MCH - OB/GYN Chief Clinical Coordinator's Corner

Maternal Child Health ‹ CCC Corner ‹ November 2008

OB/GYN CCC Corner - Maternal Child Health for American Indians and Alaska Natives

Volume 6, No. 11, November 2008

Features

American College of Obstetricians and Gynecologists

ACOG Practice Bulletin #98 Ultrasonography in Pregnancy

Most women have at least one ultrasound examination during pregnancy. The purpose of this document is to present evidence regarding the methodology of, indications for, benefits of, and risks associated with obstetric ultrasonography in specific clinical situations. Portions of this document were developed collaboratively with the American College of Radiology and the American Institute of Ultrasound in Medicine. The sections that address physician qualifications and responsibilities, documentation, quality control, infection control, and patient safety contain recommendations from the American College of Obstetricians and Gynecologists.

Summary of Recommendations and Conclusions
The following conclusions are based on good and consistent evidence (Level A):

Ultrasound examination is an accurate method of determining gestational age, fetal number, viability, and placental location.
Gestational age is most accurately determined in the first half of pregnancy.
Ultrasonography can be used in the diagnosis of many major fetal anomalies.
Ultrasonography is safe for the fetus when used appropriately.

The following conclusions are based on limited or inconsistent evidence (Level B):

Ultrasonography is helpful in detecting fetal growth disturbances.
Ultrasonography can detect abnormalities in amniotic fluid volume.

The following conclusion and recommendation are based primarily on consensus and expert opinion (Level C):

The optimal timing for a single ultrasound examination in the absence of specific indications for a firsttrimester examination is at 18–20 weeks of gestation.
The benefits and limitations of ultrasonography should be discussed with all patients.

Proposed Performance Measure

Documentation of the discussion of the benefits and limitations of ultrasonography

American College of Obstetricians and Gynecologists. ACOG Practice Bulletin #98, October 2008. Ultrasonography in pregnancy. Obstet Gynecol. 2008 Oct;112(4):951-61. http://www.ncbi.nlm.nih.gov/pubmed/18827142

ACOG Committee Opinion #419 Use of Progesterone to Reduce Preterm Birth

ABSTRACT: Preterm birth affects 12% of all births in the United States. Recent studies support the hypothesis that progesterone supplementation reduces preterm birth in a select group of women. Despite the apparent benefits of progesterone, the ideal progesterone formulation is unknown. The American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice and the Society for Maternal Fetal Medicine believe that further studies are needed to evaluate the optimal preparation, dosage, route of administration, and other indications for the use of progesterone for the prevention of preterm delivery. Based on current knowledge, it is important to offer progesterone for pregnancy prolongation to only women with a documented history of a previous spontaneous birth at less than 37 weeks of gestation.

American College of Obstetricians and Gynecologists. ACOG Committee Opinion #419, October 2008. Obstet Gynecol. 2008 Oct;112(4):963-5. http://www.ncbi.nlm.nih.gov/pubmed/18827143

ACOG NEWS RELEASE; October 1, 2008
Pregnant Women Reminded to Get Flu Vaccination
Washington, DC - The American College of Obstetricians and Gynecologists (ACOG) reminds women, including those who are pregnant, to get their annual vaccination for the upcoming influenza (flu) season which runs from October through mid-May in the US. According to ACOG, flu vaccination should be a routine part of prenatal care, and the ideal time to vaccinate pregnant women is October and November.

Roughly one-fifth of the US population is infected with the flu virus each year, according to the Centers for Disease Control and Prevention (CDC). Pregnant women have higher rates of illness and death from the flu than other groups. The CDC estimates that each year 200,000 people with the flu require hospitalization, and approximately 36,000 die from flu-related illness. In 2005, flu/pneumonia was the eighth leading cause of death overall in the US.

There are two types of flu vaccine: the injection and a nasal-spray vaccine. The flu shot is an inactivated vaccine that contains killed virus and is administered intramuscularly, usually in the arm. It is approved for use in people older than six months, including healthy people and those with chronic medical conditions. The nasal-spray vaccine is made with live, weakened flu viruses and is approved for use in people ages 2 to 49. It is not approved for pregnant women, however. Women who are breastfeeding can choose either vaccine type.

The flu vaccination (injection) is both safe and effective for pregnant women and offers some immunity to their infants as well. Some pregnant women may be concerned about the safety of the flu vaccine because some contain thimerosal, a mercury-containing antibacterial compound. ACOG supports the recommendations and findings of the federal Advisory Committee on Immunization Practices, which found that there is no evidence showing that thimerosal is a danger to the health of the pregnant woman or her fetus. Thimerosal-free flu vaccines are available, but they tend to be more expensive.

In addition to pregnant women, other special high-risk populations should make sure to be vaccinated every year. These include people older than 50; people of any age who have diabetes, asthma, heart disease, a weakened immune system, or other chronic illnesses, and their caregivers; nursing home residents; health care workers; and household contacts and caregivers of children younger than five and of adults age 50 and older.

Some people should not get the flu vaccine without first talking with their physician including those: with a severe allergy to chicken eggs; who have had a prior severe reaction to the flu vaccine; who previously developed Guillain-Barre' syndrome within six weeks of receiving the flu vaccine; who are children less than six months old; and who currently have a moderate-to-severe illness with a fever.

Both types of flu vaccine are effective at preventing the flu. Some people who receive the flu shot may have minor side effects, usually lasting only a day or two, such as soreness, redness, or swelling at the injection site; low-grade fever; and/or aches. On rare occasions the flu vaccine can cause a severe allergic reaction. The nasal-spray vaccine may cause side effects such as runny nose, headache, sore throat, and cough in adults and runny nose, wheezing, headache, vomiting, muscle aches, and fever in children.

The American Lung Association has an online "Flu Clinic Locator" that can help women find facilities that are administering flu shots. Go to: www.lungusa.org.

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American Family Physician

Atypical Moles

ABSTRACT: Atypical moles can be distinguished visually by clinical features of size greater than 6 mm in diameter, color variegation, indistinct borders, and textured surface. All patients who have atypical moles should be counselled about sun avoidance, screening of family members, and regular skin checks at least once per year. Total body photography and dermoscopy can aid in regular skin monitoring for changes in atypical moles and the emergence of new lesions. The presence of multiple atypical moles increases the risk of melanoma. The greatest risk of melanoma is in patients who have more than 50 atypical moles and two or more family members with melanoma (familial atypical mole and melanoma syndrome). Atypical moles should be removed when they have features suggestive of malignant transformation. Elliptical excision is the preferred removal technique. Removing all atypical moles is neither necessary nor cost effective.

Cyr, PR. Atypical Moles. Am Fam Physician. 2008 Sep 15;78(6):735-40. http://www.ncbi.nlm.nih.gov/pubmed/18819240

http://www.aafp.org/afp/20080915/735.html

Patient Education Handout: Atypical Moles: What You Should Know
http://www.aafp.org/afp/20080915/741ph.html

Management of mastitis in breastfeeding women

ABSTRACT: Mastitis occurs in approximately 10 percent of U.S. mothers who are breastfeeding, and it can lead to the cessation of breastfeeding. The risk of mastitis can be reduced by frequent, complete emptying of the breast and by optimizing breastfeeding technique. Sore nipples can precipitate mastitis. The differential diagnosis of sore nipples includes mechanical irritation from a poor latch or infant mouth anomalies, such as cleft palate or bacterial or yeast infection. The diagnosis of mastitis is usually clinical, with patients presenting with focal tenderness in one breast accompanied by fever and malaise. Treatment includes changing breastfeeding technique, often with the assistance of a lactation consultant. When antibiotics are needed, those effective against Staphylococcus aureus (e.g., dicloxacillin, cephalexin) are preferred. As methicillin-resistant S. aureus becomes more common, it is likely to be a more common cause of mastitis, and antibiotics that are effective against this organism may become preferred. Continued breastfeeding should be encouraged in the presence of mastitis and generally does not pose a risk to the infant. Breast abscess is the most common complication of mastitis. It can be prevented by early treatment of mastitis and continued breastfeeding. Once an abscess occurs, surgical drainage or needle aspiration is needed. Breastfeeding can usually continue in the presence of a treated abscess.

Spencer JP. Management of mastitis in breastfeeding women. Am Fam Physician. 2008 Sep 15;78(6):727-31. http://www.ncbi.nlm.nih.gov/pubmed/18819238

http://www.aafp.org/afp/20080915/727.html

Patient Education Handout: Mastitis, What Should You Know?
http://www.aafp.org/afp/20080915/732ph.html

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AHRQ

Behavioral Modification Programs Help Obese Children Manage Their Weight

AHRQ released a new report, Effectiveness of Weight Management Programs in Children and Adolescents, that shows obese school-age kids and teens can lose weight or prevent further weight gain if they participate in medium- to high-intensity behavioral management programs. Researchers found that after completing weight management programs, obese children would weigh between 3 pounds and 23 pounds less, on average, than obese children not involved in such programs. Among those enrolled, the weight difference would be greatest among heavier children as well as in those enrolled in more intensive programs. Researchers also found that weight improvements could be maintained for up to a year after the program ended. The report also showed that adding prescription drugs to a behavioral weight management program helped extremely obese adolescents lose weight. However, no studies evaluated maintenance of weight loss after drug treatment ended.

http://www.ahrq.gov/clinic/tp/chwghttp.htm

Copies of the report may be ordered free of charge by calling the AHRQ Publications Clearinghouse at 1-800-358-9295 or sending an E-mail to AHRQPubs@ahrq.hhs.gov. For information on how children's and teenagers weight is assessed and a BMI calculator to use for them, go to http://apps.nccd.cdc.gov/dnpabmi/Calculator.aspx.

AHRQ also has a free DVD for families and children age 5 to 9 called Max's Magical Delivery: Fit for Kids. The 30-minute DVD teaches children and their parents about smart eating and physical activity. Copies are available by calling 1-800-358-9295 or E-mailing AHRQPubs@ahrq.hhs.gov.

Task Force Finds Several Methods Equally Effective for Colorectal Cancer Screening

In a change from its previous recommendation, the U.S. Preventive Services Task Force now recommends that adults age 50 to 75 be screened for colorectal cancer using annual high-sensitivity fecal occult blood testing, sigmoidoscopy every 5 years with fecal occult testing between sigmoidoscopic exams, or colonoscopy every 10 years. The Task Force also recommended against routine colorectal cancer screening in adults between the ages of 76 and 85 because the benefits of regular screening were small compared with the risks. Adults over the age of 85 should not be screened at all because the harms of screening may be significant, and other conditions may be more likely to affect their health or well-being.

U.S. Preventive Services Task Force. Screening for Colorectal Cancer: U.S. Preventive Services Task Force Recommendation Statement. AHRQ Publication 08-05124-EF-3, October 2008. Agency for Healthcare Research and Quality, Rockville, MD.
http://www.ahrq.gov/clinic/uspstf08/colocancer/colors.htm

A print copy of the summary and related material is available by sending an e-mail to ahrqpubs@ahrq.hhs.gov.

New Recommendations on Behavioral Counseling to Prevent Sexually Transmitted Infections

The Task Force recommends high-intensity behavioral counseling to prevent sexually transmitted infections (STIs) for all sexually active adolescents and for adults at increased risk for STIs. The Task Force also concluded that evidence is insufficient to assess the balance of benefits and harms of behavioral counseling to prevent STIs in non-sexually active adolescents and in adults not at increased risk for STIs. Despite advances in screening, diagnosis, and treatment of STIs, they remain an important cause of death in the U.S. An estimated 19 million new STIs occur in the United States, almost half among people from 15 to 24 years of age. Common sexually transmitted infections include chlamydia, hepatitis B, hepatitis C, herpes, HIV and syphilis and direct medical costs are estimated at $15 billion annually.

