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Volume 4, No. 7, July 2006
Features
American Family Physician**
Cochrane for Clinicians
Planned Early Birth vs. Expectant Management for PROM
Clinical Question
Is induction or expectant management more appropriate for premature rupture of membranes at term (PROM)?
Evidence-Based Answer
Induction of labor in patients with PROM does not increase the rates of cesarean delivery or operative vaginal delivery. Among patients who are induced there is a slightly lower incidence of chorioamnionitis (relative risk [RR] 0.74; 95% confidence interval [CI], 0.56 to 0.97) and a lower rate of infant admissions to the neonatal intensive care unit (NICU; RR 0.73; 95% CI, 0.58 to 0.91). The evidence in this study shows induction to be a reasonable option with no increased risk of operative delivery or of harm to mother or neonate.
Practice Pointers
PROM is defined as rupture of membranes that occurs at term but before the onset of labor. It occurs in approximately 8 percent of pregnancies; 50 percent of patients deliver within five hours of membrane rupture, and 95 percent of patients deliver within 28 hours. The most significant risk of PROM is intrauterine infection, which increases with duration of rupture. Fetal risks include cord compression and ascending infection.1 Historically, two approaches have been used: induction or expectant management. Induction involves intervening to induce labor at diagnosis or within six to eight hours of rupture of membranes. Expectant management allows the onset of labor to occur spontaneously without intervention.
Dare and colleagues performed a systematic review of randomized controlled trials to compare outcomes of induction with oxytocin (Pitocin) or prostaglandin E2 gel (Prostin E2) versus expectant management of PROM in low-risk patients. They identified 12 trials with a total of 6,814 women. Maternal mortality was examined in one study and there were no maternal deaths in either arm. There was no difference between the two management approaches in the rates of cesarean delivery or of operative vaginal deliveries. Fewer women who underwent induction developed chorioamnionitis. Compared with expectant management, one case of chorioamnionitis will be avoided for every 50 women undergoing induction for PROM. Also, there were fewer cases of endometritis in the induction groups (RR 0.30; 95% CI, 0.12 to 0.74; four trials, 445 women).
Time from rupture of membranes to birth was reduced by 13 hours in patients receiving oxytocin and by eight hours in those receiving prostaglandin compared with expectant management. Patients who underwent expectant management also had higher rates of dissatisfaction. Only one study reported uterine rupture, with one rupture in the prostaglandin arm of that study and none in the expectant management arm. This difference was not statistically significant (95% CI, 0.12 to 68.50).
There were fewer NICU admissions in the induction group. One NICU admission was avoided for every 20 women induced for PROM. In one large study, neonates born in the expectant management group were more likely to spend more than 24 hours in the NICU. However, there were no statistically significant differences between the two groups regarding infant success of breastfeeding or incidences of cord prolapse and neonatal infection.
A meta-analysis published in 2005 found that misoprostol (Cytotec) was as safe and effective as oxytocin for induction of patients with PROM.
http://www.aafp.org/afp/20060701/cochrane.html
Source: Dare MR, et al. Planned early birth versus expectant management (waiting) for prelabour rupture of membranes at term (37 weeks or more). Cochrane Database Syst Rev 2006;(1):CD005302.
REFERENCES
1. ACOG Practice Bulletin. Premature rupture of membranes. Clinical management guidelines for obstetrician-gynecologists. Number 1, June 1998. American College of Obstetricians and Gynecologists. Int J Gynaecol Obstet 1998;63:75-84.
2. Lin MG, Nuthalapaty FS, Carver AR, Case AS, Ramsey PS. Misoprostol for labor induction in women with term premature rupture of membranes: a meta-analysis. Obstet Gynecol 2005;106:593-601.
American College of Obstetricians and Gynecologists
William H. J. Haffner American Indian / Alaska Native Women’s Health Award
The ACOG Committee on American Indian Affairs would like to establish the William H. J. Haffner American Indian/Alaska Native Women’s Health Award. This award recognizes an individual who has made a major contribution to raising the level of health and/or improving AI/AN women’s health care.
