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July 2005 CCC Corner > Features
Features
American
Family Physician**
Patient-Oriented Evidence that Matters (POEMS)*
Three Days of Ciprofloxacin Better for Uncomplicated UTI
Clinical Question: Are amoxicillin-clavulanate and ciprofloxacin equivalent
as a three-day treatment for uncomplicated cystitis in women?
Bottom Line: Three days of ciprofloxacin is superior to three days of amoxicillin-clavulanate
in the treatment of uncomplicated cystitis in women. In areas where resistance
is not yet a significant problem, physicians should use less expensive trimethoprim-sulfamethoxazole
as a first-line agent. (Level of Evidence: 1b-) http://www.aafp.org/afp/20050615/tips/7.html
*POEM Rating system: http://www.infopoems.com/levels.html POEM
Definition: http://www.aafp.org/x19976.xml
** The AFP sites will sometimes ask for a username and password. Instead just ‘hit;
cancel on the pop up password screen, and the page you are requesting will come
up without having to enter a username and password.
Gonorrhea Clinical Evidence Concise, A Publication of BMJ
What are the effects of treatments for uncomplicated infections in men and
nonpregnant women?
beneficial
Single-dose Antibiotic Regimens (Based on Comparisons
of Results Across Arms of Different Trials). One systematic review found limited evidence that single-dose
regimens (e.g., ceftriaxone, ciprofloxacin, gatifloxacin, spectinomycin, azithromycin,
ofloxacin, and cefixime) achieve cure rates of 95 percent or higher in urogenital
or rectal infection. Cure rates were lower (about 80 percent) for pharyngeal
infection. Resistance to penicillins, tetracyclines, and sulfonamides is now
widespread, and resistance to fluoroquinolones has become common in some geographic
areas.
What are the effects of treatments for uncomplicated infections in pregnant
women?
beneficial
Single-dose Antibiotic Regimens. One systematic review found that antibiotic
treatment (e.g., amoxicillin plus probenecid, spectinomycin, ceftriaxone, and
cefixime) was effective for curing gonorrhea in pregnant women. We found no reports
of serious adverse effects.
What are the effects of treatments for disseminated gonococcal infection?
likely to be beneficial
Multidose Antibiotic Regimens (Based on Nonrandomized
Controlled Trials Evidence and Consensus). We found no randomized controlled trials (RCTs) assessing treatments
for disseminated gonococcal infection, but there is consensus that multidose
regimens using injectable cephalosporins or quinolones (except where quinolone-resistant
Neisseria gonorrhoeae have been reported) are the most effective treatments.
We found no reports of treatment failures with these regimens.
What are the effects of dual treatment for gonorrhea and chlamydia infection?
unknown effectiveness
Dual Antibiotic Treatment. Dual treatment with an antimicrobial effective
against gonorrhea and chlamydia infections is based on theory and expert opinion
rather than on evidence from RCTs. The balance between benefits and harms will
vary with the prevalence of coinfection in each population. http://www.aafp.org/afp/20050701/bmj.html
Clinical Evidence Concise, A Publication of BMJ Publishing Group
http://www.clinicalevidence.com/ceweb/conditions/seh/1604/1604.jsp
Low-Molecular-Weight Heparin for Initial Treatment of Venous
Thromboembolism
Clinical Scenario Cochrane for Clinicians
A 72-year-old woman presents with swelling and pain in her calf that has lasted
two days. Evaluation reveals that she has an acute thromboembolism of the deep
femoral vein.
Clinical Question
Should venous thromboembolism initially be treated with unfractionated heparin
or a low-molecular-weight heparin (LMWH)?
Reviewers' Conclusions. LMWH is more effective than unfractionated heparin
for the initial treatment of venous thromboembolism. LMWH significantly reduces
the occurrence of major hemorrhage during initial treatment and overall mortality
at follow-up.
Evidence-Based Answer
LMWH is safer and more effective than unfractionated heparin for initial treatment
of venous thromboembolism.
The practice recommendations in this activity are available online at http://www.cochrane.org/cochrane/revabstr/AB001100.htm
Follow-up After Surgically Treated Breast Cancer Cochrane
for Clinicians
Clinical Question
What follow-up should women have after surgical treatment of breast cancer?
Evidence-Based Answer
The best available evidence supports
clinical breast examinations every three to six months for five years and annual
mammography for asymptomatic breast cancer survivors. More intensive follow-up
and subspecialist visits do not improve survival.
Practice Pointers
Rojas and colleagues identified four studies that compared different approaches
to follow-up in 3,055 women who were surgically treated for Stage I, II, or III
breast cancer. Two studies (2,563 women) compared a minimal follow-up strategy
(i.e., clinical breast examination every three to six months and annual mammography)
with more intensive follow-up that included laboratory and imaging tests such
as chest radiograph and bone scan in addition to regular examinations. After
five to 10 years, the studies found no difference in overall mortality (relative
risk [RR], 0.98; 95 percent confidence interval [CI], 0.84 to 1.15) or quality
of life between groups. One study found a benefit in disease-free survival in
the intensive follow-up group (bone scan and chest radiograph every six months),
though the other did not. The pooled RR for disease-free survival for both studies
was 0.84 (P = .05; 95 percent CI, 0.71 to 1.00).
