care: Still the neglected step child of perinatal services?
-Implanon- A single rod contraceptive implant…
-Harm Resulting from Inappropriate Telephone Triage in Primary Care
-How important is maternal intratpartum glucose to neonatal hypoglycemia?
-Must Honor Advance Directives - Palliative Medicine's Role in the Continuity of Care
-Sexual Education / HIV Education and youth
-Weight Loss Should be the Primary Intervention for Risk of Diabetes
Entire September 2006 hard copy newsletter here
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/06SepOL.pdf
If you want a copy of the CCC Digest mailed to you each month, please contact nmurphy@scf.cc
Domestic Violence
A must WEB site for CHILD Abuse care and practice info
Ann S. Botash, MD at Upstate New York and colleagues has developed an extraordinary and comprehensive web site, cross referenced, appended, and updated---this could be your go-to reference for everything related to child maltreatment and child sexual abuse. Site is extremely intuitive and reflective of everyday practice needs.
The CPT code tells the insurer "what" was done (i.e. type of visit), and the ICD-9 tells "why" or the diagnosis. http://www.childabusemd.com/documentation/coding-billing.shtml#cpt
Elder Care News
Palliative Care Training
We have the opportunity for training in palliative and end-of-life care made possible through a partnership with the National Cancer Institute Office of Education and Special Initiatives (NCI/OESI).
January 23 – 25, 2007 (with January 22 and 26 as possible travel days) in Window Rock, Arizona.
This training is structured around the EPEC-O curriculum. The EPEC-O curriculum was produced by The EPEC Project™ with major funding provided by National Cancer Institute, with supplemental funding provided by the Lance Armstrong Foundation. It is a modular curriculum, well suited to a Train the Trainer model.
Our intent with this first training is to develop a national cohort of clinicians who are familiar with the curriculum and comfortable with the content. They would not only use the content in local program development and education, but be available for Area or regional training using the curriculum.
NCI/OESI views this as an ongoing relationship and hopes to continue to partner with us in the development of Area or regional trainings starting later in FY07. This would bring dollars to the Areas to continue this training.
We have asked the Area Chief Medical Officers to nominate individuals from each Area for training. An important consideration is that we expect the folks attending this training to be able to be available to serve as trainers for regional or Area trainings. We have funding to support travel and per diem for two trainers from each Area but we have additional capacity for Area or Service Unit sponsored trainers. We would recommend the nomination of one physician and either a nurse, pharmacist, or behavioral health professional from each Area. We need to identify attendees by October 31.
Attached you will find a draft curriculum outline for the training. We have IHS faculty as well as faculty from NCI and the Mayo Clinic.
Dr. Tim Domer at Fort Defiance Indian Hospital is leading this training. Please contact him with questions regarding the specifics of the training: Tim.Domer@ihs.gov 928-729-8021.
Feel free to contact me as well with any questions, comments, suggestions. Your feedback helps us stay on track.
Let your Area CMO know of your interest sending folks to attend the meeting.
How is the Indian Health System providing palliative and end-of-life care?
We need your help. We are trying to get a handle on where we are in the Indian Health System (IHS, Tribal, and Urban programs) when it comes to providing palliative and end-of-life care.
-We have designed a brief (5 minutes) survey to get the perspective of physicians, nurses, pharmacists, and administrators working in the health system, tasked with providing the care.
-This survey is being sent out through various list serves. If you have already completed the survey, we apologize for the duplication; disregard this message.
-Please feel free to share the link with others. We hope to reach as many facilities as possible and recognize that there may be different perspectives in a single facility.
The survey is available by clicking on this link:
Palliative Care Services and Access Survey
or by clicking on, or cutting and pasting this URL:
http://www.surveymonkey.com/s.asp?u=231271843431
If you have questions, feel free to call me at 413-584-0790 or 615-417-4915.
Thank you!
Bruce Finke, MD
IHS Elder Care Initiative
The Last Hours of Living: Practical Advice for Clinicians
A free CME module with very helpful ideas and resources including:
Preparing for the Last Hours of Life
Physiologic Changes and Symptom Management
Two Roads to Death
When Death Occurs
Notifying Others of the Death
Pronouncing Death
Summary of Take-Home Lessons
References
Related Resources
http://www.medscape.com/viewprogram/5808?sssdmh=dm1.217567&src=top10#
Family Planning
Ortho Evra Patch Linked to Risk for Venous Thromboembolism
On September 21, 2006 the US Food and Drug Administration (FDA) and Ortho-McNeil Pharmaceutical (a Johnson & Johnson company) notified healthcare professionals regarding changes to the safety labeling for a weekly norelgestromin/ethinyl estradiol transdermal system (Ortho Evra).
The label has been updated to reflect new data from 2 US epidemiologic studies that evaluated the relative risk for developing nonfatal venous thromboembolism (VTE) in women using the contraceptive patch vs oral contraceptives containing 35 µg of ethinyl estradiol, according to an alert sent yesterday from MedWatch, the FDA's safety information and adverse event reporting program. Both studies were conducted using electronic healthcare claims data, and the second study also included patient chart reviews.
Although findings from the first study revealed no significant difference in VTE risk for patch users compared with those taking oral contraceptives containing 35 µg of ethinyl estradiol (odds ratio [OR] = 0.9; 95% confidence interval [CI], 0.5 - 1.6), the second study linked the patch to more than double the risk for the event (OR = 2.4; 95% CI, 1.1 - 5.5).
The FDA notes that the latter finding supports the agency's concerns regarding the risk for VTE in women using the contraceptive patch.
Healthcare professionals are advised to balance the higher estrogen exposure and the possible increased risk of VTE against the chance of pregnancy if the patch is not used; contraceptive options other than the patch should be considered for women with risk factors for thromboembolic disease.
Adverse events related to use of the norelgestromin/ethinyl estradiol contraceptive patch should be reported to the FDA's MedWatch reporting program by phone at 1-800-FDA-1088, by fax at 1-800-FDA-0178, online at http://www.fda.gov/medwatch , or by mail to 5600 Fishers Lane, Rockville, MD 20852-9787. http://www.medscape.com/viewarticle/544925?sssdmh=dm1.217567&src=top10
Featured Website David Gahn, IHS Women’s Health Web Site Content Coordinator
New Breastfeeding Web Page for the Indian Health System
The Maternal Child Health Website now boasts a new breastfeeding website developed by Suzan Murphy in Phoenix. The site is located at http://www.ihs.gov/MedicalPrograms/MCH/M/bf.cfm.
The page contains many useful links for providers such as the Health and Human Services National Women’s Health Information Center which contains a wealth of accurate and pertinent information. Also available through the web page is access to the IHS Breastfeeding Guide with online ordering (up to 100 copies for free). You can also find the IHS Circular on the Lactation Support Policy in the Workplace which details the official policy on how we are to support our employees who are lactating.
PS: Don’t forget to regularly visit the MCH Home Page at http://www.ihs.gov/MedicalPrograms/MCH/index.cfm.
There you will easily find links to new postings on the entire MCH site such as new USPSTF guidelines on breast and cervical cancer screening and the new CDC guidelines for the treatment of STD’s.
As always, comments and contributions on the website are welcome and encouraged.
Frequently asked questions
Q. Is my first trimester patient always hyperthyroid if her labs are abnormal?
A. No, not necessarily. If she is clinically stable, then wait till 18-20 weeks to decide. See details
More about the question
A patient presents in the first trimester with hyperemesis. One of your colleagues obtains a complete thyroid function panel. The thyroid stimulating hormone (TSH) is significantly decreased. The patient follows up with you and wants to know how soon she should start her hyperthyroid medication.
Quick answer
If clinically stable, then wait till 18-20 weeks to decide if the patient is truly hyperthyroid
Now, let’s explore this issue a little more closely.
The rest of the answer is here
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/Hyperthy4706.doc
Indian Child Health Notes - Steve Holve, Pediatrics Chief Clinical Consultant
October 2006 – Highlights
-Early prednisone therapy in Henoch-Schonlein purpura
-Physician documentation of neonatal risk assessment for perinatal infections.
-The Alaska Haemophilus influenzae type b experience: lessons in controlling
a vaccine-preventable disease
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ICHN1006.doc
Information Technology
New patient wellness handout
OIT is pleased to announce the release of the new patient wellness handout. Please see the attached instructions for more details on this handout. This functionality is part of the new health summary patch (Patch APCH*2*15). OIT would like to thank Chris Lamer, Mary Wachacha and others for their ongoing work with OIT in patient education and wellness.
The Health Summary patch adds a new option to generate an Adult Patient Wellness Handout. The Adult Patient Wellness Handout is a new addition to the IHS Health Summary. The goal of the Wellness Handout is to empower patients to increase their role in their own health care. The Wellness Handout provides access to key patient clinical information to enhance patient education and knowledge. This should help improve clinical outcomes and health status.
The Health Summary patch also fixes/modifies the following functionality
on the health summary:
1) Changes the term "prescribed at" to "dispensed at" in
the medication components.
2) Changes the domestic violence exam terminology to "DOMESTIC VIOLENCE
SCREENING" in the exam section and adds the result of the Domestic Violence
Screening to the exam section.
3) Adds a new Depression Screening Health maintenance reminder this reminder.
Check with your computer operations or IT department if you would like this item
added to a health summary that you use.
4) Adds a new supplement which allows you to display only medications that
have been documented as being "chronic" through the pharmacy package
or electronic health record (EHR).
Please ask you site manager for further details.
