August 2005 CCC Corner > Features
Features
American
Family Physician**
Aspirin Prevents Stroke, but Not Cardiovascular Disease, in Women
Clinical Question: Does aspirin prevent cardiovascular disease in women?
Bottom Line: Aspirin reduces the risk of stroke and transient ischemic attack
in women, but does not reduce the risk of myocardial infarction or cardiovascular
death. The reduction in strokes over 10 years (NNT = 444) must be balanced against
an increase in serious gastrointestinal bleeding (NNH = 553). No change regarding
all-cause mortality was seen in this large, long study.
(Level of Evidence: 1b) http://www.aafp.org/afp/20050801/tips/9.html
Intensive Diet-Behavior-Physical Activity Program for Obesity in Children
Clinical Question: Can a specific program of diet and exercise
result in sustained weight loss in children?
Bottom Line: An intensive three-month program of dietary counseling, a hypocaloric
diet, and structured exercise can cause weight loss in children that is sustained
over one year. More important, the program seemed to increase the amount of exercise
the children performed, and this increase was sustained after the intervention
was discontinued. (
Level of Evidence: 2b) http://www.aafp.org/afp/20050801/tips/7.html
* 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.
Other AFP
NSAIDs Alone or with Opioids as Therapy for Cancer Pain: Cochrane for Clinicians
Clinical Scenario
A 70-year-old woman is diagnosed with malignant melanoma that has metastasized
to the liver and lungs. She has begun to experience abdominal pain, which you
attribute to the liver metastases. She wants to know what you recommend for pain
management.
Clinical Question
What is the most effective therapy for the management of cancer pain?
Evidence-Based Answer
Short-term trials indicate that cancer pain can be reduced with the use of
nonsteroidal anti-inflammatory drugs (NSAIDs) as initial monotherapy. NSAIDs
combined with opioids can result in slight short-term improvement in pain compared
with either agent alone. Long-term efficacy and safety of NSAIDs for cancer pain
have not been established.
http://www.aafp.org/afp/20050801/cochrane.html#c1
Health Literacy: The Gap Between Physicians and Patients
http://www.aafp.org/afp/20050801/463.html
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ACOG
Management of Endometrial Cancer
ACOG Practice Bulletin NUMBER 65, AUGUST 2005
Summary of Recommendations and Conclusions
The
following recommendations are based on limited or inconsistent scientific evidence
(Level B):
- Most women with endometrial cancer should undergo systematic surgical staging,
including pelvic washings, bilateral pelvic and paraaortic lymphadenectomy, and
complete resection of all disease. Exceptions to this include young or perimenopausal
women with grade 1 endometrioid adenocarcinoma associated with atypical endometrial
hyperplasia and those at increased risk of mortality secondary to comorbidities.
- Women with atypical endometrial hyperplasia and endometrial cancer who desire
to maintain their fertility may be treated with progestin therapy. Following
therapy they should undergo serial complete intrauterine evaluation approximately
every 3 months to document response. Hysterectomy should be recommended for women
who do not desire future fertility.
- Patients with surgical stage I disease may be counseled that postoperative
radiation therapy can reduce the risk of local recurrence, but the cost and toxicity
should be balanced with the evidence that it does not improve survival or reduce
distant metastasis.
- For those women who have not received radiation therapy, pelvic examinations
every 3–4 months for 2–3 years, then twice yearly following surgical
treatment of endometrial cancer are recommended for detection and treatment of
recurrent disease.
The following recommendations are based primarily on consensus
and expert opinion (Level C):
- Women who cannot undergo systematic surgical staging because of comorbidities
may be candidates for vaginal hysterectomy.
- Only a physical examination and a chest radiograph are required for preoperative
staging of the usual (type I endometrioid grade 1) histology, clinical stage
I patient. All other preoperative testing should be directed toward optimizing
the surgical outcome.
Management of endometrial cancer. ACOG Practice Bulletin No. 65. American
College of Obstetricians and Gynecologists. Obstet Gynecol 2005;106:413–25
Non-ACOG Members
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16055605&query_hl=4
ACOG Members
http://www.acog.org/publications/educational_bulletins/pb065.cfm
Health Care for Homeless Women
Homelessness is a considerable social and health problem in the United States
with far-reaching effects on the health of homeless women. Homeless women are
at higher risk for injury and illness and are less likely to obtain needed health
care than women who are not homeless. It is critical to undertake efforts to
prevent homelessness. Until this can be accomplished, community-based services
targeted specifically to this population that provide both health care and support
services are essential. Health care providers can help address the needs of the
homeless by identifying their own patients who may be homeless, treating their
health problems, offering preventive care, and working with the community to
improve the full range of resources available to these individuals.
Health Care for Homeless Women. ACOG Committee Opinion No. 312. American
College of Obstetricians and Gynecologists. Obstet Gynecol 2005;106:429–34.
Non-ACOG Members
http://www.ncbi.nih.gov/entrez/query.fcgi
ACOG Members
http://www.acog.org/publications/committee_opinions/co312.cfm
Two Major Women's Health Groups Call Attention to a Leading Reproductive
Cancer
The American College of Obstetricians and Gynecologists (ACOG) and the Society
of Gynecologic Oncologists (SGO) today issued guidance to physicians for diagnosing,
managing, and treating endometrial cancer, the most common female genital tract
malignancy. In the US, more than 40,000 women will be diagnosed with endometrial
cancer this year; it is the fourth most common cancer in women, behind lung,
breast, and colon cancer. Approximately 7,310 women die annually from the disease.
Because it is the most common cancer of the female reproductive system, nearly
all ob-gyns will encounter the disease sometime in their career.
Written in partnership with the SGO, the new ACOG Practice Bulletin, "Management
of Endometrial Cancer," provides information on the epidemiology, the cause(s)
and effects of the disease, and the management strategies, that will allow ob-gyns
to identify women at increased risk, help diagnose cases early, and recommend
treatment options. The document also outlines instances in which patients may
benefit from referral to a gynecologic oncologist.