One study with 296 women compared hospital-based subspecialist follow-up with
follow-up by the patient's family physician. There was no significant difference
in the likelihood of recurrence (7 percent with family physicians versus 11 percent
with subspecialists) and patients reported more satisfaction with care from their
family physician. A limitation of these studies is their age, but recent evidence-based
guidelines are consistent with their findings. The Institute for Clinical Systems
Improvement1 and the National Comprehensive Cancer Network2 also recommend clinical
breast examinations every four to six months for five years, then annually, with
annual mammograms for asymptomatic breast cancer survivors. They do not recommend
routine laboratory or imaging studies for asymptomatic women who are not expected
to have a recurrence. http://www.aafp.org/afp/20050701/cochrane.html
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ACOG
Hemoglobinopathies in Pregnancy
Summary of Recommendations and Conclusions
The following recommendations are based on good and consistent scientific
evidence (Level A):
- Individuals of African, Southeast Asian, and Mediterranean descent are at
increased risk for being carriers of hemoglobinopathies and should be offered
carrier screening and, if both parents are determined to be carriers, genetic
counseling.
- A complete blood count and hemoglobin electrophoresis are the appropriate
laboratory tests for screening for hemoglobinopathies. Solubility tests alone
are inadequate for screening because they fail to identify important transmissible
hemoglobin gene abnormalities affecting fetal outcome.
- Couples at risk for having
a child with sickle cell disease or thalassemia should be offered genetic counseling
to review prenatal testing and reproduction options. Prenatal diagnosis of hemoglobin-opathies
is best accomplished by DNA analysis of cultured amniocytes or chorionic villi.
Hemoglobinopathies in pregnancy. ACOG Practice Bulletin No. 64. American College
of Obstetricians and Gynecologists. Obstet Gynecol 2005;106:203–11.
ACOG Members
http://www.acog.org/publications/educational_bulletins/pb064.cfm
Pregnancy and Depression: What Women Need to Know
In response to recent celebrity statements about postpartum depression, The
American College of Obstetricians and Gynecologists (ACOG), the nation's leading
organization of physicians specializing in women's health care, provides the
following excerpt, "Riding the Emotional Roller Coaster," from ACOG's
PlumTM magazine, as a resource for women and their families. PlumTM is the first-ever
pregnancy magazine to target American women age 35 and older and is distributed
free of charge by obstetrician-gynecologists to their patients.
This article addresses the many physiological issues related to pregnancy
and the postpartum period. It also explores the role of hormones, the safety
of antidepressants during pregnancy, and symptoms of depression. It is written
to dispel myths and misunderstandings about perinatal and postpartum depression-both
are real and can be treated. ACOG advises women to talk with their ob-gyns about
their own feelings and concerns and about available treatments and resources.
https://www.acog.com/from_home/publications/press_releases/nr07-07-05.cfm
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AHRQ
Breast cancer risk and the effects of tamoxifen prophylaxis among women in
primary care
http://www.ahrq.gov/research/may05/0505RA14.htm#head14
Acupuncture appears promising for the treatment of depression during pregnancy
http://www.ahrq.gov/research/may05/0505RA16.htm#head16
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Ask A Librarian: Diane Cooper, M.S.L.S. / NIH
A new quick and easy way to find best clinical articles: PubMed Clinical Queries
If
you want to know the answers to these questions or if you just want to spend
less time looking for just the right article…
What is ‘Search by Clinical Study Category’?
What is ‘Find Systematic Reviews’?
How to find and use PubMed Clinical Queries?
…then go to…IHS Primary Care Provider, March 2005 Volume 30,
No. 3, page 73
http://www.ihs.gov/PublicInfo/Publications/HealthProvider/issues/PROV0305.pdf
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Breastfeeding
1st week of life critical window for ingestion of maternal "diabetic" breast
milk
CONCLUSIONS: Neither late neonatal DBM intake nor the duration of breast-feeding
has an independent influence on childhood risk of overweight or IGT in ODM. Therefore,
the 1st week of life appears to be the critical window for nutritional programming
in ODM by ingestion of maternal "diabetic" breast milk. Rodekamp E,
et al Long-Term Impact of Breast-Feeding on Body Weight and Glucose Tolerance
in Children of Diabetic Mothers: Role of the late neonatal period and early infancy.
Diabetes Care. 2005 Jun;28(6):1457-62.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15920068&dopt=Abstract
Medication Use During Pregnancy and Breastfeeding
Many pregnant women or mothers
who are breastfeeding worry about whether to take medications - including prescription
and over-the-counter drugs, vitamins, and dietary or herbal supplements. This
page includes sections on frequently asked questions, fast facts about medication
use during pregnancy and while breastfeeding, CDC activities, and more.
http://www.cdc.gov/ncbddd/meds/default.htm
Breastfeeding may be associated with a reduced risk of atherosclerosis
Based on a cohort study based on a 65-year follow-up of the Carnegie (Boyd
Orr) survey of diet and health in prewar Britain. Having been breastfed was inversely
associated with common carotid intima-media thickness (IMT; difference -0.03
mm; 95% CI, -0.07 to 0.01), bifurcation IMT (difference -0.19 mm; 95% CI, -0.37
to -0.01), carotid plaque (odds ratio [OR], 0.52; 95% CI, 0.29 to 0.92), and
femoral plaque (OR, 0.54; 95% CI, 0.26 to 1.12), compared with having been bottle
fed. Martin RM et al (2005). Breastfeeding and Atherosclerosis: Intima-Media
Thickness and Plaques at 65-Year Follow-Up of the Boyd Orr Cohort. Arteriosclerosis,
Thrombosis, and Vascular Biolog 25:1482. http://atvb.ahajournals.org/cgi/content/abstract/25/7/1482?ct
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Case Managers Corner, Donna Brown, Anchorage
What is an RN Case Manager?
I was asked by my newest provider when we were introduced almost a year ago….
“What do you do? Are you a Social Worker?”
At Southcentral Foundation Women’s Health Services (WHS), Case Managers
are first and foremost, Registered Nurses. There are currently nine full-time
positions. The turnover rate in WHS is the lowest I have ever experienced in
25 years of nursing. The background of education and experience of the case managers
is very diverse. Some of the case managers were just emerging from the security
of nursing school, while others are counting down the years until retirement.