U.S. Preventive Services Task Force. Behavioral Counseling to Prevent Sexually Transmitted Infections: Clinical Summary of U.S. Preventive Services Task Force Recommendation. AHRQ Publication No. 08-05123-EF-3, October 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/uspstf08/sti/stisum.htm
http://www.ahrq.gov/clinic/uspstf08/sti/stirs.htm

A print copy of the summary and related material is available by sending an e-mail to ahrqpubs@ahrq.hhs.gov.

AHRQ’s 2008 Guide to Clinical Preventive Services Now Available

AHRQ has released the Guide to Clinical Preventive Services 2008, which highlights recommendations from the U.S. Preventive Services Task Force. In addition to previous recommendations, this year’s Guide provides new Task Force recommendations released during 2007 on aspirin or nonsteroidal anti-inflammatory drugs for the primary prevention of colorectal cancer; screening for carotid artery stenosis; screening for chronic obstructive pulmonary disease using spirometry; counseling about proper use of motor vehicle occupant restraints and avoidance of alcohol use while driving; screening for illicit drug use; screening for lipid disorders in children; and, screening for sickle cell disease in newborns. The guide contains evidence-based recommendations that have been adapted for a pocket-size book, making it easier for clinicians to consult the recommendations in their daily practice. Recommendations are presented in an indexed, easy-to-use format, with at-a-glance charts.
http://www.ahrq.gov/clinic/pocketgd.htm

A print copy of the Guide is available by sending an e-mail to ahrqpubs@ahrq.hhs.gov.

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Ask A Librarian - Diane Cooper, IHS National Library Informationist

An example of resources available on the HSRL/NIH website
The current Chair of the ACOG Committee on Indian Affairs, Tony Ogburn, has served as co-editor and author of a recent “Medical Clinics of North America” issue dedicated to women’s health. This volume includes chapters by several authors well known to anyone who has attended an IHS women’s health conference in recent years. If you are interested in reading any or all of this issue, you could view the entire issue (and thousands of other journals) directly on the HSRL website from any IHS computer. Prefer to read at home or on the road? Ms. Cooper (the IHS librarian at the Health Services Research Library) can provide you with a password for access to the HSRL website through a proxy server. Not an IHS employee? Ms. Cooper can still help with access. Diane Cooper can be reached at 301.594.2449 or at cooperd@mail.nih.gov or Diane.Cooper2@ihs.gov.

The Health Services Research Library (HSRL) website is: http://hsrl.nihlibrary.nih.gov

Here is the list of chapters from the Medical Clinics of North America issue:

Preface
Ogburn T Voss C
http://www.ncbi.nlm.nih.gov/pubmed/18721649

Barriers to Women's Health: Why Is It So Hard for Women to Stay Healthy?
Ogburn T, Voss C, Espey E.
Women's health care has made great strides in the past two decades. The recognition that women have different health care needs than men has enabled changes to take place in clinical care, research, and education. However, much remains to be done. Providing health care coverage to all women must be a high priority. Research must address the differences between men and women and how they respond to disease and treatment. The physician workforce needs to be expanded; physicians should be well trained to provide comprehensive health care to women. Strategies, such as used in Comprehensive Centers of Women's Health and women's health residencies, can improve education and increase the number of women in academia.
http://www.ncbi.nlm.nih.gov/pubmed/18721650

Preventive Health for Women: Screening and Immunizations
Zebrack JR, Brown KW.
Women's preventive health issues are frequently encountered in the outpatient setting. Many general internists feel uncomfortable meeting the needs of women due to a general lack of knowledge of women's health and inadequate training in the evaluation of female-specific care. In this article, the authors summarize evidence-based guidelines for preventive health and immunizations for women.
http://www.ncbi.nlm.nih.gov/pubmed/18721651

Contraception: What Every Internist Should Know
Espey E, Ogburn T, Fotieo D.
The human costs of unintended pregnancy-abortion and parenting under difficult circumstances-are high. For this reason, all physicians who treat female patients should be knowledgeable about the basics of contraception-both its practical uses and its public health impact. This knowledge will make physicians, including internists, better able to counsel and provide contraceptives for individual patients and to advocate for availability and access. This article discusses the problem and determinants of unintended pregnancy and reviews contraceptive methods.
http://www.ncbi.nlm.nih.gov/pubmed/18721652

Preventing Cervical Cancer: The Pap Test and the HPV Vaccine
Waxman AG, Zsemlye MM.
Women look to their internists and other primary care physicians to provide preventive health care. Periodic Pap tests are as much a part of a woman's ongoing health care as periodic lipid assessments, mammograms, screening for colon cancer, or any of the other recommended screening assessments. This article provides primary care physicians with the information needed to perform Pap tests at the appropriate intervals, or if not set up to do Pap tests themselves, to make the appropriate referrals. Also provided is the necessary information to counsel women with abnormal Pap tests who may need colposcopy or other follow-up evaluation. Finally, the role of the HPV vaccine in the prevention of cervical cancer is summarized.
http://www.ncbi.nlm.nih.gov/pubmed/18721653

Sexually Transmitted Infections and Pelvic Inflammatory Disease in Women
Trigg BG, Kerndt PR, Aynalem G.
Sexually transmitted infections (STIs) are an important public health challenge in the United States. Primary care clinicians can contribute to decreasing these largely preventable causes of morbidity and mortality by integrating routine screening, testing, counseling, treatment, and partner management of STIs into their practice. Newer tests for chlamydia and gonorrhea that can be performed on urine specimens allow screening without a pelvic examination. The most recent edition of the Centers for Disease Control and Prevention sexually transmitted disease treatment guidelines provides an evidence-based, reliable, and convenient set of recommendations for treating and caring for patients who have STIs.
http://www.ncbi.nlm.nih.gov/pubmed/18721654

Breast Disease: Benign and Malignant
Meisner AL, Fekrazad MH, Royce ME.
Breast diseases, both benign and malignant, are common. Typically, young women present with more benign pathologies; however, breast malignancies can occur in young women, especially in those harboring mutations in the BRCA genes, other inherited genetic syndromes associated with increased risk of breast cancer, or familial predisposition for breast cancer. In all women aged 40 and over presenting with abnormalities of the breast, a primary breast cancer should be ruled out because it is the leading cancer among women in developed countries.
http://www.ncbi.nlm.nih.gov/pubmed/18721655

Pelvic Masses
Barney SP, Muller CY, Bradshaw KD.
Pelvic masses develop commonly in women of all ages and states of health. Despite the variety of masses that exist, general guidelines for diagnosis and management allow most masses to be treated in a generalist setting. This article is intended to guide non-obstetric and non-gynecologic physicians through diagnosis and treatment of nonmalignant pelvic masses. It includes information on physical examination, appropriate imaging techniques, laboratory tests, and variations in treatment for adolescents and pre- and postmenopausal women. It also addresses referral guidelines for suspected malignant masses.
http://www.ncbi.nlm.nih.gov/pubmed/18721656

Basic Infertility Including Polycystic Ovary Syndrome
Brassard M, AinMelk Y, Baillargeon JP.
Infertility in women has many possible causes and must be approached systematically. The most common cause of medically treatable infertility is the polycystic ovary syndrome (PCOS). This syndrome is common in young women and is the cause of anovulatory infertility in 70% of cases. It is therefore an important condition to screen and manage in primary care medical settings. In the past 10 years, insulin sensitization with weight loss or metformin has been shown to be a safe and effective treatment for PCOS infertility that eliminates the risk of multiple pregnancy and may reduce the risk of early pregnancy loss as compared with ovulation-inductor drugs. The authors believe metformin should be considered as first-line therapy because it has the advantage to allow for normal single ovulation, for reduced early pregnancy loss, and, most importantly, lifestyle modifications and weight loss before pregnancy. Losing weight not only improves fertility but also reduces adverse pregnancy outcomes associated with obesity.
http://www.ncbi.nlm.nih.gov/pubmed/18721657

Medical Issues from Preconception Through Delivery: A Roadmap for the Internist
Carson MP, Ehrenthal D.
The age of the pregnant population and the number of pregnant women with medical issues are increasing. It is widely recognized that internists have the unique opportunity to identify potential pregnancy issues and address them before a problem arises. Therefore, it's important that we become aware of how to approach these issues. In addition to addressing medical issues in a currently pregnant woman, doctors also have the opportunity to identify issues that occurred during a prior pregnancy, such as gestational diabetes, preeclampsia, or pregnancy loss, and to decrease the risk of complications in future pregnancies. The goal of this article is to provide a roadmap to practicing internists so they will incorporate pregnancy planning into their everyday care plans. The approach is similar to that used when performing a preoperative risk assessment: We want to optimize our patients medically for pregnancy.
http://www.ncbi.nlm.nih.gov/pubmed/18721658

Prescribing Medications Safely During Pregnancy
Rayburn WF, Amanze AC.
A large body of information about medications prescribed during pregnancy is readily available to internists and patients either on-line or through books and medical journals. Much of the evidence about many prescribed drugs is either anecdotal or presented with sufficient warnings about its use during pregnancy. This article discusses specific medications to set the risks and benefits into a more proper perspective, thereby alleviating certain fears and, when necessary, improving compliance.
http://www.ncbi.nlm.nih.gov/pubmed/18721659

Domestic Violence and Rape
Toohey JS
No compilation of women's health care is complete without confronting domestic violence and sexual assault. Long recognized as a health care and physician issue, intimate partner violence continues to be one of the most frequent causes for injury and death to women in the United States and worldwide. According to the Commonwealth Fund survey in 1998, 31% of women reported either physical or sexual abuse from a husband or boyfriend. One in five American women also reported being raped during their lifetime. Careful assessment and universal screening are important tools for the primary care physician.
http://www.ncbi.nlm.nih.gov/pubmed/18721660

Menopause and the Menopausal Transition
Lund KJ
Menopause and the menopausal transition present unique preventive health and quality-of-life challenges for women. The number of patients in the menopausal age group is increasing and represents a significant portion of the population. Care of the menopausal patient can be challenging for the caregiver. This chapter reviews the major health care challenges as well as evaluation and treatment of common quality-of-life issues for menopausal patients.
http://www.ncbi.nlm.nih.gov/pubmed/18721661

Urinary Incontinence and Pelvic Organ Prolapse: Diagnosis and Treatment for the Primary Care Physician
Abed H, Rogers RG.
This article outlines a simplified approach to diagnosis and treatment of women with urinary incontinence or pelvic organ prolapse that can be used by primary care physicians to identify patients with these conditions and initiate treatment for basic problems.
http://www.ncbi.nlm.nih.gov/pubmed/18721662

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Behavioral Health Insights - Peter Stuart, IHS Psychiatry Consultant

Protecting urban American Indian young people from suicide

OBJECTIVE: To examine the likelihood of a past suicide attempt for urban American Indian boys and girls, given salient risk and protective factors.
METHODS: Survey data from 569 urban American Indian, ages 9-15, in-school youths. Logistic regression determined probabilities of past suicide attempts.
RESULTS: For girls, suicidal histories were associated with substance use (risk) and positive mood (protective); probabilities ranged from 6.0% to 57.0%. For boys, probabilities for models with violence perpetration (risk), parent prosocial behavior norms (protective), and positive mood (protective) ranged from 1.0% to 38.0%.
CONCLUSIONS: Highlights the value of assessing both risk and protective factors for suicidal vulnerability and prioritizing prevention strategies.