Background:
In the Committee’s role of visiting IHS Areas and providing on-site reviews it has a first hand look at the many dedicated clinicians working in the field of the IHS. These are men and women who have found innovative ways to provide excellent maternal and child health care with exceedingly limited resources and often in isolated and remote areas. They continue to show incredible fortitude and hope in trying circumstances. The committee felt that it should be commending these heroic efforts and shining a light on the many ways in which the IHS is succeeding.
The Committee wanted to name the award after someone who has been the living example of what the award stands for. The committee felt that Dr. William Haffner epitomizes this dedication and exceptional service to AI/AN women’s health care. Dr. Haffner had a long career within the IHS and also has been involved with the ACOG Indian Health programs from the beginning. In many cases, he has been the link between ACOG and the IHS is the establishing of long history of cooperative efforts to improve the health and welfare of AI/AN woman. While Dr. Haffner enjoys recognition and service within the College through his years of service on many committees, he also brings recognition and legitimacy to the role that ACOG has played within the IHS. He is someone who has and does move between both worlds with ease. He therefore brings a certain prestige to the award for the IHS as well. The committee foresees the honoree being recognized at ACOG’s ACM and also being recognized at the IHS’s Annual National Combined Councils awards banquet. This increases the awareness of the role ACOG continues to play in increasing access and quality of health care to AI/AN women with the IHS and Tribes.
Criteria:
- A clinician who has been outstanding in AI/AN women’s health care.
- The clinician could be but does not have to be an ob/gyn. Any health care professional such as family physicians, certified nurse midwives, nurse practitioners, registered nurses etc. could be eligible for the award.
- Awardees must demonstrate a commitment and dedication to providing exceptional health care to AI/AN women.
- They must be currently working within an IHS or Tribal position or recently retired.
Contact: Yvonne Malloy YMalloy@acog.org
Antibiotic Prophylaxis for Gynecologic Procedures. Practice Bulletin No. 74
Summary of Recommendations and Conclusions
The following recommendations are based on good and consistent scientific evidence (Level A):
- Patients undergoing abdominal or vaginal hysterectomy should receive single-dose antimicrobial prophylaxis.
- Pelvic inflammatory disease complicating IUD insertion is uncommon. The cost-effectiveness of screening for gonorrhea and chlamydia before insertion is unclear; in women screened and found to be negative, prophylactic antibiotics appear to provide no benefit.
- Antibiotic prophylaxis is indicated for suction curettage abortion.
- 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, given immediately preoperatively.
- Antibiotic prophylaxis is not recommended in patients undergoing diagnostic laparoscopy.
The following recommendations and conclusions are based on limited or inconsistent scientific evidence (Level B):
- In patients with no history of pelvic infection, HSG can be performed without prophylactic antibiotics. If HSG demonstrates dilated fallopian tubes, antibiotic prophylaxis should be given to reduce the incidence of post-HSG PID.
- Routine antibiotic prophylaxis is not recommended in patients undergoing hysteroscopic surgery.
- Cephalosporin antibiotics may be used for antimicrobial prophylaxis in women with a history of penicillin allergy not manifested by an immediate hypersensitivity reaction.
- Patients found to have preoperative bacterial vaginosis should be treated before surgery.
The following recommendations and conclusions are based primarily on consensus and expert opinion (Level C):
- Antibiotic prophylaxis is not recommended in patients undergoing exploratory laparotomy.
- Use of antibiotic prophylaxis with saline infusion ultrasonography should be based on clinical considerations, including individual risk factors.
- Patients with high- and moderate-risk structural cardiac defects undergoing certain surgical procedures may benefit from endocarditis antimicrobial prophylaxis.
- Patients with a history of anaphylactic reaction to penicillin should not receive cephalosporins.
- Pretest screening for bacteriuria or urinary tract infection by urine culture or urinalysis, or both, is recommended in women undergoing urodynamic testing. Those with positive results should be given antibiotic treatment.
