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Volume 6, No. 2, February 2008
Features
American College of Obstetricians and Gynecologists
Elective and risk–reducing salpingo-oophorectomy
ACOG Practice Bulletin No. 89
Summary of Recommendations and Conclusions
The following conclusion is based on good and consistent scientific evidence (Level A):
- In women ages 50–79 years who have had a hysterectomy, use of estrogen therapy has shown no increased risk of breast cancer or heart disease with up to 7.2 years of use.
The following recommendation is based on limited or inconsistent scientific evidence (Level B):
- Bilateral salpingo–oophorectomy should be offered to women with BRCA1 and BRCA2 mutations after completion of childbearing.
The following recommendations are based primarily on consensus and expert opinion (Level C):
- Women with family histories suggestive of BRCA1 and BRCA2 mutations should be referred for genetic counseling and evaluation for BRCA testing.
- For women with an increased risk of ovarian cancer, risk–reducing salpingo–oophorectomy should include careful inspection of the peritoneal cavity, pelvic washings, removal of the fallopian tubes, and ligation of the ovarian vessels at the pelvic brim.
- Strong consideration should be made for retaining normal ovaries in premenopausal women who are not at increased genetic risk of ovarian cancer.
- Given the risk of ovarian cancer in postmenopausal women, ovarian removal at the time of hysterectomy should be considered for these women.
- Women with endometriosis, pelvic inflammatory disease, and chronic pelvic pain are at higher risk of reoperation; consequently, the risk of subsequent ovarian surgery if the ovaries are retained should be weighed against the benefit of ovarian retention in these patients.
Elective and risk–reducing salpingo-oophorectomy. ACOG Practice Bulletin No. 89. American College of Obstetricians and Gynecologists. Obstet Gynecol 2008;111:231–41.
Surgery and Patient Choice
ABSTRACT: Acknowledgment of the importance of patient autonomy and increased patient access to information has prompted more patient–generated requests for surgical interventions not necessarily recommended by their physicians. Decision making in obstetrics and gynecology should be guided by the ethical principles of respect for patient autonomy, beneficence, nonmaleficence, justice, and veracity. Each physician should exercise judgment when determining whether information presented to the patient is adequate. When working with a patient to make decisions about surgery, it is important for obstetricians and gynecologists to take a broad view of the consequences of surgical treatment and to acknowledge the lack of firm evidence for the benefit of one approach over another when evidence is limited.
Surgery and patient choice. ACOG Committee Opinion No. 395. American College of Obstetricians and Gynecologists. Obstet Gynecol 2008;111:243–7.
http://www.ncbi.nlm.nih.gov/pubmed/18165420
Intraperitoneal Chemotherapy for Ovarian Cancer
ABSTRACT: Postoperative intravenous (IV) chemotherapy for advanced stage ovarian cancer has been the standard treatment. Recent studies have found significant survival advantages with the use of adjuvant intraperitoneal (IP) chemotherapy. Combination IV/IP chemotherapy may be an option for well counseled, carefully selected patients with optimally debulked stage III ovarian cancer. However, IV/IP treatment also has increased rates of pain, fatigue, and hematologic, gastrointestinal, metabolic, and neurologic toxicities. Given the balance of efficacy, quality of life, and toxicity, the decision to use IP chemotherapy must be individualized
Intraperitoneal chemotherapy for ovarian cancer. ACOG Committee Opinion No. 396. American College of Obstetricians and Gynecologists. Obstet Gynecol 2008;111:249–51.
http://www.ncbi.nlm.nih.gov/pubmed/18165421
American Family Physician**
Prevention and Treatment of Sexually Transmitted Diseases: An Update
The Centers for Disease Control and Prevention recently published revised guidelines for the prevention and treatment of sexually transmitted diseases. One new treatment strategy is the use of azithromycin as a primary, rather than alternative, medication for pregnant women with Chlamydia trachomatis infection. Quinolone-resistant Neisseria gonorrhoeae infection continues to increase in the United States; therefore, quinolones are no longer recommended for treatment of this infection. Expedited partner therapy gives physicians another option when addressing the need to treat partners of persons diagnosed with N. gonorrhoeae or C. trachomatis infection. Tinidazole is now available in the United States and can be used to manage trichomoniasis, including trichomoniasis resistant to metronidazole. Shorter courses of antiviral medication can be used for episodic therapy of recurrent genital herpes. Because of increasing resistance, close follow-up is required if azithromycin is used as an alternative treatment in the management of primary or secondary syphilis. Unexpected increases in the rates of lymphogranuloma venereum have occurred in the Netherlands, and physicians should remain vigilant for symptoms of this disease in the United States. Am Fam Physician 2007;76:1827-32, 1833-34
http://www.aafp.org/afp/20071215/1827.html
CDC Reports a Decrease in the Incidence of Breast Cancer
Although breast cancer is the most commonly diagnosed cancer in U.S. women, the Centers for Disease Control and Prevention (CDC) reports that the incidence of breast cancer has decreased since 1999. Data from population-based cancer registries show that invasive breast cancer decreased annually between 1999 and 2003; and, after increasing between 1999 and 2002, noninvasive breast cancer decreased between 2002 and 2003.
Data were collected from the CDC's National Program of Cancer Registries and the National Cancer Institute's Surveillance, Epidemiology, and End Results program. The largest decline occurred between 2002 and 2003 (6.1 percent for invasive disease and 2.7 percent for noninvasive disease). The decrease in breast cancer occurred across several age, cancer stage, and racial groups, with the most significant decrease occurring in women 50 years and older. Factors that may have contributed to the decrease in breast cancer include mammography screening, a decrease in the use of hormone therapy, and differences in risk-factor prevalence, diet, and lifestyle
Centers for Disease Control and Prevention
Morbidity and Mortality Weekly Report, June 8, 2007
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5622a1.htm
Recommendations for Follow-up after Early Breast Cancer Diagnoses
Background: More than 200,000 invasive breast cancer diagnoses are expected in 2007, and primary care physicians often encounter issues with screening for recurrence, familial risk, and complications of breast cancer or treatment. Hayes reviewed evidence-based guidelines from various organizations on the specific health needs in patients with early breast cancer and summarized major recommendations for follow-up in these patients.
Recommendations: In general, patients with breast cancer should be evaluated every four to six months during the year after diagnosis. After the first year, patients should receive annual evaluations if they are no longer receiving therapy, mammograms, and assessments for symptoms of recurrence.
In patients with a history of breast cancer, annual screening with mammography is the standard of care for detecting new primary breast cancer. Magnetic resonance imaging or high-resolution ultrasonography may be useful in high-risk patients, although the role of these tests in other patients has not been determined. Screening for local recurrence in patients who had breast-conserving therapy (e.g., lumpectomy) is identical to screening for new primary cancer in the contralateral breast. However, the reviewing radiologist should be notified of the patient's history because surgery or irradiation may leave residual findings on the mammogram. Patients with a history of breast cancer should receive routine age-specific screening for colon and cervical cancers.
More than 25 percent of all metastases occur five years or more after the initial diagnosis of breast cancer; therefore, patients should be routinely assessed for symptoms of metastatic disease (e.g., neurologic symptoms, bone pain, dyspnea, jaundice). Because specialized testing for metastasis (e.g., blood testing, tumor marker screening, radiographic imaging) may have false-positive rates of up to 50 percent, they should be reserved for patients with symptoms or signs that are associated with recurrence.
Breast cancer treatments may increase the risk of other cancers (e.g., endometrial carcinoma from tamoxifen [Nolvadex, brand no longer available] use; leukemia from chemotherapy; angiosarcoma from irradiation). Routine screening for treatment-related cancers is not recommended because the incidence of these cancers is less than 1 percent five years after treatment; however, patients should be educated about relevant signs and symptoms, and physicians should ask about these signs and symptoms at follow-up visits.
Although genetic testing is not recommended for all women with breast cancer, it may be useful in high-risk patients (see accompanying table). In patients without risk factors for familial cancer syndromes, the risk of carrying a mutation in a tumor suppressor gene such as BRCA1 or BRCA2 is less than 1 percent.
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Table. Indications for Genetic Counseling in Patients with a History of Breast Cancer |
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Age younger than 40 years at diagnosis |
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Ashkenazi Jewish heritage |
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Personal history of ovarian cancer or first- or second-degree relative with a history of ovarian cancer |
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Personal history of bilateral breast cancer or a first- or second-degree relative with a history of bilateral breast cancer |
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First-degree relative who was younger than 50 years when diagnosed with breast cancer |
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Two or more first- or second-degree relatives who were diagnosed with breast cancer at any age |
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Any male relative with a history of breast cancer |
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Adapted with permission from Hayes DF. Follow-up of patients with early breast cancer. N Engl J Med 2007;356:2506. |
Patients have a greater risk of osteoporosis if they are treated with aromatase inhibitors (e.g., anastrozole [Arimidex], letrozole [Femara], exemestane [Aromasin]) because these drugs have antiestrogenic effects. Bone mineral density testing should be performed before initiation of aromatase inhibitor therapy, and testing should be performed every one to two years in other patients with a history of breast cancer. Bisphosphonate therapy is preferred in these patients because raloxifene (Evista) may limit the effectiveness of aromatase inhibitors. Similarly, raloxifene should be avoided if a patient has received five years of tamoxifen therapy, because these drugs have similar mechanisms and because of the risk of breast cancer recurrence with prolonged tamoxifen use.
Cardiovascular screening and prevention measures, including regular exercise and monitoring of blood pressure and lipid levels, are important. No special testing is recommended; however, physicians should be aware of therapies that may increase the risk of cardiovascular disease. Chemotherapy with anthracyclines or trastuzumab (Herceptin) may reduce cardiac function in up to 5 percent of patients, and radiation therapy to the left chest wall may increase long-term cardiovascular risk by up to 30 percent. Tamoxifen therapy has also been associated with a threefold increase in the risk of thromboembolic and cerebrovascular diseases and should be avoided in patients with a history of these conditions.
Hayes DF. Follow-up of patients with early breast cancer. N Engl J Med June 14, 2007;356:2505-13. http://www.aafp.org/afp/20071215/tips/4.html
CDC Evaluates the Effect of Revised Guidelines on Group B Streptococci Disease
In 2002, the Centers for Disease Control and Prevention (CDC), the American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics revised guidelines for the prevention of perinatal group B streptococci (GBS) disease, which included recommending that health care professionals screen patients to identify candidates for prophylaxis. The CDC has reviewed surveillance data to compare the rates of neonatal and pregnancy-related GBS disease before and after the new guideline was released. Data were reviewed from the two years before (2000 to 2001) and after (2003 to 2005) the publication of the guideline revisions.
From 2003 to 2005, the average incidence of early-onset neonatal GBS disease was 33 percent less than in the pre-guideline revision period; however, although the incidence decreased steadily among white infants between 2003 and 2005, it increased by 70 percent during the same period in black infants. In the years after the guideline revisions, rates of pregnancy-related and late-onset neonatal GBS disease remained stable compared with baseline rates.
Although further research is needed, the authors conclude that these data highlight the need for strategies to reduce the rate of neonatal GBS disease among black infants, evaluation of missed opportunities for prevention, and continued monitoring of disease trends.
Centers for Disease Control and Prevention
Morbidity and Mortality Weekly Report, July 20, 2007
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5628a1.htm
Premenstrual Syndrome (Clinical Evidence Concise)
What are the effects of drug treatments in women with premenstrual syndrome (PMS)?
beneficial
Spironolactone. Randomized controlled trials (RCTs) found that luteal-phase spironolactone improved psychological and physical symptoms of PMS over two to six months compared with placebo.
likely to be beneficial
Alprazolam. RCTs found that luteal-phase alprazolam improved most physical and psychological symptoms of PMS after three to six months' treatment compared with placebo, including severe symptoms in women with premenstrual dysphoric disorder. Mild adverse effects were common. Benzodiazepines are associated with dependence.
Buspirone. One RCT found that buspirone (luteal or continuous) was more effective than placebo in improving self-rated global improvement at four months in women with premenstrual dysphoric disorder. Results for individual psychological and physical symptoms were inconclusive. Mild adverse effects were common.
Gonadorelin Analogues for Less Than Six Months. One systematic review found that gonadorelin analogues reduced overall symptoms of PMS over three to six months compared with placebo. Women taking gonadorelin analogues were three times more likely to have adverse effects, including hot flashes, aches, night sweats, nausea, and headaches, than women taking placebo. The addition of hormonal add-back therapy to reduce long-term adverse effects did not reduce effectiveness. However, treatment with gonadorelin analogues without hormonal add-back for longer than six months carries a serious risk of osteoporosis, limiting their usefulness for long-term treatment.
Metolazone. One RCT found that luteal-phase metolazone reduced premenstrual swelling and weight gain, and improved mood symptoms compared with placebo.
Nonsteroidal Anti-inflammatory Drugs. RCTs found that luteal-phase mefenamic acid or naproxen sodium improved physical and psychological premenstrual symptoms over three to six months compared with placebo. The RCTs provided little information on adverse effects.
trade-off between benefits and harms
Clomipramine. RCTs found that clomipramine (luteal or continuous) improved psychological symptoms of PMS over three treatment cycles, but not physical symptoms. A proportion of women stopped treatment because of adverse effects, such as drowsiness, nausea, vertigo, and headache.
Danazol. RCTs found that danazol reduced overall premenstrual symptoms after three months' treatment compared with placebo, but had important adverse effects associated with masculinization when used continuously in the long term.
Selective Serotonin Reuptake Inhibitors (SSRIs). One systematic review and subsequent RCTs found that SSRIs improved premenstrual symptoms over two to six cycles compared with placebo, but caused frequent adverse effects. Current evidence indicates no clear relationship between SSRIs and increased risk of suicide, but there is concern that SSRIs may increase the risks of self-harm and suicidal ideation. Regulatory authorities in Europe, including the United Kingdom, and in the United States have issued warnings about the use of SSRIs in children and adolescents.
What are the effects of hormonal treatments in women with PMS?
likely to be beneficial
Contraceptives (Oral). One RCT found that oral contraceptives improved certain premenstrual symptoms (i.e., appetite, acne, and food cravings) compared with placebo, but did not improve mood-related symptoms on a 21/7 day schedule. Another RCT found that oral contraceptives improved mood-related symptoms (e.g., depression, anxiety, mood swings, irritability) and physical symptoms of premenstrual dysphoric disorder (e.g., increased appetite, breast tenderness, bloated sensation, headaches, muscle pain) compared with placebo on a 24/4 day schedule.
trade-off between benefits and harms
Progesterone. One systematic review found an improvement in overall premenstrual symptoms in women taking luteal-phase progesterone for two to six months compared with placebo. A second systematic review (of two RCTs also included in the first review) found no overall improvement in premenstrual symptoms in women taking luteal-phase progesterone for two to four months compared with placebo.
