February 2005 CCC Corner > From Your Colleagues

From Your Colleagues:

Elaine Locke, ACOG

Free Job Postings for Indian Facilities Only on ACOG Career Connection

Post your ob-gyn physician jobs for FREE on ACOG’s new online career center.  ACOG Career Connection is designed especially for women’s health care professionals and provides job opportunities that are updated regularly and are targeted specifically to obstetrics and gynecology.  From the ob-gyn’s point of view, job searches are free at the ACOG Career Connection and offer more features and functionality than other job banks.

Your job posting will be available 24 hours a day, seven days a week to over 45,000 ACOG members.  With ACOG Career Connection you can:

• Post ob-gyn physician jobs for FREE

• Target your search to women’s healthcare professionals

• Review résumé database 

• Receive candidate responses immediately online

• Sign up for e-mailed “Résumé Alerts” when résumés meeting your criteria are posted  

ACOG Career Connection is part of HEALTHeCAREERS Network, an integrated Network of healthcare association job banks.  You can post jobs to over 200 disciplines within the Network.  This provides a broad reach for your position to the most qualified candidates – association members – with volume discount pricing.  Only ob-gyn physician positions in AI/AN hospitals listed under the following disciplines will be posted for free:  General Obstetrics & Gynecology; Gynecological Oncology; Maternal/Fetal Medicine; Reproductive Endocrinology.

Post your jobs today!  For more information or to post your ob-gyn physician position for free, please contact Elaine Locke at 202-863-2596 or e-mail her at Elocke@acog.org

Sandra Haldane, HQE

Web portal linking all HHS.gov sites to breast cancer education, prevention, treatment

The Dept is developing a web portal linking all HHS.gov sites specific to breast cancer education, prevention, treatment, etc in accordance with the Breast Cancer Initiative.  The portal will be for providers, care givers, and those with breast cancer.   We need 10 to 12 scenarios/tasks that users will test on the site.  For example, in the Screening and Testing section, a task might be: 'You want to know if you (or a loved one) can get a free mammography.  What information can you find?'  http://testweb.hhs.gov/breastcancer

Women and Medication Safety: Special Journal Issue Is Available Online 

The Journal of Women's Health has published a special issue on improving the use and safety of medications in women, which was edited by Rosaly Correa-de-Araujo, AHRQ's Senior Advisor for Women's Health. The articles in this issue were based on discussions at an expert meeting called by Dr. Correa-de-Araujo to highlight gender differences in medication use. Topics of the articles include evidence for gender and racial differences in drug response, the role of biological rhythms in medication safety for women, geriatric pharmacotherapy, and strategies for reducing the risk of medication errors in women. http://www.liebertonline.com/toc/jwh/14/1

Steve Holve, Tuba City 

February 2005 Indian Child Health Notes - Highlights

-Well child care was developed to match vaccination schedules 

-We agree that well child care is important 

-There is unfortunately little data to back up what takes up 25-30% of our visits 

-A review of two articles that suggest it is time to revise well child care 

-Literature review: American Indian children who keep food diaries http://www.ihs.gov/MedicalPrograms/MCH/C/documents/PedNotes0205.doc

How common is Methamphetamine use in your area?

-In your tribal area are there laws that make Methamphetamine production and use a crime?

-Should all mothers be screened at delivery for Methamphetamine use or only if medically indicated?

-What resources are available in your community if a pregnant mother is found

to be using Methamphetamine? 

-What resources are available for teenagers and adults who are Methamphetamine users?

-What programs have shown success in treating Methamphetamine addiction?

There was a moderated discussion on this topic. steve.holve@tcimc.ihs.gov

Background

http://www.ihs.gov/MedicalPrograms/MCH/M/documents/MethPrimer2705.doc

Methamphetamine, Word document by Thomas Drouhard, MD http://www.ihs.gov/MedicalPrograms/MCH/M/documents/listservmethdocument.rtf

Methamphetamine Abuse: Fact or Fiction? PPT by Diana Hu

http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ListservMethPowerpoint.ppt

Jean Howe, Chinle

Announcing the new Deputy Chief Clinical Consultant

Acting on a directive from the National Council of Chief Clinical Consultants, we conducted a national search for an OB/GYN Deputy Chief Clinical Consultant. We had to choose from some excellent candidates, any of which would have been excellent choices. Kudos to all of them.

I am happy to announce that Jean Howe will become the OB/GYN Deputy Chief Clinical Consultant.  Jean will participate in many of the national functions of the CCC.  I look forward to working her.  Originally from Vermont and trained at the University of Colorado, Dr. Howe has been an Ob/Gyn at Chinle Hospital for 7 years. She also currently serves as the Navajo Area Ob/Gyn consultant and will complete an MPH program this May. Her areas of interest include preventive services, contraception, and diabetes in pregnancy. Jean.Howe@ihs.gov

Yolanda Meza, Anchorage

Routine suctioning of meconium-stained neonates before delivery of their shoulders?

