August 2005 CCC Corner > Features

Features

American Family Physician**

Aspirin Prevents Stroke, but Not Cardiovascular Disease, in Women

Clinical Question: Does aspirin prevent cardiovascular disease in women?

Bottom Line: Aspirin reduces the risk of stroke and transient ischemic attack in women, but does not reduce the risk of myocardial infarction or cardiovascular death. The reduction in strokes over 10 years (NNT = 444) must be balanced against an increase in serious gastrointestinal bleeding (NNH = 553). No change regarding all-cause mortality was seen in this large, long study.

(Level of Evidence: 1b) http://www.aafp.org/afp/20050801/tips/9.html

Intensive Diet-Behavior-Physical Activity Program for Obesity in Children

Clinical Question: Can a specific program of diet and exercise result in sustained weight loss in children?

Bottom Line: An intensive three-month program of dietary counseling, a hypocaloric diet, and structured exercise can cause weight loss in children that is sustained over one year. More important, the program seemed to increase the amount of exercise the children performed, and this increase was sustained after the intervention was discontinued. (

Level of Evidence: 2b) http://www.aafp.org/afp/20050801/tips/7.html

* POEM Rating system : http://www.infopoems.com/levels.html POEM Definition: http://www.aafp.org/x19976.xml

** The AFP sites will sometimes ask for a username and password. Instead just ‘hit; cancel on the pop up password screen, and the page you are requesting will come up without having to enter a username and password.

Other AFP

NSAIDs Alone or with Opioids as Therapy for Cancer Pain: Cochrane for Clinicians

Clinical Scenario

A 70-year-old woman is diagnosed with malignant melanoma that has metastasized to the liver and lungs. She has begun to experience abdominal pain, which you attribute to the liver metastases. She wants to know what you recommend for pain management.

Clinical Question

What is the most effective therapy for the management of cancer pain?

Evidence-Based Answer

Short-term trials indicate that cancer pain can be reduced with the use of nonsteroidal anti-inflammatory drugs (NSAIDs) as initial monotherapy. NSAIDs combined with opioids can result in slight short-term improvement in pain compared with either agent alone. Long-term efficacy and safety of NSAIDs for cancer pain have not been established.

http://www.aafp.org/afp/20050801/cochrane.html#c1

Health Literacy: The Gap Between Physicians and Patients

http://www.aafp.org/afp/20050801/463.html

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ACOG

Management of Endometrial Cancer

ACOG Practice Bulletin NUMBER 65, AUGUST 2005

Summary of Recommendations and Conclusions
The following recommendations are based on limited or inconsistent scientific evidence (Level B):

• Most women with endometrial cancer should undergo systematic surgical staging, including pelvic washings, bilateral pelvic and paraaortic lymphadenectomy, and complete resection of all disease. Exceptions to this include young or perimenopausal women with grade 1 endometrioid adenocarcinoma associated with atypical endometrial hyperplasia and those at increased risk of mortality secondary to comorbidities.
• Women with atypical endometrial hyperplasia and endometrial cancer who desire to maintain their fertility may be treated with progestin therapy. Following therapy they should undergo serial complete intrauterine evaluation approximately every 3 months to document response. Hysterectomy should be recommended for women who do not desire future fertility.
• Patients with surgical stage I disease may be counseled that postoperative radiation therapy can reduce the risk of local recurrence, but the cost and toxicity should be balanced with the evidence that it does not improve survival or reduce distant metastasis.
• For those women who have not received radiation therapy, pelvic examinations every 3–4 months for 2–3 years, then twice yearly following surgical treatment of endometrial cancer are recommended for detection and treatment of recurrent disease.

The following recommendations are based primarily on consensus and expert opinion (Level C):

• Women who cannot undergo systematic surgical staging because of comorbidities may be candidates for vaginal hysterectomy.
• Only a physical examination and a chest radiograph are required for preoperative staging of the usual (type I endometrioid grade 1) histology, clinical stage I patient. All other preoperative testing should be directed toward optimizing the surgical outcome.

Management of endometrial cancer. ACOG Practice Bulletin No. 65. American College of Obstetricians and Gynecologists. Obstet Gynecol 2005;106:413–25

Non-ACOG Members

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16055605&query_hl=4

ACOG Members

http://www.acog.org/publications/educational_bulletins/pb065.cfm

Health Care for Homeless Women

Homelessness is a considerable social and health problem in the United States with far-reaching effects on the health of homeless women. Homeless women are at higher risk for injury and illness and are less likely to obtain needed health care than women who are not homeless. It is critical to undertake efforts to prevent homelessness. Until this can be accomplished, community-based services targeted specifically to this population that provide both health care and support services are essential. Health care providers can help address the needs of the homeless by identifying their own patients who may be homeless, treating their health problems, offering preventive care, and working with the community to improve the full range of resources available to these individuals.

Health Care for Homeless Women. ACOG Committee Opinion No. 312. American College of Obstetricians and Gynecologists. Obstet Gynecol 2005;106:429–34.

Non-ACOG Members

http://www.ncbi.nih.gov/entrez/query.fcgi

ACOG Members

http://www.acog.org/publications/committee_opinions/co312.cfm

Two Major Women's Health Groups Call Attention to a Leading Reproductive Cancer

The American College of Obstetricians and Gynecologists (ACOG) and the Society of Gynecologic Oncologists (SGO) today issued guidance to physicians for diagnosing, managing, and treating endometrial cancer, the most common female genital tract malignancy. In the US, more than 40,000 women will be diagnosed with endometrial cancer this year; it is the fourth most common cancer in women, behind lung, breast, and colon cancer. Approximately 7,310 women die annually from the disease. Because it is the most common cancer of the female reproductive system, nearly all ob-gyns will encounter the disease sometime in their career.

