November 2004 CCC Corner > Hot Topics

Hot Topics:

• Obstetrics
• Gynecology
• Child Health
• Chronic Disease and Illness

Obstetrics

3 Articles on CenteringPregnancy

# 1 CenteringPregnancy and the Current State of Prenatal Care

Prenatal care is often credited with improving pregnancy outcomes. Yet rates of low birthweight (LBW) and prematurity have risen in recent decades, calling into question the efficacy of traditional prenatal routines. Proposals have included broadening the objectives of prenatal care beyond prevention of LBW and enriching care to provide education and support for pregnant women. CenteringPregnancy, an innovative model of prenatal care that integrates extensive health education and group support with the standard prenatal exam, incorporates many of these elements. Impediments to wider implementation of CenteringPregnancy are explored, as well as proposals for addressing these challenges.

Novick G. CenteringPregnancy and the current state of prenatal care. J Midwifery Womens Health. 2004 Sep-Oct;49(5):405-11.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15351330

Or

http://www.medscape.com/viewarticle/489498_1

# 2 Pregnancy Outcomes of Adolescents Enrolled in a CenteringPregnancy Program

Adolescent pregnancy remains a significant social, economic, and health issue in the United States . The unique developmental needs of the pregnant adolescent require attention when designing prenatal care services. The CenteringPregnancy model of group prenatal care provides education and support for young women in an active and developmentally appropriate environment. Thirteen groups of adolescents (N = 124) have completed the Centering program at the Teen Pregnancy Center at Barnes Jewish Hospital in St. Louis , Missouri . Evaluation data suggest that the model has encouraged excellent health care compliance, satisfaction with prenatal care, and low rates of preterm birth and low birth weight infants.

Grady MA, Bloom KC. Pregnancy outcomes of adolescents enrolled in a CenteringPregnancy program. J Midwifery Womens Health. 2004 Sep-Oct;49(5):412-20.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15351331

Or

http://www.medscape.com/viewarticle/489499?src=mp

# 3 Redesigning prenatal care through CenteringPregnancy

CenteringPregnancy is a model of group prenatal care that provides more than 20 hours of contact time between the childbearing care provider and a cohort of pregnant women with similar due dates. During this time, each woman has the opportunity to build community with other pregnant women, learn self-care skills, get assurance about the progression of her pregnancy, and gain knowledge about pregnancy, birth, and parenting. Ten essential elements have been defined, which contribute to the success of this model of prenatal care delivery. These elements correspond with the Institute of Medicine 's 2001 challenge to improve the quality of health care in the United States . Foundational perspectives provide potential explanations for the model's growing influence and success. Implications for clinical practice and further research to link it with perinatal health outcomes are suggested.
Rising SS, Kennedy HP, Klima CS. Redesigning prenatal care through CenteringPregnancy . J Midwifery Womens Health. 2004 Sep-Oct;49(5):398-404.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15351329

OB/GYN CCC Editorial comment:

CenteringPregnancy has been used successfully throughout the Indian Health System, as well as the University of New Mexico . To date t he paucity of funded and published research on Centering is one of the great impediments to demonstrating its value, as well as to disseminating the model. Despite the lack of evidence that traditional, one-on-one prenatal care is effective, as a challenger to the status quo, a burden of demonstrating effectiveness rests on Centering's shoulders. Other innovative approaches to care have faced this challenge too, such as freestanding birth centers compared to hospital birth.

I encourage randomized studies in the AI/AN population. If you are interested in further discussion about CenteringPregnancy in Indian Health, then contact Yolanda Meza, CNM, (ANMC) ymeza@anmc.org or Judy Whitecrane (PIMC) Judy.Whitecrane@ihs.gov

Fetal Manipulation Often Best for Shoulder Dystocia 

A study suggests that episiotomy offers no benefit over fetal manipulation unless the episiotomy is made specifically to assist the infant through manipulation.