Although the first review found a wide range of adverse effects associated with progesterone (including excessive bleeding, dysmenorrhea, abdominal pain, nausea, and headache), it found no significant difference in the frequency of withdrawals caused by adverse effects.
Progestogens. One systematic review found that progestogens reduced premenstrual symptoms over three or four cycles compared with placebo. It found no significant difference between progestogens and placebo in the proportion of women who withdrew because of adverse effects. The most common adverse effects associated with progestogens are nausea, breast discomfort, headache, and menstrual irregularity. Progestogen may induce PMS symptoms in some women.
unknown effectiveness
Estrogens. Limited evidence from one RCT suggested that continuous estradiol might improve symptoms of PMS after three months' treatment compared with placebo. However, the magnitude of any effect is unclear. Important adverse effects of estrogen include increased risk of breast cancer, endometrial cancer, stroke, and venous thromboembolic disease.
Tibolone. One small RCT found limited evidence that continuous tibolone improved premenstrual symptom score over six months compared with placebo (multivitamins).
What are the effects of psychological interventions in women with PMS?
unknown effectiveness
Cognitive Behavior Therapy. Weak RCTs provided insufficient evidence to assess cognitive behavior therapy in women with PMS.
What are the effects of physical therapy in women with PMS?
unknown effectiveness
Acupuncture. One small RCT found that acupuncture was effective in reducing premenstrual symptoms from baseline scores; however, sham acupuncture also reduced symptoms.
Bright Light Therapy. One systematic review of small RCTs found no significant difference between bright light therapy and placebo in reducing depressive symptoms related to premenstrual dysphoric disorder.
Chiropractic Manipulation. One weak crossover trial provided insufficient evidence to assess chiropractic manipulation in women with PMS.
Exercise. We found no systematic review or RCT of exercise in women with PMS.
Reflexology. One RCT found limited evidence that reflexology was better than sham reflexology in reducing premenstrual symptoms at eight weeks.
Relaxation. One RCT found limited evidence that relaxation treatment was better than reading leisure material or charting symptoms in reducing premenstrual symptoms over five months. Two further weak RCTs provided insufficient evidence to assess relaxation.
What are the effects of dietary supplements in women with PMS?
beneficial
Pyridoxine. One systematic review found that luteal-phase or continuous pyridoxine (vitamin B6) was better than placebo in relieving overall symptoms of PMS over two to six months.
likely to be beneficial
Calcium Supplements. Two RCTs identified by a systematic review found that calcium supplements improved symptoms compared with placebo.
unknown effectiveness
Evening Primrose Oil. Weak RCTs provided insufficient evidence to assess the effects of evening primrose oil in women with premenstrual symptoms.
Magnesium Supplements. Weak RCTs provided insufficient evidence to assess the effects of magnesium supplements in women with PMS.
What are the effects of surgical treatments in women with PMS?
likely to be beneficial
Hysterectomy with Bilateral Oophorectomy. We found no systematic review or RCT of hysterectomy alone or hysterectomy with bilateral oophorectomy in women with PMS. Cohort studies have found almost complete eradication of the symptoms of PMS after hysterectomy plus bilateral oophorectomy and continuous estrogen placement, and there is consensus that it is effective. Surgery is rarely used, but may be indicated if there are coexisting gynecologic problems. (Based on consensus; RCTs unlikely to be conducted.)
Laparoscopic Bilateral Oophorectomy. We found no systematic review or RCT of laparoscopic bilateral oophorectomy in women with PMS. Cohort studies have found almost complete eradication of the symptoms of PMS after hysterectomy plus bilateral oophorectomy and continuous estrogen therapy, and there is consensus that it is effective. Surgery is rarely used, but may be indicated if there are coexisting gynecologic problems. (Based on consensus; RCTs unlikely to be conducted.)
unknown effectiveness
Endometrial Ablation. We found no systematic review or RCT of endometrial ablation in women with PMS.
Definition
A woman has PMS if she complains of recurrent psychological or physical symptoms occurring specifically during the luteal phase of the menstrual cycle, and often resolving by the end of menstruation.1 The symptoms can also persist during the bleeding phase.
The definition of severe PMS varies among RCTs, but in recent studies, standardized criteria have been used to diagnose one variant of severe PMS-premenstrual dysphoric disorder. These criteria are based on at least five symptoms, including one of four core psychological symptoms (from a list of 17 physical and psychological symptoms), being severe before menstruation starts and mild or absent after menstruation.2,3 The symptoms are: depression; feeling hopeless or guilty; anxiety or tension; mood swings; irritability or persistent anger; decreased interest; poor concentration; fatigue; food craving or increased appetite; sleep disturbance; feeling out of control or overwhelmed; poor coordination; headache; aches; swelling, bloating, and weight gain; cramps; and breast tenderness.
Incidence and Prevalence
Premenstrual symptoms occur in 95 percent of all women of reproductive age; severe, debilitating symptoms (PMS) occur in about 5 percent of those women.1
Etiology
The cause is unknown, but hormonal and other factors (possibly neuroendocrine) probably contribute.4,5
Prognosis
Except after oophorectomy, symptoms of PMS usually recur when treatment is stopped.
Editor's note: Tibolone is not available in the United States.
A Publication of BMJ Publishing Grouphttp://www.aafp.org/afp/20080101/bmj.htmlAHRQ
Intervention programs that focus on already violent youth are more effective than other programs for reducing violent behavior
http://www.ahrq.gov/research/jan08/0108RA6.htm
Some women with breast cancer do not receive adjuvant treatments recommended by guidelines
http://www.ahrq.gov/research/jan08/0108RA7.htm
Use of antidepressants by low-income pregnant women has jumped more than twofold, raising questions about fetal risks
http://www.ahrq.gov/research/jan08/0108RA9.htm
Regulatory warnings led to decreased use of antidepressants in children and adolescents in 2004 and 2005
http://www.ahrq.gov/research/jan08/0108RA5.htm
Ask A Librarian: Diane Cooper, M.S.L.S. / NIH
Cervical Cancer Community-Based Research Project in a Native American Community
The Messengers for Health on the Apsáalooke Reservation project uses a community-based participatory research (CBPR) approach and lay health advisors (LHAs) to generate knowledge and awareness about cervical cancer prevention among community members in a culturally competent manner. Northern Plains Native Americans, of whom Apsáalooke women are a part, continue to be disproportionately affected by cervical cancer. This article examines quantitative and qualitative changes that occurred in the community since the inception of the Messengers for Health program. Paired sample t tests are used to evaluate the one-group pretest and posttest interviews of 83 Apsáalooke women in knowledge, comfort, and cancer awareness levels. Results reveal cervical cancer knowledge gains, gains in participants' comfort discussing cancer issues, and gains in awareness of cervical cancer and the Messengers program. Field notes, meeting minutes, and community perceptions are used to qualitatively evaluate the effectiveness of the Messengers program. Practice implications are discussed.
Christopher S et al A Cervical Cancer Community-Based Participatory Research Project in a Native American Community. Health Educ Behav. 2007 Dec 12
http://www.ncbi.nlm.nih.gov/pubmed/18077653
Behavioral Health Insights, Peter Stuart, IHS Psychiatry Consultant
Autism Screening
Guest editor Joshua Cabrera, MD
Identifying children with autism early has several benefits; it allows family to adapt to unusual and challenging behaviors in their toddler, it leads to early interventions that may improve outcomes , and it opens the door for increased services at school. The American Academy of Pediatrics currently advocates screening for autism at the age of 18months.
General developmental screening tools may be abnormal when administered to autistic children, especially language screens. General screens do not distinguish children with developmental delays from autism, but can trigger further screening and evaluation. A specific screening tool for autism is the Checklist for Autism in Toddlers (CHAT). This screen consists of 9 questions asked of the parents and 5 simple in office tests, administered at the age of 18-24 months. The key elements of the CHAT assess the child’s capacity for shared attention and imaginative play, both per history and in the office.
A child demonstrates shared attention when pointing to an object of interest, for example, a stuffed giraffe, and then glancing at another person’s eyes or face to measure if they are also noticing the giraffe. The examiner also should initiate the test for shared attention by pointing to an object, demonstrating interest in it, and observing the child share the examiners attention in the object (usually through gaze). Autistic children may point as part of an imperative, but not as part of sharing attention. For example the autistic child may point at food, and may even lead you by the arm to the food, but will likely not look at your eyes or face to measure or implore your shared attention. The second key ability, imaginative play, is abundantly demonstrated in an office that has age appropriate toys. In the CHAT, developed in the UK, the examiner uses a cup to pretend to drink tea and asks the toddler to join in. Using a spoon and play bowl to pretend to scoop up stew or blue corn mush may be more appropriate for those in the Southwest. Autistic toddlers may play with toys, but do not play imaginatively with them at 18mo, focusing instead on sensory qualities such as its sound or feel. Often their play is repetitive and stereotyped as well. Toddlers who lack shared attention and imaginative play, by history and on exam, likely have an autism spectrum disorder. Children who have a mixed result, for example, whose parents report shared attention, but who can not do so for the examiner, have a moderate risk of autism.
So what role does autism screening have in day to day practice? Children who have family histories, who have language delays, or whose parents express concern for their development in language/social domains, warrant further screening and evaluation. General screening, advocated by the AAP, may be the first step to improving outcomes. Becoming familiar, or having easy access to some form of the CHAT, can improve its routine use in the office. Its essential elements, shared attention and imaginative play, can be screened for effectively with brief office tests and have good specificity for autism spectrum disorders.
For further reading on screening for autism, visit the website http://www.autismresearchcentre.com/
References:
Dev Med Child Neurol. 2005 Jul;47(7):493-9, J Eval Clin Pract. 2007 Feb;13(1):120-9
2 “Identification and Evaluation of Children with Autism Spectrum Disorders” October, 2007. Pediatrics
3 Early Identification of Autism by the CHAT J R Soc Med. 2000 Oct;93(10):521-5. J Am Acad Child Adolesc Psychiatry. 2001 Dec;40(12):1457-63.
Dr. Cabrera is a psychiatrist boarded in pediatrics, adult psychiatry, child psychiatry who has worked since 2005 in Chinle. He has particular interests in early childhood development and infant psychiatry.
Dev Med Child Neurol. 2005 Jul;47(7):493-9, J Eval Clin Pract. 2007 Feb;13(1):120-9
“Identification and Evaluation of Children with Autism Spectrum Disorders” October, 2007. Pediatrics
Early Identification of Autism by the CHAT J R Soc Med. 2000 Oct;93(10):521-5. J Am Acad Child Adolesc Psychiatry. 2001 Dec;40(12):1457-63.
Breastfeeding - Suzan Murphy, PIMC
Breast Pumps: The good, the bad, and the ugly
New families usually ask about breast pumps. Many retail pumps work well for occasional pumping. But, most retail pumps are not clinically evaluated or labeled so that families know what to expect. For example, a retail hand or electric pump may work well for the occasional bottle so mom can go to the store or out to eat, but not work well enough to maintain a milk supply when mom goes to work or school. It can be confusing and frustrating for new families and providers.
The following are suggestions for…suggesting a pump:
-If the family needs a pump for once in a while, often a retail breast pump will work. Also the hand pumps associated from hospital grade electric pumps producers, such as Medela or Ameda / Egnel will work.
-If the family needs a pump for more than 3-4 hours of routine separation, encourage them consider a hospital grade electric pump. Resources for these pumps are:
WIC
If WIC has electric pumps available, the rules are that the mom needs to be exclusively breastfeeding. This means the family cannot be receiving formula from the WIC program. If the family is getting formula on their own for occasional use, that is usually okay. If WIC doesn’t have pumps, they might be able to suggest local resources.
Locally
If the baby is in a NICU, hospitals often have pump loaners. If not, the hospital usually has hospital pump available for moms to use when they are at the hospital. Usually they have a breastfeeding consultant or staff members trained in breastfeeding support. They can be very helpful.Encourage families to check with local hospital gift shops. Sometimes they have pump loaners/rentals.
The yellow pages/internet - under “breastfeeding” is another place to look. Suggest that families look for pump resources that have an IBCLC (International Board Certified Lactation Consultant) on staff. Pump rentals often cost at least $30 per month to rent, attachments are often $30 or more.
Ebay
A word of caution: The Medela Pump in Style pumps are designed for single person use, the contaminant filter is inside the machine. Replacing the attachments will not reduce the potential contamination risk.
If your hospital or clinic is interested in having pumps to loan, the hospital grade pump companies have rental programs. Some companies have low cost “loss waivers/insurance” so that if a pump is loaned and lost, the company will assume responsibility. Rental costs to I.H.S. vary, depending on manufacturer and pump. For example, one I.H.S. facility reported a current cost of ~ $125/year for Medela Lactina Plus pumps. Attachments are $30-40 per set. For more details, check with local pump loaner stations or call PIMC Breastfeeding Helpline at 1-877-868-9473.
CCC Corner Digest
Nicely laid out hard copy - A compact digest of last month’s CCC Corner
January 2008 Highlights include:
-What happens if your patient hears their results as Negative? Positive? Normal? Abnormal?
-You can make a big difference in women’s and children’s lives
-Cesarean delivery on request not recommended if desiring several children, ACOG
-Early feeding within the first 24 hours after major abdominal gynecologic surgery is safe
-Rapid response team: Implications of findings on mortality rates for children are dramatic
-Reconsider use of rosiglitazone
-Human Immunodeficiency Virus
-Patient-Controlled Analgesia for Postoperative Pain: Cochrane Briefs
-Child and Adolescent Overweight and Obesity Recommendations
-Teens, Depression, Black Box Warnings and Suicide
-Breastfeeding, it is not just about the baby
-Improving Domestic Violence Law Enforcement Response: Tohono O'odham Nation
-Palliative / End of Life Care Training- SAVE THE DATES – March and April Courses
-Intrauterine Device and Adolescents, ACOG Committee Opinion
-Preconception Counseling for Women with DM and HTN: New module
-How should we manage a patient with a previous abruptio placenta?
-Disparities, Inequalities, or Inequities?
