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Volume 5, No. 5, May 2007
Features
American College of Obstetricians and Gynecologists
Premature Rupture of Membranes
Practice Bulletin, NUMBER 80, APRIL 2007
Summary of Recommendations and Conclusions
The following recommendations and conclusions are based on good and consistent scientific evidence (Level A):
- For women with PROM at term, labor should be induced at the time of presentation, generally with oxytocin infusion, to reduce the risk chorioamni-onitis.
- Patients with PROM before 32 weeks of gestation should be cared for expectantly until 33 completed weeks of gestation if no maternal or fetal contraindications exist.
- A 48-hour course of intravenous ampicillin and erythromycin followed by 5 days of amoxicillin and erythromycin is recommended during expectant management of preterm PROM remote from term to prolong pregnancy and to reduce infectious and gestational age–dependent neonatal morbidity.
- All women with PROM and a viable fetus, including those known to be carriers of group B streptococci and those who give birth before carrier status can be delineated, should receive intrapartum chemo-prophylaxis to prevent vertical transmission of group B streptococci regardless of earlier treatments.
- A single course of antenatal corticosteroids should be administered to women with PROM before 32 weeks of gestation to reduce the risks of RDS, perinatal mortality, and other morbidities.
The following recommendations and conclusions are based on limited and inconsistent scientific evidence (Level B):
- Delivery is recommended when PROM occurs at or beyond 34 weeks of gestation.
- With PROM at 32–33 completed weeks of gestation, labor induction may be considered if fetal pulmonary maturity has been documented.
- Digital cervical examinations should be avoided in patients with PROM unless they are in active labor or imminent delivery is anticipated.
The following recommendations and conclusions are based primarily on consensus and expert opinion (Level C):
- A specific recommendation for or against tocolysis administration cannot be made.
- The efficacy of corticosteroid use at 32–33 completed weeks is unclear based on available evidence, but treatment may be beneficial particularly if pulmonary immaturity is documented.
- For a woman with preterm PROM and a viable fetus, the safety of expectant management at home has not been established.
Premature Rupture of Membranes. ACOG Practice Bulletin No. 80. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;109:1007–19.
Patient Testing: Ethical Issues in Selection and Counseling
ABSTRACT: Recommendations to patients about testing should be based on current medical knowledge, a concern for the patient’s best interests, and mutual consultation. In addition to establishing a diagnosis, testing provides opportunities to educate, inform, and advise. The ethical principles of respect for autonomy (patient choice) and beneficence (concern for the patient’s best interests) should guide the testing, counseling, and reporting process. Clear and ample communication fosters trust, facilitates access to services, and improves the quality of medical care.
Patient Testing: Ethical Issues in Selection and Counseling. ACOG Committee Opinion No. 363. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;109:1021–3.
American Family Physician**
Prevention and Management of Postpartum Hemorrhage
Postpartum hemorrhage, the loss of more than 500 mL of blood after delivery, occurs in up to 18 percent of births and is the most common maternal morbidity in developed countries. Although risk factors and preventive strategies are clearly documented, not all cases are expected or avoidable. Uterine atony is responsible for most cases and can be managed with uterine massage in conjunction with oxytocin, prostaglandins, and ergot alkaloids. Retained placenta is a less common cause and requires examination of the placenta, exploration of the uterine cavity, and manual removal of retained tissue. Rarely, an invasive placenta causes postpartum hemorrhage and may require surgical management. Traumatic causes include lacerations, uterine rupture, and uterine inversion. Coagulopathies require clotting factor replacement for the identified deficiency. Early recognition, systematic evaluation and treatment, and prompt fluid resuscitation minimize the potentially serious outcomes associated with postpartum hemorrhage. Am Fam Physician 2007;75:875-82.
http://www.aafp.org/afp/20070315/875.html
ACOG Releases Guidelines on Antibiotic Prophylaxis for Gynecologic Procedures
Although aseptic surgical techniques have dramatically reduced the incidence of surgical site infections, these infections remain the most common surgical complication, affecting up to 5 percent of postoperative patients. Selective use of antibiotics is effective for infection prophylaxis, but this benefit must be weighed against the risk for selection of antibiotic-resistant bacteria. The American College of Obstetricians and Gynecologists (ACOG) reviewed the evidence for appropriate antibiotic prophylaxis in women undergoing gynecologic procedures.
Microorganisms from the patient's skin or vagina are the pathogenic source in most surgical site infections. These organisms are usually aerobic gram-positive cocci (e.g., staphylococci) but also may include fecal flora (e.g., anaerobic bacteria, gram-negative anaerobes) when incisions are made near the perineum or groin. Only a narrow window of antimicrobial effectiveness is available, requiring that antibiotics be administered shortly before or at the time of bacterial inoculation (i.e., when the incision is made, the vagina is entered, or the pedicles are clamped). A delay of only three hours can result in ineffective prophylaxis. Data indicate that for lengthy procedures, administering additional intraoperative doses of an antibiotic can maintain adequate levels throughout the surgery. An additional dose also may be appropriate in patients who have lost more than 1,500 mL of blood.
Laparotomies and laparoscopies do not breach surfaces colonized with vaginal bacteria, and infections after these procedures more often result from contamination with skin bacteria. Hysterosalpingography, sonohysterography, intrauterine device (IUD) insertion, endometrial biopsy, and dilation and curettage may introduce endocervical and upper vaginal bacteria into the endometrium and fallopian tubes. Physicians should consider the polymicrobial nature of these infections when choosing a treatment for endometritis or pelvic inflammatory disease.
Hysterectomy
Women undergoing abdominal or vaginal hysterectomy should receive a single dose of antibiotics. Most studies show no particular regimen to be superior to any other. Antibiotic prophylaxis is a reasonable option in women undergoing laparoscopically assisted hysterectomy, although no evidence is available to support this use. Bacterial vaginosis is a risk factor for surgical site infection after hysterectomy. Treatment of bacterial vaginosis with metronidazole (Flagyl) for at least four days, beginning just before surgery, significantly reduces vaginal cuff infection in patients with abnormal flora.
IUD Insertion and Endometrial Biopsy
Most of the risk of IUD-related infection occurs in the first few weeks to months after insertion, which suggests that contamination of the endometrial cavity during the procedure is the infecting mechanism. However, four randomized clinical trials found that pelvic inflammatory disease is uncommon after IUD insertion regardless of whether antibiotic prophylaxis is used.
A Cochrane review found that administration of doxycycline (Vibramycin) or azithromycin (Zithromax) before IUD insertion confers little benefit. ACOG concludes that prophylactic antibiotic use provides no benefit in women with negative screening results for gonorrhea and chlamydia before IUD insertion.
No data are available on infectious complications of endometrial biopsy. However, the incidence of such complications is thought to be negligible, and ACOG recommends that this procedure be performed without the use of antibiotic prophylaxis.
Laparoscopy and Laparotomy
No data are available to recommend antibiotic prophylaxis in women undergoing abdominal surgery that does not involve vaginal or intestinal procedures. Antibiotic prophylaxis is not indicated for diagnostic laparoscopy.
Hysterosalpingography, Sonohysterography, and Hysteroscopy
Postoperative pelvic inflammatory disease is an uncommon but potentially serious complication in patients undergoing hysterosalpingography. Patients with dilated fallopian tubes at the time of the procedure are at greater risk than women with nondilated tubes. Antibiotic prophylaxis is not recommended for patients with no history of pelvic infection. If the procedure demonstrates dilated fallopian tubes, 100 mg of doxycycline may be given twice daily for five days. In women with a history of pelvic infection, doxycycline can be administered before the procedure and continued if dilated fallopian tubes are found.
No data are available on which to base recommendations for women undergoing sonohysterography, but reported rates of postprocedure infection are low. The risks of sonohysterography probably are similar to those of hysterosalpingography, and the same considerations should be taken into account.
Infectious complications after hysteroscopic surgery are uncommon (0.18 to 1.5 percent of patients). A prospective study evaluating the effectiveness of amoxicillin/clavulanate (Augmentin) in preventing bacteremia associated with the procedure found no significant difference in postoperative infection between treated patients and the placebo group. Therefore, ACOG does not recommend routine antibiotic prophylaxis in women undergoing this procedure.
Surgical Abortion
A meta-analysis of 11 placebo-controlled, blinded clinical trials found that women who were given periabortal antibiotics had a 42 percent overall decreased risk of infection. ACOG concludes that antibiotic prophylaxis is effective in women undergoing surgical abortion, regardless of risk. The optimal antibiotic and dosing regimens are unclear.
Preoperative Bowel Preparation
Appropriate prophylaxis for women undergoing surgery that may involve the bowel includes a mechanical bowel preparation without oral antibiotics and the use of a broad-spectrum parenteral antibiotic administered immediately before surgery.
Antibiotic prophylaxis for gynecologic procedures. ACOG Practice Bulletin No. 74. American College of Obstetricians and Gynecologists. Obstet Gynecol 2006:108:225–34.
http://www.aafp.org/afp/20070401/practice.html#p1
Estimating 10-Year Mortality Risk
Clinical Question
What is a patient's risk of dying from vascular disease, cancer, infection, an accident, or any cause within the next 10 years?
Evidence Summary
Accurate estimates of patient risk or prognosis can be helpful to a primary care physician. For example, patients may resist participation in a screening program because they underestimate their risk. Also, women may overestimate their risk of breast cancer1 and downplay other important health risks. Comparing the risk of cancer or heart disease between smokers and nonsmokers can be useful when counseling patients about smoking cessation.
Research has shown that information about risk can be clearly communicated to patients using absolute numbers and frequencies (e.g., 12 in 1,000 patients), whereas percentages, probabilities, and likelihood ratios should be avoided.2 A group of researchers has developed a set of charts to help physicians communicate the 10-year mortality risk from vascular disease, cancer, infection, an accident, and any cause.3 The charts are separated based on sex and smoking status. Mortality rates were calculated using data from the 1998 National Center for Health Statistics Multiple Cause of Death Public
Applying the Evidence
A 60-year-old female smoker is extremely worried about her risk of breast cancer because two of her friends have been diagnosed with the disease in the past 10 years. She has no risk factors for breast cancer, but she has asked you to refer her for breast magnetic resonance imaging (she read that this was the latest and most accurate screening test). What is the best way to convince her that smoking cessation to prevent lung cancer would be more beneficial to her than breast cancer screening?
Answer: You determine that her risk of dying from breast cancer in the next 10 years is seven in 1,000. However, her risk of dying from lung cancer in that same period is 65 in 1,000, compared with five in 1,000 if she were a never smoker. Similarly, her risk of dying from heart disease or stroke in the next 10 years is 61 in 1,000, compared with 18 in 1,000 if she were a never smoker. Her overall risk of dying in the next 10 years is nearly twice as high as it would be if she were a never smoker (199 versus 105 in 1,000). The risk for smokers who quit is presumably somewhere between that for current and never smokers.
http://www.aafp.org/afp/20070315/poc.html
Infertility (see also Patient Education)
Infertility is defined as failure to achieve pregnancy during one year of frequent, unprotected intercourse. Evaluation generally begins after 12 months, but it can be initiated earlier if infertility is suspected based on history or if the female partner is older than 35 years. Major causes of infertility include male factors, ovarian dysfunction, tubal disease, endometriosis, and uterine or cervical factors. A careful history and physical examination of each partner can suggest a single or multifactorial etiology and can direct further investigation. Ovulation can be documented with a home urinary luteinizing hormone kit. Hysterosalpingography and pelvic ultrasonography can be used to screen for uterine and fallopian tube disease. Hysteroscopy and/or laparoscopy can be used if no abnormalities are found on initial screening. Women older than 35 years also may benefit from ovarian reserve testing of follicle-stimulating hormone and estradiol levels on day 3 of the menstrual cycle, the clomiphene citrate challenge test, or pelvic ultrasonography for antral follicle count to determine treatment options and the likelihood of success. Options for the treatment of male factor infertility include gonadotropin therapy, intrauterine insemination, or in vitro fertilization. Infertility attributed to ovulatory dysfunction often can be treated with oral ovulation-inducing agents in a primary care setting. Women with poor ovarian reserve have more success with oocyte donation. In certain cases, tubal disease may be treatable by surgical repair or by in vitro fertilization. Infertility attributed to endometriosis may be amenable to surgery, induction of ovulation with intrauterine insemination, or in vitro fertilization. Unexplained infertility may be managed with ovulation induction, intrauterine insemination, or both. The overall likelihood of successful pregnancy with treatment is nearly 50 percent. (Am Fam Physician 2007;75:849-56, 857-8.
http://www.aafp.org/afp/20070315/849.html
ACOG Releases Opinion on Inducing Labor for VBAC
There is a continued debate regarding whether the induction of labor with or without prostaglandins increases the risk of uterine rupture during labor. For this reason, a committee of the American College of Obstetricians and Gynecologists (ACOG) has released an updated opinion on inducing labor for vaginal birth after cesarean delivery (VBAC). The statement was published in the August 2006 issue of Obstetrics & Gynecology.
Several studies have shown an increased risk of uterine rupture after induction of labor in women who have had a previous cesarean delivery. One population-based retrospective cohort study of more than 20,000 women who had a previous cesarean delivery found that the rate of uterine rupture was 0.16 percent in those who had another cesarean delivery, 0.52 percent in those who had spontaneous labor, 0.77 percent in those with induction of labor without prostaglandins, and 2.4 percent in those with induction of labor with prostaglandins. Two larger trials of women with previous cesarean delivery found that uterine rupture was more likely to occur when labor was augmented or induced. Several studies also found that the uterine rupture rate was significantly lower in women who had successful trials of labor compared with those who had failed trials of labor (0.01 percent and 2.0 to 2.3 percent, respectively).
