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Volume 4, No. 12, December 2006/January 2007
Features
American College of Obstetricians and Gynecologists
Treatment With Selective Serotonin Reuptake Inhibitors During Pregnancy
ABSTRACT: Depression is a common condition among women of reproductive age, and selective serotonin reuptake inhibitors (SSRIs) are frequently used for the treatment of depression. However, recent reports regarding SSRI use during pregnancy have raised concerns about fetal cardiac defects, newborn persistent pulmonary hypertension, and other negative effects. The potential risks associated with SSRI use throughout pregnancy must be considered in the context of the risk of relapse of depression if maintenance treatment is discontinued. The American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice recommends that treatment with all SSRIs or selective norepinephrine reuptake inhibitors or both during pregnancy be individualized and paroxetine use among pregnant women or women planning to become pregnant be avoided, if possible.
Treatment with selective serotonin reuptake inhibitors during pregnancy. ACOG Committee Opinion No. 354. American College of Obstetricians and Gynecologists. Obstet Gynecol 2006;108:1601–3.bstet Gynecol 2006;108:1597–99.
Routine Cancer Screening
ABSTRACT: Obstetrician–gynecologists serve as primary care physicians for many women. Because the obstetrician–gynecologist may be the only physician providing routine care, clinicians should be able to provide recommendations for routine cancer screenings, including those for nongynecologic cancers. This document summarizes recommendations of the American College of Obstetricians and Gynecologists for routine cancer screening for the average-risk American woman. The obstetrician–gynecologist should discuss both benefits and limitations of screening tests with the patient.
Routine cancer screening. ACOG Committee Opinion No. 356. American College of Obstetricians and Gynecologists. Obstet Gynecol 2006;108:1611–13.
Primary and Preventive Care: Periodic Assessments
ABSTRACT: Periodic assessments offer an excellent opportunity for obstetricians and gynecologists to provide preventive screening, evaluation, and counseling. This Committee Opinion provides the recommendations of the American College of Obstetricians and Gynecologists’ Committee on Gynecologic Practice for routine assessments in primary and preventive care for women based on age and risk factors.
Primary and preventive care: periodic assessments. ACOG Committee Opinion No. 357. American College of Obstetricians and Gynecologists. Obstet Gynecol 2006;108:1615–22.
Innovative Practice: Ethical Guidelines
ABSTRACT: Innovations in medical practice are critical to the advancement of medicine. Good clinicians constantly adapt and modify their clinical approaches in ways they believe will benefit patients. Innovative practice frequently is approached very differently from formal research, which is governed by distinct ethical and regulatory frameworks. Although opinions differ on the distinction between research and innovative practice, the production of generalizable knowledge is one defining characteristic of research. Physicians considering innovative practice must disclose to patients the purpose, benefits, and risks of the proposed treatment, including risks not quantified but plausible. They should attempt an innovative procedure only when familiar with and skilled in its basic components. A clinician should share results, positive or negative, with colleagues and, when feasible, teach successful techniques and procedures to other physicians. Practitioners should be wary of adopting innovative procedures or diagnostic tests on the basis of promotions and marketing when the value of the procedures or tests has not been proved. A practitioner should move an innovative practice into formal research if the innovation represents a significant departure from standard practice, if the innovation carries unknown or potentially significant risks, or if the practitioner’s goal is to use data from the innovation to produce generalizable knowledge. If there is any question whether innovative practices should be formalized as research, clinicians should seek advice from the relevant institutional review board.
Innovative practice: ethical guidelines. ACOG Committee Opinion No. 352. American College of Obstetricians and Gynecologists. Obstet Gynecol 2006;108:1589–95
Vaginal Agenesis: Diagnosis, Management, and Routine Care
ABSTRACT: Vaginal agenesis occurs in 1 of every 4,000.10,000 females. The most common cause of vaginal agenesis is congenital absence of the uterus and vagina, which also is referred to as mullerian aplasia, mullerian agenesis, or Mayer.Rokitansky.Kuster.Hauser syndrome. The condition usually can be successfully managed nonsurgically with the use of successive dilators if it is correctly diagnosed and the patient is sufficiently motivated. Besides correct diagnosis, effective management also includes evaluation for associated congenital renal or other anomalies and careful psychologic preparation of the patient before any treatment or intervention. If surgery is preferred, a number of approaches are available; the most common is the Abbe.McIndoe operation. Women who have a history of mullerian agenesis and have created a functional vagina require routine gynecologic care and can be considered in a similar category to that of women without a cervix and thus annual cytologic screening for cancer may be considered unnecessary in this population.
Vaginal agenesis: diagnosis, management, and routine care. ACOG Committee Opinion No. 355. American College of Obstetricians and Gynecologists. Obstet Gynecol 2006;108:1605–9.
American Family Physician**
Patient-Oriented Evidence that Matters (POEMS)*
Levothyroxine Reduces Preterm Birth in Euthyroid Women
Clinical Question: Does treatment with levothyroxine improve birth outcomes for pregnant euthyroid women who test positive for thyroid peroxidase antibodies?
Setting:
Study Design: Randomized controlled trial (double-blinded)
Synopsis: White women receiving care in an academic obstetric clinic in Italy were screened for thyroid peroxidase (TPO) antibodies, free thyroxine (FT4), and thyroid-stimulating hormone (TSH) levels. Of the 1,074 women tested, 45 were excluded from the study because of overt hypothyroidism or hyperthyroidism; 984 completed the study. The 115 women who were positive for TPO antibodies and had normal FT4 and TSH levels were randomized to treatment with levothyroxine or placebo. Treatment allocation was concealed and treatment began within one week of the initial visit for prenatal care. Medication dosing for women taking active treatment was calculated according to body weight and TSH level, and was a mean of 50 mcg. The participating women and the physicians providing obstetric care were blinded to treatment assignment.
Treated women had a significant reduction in spontaneous abortion (4 versus 14 percent; number needed to treat [NNT] = 10). Preterm births also were reduced in the treated group (7 versus 22 percent; NNT = 6; 95% confidence interval, 3 to 22).
Treated women had rates of spontaneous abortion and preterm birth similar to the 869 women who screened negative for TPO antibodies. In this population, in which 11 percent of women had a positive screen result, the number needed to screen to prevent one preterm birth would be 56, and the number needed to screen to prevent one miscarriage would be 93 (assuming that all women positive for TPO antibodies would have equally positive results with treatment).
This study may have been confounded by the women in the control group, who were younger on average than those in the treatment group; this may have influenced the rate of miscarriages. Also of note is that the study was conducted in Italy where iodization of salt is not compulsory. Iodine deficiency in this population may have reduced the functional reserve needed for the physiologic increase in thyroid hormone production during pregnancy.
Bottom Line: In this study, levothyroxine treatment of euthyroid women who tested positive for TPO antibodies significantly decreased spontaneous abortions and preterm births. Screening may be indicated for populations of pregnant women with a high incidence of autoimmune thyroid disease. Further studies in various populations are needed.
(Level of evidence: 1b)
Study Reference: Negro R, et al. Levothyroxine treatment in euthyroid pregnant women with autoimmune thyroid disease: effects on obstetrical complications. J Clin Endocrinol Metab July 2006;91:2587-91.
* POEM Rating system : http://www.infopoems.com/levels.html POEM Definition: http://www.aafp.org/x19976.xml
** The AFP sites will sometimes ask for a username and password. Instead just ‘hit; cancel on the pop up password screen, and the page you are requesting will come up without having to enter a username and password.
Opioids for Management of Breakthrough Pain in Cancer Patients
Cochrane for Clinicians: Putting Evidence into Practice
Clinical Scenario
A 74-year-old man uses long-acting opioids for chest wall pain associated with lung cancer. He experiences breakthrough pain in the evenings and would like advice about the best way to treat it.
Clinical Question
What evidence is there for the use of rapid-acting opioids in the management of breakthrough cancer pain?
Evidence-Based Answer
Oral transmucosal fentanyl citrate (OTFC [Actiq]), a rapid-acting opioid, has been shown to be an effective treatment for breakthrough cancer pain. Other opioids, including immediate-release oral morphine (MSIR), also may be effective; however, evidence comparing these agents with OTFC is lacking.
Practice Pointers
Cancer pain comes in many forms and often is undertreated.2 When the pain fails to respond to acetaminophen or nonsteroidal anti-inflammatory drugs, or otherwise becomes intractable, opioids often are recommended.3 Usually, short-acting opioids are used as needed. When the pain persists throughout the day, short-acting opioids are replaced with longer-acting opioids two or three times daily to provide 24-hour relief.
Even after daily opioid dosing has been established, physicians may be called upon to treat worsening pain. In some patients, worsening pain control is a sign of worsening disease and may warrant a thorough reevaluation of the underlying causes. Opioid tolerance is another possible reason for increased medication requirements. However, increased pain (e.g., constipation and abdominal pain) also can be an adverse effect of opioids, and physicians must be careful not to misinterpret these symptoms.