-Insights on Implementing Cultural and Linguistic Competence in MCH
-Oral Health for Head Start Children: Best Practices
-What was the presenting part? The answer
-ACNM seeks Midwifery Expertise on an as-needed basis
-Informed Refusal, Leaving Against Medical Advice, and Asking Questions
-Scope of Practice - Nurse Practitioner: Regulation, Competency, and Expansion
-Less errors with standardization of corticosteroid regimens
-Screening for Chlamydial Infection: Recommendation Statement, USPSTF
-Family History more relevant to risk of GDM in nulliparous than in parous women
-Making a business case for investing in Maternal and Child Health
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/CCCC_v6_01.pdf
If you want a copy of the CCC Digest mailed to you each month, please contact nmurphy@scf.cc
Domestic Violence
2008 NICWA Annual Conference
Early Bird Registration Ends March 28, 2008! Be a part of the largest national conference that focuses on American Indian children’s issues. The 2008 NICWA Annual Conference will be located at the Sheraton Bloomington Hotel at 7800 Normandale Boulevard, Bloomington, MN 55439, (866) 837-4728 at http://www.starwoodhotels.com/sheraton/property/overview/index.html?propertyID=1493
Registration form and conference information is available at www.nicwa.org/conference Questions about registration, please contact Tileah (Tia) Begay at (503) 222-4044 ext.157 or tbegay@nicwa.org
Family violence in health care and public health settings: Accepting Manuscripts
The Family Violence Prevention and Health Practice e-journal invites you to submit manuscripts on addressing family violence in health care and public health settings. The next issue will look at the relationship between childhood and adult sexual and physical violence and obesity. For information on submission guidelines go to the “info for contributors” tab of the journal : http://www.endabuse.org/health/ejournal/
National Report: National Indian Child Welfare
Native children are overrepresented in the nation's foster care system at more than 1.6 times the expected level, according to a new report by the National Indian Child Welfare Association (NICWA) and the national, nonpartisan Kids Are Waiting campaign, a project of The Pew Charitable Trusts. Yet tribal governments are excluded from some of the largest sources of federal child welfare funding.
The report, titled Time for Reform: A Matter of Justice for American Indian and Alaskan Native Children, found that nationally, American Indian and Alaska Native children were reported to the state and found to be victims of child abuse and neglect at the rate of 16.5 per 1,000 American Indian and Alaska Native children. This rate compares to 19.5 for African American children, 16.1 for Pacific Islander children, 10.8 for White children, and 10.7 for Hispanic children. Native American children are more likely than children of other races/ethnicities to be identified as victims of neglect (65.5%), and they are least likely to be identified as victims of physical abuse (7.3%). "Giving tribes direct access to federal child welfare resources is the most important thing the federal government can do to help American Indian and Alaskan Native children and families in crisis," said Terry L. Cross, Executive Director of NICWA and member of the Seneca Nation of Indians." http://www.pewtrusts.org/uploadedFiles/wwwpewtrustsorg/Reports/
Foster_care_reform/NICWAReport.pdf
31st Annual Indian School on Alcohol and Other Drug Related Issues - Save the Date
April 5-11, 2008
ABQ , NM
http://www.aitiinc.org/AITI/Welcome.html
Improving Domestic Violence Law Enforcement Response on the Tohono O'odham Nation
The IHS Office of Emergency Services is happy to share with you that Emerging Leader, Michelle Begay's, article "Improving Domestic Violence Law Enforcement Response on the Tohono O'odham Nation" has been published in The IHS Primary Care Provider.
It was published in the October edition - October being DV Awareness Month.
Improving Domestic Violence Law Enforcement Response on the Tohono O'odham Nation
Vol. 32 #10 Oct 2007 Issue.
http://www.ihs.gov/PublicInfo/Publications/HealthProvider/issues/PROV1007.pdf
Elder Care News
2008 Education in Palliative and End-Of-Life Care-Oncology/IHS (EPEC-O/IHS)
March 25-27, 2008; Bloomington, Minnesota
The 2008 Education in Palliative and End-Of-Life Care-Oncology/IHS (EPEC-O/IHS) will be held March 25 - 27, 2008 in Bloomington, Minnesota. This intensive, interactive training course is a joint effort between the IHS and the National Cancer Institute and is evolving into one of the best opportunities available to develop specific skills related to caring for patients and families who are facing cancer and other serious chronic illnesses, and those facing the end of life.
The faculty features the top clinicians in the field. Participation is open to all physicians, nurses, social workers, and pharmacists across the Indian health system. All Indian health facilities are encouraged to support interested physicians, nurses, social workers, pharmacists and others to attend this course. If a facility wishes to send a team that would be ideal.
The National Cancer Institute has provided funds to cover travel costs and per diem for about 35 attendees for this course. We will accept applications on a first request, first served basis. Please contact Timothy Domer M.D. by e-mail at Timothy.domer@ihs.gov
A second training session will be held in Flagstaff AZ April 22-24. The location of that training will be forthcoming shortly. You may apply to attend that course at the same e-mail address.
Your e-mail application must include a statement from the CEO or Clinical Director indicating Administrations support for this training and for supporting the development of a process for providing palliative and End-of-Life care. The Service Unit will be reimbursed for travel and per diem.
The March training will be held at the Holiday Inn Select International Airport, 3 Appletree Square, Bloomington, Minnesota 55425. Please make your hotel room reservations by March 3, 2008 by calling 1-800-465-4329 or (952) 854-9000. Be sure to ask for the “Indian Health Service” group rate.
The IHS Clinical Support Center is the accredited sponsor for this meeting. For more information on CME/CEU, contact Gigi Holmes or CDR Dora Bradley at (602) 364-7777 or gigi.holmes@ihs.gov
Minimizing Adverse Drug Events in Older Patients
Adverse drug events are common in older patients, particularly in those taking at least five medications, but such events are predictable and often preventable. A rational approach to prescribing in older adults integrates physiologic changes of aging with knowledge of pharmacology. Focusing on specific outcomes, such as the prompt recognition of adverse drug events, allows the family physician to approach prescribing cautiously and confidently. Physicians need to find ways to streamline the medical regimen, such as periodically reviewing all medications in relation to the Beers criteria and avoiding new prescriptions to counteract adverse drug reactions. The incorporation of computerized alerts and a multidisciplinary approach can reduce adverse drug events. Am Fam Physician 2007;76:1837-44.
http://www.aafp.org/afp/20071215/1837.html
Family Planning
Continuous Oral Contraception May Not Reduce Bleeding Days but May Improve Sx
Conclusions: Continuous oral contraception does not result in a reduction of bleeding days over a 168d period of observation, but provides greater suppression of the ovary and endometrium. These effects are associated with improved patient symptomatology.
Legro RS et al Effects of Continuous versus Cyclic Oral Contraception: A Randomized Controlled Trial. J Clin Endocrinol Metab. 2007 Dec 4 http://www.ncbi.nlm.nih.gov/pubmed/18056769
Association of Oral Contraceptive Use, Other Contraceptive Methods, and Infertility with Ovarian Cancer Risk
In summary, we observed that the protective effect of long duration of oral contraceptive use waned after 20 years since last use. Among other contraceptive methods, most were not associated with risk, with the exception of tubal ligation (inverse association) and IUD use (positive association). History of infertility was associated with a modestly increased risk of ovarian cancer. Oral contraceptives are the only known chemoprotective agent for ovarian cancer. Future studies should continue to examine the potential waning effect of oral contraceptives with longer time since last use, as well as continue to explore potential associations with other contraceptive methods and infertility. Overall, these results do not support a positive association between circulating androgen levels and ovarian cancer risk.
Tworoger SS et al Plasma Androgen Concentrations and Risk of Incident Ovarian Cancer.
Am J Epidemiol. 2007 Nov 3; http://www.ncbi.nlm.nih.gov/pubmed/17982156
Tubal Patency Better With One Dose vs Multiple Methotrexate Doses for Ectopic
CONCLUSION(S): In terms of ipsilateral tubal obstruction, multiple-dose MTX therapy appears to have a greater negative effect on tubal patency than single-dose therapy.
Guven ES et al Comparison of the effect of single-dose and multiple-dose methotrexate therapy on tubal patency. Fertil Steril. 2007 Nov;88(5):1288-92.
http://www.ncbi.nlm.nih.gov/pubmed/17418839
Featured Website David Gahn, IHS Women’s Health Web Site Content Coordinator
New and Improved MCH Conferences page - More user friendly
The MCH Conferences page has been redesigned and updated to make it more user-friendly. The page now appears like a calendar page, so you can easily scroll through it.
If you are a more visual reader and less text based, then the new format is great for you
Take a look
http://www.ihs.gov/MedicalPrograms/MCH/F/CN01.cfm
As always the MCH Conferences sites will present you with latest information on conferences that are relevant to providing the highest possible level of care to your patients.
Other features are
-An exhaustive list of links to Other Educational Calendars, so you can sort through various conferences by conference location and educational source, as well as date.
http://www.ihs.gov/MedicalPrograms/MCH/F/CN03.cfm
-Do you vaguely remember that Course you heard about last year, or sometime in the past, but just couldn’t make it to that conference?
As many Courses recur, we have archived the past Conference postings since 2001 so you can look at old brochures, contact information, etc…..on the Conference Archive page
http://www.ihs.gov/MedicalPrograms/MCH/F/confArch07.cfm
-Can’t get away from your facility right now, but need some continuing education?
Try the Online CME Sites page.
http://www.ihs.gov/MedicalPrograms/MCH/F/CN02.cfm
Frequently Asked Questions
Frequently Asked Questions about Infant Feeding Choice
BACKGROUND INFORMATION
Why collect this data? Because it is used in the clinical performance measure called Breastfeeding Rates that is reported in the RPMS Clinical Reporting System (CRS). While this measure is currently not a GPRA measure (one reported to Congress and OMB) it is used in support of the GPRA measure Childhood Weight Control with the goal of lowering the incidence of childhood obesity in the IHS patient population. Additionally, facilities can use this data to track infant feeding patterns and breastfeeding rates within their own patient population.
Research indicates that children who were breastfed have lower incidences of overweight or obesity. For additional information, please click the link below to review the article in the March 2007 IHS Primary Care Provider.
http://www.ihs.gov/PublicInfo/Publications/HealthProvider/issues/PROV0307.pdf
How is this data used? It is used in the CRS Breastfeeding Rates topic in several measures that report:
- How many patients approximately 2 months through 1 year of age were ever screened for infant feeding choice.
- How many patients were screened at the approximate ages of 2 months, 6 months, 9 months, and 1 year.
- How many patients who were screened were either exclusively or mostly breastfed at those age ranges.
Users may run the CRS Selected Measures (Local) Reports to view all of the breastfeeding performance measures. The report also provides the option to include a list of patients and identifies the dates and ages they were screened and their infant feeding choice values. Click the link below to learn how to run this report in CRS, starting on page 206 (as numbered in the document itself, not in Adobe).
http://www.ihs.gov/misc/links_gateway/download.cfm?doc
_id=10716&app_dir_id=4&doc_file=bgp_070u.pdf
Is Infant Feeding Choice data the same as the data included in the Birth Measurements section of the EHR and with the PIF (Infant Feeding Patient Data) mnemonic in PCC? No, it is different. The information collected in these sections are intended for one-time collection of birth weight, birth order, age when formula was started, breastfeeding was stopped and solid foods started, and linking to mother/guardian. Shown below is a screen shot of this section from EHR. While this information is important, none of it is used in the logic for the CRS Breastfeeding Rates measure; only the Infant Feeding Choice data is used.
What are the definitions for the Infant Feeding Choices? The definitions are shown below and are the same definitions used in both EHR and PCC.
- Exclusive Breastfeeding: Formula supplementing less than 3 times per week (<3x per week)
- Mostly Breastfeeding: Formula supplementing 3 or more times per week (>3x per week) but otherwise mostly breastfeeding
- ½ Breastfeeding, ½ Formula Feeding: Half the time breastfeeding, half the time formula feeding
- Mostly Formula: The baby is mostly formula fed, but breastfeeds at least once a week
- Formula Only: Baby receives only formula
Who should be collecting this information and how often? It depends on how your facility is set up but any provider can collect this information. At a minimum, all providers in Well Child and Pediatric clinics should be collecting this information for patients 45-394 days old at all visits occurring during that age range. Public Health Nurses should also be collecting this information. This data can be entered in EHR or PCC/PCC+, as described below.
ENTERING INFANT FEEDING CHOICE DATA IN EHR
In which version of EHR is Infant Feeding Choice data able to be entered? EHR Version 1.1, which was deployed nationally on October 3, 2007.
How do I enter Infant Feeding Choice in EHR?
- After you have selected the patient and the visit, go to the Personal Health section. For some EHR sites, this may be included on the Wellness tab.
From the Personal Health dropdown list, select Infant Feeding, then click the Add button.
NOTE: The age of the patient must be five years or less to be able to select Infant Feeding; otherwise, Infant Feeding will not be listed in the dropdown list.
- At the Add Infant Feeding Record window, click the appropriate checkbox to select the type of infant feeding, and then click the OK button to save the value.
- The patient’s value for Infant Feeding Choice for this visit is now displayed in the Personal Health section, as shown below.
ENTERING INFANT FEEDING CHOICE DATA IN PCC/PCC+
Which data entry patch do I need? You will need to have data entry patch 8 (apcd0200.08k) installed, which was released on October 19, 2005.
How do I enter Infant Feeding Choice in PCC?
- Create a new visit or select an existing visit to append.
- At the Mnemonic prompt, type “IF” (Infant Feeding Choices) and press Enter.
- Type the number corresponding to the type of feeding and press Enter. If you do not know the number, type “??” and press Enter to see a list of choices.
- You are returned to the Mnemonic prompt. Continue with data entry of other items.
Stephanie Klepacki
CRS Project Manager/Lead Analyst
November 2, 2007
MCH Coordinator Editorial comment:
The infant feeding choice functionality is supported in the newly released EHR 1.1
The clinical performance measure called Breastfeeding Rates reported in the RPMS Clinical Reporting System (CRS) is a measure of interest. We wish to emphasize that while this measure is currently not a GPRA measure (one reported to Congress and OMB) it is used in support of the GPRA measure
Indian Child Health Notes - Steve Holve, Pediatrics Chief Clinical Consultant
February 2008
-On decreasing the use of antibiotics for acute otitis media
-The RSV Season: Is there relief in sight?
-Childhood cancer mortality trends
http://www.ihs.gov/MedicalPrograms/MCH/M/ChPedNotes.cfm
Information Technology
Four Directions Summer Research Program Applications Online for Summer 2008
Helping to create future leaders in Native American health care
Applications are now available online for Summer 2008 Four Directions Summer Research Program. Application Deadline: February 29, 2008 (postmark)
Four Directions
Summer Research Program
Harvard Medical School and Brigham and Women’s Hospital
Boston , MA
For more information and to complete the online application, please visit www.fdsrp.org
For More Information, Brochures or Applications
Elena Muench
Brigham and Women’s Hospital
Office for Multicultural Faculty Careers
Center for Faculty Development and Diversity
1620 Tremont Street , 3-014.04
Boston , MA 02120
(617) 525-7644
iCare Training
The IHS Office of Information Technology continues to offer WebEx training for the iCare (Population Management) software application. You will be able to participate in the training from the comfort of your office or conference room and will not be required to travel to obtain this training.
iCare is a tool with multiple uses for a wide variety of providers that presents diverse RPMS data through an easy to use graphical user interface (GUI).
We will continue to offer a brief intro session that will just introduce the software to participants. This session does not offer any training.
1. A Brief Introduction to iCare 30 minutes
The 2 standard training sessions are again offered and we recommend they be taken sequentially.
