February 2005 CCC Corner > Features

Features

American Family Physician**

Patient-Oriented Evidence that Matters (POEMS)*

Radio-Frequency Endometrial Ablation for Menorrhagia

Clinical Question: Is radio-frequency endometrial ablation more effective than balloon ablation for the treatment of menorrhagia?

Bottom Line: Amenorrhea is achieved more often with radio-frequency endometrial ablation than with hot-water balloon ablation. Women tend to be more satisfied with the radio-frequency technique one year after therapy. A reassessment of the treated women after a longer follow-up period is needed. (Level of Evidence: 1b-)

http://www.aafp.org/afp/20050201/tips/26.html

Esterified Estrogen and Venous Thrombotic Risk

Clinical Question: Do different formulations of estrogen similarly increase the risk of venous thrombosis?

Bottom Line: Oral therapy with conjugated equine estrogen is associated with an increased risk of venous thrombosis in a dose-dependent fashion during the time the woman takes it. Concomitant use of medroxyprogesterone further increases the venous thrombosis risk. Esterified estrogen does not appear to increase venous thrombosis risk. Until more reliable data are available from prospective comparison trials, it makes sense to strongly consider prescribing esterified estrogen to control symptoms in perimenopausal and postmenopausal women. (Level of Evidence: 3b)

http://www.aafp.org/afp/20050201/tips/27.html

Physical Therapy and Stress Urinary Incontinence

Clinical Question: Can physical therapy cure stress urinary incontinence in women with symptoms persisting longer than three months postpartum?

Bottom Line: Eight weekly sessions of pelvic floor muscle physiotherapy, including electrical stimulation and biofeedback exercises, cured stress urinary incontinence in 70 percent of the treated women. None of the control patients who received massage only was cured. Instructions for a home exercise program alone, is usual care and would have been a better control intervention. (Level of Evidence: 1b)

http://www.aafp.org/afp/20050101/tips/23.html

Lactobacillus Does Not Prevent Post-Antibiotic Vaginitis

Clinical Question: Can lactobacillus preparations, given orally, vaginally, or both, prevent post-antibiotic vaginal candidiasis?

Bottom Line: Lactobacillus, given orally, vaginally, or both, has no effect on the development of culture-proven vaginal candidiasis. Lactobacillus probiotics are effective, however, in decreasing antibiotic-associated diarrhea  

(Level of Evidence: 1b)

http://www.aafp.org/afp/20050115/tips/24.html 

Cochrane for Clinicians- AFP

Antidepressants and Smoking Cessation 

Clinical Question

Which antidepressants help patients stop smoking?

Evidence-Based Answer

Bupropion and nortriptyline increase the likelihood of smoking cessation, but selective serotonin reuptake inhibitors (SSRIs) do not.

Practice Pointers

The U.S. Preventive Services Task Force1 and U.S. Department of Health and Human Services2 recommend that physicians screen all adults for tobacco use and recommend intervention for those who report using tobacco products. There is good evidence that brief behavioral counseling and pharmacotherapy increase rates of abstinence. More intensive counseling has a dose-response relationship, with more minutes of contact producing better results. Nicotine replacement and bupropion have been approved by the U.S. Food and Drug Administration for use in smoking cessation. http://www.aafp.org/afp/20050101/cochrane.html

Spinal Manipulative Therapy for Low Back Pain

Clinical Scenario

A 42-year-old woman presents with low back pain that started after she had moved furniture a week earlier. She wants pain relief as quickly as possible and asks if she should go to a chiropractor.

Clinical Question

Should we recommend spinal manipulation as a treatment for low back pain?

Evidence-Based Answer

In the short term, manipulative therapy is as effective for acute or chronic low back pain as other treatments such as analgesics, physical therapy, exercises, back school, and routine care from a primary care physician. Radiation of pain, type of manipulation, and use of multiple modalities do not alter these results.  http://www.aafp.org/afp/20050201/cochrane.html

Efficacy of Antioxidants in GI Cancer Prevention

Clinical Question

Does supplementation with antioxidant vitamins prevent gastrointestinal (GI) cancer?