A review of these studies indicates that rates of uterine rupture are increased when labor is induced and prostaglandins and oxytocin (Pitocin) are used. However, the most consistently increased rates of uterine rupture occur in failed trials of labor. Labor induction is a reasonable option, and it may be necessary in patients with VBAC. By choosing women who are most likely to give birth vaginally and avoiding the repeated use of prostaglandins and oxytocin, risk of uterine rupture can be reduced. Still, the risk of uterine rupture should be discussed with the patient and documented in the medical record.
Induction of labor for vaginal birth after cesarean delivery. ACOG Committee Opinion No. 342. American College of Obstetricians and Gynecologists. Obstet Gynecol 2006;108:465–67.
http://www.aafp.org/afp/20070315/practice.html
ACOG Releases Guideline for Management of Postpartum Hemorrhage
Postpartum hemorrhage is responsible for almost 140,000 deaths per year worldwide and can cause serious morbidity. It can occur without warning; therefore, all physicians should be prepared to manage it properly. The American College of Obstetricians and Gynecologists (ACOG) has reviewed the risks associated with postpartum hemorrhage and released recommendations on its management. The full guideline was published in the October 2006 issue of Obstetrics & Gynecology.
The most common cause of hemorrhage is uterine atony. If a patient has excessive bleeding following delivery, the bladder should be emptied and a pelvic examination performed. Massage or compression of the uterine corpus can help slow bleeding and remove blood and clots. If the patient continues to hemorrhage, other causes should be explored (e.g., lacerations, genital tract hematomas, retained placenta, coagulopathy). Baseline studies, including complete blood count with platelets, prothrombin time, activated partial thromboplastin time, fibrinogen, and a type and cross order, should be ordered and repeated if clinically necessary.
First-line treatment of postpartum hemorrhage includes the administration of uterotonics. If these agents fail to stop contractions and bleeding, a tamponade can be effective. If the tamponade does not provide an adequate response, physicians should perform an exploratory laparotomy (a midline vertical incision to the abdomen is preferred because it provides the best possible exposure). There are several methods for controlling continued bleeding, including uterine curettage, uterine artery ligation, B-Lynch suture, hypogastric artery ligation, rupture repair, and hysterectomy.
Placenta accreta is one of the most common reasons for postpartum hysterectomy. Risk factors include placenta previa (with or without previous uterine surgery), previous myomectomy or cesarean delivery, Asherman's syndrome, submucous leiomyomata, and age older than 35 years. The presence of any of these risk factors should create a suspicion of placenta accreta, and the physician should take the appropriate precautionary steps, such as patient counseling, making blood products and clotting factors available, considering the use of cell saver technology, scheduling delivery when and where there is access to surgical personnel and tools, and assessing preoperative anesthesia.
Arterial embolization may be an option in patients with stable vital signs who have persistent bleeding. It can be performed to help stop bleeding after hysterectomy or as an alternative to a hysterectomy. If vital signs are unstable and the blood loss is significant, transfusion may be necessary. Surgical repair is required if a hemorrhage is caused by a ruptured or inverted uterus; the surgical method should be adapted to each individual patient, if possible. No matter what the cause, replacement of red cells in patients with postpartum hemorrhage is key.
Postpartum hemorrhage. ACOG Practice Bulletin No. 76. American College of Obstetricians and Gynecologists. Obstet Gynecol 2006;108:1039–47.
http://www.aafp.org/afp/20070401/practice.html#p3
Disaster-Related Physical and Mental Health: A Role for the Primary Care Provider
Natural disasters, technologic disasters, and mass violence impact millions of persons each year. The use of primary health care services typically increases for 12 or more months following major disasters. A conceptual framework for assisting disaster victims involves understanding the individual and environmental risk factors that influence post-disaster physical and mental health. Victims of disaster will typically present to family physicians with acute physical health problems such as gastroenteritis or viral syndromes. Chronic problems often require medications and ongoing primary care. Some victims may be at risk of acute or chronic mental health problems such as post-traumatic stress disorder, depression, or alcohol abuse. Risk factors for post-disaster mental health problems include previous mental health problems and high levels of exposure to disaster-related stresses (e.g., fear of death or serious injury, exposure to serious injury or death, separation from family, prolonged displacement). An action plan should involve adequate preparation for a disaster. Family physicians should educate themselves about disaster-related physical and mental health threats; cooperate with local and national organizations; and make sure clinics and offices are adequately supplied with medications and suture and casting material as appropriate. Physicians also should plan for the care and safety of their own families. Am Fam Physician 2007;75:841-6.
http://www.aafp.org/afp/20070315/841.html
AHRQ
AHRQ and the Ad Council encourage patients to ask questions and
get more involved with their health care
http://www.ahrq.gov/research/mar07/307RA1.htm
Specific primary care office systems and quality improvement strategies
may substantially affect the cost of diabetes care
http://www.ahrq.gov/research/mar07/307RA15.htm
Ask A Librarian: Diane Cooper, M.S.L.S. / NIH
Quick Check for Drugs and Lactation
When you need to know if a drug you prescribe is safe for breastfeeding mothers, here is a new and easy to use database to check.
LactMed is a peer-reviewed database of drugs to which breastfeeding mothers may be exposed. LactMed is part of the National Library of Medicine’s Toxicology Data Network (TOXNET) and contains over 450 drug records. Data include information on the levels of drugs in the breast milk and infant blood, and possible adverse effects on the nursing infant. There are suggested alternatives to those drugs when available. All data are derived from the scientific literature and fully referenced.
LactMed can be accessed using the Health Services Research Library website at http://hsrl.nihlibrary.nih.gov
-Find PubMed in the left panel and click.
-Once you are in PubMed, click on TOXNET located on their left panel.
-Next, select LactMed from the list. In the search box, enter the drug you are interested in.
Sample Record for Prozac (abbreviated for space)
DRUG LEVELS AND EFFECTS:
SUMMARY OF USE DURING LACTATION:
The average amount of drug in breastmilk is higher with fluoxetine than
with most other SSRIs and the active metabolite, norfluoxetine, is
detectable in the serum of most breastfed infants during the first 2
months postpartum and a few thereafter . . .
DRUG LEVELS:
Fluoxetine is metabolized to norfluoxetine which has antidepressant
activity that is considered to be equal to fluoxetine. In a pooled analysis of serum levels from published studies and 1unpublished case, the authors found that 20 mothers taking an averagedaily dosage of 28 mg (range 10 to 80 mg) had an average milk fluoxetine
level of 76 mcg/L (range 23 to 189 mcg/L) . . .
EFFECTS IN BREASTFED INFANTS:
Colic, decreased sleep, vomiting and watery stools occurred in a 6-day-old
breastfed infant probably caused by maternal fluoxetine . . .
POSSIBLE EFFECTS ON LACTATION:
Fluoxetine has caused increased prolactin levels and galactorrhea in
nonpregnant, nonnursing patients. The clinical relevance of
these findings in nursing mothers is not known . . .
AAP CATEGORY (comment from the American Academy of Pediatrics)
Effect on nursing infant is unknown but may be of concern.
ALTERNATE DRUGS TO CONSIDER:
Nortriptyline
REFERENCES:
1. Weissman AM, Levy BT, Hartz AJ et al. Pooled analysis of antidepressant levels in lactating mothers, breast milk, and nursing infants. Am J Psychiatry. 2004;161:1066-9.
2. Kristensen JH, Ilett KF, Hackett LP et al. Distribution and excretion of fluoxetine and norfluoxetine in human milk. Br J Clin Pharmacol. 1999;48:521-7
LactMed can be accessed using the Health Services Research Library website at http://hsrl.nihlibrary.nih.gov
Breastfeeding - Suzan Murphy, PIMC
Breastfeeding - it’s all about synergy
Research has found that adults who breastfed as infants appear to have less risk of type 2 diabetes. Now there is evidence that breastfeeding can also reduce maternal risk. In November 2005, JAMA published, Duration of Lactation and Incidence of Type 2 Diabetes, by Stuebe et al. The studies described in this article associated longer duration of breastfeeding with reduced incidence of type 2 diabetes for mothers.
Stuebe et al examined 2 Nurses’s Health Studies (NHS and NHS II) to determine the impact of feeding choice upon subsequent maternal risk of diabetes. In 1976, NHS began by enrolling 121,700 women (30-55 years old) from 11 states. In 1989, NHS II began with 116, 671 women (25-42 years old) from 14 states. In each group, participants completed similar, detailed baseline questionnaires. Every 2 years, participants completed follow-up questionnaires about medical diagnosis and related topics like pregnancy history, breastfeeding history, diet, exercise, medication, and smoking.
Until 1997, the standards used to confirm reported diagnosis of type 2 diabetes were the National Diabetes Data Group criteria. After 1997, the standards were updated as the American Diabetes Association clinical practice recommendations were implemented.
In each study, the covariates were family history of diabetes, activity level, diet, multi-vitamin use, smoking history, and BMI at 18 years and for each biannual reporting period.
Results:
- In general, for each year of breastfeeding for women with births 15 years prior, there was a decrease in risk of diabetes of 15% (NHS) and 14% (NHS II).
- Both cohorts consistently indicated a reduction in the incidence of type 2 diabetes with each year of breastfeeding. Controlling for diet, exercise, smoking, and multi-vitamin use did not significantly change the association of breastfeeding reducing risk.
- Maternal BMI did not appear significantly altered by lactation, suggesting that the reduced maternal risk for diabetes is related to improved maternal glucose homeostasis.
- Exclusivity was associated with greater benefit. After controlling for age and parity, the NHS II cohort data showed that each year of lifetime exclusive breastfeeding was associated with a 37% type 2 diabetes risk reduction compared to 24% for each year of any breastfeeding.
- Longer continuous breastfeeding appeared to have greater risk reduction benefit than the same amount of lifetime breastfeeding shared by 2 or more children. To clarify, 1 year of continuous breastfeeding with one child was associated with greater risk reduction when compared to two children breastfed for 6 months each.
- In NHS II, higher BMI at age 18 was linked with shorter breastfeeding duration. In both cohorts, the duration of breastfeeding was inversely related to family history of diabetes. Gestational diabetes did not appear to impact duration.
- For women with a history of gestational diabetes (NHS II only), the covariates of lactation history, present activity level and diet did not appear to effect diabetes risk. The consistent predictors of diabetes risk were BMI at age 18, current BMI and family history of diabetes.
- For women who did not breastfeed, the use of medication to suppress lactation was associated with increased risk of diabetes compared to those women who did not receive lactation suppression medication.
For more information, please see the article. Stuebe, et al. Duration of Lactation and Incidence of Type 2 Diabetes. JAMA, November 2005; 294:(20):2601-10.
Editorial Comment: Suzan Murphy
The questions and answers noted in my April CCC Corner Breastfeeding column are short phone call answers to sometimes complex issues.
http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0407_Feat.cfm#breast
For more in-depth information, please consider the following:
Regarding alcohol:
- When moms plan for a 12 oz of beer with pizza next weekend or a standard mixed drink or 5 oz of wine at the annual office party, the “2 hours for every drink” has clinical support.
- Often moms will choose to not drink alcohol rather than worry about timing feedings.
- Choosing to drink non-alcoholic beverages is the safest choice, for breastfeeding and driving home. Alcohol goes into the breast milk and until is metabolized out, safe levels have not been determined. Drinking extra water, more coffee, or pumping have not been shown to make the breast milk have less alcohol, like the rest of the body, the milk glands have to wait for the liver to do its job.
- Sometimes moms ask or call after drinking alcohol and need to know when it is safe to resume breastfeeding – it helps to “do the math” with moms – count the drinks, review portion size, multiple by 2 hours, - also consider when the last drink was.
- If the moms describe risky drinking patterns (defined by ACOG as more than 7 drinks per week or more than 3 drinks at a time) – consider using this opportunity to ask more questions, offer resources and information, and provide pathways for moms and families to healthier lives. ACOG link below
- Sometimes it is hard to find behaviors to praise with those who have risky or serious drinking issues. For those moms who are seeking sobriety and choose to use formula to keep their baby safe, it can be a difficult and painful choice. It may help them to acknowledge the wisdom of their decision.
Regarding tobacco, chewed or smoked:
- Mom/families often call about using (legal) tobacco. They ask if they should stop breastfeeding if they smoke or chew.
- Exposure to the baby can be from the mom smoking or smoking/chewing and breastfeeding, from 2nd hand smoke, or 2nd hand to mother and then to the baby by way of environmental exposure or breast milk. The tobacco by products that appear in breast milk and infant’s urine are cotinine and nicotine. Cotinine and nicotine are associated with SIDS and colic. There are no known safe levels. In one study, the urinary cotinine levels were higher babies breastfed by smoking moms than babies formula fed by smoking moms. ( Becker AB et al1999)
- However, study results vary. A recent study reported that babies breastfed by mothers who smoked had lower cotinine and nicotine urine levels than babies whose mothers smoked, but were formula fed. (Bajanowski T et al 2007)
- Regarding nicotine patches for smoking cessation: A recent study found use of nicotine patches to be safer option than continued smoking. When mothers were smoking almost 1 ppd, the nicotine and cotinine levels their breast milk were similar to those mothers using the 21-mg/day patch. But when the patch strength was tapered to 14-mg and 7–mg, the nicotine and cotinine concentrations decreased significantly. There was also no significant influence on the milk supply when the patch was used. (Ilett KF et al 2003)
- When a family does not use tobacco, it greatly reduces the risk of exposing new life to known problem agents. There is more to be learned. Currently, the American Academy of Pediatrics (AAP) states that the benefits of breastfeeding are greater than known risks of tobacco by products in breast milk.
Follow-up from Judy Thierry on a similar topic
I wanted to share key points from the following excerpts on a NOMOGRAM from Alcohol and Breast Feeding: Calculation of Time to Zero Level in Milk. Biol Neonate 2001;80:219-222
Objective: To create a nomogram that will guide lactating women who drink socially on how to avoid neonatal exposure to ethanol through breast milk. Design: Pharmacokinetic modeling of ethanol elimination from milk based on reference values. Calculation of the time to zero alcohol in breast milk for a range of doses and body weights. Results: The elimination of alcohol and time-to-zero levels in breast milk are described in a nomogram as a function of the amount of alcohol consumed and the body weight of the woman. Conclusions: Careful planning of a breast feeding schedule, by storing milk before drinking and/or waiting for complete alcohol elimination from the breast milk, can ensure women that their babies are not exposed to any alcohol.