- iCare - Nuts and Bolts 2.0 hours
- the Practical Use of iCare 1.5 hours
Coming Soon!!!!
We will be adding a new training session called "What's New in iCare?". This session will cover the new functionality that will be delivered in the next version of iCare. The dates for this training are yet to be decided so stay tuned for this new session.
The target audience for all of these sessions is any provider who cares for patients (e.g. physicians, mid-level providers, nurses, case managers, public health personnel, pharmacists etc.)
NOTE:You must register for these classes. They are NOT limited to participants in a particular Area; they are open to all. Below are the agendas and date/times for both classes.
You can choose to register individually or as a group. If you register individually, all you need is your computer, the ability to sign on to the internet and a telephone. If you'd like to attend as a group, one person will need to register and then sign in at the designated time. You will need a conference room, conference phone, computer and projector. Please ensure someone at your facility is responsible for taking care of these arrangements.
Please note that these are live, internet-based trainings, not recorded sessions, and people will be able to ask questions and actively participate in the class.
NOTE: All training times shown above are for the Mountain Standard Time ( Arizona Time) zone. Please ensure you adjust the time for your particular time zone.
Training Schedule
- iCare – Nuts and Bolts
Target Audience – Patient Care Providers (e.g. physicians, mid-level providers, nurses, case managers, public health personnel, pharmacists etc.)
Agenda
- Introductions and Context
- Set Up
- Background Processes
- Establishing and Changing User Preferences
- Panel Creation
- Panel Modification
- Patient Record
Session Date and Time Reg Password
iCare Nuts and Bolts Thur 12/13/2007 11:00-13:00 MST coyote
Tues 01/08/2008 13:00-15:00 MST coyote
- The Practical Use of iCare
Target Audience – Patient Care Providers (e.g. physicians, mid-level providers, nurses, case managers, public health personnel, pharmacists etc.)
Agenda
- Introductions and Context
- Scenarios
- Tips
- Using the Performance Measure views to improve outcomes
Session Date and Time Reg Password
The Practical Use of iCare Mon 12/17/2007 14:00-15:30 MST coyote
Thur 01/10/2008 10:00-11:30 MST coyote
- A Brief Introduction to iCare
Target Audience – Patient Care Providers (e.g. physicians, mid-level providers, nurses, case managers, public health personnel, pharmacists etc.) who don't have time to attend a longer session.
Agenda
- Highlights
- Background Processes
- Panel Creation and Modification
Session Date and Time Reg Password
A Brief Introduction to iCare Wed 12/12/2007 11:00-11:30 MST coyote
Mon 01/14/2008 14:00-14:30 MST coyote
Registration Information
- Click this link:
- In the Search box, type in "iCare" (do not type in the quotation marks) and click the Search button. NOTE: If you do not see the Search For box, ensure the Training Center tab is selected at the top of the WebEx window.
- All of the scheduled sessions will then be displayed in the window below. Choose the one you want to attend and click “Registration” in the Status column.
- Enter the Registration password that is shown above that corresponds to the class you want to attend.
- Click the OK button.
- Complete the registration form.
- Click the Register button.
- A Registration confirmation is displayed that contains all of the information for the training session, including the link for the session and the password to enter when you are ready to attend the session. Click the OK button to finish.
Setup (Software Install) Information:
You must have the WebEx software installed on your computer prior to attending the WebEx session. You should setup the software at least a day before the training session. You should not need anyone such as the Site Manager to install it for you. Below are the instructions.
- Click this link:
- On the left side of the window, locate Set Up
- Click Training Manager
- A message is displaying giving you information about the setup process. Click the Set Up button
- After the software is installed, click the OK button.
Attending the Session:
On the day of the scheduled training, you will receive a confirmation email. When you are ready to attend the session, connect to the WebEx session by clicking on the link in that email. You will then need to connect to the conference line. The dial information for the conference line is shown below and is also included in your registration confirmation message.
Phone Number: (877) 781-4791
Passcode: 135963#
International Health Update: Claire Wendland, Madison, WI
Multiple Chlamydia species pose an unexpected challenge for blindness prevention
In the United States, most health care providers hearing the word “chlamydia” think immediately of the sexually transmitted infection caused by Chlamydia trachomatis. Chlamydia the STI is common around the world, but C. trachomatis has long been believed also to be the major cause of trachoma, an eye infection that is the leading cause of preventable blindness worldwide. A new report calls into question some of the conventional wisdom about trachoma, and raises concerns about treatment and prevention efforts.
Trachoma is spread when ocular or respiratory secretions from an infected person get into the eyes of an uninfected person (typically through direct contact, when carried by house flies or other insects, or by shared towels). It causes a conjunctivitis that ultimately turn the eyelashes inward, resulting in corneal scratching and ulcerations. Left untreated, it progresses to blindness over a span of one to four decades. The disease is found disproportionately in poor countries, especially in Asia, the Middle East, and Africa, and especially among women. Dry and dusty places where people are inclined to rub their eyes and don’t have much water to wash may be particularly affected.
Though trachoma was once a serious problem in the United States, it has been greatly reduced by antibiotic treatment and by provision of clean water to affected communities. In fact, the CDC claims trachoma has been eradicated in the U.S., though a 1997 report on eye disease on the Navajo reservation still listed it as a significant cause of blindness there. Efforts to wipe out trachoma in the Third World, however, fail consistently. Cases quickly reappear following mass antibiotic treatment of affected communities, and may persist or reappear even when testing fails to demonstrate the presence of C. trachomatis. These anomalies led researchers to investigate whether another pathogen might be responsible.
In an endemic community in Nepal, Deborah Dean and colleagues sampled tears from 146 people in nine affected households and also did eye exams to stage them for clinical trachoma. PCR testing on the tear samples showed that half the sample was infected. The surprise was that of those infected, 35% had only C. trachomatis (and even here there were eight different genotypes involved), 20% had only C. psittaci, 10% had only C. pneumoniae, and 35% had more than one species. All three species were highly correlated with severe eye inflammation consistent with clinical trachoma, and the researchers conclude that all three are pathogenic. It’s not clear that the same pattern of infection will prevail outside Nepal. What is clear is that efforts to make a vaccine have just had a significant setback, and that monotherapy with azithromycin (which may not work for all Chlamydiaceae) can no longer be counted on to wipe out the problem.
Reference:
Dean D, Kandel RP, Adhikari HK, Hessel T Multiple Chlamydiaceae species in trachoma: implications for disease pathogenesis and control. PLoS Medicine 5(1):e14, January 2008
http://www.ncbi.nlm.nih.gov/pubmed/18177205
MCH Alert
New edition of Knowledge Path: Preconception and Pregnancy available
The new edition of Knowledge Path: Preconception and Pregnancy is a guide to resources that analyze perinatal health statistics, describe effective prenatal care programs, and report on research aimed at improving access to and quality of prenatal care and improving perinatal health outcomes. The path, produced by the MCH Library, contains consumer health resources and resources on specific aspects of preconception and pregnancy including childbirth, depression, drug and alcohol use, environmental concerns, fertility and infertility, nutrition, oral health, and tobacco use. http://www.mchlibrary.info/KnowledgePaths/kp_pregnancy.html
MCH Headlines - Judy Thierry HQE
Announcing the 2008 PREVENT Child Maltreatment Institute
The 2008 PREVENT Child Maltreatment Institute: Enhancing Leadership for Child Maltreatment Prevention offers state of the art training to experienced teams from across the country, who are working to stop child maltreatment before the first victimization or perpetration occurs. The Institute will expand skills to lead evidence-based efforts in the primary prevention of child maltreatment and provide teams with an intensive and supportive environment in which to work together with a trained coach on a prevention initiative. Participants can expect to enhance core competencies in the primary prevention of child maltreatment at the state and/or national level, including:
- planning and evaluating effective policy interventions and programs;
- stimulating organizational and social change;
- critically evaluating the literature and translating science into practice;
- effectively communicating with media and policy makers through media and legislative advocacy,
- implementing promising practices, and
- enhancing skills in achieving program sustainability.
The PREVENT Child Maltreatment Institute will include two (2) intensive three-day, on-site sessions separated by six months of working as a team at home, with selected distance education calls and guidance from an experienced coach focused on a team-developed project. The first three-day session will be held April 21-23, 2008 for Cohort 1 and April 22-24, 2008 for Cohort 2 at the Sheraton Chapel Hill Hotel, Chapel Hill North Carolina. The second session will be conducted in October, 2008.
Multi-organizational teams of up to 5 people will be selected based on their experience working together, demonstration of leadership in child maltreatment prevention AND readiness to take an increased leadership role in making social and organizational changes to prevent child/ maltreatment./ While we will consider multidisciplinary teams from local communities, the most successful applicants will be teams working in large metropolitan areas, or at the state, regional or national level that have already established working relationships. Selected teams are responsible for travel, lodging, evening meals, and a one-time non-refundable $750 team registration fee. For more information and to submit an application, please see the attached flyer and visit http://prevent.unc.edu/education/.
Children with special health care needs: Cultural competence compendium
New Resource from the National Center for Cultural Competence
The National Center for Cultural Competence (NCCC) has just released a new monograph on cultural and linguistic competence in systems serving children and youth with special health care needs and their families. The examples are related to State Title V programs, but the monograph offers insights and lessons that apply to any organization.
You can access the document at http://www.gucchdgeorgetown.net/NCCC/journey/
Novel use of road signs to emphasize the Negotiations required by families and providers and systems as they address children and their special health care needs.
Pg 91 - Alaska Newborn hearing screening program and Community Health Provider education, ANMC CHA curriculum adaptation
Medical Mystery Tour
St. John's wort for depression in a young woman
A 28-year-old female with severe major depression has achieved partial symptom remission with a selective serotonin reuptake inhibitor ( SSRI) but complains of persistent diarrhea and loss of libido. She asks you about using St. John's wort to treat her depression
Appropriate advice would include which of the following? (Select all that are true.)
- St. John's wort may be effective in milder forms of major depression
- St. John's wort is more effective than placebo in patients with severe major depression
- St. John's wort is better tolerated than prescription antidepressants
-The combination of St. John's wort and SSRIs is safe and effective for major depression.
- St. John's wort may reduce the efficacy of combined oral contraceptives
Stay tuned to the March issue for the answers and a discussion
Medscape*
PMDD Spotlight: Women With Histories of Abuse: A Clinically Meaningful Subgroup?
http://www.medscape.com/viewarticle/565755?sssdmh=dm1.329206&src=0_tp_nl_0#
HPV Vaccines: Beyond Expectations
http://www.medscape.com/viewarticle/567800
Expanding HIV Testing: Practical Screening Cases to Meet New CDC Recommendations
http://www.medscape.com/viewarticle/567593
Sexually Transmitted Infections and Cancer: Breaking the Link Through Vaccination
http://www.medscape.com/viewprogram/8225?src=nlcmealert
Hypertension and Soy: A Best Evidence Review
http://www.medscape.com/viewarticle/568288
Treatment Options for Early-Stage Breast Cancer: Information for Primary Care
http://www.medscape.com/viewarticle/567114
Top Herbal Products: Efficacy and Safety Concerns
http://www.medscape.com/viewarticle/568235
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
Smoking Status as a Predictor of Hip Fracture Risk in Postmenopausal Women
The purpose of this study was to determine the effect of cigarette smoking on the risk of hip fracture for postmenopausal women living in rural and urban areas of Northwest Texas. Former and current smoking increased the risk of hip fracture in this population of postmenopausal women. Residence in a rural county (population <100,000) also was associated with increased risk. http://www.cdc.gov/pcd/issues/2008/jan/07_0036.htm
Low dose transdermal E2 gel delivered the lowest effective dose
CONCLUSION: The 0.87 g/d dose of this new transdermal E2 gel, which delivers an estimated 0.0125 mg E2 daily, delivered the lowest effective dose for treatment of vasomotor symptoms and vulvovaginal atrophy in a population of postmenopausal women. LEVEL OF EVIDENCE: I.
Simon JA et al Low dose of transdermal estradiol gel for treatment of symptomatic postmenopausal women: a randomized controlled trial. Obstet Gynecol. 2007 Mar;109(3):588-96.
http://www.ncbi.nlm.nih.gov/pubmed/17329509
Vaginal tablets containing 25 mcg or 10 mcg estradiol are effective
CONCLUSION: Vaginal tablets with 25 mcg and 10 mcg E2 provided relief of vaginal symptoms, improved urogenital atrophy, decreased vaginal pH, and increased maturation of the vaginal and urethral epithelium. Those improvements were greater with 25 mcg than with 10 mcg E2. Both doses were effective in the treatment of atrophic vaginitis. LEVEL OF EVIDENCE: I
Bachmann G et al Efficacy of Low-Dose Estradiol Vaginal Tablets in the Treatment of Atrophic Vaginitis: A Randomized Controlled Trial. Obstet Gynecol. 2008 Jan;111(1):67-76.
http://www.ncbi.nlm.nih.gov/pubmed/18165394?dopt=Abstract
Levonorgestrel intrauterine system (LNG-IUS) reduces endometrial polyps with tamoxifen
CONCLUSION: Levonorgestrel intrauterine system (LNG-IUS) reduces the occurrence of de novo endometrial polyp in women treated with tamoxifen for breast cancer.
Chan SS et al A randomised controlled trial of prophylactic levonorgestrel intrauterine system in tamoxifen-treated women. BJOG. 2007 Dec;114(12):1510-5.
http://www.ncbi.nlm.nih.gov/pubmed/17995495
The What, Why and How of Aromatase Inhibitors: Hormonal Agents for Treatment and Prevention of Breast Cancer
The third-generation aromatase inhibitors (AIs) anastrozole, exemestane and letrozole have largely replaced tamoxifen as the preferred treatment for hormone receptor - positive breast cancer in postmenopausal women. Approximately 185,000 new cases of invasive breast cancer are diagnosed yearly, and at least half of these women are both postmenopausal and eligible for adjuvant therapy with AIs. In addition, AIs are currently being tested as primary prevention therapy in large randomised trials involving tens of thousands of women at increased risk for breast cancer. Given the volume of use, internists will increasingly see postmenopausal women who are taking or considering treatment with AIs. Physicians need to be able to: (i) briefly discuss the pros and cons of using a selective estrogen receptor modulator such as tamoxifen or raloxifene vs. an AI for risk reduction and (ii) recognise and manage AI-associated adverse events. The primary purpose of this review is to help providers with these two tasks.
http://www.medscape.com/viewarticle/567399?src=mp
Herbal practitioners improved menopausal symptoms, esp. hot flushes and low libido
CONCLUSION: The treatment package from herbal practitioners improved menopausal symptoms, particularly hot flushes and low libido. This offers evidence to support herbal medicine as a treatment choice during the menopause.