Written in partnership with the SGO, the new ACOG Practice Bulletin, "Management of Endometrial Cancer," provides information on the epidemiology, the cause(s) and effects of the disease, and the management strategies, that will allow ob-gyns to identify women at increased risk, help diagnose cases early, and recommend treatment options. The document also outlines instances in which patients may benefit from referral to a gynecologic oncologist.

"This important collaboration between ACOG and SGO is another step we have taken together to improve care for women with gynecologic cancers," says James W. Orr, Jr, MD, ACOG Fellow and immediate past president of SGO. "The comprehensive guidance offered for the management of women with endometrial cancer will contribute to improving patient outcomes."

The most common cause of endometrial cancer is an excess of estrogen unopposed by progestogen; it is more common in women who take estrogen therapy alone, without a progestin hormone, after menopause. Women who take combination birth control pills (estrogen plus progestin) appear to have a lower risk. Women are at a higher risk of endometrial cancer if they:

• Do not ovulate regularly and often miss periods
• Began menstruating before age 12
• Have never been pregnant
• Have a history of infertility
• Are 50 or more pounds overweight
• Have endometrial hyperplasia (abnormal thickening of the endometrium)
• Have late menopause (on average, around age 51)

It is important to identify women at risk for endometrial cancer in order to provide them with counseling and appropriate screening. In addition, women with anovulatory disorders or problems with ovulation should be counseled about their long-term risk of endometrial cancer, and ways they can prevent or reduce their risk of the disease.

There is no standard screening test to detect endometrial cancer and routine screening is not recommended because of the lack of an appropriate, cost-effective, and acceptable test that reduces mortality. Fortunately, most women (90%) with endometrial cancer develop symptomatic vaginal bleeding or discharge that leads to an early diagnosis and results in an increased opportunity for cure, notes ACOG. Other symptoms include pelvic pressure or discomfort. A biopsy is the accepted first step in evaluating a patient with abnormal uterine bleeding or if endometrial cancer is suspected.

According to ACOG, most women with endometrial cancer should undergo complete systematic surgical staging to help determine appropriate management. Surgery is the most common treatment for women with endometrial cancer. In the unusual instance when a patient is deemed an exceptionally poor surgical candidate, radiation treatments alone may be considered in an attempt to treat the uterine disease. Women with atypical endometrial hyperplasia or very small endometrial cancer who want to maintain their fertility may be treated with progestin therapy.

ACOG also recommends that to detect any recurrent disease, patients should undergo pelvic exams every three to four months for two to three years, then twice a year, after surgical treatment of the cancer. http://www.acog.org/from_home/publications/press_releases/nr08-01-05-3.cfm

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AHRQ

Despite revised guidelines, most obstetrician/gynecologists continue to over-screen low-risk women for cervical cancer

http://www.ahrq.gov/research/jun05/0605RA12.htm#head12

Physician supply increases in States with caps on malpractice lawsuit awards, with the greatest impact in rural areas

http://www.ahrq.gov/research/jun05/0605RA1.htm

Women respond differently to medications than men and should be proactive about their medication use

http://www.ahrq.gov/research/jun05/0605RA11.htm#head11

Efforts to help physicians improve care for underserved patients should address issues of communication and respect

http://www.ahrq.gov/research/jul05/0705RA19.htm

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Ask A Librarian: Diane Cooper, M.S.L.S. / NIH

The Known and the Unknown - Clinical Evidence Summarized

A new resource offering the best available evidence on the effects of common clinical interventions is now available online. Clinical Evidence summarizes what is known – and not known – on over 200 medical conditions and over 2,000 treatments seen in primary and hospital care. Clinical Evidence is based on thorough searches and appraisal of the literature. It is neither a textbook of medicine nor a set of guidelines. Instead it describes the best available evidence from systematic reviews, randomized control trials, and observational studies. Here are some reasons Clinical Evidence may be useful to you:

• You start with a question – Clinical Evidence does too
• Evidence is presented in clear and easy-to-read summaries
• New and updated topics are added monthly
• Includes information on benefits, harms and outcomes which will help you with you treatment decisions
• Saves you time and effort

To access Clinical Evidence go to: http://hsrl.nihlibrary.nih.gov

Click on Research Tools > Databases > Clinical Evidence

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Breastfeeding

Fentanyl During Labor May Impede Establishment of Breastfeeding

CONCLUSIONS: A dose-response relationship between fentanyl and artificial feeding has not been reported elsewhere. When well-established determinants of infant feeding are accounted for, intrapartum fentanyl may impede establishment of breastfeeding, particularly at higher doses

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Case Manager's Corner

Stress and verbal abuse in nursing

RESULTS: Respondents reported that the most frequent source of abuse was nurses (27%), followed by patients' families (25%), doctors (22%), patients (17%), residents (4%), other (3%) and interns (2%). Of those who selected a nurse as the most frequent source, staff nurses were reported to be the most frequent nursing source (80%) followed by nurse managers (20%). CONCLUSIONS: Verbal abuse in nursing is quite costly to the individual nurses, the hospitals and the patients. Nurses who regularly experience verbal abuse may be more stressed, may feel less satisfied with their jobs, may miss more work and may provide a substandard quality of care to patients.

Rowe MM, Sherlock H. Stress and verbal abuse in nursing: do burned out nurses eat their young? J Nurs Manag. 2005 May;13(3):242-8
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15819837&query_hl=23

OB/GYN CCC Editorial comment:

This is an important article that should serve to remind us that there is no role for verbal abuse in the health care setting. As over ½ of the sources of the verbal abuse are fellow health care workers, this problem can be remedied with improved communication with our colleagues.