Theresa Cullen Theresa.Cullen@ihs.gov
International Health Update: Claire Wendland, Madison, WI
Maternal survival worldwide: consensus and controversies
In the year 2000, 189 countries and many major international agencies signed a “Millennium Declaration” that was to provide a blueprint for improving conditions around the world – in particular, the conditions of the poor. The blueprint was divided into eight goals. Millennium Development Goal #5 committed signatory countries to improve maternal health; since improving health is difficult to measure, the agreement was to try to reduce maternal mortality by two thirds by 2015.
Anyone interested in maternal and child health will want to take a look at the Lancet’s new series on maternal survival, hot off the presses last week. In a series of five review articles and several associated commentaries, major figures in maternal health review what we know about maternal mortality (and to a lesser extent morbidity) and what to do about it. The upshot? Six years into the millennium, progress on maternal mortality does not look good. Statistics are unreliable, but it appears that maternal deaths have stabilized at about 400 per 100,000 live births (far from the MDG target of 141per 100,000 by 2015). Improvements in some countries, like Bangladesh, have been offset by worsening in others, such as Afghanistan and much of sub-Saharan Africa. Inequality is worse for obstetric risk than for any other health indicator: a woman in Sweden has a 1in 30,000 lifetime risk of death in childbirth, while for a woman in Sierra Leone that risk is 1 in 6.
Readers will find both consensus and controversy here. All contributors agree that political commitment and financial investment fall short of what they should be. All contributors seem to agree that funding competition between maternal health programs and child health programs, and between community-based and clinic-based programs, has been a waste of opportunity and time. (To use the memorable Cameroonian proverb quoted in one editorial, “When the elephant and the rhino fight, it is the grass that suffers.”) And all contributors agree that women have a right to birth in a safe facility attended by a skilled health worker – preferably a midwife. Major areas of controversy remain, however: chief among them are the role of home birth with skilled attendants in the developing world; the contribution of iatrogenic illness, especially infection, to maternal death; and the importance of providing safe abortion.
Review articles 1 (by C Ronsmans and WJ Graham), 2 (OMR Campbell and WJ Graham), and 5 (V Filippi et. al) are especially helpful overviews of global research on maternal health and survival. The authors provide evidence debunking some myths many of us will find hard to let go (for instance, that risk screening during antenatal care will improve maternal mortality). They also provide heartening evidence that many different strategies can improve maternal health, from improving control of infectious diseases to ensuring access to hospital care to providing midwifery in the community.
You can access all five articles and several related commentaries at www.thelancet.com
(requires free registration). Look for the Maternal Survival Series, September 30, 2006.
Other
An Entire Issue of Can J Public Health Dedicated to Health Policy
Here is just one example. There are many more
Martens PJ et al. (eds), Health Services Use of Manitoba First Nations People: Is It Related to Underlying Need? Can J Public Health. 2005 Jan-Feb;96 Suppl 1:S39-44 .
MCH Alert
What is the contribution of preterm birth to infant mortality rates?
"We found that more infants died because they were born preterm than as a result of any other cause of death," state the authors of an article published in the October 2006 issue of Pediatrics. The Healthy People 2010 objectives have identified reduction of the U.S. infant mortality rate as a national priority; however, there has been minimal progress in recent years.
The data used in the analyses were taken from the death certificates for all infants (less than 365 days of age) who died during 2002 and from the birth certificates of those infants, regardless of whether they were born in 2001 or 2002. For the 2002 linked file, 99% of infant death records were linked to the corresponding birth certificates. All analyses were weighted to account for the small fraction of unlinked records. The authors identified the top 20 leading causes of death in the linked file. The role of preterm birth for each cause was assessed by determining the proportion of infants who were born preterm for each cause of death and by considering the connection between preterm birth and the specific cause of death.
The authors found that
* There were 27,970 infant deaths in 2002, and the leading causes of death accounted for 22,273 of those deaths.
* According to traditional NCHS ranking rules, congenital malformations accounted for 5,630 (20%) of all infant deaths; short gestation/low birthweight was the second leading cause of death, accounting for 4,636
(17%) of all infant deaths.
* Overall, 93% of the 10,372 infants with causes of death the authors considered attributable to preterm birth were born at less than 37 weeks of gestation; these 9,596 infant deaths were designated as attributable to preterm birth. The vast majority (95%) of these 9,595 infants were born at less than 32 weeks of gestation and weighed less than 1,500 g at birth.
* The 9,596 deaths classified as attributable to preterm birth represented 34% of all infant deaths and 43% of all deaths among the 20 leading causes.
* With the strictest requirements for gestational age at birth (less than 32 weeks) and birthweight (less than 1,500 g), deaths classified as attributable to preterm birth represented 33% of all infant deaths and 41% of all deaths among the 20 leading causes of death.
The authors conclude that "there is an urgent need for an expanded comprehensive agenda to understand the complex social and biological factors that determine susceptibility to preterm birth, to detect women at risk early in pregnancy, and to develop and to evaluate new methods for preventing this important cause of death."
Callaghan WM, et al. 2006. The contribution of preterm birth to infant mortality rates in the United States. Pediatrics 118(4):1566-1573 http://pediatrics.aappublications.org/cgi/content/abstract/118/4/1566?rss=1
Increased efforts are needed for states to achieve all eight HP 2010 objectives
The report provides a snapshot of state progress toward achieving HP 2010 objectives with a focus on perinatal indicators associated with the following eight objectives: (1) pregnancy intention, (2) multivitamin use, (3) physical abuse, (4) cigarette smoking during pregnancy, (5) cigarette smoking cessation, (6) drinking alcohol during pregnancy, (7) breastfeeding initiation, and (8) infant sleep position.
Data for the analysis were drawn from the Pregnancy Risk Assessment Monitoring System (PRAMS), an ongoing, state- and population-based surveillance designed to monitor selected self-reported maternal behaviors and experiences that occur before, during, and after pregnancy among women who deliver live-born infants. Results from 19 states that collected data during 2000-2003 and achieved weighted response rates of greater than or equal to 70% in 1 year were included in the analysis.
The authors found that
* Preconception period -- No state achieved the HP 2010 objectives for intended pregnancy, multivitamin use during the month before pregnancy, and physical abuse during the 12 months before pregnancy.
* Prenatal period -- No state achieved the objective for abstinence from smoking during pregnancy. However, all states achieved the objective for smoking cessation during pregnancy, and more than three-fourths achieved or exceeded the objective for abstinence from alcohol during pregnancy.
* Postpartum period -- Nearly half of the states achieved the objective for breastfeeding, and slightly more than one-third achieved the objective for infant sleep position.
"More progress has been made in the health indicators related to maternal behaviors during pregnancy . . . and after pregnancy . . .
than for those related to behaviors before pregnancy," state the authors. They conclude that "continued use of PRAMS data to monitor these maternal behaviors is important for implementing, evaluating, and setting priorities for future initiatives at the state level."
Suellentrop K, Morrow B, Williams L, et al. 2006. Monitoring progress toward achieving maternal and infant Healthy People 2010 objectives --19 states, Pregnancy Risk Assessment Monitoring System (PRAMS), 2000-2003. MMWR Surveillance Summaries 55(SS09):1-11
http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5509a1.htm?s_cid=ss5509a1_e
Portal to Maternal and Child History Materials
The MCH Library recently launched a new portal on its Web site. The portal, titled Maternal and Child Health History, includes a collection of historical documents and reports related to maternal and child health (MCH) and health services for children and families in the United States. The portal focuses particularly on federal programs, including activities of the Children's Bureau and MCH services under Title V of the Social Security Act. Contents include an overview, materials in the MCH Library, special collections, legislation and program data, and links. Plans are under way to digitize materials not currently accessible in electronic format. The portal is available at http://mchlibrary.info/history/index.html
Children’s Opportunity Depends on Their Parent’s Opportunity
The Fall 2006 issue of The Future of Children, titled Opportunity in America, examines the dominant set of beliefs about America as a land of opportunity and reviews evidence on how close the nation has come to this ideal and what might be done to improve opportunity. The e-journal, published by Princeton University's Woodrow Wilson School of Public and International Affairs and the Brookings Institution, contains a collection of articles that examine how opportunity has changed over time and how it varies by race, gender, and national origin. The authors also explore how education, health, and culture affect social mobility for children born in different circumstances and what the government might do in each of these domains to make opportunity in the United States more equal. http://www.futureofchildren.org/pubs-info2825/pubs-info_show.htm?doc_id=388485
Medical Mystery Tour
The words ‘bizarre’ and ‘atypia’ in the same pathology report sentence…hmmm….
A 53 yo G6 P5015 presented to a field facility with ongoing menometrorrhagia despite conservative therapy with medroxyprogesterone 10 mg for 10 days a month for 3 months. Initial ultrasound revealed a 2.7 x 2.4 cm endometrial structure felt to be consistent with an endometrial polyp or a leiomyoma.
A follow-up ultrasound 2 months later at the field facility revealed 2 complex masses involving the endometrium with the appearance of some myometrial extension. The first was located in the mid-uterus and endometrium and was larger than the second which was located in the lower uterine segment.
An endometrial biopsy was obtained at the initial visit and was consistent with benign proliferative phase endometrium.
Examination revealed an eight week size uterus and no adnexal masses. There was urethral hypermobility, but no visible incontinence with Valsalva maneuver. The examination was otherwise unremarkable.
A discussion with the patient ensued and it was felt that further imaging modalities were indicated. In addition, the patient was offered a hysteroscopy, further endometrial sampling, and possible hysteroscopic resection. As both the above management options required transportation to a distant referral facility, the patient stated she would prefer a definitive operative intervention, if she needed to make such a trip.