CONCLUSION: In severe shoulder dystocia, if fetal manipulation can be performed without episiotomy, severe perineal trauma can be averted without incurring greater risk of brachial plexus palsy. Gurewitsch ED et al Episiotomy versus fetal manipulation in managing severe shoulder dystocia: a comparison of outcomes . Am J Obstet Gynecol. 2004 Sep;191(3):911-6.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15467564

Data support the routine use of antibiotics for women with PROM. Amoxicillin/clavulanate should be avoided due to increased risk of neonatal necrotizing enterocolitis

CONCLUSION: The administration of antibiotics after PROM is associated with a delay in delivery and a reduction in maternal and neonatal morbidity. These data support the routine use of antibiotics for women with PROM. Penicillins and erythromycin were associated with similar benefits, but erythromycin was used in larger trials and, thus, the results are more robust. Amoxicillin/clavulanate should be avoided in women at risk of preterm delivery because of the increased risk of neonatal necrotizing enterocolitis. Antibiotic administration after PROM is beneficial for both women and neonates.

Kenyon S, Boulvain M, Neilson J. Antibiotics for preterm rupture of the membranes: a systematic review. Obstet Gynecol. 2004 Nov;104(5):1051-7.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15516401&dopt=Abstract

AFI offers no advantage over single deepest pocket when performed with the BPP

CONCLUSION: The AFI offers no advantage in detecting adverse outcomes compared with the single deepest pocket when performed with the BPP. The AFI may cause more interventions by labeling twice as many at-risk pregnancies as having oligohydramnios than with the single deepest pocket

Magann EF, Doherty DA, Field K, Chauhan SP, Muffley PE, Morrison JC. Biophysical profile with amniotic fluid volume assessments. Obstet Gynecol. 2004 Jul;104(1):5-10

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15228994

Blood Mercury Levels in Young Children and Childbearing-Aged Women

This report updates NHANES 1999--2000 estimates of blood Hg levels, the first nationally representative estimates of U.S. women's and children's exposures to Hg based on biologic measures. The findings indicate that blood Hg levels in young children and childbearing-aged women usually are below levels of concern.

Fish are an important part of a diet, high in protein and nutrients and low in saturated fatty acids and cholesterol. The short-term strategy to reduce Hg exposure is to eat fish with low Hg levels and avoid or reduce consumption of fish with high Hg levels. Because exposure to methyl-Hg can harm fetuses, the Food and Drug Administration (FDA) advises that women who are or might become pregnant not eat shark, swordfish, king mackerel, and tile fish ( 9 ). In addition, EPA and the Agency for Toxic Substances and Disease Registry have established daily consumption levels of Hg considered to be without harm. State-based fish advisories and bans identify fish species contaminated by Hg and their locations and provide safety advice. The NHANES program continues to collect Hg measurements in human tissue to monitor the effectiveness of efforts to reduce Hg exposure in the U.S. population.

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5343a5.htm

Vaginal-perianal compared with vaginal-rectal cultures for group B streptococci

CONCLUSION: The group B streptococci detection rate from vaginal-perianal specimens is not significantly different from the detection rate from vaginal-rectal specimens. Therefore, pregnant women do not need to be subjected to the discomfort of collection of a rectal specimen. LEVEL OF EVIDENCE: II-2

Jamie WE, Edwards RK, Duff P. Vaginal-perianal compared with vaginal-rectal cultures for identification of group B streptococci. Obstet Gynecol. 2004 Nov;104(5):1058-61.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15516402&dopt=Abstract

Perinatal infections due to group B streptococci

Group B streptococci (GBS) emerged dramatically in the 1970s as the leading cause of neonatal infection and as an important cause of maternal uterine infection. We review the epidemiology, diagnosis, and therapy of GBS perinatal infection. In 1996, the first national consensus guidelines were released. Since then, there has been a 70% reduction in early-onset neonatal GBS infection, but no decrease in late-onset neonatal GBS disease. In 2002, new national guidelines were released recommending 1) solely a screen-based prevention strategy, 2) a new algorithm for patients with penicillin allergy, and 3) more specific practices in certain clinical scenarios. Yet many clinical issues remain, including implementation of new diagnostic techniques, management of preterm rupture of membranes, use of alternative antibiotic approaches, improvement of compliance, prevention of low birth weight infants, emergence of resistant organisms, and vaccine development.