Each case manager has physician and mid-level providers with whom we work
very closely as a team for a positive patient outcome. We work with our providers
within the clinic to provide pre-op teaching and post-op care. The case managers
each have a region within the state of Alaska to coordinate continuity of patient
care. We schedule patients for surgical procedures and transfer high risk prenatal
patients for antenatal care and delivery in Anchorage.
We also have a telephone triage nurse available from 8am to 4pm Monday through
Friday.
We utilize the ACOG recommendation, Telephone Triage book for Obstetrics and
Gynecology, Vickie E. Long, MSN, CNM and Patricia C McMullen, JD, MS, CNS, CRNP,
Lippincott, 2003.
We are interested in hearing how other case managers are utilized in providing
services for American Indians and Alaska Natives. Please feel free to contact
me dnbrown@anmc.org
Here are some helpful links: www.RNCaseManager.comhttp://www.rncasemanager.com/case_manager_training.htm
By Donna N. Brown, BSN, RNC, CMC, Southcentral Foundation
OB/GYN CCC Editorial comment:
The inclusion of RN Case Managers to the ANMC Women’s Health Service
has revolutionized clinical care and remarkably increased patient satisfaction.
Many kudos to all the Indian Health Case Managers !
The CCCC welcomes this new posting from Donna Brown and we look forward to
future entries for a RN Case Managers Corner. If other RN Case Managers have
ideas they would like to share, please feel free to contact Donna Brown at dnbrown@anmc.org
In the meantime here are some other possible resources
University of Wisconsin Nursing
http://www.son.wisc.edu/academics/msclinicalspecialties.htm
(scroll down to bottom of page)
and
Nursing Spectrum: Student’s Corner
http://www.nursingspectrum.com/StudentsCorner/CareersInNursing/Specialties/CM.htm
and
Case Management Society of America
http://www.cmsa.org/
CASE MANAGEMENT ALONG THE CONTINUUM
September 11-14, 2005, Washington, DC
20.4 contact hours, Contemporary Forums http://cforums.com/m687/bene.asp
Pre-conferences: A - 8.5 contact hours or B - 9 contact hours
Contemporary Forums Home page
www.contemporaryforums.com
CCC
Corner Digest
Nicely laid out hard copy - A compact digest of last month’s
CCC Corner
Highlights include
-Have you had your ‘morning after’ antiretroviral cocktail yet?
-Why Prozac is okay during pregnancy and not for breastfeeding…. and
why Zoloft is
-Slight delay in umbilical cord clamping better for preterm infants
-Transdermal contraceptive promising for reducing bleeding and delaying menses
-Risk of Autism: Parent, Pregnancy, and Birth Factors Found Possible Associations
-Women with pregnancy induced HTN: Increased risk for metabolic syndrome later
-Urinary Incontinence in Women: Practice Bulletin NUMBER 63, JUNE 2005
-AskUs Live! Available to all Indian Health Staff
-Being overweight may increase the risk of becoming pregnant while using OCs
-Follow-up: Answer to the May Mystery Question
-Screening for Genital Herpes: USPSTF
-West Nile Virus in Women
-Appropriate use of narcotics for chronic non-malignant (non-cancer) pain
-Screening for Gonorrhea: USPSTF Recommendation Statement
-Any new solutions to Nausea and Vomiting in Pregnancy?
-New Perinatology Corner Free CEU / CME Module
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/05jun_OL.pdf
If you want a copy of the CCC Digest mailed to you each month, please contact nmurphy@scf.cc
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Domestic
Violence
Women who declined to be surveyed regarding domestic violence were at increased
risk for adverse pregnancy outcome
Conclusion: Women who declined to be surveyed regarding domestic violence
were at increased risk for adverse pregnancy outcome. Level of Evidence: II-2n Yost
NP, et al A prospective observational study of domestic violence during pregnancy.
Obstet Gynecol. 2005 Jul;106(1):
61-5. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15994618&dopt=Abstract
Juvenile Justice Issues - Coordinating Council - Key Programs Advancing Youth
The Coordinating Council on Juvenile Justice and Delinquency Prevention is
an independent advisory committee within the executive branch. One of its main
functions is to assist in implementing the recommendations of the White House
Task Force for Disadvantaged Youth.
The Council meeting highlighted the many opportunities for collaboration among
federal and non-profit organizations. The presenters discussed the ability of
youth serving organizations to offer excellent youth development programs to
young people in low resource environments across the U.S. www.juvenilecouncil.gov
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Elder
Care News
2nd Annual Alzheimer's Disease and Dementia Update Conference
Challenges in the Care of American Indian Elders
August 19, 2005 Flagstaff, AZ
This is a conference designed specifically for Indian Country, targeting a
broad audience including health care professionals, caregivers and program staff
working with elders with dementia. Sun Health Research Institute. http://www.shri.org/conference/index.cfm
Secondary Prevention of Coronary Heart Disease in Elderly Patients
http://www.aafp.org/afp/20050615/2289.html
A Nursing Guide to the Prevention and Management of Falls in Geriatric Patients
in Long-term Care Settings
http://www.medscape.com/viewprogram/4086?src=mp
(see Medscape section for free access issues)
2005 ASCP Foundation Interdisciplinary GeroPsych/Behavioral Disorders Traineeship
This would be a good opportunity for sites looking to develop an interdisciplinary
approach to dementia and geriatric depression and anxiety. Appropriate
for physicians, NPs, PAs, plus pharmacist. Lodging and tuition are covered,
per diem and travel are not. I would be glad to look with you for additional
funding if your site commits to sponsoring a team.
http://www.ascpfoundation.org/traineeships/train_interdisciplinary.htm
I will also support applications with letters of recommendation. Bruce.Finke@ihs.gov
Prevention of Falls in Older Patients
http://www.aafp.org/afp/20050701/81.html
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Family
Planning
Low-dose oral contraceptives increase cardiovascular disease risk
Conclusions: In conclusion, a rigorous meta-analysis of the literature suggests
that current use of low-dose OCs significantly increases the risk of both cardiac
and vascular arterial events, including a significant risk of vascular arterial
complications with third generation OCs.