Antibiotic prophylaxis for gynecologic procedures. ACOG Practice Bulletin No. 74. American College of Obstetricians and Gynecologists. Obstet Gynecol 2006:108:225–34.
Ethical Ways for Physicians to Market a Practice
ABSTRACT: It is ethical for physicians to market their practices through any form of public communication provided that the communication is truthful and not misleading or deceptive. Communications should not convey discriminatory attitudes involving race, ethnicity, gender, or sexual orientation. All paid advertising must be clearly identified as such. Producing fair and accurate advertising of medical practices and services can be challenging. It often is difficult to include detailed information because of cost and size restrictions or the limitations of the media form that has been selected. If the specific advertising form does not lend itself to clear and accurate description, an alternative media format should be selected. Finally, any advertising that seeks to denigrate the competence of other individual professionals or group practices is always considered unethical.
Ethical ways for physicians to market a practice. ACOG Committee Opinion No. 341. American College of Obstetricians and Gynecologists. Obstet Gynecol 2006;108:239–42.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD=Search&DB=pubmed
AHRQ
Researchers examine gender disparities in the quality of preventive care and management of heart disease and diabetes
According to this study, women from rural areas receive less preventive care than those residing in urban areas. http://www.ahrq.gov/research/may06/0506RA10.htm
Ask A Librarian: Diane Cooper, M.S.L.S. / NIH
How to find Evidence...
...Which is to say, evidence about treating plantar fasciitis. Where can you find a recent evidence review? Cochrane, you say? Good suggestion, you’ve been reading this column. We thank you. But Cochrane’s review on plantar fasciitis is dated 2003 and states that effectiveness of treatments for heel pain is unclear. Is there something more current? Here’s another Evidenced-base Medicine resource, with more topics, and maybe a friendlier interface, Clinical Evidence, from BMJ.
What is Clinical Evidence?
Clinical Evidence (CE) is a database that summarizes what is known – and not known – on over 226 medical conditions and over 2,000 treatments seen in primary care situations. For each topic, the literature is searched using Medline, Embase, and the Cochrane Library for published systematic reviews and randomized controlled trials that answer the clinical question. For topics where there are few, or no, good systematic reviews or randomized controlled trials, the literature is searched for observational studies.
How is it put Together?
Clinical Evidence is owned by the British Medical Journal (BMJ) Group in the United Kingdom. Contributors with clinical expertise in specific fields review the selection of studies and summarize the findings to each question. Next the topic is peer reviewed by advisors; two external expert clinicians; and an editorial committee. Each topic is reviewed every 12 months for updates. New topics are added to the database monthly.
Table: Latest Clinical Evidence updates
Intimate partner violence towards women
Absence seizures in children,
Bipolar disorder,
Chlamydia (uncomplicated, genital),
Chronic fatigue syndrome,
Gastro-oesophageal reflux in children,
Irritable bowel syndrome, Neonatal jaundice,
Non-steroidal anti-inflammatory drugs,
Organophosphorus poisoning (acute),
Plantar heel pain and fasciitis,
Raynaud's phenomenon (primary),
Sinusitis (acute),
Sleep apnoea,
Sore throat,
Squamous cell carcinoma of the skin (non-metastatic),
Thromboembolism,
Tonsillitis
An Example: Using Clinical Evidence to find plantar fasciitis treatment options
You will find Clinical Evidence on the HSR Library website (http://hsrl.nihlibrary.nih.gov OR http://nihlibrary.ors.nih.gov/ezproxy/ihs.htm)
Scroll across the top menu to RESEARCH TOOLS. In the drop-down box select DATABASES. Go down the list to CLINICAL EVIDENCE.
In the main box select the subject plantar heel pain and fasciitis. Next will be a page that lists treatment options that are likely to be beneficial and treatment options that have unknown effectiveness. You can click on any of the treatments to get more information, or you can print a PDF version of the whole document outlining the randomized controlled trials and systematic reviews used to verify the effectiveness.