Evidence-Based Answer

There is no evidence that supplementation with beta carotene or vitamins A, C, or E prevents GI cancer. Data for selenium is inconsistent and based on poor-quality studies, and supplementation with this mineral should not be recommended routinely. Most importantly, combinations of antioxidant vitamins appear slightly to increase overall mortality rates.

http://www.aafp.org/afp/20050201/cochrane.html

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

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

ACOG

Coping With the Stress of Medical Professional Liability Litigation 

Obstetrician–gynecologists should recognize that being a defendant in a medical professional liability lawsuit can be one of life's most stressful experiences. Coping with the stress of medical professional liability litigation is an ongoing, complex process in which physicians often must struggle to regain a sense of professional mastery and control of their practices. Open communication with family members will assist in reducing emotional isolation and self-blame; however, legal and clinical aspects of a case must be kept confidential. Peer support and individual professional counseling can be of great benefit. Rapid intervention facilitates healthier coping strategies and can restore a sense of equilibrium and self-esteem during an unpredictable time.

Non-ACOG members

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15684197

ACOG Members

http://www.acog.org/publications/committee_opinions/co309.cfm

AHRQ

Computerized Order Entry Leads to Unwanted Testing

Web M + M - Clinical Ethics

Mrs. G visited her obstetrician for first trimester routine prenatal care. The obstetrician offered genetic testing for a variety of conditions, including Tay-Sachs and Canavan's diseases, since both Mrs. G and her husband, a healthy 35-year-old physician, were of Ashkenazi Jewish descent. Mrs. G consented to be tested and told the obstetrician that she would discuss with her husband that evening whether he wanted to have the genetic tests. The obstetrician gave Mrs. G consent forms and information to take home to her husband. The obstetrician also entered laboratory test orders in the computerized order entry system for the genetic screening panel for both Mrs. G, since she had consented to be tested, and for Dr. G, assuming he would consent to be tested. However, the obstetrician did not mention this to Mrs. G.

At home that evening, Dr. G reviewed the materials and told his wife that he definitely did not want to be tested. Several weeks later, Dr. G visited his primary care doctor for a check-up. The physician ordered routine screening laboratory tests (fasting lipid profile, complete blood count, and urinalysis) through the computerized order entry system, and the next morning Dr. G presented to the laboratory for testing. The laboratory and its computer system were the same as used by Mrs. G's obstetrician.

Unbeknownst to Dr. G, the phlebotomist drew samples not only for the routine testing ordered by his primary care doctor but also for the genetic screening, because it was listed in the computer even though Dr. G had not consented. In doing so, the phlebotomist overrode the computerized alert that prompted him to be sure the patient had consented; he assumed that the physician must have obtained consent before ordering the tests. Ten days later, the obstetrician called Mrs. G to give her "the good news" that all her screening tests were normal. The obstetrician mentioned incidentally that her husband tested positive as a carrier of Canavan's disease. This disclosure caused some distress, but no physical harm. No increased level of care was needed.

Further discussion at http://www.webmm.ahrq.gov/

Women who have given birth only via cesarean are less likely than those with vaginal deliveries to report stress incontinence

http://www.ahrq.gov/research/jan05/0105RA16.htm#head1

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

Infant Mortality:  Bad News, Good News

The U.S. infant mortality rate is higher, according to the latest analysis.  That’s the bad news.  The U.S. mortality rate (IMR) rose from 6.8 to 7.0 per 1000 live births from 2001 to 2002.  It was the first increase in IMR in 40 years.  The good news is, bucking that trend, the IMR for American Indians improved, from 9.7 to 8.6.  Other rates fro 2002 were: Asian/Pacific Islander 4.8; Hispanic 5.6; white 5.8; total 7.0; black 13.8.

Analysts said the U.S. upturn was because the proportion of very low birth-weight babies increased.  They speculated 3 possibilities that could have contributed to this change.  1.) There may have been a change in reporting live or viable births among very low weight fetuses (IMR does not include stillbirths); 2.) There may have been changes in the risk profile of expectant women, although it was not due to an increase in higher risk age groups; 3) improved medical management of pregnancy may have brought more nonviable fetuses to live birth.  National Vital Statistics Reports 53/12, Jan 24, 2005 http://www.cdc.gov/nchs/data/nvsr/nvsr53/nvsr53_12.pdf

cooperd@mail.nih.gov

Breastfeeding

American Academy of Pediatrics Revised policy on Breastfeeding

Breastmilk and the Use of Human Milk cites substantial new research on the importance of breastfeeding and sets forth principles to guide pediatricians and other health professionals in assisting women and children in the initiation and maintenance of breastfeeding. The policy statement replaces the American Academy of Pediatrics' 1997 policy statement on breastfeeding. The revised statement includes information on child, maternal, and community health benefits of breastfeeding; contraindications to breastfeeding; recommendations on breastfeeding for healthy term infants and high-risk infants; and the role of pediatricians and other health professionals in protecting, promoting, and supporting breastfeeding. The policy statement emphasizes the central role of the pediatrician in coordinating breastfeeding management and providing a medical home for the child. American Academy of Pediatrics, Section on Breastfeeding. 2005.