* In lieu of a Case Manager submission, Reynaldo Espera. R. N., from ANMC Labor and Delivery submitted the above

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CCC Corner Digest

Nicely laid out hard copy - compact digest of last month’s CCC Corner

Highlights include

-USPSTF recommends that clinicians screen all pregnant women for HIV

-Simple Educational Handouts – Kat Franklin, Sante Fe

-Elective Repeat Cesarean Delivery May Negatively Affect Neonatal Outcomes

-Benzocaine spray does not offer effective pain control during per endometrial biopsy

-OCPs are more effective than placebo for relieving dysmenorrhea in adolescents

-Death rates for CVD are higher among AI/AN than other U.S. groups

-Pregnancy and Depression: What Women Need to Know

-What is an RN Case Manager?

-2 positive blood cultures found in a postpartum patient with a fever

-Benefits of low-fat dairy products on weight loss

-What Makes a Drug Over the Counter (OTC)? The case of Plan B

-Active management of the third stage of labor among American Indian women

-Racial / Ethnic Disparities in Infant Mortality: No significant improvement in AI / AN

-Use the talk / sing test during exercise during pregnancy

-Here is a good web based calcium screening tool

-Can chlamydia be stopped?

http://www.ihs.gov/MedicalPrograms/MCH/M/documents/05JulyOL.pdf

If you want a copy of the CCC Digest mailed to you each month, please contact nmurphy@scf.cc

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Domestic Violence

Developing Leaders in Violence Prevention – Travel funding available

Please forward to any group that may be interested, including tribal organizations. Program fees and accommodation costs are borne by the Institute. Travel stipends are available for teams that may not be able to afford travel. You can contact the institute for further information. Theresa.Cullen@IHS.GOV

Cultural Competency for Non-Native Advocates and Ending Violence Against Native Women Training Institute

September 24-30, 2005, Rapid City, SD

Sacred Circle National Resource Center to End Violence Against Native Women will hold two sessions at the Holiday Inn Rushmore Plaza.  Cultural Competency for Non-Native Advocates will address the realities for Native women and strategies for inclusion and recruitment of Native women by Non-Native programs on September 24 to 26.  The Ending Violence Against Native Women Training Institute will address colonization and violence against women, dynamics of battering, federal laws including the Violence Against Women Act, coordinating a tribal community response and prioritizing women’s safety and offender accountability.  For more information, please call 1-877-733-7623. Theresa.Cullen@IHS.GOV

The 2006 PREVENT Institute:  Developing Leaders in Violence Prevention

An intensive training experience for advanced multi-organizational teams working to prevent violence before it starts.  This training is different than our Workshop in length, intensity, content, application process and types of teams selected.  Please go to www.PREVENT.unc.edu for more information on both programs.

The PREVENT Institute builds skills to:
- Enhance leadership for violence prevention and social change
- Plan, implement, evaluate and sustain evidence-based prevention efforts
- Communicate effectively with policy makers, media and others
- Develop partnerships and extend networks
Visit http://www.prevent.unc.edu/education/institute.htm for Institute information

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Elder Care News

Toward optimal screening strategies for older women: Should cost matter the most?

CONCLUSIONS: If all women receive idealized treatment, the benefits of mammography beyond age 79 are too low relative to their costs to justify continued screening. However, if treatment is not ideal, extending screening beyond age 79 could be considered, especially for women in the top 25% of life expectancy for their age.

Mandelblatt JS, et al Toward optimal screening strategies for older women. J Gen Intern Med. 2005 Jun;20(6):487-96.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15987322&query_hl=1

Comment: Burt Attico, M.D. Retired USPHS

This is a long paper, but its general theme is based on averages and costs. The rates of cancer in women are generally stated as 1 in 8, but that is actually the risk at age 85. This paper argues that screening is expensive, and, as the population "grays," this will amount to increased costs for the health system, with the potential life expectancy really not being increased significantly when breast cancer is diagnosed. This is the reason for the testing frequency then dropping when the patient gets older.

I am concerned about ethical issues with this type of cost reasoning, where economics becomes one of the major factors in deciding whether a health "benefit" is offered or not. I am going to present this to one of my friends who serves on two local Ethics Committees.

This is a treatise based on "evidence-based medicine," in which the authors distort the recommended guidelines for doing breast CA screening, and then say that you should probably totally forget screening after age 79, since screening and treatment are dramatically increasing the costs of Medical care (Medicare costs) for the number of years that are saved when compared to life expectancy. 

Old people cost too much. That's a very crude way of saying it, but I've essentially distilled it; I got lost in their math.  They start by saying that breast CA is mainly a disease of old-age, that incidence goes up after 50, that the death rate is higher after age 65, but that you should figure life expectancy when deciding whether or not to do screening. They advocate screening biennially, although the present standard is annually, and have their cost model figured on biennial screening.

I even went back and looked up the ACOG Clinical Practice Bulletins to make sure.  This article definitely conflicts, and puts a $$$-cost sign on the life and the health of older women.  I feel that its implications are basically unethical, since the implication is that these elders owe society a cost debt and should therefore pay that debt by dying - sooner rather than later, regardless of their health, regardless of whether they have something that is treatable or not.  I think we might possibly discuss the issue (screening in elders) the next time we meet (if ever).  Again, crude, but that was my interpretation of this $$$ laden article .

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Family Planning

Over-The-Counter Sales of Emergency Contraception Do Not Increase Unsafe Sex

CONCLUSION: The awareness and use of EC were low in our study population. They were not ready for more liberal delivery of ECPs as less than 50% of women supported these new delivery modes and their knowledge on ECPs use was inadequate.