Pettingell SL, Bearinger LH, Skay CL, Resnick MD, Potthoff SJ, Eichhorn J. Protecting urban American Indian young people from suicide. Am J Health Behav. 2008 Sep-Oct;32(5):465-76.
http://www.ncbi.nlm.nih.gov/pubmed/18241131

The following is a discussion of the above article from “MCH ALERT”:

"These findings for urban American Indian youth support the strategy of boosting protective factors while addressing key risk factors that impede the healthy development of young people," state the authors of an article published in the September-October 2008 issue of the American
Journal of Health Behavior. Although there has been a general decline in youth suicides since 1992 across all racial and ethnic groups, increased suicide among those ages 10-19 underscores the need for prevention efforts. Suicide is the second leading cause of death for American Indian-Alaska Native youth. The article presents findings from a study to identify the strongest risk and protective factors relative to a past suicide attempt among males and females and examines these factors in combination to predict the likelihood of a history of a suicide attempt in a sample of urban American Indian youth.

Data for the study were drawn from surveys conducted between 1995 and 1998 as part of the Indian Youth Resiliency Impact Study. Study participants (youth ages 9-15; N=569) completed a self-report survey comprising items focused on a host of factors affecting health and well-being. The resilience paradigm guided the selection of items used to develop nine scales measuring risk and protective factors in the current study. The seven protective scales in the current analysis
included (1) connectedness to others, (2) family caring, (3) parental prosocial behavior norms, (4) peer prosocial behavior norms, (5) perceived self-image, (6) positive mood, and (7) school connectedness. The two risk scales were (1) substance use and (2) violence perpetration. All analyses were conducted separately by gender. The researchers first examined bivariate relationships between the outcome, past suicide attempt, and risk and protective factors. Then, separate models were created for protective factors only and risk factors only. From these two models, the strongest risk and protective factors associated with a past suicide attempt were entered, and probability profiles were created.

The authors found that

* For girls, positive mood was the only protective factor achieving statistical significance; positive mood and parental prosocial behavior norms were significant protective factors for boys.

* For girls, the only significant risk factor was substance use; involvement in violence perpetration was the sole significant risk factor for boys.

* For girls, with the significant risk factor of substance use in the model, the likelihood of a past suicide attempt decreased from 57% to 24% in the presence of one protective factor (positive mood); for boys, the change was from 38% to 6% in the presence of violence perpetration
(one risk factor) and two significant protective factors (positive mood and parent prosocial behavior norms).

"Our study points to the necessity of responding to indications of vulnerability to suicidal involvement for those in elementary as well as secondary schools," state the authors, concluding that "the identification of salient risk and protective factors for suicide . . .creates a road map for comprehensive assessment and effective intervention."

Readers: More information is available from the following MCH Library resources:

- Emotional, Behavioral, and Mental Health Challenges in Children and Adolescents: Knowledge Path at http://www.mchlibrary.info/KnowledgePaths/kp_Mental_Conditions.html

- Racial and Ethnic Disparities in Health: Knowledge Path at http://www.mchlibrary.info/KnowledgePaths/kp_race.html

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Breastfeeding - Suzan Murphy

A Skinny Little Secret

Sometimes it takes a celebrity to make an old idea work. Now, thanks to Angelina Jolie, the secret is out about breastfeeding’s sleek down potential. While other superstars like singer Christina Aguilera, Gwyneth Paltrow (Shakespeare in Love), and Kate Winlset (Titanic) have publicly commented about how breastfeeding sped their maternal weight loss, one picture of Ms. Jolie in a “great dress” at 11 weeks post partum from twins, told the story.

While the resources available to superstars – like personal trainers, money-is-no-object menus, chefs, exotic entrees, spa pampering, etc - help post partum weight loss, they are not likely public health obesity risk interventions. But breastfeeding could be.

In the last 15 years, several clinical studies have looked at the impact of lactation on maternal weight retention. Studies of US subjects found that lactation reduced weight retention to varying degrees. Variables associated with greater weight retention included single marital status, older maternal age, not breastfeeding, mixed feeding, and/or early weaning to formula. In 1993, Dewey et al found that exclusive breastfeeding significantly enhanced weight loss if continued for at least 6 months, when compared to weight loss patterns of mothers who formula fed. In 1997, Janney C et al found that maternal weight loss was slowed when moms increased formula use or stopped breastfeeding.

A recent study by Hatsu IE et al (2008) found that exclusive breastfeeding resulted in greater maternal weight loss in the first 12 weeks when compared to mixed feeding mothers. The exclusive breastfeeding mothers consumed more calories (1980 +/- 618 kcals, vs 1541 +/-196 kcal p = 0.08). Despite less weight loss, the mixed feeding mothers reported a higher physical activity level. A limitation of the study was small size, 24 participants.

There are several factors that could contribute to breastfeeding women losing more weight than those formula or mixed feeding. The maternal levels of prolactin, oxytocin, and estrogen are different in lactating compared to non-lactating postpartum women. Many breastfeeding women do not resume menses until a year or longer post partum. Also, the caloric cost of milk production is significant. By the second month of lactation, daily breast milk production is roughly 600-900 ml, resulting in approximately 400-600 kcals of milk for the baby. There are also maternal energy costs needed to fuel lactogensis. Although the kcal cost of the mechanics of breast milk production are not yet well understood, it is likely that the process of making breast milk adds to the drain of maternal energy stores.

The same myriad of variables that complicate childhood and adult weight patterns impact maternal weight retention. Food choices/availability, stress, meal preparation methods, socio-economics, activity patterns, life style issues, co-existing diseases/handicaps, genetics, and medication can exert subtle but potentially significant sway over weight change. Controlling for these variables and others will require on-going study.

For more information about your clinic’s early feeding choice and maternal weight retention patterns, please consider data available on RPMS/EHR. The infant feeding tool will define how babies are fed and can include the mothers’ names. Specific information about the infant feeding tool is available at www.ihs.gov/MedicalPrograms/MCH/M/bf.cfm, under the Breastfeeding Headlines section: Frequently asked questions about capturing infant feeding choice on RPMS and E.H.R. or call 1-877-868-9473.

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CCC Corner Digest

Nicely laid out hard copy - A compact digest of last month’s CCC Corner

If you want a copy of the CCC Digest mailed to you each month, please contact Jean Howe

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Domestic Violence - Denise Grenier, Tucson / Rachel Locker, Warm Springs

Women sexually abused by partners have worse health than never abused women, even years after the abuse has stopped
(Funded and reviewed below by ARHQ)

Thirty-four percent of women surveyed in a large health plan had suffered from physical and/or sexual intimate partner violence (IPV) during their adult lifetime. Sexual IPV took an enormous toll on women's health, whether or not they also suffered from physical IPV—their depression and physical symptoms persisted for many years after the abuse had stopped, according to a new study.

The researchers analyzed the surveys of 3,429 insured women about whether they had ever suffered from physical or sexual IPV, as well as their mental, social, and physical health. Although 34 percent of the women had suffered from sexual and/or physical IPV, only 5 percent said they suffered the abuse within the past year. For the others, it had been a median of 19 years since the last episode of abuse. Compared with never abused women, women with a history of sexual IPV had the worst overall health.

Women with a history of sexual IPV only had scores on the mental and social health components of the Short Form-36 survey that were 4.28 to 6.22 points lower than nonabused women, and women with a history of both physical and sexual IPV had scores that were 4.95 to 5.81 points lower. Women who suffered from physical IPV only had scores that were 2.41 to 2.87 points lower than never abused women.

Depression was also more prevalent among sexually abused women than other women.

Compared with never abused women, women with a history of sexual IPV only had 2.4 to 3 times greater prevalence of depressive and severe depressive symptoms.

Women with a history of both physical and sexual IPV had 2.3 to 2.9 times greater prevalence, and women who had been physically abused only had 1.6 to 1.9 times greater prevalence of these symptoms than never abused women.

Finally, compared with never abused women, women who were both physically and sexually abused were nearly twice as likely to report fair or poor health, had more overall symptoms, more limited involvement in voluntary groups, and less trust of individuals in their community.

AHRQ Link: http://www.ahrq.gov/research/sep08/0908RA5.htm

Citation and PubMed Abstract:
Bonomi AE, Anderson ML, Rivara FP, Thompson RS. Health outcomes in women with physical and sexual intimate partner violence exposure. J Womens Health (Larchmt). 2007 Sep;16(7):987-97. http://www.ncbi.nlm.nih.gov/pubmed/17903075

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Elder Care News - Bruce Finke, Elder Care Initiative

Prescription drug misuse/abuse in the elderly

One quarter of the prescription drugs sold in the United States are used by the elderly, often for problems such as chronic pain, insomnia, and anxiety. The prevalence of abuse may be as high as 11 percent with female gender, social isolation, depression, and history of substance abuse increasing risk. Screening instruments for prescription drug abuse have not been validated in the geriatric population. Benzodiazepines, opiate analgesics, and some skeletal muscle relaxants may result in physical dependence; however, tolerance, withdrawal syndrome, and dose escalation may be less common in the older patient. Lower doses may decrease the risk of abuse and dependence; however, fear of abuse often results in a failure to adequately treat symptoms such as anxiety, pain, and insomnia.

Culberson JW, Ziska M. Prescription drug misuse/abuse in the elderly. Geriatrics. 2008 Sep 1;63(9):22-31. http://www.ncbi.nlm.nih.gov/pubmed/18763848

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Family Planning

Drospirenone for acne treatment

OBJECTIVE: To assess the efficacy of the combined oral contraceptive containing 3-mg drospirenone/20-microgram ethinyl estradiol (3-mg drospirenone/20-microgram ethinyl estradiol) administered as 24 consecutive days of active treatment after a 4-day hormone-free interval (24/4 regimen) compared with placebo for the treatment of moderate acne vulgaris.
METHODS: Healthy females aged 14-45 years with moderate acne were randomized in this double-blind study to 3-mg drospirenone/20-microgram ethinyl estradiol (n=270) or placebo (n=268) for six cycles of 28 days. The primary outcome measures of acne lesion counts and Investigator Static Global Assessment scale ratings were assessed at baseline and during cycles 1, 3, and 6.
RESULTS: The percentage reduction from baseline to endpoint for total lesions is 46.3% for 3-mg drospirenone/20-microgram ethinyl estradiol 24/4 combination oral contraceptive group and 30.6% for placebo group (P<.001). The likelihood of participants in the 3-mg drospirenone/20-microgram ethinyl estradiol 24/4 regimen group having "clear" or "almost clear" skin as rated by the investigators at endpoint was about threefold (odds ratio 3.13, 95% confidence interval 1.69-5.81; P=.001) greater than in the placebo group. The 3-mg drospirenone/20-microgram ethinyl estradiol 24/4 regimen was well tolerated.
CONCLUSION: The low-dose combined oral contraceptive containing 3-mg drospirenone/20-microgram ethinyl estradiol administered in a 24/4 regimen significantly reduced acne lesion counts more effectively than placebo and demonstrated greater improvement in the Investigator Static Global Assessment rating of acne. The safety profile was consistent with low-dose combined oral contraceptive use.

Maloney JM, Dietze P Jr, Watson D, Niknian M, Lee-Rugh S, Sampson-Landers C, Korner P. Treatment of acne using a 3-milligram drospirenone/20-microgram ethinyl estradiol oral contraceptive administered in a 24/4 regimen: a randomized controlled trial. Obstet Gynecol. 2008 Oct;112(4):773-81. http://www.ncbi.nlm.nih.gov/pubmed/18827119

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Featured Website

The Immunization Action Coalition

The Immunization Action Coalition, a 501(c)3 nonprofit organization, works to increase immunization rates and prevent disease by creating and distributing educational materials for health professionals and the public that enhance the delivery of safe and effective immunization services. The Coalition also facilitates communication about the safety, efficacy, and use of vaccines within the broad immunization community of patients, parents, health care organizations, and government health agencies.

IAC publishes three periodicals---Needle Tips, Vaccinate Adults, and Vaccinate Women with a combined circulation of nearly 300,000. Needle Tips, a 24-page publication full of information about immunization across the age span, is mailed to health professionals twice each year. Vaccinate Adults, a 12-page publication that promotes adult immunization recommendations, is sent to adult medicine specialists twice each year. Vaccinate Women, an 8- to 12-page publication, is mailed to obstetrician/gynecologists and other women's health specialists once each year.