In this case, CE reviewed systematic studies for plantar fasciitis treatments in October 2005 (more current than Cochrane’s). This current review showed unknown effectiveness of plantar fasciitis treatment due to small study sizes or no randomized controlled trials include:
- Custom made insoles
- Corticosteroid injections (short term)
- Extracorporal shock wave therapy
- Heel pads or heel cups
- Lasers
- Stretching exercises
- Surgery
- Ultrasound
Likely to be ineffective or even harmful include:
- Corticosteroid injection (medium and long-term)
- Corticosteroid injection plus local anaesthetic injection (medium to long-term)
A summary of benefits, harms and comments for each treatment option is given along with summaries of the systematic reviews and RCT if available.
Being a good clinician, however, you notice the CE review is a year old (topics are updated annually). So you use PubMed to search the last year for systematic reviews and plantar fasciitis. You find an alternative medicine article on using wheatgrass cream on chronic plantar fasciitis. The result of this randomized controlled trial showed wheatgrass cream is no more effective than a placebo cream for treatment.
Give Clinical Evidence a try. It is easy to use and fast. If you need help using this resource or any of the online resources on the HSR Library website please email me atcooperd@mail.nih.gov
Breastfeeding - Suzan Murphy, PIMC
Pain is one the reasons that moms quit breastfeeding in the first 2 weeks
For common sore nipples, there are quick fixes that can help reverse the problem.
For early sore nipples:
Look for the root problem –
Check positioning points
- The baby is "belly to belly" so the baby's face and body face the mom's body.
- The baby's mouth is open wide, on the breast, and snuggled close. The baby's nose can be squished up against the mom's breast – it is ok, the baby will pull back or let go if breathing is hard.
Latch
- Check that both lips out and at least ½ inch past the nipple onto the areola (more is better).
- Check the internal mouth and nipple connection:
- Is the baby's lower lip folded under?
- Does the mom feel the baby's lower gum bumping her when the baby sucks?
- Is the sucking rhythm jerky, snappy, not smooth?
“Yes” to any of these usually means the nipple isn't deep enough in the mouth and the baby's tongue isn't out far enough to cover the gums and effectively milk the nipple.
So, show the mom how to gently push the chin down through a couple suck cycles. The baby's mouth will open a little more, the lower lip pops out, and the tongue will drop down to cover the gums – viola! Less pain and the baby gets more milk - and it usually takes just a couple "fixed" feedings for the baby to automatically latch appropriately.
- Sometimes in the first couple days, as the baby is learning how to suck effectively, the baby will chomp on mom enough to cause tender nipples. Moms usually describe it as pain at the beginning of the feeding that goes away after the first 15-30 seconds. It usually helps for the mom to know that the discomfort will get better each day.
- If the mom is compressing or pushing down on the breast - so she can see the baby breath – it can disrupt latching and lead to sore nipples. It can help to reassure her that the baby instinctively knows that breathing important and will pull away if breathing is hard.
- If the baby is using a pacifier often, it can alter the sucking process and lead to sore nipples. Encourage the mom to use the pacifier carefully – less (and later) is more.
- To help the mom while the nipples are healing, encouragement is magic. She will feel better soon – a day or two, sometimes less. Also consider suggesting:
- Let the nipple air dry before putting the bra flap or breast pad on.
- If the nipple sticks to clothing or a breast pad, wet it first so it peels off gently without new skin.
- Topical treatments like lanolin ointment, gel pads, and tea bags. Moms often say they help. Effective positioning/latch and time help too.
- If the mom says that it hurts all the time and nothing seems to help, check with a breastfeeding consultant.
If the pain starts after the first couple weeks, thrush is likely. Both mom and baby need to be treated.
References:
Schanler R et al. Breastfeeding Handbook for Physicians, American Academy of Pediatrics and American college of Obstetricians and Gynecologists. 2006
Biancuzzo M. Breastfeeding the Newborn: Clinical Strategies for Nurses, Mosby Publishing, 2003.