Breastfeeding and the Use of Human Milk. Policy Statement. Pediatrics 115(2):496-506

http://pediatrics.aappublications.org/cgi/content/abstract/115/2/496

CCC Corner Digest

A compact digest of last month’s CCC Corner - Highlights include: 

Depo Provera and bone loss

Oral rehydration solution – reverse transfer of technology

What maneuver is in best in shoulder dystocia?

Midwives serving in Indian Country

Marriage may be good for you

Consumer Reports evaluates condoms, and 16 other contraceptive methods

Bariatric surgery may be a viable treatment option in severe obesity 

http://www.ihs.gov/MedicalPrograms/MCH/M/documents/0501_OL.pdf

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

Domestic Violence

Intimate Partner Violence During Pregnancy APRIL 2005 MCH EPI GRAND ROUNDS
PRESENTER: Kenneth D. Rosenberg, MD, MPH  

WHEN: Wednesday, April 6, 2005 at 2:00-3:00 pm EDT

WEBCAST REQUIREMENTS: To join the webcast, you must register at least a day ahead of time at http://www.uic.edu/sph/cade/mchepi/

Primary Care Discussion Forum: Domestic Violence in AI/AN - Just finished

Domestic Violence in Native Women – Moderated by Terry Cullen

Summary

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

Full Discussion

http://www.ihs.gov/MedicalPrograms/MCH/M/documents/DVDisc1405.doc

Assaults during pregnancy: both immediate and long-term adverse neonatal outcomes

CONCLUSION: Women sustaining an assault during pregnancy experience both immediate (uterine rupture, increased fetal and maternal mortality) and long-term sequelae (prematurity and low birth weight infants), which have significant negative effects on pregnancy outcome. LEVEL OF EVIDENCE: III. El Kady et al Maternal and neonatal outcomes of assaults during pregnancy. Obstet Gynecol. 2005 Feb;105(2):357-63. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15684165&dopt=Abstract

Elder Care News

Caring for elders at home: what is the best bath strategy?

This is a beautifully designed, randomized, controlled trial of bathing techniques in 73 nursing home residents with dementia who had problems with agitation during bathing.  Two specific approaches to bathing, both using techniques designed to make the bath a more comfortable process and tailor it more specifically to the mood and needs of the elder, were tested.  Agitation and aggressive behaviors declined significantly in both treatment groups but not in the control group.

Bruce Finke: Most elders with dementia in Indian country are cared for in the home, in most cases by family members.  A terribly difficult aspect of caring for elders with dementia is dealing with anger and agitation and bathing is an activity that often triggers these responses.  Our care for elders with dementia must include ensuring that family members and caregivers receive the specific education they need to provide care in the best way possible.  This study confirms that there are specific, teachable techniques that can reduce agitated behavior during bathing.  We need to think about how we can provide this information to the caregivers of our elders with dementia.

Sloane PD, Hoeffer B, Mitchell CM, McKenzie DA, Barrick AL, Rader J, Stewart BJ, Talerico KA, Rasin JH, Zink RC, Koch GG.  Effect of person-centered showering and the towel bath on bathing-associated aggression, agitation, and discomfort in nursing home residents with dementia: a randomized, controlled trial. J Am Geriatr Soc. 2004 Nov;52(11):1795-804. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15507054

Cultural Diversity at the End of Life: Issues and Guidelines

http://www.aafp.org/afp/20050201/515.html

Editorial

http://www.aafp.org/afp/20050201/editorials.html

Management of Hypertension in Older Persons

http://www.aafp.org/afp/20050201/469.html

White House Conference on Aging 

October 23-26, 2005  

Focus on policy issues that affect older Americans and the baby boom generation (born between 1946 and 1964)  WHCoA website, www.whcoa.gov

Family Planning

Hormonal Contraceptives and Weight Gain: Cochrane for Clinicians - AFP

Clinical Question

Do combination hormonal contraceptives cause weight gain?

Evidence-Based Answer

There is no causal relationship between combination contraceptives and weight gain.