Wan RS, Lo SS. Are women ready for more liberal delivery of emergency contraceptive pills? Contraception. 2005 Jun;71(6):432-7.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15914132&query_hl=27

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Frequently asked questions

Q. Is there any help or assistance with infertility through the Indian Health System?

A. Yes, basic infertility services are provided in the ITU system.

http://www.ihs.gov/MedicalPrograms/MCH/M/documents/Infertility81105.doc

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Indian Child Health Notes

August 2005 – Steve Holve, Pediatrics Chief Clinical Consultant

-Pediatric sleep apnea - you know more than you think

-Sleepy teenagers - they are not just slugs, they're victims of biology

-TB in AI/AN is down, but not out

http://www.ihs.gov/MedicalPrograms/MCH/C/documents/ICHN805.doc

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Information Technology

Free Online CME from Thomson Healthcare

All specialties

www.freecme.com

OB/GYN

http://www.freecme.com/gcourses1.php?specialty_id=41&specialty_name=OB/GYN

or go to the many posted Online CME sites on the Indian Health MCH site

../F/CN02.cfm#top

or Indian Health’s own Perinatology Corner

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

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International Health Update

Increase the interdisciplinary and transdisciplinary focus in primary health care research

The "Transdisciplinary Understanding and Training on Research - Primary Health Care (TUTOR-PHC)" program is accepting applications for its 2006 class of students. Program objectives are to build a critical mass of skilled, independent researchers through both student and faculty development; and to increase the interdisciplinary and transdisciplinary focus in primary health care research.

APPLICANTS

-Any student/practicing professional regardless of home discipline with an interest in primary health care research -Academic levels: Masters, PhD, Post-doctoral fellow, mid-career clinicians

- Deadline for application submission is October 31, 2005

FELLOWSHIPS AND OTHER BENEFITS

- Strategic Training Fellowships ranging from $17 850 to $47 250 per year depending on academic level and health professional status

- Accredited as one full graduate course through The University of Western Ontario

- Trainees receive the distinction of "CIHR Strategic Training Fellow"

- Physicians receive up to 123 MAINPRO-M1 credits

CURRICULUM

The curriculum spans one year (May 2006-April 2007) and includes:

- A three-day symposium held in May each year

- On-line lab/discussion groups (total of 12 weeks)

- On-line workshops (total of 6 weeks) and

- Mentoring of students by established primary care researchers

Website: www.uwo.ca/fammed/csfm/tutor-phc e-mail: tutor@uwo.ca

Phone: 519-661-2111 x22089 Leslie Meredith, program coordinator

Unite For Sight's 3rd Annual International Health Conference

"Empowering Communities to Bridge Health Divides"
When : April 1-2, 2006
Where: Yale University, New Haven, Connecticut
Theme: "Empowering Communities to Bridge Health Divides"
Who should attend?  Anyone interested in medicine, health education, health promotion, public health, international health, international service, or eye care
Conference Goal: To empower conference attendees to identify health needs and to develop solutions to improve access to care for the medically underserved
http://www.uniteforsight.org/2006_annual_conference.php
Early Bird Registration Rate: $25 student rate; $30 for all others
How to Submit Abstract: http://www.uniteforsight.org/2006_conference_posters.php

ABSTRACT SUBMISSION DEADLINE: AUGUST 15

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MCH Alert

New edition of the Women’s Health Data Book Released

Women's Health USA 2005, the fourth edition of the data book, presents a profile of women's health at the national level from a variety of data sources. The data book, developed by the Health Resources and Services Administration's Office of Women's Health, includes information and data on population characteristics, health status, and health services utilization. New topics in this edition include household composition, maternity leave, contraception, and adolescent pregnancy. The data book also highlights racial and ethnic disparities and gender differences in women's health. The data book is intended to be a concise reference for policymakers and program managers at the federal, state, and local levels to identify and clarify issues affecting the health of women. http://mchb.hrsa.gov/whusa_05/index.htm

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Medical Mystery Tour

Follow-up 2 positive blood cultures found in a postpartum patient with a fever

A little refresher from last issue

-This 22 year old G1 P0 presented in active labor at 40 weeks gestation after a benign prenatal course that was significant only for a positive perineum and rectal culture for beta streptococcus group B screen at 36 weeks and a weight gain of over 50 pounds with a normal glucose challenge test.

-The patient had a normal spontaneous delivery over a large 4th degree laceration. There was also an extensive left perineal laceration with avulsion. The patient had a standard repair of the 4th degree laceration and a right vulvar skin flap closure of the left perineal laceration in the delivery room. What followed was an unremarkable post partum course. The patient remained afebrile throughout with an intact perineal repair and had a normal bowel movement prior to discharge.

-The patient returned on postpartum day #5 with a temperature of 101.9 degrees F, a tender uterus with an intact perineum, and a WBC of 13.3K. The patient was re-hospitalized for endometritis and treated with metronidazole and ampicillin / sulbactam. The patient defervesced and was discharged home again on post partum day #8. The patient was called back into the hospital within hours of leaving when it was noted that 2 of her blood cultures had become positive. http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0705_Feat.cfm#mmtour

The blood cultures positive with what organism? What was the source?

The answer

The preliminary findings of gram negative rods isolated in both anaerobic bottles were called STAT to the provider. Subsequent identification revealed fusobacterium mortiferum in both bottles.

Anaerobes account for 2 to 5 percent of blood culture isolates from patients with clinically significant bacteremia, but the rate is decreasing reflecting the frequent use of anti-anaerobic antibiotics. The most common blood culture isolates among anaerobes are the B. fragilis group, which account for 60 to 80 percent. A review of the suspected portal of entry for 855 episodes of bacteremia involving anaerobes indicated an intraabdominal source in 52 percent, the female genital tract in 20 percent, the lower respiratory tract in 6 percent, the upper respiratory tract in 5 percent, and soft tissue infections in 8 percent.

Fusobacterium is one of the anaerobic bacteria species often involved in a variety of infections of the oral cavity and adjacent structures, including serious infections with suppurative (septic) thrombophlebitis of the jugular vein.