Due to our close collaboration with the Centers for Disease Control and Prevention (CDC) and the funding they provide, contributions from our members, educational grants provided by several foundations and companies, and the world-class expertise of our Advisory Board, we have been able to create, find, and distribute the most complete, up-to-date, and accurate supply and listing of immunization and hepatitis B resources available anywhere.

We would be delighted to have you join the thousands of people who support the Coalition. Your contribution is tax-deductible to the fullest extent of the law.

Help yourself to the unique resource materials we offer. All of our print materials are camera-ready, copyright-free, and reviewed by CDC for technical accuracy with the exception of opinion pieces written by non-CDC authors. Our materials are ready for you to make copies and distribute to your patients and staff. Be our guest!

http://www.immunize.org/
The Immunization Action Coalition has an excellent on-line resource page to assist providers in addressing parents' and patients’ concerns about immunization.

http://www.immunize.org/concerns/

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Frequently Asked Questions - Neil Murphy; SCF, ANMC

Q. Should we treat asymptomatic trichomonas found on a Pap smear?

A. It depends what type of Pap smear you are using. See details below

Answer
If it was a conventional Pap, then please bring the non-pregnant patient in for a confirmatory test. If it was a liquid based Pap, then you can treat the patient without further evaluation.

Treating asymptomatic trichomoniasis is not recommended in pregnant women given the potentially increased risk of preterm birth associated with antibiotic therapy, but treatment of symptomatic non-pregnant women is recommended.

Background
Treatment is indicated in all nonpregnant women* diagnosed with trichomonas vaginitis, even if asymptomatic. The rationale for treatment of asymptomatic women is that if left untreated, up to one-third become symptomatic within six months and they continue to transmit the infection to sexual partners while untreated.

The most sensitive method of detecting trichomonas vaginitis is culture. Unfortunately trichomonas culture is not available at most sites, plus one would also need a special medium to even send it to most outside laboratories. Microscopy and pH is only 50 to 70 percent sensitive and is time sensitive secondary to motility. DNA probes are sensitive and specific, but not readily available. Conventional cytology has a sensitivity of only 60 to 70 percent and false positive results are common (at least 8 percent). Thus, conventional Pap smear should not be used to diagnose trichomoniasis. Asymptomatic women with trichomonads identified on conventional Pap smear should be evaluated by wet mount, or culture if the wet mount is negative and should not be treated until the diagnosis is confirmed.

By comparison, the reliability of liquid-based cervical cytology appears to be higher. Although the sensitivity of liquid-based smears for trichomonas infection is low (61 percent), specificity is high (99 percent) compared to conventional Pap smear, resulting in a false positive rate of only 1 percent. Therefore, although liquid-based cervical cytology is not a sensitive test for diagnosis of trichomoniasis, we feel treatment of asymptomatic women with trichomonads noted on liquid-based cervical cytology is a reasonable approach.

In summary, patients with trichomonas on a conventional Pap need to come in confirmation before treatment. If you utilize a liquid based prep, then it is recommended that you treat based on that alone.

*Treating asymptomatic trichomoniasis is not recommended in pregnant women given the potentially increased risk of preterm birth associated with antibiotic therapy, but treatment of symptomatic pregnant women is recommended.

Addendum: Diagnostic tools

Diagnosis - As with other types of vaginitis, none of the clinical features of trichomonas vaginitis is sufficiently sensitive or specific to allow a diagnosis based upon signs and symptoms alone.

Microscopy and pH -The presence of motile trichomonads on wet mount is diagnostic of infection, but this occurs in only 50 to 70 percent of culture-confirmed cases. The organisms remain motile for 10 to 20 minutes after collection of the sample. Other findings that are almost invariably present with trichomonas infection, but nondiagnostic, include an elevated vaginal pH (>4.5) and an increase in polymorphonuclear leukocytes on saline microscopy.

Culture -Culture on Diamond's medium has a high sensitivity (95 percent) and specificity (>95 percent) and should be considered in patients with elevated vaginal pH, increased numbers of polymorphonuclear leukocytes and an absence of motile trichomonads and clue cells on wet mount; or when microscopy is unavailable or yields unreliable results. Alternatively, a commercial “In Pouch" T vaginalis culture system can be used and is readily available (BioMed Diagnostics,
White City, Oregon).

DNA probes - No FDA-approved PCR test for T. vaginalis is available in the United States, but several rapid diagnostic kits using DNA probes and monoclonal antibodies have been developed commercially, with a sensitivity of 90 percent and a specificity of 99.8 percent. These can be useful in areas of high prevalence where microscopy or culture is not available (i.e. high prevalence refers to STD clinics and inner city clinics serving the uninsured). A point-of-care test for trichomonas antigens, the OSOM Trichomonas Rapid Test has a sensitivity of 88.3 percent and specificity of 98.8 percent. Physicians and staff can read results in 10 minutes. The Affirm VP III Microbial Identification System (Becton Dickinson) test uses a nucleic acid probe and is read in 45 minutes.

Cervical cytology - Trichomonads are sometimes reported as an incidental finding on conventional Papanicolaou (Pap) smears. Conventional Pap smears are inadequate for diagnosis of trichomoniasis because this technique has a sensitivity of only 60 to 70 percent and false positive results are common (at least 8 percent). Thus, Pap smear should not be used to diagnose trichomoniasis. Asymptomatic women with trichomonads identified on conventional Pap smear should be evaluated by wet mount, or culture if the wet mount is negative and should not be treated until the diagnosis is confirmed.

By comparison, the reliability of liquid-based cervical cytology appears to be higher. One study involved both liquid-based cervical cytology and culture for T. vaginalis on 203 consecutive women. Forty-four women had a positive culture and 28 women had a positive liquid-based smear for trichomonads. Although the sensitivity of liquid-based smears for trichomonas infection was low (61 percent), specificity was high (99 percent) compared to conventional Pap smear, resulting in a false positive rate of only 1 percent. Therefore, although liquid-based cervical cytology is not a sensitive test for diagnosis of trichomoniasis, we feel treatment of asymptomatic women with trichomonads noted on liquid-based cervical cytology is a reasonable approach.

Resources

Trichomonas vaginitis , UpToDate
http://www.uptodateonline.com/utd/content/topic.do?topicKey=gen_gyne/28379

Diagnosis of trichomoniasis. Comparison of conventional wet-mount examination with cytologic studies, cultures, and monoclonal antibody staining of direct specimens.

ABSTRACT:
The accuracy of (1) conventional wet-mount examination, (2) Papanicolaou-stained gynecologic smears, (3) a direct slide test using fluorescein-conjugated monoclonal antibodies against Trichomonas vaginalis, and (4) two different culture media for the diagnosis of trichomoniasis in a high-risk population of 600 women was compared. Use of Feinberg-Whittington or Diamond's culture medium resulted in a diagnosis of 82 and 78 cases, respectively, and the combination of two cultures identified 88 infected women. In comparison, wet-mount examination detected only 53 (60%) of the cases. Cytologic smears were interpreted as positive for T vaginalis in 49 (56%) of the 88 cases but also resulted in seven false-positive smears, and specimens from 18 women with negative cultures were interpreted as "suspicious" for trichomoniasis. Monoclonal antibody staining detected 76 (86%) of the 88 positive specimens, including 27 (77%) of the 35 cases missed by wet-mount examination. In summary, wet-mount and cytologic studies were insensitive, and cytology study was the least specific method for diagnosis of trichomoniasis. Direct immunofluorescence with monoclonal antibodies holds promise as a sensitive and specific alternative to cultures for rapid detection of T vaginalis in clinical specimens.

Krieger JN; Tam MR; Stevens CE; Nielsen IO; Hale J; Kiviat NB; Holmes KK Diagnosis of trichomoniasis. Comparison of conventional wet-mount examination with cytologic studies, cultures, and monoclonal antibody staining of direct specimens. JAMA 1988 Feb 26;259(8):1223-7. http://www.ncbi.nlm.nih.gov/pubmed/2448502

Accuracy of detection of trichomonas vaginalis organisms on a liquid-based Papanicolaou smear

OBJECTIVE: The study was undertaken to determine the accuracy of the liquid-based Papanicolaou (Pap) smear in the detection of Trichomonas vaginalis organisms in women. STUDY DESIGN: Two hundred three consecutive patients who had the liquid-based Pap smear also underwent a culture for T vaginalis. A wet mount was performed if symptomatic. Results were analyzed for sensitivity, specificity, and positive and negative predictive values. RESULTS: Forty-four patients (21.6%) had a positive culture. On the liquid-based Pap smear, 28 patients (13.8%) were positive for T vaginalis, showing a sensitivity of 61.4%, a specificity of 99.4%, a positive predictive value of 96.4%, and a negative predictive value of 90.8%. When wet mount and culture were compared, a sensitivity of 50%, a specificity of 93%, a positive predictive value of 77%, and a negative predictive value of 80% were obtained. CONCLUSION: The presence of T vaginalis organisms, as stated by the liquid-based Pap smear pathology report, is accurate and warrants treatment without further testing.

Lara-Torre E; Pinkerton JS Accuracy of detection of trichomonas vaginalis organisms on a liquid-based Papanicolaou smear. Am J Obstet Gynecol 2003 Feb;188(2):354-6.
http://www.ncbi.nlm.nih.gov/pubmed/12592239

Bonus FAQ:

Q. Should I withhold contraception from a woman who is not ‘current’ on her pap?
A. No, there should be no barriers to the use of FDA approved contraception.

(Detailed answer to follow next month.)

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Indian Child Health Notes - Steve Holve, Pediatrics Chief Clinical Consultant

November 2008

Quote of the month
“Our capability to prevent and treat disease seems to exceed our willingness to apply our interventions.”
C Everett Koop, MD
Former Surgeon general

Article of Interest

Effectiveness of Maternal Influenza Immunization in Mothers and Infants.
N Engl J Med. 2008 Sep 17. (See “Abstract of the Month” for the abstract of this article.)

The current influenza vaccine is not licensed for use in infants < 6 months age. Unfortunately; this age group is at highest risk for morbidity and mortality from influenza infections. Researchers looked at immunizing mothers in the third trimester of pregnancy as a way to transfer immunity to infants at birth.

340 women participated in a randomized controlled trial and were followed for 24 weeks after birth. Women who were vaccinated for influenza had 36% less febrile respiratory illnesses themselves. Their infants had 29% less febrile respiratory illnesses than unvaccinated mothers. More striking was the 63% reduction of laboratory confirmed influenza in infants born to mothers that had been vaccinated. These numbers suggest that for each 100 mothers vaccinated 7 maternal febrile illnesses and 14 newborn illnesses will be prevented.

Pediatrics CCC Editorial Comment

Few interventions in medicine are this cheap and effective. Even though vaccination of pregnant women has been a recommendation of the CDC for several years the number of pregnant women vaccinated has been low. The quote from Dr. Koop above highlights the fact that we often fail to use treatments of known benefit.

Our challenge is to make sure that this intervention is available to as many patients as possible. Prenatal clinics should consider standing orders for administration of flu vaccine. Obstetric wards should also consider the use of standard orders for flu shots at discharge from mothers who were not vaccinated during pregnancy. This strategy will not result in transplacental protection of the infant but can decrease mother-child transmission.