Practice Pointers

Many women and physicians believe that weight gain is associated with combination hormonal contraceptives. The weight gain could be the result of water retention, increased muscle mass, or increased fat deposition. To test this perception, Gallo and colleagues performed a systematic review of randomized controlled trials. They included studies of at least three menstrual cycles' duration that compared combination contraceptives with placebo or other drugs, dosages, regimens, or study lengths. They found three placebo-controlled trials, none of which found a significant difference in weight gain between groups. The largest of these studies, with 473 patients, found a difference of less than 1 lb after six months. There was also no difference between groups in discontinuation of the contraceptives because of weight gain. Furthermore, most of the studies comparing two contraceptive regimens did not show differences in weight gain.

When patients are reluctant to take combination contraceptives because they fear weight gain, physicians can tell them that it is true that women gain weight with the pill and the patch. However, they also gain weight when they don't use these products. Physicians can direct them to the excellent resources on healthy lifestyles that have been developed by the National Institutes of Health.1 The "Aim for a Healthy Weight” program has an interactive Web site on diet and exercise for patients (http://www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/).

http://www.aafp.org/afp/20050101/cochrane.html

Availability and Use of Publicly Funded Family Planning Clinics: U.S. Trends, 1994-2001

The Indian Health Service was able to provide a complete listing of clinics it funds and contraceptive clients served in 2001. Nationwide, nearly 200 clinics were added through this listing, and although many of these are new sites, some may have existed but been missed previously. These added sites are concentrated in Western states, where most Indian reservations are located. http://www.guttmacher.org/pubs/journals/3620604.html

Contraceptive Needs and Services, 2001-2002 http://www.guttmacher.org/pubs/win/index.html

Frequently asked questions

Q. What is the Indian Health policy on use of chaperones?

A. There is no official IHS policy yet, but we strive to honor our patients’ dignity and choice.

http://www.ihs.gov/MedicalPrograms/MCH/m/documents/Chaperone2605.doc

Q. How does one manage possible exposure to hand foot and mouth disease in pregnancy?

A.  With reassurance, unless the mother has a febrile illness in the last week of pregnancy.

http://www.ihs.gov/MedicalPrograms/MCH/M/Hfaqs.cfm#handfootmouth

Q. The ‘quad’ second trimester screening test is expensive Is it worth it?

.A. The ‘quad’ screen is more cost effective and patient friendly.

http://www.ihs.gov/MedicalPrograms/MCH/m/documents/QuadScr122304.doc

Q. How can you predict if a placenta previa will persist based on US at 15-24 weeks?

A. If the placental edge is > 1 cm over the os, or if the cord insertion is over the os 

http://www.ihs.gov/MedicalPrograms/MCH/m/documents/USPearl2705.doc

Hormone Replacement Update

Benefits and Risks of Estrogen in Postmenopausal Women

CONCLUSIONS: The use of CEE increases the risk of stroke, decreases the risk of hip fracture, and does not affect CHD incidence in postmenopausal women with prior hysterectomy over an average of 6.8 years. A possible reduction in breast cancer risk requires further investigation. The burden of incident disease events was equivalent in the CEE and placebo groups, indicating no overall benefit. Thus, CEE should not be recommended for chronic disease prevention in postmenopausal women.    Anderson et al. Effects of conjugated equine estrogen in postmenopausal women with hysterectomy. The Women's Health Initiative Randomized Controlled Trial. JAMA April 14, 2004;291:1701-12.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15082697

Information Technology
Free CME from Harvard to 60 of our providers

1. Harvard is only waiving CME tuition 

2. Send the names to your CMO as well as a copy to me 

3. We will work directly with Harvard about notification of individuals who wish to attend 

http://www.pri-med.com/pmo/LiveProgramDetail.aspx?url=/pmo/10/HP234867

International Health Update
The Institute for OneWorld Health -- A Not-for-Profit Pharmaceutical Company

The Institute for OneWorld Health -- A Nonprofit Pharmaceutical Company  in San Francisco, California, created to find, develop, and market effective and safe drugs for these terrible diseases. Begun in 2000 by young pharmacologist Victoria Hale, the institute employs some 3 dozen people, is advised by pharmacy guru Jere Goyan, and enjoys many volunteers while receiving support primarily from foundations. It recently reported early results from a clinical trial in India finding that the cheap off-patent antibiotic, injectable paromomycin, can cure a high percentage of patients with visceral leishmaniasis.http://www.oneworldhealth.org

http://www.medscape.com/viewarticle/496086?src=mp

MCH Alert

Entire supplement on sleep in children: Cultural impacts

Cultural Issues and Children's Sleep: International Perspectives, a supplement to the January 2005 issue of Pediatrics, examines the cultural variables that impact children's sleep.  The articles represent a broad range of cultures, age groups, and subtopics and include several cross-cultural comparison studies, a longitudinal study conducted over a 10-year period, and a comprehensive review of the literature. The articles explore a number of the most important cultural issues in the pediatric sleep field including co-sleeping, adolescent sleep patterns, and napping.