Green J et al Treatment of menopausal symptoms by qualified herbal practitioners: a prospective, randomized controlled trial. Fam Pract. 2007 Oct;24(5):468-74.
http://www.ncbi.nlm.nih.gov/pubmed/17698978
Midwives Corner - Lisa Allee, CNM
1.) AI / AN women are really successful at doing this
2.) The evidence supports this
3.) Women want and benefit from this
What is this win3 best practice process?
(a.k.a. win / win / win)
It is vaginal birth after cesarean
(We need to provide them)
The following is in response to the comments of Dr. David Gahn regarding VBACs at Hastings Indian Medical Center that appeared in this column in the December issue of the CCC Newsletter (see link below). This following is a conglomeration of my and other midwives’ responses.
First, here is some overall VBAC information to ponder.
We must all remind ourselves of recent history. The change from pro-VBAC thinking to pro-repeat cesarean delivery occurred when ACOG came out with a recommendation (not a requirement) that physicians (doesn’t specify anesthesia) should be immediately available (no definition supplied).
This recommendation was based on a poorly done study of discharge diagnosis codes that actually demonstrated the same statistics on uterine rupture as previous studies of VBAC, but the authors came to very different conclusions (Lyndon-Rochelle 2001) Unfortunately, much of this country went wildly swinging to the extreme end of the pendulum’s arc and stopped offering VBACs. Luckily, some kept their heads and a plethora of research has been published since which show VBAC to be a safe and reasonable option for the majority of women with a history of cesarean deliveries and many benefits to VBAC over repeat cesarean delivery.
(Please see the many citations that have been reviewed in December Obstetrics section of this publication – link below plus this month’s Abstract of the Month. More citations were supplied by Neil Murphy and Sheila Mahoney on the Indian Health Midwives listserv discussion related to VBACs.)
Among the places that have remained sane and continued to offer VBACs are many of us in the Indian Health Service ( Alaska Native Medical Center even got an award from the American College Nurse Midwifes) and a group in the Northeast, the Northern New England Perinatal Quality Improvement Network (NNEPQIN). (link below) The folks in the New England coalition have come out with useful guidelines on deciding about VBAC and providing quality care. Their work also helped us all face a bigger picture—how we handle emergency surgery in general and how we can improve. Their suggestions include improving teamwork, communications, and skills via drills. This has the potential to improve responses to emergency birth needs beyond the very few situations related to VBACs. Those of us in IHS who have continued VBACs have shown continued success with excellent statistics and outcomes (see 2007 Indian Health Data Tally Sheet below)
Overall, the pendulum is hopefully beginning to swing back towards a more rational approach to VBACs—there was even a quote from an ACOG official that suggested a possible move towards revising their “immediately available” statement (see August 2006 Midwives Corner below)
Second, let’s go over some of the specifics raised by Dr. Gahn. Since, according to Dr. Gahn, none of the physicians or midwives at Hastings are anti-VBAC, I thought I would use the responses from other midwives and myself to formulate some suggestions to help overcome the barriers to VBACs at Hastings which were elucidated by Dr. Gahn. These suggestions can also be used by the few other IHS sites that may be experiencing problems with offering VBAC services.
- Have a journal club to present the overwhelming amount of evidence that supports providing VBAC services. Make sure to include the materials from the Northern New England Perinatal Quality Improvement Network and IHS VBAC statistics. Invite (coerce attendance, i.e., pizza or desserts, as needed) all members of the perinatal team including anesthesia and executive staff members who supervise the provider staff. This will help ensure that all involved have the information to begin providing evidence based care and should help to start the efforts to develop a functional interdisciplinary team. This should also help those obstetricians who “are not anti-TOLAC/VBAC”, but are not on board with the VBAC plan to start their process of getting on board.
- Start doing drills for obstetrical emergencies. This will help to improve skills, as well as, teamwork and communication between anesthesia, surgery, midwifery, obstetrics, nursing—your second step in team building. This should help a number of issues. It should help to impress all on-call staff to do what is necessary to improve response time with the goal of your med-staff-rules-and-regulations-required 20 minutes becoming reliable. Maybe this will help folks come to the conclusion of having key personnel located close by—i.e. a call room or on campus housing. This would solve the problem of anesthesia not being available when a VBAC patient is laboring. When the larger picture of response to any emergent surgery is focused upon then the VBAC topic, which represents a very small proportion of the potential emergency surgeries, is automatically included.
- As a department, or even better as an interdisciplinary team or service unit, review the World Health Organization and USPHS Healthy People 2010 recommendations for cesarean delivery rates. Both of these respected and esteemed organizations have clearly and repeatedly recommended cesarean delivery rates in the 10-15% range. This clearly answers the question about whether a cesarean delivery rate of 37%, which is more than double to triple these recommendations, is too high and gives a very good indication as to what is too high for a cesarean delivery rate.
- Re-evaluate how VBAC counseling is done. To provide true informed consent the numbers need to be presented clearly. The data consistently shows a uterine rupture rate of 0.5-3%--it is important to explain that this means 97-99.5 women out of 100 will not have a uterine rupture and out of the few that do, not all will have problems. It is, of course, important to discuss the risk of uterine rupture to mother and baby, but to put it in this perspective of being rare and review the high-quality, careful care we provide to women who are VBACing to help prevent problems. It is also very important to review the differences in postpartum morbidity and risk between a vaginal birth and cesarean delivery, (be sure to include the oft ignored higher rates of breastfeeding and orgasm difficulties post cesarean delivery.) If, in contrast, providers only make a recommendation of repeat cesarean delivery and an institution has a policy that only allows for repeat cesarean delivery, then they have effectively negated a woman’s right to make an informed decision in a situation where there is a choice.
- Review the postpartum morbidity and risk differences for women post vaginal birth vs. post cesarean delivery. This will help to dispel the delusion that a woman who has had a cesarean delivery is walking out of the hospital “healthy” and bring a more accurate sense of respect for what is really happening for that woman. She has just had major abdominal surgery and is in recovery from that surgery. She is in pain and is at risk for a number of post-surgical complications. Her future pregnancies have also now taken on a longer list of potential risks. Along with all this she is also a new mother with a newborn to care for and feed every 1-2 hours with an abdominal incision that she is fully aware of each time she moves. This human perspective of the implications of a cesarean delivery might help providers to be concerned with their personal and institutional cesarean delivery rates.
- Consider IHS as a model for the local standard of care. Since we are not controlled by insurance companies, we in IHS often have more opportunity then our colleagues outside IHS to provide care that is evidence-based. VBAC care is one of those situations and we can proudly stand up in the maternity care community as a model of excellent care.
Most importantly we need to respect the women we care for as the ones who are giving birth and realize that, therefore, it needs to be up to them where, how, and with whom they will do so. We are here to provide information and care—to serve not to dictate.
Please feel free to contact me for any questions or comments and for requests for links to the above mentioned resources atlisa.allee@ihs.gov.
Resources
Midwives Corner December 2007 CCCC
http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_Feat.cfm#MidWives
Indian Health Maternity and Women’s Health Data Tally Sheet, 2007
http://www.ihs.gov/MedicalPrograms/MCH/F/documents/DataTally81107.doc
Lydon-Rochelle M, et al. Risk of uterine rupture during labor among women with a prior cesarean delivery. NEJM 2001; 345:3-8. (Level III)
http://www.ncbi.nlm.nih.gov/pubmed/11439945?dopt=Abstract
Obstetric Hot Topics December 2007 CCCC
http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1207_HT.cfm#ob
Northern New England Perinatal Quality Improvement Network
Midwives Corner August 2006 CCCC
http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0806_Feat.cfm#MidWives
Judy Whitecrane: Tireless Improvement of Care for Native American women
CDR Judith Whitecrane started her professional career as a Diploma Graduate prepared nurse and over the years has continued her education in a manner which is very inspiring to any nurse.
Today Ms. Whitecrane is a Post Master's Prepared Nurse whose professional activities involve a concentration in Nurse-Midwifery.
Not only is she on staff at Phoenix Indian Medical Center, but she is the first non physician to become Vice-President of Medical Staff. Maintenance of the hospitals level II Obstetrical certification, Ms. Whitecrane is the PIMC Coordinator and Liaison to Arizona Perinatal Trust. Ms. Whitecrane is the original author of the Prenatal Questionnaire used through out the Indian Health Service, Tribal and Urban Centers (I/T/U), widely used in Indian Country. Ms. Whitecrane was one of two individuals responsible for the Public Health Nursing Teen pregnancy program which addressed many issues related to teen pregnancy.
Annually, Ms Whitecrane has overseen the Advance Practice Nurse/ Physician Assistant Seminar which has been historically held in Scottsdale, Az. This national conference has been most successful in meeting the needs of Advanced Practice Nurses & Physician Assistants.
Ms. Whitecrane serves on the National Nurse Leadership Council as one of two Advance Practice Nurse Consultants. In this role she has worked tirelessly on behalf of the many nurses she represents across the I/T/U.
Of specific commendation are her efforts to increase the awareness of the Advanced Practice Nurse working within our current personnel system. Ms. Whitecrane has advocated for the elevation of the Advanced Practice Nurse position to make it more competitive with the private sector. In doing so, she has successfully overseen the updating of the Advanced Practice Nurse Scope of Practice. Both of these activities have been most labor intensive and will have far reaching positive affects on present and future Advanced Practice Nurses working throughout the I/T/U.
Her efforts will not only pave the way for higher pay for the Advanced Practice Nurse, especially in OB and Anesthesia which continue to be the hardest positions to fill, but also will serve to promote a better understanding and provide a firmer framework for facilities who hire Advanced Practice Nurses, by having a true scope of practice which better conforms to local, regional and national guidelines and expectations.
Over the past three years, Ms. Whitecrane has taken on the role of Chairperson of the OB Task Force. This OB Task Force has created significant changes and improvements to our Labor and Delivery Unit at PIMC. She has helped in the creation of OB emergency drills which allow the staff to better learn the necessary skills to help recognize potential process problems which can be corrected. This OB Task Force has also been instrumental in the completion of the remodeling of our Obstetrical triage area to create a HIPAA compliant unit and allow safer treatment areas.
Ms. Whitecrane also started the Special Care Clinic for the pregnant women with drug abusing problems. This clinic is working well and we have seen many good outcomes since its initiation. She also has given many lectures to groups wanting to start such a clinic across I/T/U.
I know that this is long, but Judy has been at PIMC for 26 years and with IHS for 30 years and has worked tirelessly for the improvement of care to our Native American patients. She retired on Jan. 1, 2008, but her valuable services may be available to worthy causes on a contract basis.
53rd ACNM Annual Meeting & Exposition
May 23-29, 2008
Boston , MA
American College of Nurse-Midwives
http://www.acnm.org/am/index.cfm
ACNM Clinical Bulletin Recommends Intermittent Auscultation
The American College of Nurse-Midwives has issued a clinical bulletin recommending intermittent auscultation as the “preferred method for monitoring the fetal heart rate during labor for women who at the onset of labor are low risk for developing fetal academia.” The recommendation is based on numerous randomized clinical trials and a 2006 Cochrane review (including more than 33,000 women) which all show no benefit of continuous electronic fetal monitoring (EFM) over intermittent auscultation (IA) in terms of perinatal outcomes and significantly higher intervention and morbidity rates in the EFM groups. Included are guidelines on how to perform IA, recommendations from other professional organizations on the frequency of IA, and how to interpret and document IA. The bulletin recommends using a multiple-count method, but unfortunately does not come out with a recommendation or instructions for a specific counting method. References to studies on auscultation are provided to help in the decision making, however, including one that has a method of plotting the counts (see Paine’s articles below). The bulletin also sites research that shows patient satisfaction is associated with amount and quality of caregiver support and involvement in decision making and, therefore, that giving patients the choice of IA with it’s 1:1 caregiver to patient ratio and frequent human-provided assessment might increase patient satisfaction.
Comment: Here is another great resource for supporting the move to turn off the monitors and even take them out of the birthing rooms of low risk women (and please remember that most women are low risk). We have all heard over and over and over that continuous EFM does not improve outcomes, but does increase intervention and morbidity. Isn’t it time yet that we change our practice to fit the evidence? This bulletin says yes it is time! I have used IA in both home and hospital settings and it works well to monitor fetal wellbeing. It is also really wonderful how IA increases the quantity and quality of labor support the patients receive. If you do not use IA at your facility, I highly recommend moving towards it. I realize that change is hard, so here are a couple of suggestions. If your addiction to the monitor is such that you cannot go cold turkey, then try doing IA with the monitor first and work towards using a doptone. If your resistance is the 1:1 ratio and staffing issues then start with using IA when it is slow and 1:1 is not a problem. As people get use to and more skilled with IA, then creative ways to provide it when things are busier will appear. And, of course, when it is too busy and there is not enough staff then use the EFM, but realize that that decision is due to institutional needs not patient needs or for improved outcomes. Lastly, print this clinical bulletin and post it for all to see and check out the articles by Paine, et al for a great way to do IA and graph it and by the other authors for other multiple-count methods you can chose from.
Resources:
American College of Nurse Midwives. Intermittent auscultation for intrapartum fetal heart rate surveillance. J Midwifery Womens Health. 2007 May-Jun;52(3):314-9
http://www.ncbi.nlm.nih.gov/pubmed/17467602
Full article via Science Direct and Mosby’s Nursing Consult
Paine et al’s articles on auscultating fetal heart rate via Pubmed:
Auscultated fetal heart rate accelerations. Part I. Accuracy and documentation.
http://www.ncbi.nlm.nih.gov/pubmed/3633984
Auscultated fetal heart rate accelerations. Part II. An alternative to the nonstress test.
http://www.ncbi.nlm.nih.gov/pubmed/3633985
Navajo News - John Balintona, Shiprock
Biliary Gallstone Disease and Pregnancy
Biliary tract disease is the second most common general surgical condition encountered in pregnant women. Often the care of these patients is shared between the obstetric provider and other specialists, i.e. primary care providers and general surgeons. The purpose of this review is to discuss salient points in caring for pregnant patients with biliary gallstone disease. Included in the discussion is the pathophysiology of gallstones, incidence in pregnancy, evaluation of the patient, treatment options during pregnancy, and recommendations for care for obstetric patients with gallbladder disease.
In the United States, cholesterol stones are the most common type of gallstone. The formation of cholesterol stones is a result of cholesterol supersaturation and impaired gallbladder motility. Several risk factors have been associated with the increased occurrence of gallstones:
Risk Factors for Gallstone Formation
Obesity; BMI > 30
Pregnancy
Female Gender
Native American Race
Heredity
Increasing Age
Ileal disease
Drugs; estrogens, TPN, ceftriaxone
Cholelithiasis is found in about 20% of women over 40. Literature suggests that the yearly risk of intervention is about 1 – 2%. Therefore, treatment for asymptomatic disease is not warranted. Complications can occur however, which change the approach and management of this condition. Acute cholecystitis develops when there is a complete obstruction of the cystic duct usually with colonization from bacteria. Choledocholithiasis occurs when gallstones migrate from the primary site of origin through the cystic duct and into the common bile duct. Gallstones can trigger an attack of acute pancreatitis by transiently impacting in the duodenal papilla. Symptoms related to gallstone disease include steady, nonparyoxsmal pain, usually lasting more than 4 hours. Anorexia, as well as, nausea and vomiting frequently occur. Findings such as low-grade fever and leukocytosis (> 13,000 WBC) are also indicative of cholecystitis. Pancreatic involvement typically results in elevated serum amylase and lipase, elevated liver enzymes and leukocytosis.