In contrast, breakthrough pain usually is episodic and self-limited. It often recurs at certain times of the day or in response to particular triggers. When breakthrough pain occurs as a result of end-of-dose failure it can be prevented by increasing the frequency of opioid dosing-for example, administering sustained-release morphine every eight hours instead of every 12.4 In situations where breakthrough pain is more difficult to manage, patients often are given rapid-acting opioids such as OTFC or immediate-release morphine to take as needed in addition to their regular doses of longer-acting opioids.
The Cochrane reviewers assessed the evidence for the benefit of additional doses of shorter-acting opioids for breakthrough pain in patients who take long-acting opioids for chronic cancer pain. They found only a few well-designed studies, all of which involved the use of OTFC, an opioid with extremely rapid onset of pain relief that is taken in the form of orally dissolving lozenges.
Only one study compared the effectiveness of OTFC with another opioid.5 This double-blind crossover study involved 134 patients who already managed their breakthrough pain with immediate-release morphine, which has a slightly slower onset of action than OTFC. During the intervention, patients tended to have more effective relief of breakthrough pain and a more rapid onset of relief with OTFC than with immediate-release morphine. Sixty-four of the 93 patients who completed the study said they would like to continue using OTFC for their breakthrough pain. These results suggest that select cancer patients might prefer OTFC over immediate-release morphine.
A secondary objective of the review was to find evidence supporting the expert opinion of the European Association of Palliative Care (EAPC) that short-acting opioids for breakthrough cancer pain should be given in proportion to the amount of long-acting opioid being taken by the patient.6 In the four studies reviewed, the optimal safe and effective dose of short-acting opioid varied greatly from patient to patient. Thus, contrary to the EAPC's recommendations, the reviewers conclude that the optimal dose of opioids for breakthrough cancer pain is best determined through trial and error.
Rapid-acting oral opioids can cause a variety of adverse effects, including respiratory arrest in patients who have not previously used opioids. Although short-acting opioids with a less immediate onset of action (e.g., oxycodone [Roxicodone], codeine) have not been well studied as treatments for breakthrough cancer pain, clinical experience suggests that they are less likely than rapid-acting opioids to cause respiratory suppression when used for episodic pain in patients with no previous opioid use or a relatively low background exposure to long-acting opioids. However, the evidence in this Cochrane review indicates that OTFC, a rapid-acting opioid, is reasonably safe and effective for the treatment of breakthrough cancer pain in patients already taking long-acting opioids for cancer pain. In most studies, the rapid-acting opioids were introduced at low dosages and titrated upward gradually to reduce the risk of adverse effects.
REFERENCES
1. Zeppetella G, Ribeiro MD. Opioids for the management of breakthrough (episodic) pain in cancer patients. Cochrane Database Syst Rev 2006;(1):CD004311.
2. Bernabei R, Gambassi G, Lapane K, Landi F, Gatsonis C, Dunlop R, et al. Management of pain in elderly patients with cancer. SAGE Study Group. Systematic Assessment of Geriatric Drug Use via Epidemiology [Published correction appears in JAMA 1999;281:136]. JAMA 1998; 279:1877-82.
3. Carr DB, Goudas LC, Balk EM, Bloch R, Ioannidis JP, Lau J. Evidence report on the treatment of pain in cancer patients. J Natl Cancer Inst Monogr 2004;32:23-31.
4. Ventafridda V, Saita L, Barletta L, Sbanotto A, De Conno F. Clinical observations on controlled-release morphine in cancer pain. J Pain Symptom Manage 1989;4:124-9.
5. Coluzzi PH, Schwartzberg L, Conroy JD, Charapata S, Gay M, Busch MA, et al. Breakthrough cancer pain: a randomized trial comparing oral transmucosal fentanyl citrate (OTFC) and morphine sulfate immediate release (MSIR). Pain 2001;91:123-30.
6. Hanks GW, Conno F, Cherny N, Hanna M, Kalso E, McQuay HJ, et al., for the Expert Working Group of the Research Network of the European Association for Palliative Care. Morphine and alternative opioids in cancer pain: the EAPC recommendations. Br J Cancer 2001;84:587-93
http://www.aafp.org/afp/20061201/cochrane.html or http://www.cochrane.org
AHRQ
Maternal psychological distress and infrequent use of seat belts are associated with children's low use of motor vehicle restraints
http://www.ahrq.gov/research/oct06/1006RA6.htm
Less than half of parents infected with HIV tell their children about the diagnosis
http://www.ahrq.gov/research/oct06/1006RA16.htm
Ask A Librarian: Diane Cooper, M.S.L.S. / NIH
Want to keep up with evidence-based medicine?
Got time to read 50,000 articles? No? Then take a look at Evidence-Based Medicine. From the editorial offices of the British Medical Journal, this journal provides information gleaned from over 100 journals. Published 6 times a year, the most important and valid research articles are presented. For example, here are two current articles that may be of interest.
Physical exertion during pregnancy
1. Physical exertion at work during pregnancy did not increase risk of preterm delivery or fetal growth restriction. (Evidence-Based Medicine 2006; 11: 156). This prospective cohort study included 1,908 women over 16 years of age who were 24-29 weeks pregnant and stood long hours each week, lifted heavy objects 13 times or more each week, worked nights or worked greater than 46 hour weeks.
Continuous dose vs. 28 day OCs
2. Review: 6 RCTs show similar efficacy and safety for continuous dosing and 28 day combination contraceptive pills. (Evidence-Based Medicine 2006; 11: 53). Randomized controlled trials compared continuous or extended combination oral contraceptives with the traditional dosing (21 days of pills) in women of reproductive age.
To find Evidence-Based Medicine on the HSR Library website, click ONLINE JOURNALS found on the left panel of the homepage. Next click “E” to get to all journals starting with “E” and scan down to the journal.
Would you like to have regular updates in your special interest from Evidence-Based Medicine and other journals you select and have complete control over your updates? Email me for an easy “Go By” for this. And as always, if you need any information help, just email me at cooperd@mail.nih.gov
Breastfeeding - Suzan Murphy, PIMC
Flu season and Breastfeeding CDR Julie Warren, RPh, Pharmacist, PIMC *
When a breastfeeding mom gets the flu there are many medications that can help and are safe to use. General guidelines are:
- Keep breastfeeding. The baby has already been exposed. A breastfeeding mom’s immunity system will make antibodies that fight the infection, protecting both the mom and her baby.
- Take the medicine right after nursing or before baby’s longest sleep time.
- Watch baby for effects from the medicines that you take.
- Don’t choose medicines that have a variety of ingredients.
- Use “regular strength” instead of “extra strength”,”maximum strength”, or
“long acting.”
- Follow the directions on the label. Don’t take more than what is recommended .
- T ake the lowest dose recommended.
If mom has:
A fever … headache … or feel achy all over, try:
- Acetaminophen (TylenolR and many other brands)
- Ibuprofen (Advil R, Motrin R, etc.)
- Naproxen (Aleve R, etc.)
- Do not use aspirin.
A stuffy nose use:
- Best : sodium chloride nasal spray
- Phenylephrine nasal spray (Neo-Synephrine R , etc.)
- Oxymetazoline nasal spray (Afrin R and others)
- Pseudoephedrine oral tablets (Sudafed R and many other brands)
Moms may notice a decrease in breast milk production if they take Sudafed for
extended periods.
Sneezing, hay fever symptoms … her allergies are acting up, consider:
- Diphenhydramine (Benadryl R and many other brands)
- Brompheniramine + pseudoephedrine (Bromfed R, Rondec R syrup, etc.)
- Triprolidine + pseudoephedrine (Actifed R and other brands)
- Chlorpheniramine (Coricidin R and many other brands)
- Dexbrompheniramine + pseudoephedrine (Drixoral R and others)
- Loratadine (Claritin R, Alavert R, others)
- Cromolyn sodium nasal spray (Nasalcrom R)
A sore throat … even after a cup of hot tea, use:
- Warm to hot salt water gargles (don’t swallow it!)
- Throat sprays (Cepacol R Maximum Strength Sore Throat Spray, others)
- Throat lozenges (Sucrets R Regular Strength, Halls R Mentho-Lyptus Drops)
- Don’t use phenol and hexylresorcinol.
A cough, try:
- Guaifenesin with or without Dextromethorphan (Robitussin R, Robitussin DM R and
other brands with the same ingredients)
For more information about more drugs: http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT
The link is also listed on the I.H.S. MCH Breastfeeding web page, in the Medication section.
http://www.ihs.gov/MedicalPrograms/MCH/M/bfMeds.cfm
I.H.S. MCH Breastfeeding web page: Home
http://www.ihs.gov/MedicalPrograms/MCH/M/bf.cfm
*Chair, I.H.S. MCH Breastfeeding Web Page Medication Section.