Baillargeon
JP, et al Association between the Current Use of Low-Dose Oral Contraceptives
and Cardiovascular Arterial Disease: A Meta-Analysis. J Clin Endocrinol Metab.
2005 Jul;90(7):3863-70. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15814774&query_hl=13
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Frequently
asked questions
Q. Do you know of any good links to simple patient education?
A. Kat Franklin CNM compiled these Simple
Patient Education Handouts
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/PtEDHANDOUTS.doc
Q. What are some good paper based women’s resources for Advanced
Practice Nurses?
A. Here are some good paper based and web based resources for Advanced Practice
Nurses
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/APNreferWomen62305.doc
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Information Technology
Computer-assisted cognitive therapy effectively treats depression: RCT
CONCLUSIONS: A multimedia, computer-assisted form of cognitive therapy with
reduced therapist contact was as efficacious as standard cognitive therapy. Computer-assisted
therapy could decrease costs and improve access to cognitive therapy for depression.
Wright
JH, et al Computer-assisted cognitive therapy for depression: maintaining
efficacy while reducing therapist time. Am J Psychiatry. 2005 Jun;162(6):1158-64.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15930065&query_hl=2
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International Health Update
Medical Investigations of Homicides of Prisoners of War in Iraq and Afghanistan
This article reviews another human rights issue -- the medical evaluation
of cases of which prisoners potentially died of because of mistreatment or under
suspicious circumstances.
http://www.medscape.com/viewarticle/507284?src=mp (See
Medscape below for free access)
Association between subsidized housing and children’s nutritional
status
Receiving public housing subsidies is associated with anthropometric evidence
of improved nutritional status in young children among low-income renter families
in the urban populations studied in this sentinel surveillance program. Few studies
have examined the possible effects of housing assistance on the health and nutritional
status of young children from families with low incomes who are most directly
affected by these policies.
Conclusion: Decreases in housing subsidies may further compromise the nutritional
status of low-income children."
* Twenty-four percent of households without a housing subsidy were food insecure.
* Children from families with food insecurity who were not receiving housing
subsidies had lower weight-for-age than children from families with food insecurity
who were receiving housing subsidies.
* Children from families with food insecurity who were not receiving housing
subsidies were more than twice as likely to have weight-for-age 2 standard deviations
below the mean than children from families with food insecurity who were receiving
housing subsidies.
* Housing subsidy status was not associated with children's risk for fair
or poor health or history of hospitalization. There was also no association between
housing subsidy status and childhood overweight.
Meyers A, Cutts D, Frank DA, et al. 2005. Subsidized housing and children's
nutritional status: Data from a mulitisite surveillance study. Archives of Pediatrics
and Adolescent Medicine 159(6):551-556 http://archpedi.ama-assn.org/cgi/content/abstract/159/6/551
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MCH
Alert
Health Care Insurance (SCHIP) Improves racial / ethnic health disparities
The simple provision of health insurance to uninsured low-income children
may enhance efforts to reduce preexisting racial/ethnic disparities in care;
in this case, disparities in access to care, unmet need, and continuity of care
were virtually eliminated. Future expansions of SCHIP or of other health insurance
programs for children and additional research on mechanisms of disparities may
both improve care and reduce disparities among these vulnerable children.
Shone LP, Dick AW, Klein JD, et al. 2005. Reduction in racial and ethnic disparities
after enrollment in the State Children's Health Insurance Program. Pediatrics
Electronic Pages 115(6):e697-e705 http://pediatrics.aappublications.org/cgi/content/abstract/115/6/e697
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Medical
Mystery Tour
2 positive blood cultures found in a postpartum patient with a fever
-This 22 year old G1 P0 presented in active labor at 40 weeks gestation after
a benign prenatal course that was significant only for a positive perineum and
rectal culture for beta streptococcus group B screen at 36 weeks and a weight
gain of over 50 pounds with a normal glucose challenge test.
-The patient had a Stage I of 17:40 and a Stage II of 00:23 with delivery
of a viable male infant weighing 4407 g with Apgars of 8/9 over a large 4th degree
laceration. There was also an extensive left perineal laceration with avulsion.
Stage III lasted 00:05 with delivery of an intact placenta. The patient had a
standard repair of the 4th degree laceration and a right vulvar skin flap closure
of the left perineal laceration in the delivery room. What followed was an unremarkable
post partum course. The patient was discharged locally on the 3rd post partum
day. The patient remained afebrile throughout with an intact perineal repair
and had a normal bowel movement prior to discharge.
-The patient returned on postpartum day #5 with a temperature of 101.9 degrees
F, a tender uterus with an intact perineum, and a WBC of 13.3K. The patient was
re-hospitalized for endometritis and treated with metronidazole and ampicillin
/ sulbactam. The patient defervesced and was discharged home again on post partum
day #8. The patient was called back into the hospital within hours of leaving
when it was noted that 2 of her blood cultures had become positive.
The blood cultures positive with what organism? What was the source?
If you have the answer, or other questions please contact me at nmurphy@scf.cc
Otherwise we will discuss the ‘rest of the story’ in the August
Medical Mystery Tour.