"This important collaboration between ACOG and SGO is another step we
have taken together to improve care for women with gynecologic cancers," says
James W. Orr, Jr, MD, ACOG Fellow and immediate past president of SGO. "The
comprehensive guidance offered for the management of women with endometrial cancer
will contribute to improving patient outcomes."
The most common cause of endometrial cancer is an excess of estrogen unopposed
by progestogen; it is more common in women who take estrogen therapy alone, without
a progestin hormone, after menopause. Women who take combination birth control
pills (estrogen plus progestin) appear to have a lower risk. Women are at a higher
risk of endometrial cancer if they:
- Do not ovulate regularly and often miss periods
- Began menstruating before age 12
- Have never been pregnant
- Have a history of infertility
- Are 50 or more pounds overweight
- Have endometrial hyperplasia (abnormal thickening of the endometrium)
- Have late menopause (on average, around age 51)
It is important to identify women at risk for endometrial cancer in order
to provide them with counseling and appropriate screening. In addition, women
with anovulatory disorders or problems with ovulation should be counseled about
their long-term risk of endometrial cancer, and ways they can prevent or reduce
their risk of the disease.
There is no standard screening test to detect endometrial cancer and routine
screening is not recommended because of the lack of an appropriate, cost-effective,
and acceptable test that reduces mortality. Fortunately, most women (90%) with
endometrial cancer develop symptomatic vaginal bleeding or discharge that leads
to an early diagnosis and results in an increased opportunity for cure, notes
ACOG. Other symptoms include pelvic pressure or discomfort. A biopsy is the accepted
first step in evaluating a patient with abnormal uterine bleeding or if endometrial
cancer is suspected.
According to ACOG, most women with endometrial cancer should undergo complete
systematic surgical staging to help determine appropriate management. Surgery
is the most common treatment for women with endometrial cancer. In the unusual
instance when a patient is deemed an exceptionally poor surgical candidate, radiation
treatments alone may be considered in an attempt to treat the uterine disease.
Women with atypical endometrial hyperplasia or very small endometrial cancer
who want to maintain their fertility may be treated with progestin therapy.
ACOG also recommends that to detect any recurrent disease, patients should
undergo pelvic exams every three to four months for two to three years, then
twice a year, after surgical treatment of the cancer. http://www.acog.org/from_home/publications/press_releases/nr08-01-05-3.cfm
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AHRQ
Despite revised guidelines,
most obstetrician/gynecologists continue to over-screen low-risk women for cervical
cancer
http://www.ahrq.gov/research/jun05/0605RA12.htm#head12
Physician supply increases in States with caps on malpractice lawsuit
awards, with the greatest impact in rural areas
http://www.ahrq.gov/research/jun05/0605RA1.htm
Women respond differently to medications than men
and should be proactive about their medication use
http://www.ahrq.gov/research/jun05/0605RA11.htm#head11
Efforts to help physicians improve care for underserved patients
should address issues of communication and respect
http://www.ahrq.gov/research/jul05/0705RA19.htm
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Ask A Librarian: Diane Cooper, M.S.L.S. / NIH
The Known and the Unknown - Clinical Evidence Summarized
A new resource offering the best available evidence on the effects of common
clinical interventions is now available online. Clinical
Evidence summarizes
what is known – and not known – on over 200 medical conditions and
over 2,000 treatments seen in primary and hospital care. Clinical
Evidence is
based on thorough searches and appraisal of the literature. It is neither a textbook
of medicine nor a set of guidelines. Instead it describes the best available
evidence from systematic reviews, randomized control trials, and observational
studies. Here are some reasons Clinical Evidence may be useful to you:
- You start with a question – Clinical Evidence does too
- Evidence is presented in clear and easy-to-read summaries
- New and updated topics are added monthly
- Includes information on benefits, harms and outcomes which will help you
with you treatment decisions
- Saves you time and effort
To access Clinical Evidence go to: http://hsrl.nihlibrary.nih.gov
Click on Research Tools > Databases > Clinical Evidence
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Breastfeeding
Fentanyl During Labor May Impede Establishment of Breastfeeding
CONCLUSIONS: A dose-response relationship between fentanyl and artificial
feeding has not been reported elsewhere. When well-established determinants of
infant feeding are accounted for, intrapartum fentanyl may impede establishment
of breastfeeding, particularly at higher doses
Jordan
S, et al The impact of intrapartum analgesia on infant feeding.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15957994&query_hl=21
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Case Manager's Corner
Stress and verbal abuse in nursing
RESULTS: Respondents reported that the most frequent source of abuse was
nurses (27%), followed by patients' families (25%), doctors (22%), patients (17%),
residents (4%), other (3%) and interns (2%). Of those who selected a nurse as
the most frequent source, staff nurses were reported to be the most frequent
nursing source (80%) followed by nurse managers (20%). CONCLUSIONS: Verbal abuse
in nursing is quite costly to the individual nurses, the hospitals and the patients.
Nurses who regularly experience verbal abuse may be more stressed, may feel less
satisfied with their jobs, may miss more work and may provide a substandard quality
of care to patients.
Rowe
MM, Sherlock
H. Stress and verbal abuse in nursing: do burned out nurses eat their young?
J Nurs Manag. 2005 May;13(3):242-8
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15819837&query_hl=23
OB/GYN CCC Editorial comment:
This is an important article that should serve to remind us that there is no role for verbal abuse in the health care setting. As over ½ of the sources of the verbal abuse are fellow health care workers, this problem can be remedied with improved communication with our colleagues.