Recent literature on American Indian/Alaskan Native Health

Michael L. Bartholomew, MD
Naimi TS, Cobb N, Boyd D, Jarman DW, Brewer R, Nelson DE, Holt J, Espey D, Snesrud P, Chavez P. Alcohol-Attributable Deaths and Years of Potential Life Lost Among American Indians and Alaska Natives---United States, 2001-2005. MMWR Morb Mortal Wkly Rep. 2008 Aug 29;57(34);938-941. http://www.ncbi.nlm.nih.gov/pubmed/18756193

Excessive alcohol consumption is both a pervasive problem and the leading cause of preventable death in both the general U.S. population and the American Indian and Alaska Native (AI/AN) population. This study is the first to estimate the average annual number of alcohol-attributable deaths and years of potential life lost among AI/ANs. By using death certificate data and the CDC Alcohol-Related Disease Impact (ARDI) software, estimates of alcohol-attributable deaths and years of life lost were generated by analyzing multiple data sources including the Behavioral Risk Factor Surveillance System from 2001-2005.

Among AI/ANs, 1,514 alcohol-attributable deaths occurred annually from 2001-2005, accounting for 11.7% of all AI/AN deaths. For the general U.S. population, alcohol-attributable deaths accounted for 3.3% of total deaths. Acute causes, such as motor vehicle crashes, accounted for nearly 51% of these deaths, while 49% were attributed to chronic causes (alcoholic liver disease). Similarly, 60% of years of potential life lost were attributed to acute causes and nearly 40% were related to chronic conditions. Men accounted for more alcohol-attributable deaths in all age groups and nearly 7% of these deaths were in persons aged <20 years. Within the Indian Health Service (IHS) regions, the Northern Plains had the greatest number of alcohol-attributable deaths followed by the Southwest, and the Pacific Coast. Additionally, the age adjusted alcohol-attributable death rates were highest in the Northern Plains, Alaska, and the Southwest.

AI/AN age adjusted alcohol-attributed death rates were higher than the general U.S. population (55 per 100,000 for AI/AN versus nearly 27 per 100,000 for general U.S. population). The average number of years of life lost per alcohol-attributable death was 36.3 years for AI/ANs and 29.9 years for the general U.S. population.

Estimating the years of life lost and the alcohol attributed mortality rate in AI/ANs demonstrates the effect of excessive alcohol consumption within our population The authors conclude that effective population based interventions to reduce excessive alcohol consumption should be implemented and regional differences in alcohol-attributable deaths be explored.

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Information Technology - Theresa Cullen, Chief Information Officer, IHS

Alpha Testing to Start on the EHR Version of the Well Child Module

Good news! We are on the verge of alpha testing the EHR version of the Well Child Module. The electronic versions of both the Well Child and Prenatal modules will be available in EHR or as “free-standing” components for sites that have yet to migrate to the IHS EHR.

Cherokee Indian Hospital has volunteered to alpha test the EHR version of the WCM. The other iteration of the electronic version of the WCM (for sites not yet on EHR) will also be alpha tested soon.

The EHR version of the Prenatal Module is also very close to alpha testing and should be ready for testing late this fall.

For further information, contact: clarence.smiley@ihs.gov.

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International Health Update - Claire Wendland, Madison, WI

Disease risks of premastication as an infant feeding practice

Before the era of blenders, and beyond the reach of the purveyors of canned baby food, parents have long chewed up solid foods and fed the resulting mash to their weaning infants. This practice, called premastication, is old and widespread. It makes physiological sense: the chewing not only makes food manageable for little ones without teeth, but also mixes it with salivary enzymes to begin the digestive process. Unfortunately, premastication also seems to have some health risks that may not have been adequately considered.

Although the anthropological literature on premastication is not extensive (primarily because the anthropological record does not have much to say about infant feeding in general), we have evidence that it is practiced in every major region of the world. Using the Human Relations Area Files, a fascinating compendium of ethnographic records collected over the course of sixty years, I was able to identify good evidence of premastication of infant food in fifteen cultural groups from Asia, South America, North America, Oceania, and Africa. (Two others premasticate food for animals: one Amazonian group occasionally chews up taro for their prized dogs, and a South Seas people masticates yam for the boars that have grown such long spiral tusks – valuable among the South Seas islanders for ceremonial purposes – that they can no longer open their mouths enough to chew.) Anecdotal reports from the Indian Health Service indicate that premastication for infants is at least occasionally practiced among many Native peoples in North America as well, particularly among Navajo, northern Plains, and Alaska Native groups. Just how prevalent the practice is, however, is unknown.

So why does it matter? There have been suggestions that premastication can introduce the infant to pathogens carried by the adults who pre-chew their weaning food. A Canadian First Nations study (Sinha et al. 2004) implicates maternal saliva – potentially transferred to the infant through premastication and possibly also on pacifiers – in the oral-oral transmission of Helicobacter pylori, etiologic factor in both peptic ulcer and gastric cancer later in life. A Thai study (Imong et al. 1995) documents bacterial contamination of premasticated infant food and raises concerns over diarrheal diseases. Finally, a study from China (Huang 1990) raises concerns over the transmission of blood-borne pathogens in some cases: the author reports a two-fold rise in relative risk of hepatitis B among kindergartners whose mothers premasticated food for them in infancy, even when controlled for other routes of transmission. If further research confirms that blood-borne pathogens like HBV and HIV can be transmitted by premastication, even if such transmission is a relatively minor route, the implications for global health are obvious.

There are reasons for caution, however. First, the research available is preliminary; it is not at all clear whether premasticated infant food really is an important route of disease transmission. Second, the alternatives must be carefully thought through, especially for families who cannot afford commercial baby food. (Clinicians and public health professionals should be chastened by remembering the catastrophic impact of pushing bottle-feeding to mothers in the Third World.) Imong and colleagues’ Thai study of infant feeding cited above showed bacterial contamination of both premasticated and mashed foods. Anthropologists provide another cautionary tale. Public health officials convinced the Orokaiva people of Papua New Guinea that premasticating babies’ food was unhygienic and uncivilized. But their instructions to mash taro instead were ignored: mashing was a grievous offense to the taro spirit. Babies fed solid taro could not digest it; Orokaiva babies suffered critical weaning-period malnutrition because of this well-intentioned public health intervention, and the anthropologists’ suggestion that going back to premastication would help was taken as a distasteful joke. It is not yet time to rush out and start a new public health campaign against premastication, but it probably is time to start considering – and researching – the risks of this and alternative weaning approaches among those who practice them.

Sinha SK et al. The incidence of Helicobacter pylori acquisition in children of a Canadian First Nations community and the potential for parent-to-child transmission. Helicobacter 9(1):59-68, 2004. http://www.ncbi.nlm.nih.gov/pubmed/15156905

Huang MJ. [An epidemiological study on prevalence and risk factors of hepatitis B virus (HBV) infection in preschool children.] Zhongua Liu Xing Bing Xue Za Zhi 11(3):129-32, 1990. Note: article is in Chinese and only the abstract is available in English. http://www.ncbi.nlm.nih.gov/pubmed/2390775

Imong SM et al. Maternal behaviour and socio-economic influences on the bacterial content of infant weaning foods in rural northern Thailand. J Trop Pediatr 41(4):234-40,1995. http://www.ncbi.nlm.nih.gov/pubmed/7563277

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MCH Alert

MCH Library Releases New Edition of Domestic Violence Knowledge Path

Domestic Violence: Knowledge Path is an electronic guide to recent resources about identifying and responding to domestic violence within the home and the community. The knowledge path, produced by the MCH Library, contains information on Web sites, publications, databases, and
newsletters and online discussion lists. Separate sections identify resources for families and resources about children exposed to domestic violence; dating violence among adolescents; and violence between gay, lesbian, bisexual, and transgender partners. The knowledge path is
available at http://www.mchlibrary.info/KnowledgePaths/kp_domviolence.html.

MCH Library knowledge paths on other maternal and child health topics are available at http://www.mchlibrary.info/KnowledgePaths/index.html.

Article Assesses Smoking Patterns and Use of Cessation Interventions During Pregnancy

"If women enter prenatal care while smoking, there is an opportunity for clinicians to assess smoking status, counsel them to quit smoking, and provide referrals for cessation services," state the authors of an article published in the October 2008 issue of the American Journal of Preventive Medicine. Maternal smoking has been causally associated with fetal growth restriction, premature rupture of the membranes, placenta previa, placental abruption, preterm delivery, and low birthweight. In addition, in utero exposure to cigarette smoke can have long-term negative effects on the growth, development, and behaviors of offspring. Further, women who quit smoking during pregnancy have better health outcomes than those who continue to smoke. However, more than 10% of women who delivered a live infant in 2004 reported smoking during pregnancy -- far above the Healthy People goal of 1%. This study analyzed population-based surveillance data to describe women's smoking patterns and the use of cessation services during pregnancy. Smoking status during pregnancy as well as before and after entry into prenatal care was examined. Health professional assistance, the use of interventions, and barriers to quitting were also described.

Data were analyzed from 4,473 women who responded to a questionnaire from the New Jersey PRAMS (Pregnancy Risk Assessment and Monitoring System) during 2004-2005. PRAMS, a population-based survey of women whose pregnancies resulted in a live birth, is conducted in partnership with the Centers for Disease Control and Prevention and the New Jersey Department of Health and Senior Services. New Jersey was selected because it is the only PRAMS state that includes detailed supplemental questions on patterns of smoking and the use of cessation services.

The authors found that:
- Among New Jersey women who delivered a live infant, an estimated 16.2% smoked in the 3 months before pregnancy, and 7.3% smoked during the last 3 months of pregnancy. Of the 16.2% who smoked before pregnancy, half (49.8%) quit before entering prenatal care, and 5.2% quit afterwards.

-Of women who smoked before pregnancy, 92.7% reported that they were asked by their prenatal care health professionals about their smoking status. Of women who were smoking when they entered prenatal care, 56.7% reported that a health professional spent time discussing how to quit, and 31.1% reported that a health professional set a specific date to quit.

-Among women who smoked during the last 3 months of pregnancy, 52.4% tried to quit or cut back on their own, 10.2% tried to quit or cut back but did not report using a cessation method, 25.9% did not try to quit or cut back, and 11.5% used a cessation method when trying to quit or
cut back.

-The most frequent barriers to quitting were cravings for a cigarette, loss of a way to handle stress, and having other people around who smoke.

The authors conclude that "increasing the knowledge, promotion, and referral of effective smoking-cessation interventions is necessary to reduce the harmful impact of smoking on the health of women and their newborns."

Tong V, Englad LJ, Dietz PM, et al. 2008. Smoking patterns and use of cessation interventions during pregnancy. American Journal of Preventive Medicine 35(4):327-333. Abstract available at
http://www.ajpm-online.net/article/S0749-3797(08)00602-8/abstract.

Readers: More information is available from the following MCH Library resources:

- Smoking During Pregnancy: Bibliography at
http://www.mchlibrary.info/action.lasso?-database=Biblio&-layout=Web&-response=/databases/BibLists/bib_smokingpreg.html&-MaxRecords=all&-DoScript=auto_search_smokingpreg&-search

- Smoking/Tobacco Use Prevention: Bibliography at
http://www.mchlibrary.info/action.lasso?-database=Biblio&-layout=Web&-response=/databases/BibLists/bib_smokingprev.html&-MaxRecords=all&-DoScript=auto_search_smokingprev&-search

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MCH Headlines - Judy Thierry HQE

Native American Action Plan: Addressing Tobacco Abuse among Pregnant and Postpartum Women

The 32 page: "Native American Action Plan: Addressing Tobacco Abuse among Pregnant and Postpartum Women," developed by The National Partnership to Help Pregnant Smokers Quit with contractual technical assistance from LaDonna BlueEye is being released in PDF and hard copy November 1st.

Meant for Tribal Leaders, Healthcare providers, Program planners and policy makers, and Funding agencies the TOC with cases, lessons learned and action steps in each section as follows:

The National Partnership to Help Pregnant Smokers Quit
Introducing the Issues; The Problem; The Challenge; The Current Intervention;
The Opportunity
Action to Reduce Smoking among Pregnant Native Americans: The 5 C’s
1. Collaborate with other organizations; Traditional Ties
2. Cultivate cultural competency; SEMA Tobacco Project
3. Coach providers on working with Native American populations; Southern Ute Health Clinic
4. Care for patients using evidence-based practices; Alaska Nicotine Research and Control Program
5. Communicate cessation messages through multiple media; Aberdeen Healthy Start

An online version including the appendices will be available soon at:
www.tobacco-cessation.org/pregnantsmokers.htm.