The patient subsequently received an uncomplicated total vaginal hysterectomy with a left salpingo-oophorectomy. The patient was discharged on the second post operative day.
Pathologic evaluation revealed cytologic atypia present throughout the neoplasm that was of a degenerative and bizarre type. Occasional mitotic figures were identified. No tumor type necrosis was seen. The increased cellularity was felt to be somewhat increased over what one normally sees in a highly cellular leiomyoma. The pathologic material was sent to a second site for pathologic evaluation and the above impression was confirmed.
What do you think this patient’s diagnosis is?
What is the risk of recurrence?
Stay tuned to next month’s Medical Mystery Tour for the rest of the story
Medscape*
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
Associations between night sweats and other sleep disturbances
RESULTS: Thirty-four percent of the 363 patients interviewed reported night sweats, one half of whom reported saturating their bedclothes. In the multivariate model, night sweats were associated with daytime tiredness (OR = 1.99; 95% CI, 1.12-3.53), waking up with a bitter taste in the mouth (OR = 1.94; 95% CI, 1.19-3.18), legs jerking during sleep (OR = 1.78; 95% CI, 1.05-3.00), and awakening with pain in the night (OR = 1.87; 95% CI, 1.16-2.99). CONCLUSIONS: Night sweats are associated with several sleep symptoms. Both night sweats and sleep disturbances are commonly experienced by adult primary care patients. When their patients report night sweats, clinicians should consider asking about sleep quality and sleep-related symptoms.
Mold JW, Woolley JH, Nagykaldi Z. Associations between night sweats and other sleep disturbances: An OKPRN study. Ann Fam Med. 2006 Sep-Oct;4(5):423-6.
Combination Estrogen-Progestin Hormone Prescribed by Age Group
Annual Rate of Visits* to Office-Based Physicians and Hospital Outpatient Departments During Which Combination Estrogen-Progestin Hormone Therapy Was Prescribed for Women Aged >40 years, by Age Group --- United States, 2001--2003
* Per 100 women in age group.
From 2001 to 2003, the overall rate of visits to physicians during which combination estrogen-progestin hormone therapy was prescribed decreased by 44%. The decline was greatest among women aged >50 years. In July 2002, the National Institutes of Health terminated a clinical trial of combined hormone therapy (a component of the Women's Health Initiative) after investigators determined that the associated health risks outweighed the benefits.
Hing E, Brett K. Changes in U.S. prescribing patterns of menopausal hormone replacement therapy, 2001--2003. Obstet Gynecol 2006;108:33--40.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5538a6.htm?s_cid=mm5538a6_e
Unopposed Estrogen Therapy Increases Breast Cancer Risk
Postmenopausal hormone therapy increases the risk of breast cancer, but many studies attribute this risk to the combination of estrogen and progestin treatments. In a study by the Women's Health Initiative, unopposed estrogen was found to have a hazard ratio of 0.77 (adjusted confidence interval, 0.59 to 1.01) for developing breast cancer after seven years of follow-up. Chen and colleagues evaluated whether long-term use of unopposed estrogen increased the risk of invasive breast cancer in postmenopausal women.
The study analyzed data from participants in the Nurses' Health Study from 1980 to 2002, which included baseline questionnaires with information about cancer and cardiovascular risks and follow-up questionnaires that were mailed every two years. Women who were postmenopausal, had a hysterectomy, and were considered current users of unopposed conjugated estrogens (Premarin) participated in the study. Estrogen use was established through the self-reported information on the questionnaire. As the study progressed, women who became postmenopausal and had a hysterectomy were added to the analysis. The status of estrogen and progesterone receptors for breast cancer was recorded, and the main outcome measure was invasive breast cancer.
At the end of the study, 28,835 women were enrolled. Of the 934 women who had invasive breast cancer, 226 had never used estrogen therapy (see accompanying table). The researchers also found that women who had positive estrogen or progesterone receptors had the highest risk for breast cancer. Additionally, the risk of positive estrogen or progesterone receptor breast cancer was significantly higher in women who had been on unopposed estrogen for more than 15 years.
|
Invasive Breast Cancer Risk in Postmenopausal Women with Hysterectomy Who Use Unopposed Estrogen |
||
|
Duration of estrogen therapy (years) |
Cases |
Risk (95% confidence interval)* |
|
Never |
226 |
1.00 |
|
Less than 5 |
99 |
0.96 (0.75 to 1.22) |
|
5 to 9.9 |
145 |
0.90 (0.73 to 1.12) |
|
10 to 14.9 |
190 |
1.06 (0.87 to 1.30) |
|
15 to 19.9 |
129 |
1.18 (0.95 to 1.48) |
|
20 and more |
145 |
1.42 (1.13 to 1.77) |
|
P for trend for current use |
|
< .001 |
|
*-Multivariate relative risk controlled for age, age at menopause, age at menarche, body mass index, history of benign breast disease, family history of breast cancer, average alcohol consumption, and parity and age at first birth. Adapted with permission from Chen WY, Manson JE, Hankinson SE, Rosner B, Holmes MD, Willett WC, et al. Unopposed estrogen therapy and the risk of invasive breast cancer. Arch Intern Med 2006;166:1029. |
||
The authors conclude that long-term use of unopposed estrogen therapy increases the risk of breast cancer, but using estrogen for less than 10 years is not associated with an increased risk. They also note that using estrogen to prevent or treat osteoporosis usually requires long-term therapy; therefore, other options should be considered.
Chen WY , et al. Unopposed estrogen therapy and the risk of invasive breast cancer. Arch Intern Med May 8, 2006;166:1027-32.
Midwives Corner - Lisa Allee, CNM
External Fetal Monitors - Can you kick the habit?
Hindley, et al, undertook a three year research project due to the indiscriminate use of electronic fetal monitoring (EFM) in the United Kingdom despite evidence that states it should be used sparingly. They point out that extensive research in the last 30 years has shown limited benefit of EFM in low risk women and an increase in cesarean section rates when women are monitored continuously during labor. The evidence instead states that the most appropriate method of fetal monitoring for women of low obstetric risk is intermittent auscultation (IA).
Hindley, et al, present their qualitative research interviewing midwives about EFM and IA. They interviewed 58 midwives practicing in northern England with an average of 15 years of experience. For IA they found three main categories: freedom/liberating effects for the woman; closeness/proximity of the midwife; and quicker progress in labor. For EFM the categories included: oppressive/restrictive; midwife by proxy; and increased requirements for pain medications. For both monitoring methods the interviews also revealed paradoxes. For IA there was a paradox that the midwives’ positive comments were tempered by fears that they would miss some pathological event between auscultations. The paradox for EFM was that the midwives’ negative comments and their insights that EFM is causing midwives to attend less to women and more to machines and to loose sight of what is normal are contradicted by their practice realities of continuing to work with EFM, even for low risk women. In their discussion, Hindley, et al, illuminate what occurs for many midwives—a belief in the normal process of birth and a desire to work with women to support and enhance that process, but then the realities of where they work including the reliance on EFM resulting in a devaluation and decreased use of the traditional, watchful, hands-on approach of the midwife and an increased likelihood of the cascade effect leading to increasing numbers of interventions in the process of birth. They point out a persistent paradox in our practices—the evidence shows overwhelmingly that the use of EFM is not beneficial and may be harmful to patients and to midwifery practice, but we keep on using it.
Hindley, et al, bring to the forefront the quandary we are in—we know that evidence- based care would mean not using EFM, especially with low risk women, as it has not been shown to improve outcomes and has been shown to increase interventions, yet we continue to use it with virtually all laboring women. The authors discuss the many influences that make this so, including: lack of institutional support for IA; staffing issues causing EFM to be used as a midwife proxy—“a substitute for the presence of the midwife who would otherwise use the clinical skills of perception, auscultation, palpation, and communication”; trust in machines; that it’s easier to busy oneself with the monitor than to engage deeply with a laboring woman; medical policies and the persistent belief by many obstetricians that birth is inherently dangerous and should be risk managed. They also make suggestions for finding our way out of the quandary: where guidelines exist for appropriate use of EFM, audit compliance with the guidelines; provide resources for one-to-one midwifery care in labor to stop the use of EFM as a proxy; continued debate and discussion about routine use of oxytocin and epidurals that often necessitate EFM use and about precise clinical risk indicators for the use of EFM. They also offer a first step in the process of change:
Simple strategies such as removing fetal monitors from rooms might also help the midwife to consciously question the need for EFM rather than applying it routinely, merely because it is proximal.”
English midwives' views and experiences of intrapartum fetal heart rate monitoring in women at low obstetric risk: conflicts and compromises. J Midwifery Womens Health. 2006 Sep-Oct;51(5):354-60.
Editorial Comment : Lisa Allee, CNM
First, I have got to say that I love qualitative research because the results sound like actual humans and not just numbers. For example, the quotes the authors put in this article will likely ring true with many of us:
“ I think it (IA) gives the woman more freedom. She can mobilise. I think the labour tends to get quicker because she is not pinned to the bed in one position. She can move around, it’s more natural, it’s more normal.”
“I think a lot of the women feel really restricted by monitoring. It also means that as a midwife, your time is taken up with analysing and looking at the machine a lot of the time when you could be giving other support to the woman.”
“I think, especially with the monitors, they are waiting for the next pain. The focus is on the pain. Certainly, there are more epidurals as opposed to the woman who is labouring in the bath or moving about.”
“I think IA brings you closer to them, and it’s just more natural and normal, so it’s less technology that I am in favour of.”