Other Breast feeding items
Breast-Feeding Offers Resilience Against Psychosocial Stress in Children
CONCLUSIONS: Breast feeding is associated with resilience against the psychosocial stress linked with parental divorce/separation. This could be because breast feeding is a marker of exposures related to maternal characteristics and parent-child interaction.
Montgomery SM et al Breast feeding and resilience against psychosocial stress. Arch Dis Child. 2006 Dec;91(12):990-4
More Evidence Showing Breastfeeding Protects Against Type 2 Diabetes
CONCLUSION: Breastfeeding in infancy is associated with a reduced risk of type 2 diabetes, with marginally lower insulin concentrations in later life, and with lower blood glucose and serum insulin concentrations in infancy.
Owen, CG et al. Does breastfeeding influence risk of type 2 diabetes in later life? A quantitative analysis of published evidence. Am J Clin Nutr. 2006 Nov;84(5):1043-54
CCC Corner Digest
Nicely laid out hard copy - A compact digest of last month’s CCC Corner
November highlights include:
-Regular Cola Intake Reduces Bone Mineral Density in Women
-Perinatal depression evidence based care
-Magnesium sulfate tocolysis: time to quit
-‘No touch’ hysteroscopy much better tolerated
-Hot water bottles do work: Active Warming Cuts Pelvic Pain in Pre-hospital Setting
-Early adolescents worry more as they age. . . .
-Health Behaviors among American Indian/Alaska Native Women, 1998–2000 BRFSS
-Please Get Umbilical Cord Blood Gas and Acid-Base Analysis When Possible
-No Stirrups Preferred for Pelvic Examinations
-Want to keep up with evidence-based medicine?
-It is official, breastfeeding counts
-EC: Did not affect incidence of either pregnancy or STIs
-Telehealth Opportunity: Do you need nutrition services at your site?
-Anthropology in the clinic: the problem of cultural competency and how to fix it
-The rest of the story RE: ‘bizarre’ and ‘atypia’ in the same sentence…hmmm….
-What Women Want
-Prevalence of diabetes: Diagnosed Diabetes Among AI/AN Aged <35 Years
-Preoperative Evaluation
-Assessment of Adult Health Literacy
-Be Prepared: The Boy Scout motto…er…the Maternity Care Provider motto, too
-Causes of Type 2 Diabetes: Old and New Understandings
-IHS Consent Form 509 for an HIV Antibody Test is Hereby Cancelled
-Gestational Diabetes Linked to High Prevalence of Periodontal Disease
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/06NovOL.pdf
If you want a copy of the CCC Digest mailed to you each month, please contact nmurphy@scf.cc
Domestic Violence
Improving the Health Care Response to Domestic Violence in AI/AN Communities
Conference Dates: March 16th - 17th 2007
Pre-Conference Institute: March 15, 2007
San Francisco , CA
Conference Registration http://www.fvpfhealthconference.org/end_landing.htm
The institute is open to anyone, whether they are with our project or not.
Pre-Conference Institute http://www.fvpfhealthconference.org/institutes.htm
Hope to see you all there!
Elder Care News
Moderate Alcohol Consumption May Be Beneficial to Older Women
Studies have shown that alcohol consumption in middle-aged women carries risks and benefits. Notable risks include an association between higher alcohol use and cancer and an increased risk of fractures; benefits include a decrease in the 10-year mortality rate and improvement in psychological well-being. However, these benefits apply only to moderate drinking; they are attenuated in heavier drinkers. The risks and benefits of moderate alcohol consumption in women 70 years and older are not known. Despite the lack of current studies specific to older women and alcohol consumption, this age group often is advised to drink fewer than one to two drinks a day, an amount that defines moderate drinking. To address the need for more data, Byles and colleagues reported on the relationship between alcohol consumption, mental and physical status, and mortality in women 70 years and older.
The authors conclude that even though there are no studies that recommend alcohol use, this one indicates that it may be safe and beneficial for women with moderate alcohol intake to continue drinking at that level.
Byles J, et al. A drink to healthy aging: the association between older women's use of alcohol and their health-related quality of life. J Am Geriatr Soc September 2006;54:1341-7.
Family Planning
Bone Loss With Use of Depot Medroxyprogesterone Acetate Slows After 2 Years
Contrary to its "black box" warning, depot medroxyprogesterone acetate (DMPA) used for longer than 2 years does not substantially increase the risk of osteoporosis. Based on these findings, the recommendation to have bone density monitored with long-term use probably is not warranted, since most BMD is lost within the first two years, and that loss is generally not sufficient to pose an immediate risk for fracture.
CONCLUSION(S): Depot MPA-related BMD loss is substantial but occurs mostly during the first 2 years of DMPA use. Therefore, longer use may not substantially increase the risk of osteoporosis. The prolonged recovery time suggests the need to consider timing of use in relation to menopause or other factors that may impede bone remodeling.
Clark MK, et al Bone mineral density loss and recovery during 48 months in first-time users of depot medroxyprogesterone acetate. Fertil Steril. 2006 Nov;86(5):1466-74.
Few young pregnant women know about safety and effectiveness of intrauterine devices
CONCLUSION: Young women choosing contraception after a pregnancy would benefit from counseling about the relative safety and effectiveness of IUDs, allowing them to make fully informed contraceptive decisions. LEVEL OF EVIDENCE: II-2.
Stanwood
NL, Bradley
KA. Young Pregnant Women's Knowledge of Modern Intrauterine Devices. Obstet
Gynecol. 2006 Dec;108(6):1417-22
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=
retrieve&db=pubmed&list_uids=17138775&dopt=Abstract
Pregnancy Rates Unchanged by Easy Access to Emergency Contraception
CONCLUSION: This intensive strategy to enhance access to emergency contraceptive pills substantially increased use of the method and had no adverse impact on risk of sexually transmitted infections. However, it did not show benefit in decreasing pregnancy rates. LEVEL OF EVIDENCE: II-1.
Raymond
EG, et al Impact of increased access to emergency contraceptive pills: a
randomized controlled trial. Obstet
Gynecol. 2006 Nov;108(5):1098-106.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd
=retrieve&db=pubmed&list_uids=17077230&dopt=Abstract
Scientific accuracy of materials for abstinence-until-marriage education program
Abstinence Education: Efforts to Assess the Accuracy and Effectiveness of Federally Funded Programs describes the U.S. Department of Health and Human Services' (DHHS') efforts to assess the scientific accuracy of materials used in abstinence-until-marriage education programs and the efforts of DHHS, states, and researchers to assess the effectiveness of such programs. The report, produced by the Government Accountability Office, presents results in brief and background information. Discussion topics include limitations of federal and state efforts to assess the scientific accuracy of materials used in abstinence-until-marriage education programs, limits to the conclusions drawn from efforts to assess the programs' effectiveness, conclusions, and recommendations for executive action, agency comments, and evaluation.
In addition, the results of efforts that meet the criteria of a scientifically valid assessment have varied and two key studies funded by HHS that meet these criteria have not yet been completed.
A description of how DHHS selected a contractor for the abstinence-until-marriage technical assistance contract, which was awarded in September 2002, is included. http://www.gao.gov/new.items/d0787.pdf
Oral Contraceptive Use: Small Increased Risk for Premenopausal Breast Cancer
CONCLUSION: Use of OCs is associated with an increased risk of premenopausal breast cancer, especially with use before first full-term pregnancy in parous women.
Kahlenborn C, et al Oral contraceptive use as a risk factor for premenopausal breast cancer: a meta-analysis. Mayo Clin Proc. 2006 Oct;81(10):1290-302
Featured Website David Gahn, IHS Women’s Health Web Site Content Coordinator
The IHS Breastfeeding Home Page is live!
The following announcement is from Judy Thierry: The new Breast feeding page is formatted as the other MCH pages for your convenience. Here is how the pages are organized:
Center column: Title, Easy Guide PDF and the Lactation Support Program circular is available on the MCH web site / Breastfeeding page http://www.ihs.gov/MedicalPrograms/MCH/M/bf.cfm
We are also developing a Tool Kit for work sites across the ITU – coming to you in early 2007!
Right column: 9 sub pages addressing:
- Breastfeeding Benefits – baby, mom, family, community, - AAP guidelines link
- Going back to work or school
- Dad’s and family page
- Medications: prescribed and OTC and recreational
- BF, DM AND OBESITY – article
- Breastfeeding FAQ’s – latch, position, hunger cues, colostrum, supply, after birth cramping, breast engorgement, nipple care, supplements, frequency
- Twenty-two annotated links – videos of latch, feeding in emergencies, case scenarios, La Leche, USDA…
- Policy and position description examples, print materials, staff contacts – Navajo and Alaska.