CCC Corner Digest
Nicely laid out hard copy - A compact digest of last month’s CCC Corner
June 2006 Highlights include:
-Varicella Prophylaxis for high risk persons (including pregnancy): VariZIG replaces VZIG
-Achievements in Public Health: Reduction in Perinatal Transmission of HIV Infection
-What is the rate of preterm birth in Native Americans?
-Incontinence not correlated with vaginal delivery
-FDA Licenses HPV Vaccine for Prevention of Cervical Cancer in Females
-Co-occurring maternal conditions and behavior problems in children
-Group visits: Promising for chronic care management for the motivated patient
-Hormonal Contraception: Coexisting Medical Conditions, Practice Bulletin
-Early breastfeeding choice, GDM, and BMI
-4x more common than breast cancer, major morbidity / mortality: Can’t be ignored
-Refusals by pharmacists to dispense emergency contraception: a critique
-GREAT site for Health Promotion Disease Prevention Utah Department of Health
-Copious post operative mucous secretions
-Empowering women to find the power of birth is of great value
-Methamphetamine abuse among women on Navajo (Part 3 of 4)
-SANE/SAFE training and capacity
-Recommendations to Improve Preconception Health and Health Care
-Patient-Requested Cesarean: Should be performed for medical reasons
-Cesarean delivery rate: Continues to increase without improving outcomes
-September 1, 2006: Palliative Medicine's Role in the Continuity of Care
-HIV Testing and Additional Analysis of National Survey on HIV/AIDS
-Women Who Don't Snooze Enough Gain Weight
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/06JunOL.pdf
If you want a copy of the CCC Digest mailed to you each month, please contact nmurphy@scf.cc
Domestic Violence
Sexual assault victims: factors associated with follow-up care
CONCLUSION: Although only 35.5% of sexual assault victims seek follow-up, we found many factors positively and negatively associated with this. These findings may inform care strategies designed to improve follow-up for women who are at risk for significant sequelae.
Ackerman DR, et al Sexual assault victims: factors associated with follow-up care. Am J Obstet Gynecol. 2006 Jun;194(6):1653-9.
10th National Indian Nations: Conference for Victims of Crime - Call for Indian Health Input
The DOJ Office of Victims of Crime 10th National Indian Nations: Conference for Victims of Crime is very interested in having IHS presenters (from all three discipline areas in topics that relates to providing services for AI/AN victims of crime) at this conference.
This conference affords an opportunity to showcase how we are integrating IHS initiatives into specific topic areas such as Domestic violence, elder abuse, and service units that integrate services for victims of crime in Indian Country.
Of course, DOJ is a partner that has money for potential collaborations for many of your respective interests. They are interested and were have their ear to creating relationships for future funded efforts to bring services and training to Indian country.
http://www.tribal-institute.org/
4th Biennial National Conference on Health and Domestic Violence
March 16 - March 17, 2007
San Francisco, California
Rural pilot project funds for violence against women
The Office on Violence Against Women (OVW), via the Rural Domestic Violence and Child Victimization Enforcement Grants, has recently launched a new pilot program specifically targeting the unique needs of rural communities. The Faith
and Community Technical Support (FACTS) program announces the availability of approximately $2.2 million to fund a number of faith-based and community organizations (from September 2006 through August 2007) with the ability to serve rural victims of domestic violence.
Victims of domestic violence residing in rural communities face unique challenges that are often times exacerbated by the geographic isolation that comes with living in rural areas. For example, the delivery of social services in remote communities may be late or even absent. This project is designed to build much needed capacity so that appropriate and timely social service delivery is possible even in remote places. Applicants must document the capabilities of extending services to victims of domestic violence beyond the initial OVW funding. Funds are available especially for those grassroots faith-based or community organizations that have not previously received funds from the U. S. Department of Justice. Applicants must have a staff of less than 10 full-time employees and an annual domestic violence program budget of less than $100,000 (and an
overall budget less than $350,000). Subaward applications meeting the minimum eligibility requirements will be accepted from all organizations and all states, rural or non-rural.