On the other hand, fusobacterium sp. are detected in amniotic fluid in preterm labor more commonly than other anaerobes. Fusobacterium burrow through amnion tissue rapidly and sometimes are present in amnion tissue in large numbers as if penetrating between the amnion epithelial cells. Large numbers of fusobacterium have been identified in Wharton’s jelly. This suggests a peculiar propensity for these microorganisms to penetrate amnion tissue, which also covers the umbilical cord. Fusobacterium produce a variety of toxins, some of which are extraordinarily potent in stimulating cytokine formation in mononuclear phagocytes. In the setting of premature rupture of membranes it has been hypothesized that fusobacterium penetrate the fetal membranes after the tissues are exposed to these microorganisms in the cervical /vaginal fluid.

The rest of the story

The patient was treated with IV ampillin /sulbactam plus metronidazole intravenously and discharged on oral metronidazole and amoxicillin / clavulanate within 2 days of the positive blood cultures.

The patient initially did well as an outpatient, but had to be re-admitted with a fever and a breakdown of her labial repair six days later. The admission examination revealed that the 4 th degree laceration also developed a small fistula. The patient was initially treated with a broad spectrum anaerobic regimen IV, and subsequently underwent debridement and a rectovaginal fistula repair 2 days later.

Though the source can not be known with complete certainty, due the mixed microbiology of the genital system, it appears the source was the perineal and 4 th degree lacerations, and not endomyometritis as suspected with the patient’s first postpartum admission.

The rectovaginal fistula repair was well healed 8 weeks later.

Here is more information on fusobacterium infections

Anaerobic bacterial infections

Suppurative (septic) thrombophlebitis

Have a case you would like to discuss in the Medical Mystery Tour? Please contact nmurphy@scf.cc

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Medscape*

Eating Disorders and Body Image Distress in Women at Midlife - CME

http://www.medscape.com/viewprogram/4302?src=mp

Ask the Experts topics in Women's Health and OB/GYN Index, by specialty, Medscape

http://www.medscape.com/pages/editorial/public/ate/index-womenshealth

OB GYN & Women's Health Clinical Discussion Board Index, Medscape

http://boards.medscape.com/forums?14@@.ee6e57b

Clinical Discussion Board Index, Medscape

Hundreds of ongoing clinical discussions available

http://boards.medscape.com/forums?14@@.ee6e57b

Free CME: MedScape CME Index by specialty

http://www.medscape.com/cmecenterdirectory/Default

*NB: Medscape is free to all, but registration is required. It can be accessed from anywhere with Internet access. You just need to create a personal username and password.

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Menopause Management

U.S. Preventive Services Task Force

Hormone Therapy for the Prevention of Chronic Conditions in Postmenopausal Women

Summary of Recommendations

The USPSTF recommends against routine use of combined estrogen and progestin for the prevention of chronic conditions in postmenopausal women.

D recommendation .

The USPSTF found good evidence that the use of combined estrogen and progestin results in both benefits and harms. Benefits include reduced risk for fracture (good evidence) and colorectal cancer (fair evidence). Combined estrogen and progestin has no beneficial effect on coronary heart disease (CHD) and may even pose an increased risk (good evidence). Other harms include increased risk for breast cancer (good evidence), venous thromboembolism (good evidence), stroke (fair evidence), cholecystitis (fair evidence), dementia (fair evidence), and lower global cognitive function (fair evidence). Because of insufficient evidence, the USPSTF could not assess the effects of combined estrogen and progestin on the incidence of ovarian cancer, mortality from breast cancer or coronary heart disease, or all-cause mortality. The USPSTF concluded that the harmful effects of combined estrogen and progestin are likely to exceed the chronic disease prevention benefits in most women.

The USPSTF recommends against the routine use of unopposed estrogen for the prevention of chronic conditions in postmenopausal women who have had a hysterectomy.

D recommendation .

The USPSTF found good evidence that the use of unopposed estrogen results in both benefits and harms. The benefits include reduced risk for fracture (good evidence). Harms include increased risk for venous thromboembolism (fair evidence), stroke (fair evidence), dementia (fair evidence), and lowered global cognitive functioning (fair evidence). There is fair evidence that unopposed estrogen has no beneficial effect on coronary heart disease. Because of insufficient evidence, the USPSTF could not assess the effects of unopposed estrogen on the incidence of breast cancer, ovarian cancer, or colorectal cancer, as well as breast cancer mortality or all-cause mortality. The USPSTF concluded that the harmful effects of unopposed estrogen are likely to exceed the chronic disease prevention benefits in most women.

http://www.preventiveservices.ahrq.gov

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Midwives Corner: Judy Whitecrane, Phoenix

Please help us build the Midwives Indian Health Patient Education Resources page

Do you have any good ideas about links to offer to your colleagues?

Send them to nmurphy@scf.cc

Here is what the Indian Health Patient Education Resources page has so far:

CIR - Indian Health Patient Education Resources page

http://www.ihs.gov/medicalprograms/CIR/index.cfm?module=cir_patient_education

SIMPLE PATIENT EDUCATION HANDOUTS

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

Here is wide variety of MCH oriented Patient Education Resources

http://www.ihs.gov/MedicalPrograms/MCH/

Each Perinatology Corner Module has topic specific Patient Education

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

Here is one example from the Perinatology module: Diabetes in Pregnancy.

http://www.ihs.gov/MedicalPrograms/MCH/M/DP11.asp#patEdu

(The patient education resources are usually on the ‘Other Online Resources’ page of each module)

Consumer Health – Features Easy to Read Resources

http://www.ihs.gov/MedicalPrograms/consumer-health/

Women and Health Care: A National Profile

A new national survey of women on their health finds that a substantial percentage of women cannot afford to go to the doctor or get prescriptions filled. Although a majority of women are in good health and satisfied with their health care, many have health problems and do not get adequate levels of preventive care. The report also examines women’s health status, health care costs, insurance, access to care, prevention, and their role in family health care.

Women and Health Care: A National Profile is a nationally representative telephone survey of 2,766 women ages 18 and older. A shorter companion survey of 507 men was conducted for comparison purposes. http://www.kff.org/womenshealth/whp070705pkg.cfm

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Navajo News, Jean Howe, Chinle

Is the patch more dangerous than the pill?