Second, when I got to the end of this article I let out a whoop and did a little happy dance—someone finally said in print “TAKE THE MONITOR OUT OF THE ROOM”!!!! Wow, what a concept. There are some many reasons to do this, but most of all it would mean that everyone would have to really think about using EFM, it’s appropriateness and it’s implications, because to use it you would have to drag the thing into the room. This change would also make it ok to not use EFM, as appropriate, using doptones instead and, thus, make the focus of our care the laboring woman, the baby, and the family instead of the machine. Those of us who have practiced in home birth, birth centers, and internationally know that this really is ok, safe, and so satisfying for all involved. I would love to hear from any site that makes this change or has already done so!
E-mail me at lisa.allee@ihs.gov and I will include the information in a future column.
One Last Thing: It is time to update the midwifery page on the IHS website. A few ideas I have are patient education section, midwifery conferences, an ask the midwife column, why you are lucky to have midwifery care, and profiles of the different midwifery services in IHS. PLEASE send me your comments on these ideas and your suggestions for other items. Also, please send me pictures that could be used on the page! Thanks for your help!!!
Other
EMTALA language changes addresses certification of false labor
http://www.midwife.org/legislative.cfm?id=957
Navajo Corner, Jean Howe, Chinle
Great, low-cost, fun CME opportunity
The Telluride Conference, to be held on January 26-28, 2007
This is a great, low-cost, fun CME opportunity attended by many current IHS providers and IHS alumni. Please share this announcement with anyone who might be interested at your facilities.
Hope to see you there! Jean.Howe@ihs.gov
http://www.ihs.gov/MedicalPrograms/MCH/F/CN01.cfm#Jan07
Nurses Corner - Sandra Haldane, HQE
Improving Perinatal Outcomes: Reliably Using Elective Induction
and Labor Augmentation
Begins October 25
The quality of care provided during labor and delivery can become safer and more reliable through the use of "bundles" - a group of evidence-based interventions related to a disease or care process that, when executed together, result in better outcomes than when implemented individually. Elective labor induction and augmentation bundles provide reliable processes that can be used to evaluate and manage labor and delivery. Through implementing these bundles, teams improve communication and deliver those elements of care that decrease the chances that an adverse event will occur.
Upon completion of this Web&ACTION series participants will be able to:
- Implement elective induction and augmentation bundles to increase their organization's current level of performance during labor and delivery
- Engage all members of the team using effective communication and documentation techniques
- Address the barriers in their organizations during implementation of the bundles
http://www.ihi.org/IHI/Programs/ConferencesAndTraining/PerinatalWebandACTION.htm
OB/GYN CCC Editorial comment:
The Institute for Healthcare Improvement is interested in helping the Indian Health system related to the cost of the above program. Please email Carolyn Aoyama for details at Carolyn.Aoyama@ihs.gov
Office of Women's Health, CDC
Preconception Care: Science, Practice, Challenges and Opportunities
This special supplement of the Maternal and Child Health Journal includes
over 25 original papers on preconception care. The issue includes papers on the
history of preconception care, preconception health activities in the United
States, promising practices, international settings, what ob/gyns think, provider
practice regarding folic acid, what women know and believe, social marketing,
public finance policy, and more. Maternal and Child Health Journal - http://springerlink.com/content/k33g85g4242v/?p=
5e9442a6c00a40888ebe95936ebca50a&pi=4
October is Breast Cancer Awareness Month
To increase awareness of Breast Cancer, October is Breast Cancer Awareness Month
For more in formation on breast cancer see the site below:
http://www.cdc.gov/cancer/breast/basic_info/facts.htm#
Oklahoma Perspective Greggory Woitte – Hastings Indian Medical Center
Asthma in Pregnancy
Your next patient is a new OB physical. After scanning her history, you note that she reports having a medical history significant for Asthma in the past. Given the high prevalence of asthma in the general population, it is one of the more common complications of pregnancy. Pregnancies complicated with asthma are more likely to also be complicated by Preterm birth, hyperemesis gravidarium, pre-eclampsia, IUGR and neonatal mortality. The goals that should be met in taking care of this patient include:
- objectively evaluating the maternal fetal clinical condition
- control of asthma symptoms and prevention of acute attacks by avoidance/control of triggers
- Maximize lung function with drug while minimizing side effects
- patient education
Placing a patient into a category, mild-intermittent, mild-persistent, moderate or severe, based on her pre-pregnancy condition will assist in your treatment of the patient during pregnancy. However, the foundation of management of these patients is the Peak Expiratory Flow Rate (PEFR). Use of this peak flow meter can assist in management, recognition and prevention of exacerbations. Here are the National Asthma Education and Prevention Program recommendations.
Asthma and pregnancy report. NAEPP report of the Working Group on Asthma
and Pregnancy: management of asthma during pregnancy
http://www.nhlbi.nih.gov/health/prof/lung/asthma/astpreg.txt
NAEPP expert panel report 2: guidelines for the diagnosis and treatment of
asthma
http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm
NAEPP expert panel report: guidelines for the diagnosis and treatment of
asthma —update on selected topics 2002
http://www.nhlbi.nih.gov/guidelines/asthma/asthupdt.htm
Managing Asthma During Pregnancy: Recommendations for Pharmacologic Treatment--Update
2004
http://www.nhlbi.nih.gov/health/prof/lung/asthma/astpreg/astpreg_qr.pdf
Osteoporosis
Fracture risk among First Nations people
CONCLUSION: First Nations people are at high risk for fracture but the causal factors contributing to this are unclear. Further research is needed to evaluate the importance of other potential explanatory variables.
Leslie WD, et al Demographic risk factors for fracture in First Nations people. Can J Public Health. 2005 Jan-Feb;96 Suppl 1:S45-50.
and
The prior report
RESULTS: First Nations people had significantly higher rates of any fracture (age- and sex-adjusted SIR 2.23, 95% CI 2.18-2.29). Hip fractures (SIR 1.88, 95% CI 1.61-2.14), wrist fractures (SIR 3.01, 95% CI 2.63-3.42) and spine fractures (SIR 1.93, 95% CI 1.79-2.20) occurred predominantly in older people and women. In contrast, craniofacial fractures (SIR 5.07, 95% CI 4.74-5.42) were predominant in men and younger adults. INTERPRETATION: First Nations people are a previously unidentified group at high risk for fracture.
Leslie WD, et al Fracture risk among First Nations people: a retrospective matched cohort study. CMAJ. 2004 Oct 12;171(8):869-73
Patient Information
Assessment of Adult Health Literacy
The Health Literacy of America's Adults: Results from the 2003 National Assessment of Adult Literacy describes how health literacy varies across the population and where adults with different levels of health literacy obtain information about health issues. The report, produced by the National Center for Education Statistics, contains analyses that examine differences related to health literacy that are based on self-reported background characteristics among groups in 2003. Topics include health literacy levels, demographic characteristics and health literacy, overall health, health insurance coverage, and sources of information about health issues. The appendices contain sample health-literacy-assessment question, definitions of all subpopulation and background variables reported, technical notes, standard errors for tables and figures, and additional analyses. References are also included. The full report, executive summary, and appendices are available at http://nces.ed.gov/pubsearch/pubsinfo.asp?pubid=2006483
Is patient education really working? GDM patients smoke more and eat less vegetables
CONCLUSIONS: Despite their elevated risk for future diabetes, women with history of GDM who lived with children were less likely to meet fruit and vegetable consumption guidelines and more likely to smoke than women with children who did not have history of GDM.
Kieffer EC et al Health Behaviors Among Women of Reproductive Age With and Without a History of Gestational Diabetes Mellitus Diabetes Care. 2006 Aug;29(8):1788-93
HPV Vaccine: What You Need to Know (Interim Vaccine Information Statement)
This two page fact sheet answers the following questions: what is HPV, why get vaccinated, who should get HPV vaccine and when, who should not get vaccinated (or should wait), what are the risks from HPV vaccine, what if there is a severe reaction, and how can I learn more.
http://www.cdc.gov/nip/publications/VIS/vis-hpv.pdf
Stress: How to Cope with Life's Challenges
http://www.aafp.org/afp/20061015/1385ph.html
Anxiety and Panic: Getting Control over Your Feelings
http://www.aafp.org/afp/20061015/1393ph.html
Depression: What You Should Know
http://www.aafp.org/afp/20061015/1395ph.html
Emotional Health: What You Should Know
http://www.aafp.org/afp/20061015/1388ph.html
Shingles Vaccine: What You Need to Know
This two page fact sheet discusses the following issues: what is shingles, shingles vaccine information, who should not get the shingles vaccine (or should wait), risks, reactions, and more.
http://www.cdc.gov/nip/publications/VIS/vis-shingles.pdf
Cardiovascular Disease: What You Should Know
http://www.aafp.org/afp/20061015/1342ph.html
Perinatology Picks - George Gilson, Maternal Fetal Medicine, ANMC
#1 Fetal Lung Maturity Assessment
The evaluation of fetal lung maturity by use of lipid chromatography analysis of amniotic fluid surfactant with the lecithin-sphingomyelin ratio and per cent phosphatidyl glycerol (“L/S and PG”) has been standard obstetric practice for over 40 years. Over the last 20 years however, this test has been largely supplanted by the fluorescence polarization assay, which, in its current iteration, is known as the “TDx-FLM II” test (Abbott Laboratories). There is an extensive literature (see below for partial list of references) evaluating its accuracy, both evaluating its correlation with L/S and PG, as well as investigating its clinical efficacy in predicting infants diagnosed with respiratory distress syndrome (IRDS).