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Medscape*
Mammography: Is Early Detection Really the Best Form of Prevention?
http://www.medscape.com/viewarticle/499386?src=nlpromo
Ask the Experts topics in Women's Health and OB/GYN Index, by specialty, Medscape
http://www.medscape.com/pages/editorial/public/ate/index-womenshealth
OB GYN & Women's Health Clinical Discussion Board Index, Medscape
http://boards.medscape.com/forums?14@@.ee6e57b
Clinical Discussion Board Index, Medscape
Hundreds of ongoing clinical discussions available
http://boards.medscape.com/forums?14@@.ee6e57b
Free CME: MedScape CME Index by specialty
http://www.medscape.com/cmecenterdirectory/Default
*NB: Medscape is free to all, but registration is required. It can be accessed
from anywhere with Internet access. You just need to create a personal username
and password.
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Menopause Management
Benefits of low-fat dairy products on weight loss
Obesity is increasing in the United States in epidemic proportions. Epidemiologic
data suggest that people with high calcium intake have a lower prevalence of
overweight, obesity, and insulin resistance syndrome. Studies in transgenic mice
have demonstrated that calcium influences adipocyte metabolism. High calcium
intake depresses levels of parathyroid hormone and 1,25-hydroxy vitamin D. These
decreased hormone levels cause decreases in intracellular calcium, thereby inhibiting
lipogenesis and stimulating lipolysis. High dietary calcium intakes also increases
excretion of fecal fat and may increase core body temperature. Calcium from dairy
products seems to have more of an impact than calcium from dietary supplements.
Primary care providers should include recommendations about adequate calcium
intake in standard dietary counseling about weight management.
Schrager
S . Dietary calcium intake and obesity. J Am Board Fam Pract. 2005 May-Jun;18(3):205-10. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15879568&query_hl=4
OB/GYN CCC Editorial comment:
If the above recommendation work well for your patient’s individually,
that is great, otherwise please note that on the order 50 million people in the
US are lactose intolerant as is the majority of our patients and those worldwide.
Beware the recommendation made by the authors "All patients should be encouraged
to consume 3 to 4 servings of low-fat dairy”.
Testosterone Patch Helps Surgically
Menopausal With Hypoactive Sexual Desire: RCT
CONCLUSION: In surgically menopausal women with hypoactive sexual desire
disorder, a 300 mug/d testosterone patch significantly increased satisfying sexual
activity and sexual desire, while decreasing personal distress, and was well
tolerated through up to 24 weeks of use.
Buster
JE Testosterone patch for low sexual desire in surgically menopausal women:
a randomized trial. Obstet Gynecol. 2005 May;105(5 Pt 1):944-52.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15863529&query_hl=4
SSRIs Ineffective for the Management of Hot Flashes
Clinical Question: Are citalopram and fluoxetine effective therapies for
vasomotor symptoms in menopausal women?
Bottom Line: Neither citalopram nor fluoxetine improved the vasomotor symptoms
(i.e., hot flashes) of menopausal women more than placebo. As in other well-designed
clinical trials of treatments for hot flashes, there was a marked placebo effect
and improvement in all groups over time. (Level of Evidence: 1b) http://www.aafp.org/afp/20050615/tips/8.html
Hormone replacement therapy plummeted after findings from the WHI trial (AHRQ)
In the mid-1990s, an estimated 38 percent of postmenopausal women in the United
States used estrogen plus progestin hormone therapy (EPT) or estrogen therapy
alone (ET). On May 31, 2002, the Women's Health Initiative (WHI) study of hormone
therapy (HT) in women with an intact uterus was stopped after an average of 5
years because the risks associated with the use of HT (breast cancer, coronary
heart disease, and stroke) were found to outweigh the benefits.
By December 31, 2002, 5 months after the trial results were published (July
9, 2002), 46 percent fewer women were taking EPT compared with the average proportion
of women using EPT 2 years before the results were published (a decline from
14.6 percent to 7.9 percent). ET use declined by 28 percent during the same period
(from 12.6 percent to 9.1 percent).
These findings are from a study by the HMO Research Network Center for Education
and Research on Therapeutics (CERT) and the HMO Cancer Research Network. The
study was supported in part by the Agency for Healthcare Research and Quality
through funding from its patient safety program to the CERTs initiative (HS11843).
A multicenter research team used automated pharmacy data to identify all oral
and transdermal estrogen and progestin dispensed to 169,586 women aged 40 to
80 years who were enrolled in five U.S. health maintenance organizations. The
researchers examined EPT and ET use between September 1, 1999 and June 31, 2002
(baseline) and December 31, 2002 (followup).
Along with the decline in EPT use following published trial results, there
was an immediate decrease in the proportion of women beginning EPT and ET, from
0.4 percent and 0.3 percent at baseline, respectively, to 0.2 percent for both
groups at followup. A striking finding was the high discontinuation rates among
ET users despite the fact that the ET portion of the WHI trial (for women who
had undergone hysterectomies) was ongoing during the study period. The ET portion
of the trial was stopped on March 4, 2004, due to increased stroke risk. It is
unclear whether the discontinuation of ET reflected women's and providers' misunderstanding
of the HT trial results or a generalization of the HT findings to ET, note the
researchers.
http://www.ahrq.gov/research/may05/0505RA15.htm#head15
Buist DS, et al Hormone therapy prescribing patterns in the United States.
Obstet Gynecol. 2004 Nov;104(5 Pt 1):1042-50.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15516400&query_hl=4
Another AHRQ-supported study on a related topic found that the prevalence
of hormone replacement therapy among Medicaid-insured women aged 50 and older
in all racial groups also decreased significantly following release of the WHI
study findings.