Owens JA (ed.). 2005. Cultural Issues and Children's Sleep: International Perspectives. Pediatrics 115(1, Part 2):1-271.      http://pediatrics.aappublications.org/content/vol115/issue1/#SUPPLS1

Medscape*

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.

Midwives Corner: Marsha Tahquechi, CNM, GIMC

If anyone wishes to contribute to the Midwives Corner, please contact Marsha Tahquechi at GIMC Marsha.Tahquechi@IHS.GOV

Office of Women's Health, CDC

Cesarean Rate Highest Ever

Preliminary data for 2003 indicated that 27.6% of all births in the United States resulted from cesarean deliveries, an increase of 6% from 2002 and the highest percentage ever reported in the United States. After declines during 1989-1996, the total cesarean rate and the primary cesarean rate (i.e., percentage of cesareans among women with no previous cesarean delivery; 19.1% in 2003) have increased each year. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5402a5.htm

Osteoporosis

“Uncertain Role” of Biochemical Markers Use in Osteoporosis Therapy

Some folks have been using biochemical markers to follow patients on antiresorptive therapy. One example is urinary cross linked N-telopeptides (NTX). The first NTX measurement is just a baseline. The second NTX has clinical value for the patient, e.g., measure either urinary NTX or serum CTX and look for a 50 percent decline with therapy as an index of adequate treatment. 

Another approach use is to use markers in between DEXAs, perhaps as ‘poor man’s DEXA’, e.g., get a baseline NTX, start therapy, get second NTX, if one sees a good response, then skip the next DEXA as DEXAs are only covered q 24 mo and many contract health case managers may refuse to pay for the DEXA.

Recommendation — Although the optimal approach is uncertain, we recommend the second approach in which monitoring with markers is performed. We measure either urinary NTX or serum CTX and look for a 50 percent decline with therapy as an index of adequate treatment. Follow-up with a measurement of bone density in two to three years, to make sure that the predictions about bone loss were correct, is advised.

http://www.uptodateonline.com/application/topic.asp?file=minmetab/17366&type=A&selectedTitle=3~3

SUMMARY — Measurements of biochemical markers of bone turnover reflect the rates of bone resorption and bone formation. The most important clinical use for these tests is in monitoring patients taking antiresorptive therapy for osteoporosis. Other uses include following patients with Paget's disease, metastatic bone disease, and inflammatory arthritis. Measurements of urinary NTX and SERUM CTX excretion are the most specific and clinically useful markers for bone resorption, while bone-specific alkaline phosphatase is the most clinically useful marker of bone formation.

http://www.uptodateonline.com/application/topic.asp?file=minmetab/19988&type=A&selectedTitle=1~3

Biochemical markers of bone turnover — Measurements of biochemical markers of bone turnover can be used to complement measurements of BMD:

  - If the BMD is in the upper tertile, we consider the woman at low risk for osteoporosis and drug therapy to prevent bone loss is not needed.   - If the BMD is in the lowest tertile, we consider the woman at high risk for osteoporosis and we recommend preventive therapy.  - If the BMD is in the middle tertile, we recommend measuring a marker of bone turnover such as the urinary excretion of DPD or NTX; we treat women with a value above the upper limit of normal for premenopausal women.

Bruce Finke:

Biochemical markers have what best could be termed an ‘uncertain role’ at this time. With regard to using them to follow treatment, although this makes sense and should work, there really isn’t data indicating that this strategy actually works.  I’m willing to treat with bisphosphonates based on BMD knowing that this reduces the risk of fracture, and wait for more data to refine this approach. 

Another question that comes up – use in the young patient on long term Depo Provera?  It doesn’t follow that one can extrapolate to using biochemical markers to evaluate risk of future osteoporosis in a very young population on Depo Provera. We would need more data to properly evaluate.