* In lieu of a Case Manager submission, Reynaldo Espera. R. N., from ANMC Labor and Delivery submitted the above
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CCC
Corner Digest
Nicely laid out hard copy - compact digest of last month’s CCC Corner
Highlights include
-USPSTF recommends that clinicians screen all pregnant women for HIV
-Simple Educational Handouts – Kat Franklin, Sante Fe
-Elective Repeat Cesarean Delivery May Negatively Affect Neonatal Outcomes
-Benzocaine spray does not offer effective pain control during per endometrial
biopsy
-OCPs are more effective than placebo for relieving dysmenorrhea in adolescents
-Death rates for CVD are higher among AI/AN than other U.S. groups
-Pregnancy and Depression: What Women Need to Know
-What is an RN Case Manager?
-2 positive blood cultures found in a postpartum patient with a fever
-Benefits of low-fat dairy products on weight loss
-What Makes a Drug Over the Counter (OTC)? The case of Plan B
-Active management of the third stage of labor among American Indian women
-Racial / Ethnic Disparities in Infant Mortality: No significant improvement
in AI / AN
-Use the talk / sing test during exercise during pregnancy
-Here is a good web based calcium screening tool
-Can chlamydia be stopped?
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/05JulyOL.pdf
If you want a copy of the CCC Digest mailed to you each month, please contact nmurphy@scf.cc
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Domestic
Violence
Developing Leaders in Violence Prevention – Travel funding
available
Please forward to any group that may be interested, including tribal organizations.
Program fees and accommodation costs are borne by the Institute. Travel stipends
are available for teams that may not be able to afford travel. You can contact
the institute for further information. Theresa.Cullen@IHS.GOV
Cultural Competency for Non-Native Advocates and Ending Violence Against
Native Women Training Institute
September 24-30, 2005, Rapid City, SD
Sacred Circle National Resource Center to End Violence Against Native Women
will hold two sessions at the Holiday Inn Rushmore Plaza. Cultural Competency
for Non-Native Advocates will address the realities for Native women and strategies
for inclusion and recruitment of Native women by Non-Native programs on September
24 to 26. The Ending Violence Against Native Women Training Institute will
address colonization and violence against women, dynamics of battering, federal
laws including the Violence Against Women Act, coordinating a tribal community
response and prioritizing women’s safety and offender accountability. For
more information, please call 1-877-733-7623. Theresa.Cullen@IHS.GOV
The
2006 PREVENT Institute: Developing Leaders in Violence
Prevention
An intensive training experience for advanced multi-organizational teams
working to prevent violence before it starts. This training is different
than our Workshop in length, intensity, content, application process and types
of teams selected. Please go to www.PREVENT.unc.edu for
more information on both programs.
The PREVENT Institute builds skills to:
- Enhance leadership for violence prevention and social change
- Plan, implement, evaluate and sustain evidence-based prevention efforts
- Communicate effectively with policy makers, media and others
- Develop partnerships and extend networks
Visit http://www.prevent.unc.edu/education/institute.htm for
Institute information
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Elder
Care News
Toward optimal screening strategies for older women: Should cost
matter the most?
CONCLUSIONS: If all women receive idealized treatment, the benefits of mammography
beyond age 79 are too low relative to their costs to justify continued screening.
However, if treatment is not ideal, extending screening beyond age 79 could be
considered, especially for women in the top 25% of life expectancy for their
age.
Mandelblatt
JS, et al Toward optimal screening strategies for older women. J Gen Intern
Med. 2005 Jun;20(6):487-96.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15987322&query_hl=1
Comment: Burt Attico, M.D. Retired USPHS
This is a long paper, but its general theme is based on averages and costs.
The rates of cancer in women are generally stated as 1 in 8, but that is actually
the risk at age 85. This paper argues that screening is expensive, and, as the
population "grays," this will amount to increased costs for the health
system, with the potential life expectancy really not being increased significantly
when breast cancer is diagnosed. This is the reason for the testing frequency
then dropping when the patient gets older.
I am concerned about ethical issues with this type of cost reasoning, where
economics becomes one of the major factors in deciding whether a health "benefit" is
offered or not. I am going to present this to one of my friends who serves on
two local Ethics Committees.
This is a treatise based on "evidence-based medicine," in which
the authors distort the recommended guidelines for doing breast CA screening,
and then say that you should probably totally forget screening after age 79,
since screening and treatment are dramatically increasing the costs of Medical
care (Medicare costs) for the number of years that are saved when compared to
life expectancy.
Old people cost too much. That's a very crude way of saying it, but
I've essentially distilled it; I got lost in their math. They start by
saying that breast CA is mainly a disease of old-age, that incidence goes up
after 50, that the death rate is higher after age 65, but that you should figure
life expectancy when deciding whether or not to do screening. They advocate screening
biennially, although the present standard is annually, and have their cost model
figured on biennial screening.
I even went back and looked up the ACOG Clinical Practice Bulletins to make sure. This
article definitely conflicts, and puts a $$$-cost sign on the
life and the health of older women. I feel that its implications are basically unethical,
since the implication is that these elders owe society a cost debt and should
therefore pay that debt by dying - sooner rather than later, regardless of their
health, regardless of whether they have something that is treatable or not. I
think we might possibly discuss the issue (screening in elders) the next time
we meet (if ever). Again, crude, but that was my interpretation of this
$$$ laden article .
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Family
Planning
Over-The-Counter
Sales of Emergency Contraception Do Not Increase Unsafe Sex
CONCLUSION: The awareness and use of EC were low in our study population.
They were not ready for more liberal delivery of ECPs as less than 50% of women
supported these new delivery modes and their knowledge on ECPs use was inadequate.
Wan
RS, Lo
SS. Are women ready for more liberal delivery of emergency contraceptive
pills? Contraception. 2005 Jun;71(6):432-7.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15914132&query_hl=27
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Frequently
asked questions
Q. Is there any help or assistance with infertility through the Indian
Health System?