Limited hard copies are available by contacting LaDonna BlueEye at lblueeye@indiana.edu

Cough and Cold Medications Not Recommended for Children Under 4 Years of Age

FDA notified healthcare professionals and consumers that the Consumer Healthcare Products Association (CHPA) is voluntarily modifying the product labels for consumers of over the counter (OTC) cough and cold medicines to state "do not use" in children under 4 years of age. FDA supports CHPA members to help prevent and reduce misuse and to better inform consumers about the safe and effective use of these products for children. FDA continues to assess the safety and efficacy of these products and to revise its OTC list of approved ingredients and amounts for these medicines. Parents and care givers should adhere to the dosage instructions and warnings on the label that accompanies OTC cough and cold medications before giving the product to children, and should consult their healthcare professionals if they have any questions or concerns.

Read the entire 2008 MedWatch Safety Summaries, including a link to the FDA Press Release regarding the above issue at: http://www.fda.gov/medwatch/safety/2008/safety08.htm#CoughCold

United States Breastfeeding Committee Coalition Mini-Grants Application Now Open

The United States Breastfeeding Committee is launching the Coalition Mini-Grants Program this fall with funding from the Centers for Disease Control and Prevention, to support state/territory/tribal breastfeeding coalitions. This program will award several $500 to $3,000 grants, totaling $18,000 in funding for state, territory, and tribal breastfeeding coalitions.

The purpose of this program is to enhance the capacity of state/territory/tribal breastfeeding coalitions while ensuring that coalitions are not duplicating efforts. The mini-grants will promote enhanced focus on developing innovative strategies; refining, tailoring, and replicating previously successful strategies; and sharing results widely; thereby building on the work of others to enhance protection, promotion, and support of breastfeeding across the United States.

Key Dates and Deadlines:
Application Deadline: 5:00 p.m. (ET), Friday, January 9, 2009
Notification of Funded Proposals: February 6, 2009
Checks to Funded Coalitions: by February 28, 2009
Presentations at 2010 Conference: January 23-25, 2010
Final Mini-Grant Reports Due: March 31, 2010
We look forward to launching this exciting new program!

United States Breastfeeding Committee
2025 M Street, NW, Suite 800
Washington, DC 20036
Phone: (202) 367-1132
Fax: (202) 367-2132
E-mail: office@usbreastfeeding.org
Web: www.usbreastfeeding.org

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Medical Mystery Tour - Neil Murphy, Southcentral Foundation; ANMC

Test your knowledge on Polycystic Ovarian Syndrome (PCOS)

1. Menstrual cycles become more irregular in women with polycystic ovarian syndrome (PCOS) as they approach menopause

True
False

2. Medical management of adolescents with PCOS are most appropriately directed towards

Maximizing fertility
Preventing excessive weight gain
Arresting the progression of hirsutism
Decreasing insulin levels

3. Intrauterine growth retardation is associated with an increased risk of PCOS in offspring

True
False

4. Brothers of women with PCOS are at greater risk for which of the following conditions?

Decrease sperm counts
Type 2 diabetes
Hirsutism
Increased pregnancy wastage

5. The most appropriate first line modality for ovulation induction in women with PCOS is

Ovarian drilling
Clomiphene citrate
Metformin
Exogenous gonadotropin

Answers to follow in the December CCC Corner…

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Medscape*

A sampling of the CME offerings available on Medscape:

Vitamin D and Musculoskeletal Health
http://www.medscape.com/viewprogram/17495

The Expanding Benefits of HPV Vaccination: Update on Clinical Data and Expert Panel Discussion
http://www.medscape.com/viewprogram/17055

Communicating Drug Risks to Patients
http://www.medscape.com/viewprogram/17379

Adhesive Disease Associated With Gynecologic Surgery
http://www.medscape.com/viewprogram/17370

Selecting Menopausal Estrogen Therapy: Oral or Transdermal?
http://www.medscape.com/viewprogram/17277

General Medscape Links:

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

Hot flashes and subclinical cardiovascular disease: findings from the Study of Women's Health Across the Nation Heart Study

BACKGROUND: Although evidence suggests adverse vascular changes among women with hot flashes, it is unknown whether hot flashes are associated with subclinical cardiovascular disease. The aim of this study was to examine relations between menopausal hot flashes and indices of subclinical cardiovascular disease. We hypothesized that women with hot flashes would show reduced flow-mediated dilation and greater coronary artery and aortic calcification compared with women without hot flashes.
METHODS AND RESULTS: The Study of Women's Health Across the Nation Heart Study (2001 to 2003) is an ancillary study to the Study of Women's Health Across the Nation, a community-based cohort study. Participants were 492 women (35% black, 65% white) 45 to 58 years of age who were free of clinical cardiovascular disease and had a uterus and at least 1 ovary. Measures included a brachial artery ultrasound to assess flow-mediated dilation, electron beam tomography to assess coronary artery and aortic calcification, reported hot flashes (any/none, previous 2 weeks), and a blood sample for measurement of estradiol concentrations. Cross-sectional associations were evaluated with linear regression and partial proportional odds models. Hot flashes were associated with significantly lower flow-mediated dilation (beta=-1.01; SE, 0.41; P=0.01) and greater coronary artery (odds ratio, 1.48; 95% confidence interval, 1.04 to 2.12) and aortic (odds ratio, 1.55; 95% confidence interval, 1.10 to 2.19) calcification in age- and race-adjusted models. Significant associations between hot flashes and flow-mediated dilation (beta=-0.97; SE, 0.44; P=0.03) and aortic calcification (odds ratio, 1.63; 95% confidence interval, 1.07 to 2.49) remained in models adjusted for cardiovascular disease risk factors and estradiol.
CONCLUSIONS: Women with hot flashes had reduced flow-mediated dilation and greater aortic calcification. Hot flashes may mark adverse underlying vascular changes among midlife women.

Thurston RC, Sutton-Tyrrell K, Everson-Rose SA, Hess R, Matthews KA. Hot flashes and subclinical cardiovascular disease: findings from the Study of Women's Health Across the Nation Heart Study. Circulation. 2008 Sep 16;118(12):1234-40. Epub 2008 Sep 2. http://www.ncbi.nlm.nih.gov/pubmed/18765392

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Midwives Corner - Lisa Allee, CNM, 4 Corners Regional Health Center, Red Mesa, AZ

Centering Pregnancy ListServe Revived

Hello All! The Centering Pregnancy ListServe is being revived!!
This list serve is for anyone who is doing Centering, is about to start Centering, is interested in doing Centering soon or sometime in the future, or anyone who is just downright curious about Centering. It is our forum to discuss ideas, frustrations, successes, stories, trainings, etc!! Please feel free to send in anything about Centering and forward this to anyone who you think might be interested!
Here are two questions currently being discussed on the ListServe:

Who is currently doing Centering?? - where are you, how many groups are you running; average group size; and how many providers and co-facilitators are involved?

Who would be interested in an Advanced Centering Pregnancy and Parenting Training? There is some funding available to put one on if we have the numbers to support it!

To join the ListServe, please contact Lisa Allee at lisa.allee@ihs.gov.

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Navajo News - John Balintona, Shiprock

Navajo Area Women’s Health Provider Meeting

The following is a continuation of the excerpts from the Navajo Area Women’s Health Provider Meeting held in Chinle, Arizona on September 12, 2008.

MATERNITY CARE ISSUES

GPRA HIV Screening

Navajo Area target goal (74%) was met with a screening of 81.2% of eligible patients screened.
Attendees discussed ideas for maintaining and increasing screening rate, ideas included establishing scheduled audits of RPMS and implementation of rapid HIV screening tests.

Navajo Area Birth Statistics

Total of 3136 deliveries in NAIHS for 2007 which is similar to 2006
Overall cesarean delivery rate: 14.1%
Overall VBAC success rate: 92.6%
Attendees confirmed the dedication for providing VBAC services for our area.

OB Survey

Attendees discussed the results and implementation of recent NAIHS OB provider survey circulated in Summer 2008.
Results published in recent CCC Clinical Corner.

Fetal Monitoring Nomenclature

Dr. Paul Drinen, Chinle, presented a review of recent NICHD changes for fetal monitoring language.
Attendees agreed that adoption of the new NICHD guidelines should be implemented area-wide for uniformity and ease of communication.

OB Drills

Discussed specific OB Drills to include; emergency cesarean, shoulder dystocia, postpartum hemorrhage, and neonatal resuscitation.
Surveyed the group as to the use of OB Drills and to the frequency of performing the drills. Most sites performed some type of drill exercise, but the frequency varied from monthly to quarterly.
Dr. Howe can be contacted for literature regarding implementation of OB Drills.

Area-wide Nursing Shortage and Kayenta Maternity Care Update

Attendees discussed the nursing shortage in the NAIHS pertaining to L&D, Ward, and Nursery nurses.
All sites except Fort Defiance reported a shortage of available nurses.
Attendees noted a high utilization of contract and locums nurses as opposed to permanent staff.
Discussed future availability of maternity care at Kayenta Medical Center.

Prenatal Genetic Screening

Discussed the challenge in obtaining some of the genetic screening, i.e. universal first trimester screening, nuchal thickness measurements, etc.
Reviewed the cost of a variety of screening regimens.

UPCOMING EVENTS

Telluride Conference on Maternal and Child Health
Telluride, Colorado; January 30th – February 1st, 2009

Navajo Area ALSO Course
Chinle, Arizona; April 18-19, 2009 (tentative)

For additional information about this column, please contact John.Balintona@ihs.gov.

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Nurses Corner - Sandra Haldane, HQE

Strategies to prevent healthcare-associated infections in acute care hospitals

Preventable healthcare-associated infections (HAIs) occur in US hospitals. Preventing these infections is a national priority, with initiatives led by healthcare organizations, professional associations, government and accrediting agencies, legislators, regulators, payers, and consumer advocacy groups. To assist acute care hospitals in focusing and prioritizing efforts to implement evidence-based practices for prevention of HAIs, the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America Standards and Practice Guidelines Committee appointed a task force to create a concise compendium of recommendations for the prevention of common HAIs. This compendium is implementation focused and differs from most previously published guidelines in that it highlights a set of basic HAI prevention strategies plus special approaches for use in locations and/or populations within the hospital when infections are not controlled by use of basic practices, recommends that accountability for implementing infection prevention practices be assigned to specific groups and individuals, and includes proposed performance measures for internal quality improvement efforts.

Yokoe DS, Mermel LA, Anderson DJ, Arias KM, Burstin H, Calfee DP, et al. A compendium of strategies to prevent healthcare-associated infections in acute care hospitals. Infect Control Hosp Epidemiol. 2008 Oct;29 Suppl 1:S12-21. http://www.ncbi.nlm.nih.gov/pubmed/18840084

Free full text:
http://www.journals.uchicago.edu/doi/abs/10.1086/591060

New York Times article covering this issue:
http://www.nytimes.com/2008/10/09/us/09infection.html

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Office of Women's Health, CDC

What Works to Promote Cancer Screening

The Community Guide has conducted systematic reviews of interventions designed to improve early detection and control of cancer by increasing screenings for breast, cervical, and colorectal cancer. The list identifies all current Task Force on Community Preventive Services findings for increasing breast, cervical, and colorectal screening. The Task Force considered client-based interventions separately for the three types of cancer sites (breast, cervical, and colorectal) because the clients for each of these screening tests can be very different. They considered provider-oriented interventions across all three sites because providers might be influenced by similar factors when deciding whether to recommend screening for their various clients.
http://www.thecommunityguide.org/cancer/screening/

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Osteoporosis

Serum 25-hydroxyvitamin D and functional outcomes in the elderly

The objective of this article was to consider key evidence that treatment of vitamin D insufficiency has measurable clinical benefits for the musculoskeletal system in the elderly. The functional outcomes considered were increased bone mass, decreased rates of bone loss, improved muscle performance, reduced risk of falls, and reduced fracture incidence. Available evidence suggests that the elderly need a mean serum concentration of >/=65 nmol/L of vitamin D to improve muscle performance and reduce the risk of falling and >/=75 nmol/L to reduce the risk of fracture. Many elderly persons in the United States and elsewhere have serum 25-hydroxyvitamin D concentrations below these levels. For this reason, supplementation is likely to provide significant benefit to this segment of the population.