- Breastfeeding forum – list serve subscribe: http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=82&startrow=1
Left column: Site map, Up-To-Date, other IHS MCH health topics
We look forward to your comments and feedback additional links or topics you would like to see. We would like to hear what you are doing locally and send pictures of dads to Suzan Murphy for posting if you would like. Suzan.Murphy@ihs.gov
Frequently asked questions
Q. Is an informed consent necessary for all x-rays in pregnant women?
A. No, not on routine diagnostic studies. High dose procedures are treated case by case.
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/XrayConsent11506.doc
Q. Are there any Cochrane Reviews about problems with Ortho Evra or Nuva Ring?
#1
RE: a Cochrane Review of the Ortho Evra issues
This particular topic wouldn’t actually show up in the Cochrane database for many years because Cochrane only deals with randomized controlled trials.
While there has been greater publicity of the complications with the patch, it is not known whether women using Ortho Evra are at a greater risk of experiencing these serious adverse events.
What is now known is that the patch provides about 60% more estrogen than a standard 35 ug pill and that in general, increased estrogen exposure may increase the risk of blood clots. The new bolded warning specifically states that women who use Ortho Evra are exposed to about 60 percent more total estrogen in their blood than if they were taking a typical birth control pill containing 35 micrograms of estrogen.
However, the maximal blood level of estrogen (peak blood levels) is about 25% lower with Ortho Evra than with typical birth control pills. While the estrogen level with the patch remains constant for one week until the patch is removed, the peak blood levels with a daily birth control pill rapidly declines to levels that are lower than on the Orthro Evra.
FDA Updates Labeling for Ortho Evra Contraceptive Patch (see FDA full text below)
http://www.fda.gov/bbs/topics/news/2005/NEW01262.html
FDA: Questions and Answers
Ortho Evra (norelgestromin/ethinyl estradiol )
http://www.fda.gov/cder/drug/infopage/orthoevra/qa.htm
Ortho Evra product site
#2
RE: A Cochrane Review of the Nuva Ring?
Ditto above about a whether a Cochrane Review exists on this topic.
On the other hand, here haven’t been any increased reports of untoward effects for the Nuva Ring. The NuvaRing delivers 15 mcg ethinyl estradiol and 120 mcg of etonogestrel daily and is worn intravaginally for three weeks of each four-week cycle.
UpToDate
Ethinyl estradiol and etonogestrel: Drug information
Patient Education: Nuva Ring
http://www.mckinley.uiuc.edu/handouts/nuvaring/nuvaring.htm
FDA Updates Labeling for Ortho Evra Contraceptive Patch
The Food and Drug Administration today approved updated labeling for the Ortho Evra contraceptive patch to warn healthcare providers and patients that this product exposes women to higher levels of estrogen than most birth control pills. Ortho Evra was the first skin patch approved for birth control.
It is a weekly prescription patch that releases ethinyl estradiol (an estrogen hormone) and norelgestromin (a progestin hormone) through the skin into the blood stream. FDA advises women to talk to their doctor or healthcare provider about whether the patch is the right method of birth control for them.
Furthermore, women taking or considering using this product should work with their health care providers to balance the potential risks related to increased estrogen exposure against the risk of pregnancy if they do not follow the daily regimen associated with typical birth control pills. Because Ortho Evra is a patch that is changed once a week, it decreases the chance associated with typical birth control pills that a woman might miss one or more daily doses.
The addition of this new warning is a result of FDA's and the manufacturer's analysis directly comparing the levels for estrogen and progestin hormones in users of Ortho Evra with those in a typical birth control pill.
The new bolded warning specifically states that women who use Ortho Evra are exposed to about 60 percent more total estrogen in their blood than if they were taking a typical birth control pill containing 35 micrograms of estrogen. However, the maximal blood level of estrogen (peak blood levels) is about 25% lower with Ortho Evra than with typical birth control pills. While the estrogen level with the patch remains constant for one week until the patch is removed, the peak blood levels with a daily birth control pill rapidly declines to levels that are lower than on the Orthro Evra.
FDA is continuing to monitor safety reports for the Ortho Evra patch. The manufacturer, Ortho McNeil Pharmaceuticals is conducting additional studies to compare the risk of developing serious blood clots in women using Ortho Evra to the risk in women using typical birth control pills that contain 35 micrograms of estrogen.
The new labeling information is available along with additional information for healthcare providers and consumers online at: www.fda.gov/cder/drug/infopage/orthoevra/default.htm
Indian Child Health Notes - Steve Holve, Pediatrics Chief Clinical Consultant
December 2006
- Prepare yourself for bronchilitis with NEW guidlines from the AAP
- Does running water make your life better?
- Home visitation for newborns has benefits. Can we afford it? Can we not afford it?
- Forty years in partnership: the American Academy of Pediatrics and the Indian Health Service
http://www.ihs.gov/MedicalPrograms/MCH/M/ChPedNotes.cfm
Information Technology
Exam Code and Health Factor Manual
The Office of Information Technology is pleased to present the first version
of the Exam Code and Health Factor manual.
This manual includes listings and definitions of currently available health factors
and exam codes as well as a listing of inactivated exam codes and recommendations
for conversion to CPT/ICD9/procedure codes.
New health factor and exam codes include: activity level, occupation, health
literacy, and fall risk.
This manualreflects the changes in the release of AUM patch
7.1
Contact Chris Lamer Chris.Lamer@ihs.gov
Self-study Course in Epidemiology Now Available Through CDC Web Site
The Centers for Disease Control and Prevention's (CDC's) introductory self-study course, Principles of Epidemiology in Public Health Practice, 3rd ed., is now available online. The course is designed for public health professionals at the state and local levels who are or expect to be responsible for outbreak investigations or public health surveillance.
The course provides an introduction to applied epidemiology and biostatistics. Continuing education credits are offered. The course is available at no charge at http://www2a.cdc.gov/phtnonline.
A printed copy of the course can be ordered from the Public Health Foundation at http://bookstore.phf.org (telephone: 877-252-1200)
Patent Wellness Handout
Good day, the Patent Wellness Handout was released in September 2006 as part of the Health Summary package v2.0 patch 15.
The implementation and use of the PWH is currently being considered as an element of the FY 2007 Director's Performance Contract; therefor, we want to make sure that is provides the functionality that you need and the information patients want. To do so, we will be performing two tasks: the first is to assess focus groups of patients through the HPDP and DPTP throughout IHS and the second is to request your feedback as clinicians.
Please complete the following short assessment (answer all or some of the questions) and return to me ( chris.lamer@ihs.gov) no later than Wednesday, December 20, 2006. Your comments will be used to revise the application.
----------------------------------------
1] Have you used the PWH? (yes or no)
a] If no, are you familiar with it? (yes or no)
b] If yes, did you print out the form? (yes or no)
i] If no, who printed the form? (patient registration, nurse, pharmacist, provider, other)
c] If yes, when did you print the form? (before clinic visit, during visit, after visit, in pharmacy, other-describe)
2] What do you like about the PWH?
3] What do you dislike about the PWH?
4] What fields would you like to see added to the PHW? (things like patient labs, vital signs, screenings, etc)
5] What fields would you like to have removed (if any)? [none, BP, weight, medications, immunizations due, allergies)
6] What functionality would make this a better tool? (automatic printing, ability to create different kinds of handouts, other - describe)
----------------------------------------
Thank you very much for completing the assessment. Please return this form to Chris Lamer by e-mail, fax, or mail before Wednesday, December 20th, 2006:
Fax: (828) 497-5343
Address: Chris Lamer; 1 Hospital Road; Cherokee, NC 29719
Description of the Patient Wellness Handout:
The Patient Wellness Handout (PWH) is a tool that provides patients with access to some of the information in their medical record. It pulls in selected components of the patient's medical record from the RPMS database and provides a brief description about this information including: immunizations due, weight, blood pressure, allergies, and current medications. The PWH can be generated by data registration, clinicians, pharmacists, or anyone else who has normal access to the patient's medical record. The first version of the PWH was released on September 1, 2006 as a mandatory install to all IHS service units.
This tool is designed to address the Institute of Medicine's (IOM) rules of patient centered care and empower patients to improve their health and satisfaction with medical services. In combination with patient education, the patient medical handout attempts to provide the tools a patient requires to improve collaboration with providers and to assist them in make appropriate health care decisions. It is widely accepted that health information, education, and the delivery of preventive services improve patient's health care and facilitate communication between healthcare providers and patients. This can result in improved patient outcomes.
International Health Update: Claire Wendland, Madison, WI
A nurse, a doctor, and an epidemiologist were standing by the river……
Most of us have heard this anecdote: a nurse, a doctor, and an epidemiologist are standing at a river’s edge when they notice body after body floating by. The doctor and nurse jump in, fish out everyone they can, and begin resuscitating the victims. The epidemiologist runs upstream instead, hollering over her shoulder, “I’m going to see who’s pushing them in!”
In recent years, scholars from public health and related fields have increasingly proposed upstream or “structural” interventions into serious problems of public health, as opposed to the traditional education or behavior change interventions. The word “structural” in this sense refers to the social, political and economic structures that make individuals more vulnerable to disease and violence. The logic of such proposals is that, for instance, it makes little sense to combat diabetes by teaching individuals about healthy eating in a poor rural community if the only place to buy food for miles around is a gas-station convenience store specializing in Cheetos, and subsidized corn syrup production means that soda is cheaper than clean water.