The accuracy of the TDx-FLM is now considered excellent, and, in the latest studies, demonstrates that it is probably superior to L/S and PG determinations. Our consultants at the University of Washington and our reference lab have now largely abandoned the L/S and PG in favor of the TDx-FLM II. I would therefore like to propose that we also exclusively use this simpler and less costly test, which can be done locally, with results provided within several hours, and which only requires 1 mL of amniotic fluid. Currently, if the FLM is negative or indeterminate, Providence sends the specimen out for confirmation with an L/S and PG determination. This is called the “sequential” or “cascade” strategy, and was likewise proposed over 20 years ago. This takes about 48 hours for the result, accrues a substantial additional charge, and is probably not necessary with the accuracy of the current TDx-FLM II.
While most laboratories report specific cut-off points (immature: <39; indeterminate: 40-54; mature: >55 mg/g), gestational age-specific risk estimates are more accurate (see nomogram hanging in OB Triage and reference [11] below), and do not give just a “yes or no” answer. For example, a FLM of 50 at 36 weeks predicts a risk of IRDS of 4.3%, probably an acceptable risk depending on the indication for early delivery. Like the L/S, amniotic fluid specimens contaminated with significant quantities of blood, meconium, or bilirubin may give erroneous results. Insufficient data has been accrued on vaginal pool amniotic fluid specimens. All tests of fetal lung maturity, including the L/S, have over a 95% negative predictive value (if the test is reported mature, there is only a 5% chance of IRDS), but only a 60% positive predictive value (test reported as immature, but infant does not develop IRDS).
Amniocentesis for fetal lung maturity is currently only thought to be useful in 2 clinical situations: 1) between 34-36 weeks where delivery is thought to be indicated for maternal or fetal reasons, but the need is not urgent (under 34 weeks: rarely ever mature results, over 36 weeks: rarely ever severe IRDS), and 2) in a woman with unsure dating with a differential diagnosis of possible fetal growth restriction (requiring delivery) versus lesser (premature) gestational age. In other situations, if there is an urgent indication for delivery, the pregnancy should be delivered regardless of the results of fetal lung maturity testing.
References
- Tait JF, et al. Improved fluorescence polarization assay for use in evaluating fetal lung maturity. I. Development of the assay procedure. Clin Chem 1986; 32:248-54.
- Foerder CA , et al. Improved fluorescence polarization assay for use in evaluating fetal lung maturity. II. Analytical evaluation and comparison with the lecithin/sphingomyelin ratio. Clin Chem 1986; 32: 255-9.
- Ashwood Er, et al. Improved fluorescence polarization assay for use in evaluating fetal lung maturity. III. Retrospective clinical evaluation and comparison with the lecithin/sphingomyelin ratio. Clin Chem 1986; 32:260-4.
- Garite TJ, et al. Fetal maturity cascade: A rapid and cost-effective method for fetal lung maturity testing. Obstet Gynecol 1986; 67:619-22.
- Ruch AT, et al. Assessment of fetal lung maturity by fluorescence polarization in high-risk pregnancies. J Reprod Med 1993; 38:133-6.
- Herbert WNP, et al. Role of the TDx FLM assay in fetal lung maturity. Am J Obstet Gynecol 1993; 168:808-12.
- ACOG. Assessment of fetal lung maturity. ACOG Educational Bulletin #230. November 1996.
- Fantz CR, et al. Assessment of the diagnostic accuracy of the TDx-FLM II to predict fetal lung maturity. Clin Chem 2002; 48:761-5.
- Pinette MG, et al. Fetal lung maturity indices: A plea for gestational age-specific interpretation. Am J Obstet Gynecol 2002; 187:1721-2.
- Albright TS, et al. Evaluation of the effect of meconium on assessment of fetal lung maturity status by TDxFLM II testing. Obstet Gynecol 2004; 104:952-6.
- Parvin CA , et al. Predicting respiratory distress syndrome using gestational age and fetal lung maturity by fouorescent polarization. Am J Obstet Gynecol 2005; 192:199-207.
#2 Can a blood test predict pre-eclampsia? and will it help us?
The pre-eclampsia syndrome, despite having been recognized for millennia, continues to remain an enigma. Complicating 5 per cent of pregnancies, it is a leading cause of maternal death and preterm birth worldwide, and is a major public health problem. Its etiology remains elusive, and, at present, the only definitive treatment is delivery. Prediction is also problematic, and no currently available clinical test is able to determine who will develop the syndrome during pregnancy, or when. A new line of investigation however may represent a major first step towards its prediction, prevention, and treatment.
The recent publication in the New England Journal of Medicine by Levine et al (1) whose abstract appears here, is the latest in a series of studies (see references below) about several circulating anti-angiogenic factors that may reflect the etiology, and help us foretell the development, of pre-eclampsia (PEC). While they are not quite ready for “prime time” with our clients yet, being aware of ongoing developments in this field may soon have clinical relevance for us. These studies have centered around several circulating proteins which influence vascular endothelial development and homeostasis. Interestingly, these same molecules most likely play a major role in the propagation of tumors, as well as in the development of atherosclerosis.
Please bear with me on plowing through what follows, and sorry for all the abbreviations! It really is pretty cool stuff. Vascular endothelial growth factor (VEGF) and placental growth factor (PlGF) are two proteins which promote angiogenesis and induce nitric oxide (NO) and vasodilatory prostaglandins (PGI2), influencing vascular tone and blood pressure. Anti-VEGF proteins include soluble fms-like tyrosine kinase 1 (sFlt-1) and endoglin; their action is to blunt the effects of VEGF. Transforming growth factor beta-1 (TGFb-1) is a co-receptor that binds endoglin and downregulates its effect on the vascular endothelium, all maintaining the crucial balance in vascular tone that provides optimal perfusion of downstream tissues. When these molecules are circulating they are called “soluble”, and when they are bound to the vascular endothelium they are called receptors (“non-soluble”). The trophoblast (as well as invasive neoplasms), big time produces angiogenic and vasodilatory agents to allow it to invade the maternal vasculature and establish its blood supply. The failure of the conceptus to establish an adequate blood supply is thought to result in the pregnancy complications of PEC and fetal growth restriction. It is postulated that, if this high flow/low pressure system fails to become established, sFlt-1 binds to VEGF and PlGF and soluble endoglin binds TGFb-1, resulting in a rise in blood pressure as a response to attempt to enhance placental perfusion.
Levine et al, using the archived blood samples from a study you may recall, “Calcium for the Prevention of Eclampsia and Pre-eclmapsia” (the “CPEP” trial), (which involved almost 5,000 women, and did not demonstrate an effect of supplemental calcium on the prevention of the syndrome…) (6), have found some very interesting associations. This group’s earlier publication (2) found that women who subsequently developed pre-eclampsia demonstrated increased levels of sFlt-1 and reduced levels of PlGF about 5 weeks prior to the onset of the syndrome. Nevertheless, PEC did not develop in all women with high sFlt-1 and low PlGF levels, and it did develop in some women with low sFlt-1 and high PlGF.
The current study (1) now produces another missing piece of the puzzle, endoglin. In the most recent publication, the investigators found that soluble endoglin levels became markedly elevated 8-12 weeks prior to the onset of PEC. This increase occurred earlier in women who developed early PEC (<37 weeks). Likewise, an increased level of soluble endoglin was usually accompanied by an increased ratio of sFlt-1:PlGF (free PlGF was decreased and sFlt-1 was increased). Thus, soluble endoglin and sFlt-1, two anti-angiogenic proteins operating through separate mechanisms, combined to produce endothelial dysfunction and severe PEC. Interestingly, women who developed a growth restricted infant had mild early elevation of endoglin without an increase of the sFlt-1:PlGF ratio. Women who developed gestational non-proteinuric hypertension had similar elevations of soluble endoglin but smaller increases in the sFlt-1:PlGF ratio. Also, sFlt-1 levels were lower in smokers, confirming that smoking is protective against PEC, possible through the effect of nicotine on the angiogenic proteins.
So…, where does us this leave us? First of all, these data are retrospective and cross-sectional, and come from blood samples that have been frozen for over 10 years… Nevertheless, they may direct the next step, prospective longitudinal studies, which may point us more directly towards prevention and treatment. The World Health Organization (WHO) is planning just such a multi-national study. Because of the high maternal and infant morbidity and mortality occasioned by the disease in the developing world, the ability to predict which women would develop PEC might allow them to be “risked-out” non-emergently to a higher level care, or to be candidates for maternity home care so as not to deliver at home without a skilled birth attendant. The ability to carry out this same triage might serve us very well in IHS. Perhaps someday soon here at home, we may see VEGF infusions used to reverse the hypertension and proteinuria we see in our patients! But might that result in suboptimal perfusion of the utero-placental unit with a different set of complications?? Stay tuned for further developments…..
REFERENCES
- Levine RJ et al. Soluble endoglin and other circulating anti-angiogenic factors in pre-eclampsia. N Eng J Med 2006; 355:992-1005.
- Levine RJ et al. Circulating aniogenic factors and the risk of pre-eclampsia. N Eng J Med 2004; 350:672-83.
- Levine RJ et al. Urinary placental growth factor and risk of pre-eclampsia. JAMA 2005; 293:77-85.
- Buhimschi CS et al. Urinary angiogenic factors cluster hypertensive disorders and identify women with severe pre-eclampsia. Am J Obstet Gynecol 2005; 192:734-41.
- Venakatesha S et al. Soluble endoglin contributes to the pathogenesis of pre-eclampsia. Nat Med 2006; 12:642-9.
- Levine RJ et al. Trial of calcium to prevent pre-eclampsia. N Eng J Med 1997; 337:69-76.