Gibbs RS, Schrag S, Schuchat A. Perinatal infections due to group B streptococci. Obstet Gynecol. 2004 Nov;104(5):1062-76.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15516403&dopt=Abstract

Treatment of Bacterial Vaginosis in Pregnancy
CONCLUSION: The effectiveness of metronidazole therapy of bacterial vaginosis persists for > or =10 weeks. Women who underwent placebo therapy had significant remission of bacterial vaginosis over > or =10 weeks. Remission was more common when the initial vaginal microbiologic disturbances were less severe.

Klebanoff MA, et al. Time course of the regression of asymptomatic bacterial vaginosis in pregnancy with and without treatment. Am J Obstet Gynecol. 2004 Feb;190(2):363-70.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14981375

Pregnancy Nutrition Surveillance System / Pediatric Nutrition Surveillance websites

CDC is pleased to announce the availability of new Web site for the Pediatric Nutrition Surveillance System (PedNSS) and the Pregnancy Nutrition Surveillance System (PNSS) This Web site provides access to the most recent national data on prevalence data for overweight, breastfeeding initiation and duration for low-income populations and detailed information about the program-based surveillance systems. Also included at the site is training on reading the data tables, an epidemiologic approach to interpreting the data, and application of the data.

PedNSS and PNSS monitor the nutritional status of low-income infants, children and women in federally funded maternal and child health programs. PedNSS data represent more than 5 million children from birth to age 5. PNSS data represent approximately 750,000 pregnant and postpartum women. http://www.cdc.gov/pednss/

Blunt Trauma in Pregnancy

http://www.aafp.org/afp/20041001/1303.html

Seat Belt Use During Pregnancy: Patient Education

http://www.aafp.org/afp/20041001/1313ph.html

Pregnancy Prevention in Adolescents

http://www.aafp.org/afp/20041015/1517.html

Teenage Pregnancy Prevention: What Can We Do? - Editorial

http://www.aafp.org/afp/20041015/editorials.html

Introduction of Routine HIV Testing in Prenatal Care

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5346a2.htm

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Gynecology

Colposcopy Possibly Unjustified for Screening Young Women for Cervical Cancer 

INTERPRETATION: The high rate of regression recorded in this study lends support to observation by cytology in the management of LSIL in female adolescents. Negative HPV status was associated with regression, suggesting that HPV testing could be helpful in monitoring LSIL.

Moscicki AB , et al Regression of low-grade squamous intra-epithelial lesions in young women. Lancet. 2004 Nov 6;364(9446):1678-83.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15530628

Women With Atypical Glandular Cells: A Long-Term Study in a High-Risk Population

Patients with AGCs are at risk of harboring clinically significant uterine lesions and should be followed up for a substantial period despite initial negative findings.

Chhieng DC , et al Women with atypical glandular cells: a long-term follow-up study in a high-risk population. Am J Clin Pathol. 2004 Oct;122(4):575-9.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15487456

Pessary Test May Predict Urinary Incontinence After Hysterectomy 

CONCLUSION: Continent patients suffering from severe pelvic organ prolapse but with a positive pessary test are considered to be at high risk of developing postoperative symptomatic stress urinary incontinence. Among the patients in our medium-range study, TVT effectively prevented postsurgical urinary incontinence. LEVEL OF EVIDENCE: II-1
Liang CC, et al Pessary test to predict postoperative urinary incontinence in women undergoing hysterectomy for prolapse . Obstet Gynecol. 2004 Oct;104(4):795-800.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15458904

Many older patients are bothered by night sweats, day sweats, and hot flashes

CONCLUSION: Though these symptoms are similar and related, they have somewhat different associations with other variables. Clinical evaluation should include questions about febrile illnesses, sensory deficits, anxiety, depression, pain, muscle cramps, and restless legs syndrome

Mold JW, Roberts M, Aboshady HM. Prevalence and predictors of night sweats, day sweats, and hot flashes in older primary care patients: an OKPRN study. Ann Fam Med. 2004 Sep-Oct;2(5):391-7.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15506569

Pelvic symptoms in women with pelvic organ prolapse

CONCLUSION: Women with more advanced prolapse were less likely to have stress incontinence and more likely to manually reduce prolapse to void; however, prolapse severity was not associated with sexual or bowel symptoms. LEVEL OF EVIDENCE: II-2.