“More fatalities than expected occur from birth control patch”

On July 15 th, an Associated Press article with this alarming title was published in one of our local newspapers, The Gallup Independent. It reported that there was a three-fold increased risk of death with contraceptive patch use, as compared to oral hormonal contraceptive use, based on cases reported to the FDA. They cite the following risks:

The article also states that 2 blood clots occurred in the 3,300 patch users who participated in clinical trials prior to FDA approval.

The article is quite dramatic, including several touching vignettes of young women who died unexpectedly while using the patch. It offers other death rates for comparison, but only in a somewhat confusing table, and not in the text itself. (These include a death rate of 28 per 100,000 per year for pill users under 35 who smoke, 143 per 100,000 for pill users 35-44 years old who smoke, 10 per 100,000 for women at 20+ weeks gestation, and 100 per 100,000 for motorcycle riders.) The article does not state a risk for non-fatal blood clots associated with pregnancy.

This inflammatory article is another example of non-evidence based data being presented to the public in a sensational manner. The FDA reports are collected to look for unanticipated adverse outcomes associated with medication use that were not identified in studies conducted prior to FDA approval. Their collection is important but the information must be interpreted with caution. Importantly, the AP article apparently bases its risk calculations on a denominator of 800,000 patch users in 2004. Ortho states that the actual number of patch users was closer to 2,000,000 in 2004; clearly that would change the risk calculations dramatically.

This is a perplexing situation. Women’s health providers wouldn’t want to ignore potentially important safety information about the patch. But it is not clear that these spontaneously generated FDA reports actually represent important new safety information. It is our duty as providers to provide our patients with the best evidence-based information available and protect them from media hysteria. The available data shows that hormonal contraception does pose a slightly increased risk of blood clots, regardless of route (pill, patch, or vaginal ring). This risk is much less than the risk associated with pregnancy. For women who find it difficult to use other methods reliably, the contraceptive patch remains an excellent method of birth control. If anything this article illustrates the need to encourage smoking cessation in all hormonal contraception users under 35 and work with smokers 35 and over both to find acceptable alternative methods of birth control and to quit smoking.

Resources

FDA – Home page

http://www.fda.gov/default.htm

FDA APPROVES FIRST HORMONAL CONTRACEPTIVE SKIN PATCH

http://www.fda.gov/bbs/topics/ANSWERS/2001/ANS01119.html

FDA and Johnson & Johnson Warn Public About Counterfeit Contraceptive Patches Sold Through Foreign Internet Site

http://www.fda.gov/bbs/topics/NEWS/2004/NEW01017.html

Ortho Evra: Othro - McNeil

http://www.orthoevra.com/

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Office of Women's Health, CDC

Publications and Materials – Many Women’s Health Topics

Link below to recent publications and other materials related to women's health, including fact sheets, recommendations, reports, disease trends, program strategies, and more. Click on a link below to get information on the Web by health topic or to get selected documents by fax. Supplies are limited and subject to change and availability. http://www.cdc.gov/od/spotlight/nwhw/pubs.htm

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Oklahoma Perspective Greggory Woitte – Hastings Indian Medical Center

Who do you contact in Oklahoma for MCH issues?

Two contacts are Dr. George Chiarchiaro in the Area Office and Greggory Woitte at Tahlequah. George is the MCH Coordinator and has a helpful website with many resources

http://www.ihs.gov/MedicalPrograms/MCH/M/MCHC07.cfm#top

Greggory Woitte at Tahlequah is available at Greggory.Woitte@mail.ihs.gov

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Osteoporosis

Ultralow-Dose Estradiol and BMD in Postmenopausal Women

CONCLUSION: Postmenopausal treatment with low-dose, unopposed estradiol increased bone mineral density and decreased markers of bone turnover without causing endometrial hyperplasia. Ettinger B, et al. Effects of ultralow-dose transdermal estradiol on bone mineral density: a randomized clinical trial. Obstet Gynecol September 2004;104:443-51

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15339752&query_hl=18

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Patient Information

Brochure/support for sugar substitute and gestational DM

http://www.ific.org/publications/brochures/upload/gestationaldiabetes.pdf

What to Do If Your Child Swallows Something?

http://www.aafp.org/afp/20050715/292ph.html

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Perinatology Picks - George Gilson, Maternal Fetal Medicine, ANMC

Glyburide for gestational diabetes in a large managed care organization

RESULTS: In 1999 through 2000, 268 women had GDM diagnosed and were treated with insulin; in 2001 through 2002, 316 women had GDM diagnosed of which 236 (75%) received glyburide…..

CONCLUSION: In a large managed care organization, glyburide was at least as effective as insulin in achieving glycemic control and similar birth weights in women with GDM who failed diet therapy. The increased risk of preeclampsia and phototherapy in the glyburide group warrant further study

Jacobson GF et al Comparison of glyburide and insulin for the management of gestational diabetes in a large managed care organization. Am J Obstet Gynecol. 2005 Jul;193(1):118-24.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16021069&query_hl=1

Overweight and obese in gestational diabetes: the impact on pregnancy outcome

RESULTS: Four thousand and one women were enrolled. Obese women who achieved targeted levels of glycemic control had comparable pregnancy outcomes to normal weight and overweight women only when they were treated with insulin…..

CONCLUSION: In obese women with BMI > or =30 with GDM, achievement of targeted levels of glycemic control was associated with enhanced outcome only in women treated with insulin.

Langer O et al Overweight and obese in gestational diabetes: the impact on pregnancy outcome. Am J Obstet Gynecol. 2005 Jun;192(6):1768-76.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15970805&query_hl=3

Glargine use in pregnancy?