Though much epidemiologic and social science literature explores the structural determinants of poor health, few structural intervention trials have been conducted. In fact, controversy over whether such trials are worthwhile (or ethical) is substantial. A recent trial of microfinance initiatives and their effects on intimate partner violence (IPV) and HIV seroconversion rates provides us a rare opportunity to examine the effects of a structural intervention – though with mixed results.
Paul Pronyk and colleagues from the University of the Witwatersrand noted that poverty, lack of economic opportunities, and gender inequalities combine in rural South Africa to allow high levels of both HIV infection and IPV in women. Projects addressing violence and HIV through education alone have met with little success. Would improved economic opportunities for women do better? Pronyk’s team randomized eight villages in Limpopo province to intervention – establishment of a microfinance program combined with a participatory empowerment curriculum – or a comparison group. Over 400 of the poorest women in intervention villages received one or more small loans averaging $165 to support business initiatives; as a loan condition, they also attended training sessions on gender empowerment, relationships, communication, HIV and domestic violence. The researchers assessed the impact of the intervention not only on the women themselves, but also on young people living in loan recipients’ households and on randomly selected villagers. In the intervention villages, reports of intimate partner violence declined dramatically (adjusted RR 0.45, 95% CI 0.23-0.91). Intervention villagers also reported improved household communication, especially on matters of sex and sexuality, and improvement in the total value of household assets – though not food security or other measures of wealth. Several other attitudinal measures of empowerment trended toward positive change, but none met criteria for statistical significance. In addition, young people in intervention villages showed no difference in HIV seroconversion and rates of unprotected sex with someone other than a spouse. (Loan recipients themselves were not asked these questions. At a mean age of 41, the authors imply they were considered too old to discuss such matters!)
Though the study did not demonstrate the effectiveness of microfinance for HIV prevention, it is the first to show that microfinance is effective in reducing intimate partner violence. (Research in South Asia demonstrated initial increases in IPV with the initiation of microfinance, perhaps related to threats to male control of household resources, followed by a later decline.) It also demonstrates that a relatively small structural intervention can have relatively quick effects at the community level.
Pronyk PM, Hargreaves JR, Kim JC et al. Effect of a structural intervention for the prevention of intimate-partner violence and HIV in rural South Africa: a cluster randomized trial. Lancet 368:1973-83, 2006
(Full text available online at www.thelancet.com requires free registration, though)
MCH Alert
2007 Folic Acid Campaign Materials Released
The Folic Acid Now! campaign offers an online media tool kit and consumer materials that community programs can customize and use during National Folic Acid Awareness Week (January 8-14, 2007). The campaign is sponsored by the March of Dimes and the National Alliance for Hispanic Health and managed by the National Folic Acid Council (NCFA), a project of the National Healthy Mothers, Healthy Babies Coalition. The tool kit contains a media outreach worksheet and outreach activity ideas, including activities for a Hispanic community. A fact sheet and local press release (in English and Spanish) are also provided. Consumer materials, including bookmarks, brochures, and stickers (in English and
Spanish) are also available for use in sharing the folic acid message.
Materials may be downloaded from the NCFA Web site, or ordered free-of-charge. http://www.folicacidinfo.org/campaign
Three new programs proven to improve behavioral and mental health in youth
Three new program summaries that focus on child and adolescent behavior and mental health were recently added to RAND's Promising Practices Network Web site:
1.) The Social Decision Making/Problem Solving Program
helps children and adolescents in grades K-8 acquire social and decision-making skills and apply them to real situations. The program seeks to develop children's and adolescents' self-esteem, self-control, and social-awareness skills, as well as skills for coping with stress and emotions.
Evaluation results show that participants experienced improved socialization and also had better emotional and behavioral self-control, even when exposed to distressing situations. http://www.promisingpractices.net/program.asp?programid=154
2.) The Coping Cat Program
is a cognitive-behavioral therapy intervention that helps children and adolescents ages 8-17 recognize and analyze anxious feelings and develop strategies to cope with anxiety-provoking situations. The program uses several behavioral training strategies, including cognitive restructuring, simulation, real-life exposure, and relaxation training. Participants reported improved coping skills and reductions in anxiety, fear, and depression. Parents also reported improved behavioral, social, and health outcomes for their children.
http://www.promisingpractices.net/program.asp?programid=153
3.) The Reaching Educators, Children, and Parents Program
is a comprehensive school-based skills-training program designed for young children who experience both internalizing problem behaviors (withdrawn, anxious, and depressed behaviors) and externalizing problem behaviors (aggressive, oppositional, and impulsive behaviors). The program's primary goals are to reduce psychological problems and to prevent more serious problems among children who are not receiving formal mental health services. Results show that participants generally experienced decreases in both internalizing and externalizing problem behaviors, although results varied depending on who reported the behaviors: parent, teacher, peer, or the participating child. http://www.promisingpractices.net/program.asp?programid=155
2006 Edition of Women’s Health Data Book Released
Women's Health USA 2006, the fifth edition of the data book, presents a profile of women's health at the national level from a variety of data sources. The data book, developed by the Health Resources and Services Administration's Office of Women's Health, includes information and data on population characteristics, health status, and health services utilization. New topics in the 2006 edition include life expectancy, postpartum depression, food security, and smoking during pregnancy.
Racial and ethnic disparities and gender differences in women's health are also highlighted. The data book is intended to be a concise reference for policymakers and program managers at the federal, state, and local levels to identify and clarify issues affecting the health of women. It is available at http://www.mchb.hrsa.gov/whusa_06/index.htm
Medical Mystery Tour
A boy has been born in Chile with a fetus in his stomach
SANTIAGO, Chile (Nov. 24) -- A boy has been born in Chile with a fetus in his stomach in what doctors said was a rare case of "fetus in fetu" in which one twin becomes trapped inside another during pregnancy and continues to grow inside it.
Doctors carried out a scan on the boy's mother shortly before she gave birth on November 15 in the southern city of Temuco and noticed the 4-inch-long fetus inside the boy's abdomen.
It had limbs and a partially developed spinal cord but no head and stood no chance of survival, doctors said.
After the birth, doctors operated and removed the fetus from the boy's stomach. The boy, who has not been named, was recovering at Temuco's Hernan Henriquez hospital.
It's very rare," said Maria Angelica Belmar, head of the hospital's neonatal wing, speaking of fetus in fetu cases. It occurs in only one in every 500,000 live births," she told Reuters, adding that the number of cases recorded worldwide was fewer than 90.
Before you explain the embryology of this case to us, please answer this one simple question:
Which reputable medical resource was this story taken from?
National Enquirer
or
Reuters
Stay tuned till next month to find out.
(or just peruse your personal subscription to National Enquirer in the meantime)
Medscape*
Female Genital Cutting: Epidemiology, Consequences, and Female Empowerment as a Means of Cultural Change
http://www.medscape.com/viewarticle/546497?sssdmh=dm1.225677&src=0_tp_nl_0#
Recurrent Pregnancy Loss
http://www.medscape.com/viewprogram/5293?src=mp
Evaluation and Treatment of Overactive Bladder
http://www.medscape.com/viewprogram/5899?src=sr
Ask the Experts topics in Women's Health and OB/GYN Index, by specialty, Medscape
http://www.medscape.com/pages/editorial/public/ate/index-womenshealth
OB GYN & Women's Health Clinical Discussion Board Index, Medscape
http://boards.medscape.com/forums?14@@.ee6e57b
Clinical Discussion Board Index, Medscape
Hundreds of ongoing
clinical discussions available
http://boards.medscape.com/forums?14@@.ee6e57b
Free CME: MedScape CME Index by specialty
http://www.medscape.com/cmecenterdirectory/Default
*NB: Medscape is free to all, but registration is required. It can be accessed from anywhere with Internet access. You just need to create a personal username and password.
Menopause Management
Estradiol less than 5 yrs, estriol, or vaginal estrogens not associated with breast cancer
CONCLUSION: Estradiol for 5 years or more, either orally or transdermally, means 2-3 extra cases of breast cancer per 1,000 women who are followed for 10 years. Oral estradiol use for less than 5 years, oral estriol, or vaginal estrogens were not associated with a risk of breast cancer. LEVEL OF EVIDENCE: II-2.
Lyytinen H et al Breast cancer risk in postmenopausal women using estrogen-only therapy. Obstet Gynecol. 2006 Dec;108(6):1354-60.
Editorial
Collins
J. Hormones and breast cancer: should practice be changed? Obstet
Gynecol. 2006 Dec;108(6):1352-3.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db
=pubmed&list_uids=17138765&dopt=Abstract
Midwives Corner - Lisa Allee, CNM
Start ‘Em Young for Future Success and Maybe No One Will Be Left Behind
This month I digress.
