|
August 2005 CCC Corner > From
Your Colleagues
From your colleagues
Sandy Haldane, HQE
New IHS Women’s Health Consultant
and Advanced Practice Nurse Consultant
Please help me welcome CAPT Carolyn Aoyama to IHS Headquarters, Division
of Nursing.
As the IHS Women’s Health Consultant Carolyn will represent the IHS
on matters of women’s health, providing leadership and technical assistance
on program development, implementation, evaluation, and policy. As the
Advanced Practice Nurse Consultant, Carolyn will provide leadership and technical
expertise on matters pertaining to policy and standards of practice as they pertain
to Nurse Practitioners, Certified Nurse Midwives, and Certified Registered Nurse
Anesthetists. Carolyn received her BSN from the University of WI, her MPH
from Johns Hopkins and is also a Certified Nurse Midwife. Carolyn began
her nursing career in IHS as a PHN at Ft. Defiance. Carolyn has worked
as a CNM in the inner city of Baltimore and Phoenix and as the Maternal Child
Health Consultant for the State of Alaska’s Department of Health and Social
Services. Subsequently she worked as an EIS Officer with the CDC, a Public
Health Advisor in the Perinatal Care Program of HRSA’s Bureau of Primary
Health Care (BPHC), Nurse Consultant for Mental Health/Substance Abuse Service
(HRSA/BPHC/Division of Community and Migrant Health), a Community Health Center
Project Officer with HRSA/BPHC, and most recently as a Nurse Consultant with
HRSA/Bureau of Health Professions/Division of Nursing. Carolyn can be reached
at 301-443-1028 or in Suite 300 of the Reyes Building.
Public health approach to suicide prevention in an American Indian Tribal
Nation
CONCLUSIONS: Data from this community-based approach document a remarkable
downward trend-measured by both magnitude and temporal trends in the specifically
targeted age cohorts-in suicidal acts. The sequential decrease in age-specific
rates of suicide attempts and gestures is indicative of the program's success.
May
PA et al Outcome evaluation of a public health approach to suicide prevention
in an American Indian Tribal Nation. Am J Public Health. 2005 Jul;95(7):1238-44.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15933239&dopt=Abstract
Healthy Native Communities Fellowship accepting applications for 2006
Designed to build the capacity for effective health promotion practices at
the local level by increasing the knowledge, skills, and capacities of Tribal,
IHS, and Urban Indian health workers and leaders. Deadline September 1, 2005 http://www.ihs.gov/hpdp
Cardiovascular Disease: The Kaw Nation and other minority populations
Cordelia Clapp: Minority Nurse Magazine http://www.minoritynurse.com/features/health/05-03-05e.html
Ruth Lagerberg, CNM, formerly ANMC
Fetal cardiac echogenic foci on routine obstetric sonogram
What is your recommendation for follow-up for the finding of fetal cardiac
echogenic foci on routine ob sono? Level II looking for other markers of
trisomy 21 or fetal cardiac Doppler or no f/u necessary? I am working at
a community health center north of NYC - the nearest perinatologist is over an
hour away and many of our patients have limited resources, including transportation
difficulties. Level II sonos are available locally. Our back-up OBs
differ on their opinion of f/u. I did a lit search, but the literature
differs on recommendations as well.
OB/GYN CCC Editorial comment:
As luck would have it, the Indian Health system has two resources to offer
on these issues. There is a helpful FAQ, plus a free CEU /CME module
Q. What is the significance 2 nd trimester of ultrasound ( US) markers
for Down syndrome?
A. If US markers are negative, then decrease the risk by serum testing in
~1/2.
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/DSultra42205.doc
Prenatal Genetic Screening – Serum and Ultrasound - CEU
/CME module
http://www.ihs.gov/MedicalPrograms/MCH/M/TM01.cfm
Sheila F. Mahoney CNM, NIH
Cord clamping: Early versus delayed
Referring to the benefits of delayed cord clamping cited in June’s
OB/GYN & Pediatrics CCC Corner*:
I would like to refer readers to another study which showed benefits of delayed
cord clamping in preterm neonates -
CONCLUSION: The research design is feasible. The immediate benefit of improved
blood pressure was confirmed and other findings deserve consideration for further
study.
Mercer
JS, McGrath MM, Hensman A, Silver H, Oh W. Immediate and delayed cord clamping
in infants born between 24 and 32 weeks: a pilot randomized controlled trial.
J Perinatol. 2003 Sep;23(6):466-72.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=13679933&query_hl=6
…..and to an excellent review of this topic which concluded that there
were benefits of delayed cord clamping in both preterm and full term neonates.