Hillman JJ, Zuckerman IH, Lee E.. The impact of the Women's Health Initiative
on hormone replacement therapy in a Medicaid program J Womens Health (Larchmt).
2004 Nov;13(9):986-92. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15665655&query_hl=6
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Midwives Corner: Marsha Tahquechi, CNM,
GIMC
USPSTF Issues Revised Guidelines for Routing Gonorrhea Screening
The U.S. Preventative Services Task Force (USPSTF) has issued revised guidelines
for routine gonorrhea screening. The new recommendation is in favor of screening
high risk women and against the screening of low risk women and men. Risk/benefit
analysis supports the use of risk assessment screening rather than routine screening
as a cost effective method for targeting those most likely to have disease. http://www.annfammed.org/cgi/content/full/3/3/263
This publication is available for CME* http://www.medscape.com/viewarticle/505770?src=hp16.cmecallout
(See Medscape above for free access)
What Makes a Drug Over the Counter (OTC)? The case of Plan B
This is an interesting review article on the criteria utilized in determining
a medication’s eligibility for over the counter status. It also provides
an historical account of the emergency contraceptive Plan B. http://www.medscape.com/viewarticle/505440?src=hp16.lead *
(see Medscape section above for tips on how to obtain free access)
From Jenny Glifort, CNM, ANMC - More CNM News
BOOKS: The Nursing Mothers Herbal
By Jan Weingrad Smith
http://www.mosby.com/scripts/om.dll/serve?article=as1526952305001339
Resources: Evidence-based Practice
Current Resources for Evidence-Based Practice, July/August 2005
By Carol Sakala
http://www.mosby.com/scripts/om.dll/serve?article=as1526952305001789
National Indian Health Board Conference - Oct. 16-19, 2005 in Phoenix
The NIHB Conference info is up on their web site: it's Oct. 16-19, 2005 in
Phoenix you plan to attend. It's not too late to submit an application to present
a workshop. The topic is "Youth and Tradition - Our Greatest Resources," …so
presentations about birth and breastfeeding seem particularly appropriate. http://www.nihb.org/staticpages/index.php?page=200403301344379533
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Navajo News, Jean Howe,
Chinle
Active management of the third stage of labor among American Indian women
OBJECTIVE: This study's objective was to judge whether active management of
the third stage of labor is as effective in reducing maternal blood loss among
rural American Indian women as in randomized trials.
METHODS: We collected retrospective data on a cohort of largely multiparous
American Indian women having singleton vaginal births at a rural hospital in
2000-2001, comparing measures of blood loss among women receiving active (n=62)
versus routine (n=113) management of the third stage of labor. Outcomes included
both objective (postpartum hemoglobin decline) and subjective (estimated blood
loss) measures of maternal blood loss.
RESULTS: Active management was associated with reduced maternal blood loss
on several measures when compared to routine management, including incidence
of a 3 g/dl or greater postpartum hemoglobin decline (5% versus 27%), mean postpartum
hemoglobin decline (1.7 versus 2.2 g/dl), and mean estimated blood loss (355
versus 430 ml). Compared to women who received routine management, women who
received active management had 87% reduced odds of a 3 g/dl or greater postpartum
hemoglobin decline after adjusting for preeclampsia, manual placental extraction,
laceration repair, and maternal age.
CONCLUSIONS: Our findings suggest that active management of the third stage
is as effective in reducing maternal blood loss among rural American Indian women
as in randomized trials in maternity hospitals.
Fenton JJ, Baumeister LM, Fogarty J Active management of the third stage of
labor among american Indian women. Fam Med. 2005 Jun;37(6):410-4.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15933913&query_hl=1
Comment from George Gilson, MFM, Anchorage
“Get Active”
World-wide, postpartum hemorrhage, a readily preventable event, is the leading
cause of maternal death. In the U.S., PPH is likewise an important cause of maternal
morbidity and mortality. There is a significant body of evidence, now added to
by an investigation in an Indian Health setting, which should urge all of us
to implement some form of "active management of the third stage of labor" into
our own practices. It is simple, cost-effective, and can be life-saving.
Active management of the 3rd stage of labor consists of:
-administration of a uterotonic medication after delivery of the infant's
shoulders
-early clamping and cutting of the umbilical cord
-application of controlled traction to the cord (Brandt-Anders maneuver)
Active management of the 3rd stage of labor is used to hasten placental expulsion.
It's simple, evidence-based, and non-intrusive. It's particularly appropriate
in all Indian Health practice settings that attend births, but do not have access
to a large blood bank or readily available surgical facilities. Hope you will
follow the links above to review the evidence and then "get active"!
OB/GYN CCC Editorial comment:
All Indian Health facilities which provide maternity care / labor and delivery
should incorporate the active management of the 3rd stage of labor into their
routine practice guidelines.
The studies reviewed used oxytocin, ergometrine, or a mixture of those drugs
administered intravenously or intramuscularly immediately after delivery of the
infant. A subsequent review found that the combination of oxytocin and ergometrine
resulted in greater reductions in postpartum blood loss (but not in need for
transfusion) compared with oxytocin alone. However, more adverse effects (e.g.,
nausea, vomiting, hypertension) were observed with use of the combined medications.
Based on these reviews, oxytocin appears to be the agent of choice for third-stage
management in low-risk women, because of the incidence of side effects associated
with ergometrine. Hence, one common method is to administer Oxytocin 10 units
intramuscularly.
Trial findings did not substantiate the concerns regarding retained placenta.
Trials using oxytocin alone showed reduced rates of manual removal of the placenta,
whereas those using ergot preparations demonstrated increased rates. The slight
trend of increased manual removal mentioned in the Cochrane meta-analysis above
was entirely due to the results of the single trial that used intravenous ergot.