Burrows LJ, et al Pelvic symptoms in women with pelvic organ prolapse. Obstet Gynecol. 2004 Nov;104(5):982-8.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15516388&dopt=Abstract

Incontinence Products and Devices for the Elderly

Devices and products to contain or collect the urine are part of the management of bladder dysfunction, particularly urinary incontinence (UI). The aim of continence nurse experts and those who care for incontinent individuals during the past decade has been to greatly decrease the indiscriminate use of absorbent pads and garments, external collecting devices, and indwelling catheterization, through the successful treatment of urinary incontinence (UI) with behavioral interventions, drug therapies, and new surgical procedures. However, these products and devices can be beneficial for persons who are elderly, fail treatment and remain incontinent, who are too ill or disabled to participate in behavioral programs, who cannot be helped by medications, or who have a type of UI that cannot be alleviated by other interventions. The judicious use of products to contain urine loss and maintain skin integrity is a first-line defense for these patients (Fantl et al., 1996). Urinary collection devices and products that are appropriate for elderly patients, that are used by nurses in all clinical settings, and are available at local pharmacies, retail stores, medical equipment dealers or directly from manufacturers are discussed.   Newman DK. Incontinence products and devices for the elderly. Urol Nurs. 2004 Aug;24(4):316-33 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15446380

Urinary incontinence strategies for frail elderly women

Among the majority of frail older women, urinary incontinence has not been adequately assessed or treated, with resultant negative impact on quality of life. An assessment and intervention model based on type of incontinence, evidence-based interventions, and the influence of patient preference and capacity to carry out interventions are described.

Lekan-Rutledge D Urinary incontinence strategies for frail elderly women. Urol Nurs. 2004 Aug;24(4):281-3, 287-301
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15446378

Physiotherapy Helpful for Persistent Postnatal Stress Urinary Incontinence 

CONCLUSION: Multimodal supervised pelvic floor physiotherapy is an effective treatment for persistent postnatal stress urinary incontinence.

Dumoulin C, et al Physiotherapy for persistent postnatal stress urinary incontinence: a randomized controlled trial. Obstet Gynecol. 2004 Sep;104(3):504-10.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15339760

Laparoscopic vs. Abdominal Hysterectomy: a Comparison

CONCLUSIONS: Laparoscopic hysterectomy was associated with a significantly higher rate of major complications than abdominal hysterectomy. It also took longer to perform but was associated with less pain, quicker recovery, and better short term quality of life. The trial comparing vaginal hysterectomy with laparoscopic hysterectomy was underpowered and is inconclusive on the rate of major complications; however, vaginal hysterectomy took less time.
Garry R, Fountain et al The eVALuate study: two parallel randomised trials, one comparing laparoscopic with abdominal hysterectomy, the other comparing laparoscopic with vaginal hysterectomy. BMJ. 2004 Jan 17;328(7432):129
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14711749

and

CONCLUSIONS: Laparoscopic hysterectomy is not cost effective relative to vaginal hysterectomy. Its cost effectiveness relative to the abdominal procedure is finely balanced.

Sculpher M, et al Cost effectiveness analysis of laparoscopic hysterectomy compared with standard hysterectomy: results from a randomised trial. BMJ. 2004 Jan 17;328(7432):134.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14711748

Add-back therapy plus GnRH-a improves treatment of endometriosis pain

CONCLUSION(S): Add-back therapy allows the treatment of women with relapse of endometriosis-associated pain for a longer period, with reduced bone mineral density loss, good control of pain symptoms, and better patient quality of life compared with GnRH analogue alone or oral contraceptive.    Zupi E, et al Add-back therapy in the treatment of endometriosis-associated pain. Fertil Steril. 2004 Nov;82(5):1303-8.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15533351

Cognitive Behavior Therapy Should Be First-Line Therapy for Sleep-Onset Insomnia

CONCLUSIONS: These findings suggest that young and middle-age patients with sleep-onset insomnia can derive significantly greater benefit from CBT than pharmacotherapy and that CBT should be considered a first-line intervention for chronic insomnia. Increased recognition of the efficacy of CBT and more widespread recommendations for its use could improve the quality of life of a large numbers of patients with insomnia.

Jacobs GD, et al Cognitive behavior therapy and pharmacotherapy for insomnia: a randomized controlled trial and direct comparison . Arch Intern Med. 2004 Sep 27;164(17):1888-96.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15451764

Do your patients complain of poor sleep? Is it hormonal? Or something else?