- Maynard SE et al. Excess placental soluble fms-like tyrosine kinase 1 (sFlt1) may contribute to endothelial dysfunction, hypertension, and proteinuria in pre-eclampsia. J Clin Invest 2003; 111:649-58.
- Hornig C et al. Soluble VEGF receptors. Angiogenesis 1999; 3:33-9.
#3
Q. Some providers mentioned that they are recommending that all of their prenatal patients take a fish oil capsule every day, for the omega 3 fatty acids for fetal brain development, hypertensive disorders, and depression. Is this something that you are recommending also?
A.
There are some intriguing initial results psychomotor development of infants, etc… but there needs to be more evidence. Here are a few of the areas that need to be resolved: the correct dose is unknown, the actual quantity in the many supplements is unknown, too much fish oil could produce a deleterious hypervitaminosis A scenario, and there is no data on methyl Hg content. Below are a few references. Additional available upon request
-Tofail F, Kabir I, Hamadani JD, Chowdhury F, Yesmin S, Mehreen F, Huda SN. Supplementation of fish-oil and soy-oil during pregnancy and psychomotor development of infants. J Health Popul Nutr. 2006 Mar;24(1):48-56.
-Szajewska H, Horvath A, Koletzko B. Effect of n-3 long-chain polyunsaturated fatty acid supplementation of women with low-risk pregnancies on pregnancy outcomes and growth measures at birth: a meta-analysis of randomized controlled trials. Am J Clin Nutr. 2006 Jun;83(6):1337-44.
-Genuis SJ, Schwalfenberg GK. Time for an oil check: the role of essential omega-3 fatty acids in maternal and pediatric health. J Perinatol. 2006 Jun;26(6):359-65.
-Knudsen VK, Hansen HS, Osterdal ML, Mikkelsen TB, Mu H, Olsen SF. Fish oil in various doses or flax oil in pregnancy and timing of spontaneous delivery: a randomised controlled trial. BJOG. 2006 May;113(5):536-43. Epub 2006 Mar 27.
-Shoji H, Franke C, Campoy C, Rivero M, Demmelmair H, Koletzko B. Effect of docosahexaenoic acid and eicosapentaenoic acid supplementation on oxidative stress levels during pregnancy. Free Radic Res. 2006 Apr;40(4):379-84.
-Olafsdottir AS, Skuladottir GV, Thorsdottir I, Hauksson A, Thorgeirsdottir H, Steingrimsdottir L. Relationship between high consumption of marine fatty acids in early pregnancy and hypertensive disorders in pregnancy. BJOG. 2006 Mar;113(3):301-9.
-Williams CM, Burdge G. Related Articles, Long-chain n-3 PUFA: plant v. marine sources.
Proc Nutr Soc. 2006 Feb;65(1):42-50.
-Burdge GC, Sherman RC, Ali Z, Wootton SA, Jackson AA. Docosahexaenoic acid is selectively enriched in plasma phospholipids during pregnancy in Trinidadian women--results of a pilot study.
Reprod Nutr Dev. 2006 Jan-Feb;46(1):63-7.
-Paletz EM, Craig-Schmidt MC, Newland MC. Gestational exposure to methylmercury and n-3 fatty acids: effects on high- and low-rate operant behavior in adulthood.
Neurotoxicol Teratol. 2006 Jan-Feb;28(1):59-73.
-Kulkarni A, Downes E, Crook M. Successful outcome of pregnancy in a patient with familial hypertriglyceridaemia. J Obstet Gynaecol. 2006 Jan;26(1):66-7.
Freeman MP, Hibbeln JR, Wisner KL, Brumbach BH, Watchman M, Gelenberg AJ. Randomized dose-ranging pilot trial of omega-3 fatty acids for postpartum depression. Acta Psychiatr Scand. 2006 Jan;113(1):31-5.
-Pontes PV, Torres AG, Trugo NM, Fonseca VM, Sichieri R. n-6 and n-3 Long-chain polyunsaturated fatty acids in the erythrocyte membrane of Brazilian preterm and term neonates and their mothers at delivery. Prostaglandins Leukot Essent Fatty Acids. 2006 Feb;74(2):117-23.
Other
Maternal oxygen administration for fetal distress
CONCLUSION: The administration of supplemental oxygen to laboring patients with nonreassuring fetal heart rate patterns increases fetal oxygen saturation substantially and significantly. Fetuses with the lowest initial oxygen saturations appear to increase the most.
Haydon ML, et al The effect of maternal oxygen administration on fetal pulse oximetry during labor in fetuses with nonreassuring fetal heart rate patterns. Am J Obstet Gynecol. 2006 Sep;195(3):735-8
OB/GYN CCC Editorial comment:
Haydon et al would seem to be encouraging that the administration of supplemental oxygen to laboring patients with nonreassuring fetal heart rate patterns increases fetal oxygen saturation substantially and significantly. Rather, meaningful data could not be gleaned from this relatively small sample size regarding changes in FHR patterns that were subsequent to oxygen supplementation.
Unfortunately, there were no consistent changes in FHR after exposure to oxygen. The specific aspects of these changes could be addressed only in a much larger study. Haydon et al’s findings do not support or refute the use of supplemental oxygen for any specific nonreassuring FHR pattern. This would require more patients having each abnormal pattern type for analysis. Additional studies are necessary to determine the optimal supplemental oxygen concentration in labor. Larger studies would be required to evaluate the effects of oxygen therapy in nonreassuring FHR patterns on neonatal outcomes that include umbilical cord blood analyses, ventilatory assistance, and neonatal intensive care admission.
At this point the following conclusion from the Cochrane Library* still stands: There is not enough evidence to support the use of prophylactic oxygen therapy for women in labour, nor to evaluate its effectiveness for fetal distress.
In the meantime, I suggest that we initially give the laboring patient with a questionable strip a bolus of intravenous fluids to increase intravascular volume, hence increasing perfusion in addition to other conservative measures, e. g., position change, oxygen supplementation, and intrauterine resuscitation.
*Fawole B, Hofmeyr GJ. Maternal oxygen administration for fetal distress. Cochrane Database of Systematic Reviews 2003, Issue 4. Art. No.: CD000136. DOI: 10.1002/14651858.CD000136.
http://www.ihs.gov/MedicalPrograms/CIR/index.cfm?module=cir_answering_clinical_questions
Is there a nuchal translucency measurement above which there is no added benefit from first trimester serum screening?
CONCLUSION: During first trimester Down syndrome screening, whenever an NT measurement of 3.0 mm or greater is obtained there is minimal benefit in waiting for serum screening results, and no benefit for NT of 4.0 mm or greater. Differentiation between cystic hygroma and enlarged simple NT (> or = 3.0 mm) is now a moot point as both are sufficiently high risk situations to warrant immediate CVS.
Comstock CH, et al Is there a nuchal translucency millimeter measurement above which there is no added benefit from first trimester serum screening? Am J Obstet Gynecol. 2006 Sep;195(3):843-7
Repeat antenatal corticosteroids do not improve composite neonatal outcome
CONCLUSION: Repeat antenatal corticosteroids significantly reduce specific neonatal morbidities but do not improve composite neonatal outcome. This is accompanied by reduction in birth weight and increase in small for gestational age infants.
Wapner RJ, et al Single versus weekly courses of antenatal corticosteroids: evaluation of safety and efficacy. Am J Obstet Gynecol. 2006 Sep;195(3):633-42.
Outcomes after first pregnancy with early-onset preeclampsia is generally favorable
Recurrence rates for preeclampsia or preterm delivery were not related to severity of first pregnancy complications, including delivery before 28 weeks of gestation, occurrence of hemolysis, elevated liver enzymes, and low platelet count syndrome, small-for-gestational age infants, and to hereditary or acquired thrombophilias.
van Rijn BB, et al Outcomes of subsequent pregnancy after first pregnancy with early-onset preeclampsia. Am J Obstet Gynecol. 2006 Sep;195(3):723-8.
Antenatal assessment of chorionicity is accurate; incorrect Dx affect reliable management
RESULTS: Chorionicity was correctly assigned antenatally in 392/410 (95.6%) twins. The sensitivity, specificity, and positive and negative predictive values of monochorionicity assessed < or = 14 weeks were 89.8%, 99.5%, 97.8%, and 97.5%. Corresponding statistical values for the second trimester were 88.0%, 94.7%, 88.0%, and 94.7%. Two cases of inaccurate antenatal diagnoses affected patient counseling or were associated with adverse clinical outcomes. CONCLUSION: Antenatal assessment of chorionicity is accurate; however, incorrect diagnoses do occur and can affect reliable patient counseling and management.
Lee YM, et al Antenatal sonographic prediction of twin chorionicity Am J Obstet Gynecol. 2006 Sep;195(3):863-7.
AFI and birth weight: Is there a relationship in diabetics with poor glycemic control?
CONCLUSION: The previously noted relationship between elevated AFI and BW centiles in the general patient population is linear in diabetic patients with poor glycemic control.
Vink JY, et al Amniotic fluid index and birth weight: Is there a relationship in diabetics with poor glycemic control? Am J Obstet Gynecol. 2006 Sep;195(3):848-50.
Doppler peak velocity in the middle cerebral artery can replace invasive testing
CONCLUSIONS: Doppler measurement of the peak velocity of systolic blood flow in the middle cerebral artery can safely replace invasive testing in the management of Rh-alloimmunized pregnancies.