As Dr. Gilson has raised the issue of diabetes in pregnancy, here is a question that was posed to the Area Diabetes Program Director:

“There seems to be frequent discussion about glargine being best for type I diabetics (as their basal insulinization), but not for type 2 DM. Type 2 diabetics are often hyperinsulinemic - especially when pregnant. This comes up most frequently in pre-existing type 2 pregnant diabetics who have used glargine previously. I most frequently recommend switching them to NPH and lispro for the pregnancy.

Will you corroborate that philosophy, or am I just "behind the times".

Response from the Alaska Area Diabetes Program Director:

Glargine is being used extensively in type 2 diabetes.  The ANMC pharmacy, however, has it restricted to type 1 patients at the present time.  This is in part due to the cost concerns of glargine compared to NPH.  We are working with pharmacy to develop a protocol which, after approval by P & T, will allow us to use glargine in type 2 patient more liberally. We do have around 60 type 2 diabetics on glargine at the present time.  A recent article in Diabetes Care by Riddle looked at night time NPH and glargine*.  There was not great convincing evidence that glargine was significantly better than NPH in type 2 patients; however, there were less hypoglycemic episodes with the glargine group.  Both groups had similar improvement in their A1c levels.  The main advantage of glargine over NPH is it can be given any time of the day, which makes it much more "user friendly" for patients.  It is no longer necessary to only give in the evening. 

I had to do a little research to answer your second question.  And you are not "behind the times", rather in line with what most endocrinologists would recommend:

So, I had the opportunity to talk with an endocrinologist who has in-depth knowledge of glargine last night and he helped answer your question. 

Neither the analog insulins (lispro and aspart) nor glargine are FDA approved for pregnancy.  Despite this, aspart and lispro are used in pumps and for nutritional dosing during pregnancy without problems.  The issue with glargine is its binding to IGF1 receptors: glargine has a 7X greater affinity for IGF1 than other insulin(s).  This raises concerns of increased risk of possible birth defects. 

Studies in rats and (I believe) rabbits have not shown evidence of glargine related birth defects but (needless to say) there are no human studies.  Therefore most endocrinologists would not recommend glargine during pregnancy.  The endocrinologist I spoke with felt that this was, in part, due to concerns of a baby born with a birth defect whose mother has used glargine during her pregnancy.  The endocrinologist recommended either changing the patient to NPH during the pregnancy or transitioning the patient to a pump in the pre or post conception state.

CCC Comment:

Until further data is available, regimens that include short and intermediate acting insulin(s) are recommended for those Indian Health patients using insulin as their hypoglycemic agent during pregnancy.

Here is the resource discussed above, as well as the Diabetes in Pregnancy Guidelines posted on the MCH web page:

../W/Documents/DMPreg102504_000.doc

* Riddle MC, et Al The treat-to-target trial: randomized addition of glargine or human NPH insulin to oral therapy of type 2 diabetic patients. Diabetes Care. 2003 Nov;26(11):3080-6.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14578243&query_hl=5

Riddle MC. Timely initiation of basal insulin. Am J Med. 2004 Feb 2;116 Suppl 3A:3S-9S.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15013454&query_hl=5

Janka HU, Plewe G, Riddle MC, et al Comparison of basal insulin added to oral agents versus twice-daily premixed insulin as initial insulin therapy for type 2 diabetes. Diabetes Care. 2005 Feb;28(2):254-9.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15677775&query_hl=5

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Primary Care Discussion Forum

Appropriate use of narcotics for chronic non-malignant (non-cancer) pain

Moderator: Chuck North
-Are you comfortable using narcotics to treat chronic pain?
-Is there abuse of prescription controlled medications in your community?
-What controls should health professionals have in place to regulate the use of controlled substances? 
-Do you use pain contracts?  Are they useful?
-What services are available to serve your chronic pain patients in addition to primary care? 
-Are you successful in obtaining mental health services for your patients?

Other issues
-Describe your level of comfort based on your experience.
-What are the most popular drugs?  Are narcotics, benzodiazepines or stimulants most popular? 
-Are particular brand names valued more than others? 
-Do you know the local "street value" of prescription pills?
-Would you like to consult with a psychiatrist yourself about some of your patients?

This discussion is ongoing now so you can still jump in. The captured discussion so far and a number of excellent resources available from this discussion available here

http://www.ihs.gov/MedicalPrograms/MCH/M/PCdiscForumMod.asp

( please scroll down to “Narcotics for……” in alphabetical order)

How to subscribe / unsubscribe to the Primary Care Discussion Forum?

Subscribe to the Primary Care listserv

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

Unsubscribe from the Primary Care listserv

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

Questions on how to subscribe, contact nmurphy@scf.cc directly

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STD Corner - Laura Shelby, STD Director, IHS

Condom effectiveness for prevention of Chlamydia trachomatis infection

Background/objectives: A growing body of evidence is increasingly demonstrating the effectiveness of condoms for sexually transmitted infection (STI) prevention. The purpose of the present analysis was to provide a disease specific estimate for the effectiveness of condoms in preventing Chlamydia trachomatis infection while controlling for known exposure to infection.

Methods: Condom effectiveness for C trachomatis was estimated using a medical record database from a public sexually transmitted disease clinic (n = 1455). Clients were classified as having known exposure to C trachomatis if they presented to the clinic as a contact to an infected partner.

Results: Among clients with known exposure, 13.3% of consistent condom users were diagnosed with C trachomatis infection compared to 34.4% of inconsistent condom users (adjusted odds ratio = 0.10; 95% CI: 0.01 to 0.83). Among clients with unknown exposure, there was no observed protective effect of condoms.

Conclusions: This study provides further evidence that condoms are effective in preventing C trachomatis infection by reporting a disease specific estimate and restricting analyses to individuals with known exposure.