Per the Nomogram:
For a 155 pound or 70.3 Kg women: 1 drink takes 2 hr 12 min to reach ZERO level
For a 110 pound or 49.9 Kg women: 2 drinks takes 5 hr 12 min to reach Zero level
For a 210 pound or 95.3 Kg women: 1 drink takes 1 hr 51 min to reach Zero level
Several other issues are addressed in Biol Neonate 2001; 80:219-222:
-AN INFANT DETOXIFIES ALCOHOL AT ½ THE RATE OF AN ADULT
-MILK PRODUCTION VERSUS INFANT CONSUMPTION EFFECTS
-GROSS MOTOR DEVELOPMENT
-SLEEP WAKE PATTERNS
-HYPOGLYCEMIC EFFECTS OF ALCOHOL
-METHODOLOGY: ALCOHOL CONCENTRATIONS SERUM, BODY WATER
-DISTINCTION: ‘MILK POLLUTION’
-ZERO ORDER KINETICS . . .
Ho E, et al Alcohol and Breast Feeding: Calculation of Time to Zero Level in Milk. Biol Neonate 2001;80:219-222
Resources
ACOG
Clinician Tools - Drinking and Reproductive Health
www.acog.org/from_home/misc/dept_pubs.cfm
Becker AB , et al, Breast-Feeding and Environmental Tobacco Smoke Exposure, Arch Pediatr Adolesc Med, 1999 Jul;153(7):689-91
Bajanowski T et al, Nicotine and cotinine in infants dying from sudden infant death syndrome. Int J Legal Med. 2007 Feb 7
Ilett KF et al, Use of nicotine patches in breast-feeding mothers: transfer of nicotine and cotinine into human milk. Clin Pharmacol Ther. 2003 Dec;74(6):516-24.
American Academy of Pediatrics
Other
The WHO publication that details the evidence for the 10 Steps to Baby Friendly
http://www.who.int/child-adolescent-health/New_Publications/NUTRITION/WHO_CHD_98.9.pdf
CCC Corner Digest
Nicely laid out hard copy - A compact digest of last month’s CCC Corner
Highlights include
-HPV Vaccine: Newest ACIP Recommendations - Comments by Amy Groom
-When Things Go Wrong: Responding to Adverse Events
-HIV Prenatal Screening Can Saves Lives– B. Reilley / S. Giberson
-Surgery versus medical therapy for heavy menstrual bleeding
-Newborn circumcision: Improved outcomes with pediatric hospitalists
-Obesity surgeries expanding dramatically since 1998, AHRQ
-All Encouraged to Help Reduce Colorectal Cancer Deaths in Women
-Inquiring families want to know - what about breastfeeding and……
-Violence Threatens the Health of Pregnant Women and Newborns
-Guidelines for Palliative Care Services: Now Online
-Welcome to the Indian Health Methamphetamine Initiative Site
-Does misoprostol aid prior to IUD insertion?
-Testing New Drugs on the World’s Poorest Patients
-The Magic of Play
-Prolonged second stage: The rest of the story
-Being Present: The spirituality of presence in midwifery care
-Oral, not Transdermal, Estrogen Increases Risk for VTE in Women
-Prenatal screening: It is recommended for ALL ages
-Assessment of Adverse Drug Events in a Tertiary Care Medical Center
-Cesarean Delivery on Maternal Request
-Bisphosphonate Related Osteonecrosis of the Jaws
-What is the best management plan for preterm labor?
-Electronic Health Record (EHR) Implementation: Worth the effort?
-HPV Vaccine Frequently Asked Questions
-Northern Women at Most Risk: Vit. D Deficiency Widespread in Pregnancy
-Can you dispense birth control to minors without parental consent?
-How many rubella vaccines does a mother really need to get?
http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0407.cfm
If you want a copy of the CCC Digest mailed to you each month, please contact nmurphy@scf.cc
Domestic Violence – Denise Grenier, Rachel Locker
Intimate partner abuse has no age limit
http://www.ahrq.gov/research/mar07/307RA21.htm
Domestic Violence and Your Patient's Health: Asking the Right Questions
http://www.medscape.com/viewprogram/6760?sssdmh=dm1.255226&src=nlcmealert
Elder Care News
Use of the pain reliever propoxyphene is associated with a higher
risk of hip fracture among the elderly
http://www.ahrq.gov/research/mar07/307RA23.htm
Family Planning
Oral Contraception Regimen and Breakthrough Bleeding
Results: Women who had a heavier daily flow rate during the 21/7 cycle before the extended regimen were significantly more likely to have heavier flow and earlier breakthrough bleeding during the extended regimen. The average daily flow rating during the extended period was 0.21 (on the 0 to 4 scale), which improved over time. Participants who had breakthrough bleeding or spotting for seven consecutive days had a better response to a hormone-free interval than those randomized to the other treatment strategy.
Conclusion: The authors conclude that a 168-day extended oral contraception regimen resulted in an acceptable rate of breakthrough bleeding or spotting and had a high rate of continuation. The best strategy for managing bleeding during the extended cycle was a three-day hormone-free interval.
Sulak PJ, et al. Prospective analysis of occurrence and management of breakthrough bleeding during an extended oral contraception regimen. Am J Obstet Gynecol October 2006;195:935-41.
Prescribing a one-year supply of OCs contributes to more continuous use and lower costs
Results: Women who received prescriptions for 13 cycles were significantly more likely to still be receiving OCs 15 months after the initial prescription. At the 15-month follow-up, 43 percent of women who received prescriptions for 13 cycles had obtained sufficient pills for at least one year of continuous use compared with 22 percent of women given prescriptions for three months and 20 percent of those initially prescribed one month's supply. The rates of pill wastage were higher in women prescribed 13 cycles than in those prescribed three cycles (6.5 percent of cycles dispensed wasted compared with 2.0 percent), but the women initially prescribed 13 cycles completed an average of 14.5 cycles during the study compared with 9.0 cycles completed by women initially prescribed three months' supply. Despite having significantly fewer physician visits, a significantly higher percentage of women prescribed 13 cycles had Pap smears and chlamydia tests during the study. The program calculated an average saving of about $99 per patient for women prescribed 13 cycles compared with those prescribed three cycles
Conclusion: The authors conclude that prescribing a one-year supply of OCs contributes to more continuous use and lower costs than limiting prescriptions to a three-month or a one-month supply.
Foster DG, et al. Number of oral contraceptive pill packages dispensed, method continuation, and costs. Obstet Gynecol November 2006;108:1107-14 .
http://www.aafp.org/afp/20070315/tips/15.html
Does Oral Contraceptive Use Affect Breast Cancer Risk?
Conclusion: The authors conclude that OC use is associated with an increased risk of breast cancer in premenopausal women, especially when used for prolonged periods of time before their first full-term pregnancy. This risk appears to be greatest in women who had used OCs for more than four years before their first full-term pregnancy, although the reason remains unclear. The authors express concern that the ORs may be underestimations because of the potential for survivor bias in the studies they reviewed.
Kahlenborn C, et al. Oral contraceptive use as a risk factor for premenopausal breast cancer: a meta-analysis. Mayo Clin Proc October 2006;81:1290-302.
http://www.aafp.org/afp/20070315/tips/14.html
Featured Web Site David Gahn, IHS MCH Portal Web Site Content Coordinator
Must See Website: Indian Health Service HIV-AIDS Program
CDR Scott Giberson, MPH, Pharm.D, PH-C has developed a website dedicated to the IHS HIV-AIDS Program. As most of us have seen, HIV/AIDS continues to pose a serious risk to American Indians and Alaskan Natives (AI/AN). This new, robust website contains a variety of useful information including:
- A complete description of the IHS HIV/AIDS Program
- Useful CDC Fact Sheets
- Details of the support IHS receives from the Minority AIDS Initiative
- Current HIV/AIDS research initiatives and results involving AI/AN
- Clinical information including HIV/AIDS CE/CME and Clinical Guidelines for testing and treatment (including post-exposure prophylaxis)
- ARV Corner – a description of the various antiretrovirals available and the clinical trials involving these drugs
- FAQs
While the website is not yet complete, the information included is useful and reliable. It will be a valuable resource for those of us involved in testing for and treating HIV.
www.ihs.gov/medicalprograms/hivaids/
Contact: Scott.Giberson@ihs.hhs.gov
Frequently asked questions
Q. What are the actual federal regulations on sterilization? Bilateral tubal ligation, etc…
A. Go here for several resources and the Sterilization Electronic Code of Federal Regulations
http://www.ihs.gov/MedicalPrograms/MCH/M/Bfaqs.cfm#BTL
or
GPO Access Site: Sterilization Electronic Code of Federal Regulations
Indian Child Health Notes - Steve Holve, Pediatrics Chief Clinical Consultant
May 2007
-Infant deaths associated with Cough and Cold Medications- 2005
-Prevention of Childhood Pneumococcal Invasive Disease with Pneumococcal Conjugate Vaccine: Contrasting Experiences in Alaska Natives and Navajo/Apaches
-Meeting the needs of regional minority groups: the University of Washington's programs to increase the American Indian and Alaskan Native physician workforce.
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ICHN507.doc
Information Technology
Electronic Health Record (EHR) Implementation: Worth the effort?
May 1, 2007
Moderator: David Johnson, MD
-Anticipated benefits of an EHR: Demonstrated through experience?
-What are the real costs: Decreased efficiency, IT support requirements, etc…
-Effect on the provider – patient relationship
How to subscribe / unsubscribe to the Primary Care Discussion Forum?
Subscribe to the Primary Care listserv
http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=26
Unsubscribe from the Primary Care listserv
http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=26
Questions on how to subscribe, contact nmurphy@scf.cc directly
International Health Update: Claire Wendland, Madison, WI
Ethics of medicine with economically vulnerable populations: Second in the series
Last month I wrote about current controversies in the recruitment of clinical trials subjects from impoverished international sites. This month’s focus is another ethical controversy in international health: the global organ trade.
In most countries where organ transplantation is done, the list of patients waiting for kidney transplants is far longer than the number of donors. The shortage of organs, the desperation of those waiting for transplants, and the money to be made in transplantation combine to produce a situation in which ethical rules get broken, or at least bent, frequently. At least one government times prisoner executions to maximize organ harvest; rumors of organ stealing, though not substantiated, course through the Third World. In fact, though selling a kidney is almost universally illegal (it is legal in Iran, quasi-legal in India), and is widely condemned by medical societies and professional organizations, there is a well-documented black-market trade in kidneys sold by poor “donors” for cash. Some ethicists, health economists, and transplant surgeons argue that since this trade is happening anyway, it should be legalized and regulated – in part to protect would-be kidney sellers from surgery done in unsafe conditions. Others believe this is one ethical line that should not be crossed: that selling a kidney is substantially different than selling semen or plasma, and that the potential for exploitation of the poor by the rich is too great.
Tarif Bakdash, a Syrian bioethicist, and Nancy Scheper-Hughes, an American anthropologist (and director of an NGO that monitors the organ trade), debate the question of whether kidney sales should be made legal in a thought-provoking recent article in PLoS Medicine. Bakdash believes that poor people often sell their kidneys for altruistic reasons, as a last-ditch effort to provide basic needs for their families (and the social science literature backs him up on this point). It is arrogance, even hypocrisy for the wealthy to try to “protect” the poor from selling their organs, he argues: poor people “are always exploited from the day they are born, and in all avenues of life. The only thing of value left for some of them is their bodies.” Scheper-Hughes believes that such sales make human life itself the ultimate commodity, dehumanizing everyone who comes in contact with the organ trade. She sees the polarization of the world that allows some people to be seen as sources of spare parts for others as “a medical, social, and moral tragedy of immense and not yet fully recognized proportions.” Readers may be left with a disturbing conundrum: is it possible that a poor person’s sale of a kidney may be an ethical act, while a rich person buying one is unethical?
Bakdash T, Scheper-Hughes N. Is it ethical for patients with renal disease to purchase kidneys from the world’s poor? PLoS Medicine 3(10):e349, October 2006www.plosmedicine.org
Other:
One-Visit Screening for Cervical Cancer May Be Feasible in Developing Countries
CONCLUSION: A single-visit approach using visual inspection of the cervix with acetic acid wash and cryotherapy proved to be safe, acceptable, and feasible in an urban African setting.
Blumenthal PD, et al Cervical cancer prevention: safety, acceptability, and feasibility of a single-visit approach in Accra, Ghana. Am J Obstet Gynecol. 2007 Apr;196(4):407.e1-8; discussion 407.e8-9
MCH Alert
Issues that affect adolescent well-being
Child Trends recently released three new briefs in the Research-to-Results series that offer guidance on adolescent health for out-of-school-time policymakers and program administrators. Each brief provides background information on selected adolescent health issues, practical tips for recognizing signs of problems among program participants, and outcome measures that can be used in program evaluations. The briefs include the following:
* Assessing the Diet, Exercise, Body Image, and Weight of Adolescents summarizes (1) what it means to be overweight, (2) what are body image and eating disorders, (3) what to do if you suspect that someone in your program is suffering from an eating disorder, and (4) how to assess weight issues among adolescents in out-of-school-time programs.