The incidence of gallstone disease in pregnancy ranges from 1 in 1000 to 1 in 4000 for symptomatic disease. When taking into account the presence of asymptomatic cholelithiasis, the literature suggests that 2.5% to 10% of pregnant women will have this condition demonstrated on ultrasound. It is believed that several factors predispose pregnancy for the development of gallstones. First, the gallbladder volume during fasting and residual volume after contracting is twice that of nonpregnant patients. Second, Incomplete emptying may result in retention of cholesterol crystals. The effect of progesterone on smooth muscle function is though to be the cause of the slow emptying time of the gallbladder. Biliary sludge is thought to increase in pregnancy, again increasing the risk for stone formation. The signs and symptoms of biliary gallstone disease are similar in the pregnant and nonpregnant patient. Development of cholecystitis and/or pancreatitis during pregnancy increases the risk of maternal morbidity, as well as, fetal complications, e.g. preterm labor, low birthweight, fetal loss. Fetal loss is attributed to a combination of acidosis, hypovolemia, and hypoxia.
Evaluation of possible gallstone disease is similar among pregnant and nonpregnant patients. An appropriate history and physical is warranted. Consideration for other disease processes that are similar in presentation, such as acute fatty liver of pregnancy, preeclampsia, infection, etc should occur. Gestational age specific fetal surveillance and recording of maternal vital signs is warranted. Laboratory data, which may be helpful in the evaluation, include:
Complete blood count
Serum amylase
Serum lipase
Liver function tests
Serum chemistries
Urinalysis
Ultrasonography has been shown to be of greatest importance in the evaluation of patients with biliary tract disease. Stones as small as 2 mm can be seen and the sensitivity and specificity of this imaging modality is well over 95%. Findings on ultrasound that are characteristic for acute cholecystitis include tenderness over the gallbladder (ultrasound murphy’s sign), pericholecystic fluid, and thickened gallbladder wall. Cholecystoscintigraphy (HIDA) scan is another radiologic technique used in diagnosis, but is currently believed to be contraindicated in pregnancy.
Early in the evaluation empiric treatment and intervention can be initiated. The patient should be placed NPO, and should be resuscitated with intravenous fluids. Concomitant medical problems should be stabilized. Consideration should be made for nasogastric suction. Paraenteral analgesics should be given and broad antibiotic coverage should be considered especially in cases involving suspected cholecystitis or pancreatitis. In some facilities, it is standard for a consultation to be sought from general surgery and the nutrition/dietary service.
Primary treatment for symptomatic cholelithiasis in nonpregnant patients remains cholecystectomy. This procedure is safe, relieves symptoms, and has low recurrence rate. Most general surgeons would recommend immediate intervention with the exception of gallstone pancreatitis where many suggest that resolution of the pancreatitis should occur before surgery. There is a consensus that surgical intervention is warranted in pregnant patients with obstructive jaundice, acute cholecystitis failing medical management, pancreatitis, or suspected peritonitis. However, the management of symptomatic cholelithiasis remains controversial.
Medical management of symptomatic cholelithiasis includes previously described steps of bowel rest, IV hydration, IV pain control, and surgical/nutrition consultations. A number of nonsurgical approaches have been used for gallstone disease. Oral bile acid dissolution therapy, extracorporeal shock wave lithotripsy, and contact dissolution have been described, but there is little, if any, experience with these methods during pregnancy and are therefore not recommended. Some authors state that up to 80% of patients will get relief from the initial attack with conservative medical treatment. However, literature also suggests that the recurrence rate is high, up to 50% with even higher rates if the initial attack occurs during the second trimester. Some obstetric providers include symptomatic cholelithiasis as an indication for elective induction of labor in appropriate candidates. Successful induction of labor anecdotally relieves the symptoms and shortens the time to potential surgical therapy. The author believes that induction of labor at term in properly selected patients is a viable option for those with symptomatic cholelithiasis.
Surgical intervention remains a viable option even in the pregnant patient with symptomatic gall bladder disease. As noted above, surgical management is indicated in cholecystitis and pancreatitis. Several studies have shown that laparoscopic cholecystectomy is just as safe as open cholecystectomy and even has a number of advantages as well, e.g. shorter hospital stay, lower post-op pain, better cosmesis, etc. Furthermore, several case studies note that the use of the laparoscopic technique is safe and effective even in the third trimester. No strict recommendations exist regarding the obstetric aspects with patients undergoing cholecystectomy but some factors should be considered:
Perioperative fetal monitoring, especially in gestational age past 14 weeks
Adequate maternal hydration prior to surgery
Use of the open (Hassan) technique for insufflation
Placement of the patient in the left lateral recumbent position
Pneumoperitoneum pressure less than 15 mm Hg
Corticosteroid injection for fetal maturity in appropriate patients
Prophylactic tocolytic therapy
Other sources cite the use of other interventions to include percutaneous cholecystostomy and endoscopic retrograde cholangiopancreatography (ERCP) in selected patients.
Several studies have been published comparing the outcomes of medical versus surgical management of symptomatic cholelithiasis (with no evidence of cholecystitis or pancreatitis) during pregnancy. One such study concluded that surgical management is safe, decreases days in the hospital, and reduced the rate of labor induction and preterm deliveries. Furthermore, the rate of relapse of symptoms in those managed medically was significantly higher. Maternal and fetal mortality in both groups was shown to be similar. The patient’s obstetric provider should ensure that she receives an adequate consultation regarding the data and risks regarding surgical intervention.
This review highlighted several salient factors in the role of the obstetric provider in the care of pregnant patients with biliary gallstone disease. The author would like to summarize a few points that are felt to be especially important:
- Pregnancy is a risk factor for cholelithiasis.
- Asymptomatic cholelithiasis does not warrant intervention.
- Symptomatic cholelithiasis can safely be managed medically or surgically.
- There is a significant recurrence rate for symptomatic cholelithiasis in pregnancy.
- Induction of labor for appropriately selected term patients with symptomatic cholelithiasis is a viable option.
- Cholecystitis and pancreatitis increase the risk for maternal and fetal morbidity and mortality and therefore should be treated aggressively.
- The obstetric provider should provide specific recommendations regarding the obstetric aspects in patients undergoing surgical intervention.
References:
- Williams Manual of Obstetrics. Pregnancy Complications. 22nd Edition. 2007.Chapter 59. Disease of Gallbladder and Pancreas.
- Medial Complications During Pregnancy. 5th Edition. 1999. Chapter 14. Liver Diseases.
- Gabbe Obstetrics. Normal and Problem Pregnancies. 4th Edition. 2002. Chapter 14. Surgical Procedures in Pregnancy.
- Lu E, et al. American Journal of Surgery. Volume 188. Issue 6. Dec 2004. Pages 755-759. Medical Versus Surgical Management of Biliary Tract Disease in Pregnancy.
- Bellows C, et al. American Family Physician. Volume 72. No. 4. August 2005. Management of Gallstones.
Questions John.Balintona@ihs.gov
Nurses Corner - Sandra Haldane, HQE
AWHONN – numerous on line courses – materials and fees listed
Introduction to Fetal Heart Monitoring
Self-paced online course introduces fetal heart monitoring (FHM). Perinatal clinicians will gain tools to interpret FHM data, implement interventions, and evaluate the effect of interventions on maternal and fetal well-being.
Five sections cover:
Maternal-fetal overview
Uterine and fetal physiology
Electronic monitoring
Monitoring and interventions
Risk management
Individual and Group fees for courses are also available
Association of Women’s Health Obstetric and Neonatal Nurses
http://www.awhonn.org/awhonn/content.print.do?&name=02_PracticeResources/2J_DODLanding.htm
The Last Hours of Living
Clinical competence, willingness to educate, and calm and empathic reassurance are critical to helping patients and families in the last hours of living. Clinical issues that commonly arise in the last hours of living include the management of feeding and hydration, changes in consciousness, delirium, pain, breathlessness, and secretions. Management principles are the same at home or in a healthcare institution. However, death in an institution requires accommodations to assure privacy, cultural observances, and communication that may not be customary. In anticipation of the event, inform the family and other professionals about what to do and what to expect. Care does not end until the family has been supported with their grief reactions and those with complicated grief have been helped to get care
http://www.medscape.com/viewarticle/542262
PhD in Nursing Concentration in Health Policy
The University of New Mexico, College of Nursing has been approved for the PhD in Nursing Concentration in Health Policy. It will begin in Summer, 2008. Application information for the Doctoral program is on the web.
Marie L. Lobo, PhD, RN, FAAN
University of New Mexico, College of Nursing
mlobo@salud.unm.edu
Office of Women's Health, CDC
Preconception and Interconception Health Status of Women Who Recently Gave Birth
This report summarizes data from 26 Pregnancy Risk Assessment Monitoring System reporting areas that collected data during 2004 and that had achieved overall weighted response rates of >70% and had weighted data available by the time the analysis was conducted in January 2007. Data are reported on indicators regarding 18 behaviors and conditions that are relevant to preconception (i.e., prepregnancy) health and health care and 10 that are relevant to interconception (i.e., postpartum) health and health care. The number of questions that were administered varied by site; certain questions were not asked for all reporting areas. Results varied by maternal age, race/ethnicity, pregnancy intention, and health insurance status. For certain risk behaviors and health conditions, mean overall prevalence was higher among women aged <20 years, black women, women whose pregnancies were unintended, and women receiving Medicaid; however, no single subgroup was consistently at highest risk for all the indicators examined in this report. These data also can be used to identify specific groups at high risk that would benefit from targeted interventions and to plan and evaluate programs aimed at promoting positive maternal and infant health behaviors, experiences, and reproductive outcomes. In addition, the data can be used to inform policy decisions that affect the health of women and infants. http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5610a1.htm?s_cid=ss5610a1_e
Oklahoma Perspective Greggory Woitte – Hastings Indian Medical Center
Cesarean Delivery: What are the risks and benefits?
Here are a few of the recent articles that describe the risks and benefits of cesarean delivery.
Elective Cesarean Delivery Linked to Higher Risk for Infant Respiratory Morbidity
CONCLUSION: Compared with newborns delivered vaginally or by emergency caesarean sections, those delivered by elective caesarean section around term have an increased risk of overall and serious respiratory morbidity. The relative risk increased with decreasing gestational age.
Hansen AK et al Risk of respiratory morbidity in term infants delivered by elective caesarean section: cohort study. BMJ. 2008 Jan 12;336(7635):85-7
http://www.ncbi.nlm.nih.gov/pubmed/18077440
Cesarean delivery can be reduced: Identification of barriers to change is key to success
CONCLUSIONS: The cesarean delivery rate can be safely reduced by interventions that involve health workers in analyzing and modifying their practice. Our results suggest that multifaceted strategies, based on audit and detailed feedback, are advised to improve clinical practice and effectively reduce cesarean delivery rates. Moreover, these findings support the assumption that identification of barriers to change is a major key to success.
Chaillet N et al Evidence-based strategies for reducing cesarean section rates: a meta-analysis. Birth. 2007 Mar;34(1):53-64 http://www.ncbi.nlm.nih.gov/pubmed/17324180
Cesarean delivery increases the risk of maternal and neonatal morbidity and mortality CONCLUSIONS: Caesarean delivery independently reduces overall risk in breech presentations and risk of intrapartum fetal death in cephalic presentations but increases the risk of severe maternal and neonatal morbidity and mortality in cephalic presentations.
Villar J et al Maternal and neonatal individual risks and benefits associated with caesarean delivery: multicentre prospective study. BMJ. 2007 Nov 17;335(7628):1025.
http://www.ncbi.nlm.nih.gov/pubmed/17977819
The Indian Health system strongly encourages vaginal birth whenever possible and we have some of the highest VBAC rates in the country. In fact an Indian Health facility won the ACNM benchmark program award for highest VBAC rate in the US
http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0607_Feat.cfm#mmtour
Overall the Indian Health system has performed VBAC at that high rate consistently
Here is the data from our recent national meeting. It gives the VBAC rates around the whole Indian Health system
http://www.ihs.gov/MedicalPrograms/MCH/F/documents/DataTally81107.doc
If done under existing guidelines and within the standard of care, VBAC is fully covered by the Federal Tort Claim system
We should look closely at the NNEPQIN system, as it works with small rural facilities. In fact, Dr. Lauria presented similar lectures at our meetings in 2004 and again in 2007. For her 2004 presentation go to this link and scroll down to her name (in alpha order)
http://www.ihs.gov/MedicalPrograms/MCH/F/lecNotes.cfm
Here are just a few of the recent articles that have highlighted on this topic in the CCC Corner in recent months. There are many others
Can a 29% Cesarean Delivery Rate Possibly Be Justified?
http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1006_HT.cfm#ob
Vermont , New Hampshire Sections Recognized for Effort
Project Focuses on VBAC
http://www.ihs.gov/MedicalPrograms/MCH/F/ACOG01_vbac.cfm#vbac
(Dr. Cherouny was a lecturer at out meeting in ABQ)
(Small hospitals in New England have the same problems we have )
Trial of Labor After Cesarean: Evidence based guidelines
http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0805_HT.cfm#ob
VBAC: Is There Such a Thing as Low Risk?
http://www.ihs.gov/MedicalPrograms/MCH/M/MCHdownloads/NewMexico.ppt
Here is our free Indian Health CME Module on this topic
Vaginal Birth After Cesarean
http://www.ihs.gov/MedicalPrograms/MCH/M/VB01.cfm
Another approach is to look at the morbidity imposed on our AI/AN women due to all the repeat cesareans
Placental problems with previous caesarean delivery: Abruptio, previa
http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0607_HT.cfm#ob
Postcesarean delivery adhesions associated with delayed delivery of infant
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17466702
More stillbirths after previous cesarean delivery
http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0507_HT.cfm#ob
First delivery by cesarean begins cascade of risks - obstetric and perinatal outcomes
http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=17267823&dopt=AbstractPlus
Here are some things on risks
Is vaginal birth after cesarean (VBAC) or elective repeat cesarean safer in women with a prior vaginal delivery?
http://www.ncbi.nlm.nih.gov/sites/entrez?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16846571
VBAC: Smaller attributable risk than previously reported
http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0807_HT.cfm#ob
As obesity increases in our population, so does the risk of cesarean complications
Linear association between maternal pre-pregnancy body mass index and risk of caesarean section in term deliveries.
http://www.ncbi.nlm.nih.gov/pubmed/16972860
The costs to the system are higher too
Significantly higher rehospitalization rates and costs with planned cesareans
So there is precedent, ongoing successful outcomes, and extensive other literature to support VBAC in the Indian Health system.