Oepkes D, et al Doppler ultrasonography versus amniocentesis to predict fetal anemia. N Engl J Med. 2006 Jul 13;355(2):156-64
Placental inflammation and viral infection implicated in second trimester pregnancy loss
CONCLUSION: These studies demonstrate that spontaneous second trimester loss is strongly associated with histologic chorioamnionitis and viral infections.
Srinivas SK, et al Placental inflammation and viral infection are implicated in second trimester pregnancy loss Am J Obstet Gynecol. 2006 Sep;195(3):797-802
Primary Care Discussion Forum
December 1, 2006
Causes of Type 2 Diabetes: Old and New Understandings
Moderator: Ann Bullock M.D.
In 2002, the International Diabetes Federation determined that the medical literature supports 4 etiologies of type 2 diabetes:
--Genetics
--Fetal Origins
--Lifestyle
--Stress
We will explore these issues
- Diabetes prevention programs focus on lifestyle modification—what might these programs look like if lifestyle is only one factor?
- What else can be learned from the DPP (Diabetes Prevention Program)?
- Pregnancy and early life risk factors
- What are the particular roots of the diabetes and obesity epidemics in Indian Country
How to subscribe / unsubscribe to the Primary Care Discussion Forum?
Subscribe to the Primary Care listserv
http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=51
Unsubscribe from the Primary Care listserv
http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=51
Questions on how to subscribe, contact nmurphy@scf.cc directly
STD Corner - Lori de Ravello, National IHS STD Program
Prevalence of HPV Infection among Men: A Systematic Review of the Literature
Background. Human papillomavirus (HPV) infection is estimated to be the most common sexually transmitted infection; an estimated 6.2 million persons are newly infected every year in the United States. There are limited data on HPV infection in heterosexual men.
Results. We included a total of 40 publications on HPV DNA detection and risk factors for HPV in men; 27 evaluated multiple anatomic sites or specimens, 10 evaluated a single site or specimen, and 3 evaluated risk factors or optimal anatomic sites/specimens for HPV detection. Twelve studies assessed site- or specimen-specific HPV DNA detection. HPV prevalence in men was 1.3%–72.9% in studies in which multiple anatomic sites or specimens were evaluated; 15 (56%) of these studies reported _20% HPV prevalence. HPV prevalence varied on the basis of sampling, processing methods, and the anatomic site(s) or specimen(s) sampled. We included 15 publications reporting HPV seroprevalence. Rates of seropositivity depended on the population, HPV type, and methods used. In 9 studies that evaluated both men and women, all but 1 demonstrated that HPV seroprevalence was lower in men than in women.
Conclusion. HPV infection is highly prevalent in sexually active men and can be detected by use of a variety of specimens and methods. There have been few natural-history studies and no transmission studies of HPV in men. The information that we have reviewed may be useful for future natural-history studies and for modeling the potential impact of a prophylactic HPV vaccine.
Dunne, E et al Prevalence of HPV Infection among Men: A Systematic Review of the Literature. J Infect Dis 2006:194 (15 October)
http://www.journals.uchicago.edu/JID/journal/issues/v194n8/36645/36645.web.pdf
Other
FDA Approves the First Once-a-Day Three-Drug Combination Tablet for
Treatment of HIV-1
Atripla is a Landmark Achievement of Three Cooperating Companies
The Food and Drug Administration (FDA) today announced approval of Atripla Tablets, a fixed-dose combination of three widely-used antiretroviral drugs, in a single tablet taken once a day, alone or in combination with other antiretroviral products for the treatment of HIV-1 infection in adults.
Atripla, the first one-pill, once-a-day product to treat HIV/AIDS, combines the active ingredients of Sustiva (efavirenz), Emtriva (emtricitabine) and Viread (tenofovir disoproxil fumarate). Bristol-Myers Squibb and Gilead Sciences have formed a joint venture to commercialize Atripla in the United States. The collaboration is the first of its kind in the field of HIV/AIDS. In certain territories, Merck holds the rights to efavirenz. All three companies will work together to ensure the product is available to patients and physicians. Atripla will be available for use in the United States as a new product approved under a new drug application (NDA). This would allow the drug to be considered for purchase for use in 15 other countries included under the President's Emergency Plan for AIDS Relief (PEPFAR). HIV-1 affects people worldwide.
The approval of Atripla comes as the result of an expedited review process outlined in a guidance by the FDA in May 2004. With today's approval, FDA will have approved seven co-packaged or fixed-dose combination products since the guidance was issued. For more information about the FDA's Expedited Review Process for HIV/AIDS Drugs, please go to: http://www.fda.gov/oc/initiatives/hiv/
"This new product offers a welcome option for prescribers who follow
the recommended initiation of HIV-1 treatment with at least three highly active
antiretroviral drugs, a regimen that has the potential to significantly improve
the condition of many patients, and help them adhere to their regimen to help
minimize the development of viral resistance," said Dr. Steven Galson, Director
of FDA's Center for Drug Evaluation and Research. "Because all three components
of Atripla have been in use for some time, their characteristics and effects
are well known."
http://www.fda.gov/cder/drug/infopage/atripla/default.htm or http://www.fda.gov/cder/drug/infopage/atripla/qa.htm .
From Scott Giberson, Scott.Giberson@ihs.gov IHS HIV Principal Consultant
NIH launches new HIV Vaccine awareness campaign
and support of HIV vaccine research, as well as trust and participation in the research. The campaign, launched by the National Institute of Allergy and Infectious Diseases, works with community leaders, community-based and national organizations, health professionals, and educators to provide communities most affected by HIV with information about preventive HIV vaccine research and what they should know about HIV vaccine. The campaign Web site, which features background information, how to get involved, an HIV vaccine quiz, frequently asked questions, and resources, is available at http://www.bethegeneration.org
A campaign toolkit containing brochures, stickers, fact sheets, and customizable posters (many of which are available in English and Spanish) is also available at http://www.bethegeneration.org/toolkit.htm
Barbara Stillwater, Alaska State Diabetes Program
No improvement in fetal outcome, plus increased maternal morbidity: Who pays for this?
You do
More than one-quarter of all children born in the United States—over 1 million—are delivered by Cesarean section. The national bill for childbirth as a whole in 2003 totaled $34 billion, with hospital stays for C-section delivery accounting for nearly half this amount—$15 billion. Medicaid was billed for 43 percent of childbirths overall and 41 percent of those for C-section delivery. Agency for Healthcare Research and Quality, HCUP, Statistical Brief #11: Hospitalizations Related to Childbirth, 2003 http://www.hcup-us.ahrq.gov/reports/statbriefs/sb11.jsp
Who Responds to Glyburide for Gestational Diabetes?
Gestational diabetes mellitus is increasingly common and in some populations occurs in up to 14 percent of mothers. Successful treatment of gestational diabetes is associated with reduced serious maternal and fetal morbidity. Oral glyburide (Micronase) is as effective as insulin in achieving glycemic control and is associated with birth weights similar to infants whose mothers were treated with insulin. Many patients prefer oral glyburide to insulin treatment. Glyburide also is less expensive and less likely to cause hypoglycemia. However, some women do not achieve adequate glycemic control with glyburide. Kahn and colleagues studied predictors of failure of glyburide treatment with the aim of developing a tool to identify those women in whom glyburide therapy is less likely to be successful, thereby avoiding weeks of inadequate glycemic control during pregnancy.
|
Clinical Characteristics and Predictors of Glyburide (Micronase) Treatment Failure in Women with Gestational Diabetes |
||||
|
Characteristic |
Total women (N = 95) |
Glyburide failure (N = 18) |
Glyburide success (N = 77) |
P (student t-test) |
|
Maternal age (years) |
30 ± 6 |
34 ± 5 |
29 ± 5 |
.001 |
|
Maternal BMI (kg per m 2 ) |
30 ± 7 |
32 ± 8 |
30 ± 6 |
.23 |
|
Gravidity |
3 ± 2 |
4.3 ± 2.7 |
2.7 ± 1.6 |
.01 |
|
Parity |
1.2 ± 1.2 |
2 ± 1.7 |
1 ± 1 |
.03 |
|
Cigarette smoking |
8 (8) |
1 (6) |
7 (9) |
.7 |
|
History of gestational diabetes |
15 (16) |
5 (28) |
10 (13) |
.12 |
|
Gestational age at diagnosis |
27 ± 6 |
22.7 ± 7 |
28 ± 5 |
.002 |
|
Gestational age at start of glyburide (weeks) |
30 ± 6 |
24 ± 7 |
31 ± 4 |
.001 |
|
Fasting blood glucose level on three-hour glucose tolerance test (mg per dL) |
102 ± 19 |
112 ± 24 |
100 ± 17 |
.045 |
|
Weight gain (lb) |
26 ± 18 |
28 ± 26 |
26 ± 15 |
.94 |
|
BMI = body mass index. note: Values are mean ± standard deviation or n (%). Adapted with permission from Kahn BF, Davies JK, Lynch AM, Reynolds RM, Barbour LA. Predictors of glyburide failure in the treatment of gestational diabetes. Obstet Gynecol 2006;107:1306. |
||||
The authors conclude that glyburide is an effective and attractive treatment option for many mothers with gestational diabetes. Although 80 percent of mothers overall are successful with this therapy, it is most likely to fail in older, multiparous women with higher blood glucose levels early in pregnancy. The authors speculate that these women have increased insulin resistance and may be better treated with early initiation of insulin therapy.
Kahn BF, et al. Predictors of glyburide failure in the treatment of gestational diabetes. Obstet Gynecol June 2006;107:1303-9.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd
=Retrieve&dopt=AbstractPlus&list_uids=16738156
Nearly one out of two women with gestational diabetes also have periodontal
disease
In contrast, just over one in ten pregnant women without gestational diabetes
have periodontal disease. The study is the first to demonstrate a link between
poor oral health and diabetes during pregnancy.