I have no peer juried article, I don’t even have a URL link. This month’s
topic is in honor of my mom. I visited her for Thanksgiving and we read an article
in the Sunday New York Times Magazine called “Still Left Behind” about
the No Child Left Behind Act. My mom worked for 20+ years as a reading specialist
in a junior high school and has continued her work for literacy in retirement.
She has always admonished me and my sisters to read to our children every day
starting at birth and for years we had the grandma-books-of-the-month delivery
service. She was excited about this article because besides restating the previously
known facts that school success is proportional to income, the author presented
research delving into why this is. Some researchers have found a link between
a child’s school success and his/her vocabulary at age three—middle
to upper income children often have 1000+ words at that age versus lower income
children have ½ to ¼ that amount—and that the number of words
a child has at age three is directly related to the mother’s/parents’ vocabulary.
Another researcher found that not only did the parents’ vocabulary matter,
but the way the parents speak to the children plays a very important role. Parents
of successful children (mid to upper income generally) used a higher proportion
of encouragements, while parents of less successful children (generally lower
income) used a much higher proportion of discouragements when speaking to their
children. So, I was profoundly struck by the possibility that we as midwives,
nurse practitioners, obstetricians, and pediatricians could have an influence
on parents and, thus, their children by pointing out three rules:
- Follow Grandma Allee’s rule of reading to your child every day starting at birth.
- Improve your vocabulary and use your new words with your child.
- Make sure at the end of every day that you have said more encouraging things to your child than discouraging things.
I did this with a couple expecting their second child the other day and it took about a minute and they said thank you for the information! It can fit into a busy clinic!!
Happy Holidays and Happy Reading!
(If you want to read the article it is Still Left Behind in the November 26, 2006 Sunday New York Times Magazine.) Lisa.Allee@ihs.gov
http://www.nytimes.com/pages/magazine/index.html?adxnnl=1&adxnnlx=1165467769
TvXMoHTM4MvgdiqsiuPe2g
Navajo Corner, Tomekia Strickland, Chinle
GYN Spotlight: Endometrial ablation
Pre-menopausal dysfunctional uterine bleeding unrelated to malignancy continues to be a significant problem for women wrought with social embarrassment, disruption of daily activities, and morbidity associated with anemia. Not only is it a challenging condition for the patient but dysfunctional uterine bleeding usually requires lengthy and frequent outpatient visits for appropriate evaluation and management. Many times, patients have suffered for years with the condition and often present discouraged after a series of failed hormonal regimens. Hysterectomy, the only procedure that is 100% effective in eliminating abnormal uterine bleeding, is often less acceptable to Native American women than other populations, both for cultural reasons and because of a general reluctance to undergo major surgery. Thus endometrial ablation has risen as an ideal treatment option for women who have completed child bearing, failed conservative management, and desire uterine conservation.
The Department of Gynecology at Chinle Service Unit is now offering endometrial ablation to appropriate candidates, as are some other I.H.S. sites. There are several global endometrial ablation techniques that have become available nationally over the past few years. Global endometrial ablation refers to a series of FDA approved newer generation technologies that do not require an operative hysteroscope. These include Thermachoice (hot liquid filled balloon), hydrothermal ablation (circulating hot water), Novasure (bipolar desiccation), Her Option (cryoablation)and Microwave ablation. This is in contrast to the standard technique which uses monopolar energy via a rollerball, roller barrel, or resectoscope requiring operative hysteroscopy. There is also increased risk of uterine perforation and fluid overload with the standard techniques. We have started using the Novasure system which is a global ablative technique that utilizes a three dimensional bipolar gold mesh that when inserted conforms to the shape of the uterine cavity. The average ablation time for Novasure® is 90 seconds.*It also has the advantage of not requiring hormonal pretreatment to thin the endometrial lining. When
used correctly, the global ablative techniques are considered safe, effective, fast, simple to perform, painless and cost effective to both physician and patient. Many of these procedures can also be performed as office based procedures.
Like the standard technique, global ablation techniques are considered successful not so much according to amenorrhea rates, but by reduction in menstrual flow. Hypomenorrhea correlates with high rates of subjective patient satisfaction usually greater than 80-90%. The amenorrhea rates for some of the devices are as follows: Thermachoice 14% at 12-24 months; Microwave 38% at 3 years; and Novasure 51% at 1 year.
In conclusion, global endometrial ablation will most likely continue to become an increasingly popular and primary minimally invasive surgical treatment option for women who have completed childbearing and continue to suffer for abnormal uterine bleeding despite medical therapy. Like all medical and surgical interventions, care must be taken to evaluate each patient carefully and individualize their treatment plan accordingly. “Endometrial Ablation” by UpToDate www.uptodate.com provides a detailed discussion on the indications, contraindications and safety profiles for each ablative procedure. If you would like more information about our exciting but still new experience with Novasure, please feel free to contact me at tomekia.strickland@ihs.gov
Nurses Corner - Sandra Haldane, HQE
Nurses less satisfied than physicians or nurse managers: Perceptions of teamwork on L/D
Caregiver role influences perceptions of teamwork. Overall, physicians and nurse managers were much more satisfied than nurses with the collaboration they experienced. For example, anesthesiologists had higher scale scores than certified registered nurse anesthetists for five of the six teamwork climate items. Most (80 percent) L&D staff felt it was easy for personnel in their unit to ask questions. However, only 55 percent found it easy to speak up if they perceived a problem with patient care, and only half felt that conflicts were appropriately resolved. The study was supported in part by the Agency for Healthcare Research and Quality (HS11544).
http://www.ahrq.gov/research/oct06/1006RA2.htm
Nurses play on important role in its detection and can reduce depressive symptoms
CONCLUSION: Results from this study suggest that nursing care and problem solving training may be use confidently in the primary care setting by nurses for women with postpartum depressive symptoms. PRACTICE IMPLICATION: Nurses play on important role in its detection and can reduce depressive symptoms. Public health nurses are equipped with care paths addressing specific health needs of depressed women in the primary care setting. Our finding indicate that these two programs of study can converge with meaningful results, and perhaps future research could address these points in a theoretical framework.
Tezel A; Gözüm S Comparison of effects of nursing care to problem solving training on levels of depressive symptoms in post partum women. Patient Educ Couns. 2006; 63(1-2):64-73
For Neonatal Nurses- Primer on Antenatal Testing: 2 Parts: Tests of Fetal Well-Being / PTL
A number of new antenatal testing tools are being used in obstetric practice to evaluate the clinical picture of the fetus in utero. Results of these tests may prompt transfer to a tertiary facility for delivery or further antenatal monitoring. Part 2 of this 2-part series will describe antenatal testing methods used to determine fetal well-being, as well as highlight the emerging developments in the field of fetal surveillance. The ability to interpret antenatal testing results may help the neonatal team triage to assure bed availability, and predict and provide appropriate staffing for new admissions, and is an important foundation for subsequent neonatal risks and clinical care.
Wyatt SN, Rhoads SJ. A primer on antenatal testing for neonatal nurses: part 2: tests of fetal well-being. Adv Neonatal Care. 2006 Oct;6(5):228-41
and
Wyatt SN, Rhoads SJ. A primer on antenatal testing for neonatal nurses: part 1. Tests used to predict preterm labor. Adv Neonatal Care. 2006 Aug;6(4):175-80
6th Annual SUMMER INSTITUTE ON EVIDENCE-BASED PRACTICE ‘07
Theme: “Quality and Safety”
July 12-14, 2007
Pre Conferences July 11
Crowne Plaza Riverwalk Hotel, San Antonio, Texas
The Institute prepares healthcare providers from multiple disciplines for an increasing role in evidence-based practice to improve healthcare. National leaders present the latest in evidence-based quality improvement. Be part of a leading national conference on evidence-based quality improvement!
For online brochure, after January 1 visit our website: www.acestar.uthscsa.edu
Office of Women's Health, CDC
HPV Information for Clinicians
This 36-page brochure discusses the transmission, prevention, detection and clinical management of human papillomavirus.
This brochure covers the natural history, risk factors, transmission, prevention and management of HPV infection and associated conditions, including new technologies and guidelines for the prevention, screening and management of cervical cancer. It has been tested with providers across a range of specialties and primary practice settings.
In the coming weeks, [CDC] will also be posting four sets of counseling messages, developed to facilitate provider-patient communication about HPV and associated diseases. These will include messages for
(1) prospective vaccine recipients,
(2) women receiving the HPV DNA test with Pap for cervical cancer screening,
(3) women with a high-risk HPV DNA test result, and
(4) patients with genital warts.
The clinician brochure with counseling-message inserts should be available for print ordering in early 2007, though they will not be available in bulk. We have provided PDF and high-resolution options online for those who wish to print and reproduce the brochure on their own. As always, we encourage you to share these materials with interested colleagues and providers in the field.
http://www.cdc.gov/std/HPV/hpv-clinicians-brochure.htm
It can also be accessed from our HPV page at www.cdc.gov/std/hpv
Finally, for those interested, you can now register for email notifications whenever updates are made to CDC's HPV page. To do this, click on the new link at the top of our HPV page www.cdc.gov/std/hpv called "Email updates."