Should VBAC be offered at your facility?
Please see the Abstract of the Month and Midwives Corner, above, for help with that answer.
Osteoporosis
Nonpharmacologic Management of Osteoporosis to Minimize Fracture Risk
Nonpharmacologic therapies for osteoporosis, including orthoses, exercise, calcium and vitamin D, fall prevention, and kyphoplasty, complement pharmacotherapy in minimizing fracture risk and maximizing bone mineral density. In patients who cannot or who choose not to take antiosteoporotic medications, these interventions have a definitive role in treatment.
http://www.medscape.com/viewarticle/567334
Postmenopausal Hormone Therapy and Risk of Cardiovascular Disease by Age and Years Since Menopause
Treating Menopausal Symptoms
It is clear that, in general, not all women require treatment for menopausal symptoms. Only approximately 10% of women seek medical help for their symptoms, and it appears that symptoms of nervousness and tension, which may or may not be related to menopause, have the strongest effects on quality of life during the climacteric period.[8-10] However, there is a subset of women, particularly those early in menopause, who truly suffer with menopausal symptoms on a daily basis. For these women, hormone therapy is particularly effective for the management of hot flashes, whereas urogenital symptoms are best managed with localized vaginal treatment.
It should be noted that the analysis of WHI also reached an important conclusion which directly affects the clinical management of menopausal symptoms in older women. Not only were women over 60 years of age at increased risk for coronary heart disease events with hormone therapy, but older women with moderate or severe menopausal symptoms were particularly at risk. This is a critical finding which places these patients and their providers in a conundrum: Hormone therapy is the most effective treatment for menopausal symptoms, but the very women over 60 who might most benefit from this therapy have the highest risk for coronary events associated with hormonal treatment.
Clinicians should offer women with significant menopausal symptoms an overall risk assessment for all of the potential complications of hormone therapy. This evaluation should focus on taking a complete history but should also include an assessment of the lipid profile, as women with increased concentrations of low-density lipoprotein appear to be at particularly high risk for cardiovascular events associated with hormone therapy.[2] All women over the age of 50 should receive annual mammography, regardless of the decision to use hormone therapy.
For women with significant menopausal symptoms who do not have a significant risk for complications of hormone therapy, treatment may be prescribed at the lowest dose and for the shortest duration possible. Seventy-five percent of women who try to stop hormone therapy are successful, and half of women stop using hormone therapy in the first 12 months.[11] Therefore, it is reasonable to try to wean off hormone treatment during the first year. Women whose symptoms return after a trial without hormone therapy may try to taper off treatment again in 6 months. If patients and clinicians remain vigilant as to the possible adverse events of hormone therapy, the risk for adverse events should be relatively small in relation to the improvement in menopausal symptoms.
http://www.medscape.com//viewarticle/559366?sssdmh=dm1.329206&src=0_tp_nl_0#
Depression Associated With Low Bone Mineral Density
CONCLUSIONS: Low BMD is more prevalent in premenopausal women with MDD. The BMD deficits are of clinical significance and comparable in magnitude to those resulting from established risk factors for osteoporosis, such as smoking and reduced calcium intake. The possible contribution of immune or inflammatory imbalance to low BMD in premenopausal women with MDD remains to be clarified.
Eskandari F et al Low bone mass in premenopausal women with depression. Arch Intern Med. 2007 Nov 26;167(21):2329-36.
http://www.ncbi.nlm.nih.gov/pubmed/18039992
Patient Information
Patients Prefer the Method of "Tell Back- Collaborative Inquiry" to Assess Understanding
Conclusions: Patients strongly prefer the Tell Back-Collaborative inquiry when assessing their understanding. We recommend that physicians ask patients to restate what they understand using their own words and that they use a patient-centered approach.
Kemp et al Patients Prefer the Method of "Tell Back- Collaborative Inquiry" to Assess Understanding of Medical Information. J Am Board Fam Med 2008;21 24-30
http://www.jabfm.org/cgi/content/abstract/21/1/24?etoc
Sexually Transmitted Diseases-Prevention and Treatment for You and Your Partner
http://www.aafp.org/afp/20071215/1833ph.html
Perinatology Picks - George Gilson, Maternal Fetal Medicine, ANMC
Women with cardiovascular risk factors may be predisposed to pre-eclampsia
RESULTS: After adjustment for smoking; previous pre-eclampsia; parity; maternal age, education, and socioeconomic position; and duration between baseline measurements and delivery, positive associations were found between prepregnancy serum levels of triglycerides, cholesterol, low density lipoprotein cholesterol, non-high density lipoprotein cholesterol, and blood pressure and risk of pre-eclampsia. The odds ratio of developing pre-eclampsia for women with baseline systolic blood pressures greater than 130 mm Hg (highest fifth) was 7.3 (95% confidence interval 3.1 to 17.2) compared with women with systolic blood pressures less than 111 mm Hg (lowest fifth). Similar results were found for nulliparous and parous women. Women who used oral contraceptives at baseline had half the risk of pre-eclampsia compared with never or former users (0.5, 0.3 to 0.9).
CONCLUSION: Women with cardiovascular risk factors may be predisposed to pre-eclampsia.
Magnussen EB et al Prepregnancy cardiovascular risk factors as predictors of pre-eclampsia: population based cohort study. BMJ. 2007 Nov 10;335(7627):978
http://www.ncbi.nlm.nih.gov/pubmed/17975256
Obstetric outcomes in cancer survivors are reassuring
RESULTS: The mean age at delivery was 29 years (standard deviation 5.66) and 26 years (standard deviation 5.62) in the exposed and unexposed groups respectively (P<.001). Multiple logistic regression showed that cancer survivors had higher rates of postpartum hemorrhage (odds ratio [OR] 1.56, 95% confidence interval [CI] 1.09-2.23) and operative or assisted delivery (abdominal or vaginal) (OR 1.33, 95% CI 1.14- 1.54). Preterm delivery (at less than 37 weeks of gesation) was also found to be higher in this group compared with non-cancer women (OR 1.33, 95% CI 1.01-1.76).
CONCLUSION: While largely reassuring to women intending to become pregnant after surviving cancer, the results indicate areas of increased risk that require additional surveillance.
Clark H, et al Obstetric outcomes in cancer survivors. Obstet Gynecol. 2007 Oct;110(4):849-54. http://www.ncbi.nlm.nih.gov/pubmed/17906019
Booster dose of betamethasone just before preterm birth: Results caution against
CONCLUSIONS: According to this study, a single booster dose of betamethasone just before preterm birth may perturb respiratory adaptation. These results caution against uncontrolled use of a repeat dose of glucocorticoid in high-risk pregnancies.
Peltoniemi OM et al Randomized trial of a single repeat dose of prenatal betamethasone treatment in imminent preterm birth. Pediatrics. 2007 Feb;119(2):290-8.
http://www.ncbi.nlm.nih.gov/pubmed/17272618
Conservative management 1 st choice for severe hydronephrosis in pregnancy
CONCLUSION: Double pigtail stent insertion is effective for the treatment of moderate or severe symptomatic hydronephrosis in pregnancy, and showed a lower failure rate than the conservative treatment. However, due to the complications and discomfort with surgical treatment, conservative treatment should still be the first choice.
Tsai YL et al Comparative study of conservative and surgical management for symptomatic moderate and severe hydronephrosis in pregnancy: a prospective randomized study. Acta Obstet Gynecol Scand. 2007;86(9):1047-50. http://www.ncbi.nlm.nih.gov/pubmed/17712643
Primary Care Discussion Forum - Ann Bullock, Cherokee, NC
Topic: Mental health issues in children and adolescents
When: March 2008
Moderator : Dr. Frank Armao, Psychiatry staff at Winslow
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STD Corner - Lori de Ravello, National IHS STD Program
The cervical cancer risk is still increased 25 years after treatment for CIN 3
CONCLUSIONS: Women previously treated for cervical intraepithelial neoplasia grade 3 are at an increased risk of developing invasive cervical cancer and vaginal cancer. This risk has increased since the 1960s and is accentuated in women aged more than 50. The risk is still increased 25 years after treatment.
Strander B et al Long term risk of invasive cancer after treatment for cervical intraepithelial neoplasia grade 3: population based cohort study. BMJ. 2007 Nov 24;335(7629):1077.
http://www.ncbi.nlm.nih.gov/pubmed/17959735
HPV Vaccine Acceptance Among Mid-Adult Women
Results: Mid-adult women who received the HPV vaccine were more likely to be younger than 55 years (P < .001); have had an abnormal Papanicolaou test (odds ratio [OR], 2.15; 95% CI, 1.18–3.92); understand that HPV causes cervical cancer (OR, 2.39; 95% CI, 1.08–5.30); feel at risk for HPV infection (OR, 2.14; 95% CI, 1.00–4.57), and feel it is important for their partner (OR, 25.20; 95% CI, 9.66–65.72) and children (OR, 3.54; CI, 0.51–24.56) to get the HPV vaccine. Monogamous mid-adult women (OR, 0.46; 95% CI, 0.21–1.00); women who did not want any vaccines (OR, 0.26; 95% CI, 0.07–0.92); and women who felt it was too late to get the vaccine (OR, 0.18; 95% CI, 0.08–0.44) were less likely to want the HPV vaccine.
Conclusions: These clinical predictors of HPV vaccine acceptance will help clinicians recognize mid-adult women who may be more receptive to vaccination.
Ferris DG et al HPV Vaccine Acceptance Among Mid-Adult Women J Am Board Fam Med 2008;21 31-37 http://www.jabfm.org/cgi/content/abstract/21/1/31?etoc
Adding HPV test to the Pap test to screen in mid-30s reduces grade 2 or 3 CIN and cancer
CONCLUSIONS: The addition of an HPV test to the Pap test to screen women in their mid-30s for cervical cancer reduces the incidence of grade 2 or 3 cervical intraepithelial neoplasia or cancer detected by subsequent screening examinations.
Human papillomavirus and Papanicolaou tests to screen for cervical cancer.
N Engl J Med. 2007 Oct 18;357(16):1589-97. http://www.ncbi.nlm.nih.gov/pubmed/17942872
New point of care Chlamydia Rapid Test: Bridging the gap between Dx and Treatment
CONCLUSIONS: The performance of the Chlamydia Rapid Test with self collected vaginal swabs indicates that it would be an effective same day diagnostic and screening tool for Chlamydia infection in women. The availability of Chlamydia Rapid Test results within 30 minutes allows for immediate treatment and contact tracing, potentially reducing the risks of persistent infection and onward transmission. It could also provide a simple and reliable alternative to nucleic acid amplification tests in chlamydia screening programmes.
Mahilum-Tapay L, et al New point of care Chlamydia Rapid Test--bridging the gap between diagnosis and treatment: performance evaluation study. BMJ. 2007 Dec 8;335(7631):1190-4.
http://www.ncbi.nlm.nih.gov/pubmed/18055487
Recurring C. trachomatis Infections in Young Women
Background: The Institute of Medicine reports that sexually transmitted infections (STIs) are a "hidden epidemic" because the public and health care professionals underestimate the impact of these infections. Young women are particularly at risk of STIs because they tend to have multiple sexual partners, do not recognize long-term effects of STIs, and tend not to seek STI-related health care. The rate of Chlamydia trachomatis infection in women 15 to 24 years of age is more than 2,000 cases per 100,000 women. Studies show that 5 to 30 percent of women in this age group receive screening and are positive for C. trachomatis. The impact of this infection in young women includes increased risk of infertility, chronic pelvic pain, pelvic inflammatory disease, and human immunodeficiency virus (HIV) infection. Niccolai and colleagues assessed the frequency and pattern of C. trachomatis recurrence in young women.
The Study: The cohort study included adolescent women from 10 public health clinics. Patients were included if they were 14 to 19 years of age, sexually active, nulliparous, and HIV negative. Participants were evaluated at baseline and at six, 12, and 18 months. At each evaluation, a urine sample was used to test for C. trachomatis. Data were also collected using structured face-to-face interviews and reviews of medical records and health department reports of C. trachomatis infections. The main outcome measure was the diagnosis of recurrent C. trachomatis infection.
Results: For the 411 participants in the study, the mean age was 17.3 years, and the mean follow-up was 4.7 years per person. The average age of participants at first intercourse was 14.5 years, and the mean number of lifetime partners was 4.0. C. trachomatis infections were diagnosed in 52.6 percent of participants; of these, 56.9 percent were diagnosed with recurrent infections. The rate of recurrent infection was 42.1 per 1,000 person-months, and the median time to recurrent infection was 5.2 months.
Conclusion: The authors conclude that recurrent C. trachomatis infections pose a significant health burden in young women. They add that the recurrence rate in this population may be higher than previously recognized.
Niccolai LM, et al. Burden of recurrent Chlamydia trachomatis infections in young women: further uncovering the "hidden epidemic." Arch Pediatr Adolesc Med. March 2007(3);161:246-251.
http://www.ncbi.nlm.nih.gov/pubmed/17339505
Barbara Stillwater, Alaska State Diabetes Program
Resolving to Lose Weight in the New Year?
As You Try To Find a Weight Loss Plan for 2008, Here’s What You Need to Know
People who want to lose weight in 2008 but can’t decide which weight-loss plan to follow may want to ask their health care provider about the American Diabetes Association’s ( ADA) new Clinical Practice Recommendations, issued today.
The revised Recommendations, which help health care providers treat people with diabetes or at risk for diabetes using the most current evidence available, include a revision in the nutrition section indicating that diets restricting carbohydrates or fat calorie intake are equally effective for reducing weight in the short term (up to one year).
But far more important than which diet you choose is whether you can stick to it! The ADA also cites scientific evidence showing that how well a person adheres to a diet is one of the biggest determinants in whether they’ll succeed in losing weight.
Set Your Goals
Set a realistic weight loss goal. Think about losing 5, 10 or 15 pounds. One of your goals should be to lose a few pounds and be able to keep it off for a long time. Here are some tips to help you make goals.
- Identify a support system, family, friends or co-workers, who will support your weight loss efforts.
- Do a self-check on what and when you eat. Keep honest food records for about a week. Write down everything you eat or drink. Use these records to set a few food goals.
- Be ready to gradually change your food habits (and perhaps your family's food habits) for good. Say good bye to some of your unhealthy habits and food choices.
- Do a physical activity self-check. How much exercise do you get? How can you work more of it into your day?