Dawson-Hughes B. Serum 25-hydroxyvitamin D and functional outcomes in the elderly. Am J Clin Nutr. 2008 Aug;88(2):537S-540S. http://www.ncbi.nlm.nih.gov/pubmed/18689397

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Patient Information

Free Flu Materials from the CDC

December 8-14, 2008 is National Influenza Vaccination Week. Make sure that your community is ready with patient educational materials and posters from the CDC. This year’s seasonal flu materials are free for download—no printed versions are available. They may be printed on a standard office printer, or you may use a commercial printer.

Emphasis remains on outreach to high-risk groups, as well as parents of all children, health care workers, and people in the workplace.
http://www.cdc.gov/flu/professionals/flugallery/index.htm

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Perinatology Picks

Cesarean delivery for the second twin

OBJECTIVE: To examine maternal and infant outcomes after a vaginal delivery of twin A and a cesarean delivery of twin B, and to identify whether the second twin experienced increased short-term morbidity as part of a combined route of delivery.
METHODS: Between January 1, 1999, and December 31, 2000, a prospective cohort study of all cesarean deliveries was conducted at 13 university centers. This secondary analysis was limited to women with twin gestations who experienced labor and underwent cesarean delivery. We compared outcomes of the second twin in women who had vaginal delivery of the first twin and a cesarean delivery of the second twin to those who had cesarean delivery of both twins.
RESULTS: One thousand twenty-eight twin pregnancies experienced labor and underwent cesarean delivery; 179 (17%) had a combined vaginal/cesarean delivery. Gestational age at delivery was 34.6 weeks in both groups (P=.97). The rupture of membranes to delivery interval was longer in the combined group (3.2 compared with 2.3 hours, P<.001). Endometritis and culture-proven sepsis in the second twin were more common in the combined group, respectively (n=24, odds ratio 1.6, 95% confidence interval, 1.0-2.7; n=15, odds ratio 1.8, 95% confidence interval, 1.0-3.4). These differences were not significant after logistic regression analysis. There were no statistically significant differences in an arterial cord pH of less than 7.0, Apgar score less than or equal to 3 at 5 minutes, seizures, grade III or IV intraventricular hemorrhage, hypoxic ischemic encephalopathy, or neonatal death.
CONCLUSION: Combined twin delivery may be associated with endometritis and neonatal sepsis when compared with a twin delivery where both are delivered by cesarean in twin pregnancies experiencing labor. More serious neonatal sequelae, including hypoxic ischemic encephalopathy and death, were not affected by the route of delivery of the second twin.

Alexander JM, Leveno KJ, Rouse D, Landon MB, Gilbert SA, Spong CY, et al. Cesarean delivery for the second twin. Obstet Gynecol. 2008 Oct;112(4):748-52. http://www.ncbi.nlm.nih.gov/pubmed/18827115

Accuracy of ultrasonographic fetal weight estimation in twin pregnancies

OBJECTIVE: To compare the accuracy of fetal weight estimations between normal and growth-restricted twin and singleton pregnancies in a single tertiary center.
METHODS: The computerized ultrasound database of a tertiary center was searched for all fetal weight estimations made in twin pregnancies from 2001 to 2006, which were performed up to 3 days before delivery. Accuracy was compared with a control group of singleton pregnancies at a 3:1 ratio. Estimated fetal weight was calculated by the Hadlock formula. Analyses were performed for the whole group and for pregnancies associated with fetal growth restriction and discordancy. RESULTS: The study groups included 278 twins and 834 singleton pregnancies. The twins group was characterized by a higher mean absolute percentage error compared with the singleton group (8.9% compared with 6.8%). Accuracy was lower for the second twins than for the first twins. When comparing the subgroup of fetal growth restriction, differences in sensitivity and specificity were small for singleton compared with overall twins (47.5% compared with 48.9% and 97.7% compared with 95.7%, respectively). Overall accuracy was better in the singleton group (95% compared with 88%), mainly due to relatively low accuracy in the second twin (86%). For detection of discordancy, estimated fetal weight had a sensitivity of 52%, specificity of 88%, and overall accuracy of 81%.
CONCLUSION: The accuracy of the ultrasonographic estimated fetal weight seems to be lower for twin gestations than for singleton gestations, especially for second twins. These data should be considered by clinicians when making decisions based on ultrasonographic characteristics.

Danon D, Melamed N, Bardin R, Meizner I. Accuracy of ultrasonographic fetal weight estimation in twin pregnancies. Obstet Gynecol. 2008 Oct;112(4):759-64. http://www.ncbi.nlm.nih.gov/pubmed/18827117

Nicotine gum for pregnant smokers: a randomized controlled trial

OBJECTIVE: To estimate the safety and efficacy of treatment with 2-mg nicotine gum for smoking cessation during pregnancy.
METHODS: Pregnant women who smoked daily received individualized behavioral counseling and random assignment to a 6-week treatment with 2-mg nicotine gum or placebo followed by a 6-week taper period. Women who did not quit smoking were instructed to reduce the number of cigarettes smoked by substituting with gum. Measures of tobacco exposure were obtained throughout the study.
RESULTS: Participants in the nicotine (n = 100) and placebo (n = 94) groups were comparable in age, race/ethnicity, and smoking history. Biochemically validated smoking-cessation rates were not significantly higher with nicotine gum compared with placebo (after 6 weeks of treatment: 13% compared with 9.6%, P=.45; at 32-34 weeks of gestation: 18% compared with 14.9%, P=.56). Using a completer analysis, nicotine gum significantly reduced the number of cigarettes smoked per day (nicotine gum: -5.7 [standard deviation (SD)=6.0]; placebo: -3.5 [SD=5.7], P=.035), and cotinine concentration (nicotine gum: -249 ng/mL [SD=397]; placebo: -112 ng/mL [SD=333]; P=.04). Birth weights were significantly greater with nicotine gum compared with placebo (3,287 g [SD=566] and 2,950 g [SD=653], respectively, P<.001). Gestational age was also greater with nicotine-replacement therapy than with placebo (38.9 weeks [SD=1.7] and 38.0 weeks [SD=3.3], respectively; P=.014).
CONCLUSION: Although nicotine gum did not increase quit rates, use of nicotine gum increased birth weight and gestational age, two key parameters in predicting neonatal wellbeing.

Oncken C, Dornelas E, Greene J, Sankey H, Glasmann A, Feinn R, Kranzler HR. Nicotine gum for pregnant smokers: a randomized controlled trial. Obstet Gynecol. 2008 Oct;112(4):859-67. http://www.ncbi.nlm.nih.gov/pubmed/18827129

Risk of development of diabetes mellitus after diagnosis of gestational diabetes

BACKGROUND: It is generally appreciated that gestational diabetes is a risk factor for type 2 diabetes. However, the precise relation between these 2 conditions remains unknown.
We sought to determine the incidence of diabetes mellitus after diagnosis of gestational diabetes.
METHODS: We used a population-based database to identify all deliveries in the province of Ontario over the 7-year period from Apr. 1, 1995, to Mar. 31, 2002. We linked these births to mothers who had been given a diagnosis of gestational diabetes through another administrative database that records people with diabetes on the basis of either physician service claims or hospital admission records. We examined database records for these women from the time of delivery until Mar. 31, 2004, a total of 9 years. We determined the presence of diabetes mellitus according to a validated administrative database definition for this condition.
RESULTS: We identified 659 164 pregnant women who had no pre-existing diabetes. Of these, 21 823 women (3.3%) had a diagnosis of gestational diabetes. The incidence of gestational diabetes rose significantly over the 9-year study period, from 3.2% in 1995 to 3.6% in 2001 (p < 0.001).The probability of diabetes developing after gestational diabetes was 3.7% at 9 months after delivery and 18.9% at 9 years after delivery. After adjustment for age, urban or rural residence, neighbourhood income quintile, whether the woman had a previous pregnancy, whether the woman had hypertension after the index delivery, and primary care level before the index delivery, the most significant risk factor for diabetes was having had gestational diabetes during the index pregnancy (hazard ratio 37.28, 95% confidence interval 34.99–40.88; p < 0.001). Age, urban residence and lower income were also important factors. When analyzed by year of delivery, the rate of development of diabetes was higher among the latest subcohort of women with gestational diabetes (delivery during 1999–2001) than among the earliest subcohort (delivery during 1995 or 1996) (16% by 4.7 years after delivery v. 16% by 9.0 years).
INTERPRETATION: In this large population-based study, the rate of development of diabetes after gestational diabetes increased over time and was almost 20% by 9 years. This estimate should be used by clinicians to assist in their counselling of pregnant women and by policy-makers to target these women for screening and prevention.

Feig DS, Zinman B, Wang X, Hux JE. Risk of development of diabetes mellitus after diagnosis of gestational diabetes CMAJ 2008;179(3):229-34. http://www.ncbi.nlm.nih.gov/pubmed/18663202

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Primary Care Discussion Forum - Ann Bullock, Cherokee, NC

Ongoing discussion of Geriatric Medication Issues

This discussion is being led by Bruce Finke, MD and Chris Lamer, PharmD. The case study which will serve as the springboard for our discussion is below. This is certainly a topic that affects all of us in I/T/U settings---how do we offer the benefits of preventive and therapeutic medications to elders without causing more harm than good? We hope you will participate with your thoughts and experiences as the discussion progresses over the next couple weeks. Welcome to Drs Finke and Lamer, the IHS Elder Care Consultant and IHS Clinical Informaticist for Health Education, respectively. See the instructions on enrollment after the following case description.

Case:
An 80 year old woman comes to see you for a routine follow-up. You have seen her episodically in walk-in but her primary care was provided by a physician who recently left. She is accompanied by her daughter who teaches 1st grade at the elementary school.

You greet her and ask her how she is doing. She complains about pain in her knees and thumbs and that her left wrist and hand are still not back to normal after her recent fracture. You are reminded that you saw her in walk-in after that fall (she had tripped on a step when she was pulling weeds from the flowerbed in her front yard)

You take a moment to review her medical problem list and medications. You see that she has diagnoses of diabetes, hypertension, hyperlipidemia, arthritis. You see atrial fibrillation on her problem list but notice that in her most recent visits she was in sinus rhythm. It appears that she had several episodes of atrial fibrillation with a controlled rate in the past two years but is mostly in sinus rhythm.

Current medications:
Aspirin EC 81mg daily
Lisinopril 10mg daily
Diltiazem 180mg daily
Atenolol 25mg daily
Alprazolam 0.5mg prn started by the surgeon after the fall
Digoxin 0.25mg daily
Glyburide 10mg BID
Metformin XR 1000mg BID
Tylenol #3, 2 tablets Q4-6h prn pain
Ibuprofen 600mg Q6h prn pain
Tylenol PM 2 tabs HS prn sleep
Lansoprazole 30mg daily
Glucosamine 600mg TID
Simvistatin 5mg daily

Vitals:
T: 94.4 P: 65 R: 18 BP: 150/72 Pain: 5 / 10

Labs at the last visit:
AIC: 8.2%, goes to 9.0% with change in meds.
LDL: 125
TSH: normal
B12: 330
CBC: 13.2 / 42.2
Chemistries: Na+: 142 K+: 3.8 Cl: 108 HCO3: 28 Cr: 1.1 Bun: 28 glucose: 165 random
Albumin: 3.8
eGFR: 47.05

What do you think about this elderly woman’s medication management?