Educating obstetric providers about early cord clamping and controlled cord
traction will be necessary in maternity units where active management is not
standard. Other agents, including prostaglandins such as misoprostol, are currently
under investigation for use in the management of the third stage of labor.
This abstract was forwarded to the CCCC by Larry Leeman, formerly at Zuni,
now at the University of New Mexico. This article was coauthored by John Fogarty,
one of the affiliated FP faculty at Crownpoint IHS.
Other links of Interest
Cochrane for Clinicians: Putting Evidence into Practice
http://www.aafp.org/afp/20030515/cochrane.html
eMedicine
http://www.emedicine.com/med/topic3569.htm
The Cochrane Library
http://www.update-software.com/cochrane/abstract.htm
Annual Navajo Area Women’s Health Provider Meeting
and
Upcoming ALSO Course in Shiprock
The Navajo Area Annual Meeting will be held Friday, September 23rd, from 11am
to 3pm in Chinle. It will be preceded by a 9am meeting of the Four Corners Midwifery
Chapter.
Please let me know of any topics that you would like to discuss.
The ALSO course will be held September 24th and 25th in Shiprock. Registration
forms will be available soon from Mary Porvaznik at Shiprock. mary.porvaznik@ihs.gov
For those of you working at federal facilities, please don’t forget
to file those travel orders soon, before the fiscal year close out… Please
share this information with any new Women’s Health providers that have
joined your teams. Hope to see you there!!
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Office
of Women's Health, CDC
Racial / Ethnic Disparities in Infant Mortality: No significant improvement
in AI / AN
On the basis of data for 1995-2002 combined, the target of 4.5 infant deaths
per 1,000 live births had been achieved by few racial/ethnic populations. During
1995-2002, IMRs declined for all racial/ethnic populations; however, the decrease
for infants of American Indian/Alaska Native mothers was not statistically significant.
Mathews TJ, Keppel KG. 2005. Racial/ethnic disparities in infant mortality
United States, 1995-2002. Morbidity and Mortality Weekly Report 54(22):553-556. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5422a1.htm
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Oklahoma
Perspective Greggory Woitte – Hastings Indian Medical Center
Patient should be capable of talking or singing during exercise during pregnancy
Exercise has been recommended as adjunct for diabetic management as well as
weight loss. The current guidelines for exercise, according to the American College
of Sports Medicine, is at least 30 minutes of physical exertion over the course
of a day on most days of the week. As we are a country that is growing larger
and larger (around the waistline), we as providers are seeing the need for exercise
in our patients. If your patient population is similar to mine, there is a large
number of patients with diabetes and are obese.
But what about our pregnant patients?
It is widely accepted that exercise during pregnancy is safe, however; there
are a few guidelines that should be observed. Activities that increase the risk
of falling should prompt counseling the patient about the risk of abdominal trauma
with a fall. Scuba diving is an absolute contraindication due to the possibility
of decompression sickness in the fetus.
Patients should be evaluated prior to starting an exercise program to ensure
that no preexisting condition exists. ACOG has put out a Committee opinion that
lists absolute and relative contraindications to aerobic exercise during pregnancy
as well as warning signs to terminate exercising. Patients who are healthy and
pregnant should be encouraged to engage in regular exercise before, during and
after a pregnancy.
Exercise during pregnancy and the postpartum period. ACOG Committee Opinion
No. 267. American College of Obstetricians and Gynecologists. Obstet Gynecol
2002;99:171–173
Non-ACOG Members
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11777528&query_hl=1
ACOG members:
http://www.acog.org/publications/committee_opinions/co267.cfm
OB/GYN CCC Editorial comment:
I welcome Dr. Woitte’s comments as they echo those of ACOG and emphasize
those of the Indian Health system. Moderate exercise in pregnancy is recommended
in general, and highly recommended in diabetes in pregnancy. The latter recommendation
includes both new onset gestational diabetes and pre-existing diabetes.
Here is Appendix F from the Diabetes in Pregnancy Guidelines posted on the
Indian Health Clinical Guidelines web site, page 18, for more details
Exercise guidelines to improve glucose control
Type of activities:
Aerobic activities such as walking, stationary cycling, or swimming
Frequency:
At least 3 days per week
Duration:
20-45 minutes per session
Intensity:
Moderate. The “talk-sing test” may be used – the patient
should be able to talk while
exercising; if she can sing, the pace can be increased. If using rating of
perceived
exertion (RPE) exertion level should feel “fairly light” to “somewhat
hard”.
Patient should warm-up before and cool down after exercise, drink plenty of
water, and
have snacks nearby if needed.
Initial exercise consult:
Assessment of current physical activities and level of readiness for exercise
Education/Information on exercise and GDM
Individualized exercise plan
Supervised exercise:
Measure blood glucose pre and post exercise
Exercise on treadmill and/or recumbent cycle
Monitor perceived exertion
Monitor blood pressure and/or heart rate as needed
../W/Documents/DMPreg102504_000.doc
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Osteoporosis
Here is a good web based calcium screening tool
From Stephen Rudd, Warm Springs, OR
http://www.eatsmart.org/external/default.asp?URL=/games/c_calculator/
Benefits and limitations of quantitative heel ultrasound in screening for
osteoporosis
The National Osteoporosis Foundation has an excellent, brief review of the
benefits and limitations of quantitative heel ultrasound in screening for osteoporosis
at http://www.nof.org/cmeexam/Issue1QUS/QUSOnlineCME.pdf
The review complements and supports the approach suggested by Brown and Finke
in the October
2004 issue of the IHS Primary Care Provider that heel ultrasound can be used
to increase access to osteoporosis screening and treatment where central DEXA
is not available. However the NOF article suggests a lower threshold for
DEXA following heel ultrasound (DEXA if less than -1 or between 1 and -1 if there
are risk factors) than is suggested in the algorithm accompanying the article
by Brown and Finke.