Additional resources for programs on healthy diet and eating disorders are also provided. http://www.childtrends.org/Files//Child_Trends-2007_03_14_RB_TeenDietandOST.pdf
* Assessing the Mental Health of Adolescents summarizes the signs and symptoms of depression, suicide risk, and anxiety disorders and suggests research questions that can help programs screen for or monitor mental health issues. Additional program resources on these topics are also provided. http://www.childtrends.org/Files//MentalHealth.pdf
* Assessing Substance Use and Abuse Among Adolescents discusses the signs and symptoms of alcohol and drug use and provides recommendations to assess substance use among adolescents in out-of-school-time programs. Additional program resources on tobacco use, alcohol use, and illicit drug use are also provided. http://www.childtrends.org/Files//Substance%20Use.pdf
Surgeon General Issues National Call to Action on Underage Alcohol Use
The Surgeon General's Call to Action to Prevent and Reduce Underage Drinking focuses national attention on the social costs and personal consequences of underage alcohol use and the process of solving this public health problem. The call to action, published by the Office of the Surgeon General, presents research that offers new opportunities for prevention and intervention by furthering an understanding of underage alcohol use as a developmental phenomenon -- a behavior directly related to maturational processes in adolescence. Topics include the scope of the problem, alcohol use and adolescent development, and prevention and reduction of alcohol use and alcohol use disorders in adolescents.
Action steps, a conclusion, and references are also presented. The appendix contains a definition of a "standard drink" and diagnostic criteria for alcohol abuse and dependence. http://www.surgeongeneral.gov/topics/underagedrinking/calltoaction.pdf
Adolescent sexual behavior and strategies for reducing early pregnancy and childbearing
With One Voice 2007: America's Adults and Teens Sound Off About Teen Pregnancy assesses public opinion on adolescent pregnancy. The survey is the fifth in a series of nationally representative surveys conducted by the National Campaign to Prevent Teen Pregnancy that have asked adolescents (ages 12-19) and adults (ages 20 and older) a consistent, core set of questions about adolescent pregnancy and related issues.
Topics include parental and other adult influence; abstinence and contraception;
regret, virginity, older partners, and attitudes about adolescent sex; gender
differences; religion; social norms and beliefs; and media. Data are presented
in charts and, where available, results from previous surveys (2001-2006) are
included. A description of the survey methodology and a summary are also provided.
The survey is intended to provide insights for policymakers, program administrators,
families, and others about adolescent pregnancy and factors that influence adolescents'
decisions about sex.
http://www.teenpregnancy.org/resources/data/pdf/WOV2007_fulltext.pdf
MCH Headlines: Judy Thierry HQE
Do you walk around your vehicle before getting in it? You should
Pedestrian child fatalities kids and cars website eliminating deaths due to backing out know your blind spots http://www.kidsandcars.org /
Links for child safety – videos “Don’t Back Blind”
Know your vehicles blind spots - visual aid to instruct parents
- NBC today show – 7 minute spot story, consumer report ‘walk through’ on REAL blind spots and what automakers are designing as ‘parking assists’ i.e. video, sonar or radar AND making a habit of “WALKING AROUND THE VEHICLE”.
- Don’t Back Blind – PSA’s
Short PSA videos compelling visual stories and informational
- "Driving blind"
- Making cars safer for children – windows, doors, etc.
- View Point -- The Consumers Union Perspective - "Cars should be made safer for children." October 2003
- 'Back up systems' – pdf at this site
http://www.consumerreports.org/cro/cars/safety-recalls/mind-that-blind-spot-1005/overview/index.htm
Really! these are the distances! - 9 to 45 feet depending on vehicle size and driver
note BEST and worst by gender (basically men are bigger than women - so it is the sitting height that is being represented here)
The WHO publication that details the evidence for the 10 Steps to Baby Friendly
Thanks to Cindy Turner at Baby Friendly USA cturner@babyfriendlyusa.org
WHO Link
http://www.who.int/child-adolescent-health/New_Publications/NUTRITION/WHO_CHD_98.9.pdf
Second round request for Oral Health Preceptorship applications Announcement OHRA Preceptorship Program Phase II
The MCH Program on behalf of the American Academy of Pediatrics recently sent out an announcement and have received 10 applications from ITU sites for the first round.
Now, there is an opportunity for 3 additional AIAN sites to be funded in this second round.
Please take advantage of this training.
AAP Wendy Nelson wnelson@aap.org
[For those who applied in Feb/March you do not need to apply again! Notification soon.]
Do HIV Testing Rates Improve When Written Consent Is No Longer Required?
-Written informed consent is a barrier to testing and to identifying infected
individuals.
Secular trends in implementing routine HIV testing in healthcare settings could
explain some of the testing increase seen in this study. However, the rapidity
with which the testing rate increased after the policy change, and the increased
number of patients identified, are impressive. This report lends further evidence
that written informed consent is a barrier to testing and to identifying infected
individuals. AIDS Clinical Care, Volume 4, Number 6 http://www.medscape.com/viewarticle/554615
Zetola NM et al. Association between rates of HIV testing and elimination of written consents in San Francisco. JAMA 2007 Mar 14; 297:1061-2
MCH Coordinator Editorial comment:
As you are aware, the IHS removed IHS Form 509 (which previously required separate and specific written informed consent for an HIV Test) in October 2006. There are ongoing and completed studies that support this type of policy action and implementation of more routinized testing – for one example, see below. However, also as noted above, states still have jurisdiction to mandate that HIV testing be accompanied by specific written consent for an HIV test. Many states are now revisiting this issue with CDC and are continually discussing potential changes in by-laws, policies, etc. Please contact your state if you have questions and do not rely on internet/online reports of ‘current’ state HIV testing requirements since they have potential to be out-of-date. Also, ask your state specifically if it is possible to acquire verbal consent and document in the chart vice separate written consent.
You are invited to join a Meth PH Forum
Interested individuals are invited to join a new Virtual Office at www.HealthDisparities.net Meth PH Forum Virtual Office (VO).
The VO includes a listserv, resources, library, calendar of shared events, announcement capacity, working documents for review or documents 'in-progress' section; all of which can be used as a means for communication. If you will be involved with this group, please join the Meth PH Forum VO.
Membership
Membership is for a broad array of public health officials at the municipal, state, county, Tribal and federal level. Health care providers; child educators; academicians; child welfare workers; public safety workers; judicial and law enforcement entities and other stakeholders who share in the public health response to methamphetamine should consider subscribing.
Joining the VO
If you do not already have an account at HealthDisparities.net, go to http://www.healthdisparities.net and follow the link at the top right hand side of the page for "new user signup". When you get to the section of "New User Signup" called "Group Memberships", make sure you put a check mark next to Meth PH Forum VO.
Group membership results in access to the VO as well as automatic subscription to the listserv. To opt out of the listserv or change any of your HDC listserv subscription settings, first log-in to the site then go to the "Community" menu and choose "Listserv". Check or uncheck the boxes and then click "Save" to alter your listserv subscriptions.
If you already have an account at HealthDisparities.net, just log-in at the website with user name and password and go to the "Office" menu, choose "My Account" and click on "Group Memberships". Then put a check mark next to Meth PH Forum VO under "National Groups" and click "Save Changes".
Contact us
If you have any questions feel free to contact:
CAPT Judith Thierry, DO, MPH, Maternal and Child Health Program, Indian Health Service at judith.thierry@ihs.gov or CAPT Stephanie Bryn, HRSA, MCHB at Sbryn@hrsa.gov or the HDC Webmaster at webmaster@healthdisparities.net
Canada HPV vaccine rollout
The Canadian government on Monday announced that it is including about $258
million in the 2007-2008 budget to help pay for provincial human papillomavirus
vaccination programs, Toronto's Globe and Mail reports. Canada's National Advisory
Committee on Immunization has recommended that girls ages nine to 13 be vaccinated
against HPV, as well as older girls and women who might already be sexually active
but not infected with the virus. The budget allocation, which will be distributed
to provinces over the next year, "does not imply" that a mandatory
vaccination program will be instituted in Canada, but it "does make the
possibility more likely," according to the Globe and Mail. The total estimated
cost for provincial HPV vaccination is estimated to be more than $860 million,
according to the Department of Finance. About 400 women in Canada die from cervical
cancer annually. According to the Globe and Mail, the budget allocation is being
lauded by health professionals but could "alienate some elements of the
socially right-wing base" of the ruling Conservative Party (Galloway, Globe
and Mail, 3/20).
http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=43718
Significant Association between Smoking, Mental Disorders in Pregnant
Women
Alert to Healthcare Providers: Research Supports the Benefit of Screening
for Mental Disorders in Pregnant Women Unable to Quit Smoking
New research has identified an association between mental disorders and nicotine dependence among pregnant women in the United States, not unlike what has been reported in the general population. The presence of these mental disorders in nicotine addicted pregnant women may make quitting smoking more difficult. Published in the April 2007 issue of Obstetrics and Gynecology, this study was supported in part by the National Institute on Drug Abuse (NIDA), part of the National Institutes of Health.
The study included 1,516 pregnant women at least 18 years old who took part in the 2001–2002 National Epidemiologic Survey of Alcohol and Related Conditions, a nationally representative survey of more than 43,000 U.S. adults administered by the National Institute on Alcohol Abuse and Alcoholism (NIAAA).
Researchers found that 21.7 percent of the pregnant women in the study used cigarettes and among those women, 57.2 percent were nicotine dependent. These results indicate that in the United States an estimated 12.4 percent of pregnant women are addicted to cigarettes. Women with nicotine dependence were more likely to meet criteria for at least one mental disorder compared to those that did not use cigarettes during pregnancy. Significant associations were found for dysthymia (a chronic depressive condition), major depressive disorder, and panic disorder.
“Understanding that these co-morbidities exist may shed light on why some women are unable to abstain from smoking during pregnancy even though they understand the negative health impact for them and their unborn children,” says NIDA Director Dr. Nora D. Volkow. "There is tremendous value in screening pregnant women who are unable to abstain from smoking for mental disorders — to not only identify and treat those who have been undiagnosed but also to improve successful quit smoking attempts.”
Encouraging women to quit smoking before they become pregnant is important to the health of the fetus, in addition to improving the health of the mother. Pregnant women who smoke cigarettes run an increased risk of having infants with low birth weight and their children face an increased risk for learning and behavioral problems.
The National Institute on Drug Abuse is a component of the National Institutes of Health, U.S. Department of Health and Human Services. NIDA supports most of the world’s research on the health aspects of drug abuse and addiction. The Institute carries out a large variety of programs to ensure the rapid dissemination of research information and its implementation in policy and practice. Fact sheets on the health effects of drugs of abuse and information on NIDA research and other activities can be found on the NIDA home page at www.drugabuse.gov.
http://www.nih.gov/news/pr/apr2007/nida-03.htm
Carbon Monoxide Kills Subtly, Silently
The subtle quiet killer Carbon Monoxide [Carbon monoxide (CO) is a colorless, odorless gas that is produced as a result of incomplete burning of carbon-containing fuels. Exposure to CO reduces the blood's ability to carry oxygen] a quick review below will keep you and your community thinking of the exposures, risky heating and when to think in your differential diagnosis that CO exposure may be a foot. Riding in the back of pick-up trucks, non-passenger intended spaces in vehicles is also unwise. Another hidden CO exposure is cigarette smoke – first or second hand.
Carbon monoxide (CO) from gasoline-powered generators that may be used during winter weather-related power outages can kill in minutes. Consumers should never use a generator, charcoal or gas grill in an enclosed area. In addition, fuel-burning appliances can cause carbon monoxide poisoning if they are improperly installed, poorly maintained, have defective or blocked venting systems, or are misused.
To help prevent deaths and injuries, CPSC urges consumers to:
- Have your heating system, water heater and any other gas, oil, or coal burning appliances serviced by a qualified technician every year.
- Install battery-operated CO and smoke alarms in your home. Locate CO alarms outside the bedrooms in each separate sleeping area. Locate smoke alarms on each level of the house and inside every bedroom.
- Replace smoke and CO alarm batteries in the spring and fall when you change the time on your clocks.
- If an alarm sounds, leave your home immediately and call 911.
- Seek medical attention immediately if you are feeling dizzy, lightheaded or nauseous. These are symptoms of CO poisoning.
additional information hazards associated with carbon monoxide and safe use of portable generators.
http://www.cpsc.gov/generator.html
HIV Care at a Crossroads: The Emerging Crisis in the US HIV Epidemic
Audio Article discusses the crossroads. Narrative accompanies. Full article discusses increase funding 4 minute video presentation intro to article routine opt out predicting increase numbers pressing on treatment and care system Title III clinics now at or above capacity
Shifts in epidemiology, patient volume in flat funded programs. Dec 06 reauthorized RWCA 109-405 3.7% modest annual increase in Title III funding of RWCA. Will it meet the needs?
http://www.medscape.com/viewarticle/553119?src=mp
Medical Mystery Tour
Which Indian Health facilities lead the entire U.S. in national obstetric benchmarks?
And better yet, how can we translate that success to other Indian Health sites?
About Benchmarking
Benchmarking is a method for comparing your facilities care processes to those of the practices in the field that demonstrate the best outcomes. Identifying "best practices" through benchmarking allows all who participate in the process to improve and adapt the care they provide in order to obtain superior outcomes: high satisfaction, patient safety, effectiveness and efficiency.
One Example: ACNM
The purpose of the American College of Nurse-Midwives (ACNM) Benchmarking Program is to provide a midwifery-specific mechanism to improve and maintain the superior quality of midwifery care provided to women and children by promoting member awareness of "best practices." To facilitate this, members are encouraged to participate in benchmarking their practice against other midwifery practices in the country.
In the meantime
The answers will be discussed in the next edition of the CCC Corner. In the meantime, if your facility is not one of facilities I am going to announce next month, then you should attend the 2007 National Indian Women’s Health and MCH Conference. The Conference will be in Albuquerque, NM August 15- 17, 2007.
The theme of the meeting is “Improve the System: Improve the Outcome” so it will explore how we can all work together to raise the AI/AN health status to the highest possible status.
There will be national benchmark organizations (Institute for Healthcare Improvement, American College of Nurse-Midwives, American College of Obstetricians and Gynecologists, Kaiser Family Foundation, etc…), internationally known speakers, and a rather extensive clinical Program.
The meeting is only every 3 years, so you and a team from your facility should try your best to attend. You can either use your local facility funds, because there is a program review function, or use your CME /CEU funds. In addition, limited scholarships are available.