A. Yes, basic infertility services are provided in the ITU system.
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/Infertility81105.doc
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Indian Child Health Notes
August 2005 – Steve Holve, Pediatrics Chief Clinical Consultant
-Pediatric sleep apnea - you know more than you think
-Sleepy teenagers - they are not just slugs, they're victims of biology
-TB in AI/AN is down, but not out
http://www.ihs.gov/MedicalPrograms/MCH/C/documents/ICHN805.doc
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Information Technology
Free Online CME from Thomson Healthcare
All specialties
www.freecme.com
OB/GYN
http://www.freecme.com/gcourses1.php?specialty_id=41&specialty_name=OB/GYN
or go to the many posted Online CME sites on the Indian Health MCH site
../F/CN02.cfm#top
or Indian Health’s own Perinatology Corner
http://www.ihs.gov/MedicalPrograms/MCH/M/perCrnr.cfm
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International Health Update
Increase the interdisciplinary and transdisciplinary focus in primary
health care research
The "Transdisciplinary Understanding and Training on Research - Primary
Health Care (TUTOR-PHC)" program is accepting applications for its 2006
class of students. Program objectives are to build a critical mass of skilled,
independent researchers through both student and faculty development; and to
increase the interdisciplinary and transdisciplinary focus in primary health
care research.
APPLICANTS
-Any student/practicing professional regardless of home discipline with an
interest in primary health care research -Academic levels: Masters, PhD, Post-doctoral
fellow, mid-career clinicians
- Deadline for application submission is October 31, 2005
FELLOWSHIPS AND OTHER BENEFITS
- Strategic Training Fellowships ranging from $17 850 to $47 250 per year
depending on academic level and health professional status
- Accredited as one full graduate course through The University of Western
Ontario
- Trainees receive the distinction of "CIHR Strategic Training Fellow"
- Physicians receive up to 123 MAINPRO-M1 credits
CURRICULUM
The curriculum spans one year (May 2006-April 2007) and includes:
- A three-day symposium held in May each year
- On-line lab/discussion groups (total of 12 weeks)
- On-line workshops (total of 6 weeks) and
- Mentoring of students by established primary care researchers
Website: www.uwo.ca/fammed/csfm/tutor-phc e-mail: tutor@uwo.ca
Phone: 519-661-2111 x22089 Leslie Meredith, program coordinator
Unite For Sight's 3rd Annual International Health Conference
"Empowering Communities to Bridge Health Divides"
When : April 1-2, 2006
Where: Yale University, New Haven, Connecticut
Theme: "Empowering Communities to Bridge Health Divides"
Who should attend? Anyone interested in medicine, health education, health
promotion, public health, international health, international service, or eye
care
Conference Goal: To empower conference attendees to identify health needs and
to develop solutions to improve access to care for the medically underserved
http://www.uniteforsight.org/2006_annual_conference.php
Early Bird Registration Rate: $25 student rate; $30 for all others
How to Submit Abstract: http://www.uniteforsight.org/2006_conference_posters.php
ABSTRACT SUBMISSION DEADLINE: AUGUST 15
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MCH
Alert
New edition of the Women’s Health Data Book Released
Women's Health USA 2005, the fourth edition of the data book, presents a
profile of women's health at the national level from a variety of data sources.
The data book, developed by the Health Resources and Services Administration's
Office of Women's Health, includes information and data on population characteristics,
health status, and health services utilization. New topics in this edition include
household composition, maternity leave, contraception, and adolescent pregnancy.
The data book also highlights racial and ethnic disparities and gender differences
in women's health. The data book is intended to be a concise reference for policymakers
and program managers at the federal, state, and local levels to identify and
clarify issues affecting the health of women. http://mchb.hrsa.gov/whusa_05/index.htm
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Medical
Mystery Tour
Follow-up 2 positive blood cultures found in a postpartum patient
with a fever
A little refresher from last issue
-This 22 year old G1 P0 presented in active labor at 40 weeks gestation after
a benign prenatal course that was significant only for a positive perineum and
rectal culture for beta streptococcus group B screen at 36 weeks and a weight
gain of over 50 pounds with a normal glucose challenge test.
-The patient had a normal spontaneous delivery over a large 4th degree laceration.
There was also an extensive left perineal laceration with avulsion. The patient
had a standard repair of the 4th degree laceration and a right vulvar skin flap
closure of the left perineal laceration in the delivery room. What followed was
an unremarkable post partum course. The patient remained afebrile throughout
with an intact perineal repair and had a normal bowel movement prior to discharge.
-The patient returned on postpartum day #5 with a temperature of 101.9 degrees
F, a tender uterus with an intact perineum, and a WBC of 13.3K. The patient was
re-hospitalized for endometritis and treated with metronidazole and ampicillin
/ sulbactam. The patient defervesced and was discharged home again on post partum
day #8. The patient was called back into the hospital within hours of leaving
when it was noted that 2 of her blood cultures had become positive. http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0705_Feat.cfm#mmtour
The blood cultures positive with what organism? What was the source?
The answer
The preliminary findings of gram negative rods isolated in both anaerobic
bottles were called STAT to the provider. Subsequent identification revealed
fusobacterium mortiferum in both bottles.
Anaerobes account for 2 to 5 percent of blood culture isolates from patients
with clinically significant bacteremia, but the rate is decreasing reflecting
the frequent use of anti-anaerobic antibiotics. The most common blood culture
isolates among anaerobes are the B. fragilis group, which account for 60 to 80
percent. A review of the suspected portal of entry for 855 episodes of bacteremia
involving anaerobes indicated an intraabdominal source in 52 percent, the female
genital tract in 20 percent, the lower respiratory tract in 6 percent, the upper
respiratory tract in 5 percent, and soft tissue infections in 8 percent.
Fusobacterium is one of the anaerobic bacteria species often involved in
a variety of infections of the oral cavity and adjacent structures, including
serious infections with suppurative (septic) thrombophlebitis of the jugular
vein.