Excessive daytime sleepiness (EDS) or somnolence is common in our patients and in society in general. The most common cause of EDS is "voluntary" sleep restriction. Other common causes include sleep-fragmenting disorders such as the obstructive sleep apnea syndrome. Somewhat less familiar to the clinician are EDS conditions arising from central nervous system dysfunction. Of these so-called primary disorders of somnolence, narcolepsy is the most well known and extensively studied, yet often misunderstood and misdiagnosed. Idiopathic hypersomnia, the recurrent hypersomnias, and EDS associated with nervous system disorders also must be well-understood to provide appropriate evaluation and management of the patient with EDS. This review summarizes the distinguishing features of these clinical syndromes of primary EDS. A brief overview of the pharmacological management of primary EDS is included.

Black JE, Brooks SN, Nishino S. Narcolepsy and syndromes of primary excessive daytime somnolence. Semin Neurol. 2004 Sep;24(3):271-82.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15449220

Or

http://www.medscape.com/viewarticle/491437?src=mp

Laparoscopic Excision Often Helpful for Endometriosis

CONCLUSION(S): Laparoscopic excision of endometriosis is more effective than placebo at reducing pain and improving quality of life. Surgery is associated with a 30% placebo response rate that is not dependent on severity of disease. Approximately 20% of women do not report an improvement after surgery for endometriosis.
Abbott J, et al Laparoscopic excision of endometriosis: a randomized, placebo-controlled trial. Fertil Steril. 2004 Oct;82(4):878-84.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15482763

or

http://www.medscape.com/viewarticle/491783?src=mp

Ultrasound Therapy Effective for Vulvar Dystrophy

CONCLUSION: Vulvar dystrophy could be effectively treated with focused ultrasound therapy. This approach appears to be a new promising treatment method, although further studies are still needed. LEVEL OF EVIDENCE II-3:   Li C, et al Focused Ultrasound Therapy of Vulvar Dystrophies: A Feasibility Study. Obstet Gynecol. 2004 Nov;104(5):915-921.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15516378

Stress urinary incontinence - An excellent review of management

Nygaard IE, Heit M. Stress urinary incontinence. Obstet Gynecol. 2004 Sep;104(3):607-20.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15339776

Management of Cervical Cytologic Abnormalities

http://www.aafp.org/afp/20041115/1905.html

The 2001 ASCCP Management Guidelines for Cervical Cytology: Editorial

http://www.aafp.org/afp/20041115/editorials.html

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Child Health

Cholestasis of pregnancy - Bile acid pneumonia: a "new" form of neonatal respiratory distress syndrome?

Our experience suggests that a high level of attention in the management of newborn infants (even near-term infants) born from women with intrahepatic cholestasis of pregnancy is necessary to detect as soon as possible signs and symptoms of this "unexpected" RDS, which can assume a very severe clinical picture. In such instances, we recommend that the diagnosis of BA pneumonia be kept in mind and that exogenous surfactant be given as soon as possible, even in the presence of indices of normal lung maturity in the amniotic fluid. Finding high levels of BA and lysophosphatidylcholines in the bronchoalveolar lavage of affected infants would aid in support of the diagnosis     Zecca E, Costa S, Lauriola V, Vento G, Papacci P, Romagnoli C.

Bile acid pneumonia: a "new" form of neonatal respiratory distress syndrome? Pediatrics. 2004 Jul;114(1):269-72
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15231944

AHRQ and its partners launch new tools to help combat childhood obesity

http://www.ahrq.gov/research/oct04/1004RA1.htm

AAP to Issue Advisory to Help Diagnose, Treat and Monitor Depressed Children

Since the Food and Drug Administration's (FDA) Oct. 15 announcement that all antidepressants prescribed to children must be marked with a "black box" warning due to increased risk of suicidal thinking and behavior, the AAP has been working to address the questions and concerns of pediatricians. These include the appropriateness of the proposed monitoring schedule and any liability issues. While the drugs are not contraindicated, FDA instructs prescribers to balance the risk with clinical need.