Oklahoma Perspective Greggory Woitte – Hastings Indian Medical Center
Reduction in Teen Pregnancies
The preliminary numbers from 2005 from the CDC show a 2% reduction in teenage pregnancies down to its lowest recorded level in 65 years. The biggest decline was in the ages 15-17 year group. Here in Oklahoma, we were the 8th highest state in the nation for teen births ages 15-19 in 2002. Like all other states, we as women’s health providers have to work hard at encouraging young women to delay sexual activity as well as taking steps to prevent becoming pregnant. ACOG recently released a statement that a 13 month supply of OCPs showed a greater likelihood of continuation and use and would be very beneficial in the continued reduction of teen pregnancies. In fact, it is estimated that for every dollar invested in teen pregnancy prevention programs, at least $2.65 were saved in direct medical and social service costs (The National Campaign to Prevent Teen Pregnancy. Not Just Another Single Issue: Teen Pregnancy’s Link to Other Social Issues, 2002).
State of the State’ Health, 2005, Oklahoma State Board of Health
http://www.health.state.ok.us/board/state05/SOSH05.pdf#page=14
NCHS Health E Stats – Births-Preliminary Data for 2005
http://www.cdc.gov/nchs/products/pubs/pubd/hestats/prelimbirths05/prelimbirths05.htm
ACOG Statement 13 month Supply of OCPS leads to more consistent use
http://www.acog.com/from_home/publications/press_releases/nr11-01-06-2.cfm
Osteoporosis
Significant bone loss: Both low molecular weight heparin and unfractionated heparin
CONCLUSION: In this study, the incidence of clinically significant bone loss (> or = 10%) in the femur in women who received thromboprophylaxis in pregnancy is approximately 2% to 2.5% and appears to be similar, regardless of whether the patient receives low molecular weight heparin therapy or unfractionated heparin therapy.
Casele H et al Bone density changes in women who receive thromboprophylaxis
in pregnancy.
Am
J Obstet Gynecol. 2006; 195(4):1109-13
Updated Position Statement for Calcium Intake in Postmenopausal Women
CONCLUSIONS: The most definitive role for calcium in peri- and postmenopausal women is in bone health, but, like most nutrients, calcium has beneficial effects in many body systems. Based on the available evidence, there is strong support for the importance of ensuring adequate calcium intake in all women, particularly those in peri- or postmenopause.
North American Menopause Society. The role of calcium in peri- and postmenopausal women: 2006 position statement of the North American Menopause Society. Menopause. 2006 Nov-Dec;13(6):862-77
Teriparatide alone is less cost-effective than alendronate alone for the treatment of women with severe osteoporosis
Teriparatide is a promising new agent for the treatment of osteoporosis (loss of bone mass density). The drug increases bone density and reduces fractures in women with severe osteoporosis (those with low bone mass and preexisting fractures) by directly stimulating new bone formation. Yet therapy with teriparatide alone is more expensive and produces a smaller increase in quality-adjusted life years (QALYs) than therapy with alendronate, the U.S. market leader in osteoporosis medications. Sequential teriparatide/alendronate therapy appears expensive; however, it could become more cost-effective in certain circumstances.
Researchers analyzed data from three osteoporosis fracture trials to compare the cost per QALY for usual care (calcium or vitamin D supplementation) with that of three medication strategies for the first-line treatment of high-risk osteoporotic women (postmenopausal white women with low bone density and vertebral fracture). The three medication strategies included 5 years of alendronate therapy, 2 years of teriparatide therapy, and 2 years of teriparatide therapy followed by 5 years of alendronate therapy (sequential teriparatide/alendronate).
Compared with usual care, the cost of alendronate treatment was $11,600 per QALY. Teriparatide alone was less cost-effective than alendronate at $172,300 per QALY, even if its efficacy lasted 15 years after treatment. The cost of sequential teriparatide/alendronate therapy was $156,500 per QALY compared with alendronate alone. This sequential therapy was less cost-effective than alendronate, even if fractures were eliminated during the alendronate phase. However, it would become cost-effective (less than $50,000 per QALY) if the price of teriparatide decreased 60 percent, if used in elderly women with severe osteoporosis, or if 6 months of teriparatide therapy had comparable efficacy to 2 years of treatment. The study was supported in part by the Agency for Healthcare Research and Quality (T32 HS00028).
http://www.ahrq.gov/research/oct06/1006RA7.htm
Patient Information
Preventing Injuries in School-age Children and Teenagers
http://www.aafp.org/afp/20061201/1870ph.html
Lactose Intolerance: What You Should Know
http://www.aafp.org/afp/20061201/1923ph.html
Myths and Facts About Food Allergies
http://www.aafp.org/afp/20061201/1919ph.html
Perinatology Picks - George Gilson, Maternal Fetal Medicine, ANMC
Amniocentesis procedure-related loss risk of approximately 1 in 1600, not prior 1 in 200
Women undergoing amniocentesis were 1.1 times more likely to have a spontaneous loss
RESULTS: The spontaneous fetal loss rate less than 24 weeks of gestation in the study group was 1.0% and was not statistically different from the background 0.94% rate seen in the control group (P=.74, 95% confidence interval -0.26%, 0.49%). The procedure-related loss rate after amniocentesis was 0.06% (1.0% minus the background rate of 0.94%). Women undergoing amniocentesis were 1.1 times more likely to have a spontaneous loss (95% confidence interval 0.7-1.5). CONCLUSION: The procedure-related fetal loss rate after midtrimester amniocentesis performed on patients in a contemporary prospective clinical trial was 0.06%. There was no significant difference in loss rates between those undergoing amniocentesis and those not undergoing amniocentesis. LEVEL OF EVIDENCE: II-2.
Eddleman KA et al Pregnancy loss rates after midtrimester amniocentesis. Obstet Gynecol. 2006; 108(5):1067-72
Second twins: 97 cesarean deliveries (NNT) prevent a single serious morbidity or mortality
OBJECTIVE: Patients are given options with regard to the mode of delivery with increasing frequency. The manner in which obstetricians frame the risk/benefit information can have dramatic impact on the ultimate decision made by the patient. STUDY DESIGN: Recently published epidemiologic data reported increased morbidity and mortality to the second twin on the basis of mode of delivery. In this analysis, the findings of the epidemiologic studies were translated from odds ratio into the number of cesarean deliveries that would be required to prevent an adverse outcome for the second twin. RESULTS: For gestations of > or = 36 weeks, 97 cesarean deliveries would need to be performed to prevent a single serious morbidity or mortality in a second twin. This number is within the range needed to prevent uterine rupture associated with trial of labor following cesarean delivery (556) or morbidity related to vaginal breech delivery (167). CONCLUSION: Number needed to treat may be more useful than odds risk assessment in patient counseling.
Meyer MC Translating data to dialogue: how to discuss mode of delivery with your patient with twins. Am J Obstet Gynecol. 2006 Oct;195(4):899-906
Iron / folate supplementation: Not replaced by a multiple-micronutrient supplement
AUTHORS' CONCLUSIONS: The evidence provided in this review is insufficient to suggest replacement of iron and folate supplementation with a multiple-micronutrient supplement. A reduction in the number of low birthweight and small-for-gestational-age babies and maternal anaemia has been found with a multiple-micronutrient supplement against supplementation with two or less micronutrients or none or a placebo, but analyses revealed no added benefit of multiple-micronutrient supplements compared with iron folic acid supplementation. These results are limited by the small number of studies available. There is also insufficient evidence to identify adverse effects and to say that excess multiple-micronutrient supplementation during pregnancy is harmful to the mother or the fetus. Further research is needed to find out the beneficial maternal or fetal effects and to assess the risk of excess supplementation and potential adverse interactions between the micronutrients.
Haider BA; Bhutta ZA Multiple-micronutrient supplementation for women during pregnancy.
Cochrane Database Syst Rev. 2006; (4):CD004905
Treatment of periodontitis does not alter PTB, low birth weight, or fetal growth restriction
CONCLUSIONS: Treatment of periodontitis in pregnant women improves periodontal disease and is safe but does not significantly alter rates of preterm birth, low birth weight, or fetal growth restriction.
Michalowicz BS et al Treatment of periodontal disease and the risk
of preterm birth.
N
Engl J Med. 2006; 355(18):1885-94 (ISSN: 1533-4406)
Preterm babies have an increased risk of asthma compared with term babies
CONCLUSIONS: The weight of evidence shows that preterm babies have an increased risk of asthma compared with term babies. CLINICAL IMPLICATIONS: Recognition of prematurity as a determinant of asthma emphasizes the importance of active treatment of physiologic airflow obstruction and a need for special preventive measures against known environmental determinants of asthma in preterm babies.
Jaakkola JJ et al Preterm delivery and asthma: a systematic review and
meta-analysis.