On the other hand, fusobacterium sp. are detected in amniotic fluid in preterm
labor more commonly than other anaerobes. Fusobacterium burrow through amnion
tissue rapidly and sometimes are present in amnion tissue in large numbers as
if penetrating between the amnion epithelial cells. Large numbers of fusobacterium
have been identified in Wharton’s jelly. This suggests a peculiar propensity
for these microorganisms to penetrate amnion tissue, which also covers the umbilical
cord. Fusobacterium produce a variety of toxins, some of which are extraordinarily
potent in stimulating cytokine formation in mononuclear phagocytes. In the setting
of premature rupture of membranes it has been hypothesized that fusobacterium
penetrate the fetal membranes after the tissues are exposed to these microorganisms
in the cervical /vaginal fluid.
The rest of the story
The patient was treated with IV ampillin /sulbactam plus metronidazole intravenously
and discharged on oral metronidazole and amoxicillin / clavulanate within 2 days
of the positive blood cultures.
The patient initially did well as an outpatient, but had to be re-admitted
with a fever and a breakdown of her labial repair six days later. The admission
examination revealed that the 4 th degree laceration also developed a small fistula.
The patient was initially treated with a broad spectrum anaerobic regimen IV,
and subsequently underwent debridement and a rectovaginal fistula repair 2 days
later.
Though the source can not be known with complete certainty, due the mixed
microbiology of the genital system, it appears the source was the perineal and
4 th degree lacerations, and not endomyometritis as suspected with the patient’s
first postpartum admission.
The rectovaginal fistula repair was well healed 8 weeks later.
Here is more information on fusobacterium infections
Anaerobic
bacterial infections
Suppurative
(septic) thrombophlebitis
Have a case you would like to discuss in the Medical Mystery Tour? Please
contact nmurphy@scf.cc
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Medscape*
Eating Disorders and Body Image Distress in Women at Midlife - CME
http://www.medscape.com/viewprogram/4302?src=mp
Ask the Experts topics in Women's Health and OB/GYN Index, by specialty,
Medscape
http://www.medscape.com/pages/editorial/public/ate/index-womenshealth
OB GYN & Women's Health Clinical Discussion Board Index, Medscape
http://boards.medscape.com/forums?14@@.ee6e57b
Clinical Discussion Board Index, Medscape
Hundreds of ongoing clinical discussions available
http://boards.medscape.com/forums?14@@.ee6e57b
Free CME: MedScape CME Index by specialty
http://www.medscape.com/cmecenterdirectory/Default
*NB: Medscape is free to all, but registration is required. It can be accessed
from anywhere with Internet access. You just need to create a personal username
and password.
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Menopause Management
U.S. Preventive Services Task Force
Hormone Therapy for the Prevention of Chronic Conditions in Postmenopausal
Women
Summary of Recommendations
The USPSTF recommends against routine use of combined estrogen and progestin
for the prevention of chronic conditions in postmenopausal women.
D recommendation .
The USPSTF found good evidence that the use of combined estrogen and progestin
results in both benefits and harms. Benefits include reduced risk for fracture
(good evidence) and colorectal cancer (fair evidence). Combined estrogen and
progestin has no beneficial effect on coronary heart disease (CHD) and may even
pose an increased risk (good evidence). Other harms include increased risk for
breast cancer (good evidence), venous thromboembolism (good evidence), stroke
(fair evidence), cholecystitis (fair evidence), dementia (fair evidence), and
lower global cognitive function (fair evidence). Because of insufficient evidence,
the USPSTF could not assess the effects of combined estrogen and progestin on
the incidence of ovarian cancer, mortality from breast cancer or coronary heart
disease, or all-cause mortality. The USPSTF concluded that the harmful effects
of combined estrogen and progestin are likely to exceed the chronic disease prevention
benefits in most women.
The USPSTF recommends against the routine use of unopposed estrogen for the
prevention of chronic conditions in postmenopausal women who have had a hysterectomy.
D recommendation .
The USPSTF found good evidence that the use of unopposed estrogen results
in both benefits and harms. The benefits include reduced risk for fracture (good
evidence). Harms include increased risk for venous thromboembolism (fair evidence),
stroke (fair evidence), dementia (fair evidence), and lowered global cognitive
functioning (fair evidence). There is fair evidence that unopposed estrogen has
no beneficial effect on coronary heart disease. Because of insufficient evidence,
the USPSTF could not assess the effects of unopposed estrogen on the incidence
of breast cancer, ovarian cancer, or colorectal cancer, as well as breast cancer
mortality or all-cause mortality. The USPSTF concluded that the harmful effects
of unopposed estrogen are likely to exceed the chronic disease prevention benefits
in most women.
http://www.preventiveservices.ahrq.gov
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Midwives Corner:
Judy Whitecrane, Phoenix
Please help us build the Midwives Indian Health Patient Education
Resources page
Do you have any good ideas about links to offer to your colleagues?
Send them to nmurphy@scf.cc
Here is what the Indian Health Patient Education Resources page has so far:
CIR - Indian Health Patient Education Resources page
http://www.ihs.gov/medicalprograms/CIR/index.cfm?module=cir_patient_education
SIMPLE PATIENT EDUCATION HANDOUTS
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/PtEDHANDOUTS.doc
Here is wide variety of MCH oriented Patient Education Resources
http://www.ihs.gov/MedicalPrograms/MCH/
Each Perinatology Corner Module has topic specific Patient Education
http://www.ihs.gov/MedicalPrograms/MCH/M/perCrnr.cfm
Here is one example from the Perinatology module: Diabetes in Pregnancy.
http://www.ihs.gov/MedicalPrograms/MCH/M/DP11.asp#patEdu
(The patient education resources are usually on the ‘Other Online Resources’ page
of each module)
Consumer Health – Features Easy to Read Resources
http://www.ihs.gov/MedicalPrograms/consumer-health/
Women and Health Care: A National Profile
A new national survey of women on their health finds that a substantial percentage
of women cannot afford to go to the doctor or get prescriptions filled. Although
a majority of women are in good health and satisfied with their health care,
many have health problems and do not get adequate levels of preventive care.