2007 National Indian Women’s Health and MCH Conference
http://www.ihs.gov/MedicalPrograms/MCH/F/CN01.cfm#Aug07
Resources
Collins-Fulea C, et al Improving midwifery practice: the American College of Nurse-Midwives' benchmarking project. J Midwifery Womens Health. 2005 Nov-Dec;50(6):461-71.
or
http://download.journals.elsevierhealth.com/pdfs/journals/
1526-9523/PIIS1526952305003302.pdf
ACNM Benchmarking Program
http://www.acnm.org/education.cfm?id=842
Medscape*
Bone Density Evaluation in Teens Prevents Future Osteoporosis
http://www.medscape.com/viewarticle/545997?src=0_nl_cme_9
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
Emergence of a range of nonhormonal treatments for vasomotor symptoms
CONCLUSION: The availability of centrally active therapies for menopausal vasomotor symptoms with risks and benefits clearly defined by results from well-designed clinical trials has the potential to allay safety concerns that are associated with the treatment of these common symptoms.
Rapkin AJ Vasomotor symptoms in menopause: physiologic condition and central nervous system approaches to treatment. Am J Obstet Gynecol. 2007; 196(2):97-106
Early Estrogen Therapy May Reduce Cardiovascular Risks
Secondary analyses of findings from the Women’s Health Initiative (WHI) suggest that women who begin hormone therapy within 10 years of menopause may have less risk of coronary heart disease (CHD) due to hormone therapy than women farther from menopause.
The analysis of both estrogen and estrogen plus progestin data from the Women's Health Initiative (WHI) hormone trials shows a 24 percent reduction in risk for coronary heart disease events in women starting hormone therapy less than 10 years after menopause The analysis also showed a 30 percent reduction in overall deaths among women aged 50 to 59 using hormone therapy. However, the new study also found that hormone therapy increased coronary heart disease events by 28 percent in older women, and that deaths increased by 14 percent in women aged 70 to 79. There was a slightly elevated risk of stroke at all ages studied.
Rossouw JE, et al Postmenopausal Hormone Therapy and Risk of Cardiovascular Disease by Age and Years Since Menopause JAMA. 2007 Apr 4;297(13):1465-77
Midwives Corner - Lisa Allee, CNM
Ultrasound affects mice brains in negative ways: First, do no harm
I was flipping through the November/December issue of Mothering magazine and found a citation of an interesting research article on the effects of ultrasound on mice brains. It has scary findings for an intervention that is often considered routine and benign by providers and patients.
Eugenius, et al*, found that when fetal mice are exposed to 30 minutes or more of ultrasound that “a small but statistically significant number of neurons fail to acquire their proper position and remain scattered within inappropriate cortical layers and/or in the subjacent white matter. The magnitude of dispersion of labeled neurons was variable but systematically increased with duration of exposure to USW.” Yikes! This means that cells in the brain are not all in the right place. Okay, you’re saying these are mice, not humans. In their discussion the authors discuss this—it might not apply to humans, but then again it might in a big way:
First it may not be applicable because “..the distance between the exposed cells and transducer in our experiments is shorter than in human. Furthermore, the duration of neuronal production and the migratory phase of cortical neurons in the human fetus lasts
18 times longer than in mice (between 6 and 24 weeks of gestation, with the peak occurring between 11 and 15 weeks), compared with the duration of only
1 week (between E11 and E18) in the mouse. Thus, an exposure of 30 min represents a much smaller proportion of the time dedicated to development of the cerebral cortex in human than in mouse and, thus, could have a lesser overall effect, making human corticogenesis less vulnerable to USW” (ultrasound mwaves.)
But on the other hand, “There are also some reasons to think that the USW may have a similar or even greater impact on neuronal migration in the human fetal brain. First, migrating neurons in the human forebrain are only slightly larger than in the mouse, and, with the acoustic absorption provided by the tissue stand-off pad, the amount of energy absorbed within a comparable small volume of tissue during the USW exposure was in the same general range. Second, the migratory pathway in the convoluted human cerebrum is curvilinear and at least an order of magnitude longer. Thus, the number of neurons migrating along the same radial glial fascicle, particularly at the later stages of corticoneurogenesis, is much larger and their routes are more complex, increasing the chance of a cell going astray from its proper migratory course. Third, the inside-to-outside settling pattern of isochronously generated neurons in primates is more precise than in rodents and thus, the tolerance for malpositioning may be smaller. In addition, different functional areas in the primate cortex are generated by different schedules so that exposure to USW may potentially affect selective cortical areas and different layers, depending on the time of exposure, potentially causing a variety of symptoms.”
These effects of ultrasound are hard to study in humans because the testing to find ectopic cells in the brain cannot be done in humans according to the authors. There are some things that are known and are concerning: “even a small number of ectopic cells might, as a result of specific position and inappropriate connectivity, be a source of epileptic discharge or abnormal behavior. Although we have not as yet generated behavioral data, previous studies in rodents and primates indicate that prenatal exposure to USW may affect higher brain function of the offspring. Furthermore, there are numerous human neuropsychiatric disorders that are thought to be the result of misplacement of cells as a consequence of abnormal neuronal migration.” The authors go on to say that their research supports the recommendation by the FDA that medically non-indicated commercial ultrasound videos should not be done.
I find this research concerning for more than just ultrasound videos offered in malls. I wonder about repeated ultrasounds for medical indications, dating ultrasounds during the most vulnerable periods of cell migration in the brain, antenatal testing that has never been shown to improve outcomes, and, the biggest of all, continuous fetal monitoring during labor for hours on end. Remember: the ultrasound to create pictures is pulsed—only 1/100th of the time is actual exposure to ultrasound—whereas the fetal monitor on L & D is a continuous deluge of ultrasound—it is not pulsed, the whole time is exposure to ultrasound and the effects these researchers found increased with time. Yes, most monitoring is after the time of migration of neurons cited above, but we do know that the human brain continues to develop in a big way for the rest of intrauterine life and a long time after, so there may be are other effects on the brain cells. Anyone heard tell of increased rates of autism, depression, bipolar disease, behavioral problems, etc. in the current crop of young ‘ens?? Food for thought . . .
Other Resources:
Physics and safety of diagnostic ultrasound in obstetrics and gynecology, UpToDate
Indications for diagnostic obstetrical ultrasound examination , UpToDate
Eugenius SB et al Prenatal
exposure to ultrasound waves impacts neuronal migration in mice. PNAS | August
22, 2006 | vol. 103 | no. 34 | 12903-12910. Published online before print August
10, 2006, 10.1073/pnas.0605294103
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd
=retrieve&db=pubmed&list_uids=16901978&dopt=Abstract
Navajo News, Jean Howe, Chinle
BTL: Nearly one half of women under 25 years old request information on reversal
It seems that hardly a month goes by without a woman coming in to our clinic asking about how she can “get her tubes untied”. This continues to happen, despite the intensive counseling that we conduct prior to the procedure. Thus I was intrigued by a recent article in the journal Contraception, “Consent to Sterilization section of the Medicaid-Title XIX form: is it understandable?” The authors assessed the readability and comprehension characteristics of the current “Consent to Sterilization” form using a tool specifically designed for informed consent documents (Readability and Processability Form or RPF). The current sterilization consent scored in the poor range when assessed with this tool. A Fry reading level assessment corresponded to ninth grade level. The authors also presented a proposal for a revised form, which scored in the excellent range with an RPF assessment and had a Fry reading level of sixth grade.
Of course informed consent for sterilization doesn’t involve solely the use of the federal permit. A second operative consent, specific to the planned procedure, is also required. And true informed consent isn’t just about signing papers; it must involve a careful and thorough discussion of the planned procedure, the alternatives, and the risk of sterilization failure and the possibility of regret. The permanence of the procedure is emphasized throughout this process. Yet life is unpredictable and a woman’s circumstances may change. A woman who is completely sure that she wishes to proceed may return later, asking about sterilization reversal and sharing a compelling story of previous domestic violence or depression or of a new marriage.
Information about the risk of regret is available from the U.S. Collaborative Review of Sterilization (CREST) study, which followed 11,232 women aged 18-44 who had sterilizations between 1978 and 1987 for up to 14 years. One analysis, by Hillis, et al., clearly showed that the risk of regret is highest in the youngest women. As part of the study, follow-up visits were conducted over 14 years and participants were asked at each visit “Do you still think tubal sterilization as a permanent method of birth control was a good choice for you?” and found that, for women under 30 at the time of sterilization, the risk of regret was 20.3%. For women 30 or older at the time of sterilization, the risk of regret was 5.9%. Another study of the same population assessed the likelihood of regret by analyzing who requested information about reversal. In this analysis, Schmidt, et al. again found the highest risk of regret amongst the youngest women. When analyzed by age, 40.4% of women who were under 25 at the time of sterilization requested information about reversal. This decreased with age as follows: 15.6% for women ages 25-30, 8.2% for women ages 31-35, and 4.4% for women over 35 years old. Non-white race, < 12 years of formal education, unmarried status, a history of induced abortion, and postpartum sterilization, especially after vaginal delivery, were all associated with a higher incidence of regret, as was sterilization performed within 7 years of the birth of the youngest child. Interestingly, the number of living children did not correlate with the risk of regret. In some cases the probability of regret was cumulative, for example women who were both under 25 and unmarried at the time of sterilization had a 49% risk of regret. Ultimately 1.1% of the study population obtained a tubal reversal procedure; this was 8-fold more likely for women who were sterilized at less than 30 then over 30 years of age.
One could view this information from the opposite perspective; 94% of women over 30 and almost 80% of women under 30 did not regret their decision to be sterilized. Even amongst the youngest age cohort, almost 60% of women under 25 did not express regret about sterilization during up to 14 years of follow-up. Yet the fact that almost half of women sterilized at a young age subsequently regretted the procedure is compelling. Sterilization is one of many contraceptive options that we can make available to our patients but it deserves a special status because of its permanence. The same level of protection against unplanned pregnancy can be achieved with an IUD which both avoids the morbidity and risks of surgery and is completely reversible.
I am encouraged by Zite and her colleagues efforts in reassessing the federal sterilization consent form. Although we are unlikely to see new forms anytime soon, this serves as another reminder of the need to both simultaneously respect our patients’ autonomy in making contraceptive and sterilization decisions for themselves and their families and to equip them with proper tools to make these decisions. These tools include both well-written and understandable consent forms and extensive pre-procedure education that includes thorough discussions of the alternatives to sterilization, the permanence of the procedure, and the possibility of regret.
Zite , NB , Philipson, SJ, Wallace, LS, “Consent to Sterilization section of the Medicaid-Title XIX form: is it understandable?”, Contraception, 2007(75);256-260.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD=search&DB=pubmed
Hillis , SD , et al., “Poststerilization regret: Findings from the United States Collaborative Review of Sterilization”, Obstetrics and Gynecology, 1999(93)889-95.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD=Search&DB=pubmed
Schmidt, JE, et al., “Requesting information about and obtaining reversal after tubal sterilization: findings from the U.S. Collaborative Review of Sterilization”, Fertility and Sterilization, 2000(74)892-8.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD=Search&DB=pubmed
Deputy OB/GYN CCC Editorial comment:
How are you going to solve your dilemma of first trimester screening
in a rural setting?
Last month I wrote about new recommendations from ACOG for first trimester genetic
testing and the challenges that rural facilities face in trying to comply with
these recommendations. I had hoped to follow-up this month with some possible
solutions to this dilemma but this issue is proving to pose quite a challenge.
Again, if you work at a rural facility and have found a way to offer first trimester
screening, or combined first/second trimester screening, please share!
Also, if you have created or found a low-literacy patient education sheet for this testing, please let me know. My e-mail address is: jean.howe@ihs.gov.
Nurses Corner - Sandra Haldane, HQE
Two summer programs for high school students
July 21-28, 2007---The Cornell Association for the Technological Advancement of Learned Youth in Science and Technology (CATALYST) program is a one-week summer residential program for rising high school sophomores, juniors, and seniors from underrepresented backgrounds.
July 21-28, 2007 -The CURIE Academy is a one-week residential program for high school
girls who excel in math and science and want to learn more about careers
in engineering . http://www.engineering.cornell.edu/diversity/office-diversity-programs/summer-programs/highschool-
programs/curie-academy/index.cfm
Women sacrifice sleep to "Do It All," survey finds
American women are struggling to “do it all” and are sacrificing sleep to juggle their family and work responsibilities, according to a new survey led by a professor in the School of Nursing at the University of California, San Francisco.
The 2007 Sleep in America Poll, sponsored by the National Sleep Foundation, queried more than 1,000 adult women nationwide across all ages and races. It found that 60 percent of American women get fewer than one or two nights of good sleep each week, and 40 percent have sleep problems every night. The result is a significant impact on their mental and physical health, personal lives, professional work and driving safety.
“We found that the majority of American women are continually sleep deprived, either because of young children, biological changes like pregnancy and menopause, stress or pets,” said Kathryn Lee, PhD, a professor in the Department of Family Health Care Nursing in the UCSF School of Nursing, who led this year’s study. “The impact on their families, personal and professional lives, and society is enormous.”
The survey results were reported at the Foundation’s two-day scientific workshop on women and sleep, held in conjunction with the Atlanta School of Sleep Medicine. National Sleep Awareness Week, an annual health promotion campaign sponsored by the Foundation.
Survey participants reported that the lack of sleep caused them to be late to work, experience high stress, feel depressed or anxious, forego exercise, be too tired for sex, drive while drowsy and have little time for personal or family relationships.
Findings showed the primary cause of sleep deprivation was women’s efforts to fulfill their responsibilities in all aspects of their lives, including in professional work, child care, family needs and spousal relationships. Women’s sleep is further compromised by biological changes at various reproductive life stages, according to Lee.
The problem was most acute among working mothers, whom the study termed the “briefcase and backpack” group. Those women’s efforts to manage full-time work schedules as well as family responsibilities left them staying up late and continually sleep deprived, according to survey results.