INTERPRETATION: Routine intrapartum oropharyngeal and nasopharyngeal suctioning of term-gestation infants born through MSAF does not prevent MAS. Consideration should be given to revision of present recommendations. Vain NE, et al Oropharyngeal and nasopharyngeal suctioning of meconium-stained neonates before delivery of their shoulders: multicentre, randomised controlled trial. Lancet. 2004 Aug 14;364(9434):597-602.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15313360

OB/GYN CCC Editorial comment:

This is the first randomized controlled trial to assess routine oropharyngeal and nasopharyngeal suctioning of meconium-stained neonates before delivery of their shoulders. Though the numbers are not large, each Indian Health facility should re-evaluate this practice as it reflects on staffing manpower issues at their facility. njm  

Comments Steve Holve, Pediatric CCC 

Since the report in 1976 by Carson et al the AAP and ACOG have recommended intrapartum oropharyngeal suctioning of newborns to prevent meconiium aspiration syndrome. The assumption was that aspiration of meconium was an intrapartum event. Unfortunately, in recent years there is good evidence that many, if not all, episodes of severe meconium aspiration occur in utero and that intrapartum suctioning will not prevent these infants from developing meconium aspiration syndrome (MAS).

From the pediatric point of view, there is good evidence (Pediatrics 105:1: 1- 7, 2000*) that vigorous infants born through meconium stained fluid are at little risk for MAS and do not need delivery room intubation by the pediatrican. This study also pointed out that intubation has risks, though the complications were rare and transient.

What to do? Current Neonatal Resuscitation Program guidelines still recommend intraparutm suctioning of meconium stained infants by the maternity provider, but no longer recommend delivery room intubation of meconium stained infants if they are vigorous. 

Should the same standard apply to maternity providers? Is there a small subgroup of infants (those with signs of intrapartum distress such as flat strips or thick meconium) who might benefit from intrapartum suctioning of the oropharynx? These issues need to be addressed in the literature and then applied to local practice guidelines.

* Wiswell TE, et al Delivery room management of the apparently vigorous meconium-stained neonate: results of the multicenter, international collaborative trial. Pediatrics. 2000 Jan;105(1 Pt 1):1-7. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=10617696&dopt=Abstract

Suzan Murphy, Lactation Consultant, PIMC

Methamphetamine abuse and breastfeeding

Dr. Hale et al have indicated that moms with a +UDS for methamphetamine at delivery may still be able to breastfeed safely because the amount of methamphetamine that gets into the colostrum is small, and the amount colostrum that the baby receives is also small, making the methamphetamine dose negligible. Unfortunately, as the baby grows, the subsequent use and feedings may be a problem. There has been newspaper publicity about methamphetamine user’s breastfeeding and their babies dying. It is not yet a clearly understood issue. Suzan.Murphy@ihs.gov

OB/GYN CCC Editorial comment:

There will be a Primary Care Discussion Forum about Methamphetamine Use in Indian Country starting April 1, 2005 moderated by Steve Holve. Go here to subscribe njm

http://www.ihs.gov/generalweb/helpcenter/helpdesk/index.cfm?module=listserv&option=subscribe&newquery=1

Or contact nmurphy@scf.cc

Chuck North, Albuquerque

Patients with more than one medical condition: How can guidelines help?

We do pretty well on patients with one disease but increasingly our patients have multiple diseases as pointed out in the NEJM article (below).  As the number of diseases and conditions increase, the value of the guidelines decreases and the need for better data is more apparent, hence our interest in practice based research networks such as RIOS-Net.  AHRQ and Medicare are very interested in the adoption of effective treatment for the top ten conditions as affecting Medicare beneficiaries, i.e. heart disease, pneumonia, stroke, diabetes, asthma, arthritis and depression

Pitfalls in Disease Specific Guidelines in multiple conditions , NEJM

http://www.ihs.gov/MedicalPrograms/MCH/M/documents/guidelinepitfallsnejm.pdf

Other resources.