The report also examines women’s health status, health care costs, insurance,
access to care, prevention, and their role in family health care.
Women and Health Care: A National Profile is a nationally representative
telephone survey of 2,766 women ages 18 and older. A shorter companion survey
of 507 men was conducted for comparison purposes. http://www.kff.org/womenshealth/whp070705pkg.cfm
Top of Page
Navajo News, Jean Howe,
Chinle
Is the patch more dangerous than the pill?
“More fatalities than expected occur from birth control patch”
On July 15 th, an Associated Press article with this alarming title was published
in one of our local newspapers, The Gallup Independent. It reported that there
was a three-fold increased risk of death with contraceptive patch use, as compared
to oral hormonal contraceptive use, based on cases reported to the FDA. They
cite the following risks:
Risk group |
Risk of non-fatal blood clot |
Risk of death |
Non-smokers, <35 years old, on oral contraceptive pills |
1-3 in 10,000 |
1 in 200,000 |
Non-smokers, <35 years old, using contraceptive patch |
12 in 10,000 |
3 in 200,000 |
The article also states that 2 blood clots occurred in the 3,300 patch users
who participated in clinical trials prior to FDA approval.
The article is quite dramatic, including several touching vignettes of young
women who died unexpectedly while using the patch. It offers other death rates
for comparison, but only in a somewhat confusing table, and not in the text itself.
(These include a death rate of 28 per 100,000 per year for pill users under 35
who smoke, 143 per 100,000 for pill users 35-44 years old who smoke, 10 per 100,000
for women at 20+ weeks gestation, and 100 per 100,000 for motorcycle riders.)
The article does not state a risk for non-fatal blood clots associated with pregnancy.
This inflammatory article is another example of non-evidence based data being
presented to the public in a sensational manner. The FDA reports are collected
to look for unanticipated adverse outcomes associated with medication use that
were not identified in studies conducted prior to FDA approval. Their collection
is important but the information must be interpreted with caution. Importantly,
the AP article apparently bases its risk calculations on a denominator of 800,000
patch users in 2004. Ortho states that the actual number of patch users was closer
to 2,000,000 in 2004; clearly that would change the risk calculations dramatically.
This is a perplexing situation. Women’s health providers wouldn’t
want to ignore potentially important safety information about the patch. But
it is not clear that these spontaneously generated FDA reports actually represent
important new safety information. It is our duty as providers to provide our
patients with the best evidence-based information available and protect them
from media hysteria. The available data shows that hormonal contraception does
pose a slightly increased risk of blood clots, regardless of route (pill, patch,
or vaginal ring). This risk is much less than the risk associated with pregnancy.
For women who find it difficult to use other methods reliably, the contraceptive
patch remains an excellent method of birth control. If anything this article
illustrates the need to encourage smoking cessation in all hormonal contraception
users under 35 and work with smokers 35 and over both to find acceptable alternative
methods of birth control and to quit smoking.
Resources
FDA – Home page
http://www.fda.gov/default.htm
FDA APPROVES FIRST HORMONAL CONTRACEPTIVE SKIN PATCH
http://www.fda.gov/bbs/topics/ANSWERS/2001/ANS01119.html
FDA and Johnson & Johnson Warn Public About Counterfeit Contraceptive
Patches Sold Through Foreign Internet Site
http://www.fda.gov/bbs/topics/NEWS/2004/NEW01017.html
Ortho Evra: Othro - McNeil
http://www.orthoevra.com/
Top of Page
Office of Women's Health, CDC
Publications and Materials – Many Women’s Health Topics
Link below to recent publications and other materials related to women's
health, including fact sheets, recommendations, reports, disease trends, program
strategies, and more. Click on a link below to get information on the Web by
health topic or to get selected documents by fax. Supplies are limited and subject
to change and availability. http://www.cdc.gov/od/spotlight/nwhw/pubs.htm
Top of Page
Oklahoma
Perspective Greggory Woitte – Hastings Indian Medical Center
Who do you contact in Oklahoma for MCH issues?
Two contacts are Dr. George Chiarchiaro in the Area Office and Greggory Woitte
at Tahlequah. George is the MCH Coordinator and has a helpful website with many
resources
http://www.ihs.gov/MedicalPrograms/MCH/M/MCHC07.cfm#top
Greggory Woitte at Tahlequah is available at Greggory.Woitte@mail.ihs.gov
Top of Page
Osteoporosis
Ultralow-Dose Estradiol and BMD in Postmenopausal Women
CONCLUSION: Postmenopausal treatment with low-dose, unopposed estradiol increased
bone mineral density and decreased markers of bone turnover without causing endometrial
hyperplasia. Ettinger B, et al. Effects of ultralow-dose transdermal estradiol
on bone mineral density: a randomized clinical trial. Obstet Gynecol September
2004;104:443-51
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15339752&query_hl=18
Top of Page
Patient
Information
Brochure/support for sugar substitute and gestational DM
http://www.ific.org/publications/brochures/upload/gestationaldiabetes.pdf
What to Do If Your Child Swallows Something?
http://www.aafp.org/afp/20050715/292ph.html
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Perinatology Picks -
George Gilson, Maternal Fetal Medicine, ANMC
Glyburide for gestational diabetes in a large managed care organization
RESULTS: In 1999 through 2000, 268 women had GDM diagnosed and were treated
with insulin; in 2001 through 2002, 316 women had GDM diagnosed of which 236
(75%) received glyburide…..
CONCLUSION: In a large managed care organization, glyburide was at least
as effective as insulin in achieving glycemic control and similar birth weights
in women with GDM who failed diet therapy. The increased risk of preeclampsia
and phototherapy in the glyburide group warrant further study
Jacobson
GF et al Comparison of glyburide and insulin for the management of gestational
diabetes in a large managed care organization. Am J Obstet Gynecol. 2005 Jul;193(1):118-24.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16021069&query_hl=1
Overweight and obese in gestational diabetes: the impact on pregnancy outcome
RESULTS: Four thousand and one women were enrolled. Obese women who achieved
targeted levels of glycemic control had comparable pregnancy outcomes to normal
weight and overweight women only when they were treated with insulin…..