That group reported an average of only six hours in bed per night. Nearly three-quarters of working mothers said they also suffered from insomnia or lack of sleep.
“This is not to say that mothers should not be in the workforce,” Lee said. “In fact, they are often the most productive, organized and efficient members of the staff. But it does point out the need for employers and our society as a whole to support them better.”
Lee said this support could include more flexible work hours, onsite child care, shuttle services to reduce driving risks, cafeterias that offer take-home meals for families, and opportunities for women to get exercise during the work day. It also could include greater support from spouses in handling home responsibilities, including preparing meals.
Other survey findings include:
• Sleep and exercise are the first things to go when women have too much to do in a day. The last to go is work.
• Nearly half of all women say they don’t get enough sleep every night.
• 30 percent of pregnant women and 42 percent of post-partum women report rarely getting a good night’s sleep, while 84 percent suffer from insomnia a few nights per week.
• Women wake frequently during the night due to noise (39 percent), giving care to children (20 percent) and pets (17 percent).
• 47 percent of women say they have no one to help with childcare at night;
• 35 percent of working moms report driving while drowsy.
• 65 percent drink caffeinated beverages to cope with the lack of sleep.
Lee said these results substantiate two decades of research she has conducted on women’s sleep patterns, most of which has concentrated on biologically-related sleep deficits throughout women’s life cycle.
This is the Foundation’s 10th annual survey of the American public’s sleep habits and the first to focus on women’s sleep patterns at all ages and biological states. Previous studies have focused on adults in general; older adults; infants, toddlers and young school children; and adolescents.
The National Sleep Foundation is an independent, nonprofit organization dedicated to improving public health and safety by achieving greater understanding of sleep and sleep disorders.
UCSF is a leading university that advances health worldwide by conducting advanced biomedical research, educating graduate students in the life sciences and health professions, and providing complex patient care. http://www.ucsf.edu/
How Should We Counsel Women About HPV Testing?
Question
In our practice, we are now doing HPV screening when we do Pap smears for women over 30 years old and for younger women if their Pap results are equivocal. How should we adapt our patient counseling in light of this new practice?
The National Association of Nurse Practitioners in Women's Health (NPWH) recently issued guidelines for cervical cancer screening, based on those issued by the American Society of Colposcopy and Cervical Pathology. These new guidelines reflect evidence-based advances in our understanding of the natural history of human papilloma virus (HPV), its influence on the development of cervical dysplasia and cancer, and the role of HPV DNA testing as an adjunct to Pap tests. A preview of the guidelines is now available on the NPWH Web site.[1]
Your practice is currently screening according to those guidelines, which recommend routine HPV screening, in addition to a Pap test, for all women over 30 years of age. NPWH does not recommend routine HPV screening for women younger than 30 unless they have an equivocal or ASCUS (atypical squamous cells of undetermined significance) Pap result. Younger women may be infected with HPV, but in most cases the HPV infection clears on its own. Routine screening in the under-30 population can lead to overdiagnosis and unnecessary follow-up. Persistent high-risk HPV is the causative factor for cervical dysplasia and cancer.[1]
The NPWH guidelines also emphasize the importance of counseling for women over the age of 30 years who are routinely tested regarding the need for and the significance of HPV testing. Because HPV is a sexually transmitted infection, being told that she is HPV-positive can be alarming news to a woman who has been in a monogamous relationship for many years when actually the positive result may indicate a persistent infection that has never cleared. Younger women may also find the news of a positive HPV test alarming, particularly if they are not aware that the test might be done if their Pap result is abnormal.
Following are the points recommended by NPWH for counseling women about HPV screening:
- Cervical cancer is preventable and caused by high-risk types of HPV;
- Most women will have an HPV infection at some point in their life;
- The virus is usually cleared by an immune response;
- Persistent HPV infection by high-risk types is the factor that increases the risk for cervical cancer;
- Infection with HPV is common but cervical cancer is rare;
- When an HPV test is positive, it does not mean that the virus is new or that a partner has been unfaithful; and
HPV can persist in the cells for decades so a positive test does not necessarily indicate a new infection.
NPWH recommends covering these points at the time of testing to decrease potential anxiety associated with a positive result.
http://www.medscape.com/viewarticle/552678?sssdmh=dm1.255206&src=0_tp_nl_0#
17 Interventions That Work: Lessons Learned from PHNs in the Field
Getting Behind the Wheel Minnesota Public Health
http://www.health.state.mn.us/divs/cfh/ophp/resources/phnnews/docs/0606wheelbook.pdf
Reducing turnover of registered nurses and certified nursing assistants will help maintain nursing home staffing levels
http://www.ahrq.gov/research/mar07/307RA24.htm
Office of Women's Health, CDC
Quadrivalent Human Papillomavirus Vaccine: Recommendations of the Advisory Committee on Immunization Practices
These recommendations represent the first statement by the Advisory Committee on Immunization Practices on the use of a quadrivalent human papillomavirus (HPV) vaccine licensed by the U.S. Food and Drug Administration on June 8, 2006. This report summarizes the epidemiology of HPV and associated diseases, describes the licensed HPV vaccine, and provides recommendations for its use for vaccination among females aged 9-26 years in the United States.
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr56e312a1.htm?s_cid=rr56e312a1_e
Oklahoma Perspective Greggory Woitte – Hastings Indian Medical Center
Cesarean Delivery on Maternal Request
It was in June of last year when I last wrote about the NIH Consensus conference on Cesarean Delivery on Maternal Request (CDMR). Over the past year there has been several articles written on the subject. The most recent of which is published in the New England Journal of Medicine by Ecker and Frigoletto (excerpted below).
Here at Hasting’s Indian Medical Center, we are beginning to explore this issue through journal clubs and dialogue. We have had more patients recently requesting Cesarean Delivery over the past year. A review of the NIH Consensus conference points out that most of the evidence is weak or non-existent to support planned vaginal or cesarean delivery. Moderate quality evidence is available for only three outcome variables (postpartum hemorrhage, maternal length of stay, and neonatal respiratory morbidity). .
ACOG sent out a news release on May 9, 2006 after the NIH consensus conference. In it they point out that more research is needed and that CDMR is not recommended for women planning on having several children due to the risks of placenta previa and placenta accreta increasing with each cesarean delivery. In addition, Dr. Zinberg, Deputy Executive Vice President of ACOG states “ACOG continues to review all of the issues surrounding maternal-request cesarean, but at this time our position is that cesareans should be performed for medical reasons.”
A number of the articles written have pointed out ACOG’s position that a cesarean delivery on maternal request can be ethically justified at times. In ACOG’s “Surgery and Patient Choice: The Ethics of Decision Making,” ACOG states that “In the absence of significant data on the risks and benefits of cesarean delivery, the burden of proof should fall on those who are advocates for a change in policy in support of elective cesarean delivery (ie, the replacement of a natural process with a major surgical procedure.”
As many of the articles and editorials written over the past year have pointed out, caution should be used when a patient requests a cesarean delivery. Moving slowly in the absence of good evidence is a prudent option. While support for a women’s choice is without question of paramount importance, performing cesarean deliveries on maternal request may ultimately lead to a violation of the Hippocratic Oath to do no harm.
OB/GYN CCC Editorial comment:
Looking for sanity in the ever increasing cesarean delivery rate
Ecker and Frigoletto state the key question centers on both the number needed to treat to avoid one adverse neonatal outcome and the level of risk that is currently considered acceptable. As practicing obstetricians, we find that the risk that women are now willing to assume in exchange for a measure of potential benefit, especially for the neonate, has changed: for many, the level of risk of an adverse outcome that was tolerated in the past to avoid cesarean delivery is no longer acceptable, and the threshold number needed to treat has thus been reset.
In the face of the resulting continued increase in cesarean deliveries, our obligation as providers is to educate patients about the trade-offs entailed in choosing a particular course or intervention and to ensure that their choices are congruent with their own philosophy, plans, and tolerance of risk. In areas in which there is still uncertainty, we must organize clinical trials that will produce the data we require for counseling patients. For the moment, however, few of the relevant factors seem likely to change, and the cesarean rate can be predicted to continue its climb.
The March 2006 National Institutes of Health (NIH) State-of-the-Science Conference report concluded that there was a need for research that explicitly compared outcomes of planned cesarean delivery with outcomes of planned vaginal delivery. Declercq et al examines 6 years of data from a population-based linked data system to create a refined measure identifying women with planned cesareans and planned vaginal births and comparing maternal outcomes and costs associated with these two options.
1.) planned cesarean increases complications and re-hospitalizations and
2.) planned cesarean increases cost
Declercq et al document a small, but consistent growth in planned primary cesareans, but higher costs, longer hospital stays, and substantially greater risks of maternal re-hospitalization associated with these deliveries.
The authors found that
* The rate of re-admission to a hospital (per 1,000) within 1 month of delivery for planned vaginal births was significantly lower than that for planned primary cesarean births (7.5 vs. 19.2). Adjusting for age, race or ethnicity, and parity, a woman who had a planned primary cesarean birth was 2.3 times as likely as a woman who had a planned vaginal birth to be re-admitted in the first month after the birth.
* The leading reason for re-admission associated with planned primary cesarean births in the first 30 days after birth was surgical wound complications. Postpartum infections were a major cause of re-admission for both groups, with the rate of re-admission for infection after planned primary cesarean births almost twice as high as that of infection after planned vaginal births.
* The average initial maternal (excluding infant) hospital costs in 2003 dollars for a planned primary cesarean birth were 76% higher than the average initial costs for a planned vaginal birth ($4,372 vs. $2,487).
* Women who had a planned primary cesarean birth averaged 4.3 days in their initial stay and 4.4 days in cases of re-admission, compared with
2.4 and 3.9 days, respectively, for those with a planned vaginal birth.
* Costs associated with a planned primary cesarean birth, compared with costs associated with a planned vaginal birth, were higher for both delivery (65%) and postpartum re-admission (11%).
Kennare R, et al just reported that after the first cesarean, the risks increase in next pregnancy. Specifically, cesarean delivery is associated with increased risks for adverse obstetric and perinatal outcomes in the subsequent birth. However, some risks may be due to confounding factors related to the indication for the first cesarean.
Dr. Woitte reminds us to do no harm. Declercq et al and Kennare R, et al findings suggest that planned primary cesareans are not without immediate health consequences for mothers and financial implications for society. Clinicians should be aware of the increased risk for maternal re-hospitalization after cesarean deliveries to low-risk mothers when counseling women about their choices.
Reference:
Declercq E, Barger M, Cabral HJ, et al. 2007. Maternal outcomes associated with planned primary cesarean births compared with planned vaginal births. Obstetrics and Gynecology 109(3):669-677. http://www.greenjournal.org/cgi/content/abstract/109/3/669?etoc or
Ecker
JL, Frigoletto
FD Jr. Cesarean delivery and the risk-benefit calculus. N
Engl J Med. 2007 Mar 1;356(9):885-8. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd
=retrieve&db=pubmed&list_uids=17329693&dopt=Abstract
Or http://content.nejm.org/cgi/content/full/356/9/885
Kennare R, et al Risks of adverse outcomes in the next birth after a first cesarean delivery. Obstet Gynecol. 2007 Feb;109(2 Pt 1):270-6
NIH Consensus Conference Report
http://consensus.nih.gov/2006
/2006CesareanSOS027html.htm
Patient-Requested Cesarean Update, ACOG Press Release
http://www.acog.org/from_home/publications/press_releases/nr05-09-06-1.cfm
Surgery and Patient Choice: The Ethics of Decision Making
http://www.acog.org/from_home/publications/ethics/ethics021.pdfOsteoporosis
Calcium Supplementation May Not Benefit Healthy Children
Results: The meta-analysis incorporated 19 RCTs with 2,859 participants three to 18 years of age. Calcium supplements of 300 to 1,200 mg per day were reported. All eligible studies used tablets or pills as the source of calcium; none used dairy foods. Studies used different body sites and techniques to measure changes in bone mineral density. Overall, a modest increase (1.7 percentage points) was found in the upper limb and in total body bone mineral content, but no effect was found at the femoral neck or lumbar spine. The effect on the upper limb persisted after supplementation ended but was unlikely to be clinically significant. Although girls seemed to benefit more than boys from supplementation, the difference was not statistically significant. None of the subgroup analyses showed any significant findings.
Conclusion: The authors conclude that calcium supplementation had little effect on bone mineral density in healthy children and that the observed slight increase in the upper limb should be interpreted with caution because of design factors in the studies and meta-analysis. They suggest more studies of supplementation with vitamin D are needed and that measures to increase fruit and vegetable intake may be more appropriate nutritional interventions.
Winzenberg T, et al. Effects of calcium supplementation on bone density in healthy children: meta-analysis of randomised controlled trials. BMJ October 14, 2006;333:775-8.
Osteoporosis Patients Likely to Pause Medication
CONCLUSION: Extended gaps in treatment are common among users of osteoporosis medications. Because the effectiveness of these drugs used in an interrupted way is unknown, compliance interventions should emphasize the need for continuous medication use. Further research is needed to understand why patients often go for months without refilling prescriptions and also whether similar utilization patterns exist for other chronic medications
Brookhart MA, et al Gaps in treatment among users of osteoporosis medications: the dynamics of noncompliance. Am J Med. 2007 Mar;120(3):251-6.
The Impact of Adherence and Persistence in the Pharmacological Management of Osteoporosis
Role and Importance of Calcium in Preventing and Managing Osteoporosis
Medscape CME
http://www.medscape.com/viewprogram/5237?src=0_nl_cme_9
Postmenopausal Osteoporosis: Putting the Risk for Osteonecrosis of the Jaw Into Perspective
http://www.medscape.com/viewprogram/6720?sssdmh=dm1.255206&src=0_tp_nl_0#Patient Information
Infertility: What You Should Know
http://www.aafp.org/afp/20070315/857ph.html
Perinatology Picks - George Gilson, Maternal Fetal Medicine, ANMC
Preconception counseling for women with diabetes and hypertension: What should the primary care provider do about their prescription medications?