National Guidelines Clearinghouse   www.guidelines.gov

Institute for Clinical System Improvement   www.icsi.org

Cochrane Library, clinicially applied topics, A-Z    www.informedhealthonline.org

Vanderbilt Center for Evidence-Based Medicine www.ebm.vanderbilt.edu

Health Affairs, Vol. 24, No.1 devoted to EBM http://www.healthaffairs.org/

Single digit need to treat (NNT) obesity are remarkable statistics - should spur us on 

1. Manage obesity as a chronic relapsing disease 

2. Use BMI as a vital sign to screen for overweight/obese patients and to decide treatment (PPV=97%) 

3. Modest weight loss (10%) positively affects prevention/treatment of hypertension (NNT=3), diabetes (NNT=9) and hyperlipidemia 

4. Effective treatments exist for overweight/obese patients and a combination of diet and exercise provides the best results (NNT=7) 

5. Counsel patient to achieve a goal of 10% reduction in weight (500 to 800 kcal/day decrease to affect 1-2 pound loss/week) 

6. Counsel patient to exercise to achieve a goal of any increased energy expenditure 

7. Weight loss has an impact on important disease states and risk factors.  Effective strategies exist for the management of obesity when viewed as a chronic relapsing disease. 

 Orzano AJ, Scott JG.Diagnosis and treatment of obesity in adults: an applied evidence-based review. J Am Board Fam Pract. 2004 Sep-Oct;17(5):359-69. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15355950

OB/GYN CCC Editorial comment:

Please note the above resources and many others are available on the national CCC website and the MCH website njm

Clinical Guidelines: A - Z

http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-clinguid.cfm

Clinical Guidelines: by Organ System

http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-organSys.cfm

Clinical Guidelines: Overall Clearinghouses or Agencies

http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-clearHouse.cfm

Clinical Guidelines: Indian Health Specific

http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-guidesA-Z.cfm

Evidence Based Medicine page – MCH

http://www.ihs.gov/MedicalPrograms/MCH/M/MCHebp.cfm

Lori de Ravello, Albuquerque

Contraceptive Methods Among Women: Quickstats

IThe most frequent contraceptive method among women aged 15--44 years was oral contraception. Other leading methods were female sterilization and the male condom. A smaller, but significant, number of women were using the newer, long-acting hormonal methods, including injectables, implants, and the patch. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5406a5.htm and

http://www.cdc.gov/nchs/nsfg.htm.

Judy Thierry, HQE

Discourage use of infant car seats as long term sleep environments

Although I have not seen the epidemiological data about SIDS deaths while infants are sitting, it is not uncommon to see an infant in childcare asleep in the car seat inside the crib.

In keeping with NC child care licensing rules and the legal mandate, we advise providers to remove infants from the car seat and place the infants on their back to sleep in the crib.

We also remind providers and ask them to inform the parents:

1.  Sleeping in car seats is a violation of NC child care licensing rules 2. Car seats were designed for transportation safety, NOT as sleep environments 3.  Car seat manufacturers advise not to leave children unattended in car seats 4.  Not to use the car seat covers (with the hole cut-out for baby's face) made to fit over the entire car seat - dangers include overheating and suffocation 

Re: respiration 1.  We demonstrate how the infant's lungs are compressed when sitting and slumped in a car seat, and do a visual comparison with back to sleep position on a flat surface in a crib 2.  If the head is leaning forward, the airways are further compressed

Christine O'Meara, MA, MPH, Campaign Coordinator, North Carolina Back To Sleep Campaign for SIDS Risk Reduction. North Carolina Healthy Start Foundation www.NCHealthyStart.org 

Training for Nursery Room Nurses on Back to Sleep

The Missouri Department of Health and Senior Services did a survey in 2000 of hospital nursery room nurses to look at how infants were placed to sleep.  The study was published in the May/June 2004 issue of MCN, Vol 29. No. 3.  

As a result of this survey, the Department issued an RFP in December 2003 to develop a training for Nursery Room Nurses on Back to Sleep. CEUs are being given for this program also, and it will also be available on the internet and on CD Rom.  Karen Schenk, SchenK@dhss.mo.gov

Tony Dekker, M.D. New Addiction Medicine Chief Clinical Consultant (CCC)

Addiction medicine has just been added as a CCC.  Dr. Dekker understands some of the great burden of substance abuse in the AI/AN community. Dr. Dekker works at Phoenix Indian Medical Center with Diane Pond who is also a pain expert Dr. Pond is the Chief of Anesthesia and the IHS Chief Clinical Consultant for Anesthesia. Here is Dr. Dekker’s CCC webpage

http://www.ihs.gov/NonMedicalPrograms/NC4/nc4-adctnpn.asp

The Chief Clinical consultants - are available for your consultation

The Chief Clinical consultants - are available for consultation, review of programs, review of articles, and telephone consultation on their subject or specialty.  