CONCLUSION: In obese women with BMI > or =30 with GDM, achievement of
targeted levels of glycemic control was associated with enhanced outcome only
in women treated with insulin.
Langer
O et al Overweight and obese in gestational diabetes: the impact on pregnancy
outcome. Am J Obstet Gynecol. 2005 Jun;192(6):1768-76.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15970805&query_hl=3
Glargine use in pregnancy?
As Dr. Gilson has raised the issue of diabetes in pregnancy, here is a question
that was posed to the Area Diabetes Program Director:
“There seems to be frequent discussion about glargine being best for
type I diabetics (as their basal insulinization), but not for type 2 DM. Type
2 diabetics are often hyperinsulinemic - especially when pregnant. This
comes up most frequently in pre-existing type 2 pregnant diabetics who have
used glargine previously. I most frequently recommend switching them to NPH and
lispro for the pregnancy.
Will you corroborate that philosophy, or am I just "behind the
times".
Response from the Alaska Area Diabetes Program Director:
Glargine is being used extensively in type 2 diabetes. The
ANMC pharmacy, however, has it restricted to type 1 patients at the present time. This
is in part due to the cost concerns of glargine compared to NPH. We are
working with pharmacy to develop a protocol which, after approval by P & T,
will allow us to use glargine in type 2 patient more liberally. We do have
around 60 type 2 diabetics on glargine at the present time. A recent
article in Diabetes Care by Riddle looked at night time NPH and glargine*. There
was not great convincing evidence that glargine was significantly better than
NPH in type 2 patients; however, there were less hypoglycemic episodes with the
glargine group. Both groups had similar improvement in their A1c levels. The
main advantage of glargine over NPH is it can be given any time of the day, which
makes it much more "user friendly" for patients. It is no longer
necessary to only give in the evening.
I had to do a little research to answer your second question. And you
are not "behind the times", rather in line with what most endocrinologists
would recommend:
So, I had the opportunity to talk with an endocrinologist who has in-depth
knowledge of glargine last night and he helped answer your question.
Neither the analog insulins (lispro and aspart) nor glargine are FDA approved
for pregnancy. Despite this, aspart and lispro are used in pumps and for
nutritional dosing during pregnancy without problems. The issue with glargine
is its binding to IGF1 receptors: glargine has a 7X greater affinity for IGF1
than other insulin(s). This raises concerns of increased risk of possible
birth defects.
Studies in rats and (I believe) rabbits have not shown evidence of glargine
related birth defects but (needless to say) there are no human studies. Therefore
most endocrinologists would not recommend glargine during pregnancy. The
endocrinologist I spoke with felt that this was, in part, due to concerns of
a baby born with a birth defect whose mother has used glargine during her pregnancy. The
endocrinologist recommended either changing the patient to NPH during the
pregnancy or transitioning the patient to a pump in the pre or post conception
state.
CCC Comment:
Until further data is available, regimens that include short and intermediate
acting insulin(s) are recommended for those Indian Health patients using insulin
as their hypoglycemic agent during pregnancy.
Here is the resource discussed above, as well as the Diabetes in Pregnancy
Guidelines posted on the MCH web page:
../W/Documents/DMPreg102504_000.doc
* Riddle
MC, et Al The treat-to-target trial: randomized addition of glargine or human
NPH insulin to oral therapy of type 2 diabetic patients. Diabetes Care. 2003
Nov;26(11):3080-6.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14578243&query_hl=5
Riddle
MC. Timely initiation of basal insulin. Am J Med. 2004 Feb 2;116 Suppl 3A:3S-9S.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15013454&query_hl=5
Janka
HU, Plewe
G, Riddle
MC, et al Comparison of basal insulin added to oral agents versus twice-daily
premixed insulin as initial insulin therapy for type 2 diabetes. Diabetes Care.
2005 Feb;28(2):254-9.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15677775&query_hl=5
Top of Page
Primary
Care Discussion Forum
Appropriate use of narcotics for chronic non-malignant (non-cancer)
pain
Moderator: Chuck North
-Are you comfortable using narcotics to treat chronic pain?
-Is there abuse of prescription controlled medications in your community?
-What controls should health professionals have in place to regulate the use
of controlled substances?
-Do you use pain contracts? Are they useful?
-What services are available to serve your chronic pain patients in addition
to primary care?
-Are you successful in obtaining mental health services for your patients?
Other issues
-Describe your level of comfort based on your experience.
-What are the most popular drugs? Are narcotics, benzodiazepines or stimulants
most popular?
-Are particular brand names valued more than others?
-Do you know the local "street value" of prescription pills?
-Would you like to consult with a psychiatrist yourself about some of your patients?
This discussion is ongoing now so you can still jump in. The captured discussion
so far and a number of excellent resources available from this discussion available
here
http://www.ihs.gov/MedicalPrograms/MCH/M/PCdiscForumMod.asp
( please scroll down to “Narcotics for……” in alphabetical
order)
How to subscribe / unsubscribe to the Primary Care Discussion Forum?
Subscribe to the Primary Care listserv
http://www.ihs.gov/generalweb/helpcenter/helpdesk/index.cfm?module=listserv&option=subscribe&newquery=1
Unsubscribe from the Primary Care listserv
http://www.ihs.gov/generalweb/helpcenter/helpdesk/index.cfm?module=listserv&option=unsubscribe&newquery=1
Questions on how to subscribe, contact nmurphy@scf.cc directly
Top of Page
STD
Corner - Laura Shelby, STD
Director, IHS
Condom effectiveness for prevention of Chlamydia trachomatis infection
Background/objectives: A growing body of evidence is increasingly
demonstrating the effectiveness of condoms for sexually transmitted infection
(STI) prevention. The purpose of the present analysis was to provide a disease
specific estimate for the effectiveness of condoms in preventing Chlamydia
trachomatis infection while controlling for known exposure to infection.