Are there medications prescribed that she perhaps should not be taking? Are there medications that she is taking that she should perhaps not be prescribed? What further information do you need or want?

How to subscribe / unsubscribe to the Primary Care Discussion Forum?

Subscribe to the Primary Care listserv
http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=51

Unsubscribe from the Primary Care listserv
http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=51

Questions on how to subscribe, contact ANNBULL@nc-cherokee.com directly.

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STD Corner - Lori de Ravello, National IHS STD Program

This month I wanted to draw attention to draw attention to some innovative uses of technology that are being used to prevent STDs/HIV and to promote safe sex.

Project Red Talon Launches MySpace Page

Project Red Talon, the STD/HIV prevention program at the Northwest Portland Area Indian Health Board, has launched a MySpace page to reach Native youth and young adults with age-appropriate STD/HIV prevention information. Encourage Native youth in your community to check it out and send Project Red Talon their comments and feedback. The website link is: http://www.myspace.com/projectredtalon. Project Red Talon’s website is: http://www.npaihb.org/epicenter/project/project_red_talon.

Some other innovative uses of technology to address STDs include:

Confidential web-based chlamydia testing - At “I Want the Kit” people living in participating areas can confidentially order a home-based chlamydia test that gets returned to the project’s lab in an unmarked envelope. Results are provided, linkages to local public health agencies for partner services are made, and treatment is provided. The Alaska native Tribal Health Consortium, the State of Alaska STD Program, and the IHS National STD Program are having discussions about implementing a variation of I Want the Kit in Alaska in the near future. To learn more, visit www.iwantthekit.org

Anonymous web-based partner notification - InSpot is a web-based service that allows you to anonymously tell sex partners they have been exposed to an STD. InSpot’s website is www.inspot.org

Cellular ringtones with a STD message - BBC World Trust has produced a cellular phone ringtone in India that says "condom, condom" to promote safer sex and curb the spread of HIV in the country. It features a popular professional singer who sings the word "condom" more than 50 times—a "playful approach" that some advocates hope will "spark discussion and make condoms more socially acceptable”. To hear the ring tone, visit: http://www.condomcondom.org.

Safe sex messages via text messaging - SexText is a project developed by the San Francisco Department of Health where youth can text a number that allows to receive targeted STD prevention messages tailored for their geographic location. Some rural areas—such as Wyoming—have considered using this service. To learn more, visit www.sextextsf.org

Internet dating for people with STDs/HIV - There are many websites that link people who know they have STDs or HIV. People who use these sites say it takes the stigma of having to disclose having an STD or HIV to a new partner away, since both people know up front that they both have something. To learn more, visit: Meet People with Herpes (www.MPwH.net), Positive Personals (www.positivepersonals.com), Positive Singles (www.positivesingles.com), A Greater Date (www.agreaterdate.com)

Advertising on social networking sites - The Queensland Government in Australia is launching a "Safe Sex. No Regrets" campaign through advertisements on internet sites such as MySpace, Facebook and Google.

The IHS National STD Program would be interested in hearing about other uses of technology to prevent STDs/HIV, especially those that are being used in Indian Country. Also, do you think any of these mentioned uses of technology would work in your community? Why or why not? Let us hear from you! lori.deravello@ihs.gov

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Barbara Stillwater, Alaska State Diabetes Program

Postpartum screening for diabetes after a gestational diabetes mellitus-affected pregnancy

OBJECTIVE: To estimate trends in postpartum glucose testing in a cohort of women with gestational diabetes mellitus (GDM).
METHODS: A validated computerized algorithm using Kaiser Permanente Northwest automated data systems identified 36,251 live births or stillbirths from 1999 through 2006. The annual percentage of pregnancies complicated by gestational diabetes with clinician orders for and completion of a fasting plasma glucose (FPG) test within 3 months of delivery was calculated. Logistic regression with generalized estimating equations was used to test for statistically significant trends.
RESULTS: The percentages of pregnancies affected by GDM increased from 2.9% in 1999 to 3.6% in 2006 (P<.01). Clinician orders for postpartum tests increased from 15.9% in 1999 to 79.3% in 2004 (P<.01), and then remained stable through 2006. Completed FPG tests increased from 9.0% in 1999 to 57.8% in 2004 (P<.01), and then remained stable through 2006. No oral glucose tolerance tests were ordered. From 2004 to 2006, the practice site where women received care was the factor most strongly associated with the clinician order, but it was not predictive of test completion. Among women with clinician orders, those who were Asian or Hispanic or who attended the 6-week postpartum examination were more likely to complete the test than their counterparts.
CONCLUSION: Postpartum glucose testing in women with GDM-affected pregnancies increased over time. However, even in recent years, 42% of women with GDM-affected pregnancies failed to have a postpartum FPG test, and no test was ordered for 21% of GDM-affected pregnancies.

Dietz PM, Vesco KK, Callaghan WM, Bachman DJ, Bruce FC, Berg CJ, England LJ, Hornbrook MC. Postpartum screening for diabetes after a gestational diabetes mellitus-affected pregnancy.
Obstet Gynecol. 2008 Oct;112(4):868-74. http://www.ncbi.nlm.nih.gov/pubmed/18827130

The association between low birth weight and type 2 diabetes: contribution of genetic factors

BACKGROUND: Low birth weight has been associated with an increased risk of type 2 diabetes in adulthood. Poor fetal nutrition has been suggested to explain this association. Our objective was to determine whether genetic factors contribute to the association between low birth weight and subsequent risk of type 2 diabetes.
METHODS: We retrieved information from original birth records on same-sex Swedish twins with known zygosity, born from 1926 to 1958. We used regression models to investigate whether birth weight was associated with risk of type 2 diabetes in the cohort of twins overall, and in case-control analyses within disease-discordant dizygotic and monozygotic twin pairs.
RESULTS: Of 18,230 twins, 592 (3.2%) had type 2 diabetes. The rate of type 2 diabetes consistently increased with decreasing birth weight, from 2.4% among twins with birth weights of 3500 g or more to 5.3% among those with birth weights less than 2000 g. In the cohort analysis, in which twins are analyzed as independent individuals, the adjusted odds ratio (95% confidence interval) of type 2 diabetes per 500-g decrease in birth weight was 1.44 (1.28-1.63). When we compared the diseased twin with the healthy cotwin, the corresponding odds ratios were 1.38 (1.02-1.85), among dizygotic twins, and 1.02 (0.63-1.64), among monozygotic twins. CONCLUSIONS: Low birth weight is associated with type 2 diabetes in adulthood. The difference in this association between monozygotic and dizygotic twin pairs suggests that genetic mechanisms play an important role in this association.

Johansson S, Iliadou A, Bergvall N, dé Fairé U, Kramer MS, Pawitan Y, et al. The association between low birth weight and type 2 diabetes: contribution of genetic factors. Epidemiology. 2008 Sep;19(5):659-65. http://www.ncbi.nlm.nih.gov/pubmed/18714437

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Women's Health Headlines, Carolyn Aoyama, HQE

A web-based resource for oral health providers on screening for domestic violence

Oral health providers are in a pivotal position for identifying head, face and neck injuries typical of domestic violence or child abuse. As primary care providers, we hope to engage them in domestic violence screening so they can also begin to connect women with community advocates as well as the medical, behavioral health and social services that their patients may wish to access.

I am excited to announce that through collaboration with among IHS Division of Oral Health, IHS Women's Health, HRSA's Maternal and Child Health Bureau, and the National Maternal and Child Oral Health Resource Center, a web-based "portal" to materials on domestic violence and oral health is now available at http://www.mchoralhealth.org/AZ.html.

The link takes you to a page on the National MCH Oral Health Resource Center's web site that has a list of references arranged in alphabetical order. Under "D" you will see "Domestic violence and oral health."

Click on the 'library' that appears to the right of "Domestic Violence and oral health" and you'll see 11 items featured - the first three focus on domestic violence, the other eight focus on child abuse.

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Save the dates

2008 Indian Health Information Management Conference, “Managing Health Information Technology to Improve Performance and Outcomes”

December 15 – 19, 2008 ; Phoenix, Arizona
Information at: http://www.ihs.gov/cio/ihimc/

Telluride Midwinter Conference on Maternal and Child Health

January 30th – February 1st, 2009
Fun and inexpensive CME
Telluride, Colorado
http://www.ihs.gov/MedicalPrograms/MCH/F/CN01.cfm?module=09&option=1#top

First International Meeting on Indigenous Women’s Health/Third International Meeting on Indigenous Child Health Conference; Many Voices into One Song

Women’s Health March 4-6, 2009
Child Health March 6-8, 2009
Albuquerque , NM
Joint conference of Women’s Health and Children’s Health Providers from Canada and the United States
http://www.ihs.gov/MedicalPrograms/MCH/F/CN01.cfm?module=09&option=3#top

Advances in Indian Health Conference

April 21-24, 2009 in Albuquerque, NM
Indian Health's conference for primary care providers and nurses
28 hours of CME/CE credit
Optional Diabetes track
Contact the Course Director, Dr. Ann Bullock, at annbull@nc-cherokee.com for more information.

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What's new on the ITU MCH web pages?

There are several upcoming Conferences

and Online CME/CEU resources, etc….

and the latest Perinatology Corners (free online CME from IHS)

…or just take a look at the What’s New page

Did you miss something in the last OB/GYN Chief Clinical Consultant Corner?

The October 2008 OB/GYN CCC Corner is available.

Hot Topics ‹ Previous

OB/GYN

Jean Howe, MD, MPH is the Obstetrics and Gynecology Chief Clinical Consultant (OB/GYN C.C.C.). Dr. Howe 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 American Indian and Alaska Native women and also indigenous peoples around the world. Please don't hesitate to contact her by e-mail (jean.howe@ihs.gov) or phone at (928) 674-7422.

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Maternal Child

Volume 6, No. 11, November 2008

Features

American College of Obstetricians and Gynecologists

American Family Physician

AHRQ

Ask A Librarian - Diane Cooper, IHS National Library Informationist

Behavioral Health Insights - Peter Stuart, IHS Psychiatry Consultant

Breastfeeding - Suzan Murphy

CCC Corner Digest

Domestic Violence - Denise Grenier, Tucson / Rachel Locker, Warm Springs

Elder Care News - Bruce Finke, Elder Care Initiative

Family Planning

Featured Website

Frequently Asked Questions - Neil Murphy; SCF, ANMC

Indian Child Health Notes - Steve Holve, Pediatrics Chief Clinical Consultant

Information Technology - Theresa Cullen, Chief Information Officer, IHS

International Health Update - Claire Wendland, Madison, WI

MCH Alert

MCH Headlines - Judy Thierry HQE

Medical Mystery Tour - Neil Murphy, Southcentral Foundation; ANMC

Medscape*

Menopause Management

Midwives Corner - Lisa Allee, CNM, 4 Corners Regional Health Center, Red Mesa, AZ

Navajo News - John Balintona, Shiprock

Nurses Corner - Sandra Haldane, HQE

Office of Women's Health, CDC

Osteoporosis

Patient Information

Perinatology Picks

Primary Care Discussion Forum - Ann Bullock, Cherokee, NC

How to subscribe / unsubscribe to the Primary Care Discussion Forum?

STD Corner - Lori de Ravello, National IHS STD Program

Barbara Stillwater, Alaska State Diabetes Program

Women's Health Headlines, Carolyn Aoyama, HQE

Save the dates

What's new on the ITU MCH web pages?

Did you miss something in the last OB/GYN Chief Clinical Consultant Corner?

OB/GYN