CONCLUSION: For both term and preterm infants, few, if any, risks were associated
with delayed cord clamping. Longitudinal studies of infants with immediate and
delayed cord clamping are needed.
Mercer
JS. Current best evidence: a review of the literature on umbilical cord clamping.
J Midwifery Womens Health. 2001 Nov-Dec;46(6):402-14. Review.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11783688&query_hl=6
OB/GYN CCC Editorial comment:
At this time the comments above are best applied to pre-term delivery as
the weight of evidence favors early cord clamping in term delivery.
There are two main approaches to term third stage management
Expectant management — Expectant or physiologic management consists
of delivery of the placenta without the use of uterotonic agents, cord clamping,
or cord traction.
Active management — Active management generally consists of early cord
clamping, controlled cord traction, and administration of a uterotonic agent.
A classic study randomly assigned 1795 women to expectant or active third
stage labor management. Actively managed patients
-received 5 IU of oxytocin and 0.5 mg of ergometrine upon delivery of the
fetal anterior shoulder
-followed by controlled cord traction.
Almost all women allocated to active management actually received it, while
just under one-half of those allocated to physiological management received no
intervention. The active management group had a significantly lower incidence
of postpartum hemorrhage (6 versus 18 percent) and a shorter median duration
of the third stage (5 versus 15 minutes).
A Cochrane review of five studies comparing active versus expectant management
of the third stage of labor. Expectant management of the third stage of labour
involves allowing the placenta to deliver spontaneously or aiding by gravity
or nipple stimulation. Active management involves administration of a prophylactic
oxytocic before delivery of the placenta, and usually early cord clamping and
cutting, and controlled cord traction of the umbilical cord.
Cochrane found that active management was associated with reduced risks of:
maternal blood loss (weighted mean difference -79.33 mL, 95 percent CI -94.29
to -64.37); postpartum hemorrhage of more than 500 mL (relative risk 0.38, 95
percent CI 0.32 to 0.46); and prolonged third stage of labor (weighted mean difference
-9.77 minutes, 95 percent CI -10.00 to -9.53). Active management was defined
as administration of a prophylactic oxytocic before delivery of the placenta;
typically with early cord clamping and cutting and controlled traction of the
umbilical cord. The authors concluded that "active management should be
the routine management of choice for women expecting to deliver a baby by vaginal
delivery in a maternity hospital.
Active management of labor is the most common standard of care for term patients,
plus there is recent data from Indian Country to support active management of
term third stage of labor in Indian Health. http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0705_Feat.cfm#navajo
Resources
Prendiville WJ; Elbourne D; McDonald S Active versus expectant management
in the third stage of labour. Cochrane Database Syst Rev 2000;(3):CD000007.
http://www.update-software.com/cochrane/abstract.htm
Prendiville WJ; Harding JE; Elbourne DR; Stirrat GM The Bristol third stage
trial: active versus physiological management of third stage of labour. BMJ 1988
Nov 19;297(6659):1295-300.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=3144366&query_hl=12
Rabe H, et al. Early versus delayed umbilical cord clamping in preterm infants.
Cochrane Database Syst Rev 2004;(3):CD003248
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15495045&query_hl=6
Chuck North, Albuquerque
Advances in Indian Health, 6th Annual
Save the dates brochure
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/Advancesflyer2006.pdf
Miles Rudd, Warm Springs, OR
Relative value of physical exam of the breast as a screening tool
Miles Rudd at Warm Springs, OR raised the issue of the relative value of
physical exam of the breast exam in cancer screening.
Here are some brief bulleted points for Dr. Eve Espey’s presentation
on Breast Cancer at the 2005 IHS / ACOG Obstetric, Neonatal and Gynecologic Care
Postgraduate Course. More complete discussion below.
Breast self exam (BSE) Canadian Task Force on Prevention*
Fair evidence of no benefit
Good evidence of harm
Overall fair evidence that routine teaching of BSE should be excluded from
the annual exam
USPSTF: 2002, Should we recommend BSE?
BSE: insufficient evidence to recommend for or against
Studies evaluating BSE
- 2 RCTs, 1 quasi RCT, 3 case-control studies
- No difference in breast cancer mortality
- No difference in stage of cancer at diagnosis
- More provider visits: 8% vs. 4%
- More benign biopsies
ACOG Practice Bulletin: Breast cancer screening, April, 2003
Despite a lack of definitive data for or against breast self-examination,
breast self-examination has the potential to detect palpable breast cancer and
can be recommended.