Other resource-biochemical markers

Screening for osteoporosis

http://www.uptodateonline.com/application/topic.asp?file=minmetab/19499&type=A&selectedTitle=2~3

Fracture Protection Lost Five Years After Stopping Hormone Replacement Therapy

CONCLUSION: Postmenopausal women who have discontinued HT within the past 5 years have a risk for hip fracture that is at least as high as that in women who have never used HT. LEVEL OF EVIDENCE: II-2

Yates J, et al Rapid loss of hip fracture protection after estrogen cessation: evidence from the National Osteoporosis Risk Assessment. Obstet Gynecol. 2004 Mar;103(3):440-6. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14990403

Impact of Intense Exercise on Early Osteopenia in Women

CONCLUSION: General purpose exercise programs with special emphasis on bone density can significantly improve strength and endurance and reduce bone loss, back pain, and lipid levels in osteopenic women in their critical early postmenopausal years

Kemmler W, et al. Benefits of 2 years of intense exercise on bone density, physical fitness, and blood lipids in early postmenopausal osteopenic women. Results of the Erlangen Fitness Osteoporosis Prevention Study (EFOPS). Arch Intern Med May 24, 2004;164:1084-91.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15159265

Patient Information

Painful Menstrual Periods

http://www.aafp.org/afp/20050115/292ph.html

Urinary Tract Infections

http://www.aafp.org/afp/20050101/133ph.html

Pelvic Floor Muscle Exercises

http://www.aafp.org/afp/20050115/329ph.html

Microscopic Hematuria

http://www.aafp.org/afp/20050101/135ph.html

Heart Palpitations

http://www.aafp.org/afp/20050215/755ph.html

Constipation

http://www.aafp.org/afp/20050201/539ph.html

Irritable Bowel Syndrome

http://www.aafp.org/afp/20050201/547ph.html

Inflammatory Bowel Disease

http://www.aafp.org/afp/20050201/553ph.html

Kidney Cysts

http://www.aafp.org/afp/20050101/130ph.html

Polycystic Kidney Disease

http://www.aafp.org/afp/20050101/137ph.html

Alcoholism-What Should I Know About It?

http://www.aafp.org/afp/20050201/509ph.html

Health Care After Cancer Treatment

http://www.aafp.org/afp/20050215/713ph.html

Panic Attacks

http://www.aafp.org/afp/20050215/740ph.html

Primary Care Discussion Forum

April 1, 2005: Methamphetamine use in Indian Country

Moderator: Steve Holve

-How common is Methamphetamine use in your area?

-In your tribal area are there laws that make Methamphetamine production and use a crime?

-Should all mothers be screened at delivery for Methamphetamine use or only if medically indicated?

-What resources are available in your community if a pregnant mother is found

to be using Methamphetamine? 

-What resources are available for teenagers and adults who are Methamphetamine  

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

Subscribe to the Primary Care listserv 

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

Unsubscribe from the Primary Care listserv

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

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

STD Corner - Laura Shelby, STD Director, IHS

Men have often been overlooked for routine chlamydia screening 

In this study conducted in 4 cities, 96% of males screened were asymptomatic and had an overall percent positivity at 7%. At 7% percent positivity, chlamydia is moderately high among men tested in nonclinical and clinical settings. Schillinger, et al Prevalence of Chlamydia trachomatis Infection Among Men Screened in 4 U.S. Cities.  Sexually Transmitted Diseases. 32(2):74-77, February 2005. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15668611

Other STD News

Expedited treatment of sex partners reduces the rates gonorrhea or chlamydial infection  

CONCLUSIONS: Expedited treatment of sex partners reduces the rates of persistent or recurrent gonorrhea or chlamydial infection  Golden MR, et al. Effect of expedited treatment of sex partners on recurrent or persistent gonorrhea or chlamydial infection. N Engl J Med. 2005 Feb 17;352(7):676-85.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15716561&dopt=Abstract

and 

Editorial: Toward Better Control of Sexually Transmitted Diseases

Erbelding EJ, et al Toward better control of sexually transmitted diseases.N Engl J Med. 2005 Feb 17;352(7):720-1. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15716568&dopt=Abstract

Health Burden Due to Unsafe Sex High in U.S.