Case #1
AD is a 25 y/o nullipara with newly diagnosed type 2 diabetes mellitus and moderate essential hypertension. She also has been trying to become pregnant. Her blood sugars have been fairly well controlled with diet and exercise, but her blood pressure is persistently greater than 140/90. Because of her dual problem, would it be appropriate to start an angiotensin converting enzyme (ACE) inhibitor? Could we then discontinue it when she becomes pregnant? Or would it be safer to start another medication that would be safer in pregnancy since she is not using any form of contraception?
Case #2
RYC is a 34 y/o G3P3 with known type 2 diabetes mellitus. Her blood sugars have been fairly well controlled with diet and metformin. She has recently remarried and is trying to conceive. On her most recent evaluation she is found to have the new onset of significant, but not nephrotic syndrome range, proteinuria (1.5 g/24 h). Would it be wise to start her on an ACE inhibitor, or an angiotensin receptor blocker (ARB), at this time?
Case #3
IN is a 22 y/o nullipara who hyperlipidemia. There is a strong family history of coronary artery disease, and her cholesterol has not been able to be brought below 250 mg/dL despite diet and exercise. Her triglycerides and LDL are also elevated, but her HDL is normal. Her BMI is 34 kg/M2. She desires to become pregnant within the year and does not wish to use any method of contraception. Would it be appropriate to start her on an HMG-CoA reductase inhibitor (a “statin”) at this time?
Discussion
The women in the above case vignettes are commonly encountered in primary care practice, and present somewhat of a management dilemma. Good guidelines for the use of common primary care therapies in women of child-bearing age with diabetes, hypertension, and hyperlipidemia, are not readily available. Nevertheless, such problems are being more commonly encountered as the “obesity epidemic” progresses, especially in our population. Is the risk of adverse cardiovascular events the same in these young women as it is in their over 50 year old counterparts? What is the risk of teratogenicity if they should become pregnant on the various medicines we prescribe?
The angiotensin converting enzyme inhibitors (ACE) such as lisinopril, enalapril, etc., are contraindicated in pregnancy. Because they relax the glomerular afferent arteriole, they enhance glomerular blood flow and thus reduce the incidence and severity of proteinuria and hypertension in diabetic and hypertensive patients, a desirable effect. However, in the fetus, they can create a situation of such persistent glomerular high flow that destruction of the delicate fetal glomerular capillary network may result. This can then result in fetal renal failure and oligohydramnios. This may be seen during the latter half of pregnancy, or in the newborn period. While this situation may be reversible if the ACE is stopped, that cannot be assured. These same effects have unfortunately also been described with the angiotensin receptor blockers (ARB), such as candesartan. More recent data have now demonstrated that ACE are also first trimester teratogens, and are associated with congenital defects of the cardiovascular (atrial and ventricular septal defects) and central nervous system and skeleton (spina bifida, microcephaly, calvarial hypoplasia). Their use in the peri-conceptional period is therefore no longer recommended. ACE also appear in small quantities in breast milk. While I could not find any evidence of adverse neonatal effects in breastfed infants whose mothers were on ACE, I could likewise not find any pediatricians who were comfortable with that situation . . .
REFERENCES
- Vijan S, et al. Screening, prevention, counseling, and treatment for complications of type II diabetes mellitus. J Gen Intern Med 1997; 12:567-80.
- Klinke JA, Toth EL. Preconception care for women with type 1 diabetes. Canadian Fam Physician 2003; 49:769-73.
- Leguizamon G, Reece A. Effect of medical therapy on progressive nephropathy: Influence of pregnancy, diabetes, and hypertension. J Mat Fet Med 2000; 9:70-8.
- ReproTox Data Base. Agent #: 3356, ACE Inhibitors. July 2006.
- Lip GYH, et al. Angiotensin-converting enzyme inhibitors in early pregnancy. Lancet 1997; 350:1446-7.
- Cooper WO, et al. Angiotensin-converting enzyme inhibitors and the risk of major malformations. N Eng J Med 2006; 354:2443-51.
- Ordovas JM, et al. Plasma lipids and cholesterol esterification rate during pregnancy. Obstet Gynecol 1984; 63:20-5.
- Dejager S, Turpin G. Hyperlipidemia in pregnancy. Press Med 1996; 25:1839-45.
- ReproTox Data Base. Agent #: 4039, Atorvastatin. May 2004.
- Hosokawa A, et al. Use of lipid-lowering agents (statins) during pregnancy. Canadian Fam Physician 2003; 49:774-8.
- Edison RJ, Muenke M. Evidence for human teratogenicity of statins. Birth Defects Res 2003; 67:318-23.
OB/GYN CCC Editorial comment:
Is the glass ½ empty or ½ full?
The fact that so many of our AI/AN patients have diabetes and/or hypertension at younger ages is one of our greatest challenges. On the other hand, their diabetes and hypertension are well controlled enough that they can successfully pursue pregnancy. The above discussion is a helpful first step. We will develop this discussion further, so keep your eyes peeled for an upcoming Perinatology Corner module on this topic.
Findings from an observational study published in The New England Journal of Medicine in June 2006 revealed that infants exposed to ACE inhibitors during the first trimester of the gestational period had an increased overall relative risk (RR) for congenital malformations compared with those not exposed (RR, 2.71; 95% confidence interval [CI], 1.72 - 4.27). Half of these defects were various cardiac septal defects, and the remainder included some defects of the central nervous, urologic, or other systems. Women receiving ACE inhibitor therapy were generally older and more likely to have other chronic conditions compared with those not receiving therapy.
Here is an update from the FDA on “First-Trimester Exposure to Benazepril HCl (Lotensin) Linked to Birth Defects” http://www.medscape.com/viewarticle/554655?sssdmh=dm1.262465&src=ddd#1
In the meantime, I think you will find the link below helpful as it combines risks and benefits beginning with rare events such as Rhabdomyolysis, moving on to myalgia, and other systems effects and the overall benefits to statin’s use as indicated in risk reduction of CVD which is the number one killer of AIAN women. This link from Medscape discusses statins in a CME combined discussion http://www.medscape.com/viewarticle/550619
Other Resources
More results from a search at the Medscape website.
http://search.medscape.com/all-search?newSearch=1&queryText=statins
More on ACE’s
http://search.medscape.com/all-search?newSearch=1&queryText=aces
ARB’s angiotensin receptor blockers and their protective effects may add to the discussion
http://www.medscape.com/viewarticle/551042
Other
Re-visiting the issue of "Amnisure
CONCLUSION: Measurement of placental alpha-microglobulin-1 in cervicovaginal secretions is superior to conventional clinical assessment in the diagnosis of rupture of membranes. LEVEL OF EVIDENCE: II.
Lee SE, et al Measurement of placental alpha-microglobulin-1 in cervicovaginal discharge to diagnose rupture of membranes. Obstet Gynecol. 2007 Mar;109(3):634-40
MFM Editorial comment:
Just wanted to re-visit this issue of "Amnisure" as a more accurate and user-friendly method of diagnosing ruptured membranes, especially in areas with facilities inexperienced with this problem on frequent basis, or in doubtful cases here (not to replace the usual clinical criteria we would continue to routinely use).
Low-dose dopamine for pre-eclampsia with oliguria should not be used other than in trial
MAIN RESULTS: Only one randomised placebo controlled trial of six hours' duration, including 40 postpartum women, was found. This study showed a significant increase in urinary output over six hours in women receiving dopamine. It is unclear if this was of any benefit to the women.
AUTHORS' CONCLUSIONS: It is unclear whether low-dose dopamine therapy for pre-eclamptic women with oliguria is worthwhile. It should not be used other than in prospective trials.
Steyn D; Steyn P Low-dose dopamine for women with severe pre-eclampsia. Cochrane Database Syst Rev. 2007; (1):CD003515
Probiotics for preventing preterm labour
AUTHORS' CONCLUSIONS: Although the use of probiotics appears to treat vaginal infections in pregnancy, there are currently insufficient data from trials to assess impact on preterm birth and its complications.
Othman M; Neilson J; Alfirevic Z Probiotics for preventing preterm labour. Cochrane Database Syst Rev. 2007; (1):CD005941
Primary Care Discussion Forum
Electronic Health Record (EHR) Implementation: Worth the effort?
May 1, 2007
Moderator: David Johnson, MD
-Anticipated benefits of an EHR: Demonstrated through experience?
-What are the real costs: Decreased efficiency, IT support requirements, etc…
-Effect on the provider – patient relationship
How to subscribe / unsubscribe to the Primary Care Discussion Forum?
Subscribe to the Primary Care listserv
http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=26
Unsubscribe from the Primary Care listserv
http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=26
STD Corner - Lori de Ravello, National IHS STD Program
HIV/AIDS among AI/AN Fact Sheet
CDC Fact sheet – updated from previous version.
Available at http://www.cdc.gov/hiv/resources/factsheets/aian.htm
HIV/AIDS protective factors among urban American Indian youths
This research examined how family and individual factors influence 3 HIV/AIDS risk behaviors: having more than 1 sexual partner in the last 3 months, substance use at last sexual intercourse, and condom non-use at last sexual intercourse. The sample includes 89 sexually active American Indian adolescents living in a large Southwestern U.S. city. Logistic regression results revealed that family communication acts as a protective factor against HIV risk through a lower reported substance use during last sexual intercourse, but it did not appear to affect the number of multiple recent sex partners. Family and personal involvement in American Indian cultural activities, both low on average in this urban sample, had no effect on outcomes. This study advances knowledge on sexual health risk and protective factors among American Indian adolescents, an understudied group, and provides implications for prevention intervention with American Indian youths and their families. http://muse.jhu.edu/journals/journal_of_health_care_for_the_poor_and_underserved/
Marsiglia FF, Nieri T, Stiffman AR HIV/AIDS protective factors among urban American Indian youths. Journal of Health Care for the Poor & Underserved. 17(4):745-58, 2006 Nov.
HIV-related risk behaviors, perceptions of risk, HIV testing, and exposure to prevention messages and methods among urban American Indians and Alaska Natives
The goal of this study was to describe HIV risk behaviors, perceptions, testing, and prevention exposure among urban American Indians and Alaska Natives (AI/AN). Interviewers administered a questionnaire to participants recruited through anonymous peer-referral sampling. Chi-square tests and multiple logistic regression were used to compare HIV testing by perception of risk and risk behavior status. Of 218 respondents with seronegative or unknown HIV status, 156 (72%, 95% confidence interval [CI]: 66-78%) reported some HIV risk behavior: 57 (26%, 95% CI: 20-32%) high-risk behavior, and 99 (45%, 95% CI: 39-52%), potentially high-risk. Among respondents reporting high-risk behavior, 44% rated themselves at no or low risk for HIV infection. Overall, 180 respondents (83%, 95% CI: 78-88%) had ever received an HIV test, 79 (36%, 95% CI: 31-57%) in the past year. HIV risk behaviors and perception of risk were independently associated with recent HIV testing after adjustment for gender, income, and homelessness (odds ratio [OR] = 3.6; 95% CI: 1.5-9.0 for high-risk behavior vs. no reported risk behavior, and OR: 3.2; 95% CI: 1.3-7.6, for high vs. no perceived risk). Addressing inaccurate perception of risk may be a key to improving uptake of HIV testing among high-risk urban AI/AN.
http://www.atypon-link.com/GPI/toc/aeap/18/6
Lapidus JA, Bertolli J, McGowan K, Sullivan P HIV-related risk behaviors, perceptions of risk, HIV testing, and exposure to prevention messages and methods among urban American Indians and Alaska Natives. AIDS Education & Prevention. 18(6):546-59, 2006 Dec.
Impact of HPV Immunization on Gynecologic Cancers
Conclusion: In the United States, approximately 3,700 new cases of vulvar cancer are diagnosed every year, with about 800 women dying from it. The incidence is increasing, particularly in younger women with HPV infection. The authors conclude that prophylactic immunization could prevent many of these lesions and help patients avoid complex and distressing treatment, as well as death, from several genital neoplasias.
Hampl M, et al. Effect of human papillomavirus vaccines on vulvar, vaginal, and anal intraepithelial lesions and vulvar cancer. Obstet Gynecol December 2006;108:1361-8.
http://www.aafp.org/afp/20070315/tips/16.html
Increases in Gonorrhea - Eight Western States, 2000-2005
This report describes the epidemiology of gonorrhea in eight western states that reported large increases in gonorrhea incidence rates from 2000 to 2005. The eight states are Alaska, California, Hawaii, Nevada, New Mexico, Oregon, Utah and Washington. The results indicated that both sexes and all specified age and racial/ethnic groups experienced increases in gonorrhea rates. Causes for these increases remain unclear; however, data suggest they likely resulted from a combination of increases in the number of tests performed, trends in the types of test performed, and actual increases in disease occurrence. The gonorrhea rate among females increased 58.5%, from 52.3 per 100,000 in 2000 to 82.9 in 2005.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5610a4.htm?s_cid=mm5610a4_e
Sexually transmitted infections during pregnancy
Two million of the 15 million (13.3%) new cases of sexually transmitted infections (STIs) among persons 15 to 49 years old occur in pregnant women. Access to care and a provider's ability to assess risk, screen, and treat STIs are critical factors in preventing adverse pregnancy outcomes. Significant variations in provider STI screening and treatment practices exist despite recommended guidelines. This article reviews issues related to screening and management of common STIs during pregnancy, with emphasis on the new 2006 US Centers for Disease Control and Prevention Sexually Transmitted Diseases Treatment Guidelines and recently revised recommendations for HIV testing of pregnant women in healthcare settings.
Johnson HL, Erbelding EJ, Ghanem KG. Sexually transmitted infections during pregnancy. Curr Infect Dis Rep. 2007 Mar;9(2):125-33.