Addiction Medicine, Tony Dekker, PIMC     Anthony.Dekker@ihs.gov

Advance Practice Nurses, Ursula Knoki-Wilson, CNM, Chinle  Ursula.Knoki-Wilson@ihs.gov

Anesthesiology, Diane Pond, MD, PIMC    Diane.Pond@ihs.gov

Family Medicine, Charles North, MD, Albuquerque   CNorth@abq.ihs.gov

Internal Medicine, Charles (Ty) Reidhead, MD, Whiteriver  Charles.Reidhead@ihs.gov

Nephrology, Andrew Narva, MD, Albuquerque    Andrew.Narva@ihs.gov

OB/GYN, Neil Murphy, MD, ANMC     nmurphy@scf.cc

Ophthalmology, James Cox, MD, GIMC     James.Cox@ihs.gov

Optometry, Richard Hatch, OD, GIMC     Richard.Hatch@ihs.gov

Pediatrics, Steve Holve, MD, Tuba City     steve.holve@tcimc.ihs.gov

Lois Goode, Physical Therapy, White River    Lois.Goode@ihs.gov

Physician Assistant, Harry B. Taylor, PA-C, Lawton  htaylor@sirinet.net

Podiatry, Eugene Dannels, DPM, PIMC     Eugene.Dannels@ihs.gov

Surgery, Hope Baluh, MD, Tahlequah     Hope.Baluh@mail.ihs.gov

What is the definition of ‘preventable or avoidable maternal death?

I am looking for definitions of "preventable" or avoidable maternal death to help guide us in determining how we want to conceptualize "preventability" when it comes to reviewing pregnancy-related deaths. If any of you have definitions or thoughts you would be willing to share with me, they would be much appreciated. Judith Thierry  Judith.Thierry@ihs.gov

Native American Outreach: National Partnership to Help Pregnant Smokers Women smoke cigarettes for different reasons. Some smoke to relieve stress or because they think it will help them control their weight. Younger women may start smoking as a way of rebelling, declaring their independence, or gaining acceptance by their peers. For Native American women, tobacco's ceremonial role in the community plays a large part in their decision to begin smoking. American Indians/Alaska Natives have the highest rates of smoking during pregnancy than any other ethnic group in the United States. There is a critical need to reach these women with effective tobacco cessation interventions.

The National Partnership to Help Pregnant Smokers Quit is committed to reaching out to Native American communities to increase cessation training for providers and to make resources available where they are needed the most. Recently, the National Partnership's Healthcare Provider working group completed a needs assessment with American Indian/Alaska Native healthcare providers to gather information on the types of culturally appropriate cessation materials they are using. Contact Catherine Rohweder at rohweder@mail.schsr.unc.edu

SIDS Alliance provides technical assistance: education, outreach and support

The National SIDS and Infant Death Program Support Center of First Candle/SIDS Alliance provides technical assistance to professionals in managing infant death education, outreach and support.  If you are interested please contact me Judy Thierry 301-443-5070 and I can get you in touch with Mariam Sokol and Deborah Boyd from First Candle on what we can do together for a training specific to your area, region.   If you want to contact them directly they can be reached at: FirstCandle http://www.firstcandle.org/about/staff.html

AAP - Child Care provider ppt presentation and manual

20% access rate of SIDS in Child Care settings. Slides http://www.healthychildcare.org/PPT/256

AAP/ NICHD - Child care provider training manual http://www.healthychildcare.org/pdf/SIDSfinal.pdf

AAP: Child Care providers on back to sleep

http://www.healthychildcare.org/pdf/summer2000hcca.pdf

Asthma card - Child care, Allergy and Asthma Foundation of America

http://www.aafa.org/pdfs/childcard_allergyaction_card.pdf

Proper way of infant being placed to sleep – Avoid SIDS

CJSIDS foundation has two AI/AN video's of infants being placed to sleep www.cjsids.com

WONDER now has natality data you can query

http://wonder.cdc.gov/nataJ.html

NFIMR poster - web site with good PDF

I sent out a link to the poster that was not as good of quality as these from the Commonwealth

directly – I spoke with them by phone. Their walk through the web site is worth the trip

Click on “ccpc” and then click on “public health education”. http://www.vcu.edu/ccpc/

Judy Whitecrane, Phoenix

It makes it easy for moms to remember:  2 days, 2 weeks, and 2 months

At PIMC, We have a 2 day and 2 week infant check by peds.  Then there is a 2 month Mom-Baby clinic with CNM's doing postpartum and pediatricians doing well-baby.

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OB/GYN

Dr. Neil Murphy is the Obstetrics and Gynecology Chief Clinical Consultant (OB/GYN C.C.C.). Dr. Murphy is very interested in establishing a dialogue and/or networking with anyone involved in women's health or maternal child health, especially as it applies to Native or indigenous peoples around the world. Please don't hesitate to contact him by e-mail or phone at 907-729-3154.