Methods: Condom effectiveness for C trachomatis was
estimated using a medical record database from a public sexually transmitted
disease clinic (n = 1455). Clients were classified as having known exposure to C
trachomatis if they presented to the clinic as a contact to an infected
partner.
Results: Among clients with known exposure, 13.3% of consistent
condom users were diagnosed with C trachomatis infection compared to
34.4% of inconsistent condom users (adjusted odds ratio = 0.10; 95% CI: 0.01
to 0.83). Among clients with unknown exposure, there was no observed protective
effect of condoms.
Conclusions: This study provides further evidence that condoms
are effective in preventing C trachomatis infection by reporting a disease
specific estimate and restricting analyses to individuals with known exposure.
M Niccolai, A Rowhani-Rahbar, H Jenkins, S Green, and D W Dunne. Condom effectiveness
for prevention of Chlamydia trachomatis infection Sex Transm Infect
81: 323-325
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16061540&query_hl=1
The percentage of male teens who reported ever having sexual intercourse decreased
significantly for both younger (aged 15--17 years) and older (aged 18--19 years)
teens from 1995 to 2002. Among females, the percentage who reported ever having
sexual intercourse declined significantly for those aged 15--17 years. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5430a7.htm
Additional information is available at http://www.cdc.gov/nchs/nsfg.htm
Other News on STIs
Prenatal screening and treatment are needed to identify pregnant
women with asymptomatic chlamydial infections http://www.ahrq.gov/research/jul05/0705RA15.htm
Top of Page
Barbara
Stillwater, Alaska State Diabetes Program
Women the stronger gender? Men more carbohydrate intolerant / less
physical endurance
CONCLUSIONS: Severely obese men were more carbohydrate-intolerant and sustained
less physical endurance than was predicted according to standards in comparison
with obese women. The cycle ergometer data indicated that male gender was associated
with less physical fitness.
Dolfing
JG, et al Different cycle ergometer outcomes in severely obese men and women
without documented cardiopulmonary morbidities before bariatric surgery. Chest.
2005 Jul;128(1):256-62.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16002944&query_hl=2
Teen Inactivity Leads to Obesity for Girls
Decreasing physical activity during adolescence seems to play a major role
in weight gain among girls as they transition from children to women. Inactive
girls gained an average of 10 pounds to 15 pounds more than girls who were active
between the ages of 9 and 19.The number of calories consumed increased marginally
and did not appear to be associated with the weight gain.
INTERPRETATION: Changes in activity levels of US girls during adolescence
significantly affected changes in BMI and adiposity. Thus, preventing the steep
decline in activity during adolescence is an important method to reduce obesity.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16039332&query_hl=6
Cardiovascular Fitness Inversely Linked to Risk of Metabolic Syndrome
CONCLUSIONS: Low cardiorespiratory fitness is a strong and independent predictor
of incident metabolic syndrome in women and men. Clinicians should consider the
potential benefits of greater cardiorespiratory fitness in the primary prevention
of metabolic syndrome, particularly among patients who have already begun to
cluster metabolic syndrome components.
Lamonte
MJ, et al Cardiorespiratory Fitness Is Inversely Associated With the Incidence
of Metabolic Syndrome. A Prospective Study of Men and Women. Circulation. 2005
Jul 11;
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16009797&dopt=Abstract
Relationship of Obesity and Fitness Level to Cardiovascular Risk
and Diabetes
CONCLUSIONS: Among women undergoing coronary angiography for suspected ischemia,
higher self-reported physical fitness scores were independently associated with
fewer CAD risk factors, less angiographic CAD, and lower risk for adverse CV
events. Measures of obesity were not independently associated with these outcomes.
Wessel
TR, et al Relationship of physical fitness vs body mass index with coronary
artery disease and cardiovascular events in women. JAMA. 2004 Sep 8;292(10):1179-87.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15353530&query_hl=9
New CERTs Program Brief on Women's Health Is Available
AHRQ released a new program brief on women's health from its Centers for
Education and Research on Therapeutics (CERTs) program. The program brief highlights
risks and benefits identified in CERTs studies of medical therapies in women
such as the association between cholesterol-lowering drugs and hip fractures,
as well as heart rhythms and the menstrual cycle, and antibiotic resistance and
urinary tract infections. It also addresses current treatment information for
physicians and their patients on the use of hormone therapy and prescription
drug use by pregnant women. http://www.ahrq.gov/clinic/certswomen.htm or
e-mail ahrqpubs@ahrq.gov
Top of Page
What's
new on the ITU MCH web pages?
Q. Is there any help or assistance with infertility through the Indian
Health System?
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/Infertility81105.doc
Prescription
Opioids: Good, bad, and ugly, Sidney Schnoll MD PHD
Eve Espey M.D. - Breast
Cancer Screening
2005 IHS/ACOG Obstetric, Neonatal and Gynecologic Care Postgraduate Course
Simple Patient Education Handouts
Active management of the third stage of labor among American Indian women
Atlas of Heart Disease and Stroke in AI/AN
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
Top of Page
Save
the dates
Treatment and Management of HIV Infection in the United States
- September 15-18, 2005
- Atlanta , Georgia
- 16.5 Credits, Univ. of California @ San Francisco / VA Administration
- First domestic conference of its kind. Mark your calendar
- http://www.USHIVconference.org/
National Indian Health Board: Youth and Tradition - Our Greatest
Resources
Centering Pregnancy - Group Prenatal Care
Advances in Indian Health, 6 th Annual
Native Peoples of North America HIV/AIDS Conference
ACOG 2006 Annual Clinical Meeting (ACM)
Back to top
Did you miss something in the last OB/GYN Chief Clinical Consultant Corner?
The July 2005 OB/GYN CCC Corner is available at:
http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0705.cfm |