Osteoporosis screening and management is a rapidly evolving area and one in
which evidence-based strategies must be reviewed frequently and adjusted to reflect
new information.
Brown SR and Finke B. Osteoporosis and Fracture Prevention in the Indian Health
System: Toward a Public Health Approach. The IHS Primary Care Provider,
October 2004;29(10):229-234 http://www.ihs.gov/PublicInfo/Publications/HealthProvider/issues/PROV1004.pdf
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Patient
Information
Simple Patient Education Handouts
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/PtEDHANDOUTS.doc
Endometriosis, from WebMD Health (*See Medscape above for free access)
http://www.medscape.com/viewarticle/504171?src=sr
http://www.medscape.com/viewarticle/504157?src=sr
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Primary
Care Discussion Forum
August 1, 2005 Appropriate use of narcotics for chronic non-malignant (non-cancer)
pain
Moderator: Chuck North
-Are you comfortable using narcotics to treat chronic pain?
-Is there abuse of prescription controlled medications in your community?
-What controls should health professionals have in place to regulate the use
of controlled substances?
-Do you use pain contracts? Are they useful?
-What services are available to serve your chronic pain patients in addition
to primary care?
-Are you successful in obtaining mental health services for your patients?
How to subscribe / unsubscribe to the Primary Care Discussion Forum?
Subscribe to the Primary Care listserv
http://www.ihs.gov/generalweb/helpcenter/helpdesk/index.cfm?module=listserv&option=subscribe&newquery=1
Unsubscribe from the Primary Care listserv
http://www.ihs.gov/generalweb/helpcenter/helpdesk/index.cfm?module=listserv&option=unsubscribe&newquery=1
Questions on how to subscribe, contact nmurphy@scf.cc directly
Top of Page
STD
Corner - Laura Shelby, STD
Director, IHS
Can chlamydia be stopped?
Chlamydia is a rampant sexually transmitted disease, the world's leading cause
of preventable blindness and a possible contributor to heart disease. Recent
discoveries are suggesting new ways to curtail its spread.
David M. Ojcius, Toni Darville and Patrik M. Bavoil Can chlamydia be stopped?
Sci Am. 2005 May;292(5):72-9.
http://www.sciam.com/article.cfm?articleID=000C5367-144D-1264-944D83414B7F0000
Chlamydia trachomatis infection in a colposcopy unit
An audit of a fast track referral system for infected patients to a genitourinary
medicine department and a survey of patients' demography, clinical findings and
partner details.
We had previously shown that screening and treating patients for Chlamydia
trachomatis prior to termination of pregnancy significantly reduces postoperative
morbidity. Our success led us to consider screening women attending our colposcopy
unit and this was introduced in 1998. However, it became apparent that a formal
protocol was needed for managing women who had positive results to ensure that
all patients and their partners were adequately treated. An interdepartmental
protocol was devised for fast track referral of infected patients to the Genitourinary
Medicine (GUM) clinic Health Advisor who arranged immediate treatment and partner
notification. A re-audit, presented here, has shown that the introduction of
the protocol has resulted in all infected patients receiving adequate treatment
and partner notification with minimal use of doctor time or disruption of routine
GUM services. We suggest that our system is effective and could be extended to
other clinics where chlamydia screening is carried out
Blackwell A.1; Linton D.2; Emery S.3; Calvert J.3 International
Journal of STD & AIDS, 1 October 2003, vol. 14, no. 10, pp. 661-664(4)
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14596768&query_hl=7
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Barbara
Stillwater, Alaska State Diabetes Program
Waist Circumference Can Exclude Insulin Resistance and Identify Those
At Greatest Risk
A waist circumference of less than 39.4in. (100 cm)
excludes individuals of both sexes from being at risk of being insulin resistant.
Although insulin resistance is an important pathogenic factor in common metabolic
disorders, no easy clinical test exists for predicting the insulin resistance
of an individual. Waist circumference is a simple tool to exclude insulin resistance
and to identify those at greatest risk, therefore those who would benefit most
from lifestyle adjustments.
Hans Wahrenberg et al Use of waist circumference to predict insulin resistance:
retrospective study. BMJ 2005;330:1363-1364. 11 June 2005
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15833749&query_hl=1
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What's
new on the ITU MCH web pages?
Simple Patient Education Handouts
Active management of the third stage of labor among American Indian women
Atlas of Heart Disease and Stroke in AI/AN
There are several upcoming Conferences
and Online
CME/CEU resources, etc….
and the
latest Perinatology Corners (free online CME from IHS)
…or just take a look at the What’s
New page
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Save
the dates
Comprehensive Colposcopy course, ASCCP
Primary Care Provider Training in Addictions
- August 8 - 12, 2005
- Tacoma, WA
- Alcoholism and Substance Abuse Program Branch (ASAPB), IHS
Clinical Training in American Indian/Alaska Native Alcohol and Other Drug Abuse
Contact Teresa Sappier, Behavioral Health HQE Teresa.Sappier@ihs.gov
Treatment and Management of HIV Infection in the United States
- September 15-18, 2005
- Atlanta, Georgia
- 16.5 Credits, Univ. of California @ San Francisco / VA Administration
- First
domestic conference of its kind. Mark your calendar
- http://www.USHIVconference.org/
National Indian Health Board: Youth and Tradition - Our Greatest Resources
Native Peoples of North America HIV/AIDS Conference
Back to top
Did you miss something in the last OB/GYN Chief Clinical Consultant Corner?
The June 2005 OB/GYN CCC Corner is available at:
http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0605.cfm |
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