“The risks of overweight and obesity are well known. We recognize that people are looking for realistic ways to lose weight,” said Ann Albright, PhD, RD, President, Health Care and Education, American Diabetes Association. “The evidence is clear that both low-carbohydrate and low-fat calorie restricted diets result in similar weight loss at one year. Short-term weight loss is beneficial, but what is most important for health is keeping the weight off long-term,” said Albright. “We also want to continue to emphasize the importance of regular physical activity, both to aid in maintenance of weight loss, and also for the positive health gains associated with exercise that are independent of weight loss.”
Monitor Your Health
The ADA also caution people with diabetes to carefully monitor their health when following restrictive weight-loss plans. People following low-carb diets may replace calories from carbohydrate with fat or protein. That makes it even more important for them to monitor their lipid profiles (blood fats, including cholesterol and triglycerides). High protein diets may also worsen kidney problems. So people who have kidney disease should consult a physician about the appropriate amount of protein for them to consume and also be sure to carefully monitor their kidney functions.
Being overweight or obese and inactive are major contributing factors to the onset of type 2 diabetes. Overweight and obesity also complicate the treatment of diabetes (both type 1 and type 2) and can contribute to the development of other health problems, such as heart disease and cancer. In the United States, rates of type 2 diabetes in adults and children have risen dramatically in recent years, along with the national epidemic of obesity.
Does being overweight or obese increase subsequent hysterectomy risk?
Women who are overweight from the age of 36 and those who are obese from the age of 43 and 53 have a higher risk of hysterectomy than underweight and normal-weight women.
-There are many health difficulties associated with obesity and the MRC study shows that, particularly after the age of 36, being overweight or obese can be linked to hysterectomy in later life. There are risks associated with hysterectomy and these are heightened if the patient is obese. With a growing prevalence of obesity in the community, the MRC study findings are a cause of concern.
CONCLUSIONS: These results suggest that variation in hysterectomy rates may be partially explained by variation in adiposity, and so with the recent changes in levels of overweight and obesity in populations, there may be increasing demand for gynaecological treatments in the future.
Cooper R et al Is adiposity across life associated with subsequent hysterectomy risk? Findings from the 1946 British birth cohort study. BJOG. 2008 Feb;115(2):184-92; discussion 192 .
http://www.ncbi.nlm.nih.gov/pubmed/18081600
Prepregnancy BMI, hypertensive disorders of pregnancy, and long-term maternal mortality
CONCLUSION: Elevated prepregnancy BMI is associated with increased risk of hypertensive disorders of pregnancy (HDP), which are in turn is associated with increased long-term maternal mortality rates. This association between HDP and mortality rates increases with elevated prepregnancy BMI.
Samuels-Kalow ME et al Prepregnancy body mass index, hypertensive disorders of pregnancy, and long-term maternal mortality. Am J Obstet Gynecol. 2007 Nov;197(5):490.e1-6. http://www.ncbi.nlm.nih.gov/pubmed/17714679
Glycemic Profiles During Pregnancy Differ Between Type 1 and Type 2 Diabetes
CONCLUSIONS: Continuous glucose monitoring reveals clear differences in the level of glycemic control that exist in women with type 1 and type 2 diabetes. These data will guide therapeutic interventions aimed at optimizing glycemic control and improving the pregnancy outcomes of both type 1 and type 2 diabetes.
Murphy HR, et al Changes in the glycemic profiles of women with type 1 and type 2 diabetes during pregnancy. Diabetes Care. 2007 Nov;30(11):2785-91
http://www.ncbi.nlm.nih.gov/pubmed/17666464
Miscarriage and abortion triple chances of future low birth weight babies
Women who have miscarried or had an abortion run three times the normal risk of having a subsequent low birth weight baby.
CONCLUSION: Previous abortion is a significant risk factor for LBW and PB, and the risk increases with the increasing number of previous abortions. Practitioners should consider previous abortion as a risk factor for LBW and PB.
Brown JS et al Previous abortion and the risk of low birth weight and preterm births.
J Epidemiol Community Health. 2008 Jan;62(1):16-22 .
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=18079328
Women's Health Headlines, Carolyn Aoyama, HQE
Women's Leadership Scholarship
Women's Leadership Scholarship is a program of the Channel Foundation, a small, private foundation based in Seattle, Washington, USA that promotes leadership in women's human rights around the globe. Channel's mission is to fund and create opportunities for groups working in many regions of the world to ensure that women's human rights are respected, protected, and fulfilled.
Eligible candidates include women leaders from the Global South and/or from indigenous groups who also meet all the following criteria:
1. They are committed to grassroots organizing and the needs of their communities or indigenous group.
2. They have proof of a bachelor's or a higher degree.
3. They have at least three years of work experience dealing with critical human rights concerns, and other social, educational, environmental, health or economic conditions that negatively affect their communities.
4. They have been accepted into a non-doctoral graduate program at an accredited university for full-time study/research related to their work experience in human rights, sustainable development, and/or public health.
5. They can show evidence of financial need for educational support.
6. They intend to return to their home countries to work, utilizing training and research acquired in the study program.
http://www.nativeleaders.org:80/how.html
New Resource from the National Center for Cultural Competence
The National Center for Cultural Competence (NCCC) has just released a new monograph on cultural and linguistic competence in systems serving children and youth with special health care needs and their families.
Many examples are related to State Title V programs, but the monograph offers insights and lessons that apply to any organization.
You can access the document at http://www.gucchdgeorgetown.net/NCCC/journey/
Ending Violence Against Native Women Training Institute and scholarship opportunity
We are excited to kick off the New Year with our 5 day to be held in Atlanta, GA, January 28th - February 1, 2008. If you have any questions contact Coya Artichoker at 605-341-2050.
We are also pleased to announce this NEW exciting to attend the Institute!
The Tribal Judicial Institute at the University of North Dakota School of Law has monies for ten tribal judicial personnel (prosecutors, judges, probation officers, etc.) to attend the Sacred Circle Domestic Violence Training Institute in Atlanta, GA on January 28 th-February 1 st, 2008. The scholarship covers airfare, registration and lodging but will not cover per diem.
If a person is interested in requesting a scholarship, please contact Melissa Johnson at 701-777-6306
Training:
http://www.sacred-circle.com/SC%20at%20a%20glance2008.pdf
Registration:
http://www.sacred-circle.com/Registration%20from2008.pdf
Native Women's Health and Well-Being Conference
National Indian Women's Health Resource Center (NIWHRC) conference, “Native Women's Health and Well-Being Conference” which will be held June 9-11, 2008, in Albuquerque, New Mexico.
The purpose of the conference is to celebrate the 10th year anniversary of NIWHRC by hosting a conference to raise awareness abut the many health issues affecting American Indian and Alaska Native women. The conference will focus on Mental, Physical, Emotional, and Spiritual well being form the health prevention/health promotion approach. They also plan to have a youth track focusing on Positive Choices and Healthy Relationships. They are planning for 300 participants and the audience is targeted toward grassroots native women, women's health advocates in tribal communities, health educations staff, and other health providers. It will be certified by CHES. Examples of information and workshops will include: Indian Women in Action; HIV Intergenerational Approach across the lifespan; cardiovascular health, Violence against women prevention; traditional mentoring, coalition building and others. They want to share with others their positive experiences with some of the OWH programs they have been involved with.
Pam Iron, Executive Director
National Indian Women's Health Resource Center
Women's History Month: March 2008
National Women's History Month's roots go back to March 8, 1857, when women from New York City factories staged a protest over working conditions. International Women's Day was first observed in 1909, but it wasn't until 1981 that Congress established National Women's History Week to be commemorated the second week of March.
In 1987, Congress expanded the week to a month. Every year since, Congress has passed a resolution for Women's History Month, and the president has issued a proclamation.
153.6 million
The number of females in the United States as of Oct. 1, 2007. The number of males is 149.4 million.
As of July 1, 2006, males outnumbered females through age 41. Starting at 42, women outnumbered men. At 85 and older, there were more than twice as many women as men. Source: Population estimates
Motherhood
82.8 million
Estimated number of mothers of all ages in the United States.
1.9
Average number of children that women 40 to 44 had given birth to as of 2004, down from
3.1 children in 1976, the year the Census Bureau began collecting such data. Likewise, the percentage of women in this age group who were mothers was 81 percent in 2004, down from 90 percent in 1976.
Earnings
$32,649
The median annual earnings of women 16 or older who worked year-round, full time, in 2006. Women earned 77 cents for every $1 earned by men.
98 cents
The amount women ($48,586) in the District of Columbia, who worked year-round, full time, earned for every $1 their male counterparts earned ($49,544) in 2006. Among all states or state equivalents, the district was where women were closest to earnings parity with men.
Connecticut , Maryland and New Jersey were the only states where median earnings for women were greater than $40,000.
$61,081
Median earnings of women working in computer and mathematical jobs, the highest for women among the 22 major occupational groups. In the community and social services group, women's earnings as a percentage of men's earnings were higher than 90 percent.
Education
32%
Percent of women 25 to 29 who had attained a bachelor's degree or higher in 2006, which exceeded that of men in this age range (25 percent).
Eighty-eight percent of women and 84 percent of men in this same age range had completed high school.
86%
Percent of women 25 and older who had completed high school as of 2006.
High school graduation rates for women
continued to exceed those of men (85 percent). Source: Educational Attainment in the United States: 2006
26.8 million
Number of women 25 and older with a bachelor's degree or more education in 2006, more than double the number 20 years earlier.
27%
Percent of women 25 and older who had obtained a bachelor's degree or more as of 2006. This rate was up 11 percentage points from 20 years earlier. Source: Educational Attainment in the United States: 2006
894,000
The projected number of bachelor's degrees that will be awarded to women in the 2007-08 school year, who are also projected to earn 380,000 master's degrees during this period. Women would, therefore, earn 59 percent of the bachelor's and 61 percent of the master's degrees awarded during this school year. In addition, women would earn a majority (52 percent) of first-professional degrees, such as law and medical.
Businesses
More than $939 billion
Revenue for women-owned businesses in 2002. There were 116,985 women-owned firms with receipts of $1 million or more.
Nearly 6.5 million
The number of women-owned businesses in 2002. Women owned 28 percent of all nonfarm businesses.
More than 7.1 million
Number of people employed by women-owned businesses. There were 7,231 women-owned firms with 100 or more employees, generating $274 billion in gross receipts. Nearly one in three women-owned firms operated in health care and social assistance, and other services, such as personal services, and repair and maintenance. Women owned 72 percent of social assistance businesses and just over half of nursing and residential care facilities. Wholesale and retail trade accounted for 38.2 percent of women-owned business revenue.
13%
Percentage of women-owned firms in California. California had the most women-owned firms at 870,496. New York was second with 505,077 or 8 percent of all firms. Texas was third in number of firms with 468,705, accounting for 7 percent of all firms.
Voting
65%
Percentage of female citizens 18 and older who reported voting in the 2004 presidential election. Sixty-two percent of their male counterparts cast a ballot.
Jobs
59%
On average in 2006, the percent of females 16 and older who participated in the labor force, representing about 70.2 million women.
More than 50 million women worked full time. The participation rate for males in this age category was 74 percent.
37%
Percent of females 16 or older who work in management, professional and related occupations, compared with 31 percent of males.
22 million
Number of female workers in educational services, health care and social assistance industries. More women work in this industry group than in any other. Within this industry group, 11 million work in the health care industry and 8.4 million in educational services.
39%
In 2004, among women 20 to 64 who did not work for four or more consecutive months, the percentage taking care of children or others.
This was the primary reason among such women for not working. By comparison, 2 percent of corresponding men did not work for this reason.
60%
Chances that your taxes will be prepared by a woman, as this is the percentage of tax preparers who are women. In addition, 77 percent of travel agents are women, so it is likely a woman will help you plan your next vacation .
84,000
Number of female police officers. In addition, there are about 9,000 women firefighters, 315,000 lawyers, 278,000 physicians and surgeons, and 37,000 pilots.
Military
202,000
Total number of active duty women in the military, as of Sept. 30, 2006.
Of that total, 34,000 women were officers, and 168,000 were enlisted.
15%
Proportion of members of the armed forces who were women, as of Sept. 30, 2006. In 1950, women comprised less than 2 percent.
1.7 million
The number of military veterans who are women.
Marriage
62.4 million
Number of married women (including those who are separated or have an absent spouse) in 2006. There were 59.8 million unmarried (widowed, divorced or never married) women.
18%
Percentage of married couples in which the wife earned at least $5,000 more than the husband in 2006. Among 22 percent of married couples, the wife had more education than the husband.
5.6 million
Number of stay-at-home mothers nationwide in 2006, up from 4.6 million a decade earlier.
Computers
84%
Proportion of women with computers in the home in 2003 who made use of that computer, 2 percentage points higher than the corresponding proportion for men. This reverses the computer use gender gap exhibited during the 1980s and 1990s.
The Spirit of Volunteerism
30%
Percentage of women who volunteer. The corresponding rate for men is 23 percent. Overall, 36 million women perform unpaid volunteer activities
Sports
3 million
Number of girls who participated in high school athletic programs in the
2005-06 school year. In the 1975-76 school year, only 1.6 million girls were members of a high school athletic team.
168,583
Number of women who participated in an NCAA sport in 2005-06.
Editor's note: The preceding data were collected from a variety of sources and may be subject to sampling variability and other sources of error.
Facts for Features are customarily released about two months before an observance in order to accommodate magazine production timelines.
Questions or comments should be directed to the Census Bureau's Public Information
Office: telephone: 301-763-3030; fax: 301-763-3762; or e-mail: pio@census.gov
Save the dates
Training in Palliative and End of Life Care
- March 25 -27, 2008
- Minneapolis , MN
- Contact Tim Domer MD at tim.domer@ihs.gov
Keeping Native Women & Families Healthy & Strong
- April 23-25, 2008
- Milwaukee , WI
- Great Lakes Tribal Epidemiology Center
- E-mail contact EpidemiologyCenter@gmail.com
IHS Basic Colposcopy Course
- April 9 - 11, 2008
- Albuquerque , NM
- Contact AWaxman@salud.unm.edu
IHS Colposcopy Update & Refresher Course
- April 9 - 11, 2008
- Albuquerque , NM
- Contact AWaxman@salud.unm.edu
Training in Palliative and End of Life Care
- April 22-24, 2008
- Flagstaff , AZ
- Contact Tim Domer MD at tim.domer@ihs.gov
Advances in Indian Health (AIH) Conference
- April 29 – May 2, 2008
- Albuquerque , New Mexico
- 28 credits, Indian Country’s Primary Care Conference
http://www.ihs.gov/MedicalPrograms/MCH/F/CN01.cfm?module=2008&option=may#top
What's new on the ITU MCH web pages?
How to strengthen pelvic floor muscles?
There are several upcoming Conferences
and Online CME/CEU resources, etc….
and the latest Perinatology Corners (free online CME from IHS)
…or just take a look at the What’s New page
Did you miss something in the last OB/GYN Chief Clinical Consultant Corner?
The December 2007 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.