Risk reduction counseling for prevention of sexually transmitted infections: how it works and how to make it work
Prevention research in the past decade has proved the efficacy of risk reduction counselling in reducing the risks for sexually transmitted infections (STIs). The question currently facing STI service providers is therefore not so much whether counselling should be part of the standard of STI care but rather how this intervention can be implemented given the logistical and resource constraints of a busy practice setting. After a brief introduction of the history and an overview of the models for risk reduction counselling and their theoretical and scientific underpinnings, the focus of this paper will be on the extent to which individual prevention models have been adopted in different clinical settings, the impediments to implementation and suggestions for improvement.
Risk reduction counselling for prevention of sexually transmitted infections: how it works and how to make it work C A Rietmeijer Sexually Transmitted Infections, Feb. 2007, Vol. 83 ,1, p. 2-9.
Racial / ethnic disparities in diagnoses of HIV/AIDS--33 states, 2001-2005.
During 2001-2004, blacks accounted for 51% of newly diagnosed human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) infections in the United States. This report updates HIV/AIDS diagnoses during 2001-2005 among black adults and adolescents and other racial/ethnic populations reported to CDC through June 2006 by 33 states that had used confidential, name-based reporting of HIV and AIDS cases since at least 2001. Of the estimated 184,991 adult and adolescent HIV infections diagnosed during 2001-2005, more (51%) occurred among blacks than among all other racial/ethnic populations combined. Most (62%) new HIV/AIDS diagnoses were among persons aged 25-44 years; in this age group, blacks accounted for 48% of new HIV/AIDS diagnoses. New interventions and mobilization of the broader community are needed to reduce the disproportionate impact of HIV/AIDS on blacks in the United States. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5609a1.htm
Racial/ethnic disparities in diagnoses of HIV/AIDS--33 states, 2001-2005. MMWR Morb Mortal Wkly Rep. 2007 Mar 9;56(9):189-93.
Burden of recurrent Chlamydia trachomatis: further uncovering the "hidden epidemic"
RESULTS: During the follow-up period of 23 318 person-months (mean, 4.7 years per person), 216 participants (52.6%) were diagnosed as having C trachomatis infection, and 123 participants (29.9% of the total sample and 56.9% of those with initial infections) were diagnosed as having recurrent C trachomatis infections. Of 456 C trachomatis diagnoses made during the study period, 241 (52.9%) were recurrent infections. The rate of recurrent infections was 42.1 per 1000 person-months. The median time to recurrent infection was 5.2 months. CONCLUSION: Recurrent C trachomatis infections comprise a substantial health burden among young women, possibly higher than previously recognized in this vulnerable population.
Niccolai LM et al Burden of recurrent Chlamydia trachomatis infections in young women: further uncovering the "hidden epidemic". Arch Pediatr Adolesc Med. 2007 Mar;161(3):246-51.
http://archpedi.ama-assn.org/cgi/content/full/161/3/246
or
Home screening for sexually transmitted diseases in high- risk young women
RESULTS: Of 197 women in the intervention group, 140 (71%) returned at least one home test and 25 of 249 (10%) of home tests were positive. Women who received home screening tests completed significantly more STD tests overall (1.94 vs. 1.41 tests per woman-year, p<0.001) and more STD tests in the absence of symptoms (1.18 vs. 0.75 tests per woman-year, p<0.001). More women in the intervention group completed at least one test when asymptomatic (162 (82.2%) vs. 117 (61.3%), p<0.001). The intervention was most effective among women recruited outside of medical clinics. There was no significant difference in the overall rate of STDs detected. CONCLUSIONS: Home screening significantly increased the utilization of chlamydia and gonorrhea testing in this sample of high risk young women, and thus represents a feasible strategy to facilitate STD testing in young women.
Cook RL, et al Home screening for sexually transmitted diseases in high- risk young women: randomized controlled trial. Sex Transm Infect. 2007 Feb 14;
Pregnancy and STD Prevention Counseling: Motivational Interviewing
RESULTS: At baseline, 59% of all participants reported a high level of contraceptive use, 19% a low level and 22% nonuse. At two months, the proportions of intervention and control participants who had improved their level of use or maintained a high level (72% and 66%, respectively) were significantly larger than the proportions who had reported a high level of use at baseline (59% and 58%, respectively). No significant differences were found between the groups at 12 months, or between baseline and 12 months for either group. During the study, 10-11% of intervention and control participants became pregnant, 1-2% received a chlamydia diagnosis and 7-9% had another STD diagnosed. CONCLUSIONS: Repeated counseling sessions may be needed to improve contraceptive decision-making and to reduce the risk of unintended pregnancy and STDs. Petersen R, et al Pregnancy and STD Prevention Counseling Using An Adaptation of Motivational Interviewing: A Randomized Controlled Trial. Perspect Sex Reprod Health. 2007 Mar;39(1):21-8.
http://www.blackwell-synergy.com/doi/pdf/10.1363/3902107
or
Bi-Sexual Health: An Introduction and Model Practices for HIV/STI Programming
Sexual health issues affecting bisexuals have been largely ignored and underrepresented in academic and professional literature. Many bisexuals have negative experiences with health care providers, whether it is because they are afraid to come out to their providers or because their providers give them improper or incomplete information on HIV/STI prevention. This report serves as an introduction to bisexuality and a model programming guide for HIV/STI prevention.
http://www.thetaskforce.org/downloads/reports/reports/BisexualHealth.pdf
Created by the National Gay and Lesbian Task Force Policy Institute, BiNet USA and the Fenway Institute.
Barbara Stillwater, Alaska State Diabetes Program
New recommendations for gestational weight gain may be required in obesity epidemic
As childhood obesity is increasing in prevalence and effective treatment remains elusive, preventing childhood obesity remains critical. The Institute of Medicine might need to re-evaluate its recommendations for weight gain in (pregnancy), considering not only birth outcomes but also risk of obesity for both mother and child. Pregnant women might aim for the lower end of their recommended weight gain RESULTS: Greater weight gain was associated with higher child body mass index z-score (0.13 units per 5 kg [95% CI, 0.08, 0.19]), sum of subscapular and triceps skinfold thicknesses (0.26 mm [95% CI, 0.02, 0.51]), and systolic blood pressure (0.60 mm Hg [95% CI, 0.06, 1.13]). Compared with inadequate weight gain (0.17 units [95% CI, 0.01, 0.33]), women with adequate or excessive weight gain had children with higher body mass index z-scores (0.47 [95% CI, 0.37, 0.57] and 0.52 [95% CI, 0.44, 0.61], respectively) and risk of overweight (odds ratios, 3.77 [95% CI: 1.38, 10.27] and 4.35 [95% CI: 1.69, 11.24]).
CONCLUSION: New recommendations for gestational weight gain may be required in this era of epidemic obesity.
Oken E, et al Gestational weight gain and child adiposity at age 3 years. Am J Obstet Gynecol. 2007 Apr;196(4):322.e1-8
Elevated Autoantibodies Linked to Preeclampsia
Study points to potential biomarkers for risk assessment. These data suggest that, as with sFlt-1 and insulin resistance, the AT1-AA does not regress completely after delivery and, secondarily, that correlations exist among these variables. The impact of AT1-AA after preeclampsia, especially in the context of cardiovascular risk, remains to be determined.
Hubel CA, et al Agonistic angiotensin II type 1 receptor autoantibodies in postpartum women with a history of preeclampsia. Hypertension. 2007 Mar;49(3):612-7 .
Cholesterol Could be Key to Treating Fetal Alcohol Syndrome
Small amounts of alcohol can interfere with the growth of a fetus, but added cholesterol may help prevent a wide array of neurological and physical defects from alcohol exposure, according to a new study in laboratory fish. Conclusion: We have shown that a simple post-translational modification defect in a key morphogen may contribute to an environmentally induced complex congenital syndrome. This insight into FASD pathogenesis may suggest novel strategies for preventing these common congenital defects.
Li YX, et al Fetal alcohol exposure impairs hedgehog cholesterol modification and signaling. Lab Invest. 2007 Mar;87(3):231-240
Women's Health Headlines, Carolyn Aoyama, HQE
Weaving it all together: 2007 Behavioral Health Conference
June 11-14, 2007
Albuquerque , NM
SAMHSA / IHS
Doctors, nurses, tribal leaders, behavioral health/substance abuse program providers, psychologists, therapists, counselors, traditional healers, health program administrators, CSAT, CSAP and CMHS tribal grantees, youth, elders and other concerned community members are highly encouraged to attend.
http://www.kauffmaninc.com/2007bhconference/
Continuing Education - Quadrivalent Human Papillomavirus Vaccine: Recommendations of the Advisory Committee on Immunization Practices
This activity has been approved for 1.75 contact hours (continuing nursing education); a maximum of 1.75 hours in category 1 credit (continuing medical education credit for nonphysicians); a maximum of 1.75 hours in category 1 credit (continuing medical education); and 0.15 continuing education units.
http://www2a.cdc.gov/ce/CourseDetails.asp?ActivityId=56-02&ProgramName=MMWR#Fees
Newly completed Pregnancy and Postpartum Quitline Toolkit
For a one per person hard copy of the Quitline Toolkit sent to you (include your mailing address)
Contact: Lauren DiBiaseldibiase@schsr.unc.edu or http://www.helppregnantsmokersquit.org/
How to Best Get the HPV Vaccine Information Sheets signed?
Question:
Is it OK for us to send consent forms home to parents, with a letter and Vaccine Information Sheet (VIS) sheet for Gardasil, and have them returned to me at the school and immunize them at the school? Or do I need to have the parent present to sign consent for the immunization. Is there an IHS "rule"? When I ask locally all I get is opinion and they differ.
Answer:
How should we distribute Vaccine Information Sheet ( VIS’s)
when the parent or legal representative of a minor is not present at the time
the vaccination is given, for example during a school-based adolescent vaccination
program?
CDC’s legal advisors have proposed two alternatives for this situation:
- Consent Prior to Administration of Each Dose of a Series. With this alternative the VIS must be mailed or sent home with the student around the time of administration of each dose. Only those children for whom a signed consent is returned may be vaccinated. The program must place the signed consent in the patient's medical record.
- Single Signature for Series. This alternative is permissible only in those States where a single consent to an entire vaccination series is allowed under State law and in those schools where such a policy would be acceptable. The first dose of vaccine may be administered only after the parent or legal representative receives a copy of the VIS and signs and returns a statement that a) acknowledges receipt of the VIS and provides permission for their child to be vaccinated with the complete series of the vaccine (if possible, list the approximate dates of future doses); and b) acknowledges their acceptance of the following process regarding administration of additional doses:
- prior to administration of each dose following the initial dose, a copy of the VIS will be mailed to the parent (or legal representative) who signs the original consent at the address they provide on this statement, or the VIS will be sent home with the student; and
- the vaccine information statements for the additional doses will be accompanied by a statement notifying the parent that, based on their earlier permission, the next dose will be administered to their child (state the date), unless the parent returns a portion of this statement by mail to an address provided, to arrive prior to the intended vaccination date, in which the parent withdraws permission for the child to receive the remaining doses.
The program must maintain the original consent signature and any additional dose veto statements in the patient's medical record. A record must be kept of the dates prior to additional doses that the VIS was mailed, or sent home with the adolescent.
http://www.cdc.gov/nip/publications/VIS/vis-facts.htm#Anc6
Race/ethnicity, socioeconomic status, and lifetime morbidity burden in the WHI
RESULTS: Five percent of all women in the study population had high lifetime morbidity burden. Women with high lifetime morbidity were more likely to be AIAN or black; poor; less educated; divorced, separated, or widowed; past or current smokers; obese; uninsured or publicly insured. Lower SES was associated with higher morbidity among most women. The extent to which morbidity was higher among lower SES compared to higher SES women was about the same among Hispanic women and white women, but was substantially greater among black and AIAN women compared with white women. CONCLUSIONS: This study demonstrates the importance of considering race/ethnicity and class together in relation to health outcomes.
Gold R, et al Race/ethnicity, socioeconomic status, and lifetime morbidity burden in the women's health initiative: a cross-sectional analysis. Journal of Women's Health. 15(10):1161-73, 2006 Dec. http://www.liebertonline.com/doi/pdf/10.1089/jwh.2006.15.1161
What's new on the ITU MCH web pages?
Electronic Health Record (EHR) Implementation: Worth the effort?
http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForumMod.cfm#ehr
Implementation and Use of an Electronic Health Record within the
Indian Health Service J
Am Med Inform Assoc. 2007 March-April
http://www.ihs.gov/MedicalPrograms/MCH/F/documents/Sequist4207.doc
There are several upcoming Conferences
and Online CME/CEU resources, etc….
and the latest Perinatology Corners (free online CME from IHS)
…or just take a look at the What’s New page
Save the dates
Training Course in MCH Epidemiology
- Albuquerque , New Mexico
- June 10 - 15, 2007
- Sponsored by HRSA / MCHB and CDC
http://www.crpcorp.info/mchtraining2007.htm
Weaving it all together: 2007 Behavioral Health Conference
- June 11-14, 2007
- Albuquerque , NM
- SAMHSA / IHS
http://www.kauffmaninc.com/2007bhconference/
Native Women’s Health and MCH Conference
- August 15 -17, 2007
- Albuquerque , NM
- Questions? Contact nmurphy@scf.cc
http://www.ihs.gov/MedicalPrograms/MCH/F/CN01.cfm#Aug07
3rd Annual American Indian and Alaska Native Long Term Care Conference
- September 5-6, 2007
- Albuquerque , New Mexico
- Visit http://www.aianlongtermcare.org
- Contact Bruce.Finke@ihs.gov
I.H.S. / A.C.O.G. Obstetric, Neonatal, and Gynecologic Care Course
- September 16 – 20, 2007
- Denver , CO
- Contact Yvonne Malloy at 202-863-2580 or YMalloy@acog.org
Did you miss something in the last OB/GYN Chief Clinical Consultant Corner?
The April 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.