M Niccolai, A Rowhani-Rahbar, H Jenkins, S Green, and D W Dunne. Condom effectiveness for prevention of Chlamydia trachomatis infection Sex Transm Infect 81: 323-325          

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16061540&query_hl=1

The percentage of male teens who reported ever having sexual intercourse decreased significantly for both younger (aged 15--17 years) and older (aged 18--19 years) teens from 1995 to 2002. Among females, the percentage who reported ever having sexual intercourse declined significantly for those aged 15--17 years. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5430a7.htm

Additional information is available at http://www.cdc.gov/nchs/nsfg.htm

Other News on STIs

Prenatal screening and treatment are needed to identify pregnant women with asymptomatic chlamydial infections http://www.ahrq.gov/research/jul05/0705RA15.htm

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Barbara Stillwater, Alaska State Diabetes Program

Women the stronger gender? Men more carbohydrate intolerant / less physical endurance

CONCLUSIONS: Severely obese men were more carbohydrate-intolerant and sustained less physical endurance than was predicted according to standards in comparison with obese women. The cycle ergometer data indicated that male gender was associated with less physical fitness.
Dolfing JG, et al Different cycle ergometer outcomes in severely obese men and women without documented cardiopulmonary morbidities before bariatric surgery. Chest. 2005 Jul;128(1):256-62.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16002944&query_hl=2

Teen Inactivity Leads to Obesity for Girls

Decreasing physical activity during adolescence seems to play a major role in weight gain among girls as they transition from children to women.  Inactive girls gained an average of 10 pounds to 15 pounds more than girls who were active between the ages of 9 and 19.The number of calories consumed increased marginally and did not appear to be associated with the weight gain.

INTERPRETATION: Changes in activity levels of US girls during adolescence significantly affected changes in BMI and adiposity. Thus, preventing the steep decline in activity during adolescence is an important method to reduce obesity.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16039332&query_hl=6

Cardiovascular Fitness Inversely Linked to Risk of Metabolic Syndrome

CONCLUSIONS: Low cardiorespiratory fitness is a strong and independent predictor of incident metabolic syndrome in women and men. Clinicians should consider the potential benefits of greater cardiorespiratory fitness in the primary prevention of metabolic syndrome, particularly among patients who have already begun to cluster metabolic syndrome components.

Lamonte MJ, et al Cardiorespiratory Fitness Is Inversely Associated With the Incidence of Metabolic Syndrome. A Prospective Study of Men and Women. Circulation. 2005 Jul 11;

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16009797&dopt=Abstract

Relationship of Obesity and Fitness Level to Cardiovascular Risk and Diabetes 

CONCLUSIONS: Among women undergoing coronary angiography for suspected ischemia, higher self-reported physical fitness scores were independently associated with fewer CAD risk factors, less angiographic CAD, and lower risk for adverse CV events. Measures of obesity were not independently associated with these outcomes.

Wessel TR, et al Relationship of physical fitness vs body mass index with coronary artery disease and cardiovascular events in women. JAMA. 2004 Sep 8;292(10):1179-87.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15353530&query_hl=9

New CERTs Program Brief on Women's Health Is Available

AHRQ released a new program brief on women's health from its Centers for Education and Research on Therapeutics (CERTs) program. The program brief highlights risks and benefits identified in CERTs studies of medical therapies in women such as the association between cholesterol-lowering drugs and hip fractures, as well as heart rhythms and the menstrual cycle, and antibiotic resistance and urinary tract infections. It also addresses current treatment information for physicians and their patients on the use of hormone therapy and prescription drug use by pregnant women. http://www.ahrq.gov/clinic/certswomen.htm or e-mail ahrqpubs@ahrq.gov

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What's new on the ITU MCH web pages?

Q. Is there any help or assistance with infertility through the Indian Health System?

http://www.ihs.gov/MedicalPrograms/MCH/M/documents/Infertility81105.doc

Prescription Opioids: Good, bad, and ugly, Sidney Schnoll MD PHD

Eve Espey M.D. - Breast Cancer Screening

2005 IHS/ACOG Obstetric, Neonatal and Gynecologic Care Postgraduate Course

Simple Patient Education Handouts

Active management of the third stage of labor among American Indian women

Atlas of Heart Disease and Stroke in AI/AN

There are several upcoming Conferences

and Online CME/CEU resources, etc….

and the latest Perinatology Corners (free online CME from IHS)

…or just take a look at the What’s New page

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Save the dates

Treatment and Management of HIV Infection in the United States

• September 15-18, 2005
• Atlanta , Georgia
• 16.5 Credits, Univ. of California @ San Francisco / VA Administration
• First domestic conference of its kind. Mark your calendar
• http://www.USHIVconference.org/

National Indian Health Board: Youth and Tradition - Our Greatest Resources

• October 16-19, 2005
• Phoenix , AZ
• Distinguished presenters and informative workshops
• http://www.nihb.org/staticpages/index.php?page=200403301344379533

Centering Pregnancy - Group Prenatal Care

• October 21 and 22, 2005
• Zuni, NM - Directions available
• Registration sheet online (pdf 701KB)
• Contact Amy Doughty

Advances in Indian Health, 6 th Annual

• May 2-6, 2006
• Albuquerque , NM
• Save the dates brochure
• ../F/CN01.cfm#May06

Native Peoples of North America HIV/AIDS Conference

• May 3–6, 2006
• Anchorage , Alaska
• Embracing Our Traditions, Values, and Teachings www.embracingourtraditions.org
• National Institutes of Health (NIH), DHHS
• http://www.ou.edu/rec/pdf/Native_Fact_Sheet.pdf

ACOG 2006 Annual Clinical Meeting (ACM)

• May 6-10, 2006
• Washington , DC
• Save the dates brochure
• http://www.acog.org/abstract%2Dsubmission/

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Did you miss something in the last OB/GYN Chief Clinical Consultant Corner?

The July 2005 OB/GYN CCC Corner is available at:
http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0705.cfm

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.