The AAP supports the FDA's action, but additional guidance is being given to help pediatricians and other health professionals meet the needs of their patients with depression. The AAP is currently working with the American Psychiatric Association, the American Academy of Child and Adolescent Psychiatry and the American Academy of Family Physicians to develop an advisory for health professionals to help diagnose, treat and monitor depressed children. It is expected to be ready for distribution early in 2005.

The AAP is also calling on the FDA to clarify and modify its proposed monitoring schedule. The December AAP News issue has an article explaining the AAP action, along with suggested clinical advice http://aapnews.aappublications.org/cgi/content/full/e2004146v1

FDA information on this issue can be found at: http://www.fda.gov/cder/drug/antidepressants

Childhood Bullying: Implications for Physicians

http://www.aafp.org/afp/20041101/1723.html

Bullying: Patient Education

http://www.aafp.org/afp/20041101/1729ph.html

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Chronic disease and Illness

A novel specific prophylaxis for menstrual-associated migraine.

CONCLUSIONS: All currently available estrogen-containing oral contraceptives produce a premenstrual fall in ethinyl estradiol concentration equal to or greater than 20 microg. Estrogen supplementation during the placebo week can reduce the magnitude of this fall to less than 20 microg. When the decline is limited to the equivalent of 10 microg ethinyl estradiol, menstrual-associated migraine is prevented. At an average cost of six dollars per headache-day prevented, this represents an effective and inexpensive strategy for a common migraine trigger.

Calhoun AH. A novel specific prophylaxis for menstrual-associated migraine. South Med J. 2004 Sep;97(9):819-22.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15455962

Identifying patients who require a change in their current acute migraine treatment

Results: The test-retest reliability of the 27 Migraine-ACT questions ranged from good to excellent, and correlation coefficients were highly significant for all items. The consistency of reporting the yes and no answers was also excellent. Correlations of Migraine-ACT items with SF-36 and MIDAS items and SF-36, MIDAS and MTAQ total scores indicated that the following were the most discriminating items, in the respective four domains, and constitute the final Migraine-ACT questionnaire:

Dowson AJ, et al Identifying patients who require a change in their current acute migraine treatment: the Migraine Assessment of Current Therapy (Migraine-ACT) questionnaire. Neurol Sci. 2004 Oct;25 Suppl 3:S276-8.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15549559

National Diabetes Awareness Month --- November 2004

November is National Diabetes Awareness Month. An estimated 18.2 million persons in the United States (i.e., 6.3% of the population) have diabetes. However, 5.2 million (29%) of these persons have not had their condition diagnosed. Persons with diabetes have a risk of premature death that is approximately two times greater than that of persons without the disease. From 1980 to 2002, the number of persons with diabetes in the United States more than doubled. In 2000, diabetes was the sixth leading cause of death in the United States and cost the nation more than $132 billion dollars in health-care expenditures. Additional information about diabetes is available from CDC at http://www.cdc.gov/diabetes .

Acne patients should include attention to anger and other chronic emotional states

CONCLUSIONS: Anger is associated with the quality of patients' lives and with their satisfaction with treatment. Care of acne patients should include attention to anger and other chronic emotional states, quality of life, as well as to clinical severity. Simple guidelines are suggested for how clinicians might approach this important aspect of care

Rapp DA, e t al Anger and acne: implications for quality of life, patient satisfaction and clinical care. Br J Dermatol. 2004 Jul;151(1):183-9 .
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15270889

Prevalence of Overweight and Obesity Among Adults with Diagnosed Diabetes

The prevalence of obesity among adults overall in the United States increased from 22.9% during 1988--1994 to 30.5% during 1999--2002 ( 5,6 ); the prevalence of obesity among adults with diagnosed diabetes remained high, at 45.7% during 1988--1994 and 54.8% during 1999-2002

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5345a2.htm

The colon is a pelvic organ too: taking the Couric challenge

Through her position and passion, Katie Couric has been able to motivate legions of viewers to talk about their bowels, to learn about their colon cancer risks, and in many cases, to take action and undergo screening. Well, the colon is a pelvic organ and obstetricians-gynecologists should play an active role in preventing death from colon cancer..

Karlan BY. The colon is a pelvic organ too: taking the couric challenge. Obstet Gynecol. 2004 Nov;104(5):907-9.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15516375&dopt=Abstract

OB/GYN CCC Editorial comment:

As we struggle to rediscover a place for the 'Annual Exam' in our practices please consider that colon cancer is increased among AI/AN women.