Costs of BSE
- $700 per competent frequent self-examiner
- Opportunity cost: limited time for counseling
- Anxiety, worry, depression
Summary
- Take down your shower card for BSE
- Encourage mammography
- Work up palpable masses
- Don’t worry quite so much…
OB/GYN CCC Editorial comment:
The data shows that the foundation of any breast cancer screening effort
is a comprehensive mammography based program. The history and physical examination
are an important adjuncts to screening, but should not delay, or become barriers
to mammography. An equally important public health systems ‘process’ is
a robust follow-up system. The RPMS Women’s Health Program, or other tracking
system software packages, can be critical to maintaining adequate screening follow
up.
What is the Indian Health Manual suggested approach? National benchmarks?
The Indian Health Manual suggested approach is based on mammography and is
compatible with national benchmarks. The article referenced below is a good summary
of the national benchmarks, though is not entirely internally consistent. The
first part of the article articulates the limitations of the data on clinical
breast exam (CBE). The second part (their ‘Recommendations’) is essentially
a primer on performing the extensive Mammacare exam.
Though Mammacare has been shown to find more lesions during the lengthy exam,
the increased detection of non-malignant lesions does not improve breast cancer
outcomes.
Saslow
D, et al Clinical breast examination: practical recommendations for optimizing
performance and reporting. CA Cancer J Clin. 2004 Nov-Dec;54(6):327-44
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15537576&query_hl=2
The above are just a few of Dr. Espey’s many helpful points. The whole
presentation is here: http://www.ihs.gov/MedicalPrograms/MCH/M/documents/BreastCa2005.ppt
or
Please also see the Reference Text Chapter from the Postgraduate Course
http://www.ihs.gov/medicalprograms/MCH/M/MCHdownloads/Chap_P.pdf?page=2
IHS Manual Part 3 – Chapter 13.11F1
“Resources for screening mammography should be identified for patients
at increased risk for breast cancer as based upon age as well as other personal
and familial risk factors.”
http://www.ihs.gov/PublicInfo/Publications/IHSManual/Part3/pt3chapt13/pt3chpt13.htm
IHS Women’s Health Breast Cancer web page
../W/WHcancer.asp#breast
*USPSTF and Canadian TFPHC Rating of evaluations
A: Strong recommendation to include the service
B: Recommendation to include the service
C: No recommendation either for or against
D: Recommendation against routine provision of the service
I: Evidence insufficient
Jennifer Retsinas, ANMC
Uterine fibroids: uterine artery embolization versus abdominal hysterectomy
CONCLUSION: Compared with hysterectomy, UAE is safe and effective for treatment
of bleeding fibroids, necessitates a shorter hospital stay, and results in fewer
major complications
Pinto
I, et al Uterine fibroids: uterine artery embolization versus abdominal hysterectomy
for treatment--a prospective, randomized, and controlled clinical trial. Radiology.
2003 Feb;226(2):425-31.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12563136&query_hl=6
Phil Smith, HQE
New Outreach: Updated educational materials about the Prescription Drug Benefit
http://www.cms.hhs.gov/medicarereform/factsheets.asp
Judy Thierry, HQE
Many girls are at a literal standstill
Decline in physical activity plays key role in weight gain among adolescent
girls
http://www.nih.gov/news/pr/jul2005/nhlbi-13.htm
Trends and Regional Differences: Latest available
It has come to my attention that some of you do not have the latest Trends and Regional Differences publications produced by our Statistics Branch. The 2000-2001 Trends and Regional Differences contains data from 1996-1998. They are not online, hence you need to order the mailed publications. If you would like to order them, please go to https://propshop.psc.gov/ and begin by clicking the Product Distribution link.
Contact dsaum@psc.gov for any problems with ordering.
NB: Tribal and Seattle Urban program would follow under the '50 states category'. Please call us (DPS) at 301-443-1180 or Priscilla Sandoval 301-443-9436. We will provide your UserID and password.
Great resource: MCH Alert
If you have not subscribed to this list serve the link is below at the end
of the email and here as well.
To subscribe to MCH Alert, send an e-mail message to MCHAlert-request@list.ncemch.org
with SUBSCRIBE in the subject line. You do not need to enter any text in
the body of the message.
”Weaving WIC into Our Traditional Families”
National Indian and Native American Coalition August 27-30, 2005 Tempe, Arizona
http://www.itcaonline.com/event008/eventreg.html
Child Protection Handbook 2004, IHS/BIA
IHS Office of Behavioral Health - BIA funded the development of a CD ROM
http://www.ccan.ouhsc.edu/nativeamerican.asp or http://www.ccan.ouhsc.edu/CPT.htm
Carol Treat, Nutritionist, ANMC
Brochure/support for sugar substitute and gestational DM
http://www.ific.org/publications/brochures/upload/gestationaldiabetes.pdf
Back to top |
Acrobat
Flash
Zip File
WordPerfect
MS Word
Excel
PowerPoint