As part of an analysis of the burden of disease and injury in the United States, we identified and quantified the incidence of adverse health events, deaths, and disability adjusted life years (DALY) attributed to sexual behaviour. In 1998, about 20 million such events (7532/100 000 people) and 29 782 such deaths (1.3% of all US deaths) occurred, contributing to 2 161 417 DALYs (6.2% of all US DALYs). The majority of incident health events (62%) and DALYs (57%) related to sexual behaviour were among females, and curable infections and their sequelae contributed to over half of these. Viral infections and their sequelae accounted for nearly all sexual behaviour related deaths-mostly HIV/AIDS. Sexual behaviour attributed DALYs in the United States are threefold higher than that in overall established market economies.

Ebrahim SH, et al Sexual behaviour: related adverse health burden in the United States. Sex Transm Infect. 2005 Feb;81(1):38-40.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15681721

HSV-2 Testing and Treatment of Pregnant Women Appears Worthwhile

CONCLUSION: Compared with commonly accepted benchmarks for cost-effectiveness (<$50,000/QALY), type-specific HSV-2 serologic testing of pregnant women may be a cost-effective strategy. Baker D  et al Cost-effectiveness of herpes simplex virus type 2 serologic testing and antiviral therapy in pregnancy. Am J Obstet Gynecol. 2004 Dec;191(6):2074-84.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15592294

Barbara Stillwater, Alaska State Diabetes Program

Walk 2000 More Steps a Day and Never Gain Another Pound
6000 steps a day significantly reduces risk of death, and 8000-10,000 a day promotes weight loss.  If you add just 2000 more steps a day to your regular activities, you may never gain another pound. So says research by Dr. James O. Hill of the Center for Human Nutrition at the University of Colorado Health Sciences Center. To lose weight, add in more steps.  Sedentary people in the USA generally move only 2000-3000 steps a day. Previous studies have shown that moving 6000 steps a day significantly reduces risk of death, and 8000-10,000 a day promotes weight loss.  How far is 2000 steps? It is about a mile. But the benefits for health and for weight management don't depend on you walking a mile all at one time, but simply adding in more steps throughout the day.  By wearing a pedometer all day, you are motivated to add in extra steps whenever you can.  There are many little trips that can add up to a mile or two a day - parking further from the door of your destination, taking the stairs rather than the elevator, pace around as you talk on the telephone, take a marching-in-place minute once an hour.  "All in all, it is entertaining to ponder that such a seemingly insignificant gadget may be of practical importance in the war on obesity!" said Catrine Tudor-Locke, Ph.D., Department of Exercise and Wellness, Arizona State University in the conclusion of a report by the President's Council of Physical Fitness and Sports, June, 2002. http://www.fitness.gov/home_pubs.htm

Fit And Fat Not Good Enough

CONCLUSIONS: Both increased adiposity and reduced physical activity are strong and independent predictors of death   Hu FB, et al Adiposity as compared with physical activity in predicting mortality among women. N Engl J Med. 2004 Dec 23;351(26):2694-703. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15616204

15-Year Study Shows Link Between Fast Food, Obesity and Insulin Resistance

INTERPRETATION: Fast-food consumption has strong positive associations with weight gain and insulin resistance, suggesting that fast food increases the risk of obesity and type 2 diabetes

Pereira MA, et al Fast-food habits, weight gain, and insulin resistance (the CARDIA study): 15-year prospective analysis. Lancet. 2005 Jan 1;365(9453):36-42.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15639678

How Well Do Adults Follow Prescriptions for insulin?

CONCLUSIONS: Adults prescribed a specific insulin regimen averaged using 77% of prescribed doses, demonstrating good intention to follow the prescription. However, HbA1c higher than the recommended level suggested that the rate of insulin use, the prescribed regimen, or both were inadequate to achieve good glycemic control in patients with long-term insulin use.

Cramer JA, Pugh MJ. The influence of insulin use on glycemic control: How well do adults follow prescriptions for insulin? Diabetes Care. 2005 Jan;28(1):78-83.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15616237&dopt=Abstract

What's new on the ITU MCH web pages?