The team of researchers analyzed health data from 256 pregnant women who participated
in the National Health and Nutrition Examination Study III. Based on their analysis,
the researchers recommend that dental care during pregnancy should be considered
as a way to help prevent gestational diabetes. Xiong
X, et al Periodontal disease and gestational diabetes mellitus. Am
J Obstet Gynecol. 2006 Oct;195(4):1086-9
Mothers Who Gain Weight Between Pregnancies Experience Pregnancy Complications
FINDINGS: Compared with women whose BMI changed between -1.0 and 0.9 units, the adjusted odds ratios for adverse pregnancy outcomes for those who gained 3 or more units during an average 2 years
INTERPRETATION: These findings lend support to a causal relation between being overweight or obese and risks of adverse pregnancy outcomes. Additionally they suggest that modest increases in BMI before pregnancy could result in perinatal complications, even if a woman does not become overweight. Our results provide robust epidemiological evidence for advocating weight loss in overweight and obese women who are planning to become pregnant and, to prevent weight gain before pregnancy in women with healthy BMIs.
Villamor E, Cnattingius S. Interpregnancy weight change and risk of adverse pregnancy outcomes: a population-based study. Lancet. 2006 Sep 30;368(9542):1164-70
The growing trends in maternal obesity
How does obesity affect reproductive health and fertility? International research was initiated to answer these questions and investigate the impact and consequences of obesity on women’s health.
This month’s edition of the BJOG journal documents a number of these articles and is devoted entirely to obesity and its effects on women, in particular to problems associated with maternal obesity.
There are 16 scientific studies, review articles, and commentaries in the October issue, conducted by leading experts in the specialty. Topics covered include: prioritising for IVF and fertility treatment (Farquhar and Gillett), prevention and management strategies (Krishnamoorthy, Schram and Hill), difficulties in operating on obese women (Alexander and Liston), increased need for, and risks associated with, caesarean-sections (Barau et al), and the impaired effectiveness of epidurals during labour (Dresner et al).
http://www.blackwell-synergy.com/toc/bjo/113/10?cookieSet=1
Impact of Obesity on PCOS and Reproductive Health
About 50% of women with PCOS are overweight, and this increase in body weight has a major influence on the symptoms of PCOS and fertility.
This month’s edition of the BJOG journal documents a number of research articles on the impact of obesity on PCOS and reproductive health. PCOS is a major health problem affecting women of all ages. The prevalence of PCOS appears to be rising because of the current epidemic of obesity. PCOS accounts for 90-95% of women who attend infertility clinics with anovulation. Some of the symptoms such as unwanted facial and bodily hair, acne, obesity and infertility have profound effects on the quality of life for these women.”
There are a number of interlinking factors that affect expression of the syndrome. A gain in weight is associated with a worsening of symptoms whilst weight loss will improve the disease profile and its symptoms. The main clinical features are menstrual cycle disturbance and an increase in male hormones (hyperandrogenism), causing acne, unwanted bodily and facial hair, and alopecia.
Obesity has a negative impact on spontaneous conception, miscarriage, pregnancy and the long term health of both mother and child due to both an increased rate of congenital anomalies and the possibility of metabolic disease (including diabetes) in later life. In women with PCOS and a body mass index (BMI) >35kg/m2, 20% of pregnancies ended with stillbirth and another 20% had congenital anomalies. The supposed mechanism that increases stillbirth and congenital anomaly rate includes insulin resistance and impending or undiagnosed diabetes.
http://www.blackwell-synergy.com/toc/bjo/113/10?cookieSet=1
Metformin Use Increases Vitamin B12 Deficiency
CONCLUSIONS: Our results indicate an increased risk of vitamin B(12) deficiency associated with current dose and duration of metformin use despite adjustment for many potential confounders. The risk factors identified have implications for planning screening or prevention strategies in metformin-treated patients.
Ting RZ, et al Risk factors of vitamin B(12) deficiency in patients receiving metformin. Arch Intern Med. 2006 Oct 9;166(18):1975-9.
Gestational Diabetes Act 2006 – Summary
The proposed act has 3 main components
-Understanding and Monitoring Gestational Diabetes and Obesity during Pregnancy
-Demonstration Grant Programs
-Research Expansion of Gestational Diabetes and Obesity during Pregnancy
For more details from the American Diabetes Association
http://www.diabetes.org/advocacy-and-legalresources/federal_legislation/Gestational.jsp
Gestational Diabetes Increases the Risk of Cardiovascular Disease
Among women with a family history of type 2 diabetes, those with prior GDM were
more likely to have CVD risk factors.
From the results it was concluded that among women with a family history of type
2 diabetes, those with prior GDM were even more likely to not only have CVD risk
factors, including metabolic syndrome and type 2 diabetes, but also to have experienced
CVD events, which occurred at a younger age. Thus, women with both a family history
of type 2 diabetes and personal history of GDM may be especially suitable for
early interventions aimed at preventing or reducing their risk of CVD and diabetes.
Carr DB, et al Gestational diabetes mellitus increases the risk of cardiovascular disease in women with a family history of type 2 diabetes. Diabetes Care 29: 2078-2083.
Cardiovascular Risk Higher for Women Than Men With Type 2 Diabetes
Women with type 2 diabetes face a higher risk of cardiovascular disease than
do men with type 2 diabetes.
Women were 3.19 times more likely than men to develop cardiovascular disease, the investigators calculate. After adjustment for age, blood pressure, body-mass index, dyslipidemia, smoking, and urinary albumin excretion, the risk increased to 6.4-fold, and adjustment that included retinopathy increased the risk to 8.23-fold.
Female sex was an independent risk factor for macrovascular disease and death in our study population of normotensive patients with type 2 diabetes and microalbuminuria.
Further research is needed to fully elucidate the pathogenesis of this excessive risk in women with type 2 diabetes because, at this point, we did not find risk indicators that discriminate between women with high and low risk of cardiovascular disease.
Zandbergen AA, et al Normotensive women with type 2 diabetes and microalbuminuria are at high risk for macrovascular disease. Diabetes Care 2006;29:1851-1855
Diabetes Kills Both Obese And Non-obese Alike
Diabetes is the killer, equally so for obese or non-obese people with diabetes, say researchers from the University of Kentucky and the University of Emory, Atlanta, USA. Risk of death from obesity without diabetes is tiny when compared to risk of death with diabetes.
The researchers found that obese people, those with a Body Mass
Index (BMI) over 30, who do not have diabetes are not at a greater risk of death
than non-obese people without diabetes.
-- 11.9% of all the people had diabetes (types I or II)
-- 52% of those with diabetes were obese
-- 24% of those without diabetes were obese
-- The higher the BMI, the higher was the prevalence of diabetes
-- Organ failure risk was linked to older people, males, diabetes sufferers and
those with lower levels of lung function
Morbidly obese patients, those with a BMI over 40, were not examined separately in this study. It is also possible that the risks for non-diabetic obese people need more than a three-year study, said the researchers.
The researchers concluded that the risk of acute organ failure, followed by death, is more closely linked to whether a person has diabetes than whether or not he/she is obese.
Slynkova K et al The role of body mass index and diabetes in the development of acute organ failure and subsequent mortality in an observational cohort Critical Care 2006, 10:R137 doi:10.1186/cc5051
More Midlife Physical Activity Leads to More Old-Age Mobility
More physical activity in midlife translates to more physical mobility in old
age, researchers conclude in a new study of older adults living in the Chianti
region of Italy.
Previous studies have shown that physical activity in midlife can help prevent
a variety of chronic diseases. This study shows that greater physical activity
in your 30s, 40s and 50s has beneficial effects well into the future by helping
us maintain our ability to walk and function at older ages."
CONCLUSIONS: Older adults who reported higher levels of physical activity in midlife had better mobility in old age than less physically active ones.
Patel KV, et al. Midlife physical activity and mobility in older age: the In CHIANTI study. Am J Prev Med 31(4), 2006.
What's new on the ITU MCH web pages?
Special Care Clinic – Phoenix Indian Medical Center (PPT)
Heard about prenatal care and postpartum care? Here is something on Internatal care (PPT)
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
Best Practices and GPRA Tracking
- Nov 1-2, 2006
- Sacramento CA
- California IHS Area Office, Contact Elaine.brinn@ihs.gov
- http://www.ihs.gov/MedicalPrograms/MCH/F/documents/BestPracticesFlyer1.pdf
22nd Annual Midwinter Indian Health OB/PEDS Conference
- For providers caring for Native women and children
- January 26-28, 2007
- Telluride, CO
- Contact Alan Waxman awaxman@salud.unm.edu
TeenScreen Conference: Second Annual
- March 14 and 15, 2007
- Washington D.C.
- ContactTSConference@childpsych.columbia.edu
2nd International Meeting on Indigenous Child Health
- April 20-22, 2007
- Montreal , Quebec, Canada
- Solutions, not Problems
- Joint meeting of IHS, AAP-CONACH, First Nations and several other stakeholders
- http://www.aap.org/nach/2InternationalMeeting.htm
2007 Indian Health MCH and Women’s Health National Conference
- August 15 -17, 2007
- Albuquerque , NM
- THE place to be for anyone involved in care of AI/AN women, children
- Internationally recognized speakers
- Save the dates. Details to follow
- 10 months away and counting
- Want a topic discussed? Contact nmurphy@scf.cc
Did you miss something in the last OB/GYN Chief Clinical Consultant Corner?
The September 2006 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.