At The American College of Obstetricians and Gynecologists' 2004 Annual Clinical Meeting, Katie Couric of NBC's Today Show challenged us to increase the number of women screened for colon cancer. Colorectal cancer currently ranks third among cancer-related deaths in women and takes twice as many lives as ovarian cancer. Although our patients are eager to be screened for ovarian cancer, less than half are screened for colorectal cancer. Ironically, we have reliable techniques to detect early-stage colorectal cancer, which have been proven to reduce mortality; in contrast, diagnosing early-stage ovarian cancer has been an elusive goal.

Most organizations, including ACOG and the American Cancer Society, have issued evidence-based guidelines that recommend screening for colon cancer, beginning at age 50 in average-risk individuals.

Sigmoidoscopy and colonoscopy directly visualize colonic tumors, although accuracy depends on the skill of the operator and on the size and location of abnormalities. Flexible sigmoidoscopy is easier, safer, and less costly than colonoscopy, but only visualizes the distal third of the colon, thereby missing all proximal lesions. It has been argued that sigmoidoscopy identifies those patients most likely to benefit from colonoscopy. However, in a large study performed at 13 Veterans Administration medical centers, more than half of the patients with advanced proximal neoplasia had no distal lesions; these cancers would not have been identified if patients had been screened with sigmoidoscopy alone. Colonoscopy is often considered the "gold standard" for colorectal cancer screening. On the other hand, its accuracy is only 90% for large polyps and 75% for polyps under 1 cm. Persistent or recurrent symptoms, therefore, require further testing and follow-up.                      njm

Aggressive statin strategy best for patients with heart disease

CONCLUSIONS: An aggressive, focused statin therapy management strategy outperformed usual care in health maintenance organization and Veterans Administration clinic patients with CHD.   Koren MJ, et al Clinical outcomes in managed-care patients with coronary heart disease treated aggressively in lipid-lowering disease management clinics: the alliance study. J Am Coll Cardiol. 2004 Nov 2;44(9):1772-9.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15519006

Is Antibiotic Use Associated with Breast Cancer Risk?

CONCLUSIONS: Use of antibiotics is associated with increased risk of incident and fatal breast cancer. It cannot be determined from this study whether antibiotic use is causally related to breast cancer, or whether indication for use, overall weakened immune function, or other factors are pertinent underlying exposures. Although further studies are needed, these findings reinforce the need for prudent long-term use of antibiotics.   Velicer CM, et al Antibiotic use in relation to the risk of breast cancer. JAMA. 2004 Feb 18;291(7):827-35.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14970061

Caloric Restriction Decreases Incidence of Breast Cancer

CONCLUSIONS: Severe caloric restriction in humans may confer protection from invasive breast cancer. Low caloric intake prior to first birth followed by a subsequent pregnancy appears to be associated with an even more pronounced reduction in risk.   Michels KB, Ekbom A. Caloric restriction and incidence of breast cancer. JAMA. 2004 Mar 10;291(10):1226-30.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15010444

Vioxx Pulled From Global Market - Potential Mechanisms for Cardiovascular Risk

Mechanistically speaking, there are reasons why inhibiting COX-1 and COX-2 might affect cardiovascular risk. Because COX-1 helps promote thrombosis and COX-2 helps inhibit it, blocking COX-2 but not COX-1 could theoretically increase the risk of myocardial infarction and other thrombotic events. On the other hand, inflammation has also been implicated in cardiovascular events, so controlling inflammation via COX-2 inhibition could conceivably be protective. http://www.fda.gov/cder/drug/infopage/vioxx/default.htm

Outcomes After Cardiac Catheterization in Women

CONCLUSIONS: Sex-based differences in death rates after cardiac catheterization are time- and treatment-specific. This finding may at least partially explain the discrepancies in results from earlier studies on sex differences in outcomes of cardiac care   

King KM, et al Sex differences in outcomes after cardiac catheterization: effect modification by treatment strategy and time. JAMA. 2004 Mar 10;291(10):1220-5.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15010443

Common Dietary Supplements for Weight Loss

http://www.aafp.org/afp/20041101/1731.html

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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.