J
Allergy Clin Immunol. 2006; 118(4):823-30
Primary Care Discussion Forum
Ongoing Discussion - You still can join in
Causes of Type 2 Diabetes: Old and New Understandings
Moderator: Ann Bullock M.D.
In 2002, the International Diabetes Federation determined that the medical literature supports 4 etiologies of type 2 diabetes:
--Genetics
--Fetal Origins
--Lifestyle
--Stress
We will explore these issues
- Diabetes prevention programs focus on lifestyle modification—what might these programs look like if lifestyle is only one factor?
- What else can be learned from the DPP (Diabetes Prevention Program)?
- Pregnancy and early life risk factors
- What are the particular roots of the diabetes and obesity epidemics in Indian Country
How to subscribe / unsubscribe to the Primary Care Discussion Forum?
Subscribe to the Primary Care listserv
http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=51
Unsubscribe from the Primary Care listserv
http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=51
Questions on how to subscribe, contact nmurphy@scf.cc directly
STD Corner - Lori de Ravello, National IHS STD Program
Less than half of parents infected with HIV tell their children about the diagnosis
Parents are reluctant to disclose their HIV infection to their children, primarily because they fear the emotional impact. As a result, fewer than half (44 percent) of children are aware of their parent's HIV infection, according to a new study supported in part by the Agency for Healthcare Research and Quality (HS08578 and T32 HS00046).
Researchers interviewed 274 parents from the HIV Cost and Services Utilization Study, a nationally representative sample of HIV-infected adults receiving care for HIV. HIV-infected parents reported that 44 percent of their children ages 5 to 17 years old were aware of their parent's HIV status. Another 14 percent of children were unaware of their parent's HIV status, but knew their parent had a serious illness. In 28 percent of households with more than one child, some, but not all, children knew their parent's HIV status. Parents had discussed the possibility that HIV or AIDS might lead to the parent's death with 90 percent of children who knew about their HIV infection.
Parents did not disclose their HIV status to their children primarily due to worry about the emotional consequences of disclosure for the child (67 percent), worry that the child would tell other people (36 percent), and not knowing how to tell their child (28 percent). Many parents also feared that their children would reject them or lose respect for them. Certain parents were less likely to disclose their HIV infection than others. These included those who contracted HIV through heterosexual intercourse (rather than homosexual intercourse or intravenous drug use), those with higher CD4 cell counts (indicative of greater disease progression), those who were more socially isolated, and those with younger children. According to the parents, 11 percent of children who were aware of their parent's HIV infection worried they could catch HIV from their parent, 5 percent had experienced other children not wanting to play with them, and 9 percent had been teased or beaten up.
Corona R, et al Do children know their parent's HIV status? Parental reports of child awareness in a nationally representative sample May 2006 Ambulatory Pediatrics 6(3), pp. 138-144.
http://www.ahrq.gov/research/oct06/1006RA16.htm
Barbara Stillwater, Alaska State Diabetes Program
Three Years Later, Participants in the Diabetes Prevention Study
Still Benefiting
Lifestyle intervention has lasting benefits in those at risk of diabetes. The
effects of lifestyle intervention on diabetes risk do not disappear after active
counseling has stopped, a new follow-up of the Finnish Diabetes Prevention Study
shows. Three years after the end of the study, those in the intervention group
still had a reduced incidence of type 2 diabetes compared with the control
INTERPRETATION: Lifestyle intervention in people at high risk for type 2 diabetes resulted in sustained lifestyle changes and a reduction in diabetes incidence, which remained after the individual lifestyle counseling was stopped.
Lindstrom J et al Sustained reduction in the incidence of type 2 diabetes by lifestyle intervention: follow-up of the Finnish Diabetes Prevention Study. Lancet. 2006 Nov 11;368(9548):1673-9
Stopping the Clock on Diabetes in Women: Strategies for Prevention and Treatment Across the Lifespan
Diabetes in Women: Women's Health Seminar Series, Web cast
The National Institutes of Health (NIH), Office of Research on Women’s Health (ORWH) and the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) as part of the Women's Health Seminar Series is sponsoring a seminar on women and diabetes. Four leading experts will share information on an overview of women and diabetes, preventing cardiovascular complications of diabetes, women and diabetes, diabetes self-management, and preventing diabetes in women with and without a history of gestational diabetes. Griffin P. Rodgers, M.D., M.A.C.P., Acting Director of NIDDK, will make the opening remarks. To learn more, call 301-402-1770. http://videocast.nih.gov/PastEvents.asp?c=11
Multiparity Increase Risk for Type 2 Diabetes
Women with five or more live births are at increased risk of developing type 2 diabetes mellitus. This appears to be the case, even after adjusting for obesity and socioeconomic factors.
There were 754 incident cases of type 2 diabetes during follow-up. Type 2 diabetes incidence rates were highest among the grandmultiparous, at 23 cases/1,000 person-years and lowest among women with one to two live births, at 11 cases/1,000 person-years.
The researchers acknowledge that the bulk of diabetes risk was due to obesity and lower socioeconomic status. However, after adjusting for these recognized risk factors as well as clinical status, inflammatory markers and lifestyle factors, grandmultiparity remained a risk factor for type 2 diabetes.
Whether the link between high parity and diabetes is biological or due to lifestyle is unknown. The investigators conclude that the CONCLUSION: Breastfeeding in infancy is associated with a reduced risk of type 2 diabetes, with marginally lower insulin concentrations in later life, and with lower blood glucose and serum insulin concentrations in infancy, weight gain measures, lifestyle factors and changes in socioeconomic status. CONCLUSIONS: Grandmultiparity is predictive of future risk of diabetes after adjustment for confounders.
Nicholson WK et al Parity and risk of type 2 diabetes: the Atherosclerosis Risk in Communities Study. Diabetes Care. 2006 Nov;29(11):2349-54
New Study Weighs Benefits of Exercise, Diets
While exercise and weight loss are equally effective ways to lose weight, exercising
helps to maintain muscles. These data provide evidence that muscle mass and absolute
physical work capacity decrease in response to 12 months of CR, but not in response
to a similar weight loss induced by exercise. These findings suggest that during
exercise-induced weight loss, the body adapts to maintain or even enhance physical
performance capacity. Key words: diet, training, energy deficit, cardiovascular.
Weiss EP, et al Lower extremity muscle size and strength and aerobic capacity decrease with caloric restriction but not with exercise-induced weight loss. J Appl Physiol. 2006 Nov 9
Low-Carb Diets Reduce Coronary Disease Risk in Women
A study suggesting that low-carbohydrate diets do not increase the risk for coronary
artery disease in women may help to allay fears that people who eat higher amounts
of protein and fat, while cutting back on carbohydrates, are not trading hopes
of a slimmer waistline for increased coronary disease risk. CONCLUSIONS: Our
findings suggest that diets lower in carbohydrate and higher in protein and fat
are not associated with increased risk of coronary heart disease in women. When
vegetable sources of fat and protein are chosen, these diets may moderately reduce
the risk of coronary heart disease.
Halton TL, et al Low-carbohydrate-diet score and the risk of coronary heart disease in women. N Engl J Med. 2006 Nov 9;355(19):1991-2002.
What's new on the ITU MCH web pages?
Diabetes: Understandings About the Causes of Type 2 - Old / New
http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForumMod.cfm#diabetes
There are several upcoming Conferences
and Online CME/CEU resources, etc….
and the latest Perinatology Corners (free online CME from IHS)
…or just take a look at the What’s New page
Save the dates
22nd Annual Midwinter Indian Health OB/PEDS Conference
- For providers caring for Native women and children
- January 26-28, 2007
- Telluride, CO
- Contact Alan Waxman awaxman@salud.unm.edu
TeenScreen Conference: Second Annual
- March 14 and 15, 2007
- Washington D.C.
- ContactTSConference@childpsych.columbia.edu
2nd International Meeting on Indigenous Child Health
- April 20-22, 2007
- Montreal , Quebec, Canada
- Solutions, not Problems
- Joint meeting of IHS, AAP-CONACH, First Nations and several other stakeholders
- http://www.aap.org/nach/2InternationalMeeting.htm
2007 Indian Health MCH and Women’s Health National Conference
- August 15 -17, 2007
- Albuquerque , NM
- THE place to be for anyone involved in care of AI/AN women, children
- Internationally recognized speakers
- Save the dates. Details to follow
- Want a topic discussed? Contact nmurphy@scf.cc
Did you miss something in the last OB/GYN Chief Clinical Consultant Corner?
The November 2006 OB/GYN CCC Corner is available.
Hot Topics ‹ Previous
OB/GYN
Dr. Neil Murphy is the Obstetrics and Gynecology Chief Clinical Consultant (OB/GYN C.C.C.). Dr. Murphy is very interested in establishing a dialogue and/or networking with anyone involved in women's health or maternal child health, especially as it applies to Native or indigenous peoples around the world. Please don't hesitate to contact him by e-mail or phone at 907-729-3154.