Use an ‘Opt Out’ HIV screening policy in pregnancy

http://www.ihs.gov/MedicalPrograms/MCH/m/documents/HIVscreen52005.doc

Hormone replacement, difficulties in management

http://www.ihs.gov/MedicalPrograms/MCH/m/documents/HRT21405.doc

Prevention of preeclampsia

http://www.ihs.gov/MedicalPrograms/MCH/m/documents/AspirPreec21405.doc

Best staffing ratios

http://www.ihs.gov/MedicalPrograms/MCH/m/documents/Staffing21205.doc

Opportunities to provide Indian Health care

http://www.ihs.gov/MedicalPrograms/MCH/m/documents/Recruit21305.doc

There are several upcoming Conferences

../F/CN01.cfm#top

and Online CME/CEU resources, etc…. 

http://www.ihs.gov/MedicalPrograms/MCH/M/CN13.cfm

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

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

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

wNew.cfm#top

Save the dates

20th Annual Conference on Women’s and Children’s Healthcare

• For providers caring for Native women and children 

• February 25 - 27, 2005   

• First announcement details http://www.ihs.gov/MedicalPrograms/MCH/M/documents/tldr20051stnotice.doc

• Telluride, CO http://www.ihs.gov/MedicalPrograms/MCH/M/ConfDnlds/Tellurideagenda10-2004.doc

• Contact Alan Waxman awaxman@salud.unm.edu

 NIH: Management of Menopause-Related Symptoms 

• March 21-23, 2005 

• Bethesda, Maryland

• Consensus: State-of-the-Science Conference

• http://consensus.nih.gov/ta/025/menopausalsymptomsintro.html

IHS Advanced Colposcopy course / Refresher Workshop

• March 30 - April 1, 2005 respectively 

• Albuquerque, New Mexico 

• Brochure http://www.ihs.gov/MedicalPrograms/MCH/M/documents/Colpo05mailoutbrochure.pdf 

• Or contact Roberta Paisano Roberta.Paisano@na.ihs.gov  (505) 248-4431 

17th Annual IHS Research Conference:  International Meeting on Inuit and Native American Child Health: Innovations in clinical care and research

April 29-May 1, 2005, Seattle, WA

http://www.aap.org/nach/InternationalMeeting.htm

3rd Western MCH Epidemiology

• May 12-13, 2005

• Portland, OR

• http://sphcm.washington.edu/mchepi2005/

American College of Obstetricians and Gynecologists Annual Clinical Meeting

• May 7-11, 2005 

• San Francisco , California 

• 53rd Annual ACOG ACM http://www.acog.org/ACM2005/

Advances in Indian Health 

• May 11-13, 2005

• Albuquerque, NM

• 2004 Brochure (2005 pending)

• http://hsc.unm.edu/cme/2004%20Web%20Info/AIH2004/AIHIndex.shtml

• Contact CNorth@abq.ihs.gov

Prevention of Cardiovascular Disease & Diabetes Among AI / AN

• May 16 - 19, 2005

• Denver, CO

• Co-sponsored by IHS, Joslin, ADA, NIH

• http://professionaled.joslin.org/CourseListing/CourseDesc.asp?intCourseTypeId=4&intCourseID=1269&strFullInd=Y

2005 U.S. Public Health Conference/Global Health Summit 

• June 5-9, 2005

• Philadelphia, PA, Development of the Report on Global Health

• 40th Annual U.S. Public Health Professional Conference, June 6-9, 2005

• www.coausphsconference.org

I.H.S. / A.C.O.G. Postgraduate Course: Obstetric, Neonatal, and Gynecologic Care 

• June 19 - 23, 2005 

• Denver, CO 

• Contact Yvonne Malloy  YMalloy@acog.org 202-863-2580

• Save the date info http://www.ihs.gov/MedicalPrograms/MCH/M/documents/pgcoursesavethedate.doc

• 2005 Brochure 

• http://www.ihs.gov/MedicalPrograms/MCH/M/Documents/Brochure2005EL.doc

• June 19th at 8:00 am: NEONATAL RESUSCITATION PROGRAM 

• NRP Class size limited. Sign up now http://www.ihs.gov/MedicalPrograms/MCH/M/documents/NeonatalResuscitationProvider2.doc

• Meeting Website  ../F/CN01.cfm#June05

National Summit on Preconception Care

• JUNE 21-22, 2005

• Atlanta, Georgia

• Catalyst for national recommendations for preconception care, CDC

• http://www.signup4.net/Public/ap.aspx?EID=NATI14E

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OB/GYN

Dr. Neil Murphy is the Obstetrics and Gynecology Chief Clinical Consultant (OB/GYN C.C.C.). Dr. Murphy is very interested in establishing a dialogue and/or networking with anyone involved in women's health or maternal child health, especially as it applies to Native or indigenous peoples around the world. Please don't hesitate to contact him by e-mail or phone at 907-729-3154.