Elder Care News
When in doubt – Involve a geriatrician in your elderly female patient’s care
CONCLUSIONS: Outpatient geriatric interventions emphasizing collaboration between geriatricians and primary care physicians, chronic disease self-management, and physical activity may reduce hospitalization risk and total health care costs among vulnerable elders.
Fenton JJ et al Bringing Geriatricians to the Front Lines: Evaluation of a Quality Improvement Intervention in Primary Care J Am Board Fam Med 2006;19 331-339
http://www.jabfm.org/cgi/content/abstract/19/4/331?etoc
Family Planning
Injectable Contraception and Skeletal Health
Question
Should it be standard clinical practice to perform baseline bone density studies in young women starting Depo-Provera and to continue follow-up studies periodically thereafter?
From Maj Joyce Fiedler, MD
Answer
Injectable contraception (depot medroxyprogesterone acetate [DMPA], Depo-Provera) is used by approximately 2 million women in the United States, including 4 million adolescents, and has been associated with declining rates of unintended pregnancy and abortion in teens. Contraceptive doses of DMPA suppress ovarian production of estradiol and, accordingly, lower bone mineral density (BMD) during use. Concern that long-term use of DMPA might increase future risk of osteoporotic fractures led the US Food and Drug Administration to add a black box warning to the package labeling for DMPA in 2004. The warning states that injectable contraception should be continued for more than 2 years only if other birth control methods are inadequate and suggests that dual x-ray absorptiometry (DXA) studies might be used to monitor BMD in DMPA users.
No studies have found evidence of osteoporosis or fractures in DMPA users. Cross-sectional studies have found no evidence of reduced BMD or osteoporosis years after use of DMPA. Cohort studies conducted in the United States in adolescent and adult women have shown complete recovery of BMD after discontinuation of DMPA. Supplementation with menopausal doses of estrogen (eg, conjugated equine estrogen 0.625 mg daily or transdermal estrogen 0.05 mg patches) during DMPA use prevents any loss of BMD during DMPA use.[1]
Given the above observations, skeletal health concerns should not restrict use of DMPA. In very long-term users who may continue use of DMPA into menopause, supplemental estrogen as described in the previous paragraph can be considered. I do not believe that routine DXA testing in premenopausal women who use DMPA is appropriate because it is not likely to provide clinical benefit. Response from Andrew M. Kaunitz, MD
References
Kaunitz AM. Depo-Provera's Black Box: time to reconsider? Contraception. 2005;72:165-167
http://www.medscape.com/pages/editorial/ate/public/index/1928 (see Medscape for access details)
Initiating Hormonal Contraception
Most women can safely begin taking hormonal birth control products immediately after an office visit, at any point in the menstrual cycle. Because hormonal contraceptives do not accelerate cervical neoplasia or interfere with cervical cytology, women who have not had a recent Papanicolaou smear can begin using hormonal contraceptives before the test is performed. After childbirth, most women can begin using progestin-only contraceptives immediately. Estrogen-containing methods can safely be initiated six weeks to six months postpartum for women who are breastfeeding their infants and three weeks postpartum for women who are not breastfeeding. Women can begin any appropriate contraceptive method immediately following an early abortion. Delaying contraception may decrease adherence. Physicians can help patients improve their use of birth control by providing anticipatory guidance about the most common side effects, giving comprehensive information about available choices, and honoring women's preferences. An evidence-based, flexible, patient-centered approach to initiating contraception may help to lower the high rate of unintended pregnancy in the United States. Am Fam Physician 2006;74:105-12.
http://www.aafp.org/afp/20060701/105.html
FDA says one reported abortion pill death was unrelated
In March 2006 the US Food and Drug Administration (FDA) has notified healthcare professionals of 2 additional deaths after medical abortion with mifepristone (Mifeprex 200-mg tablets, made by Danco Laboratories, LLC), according to an alert sent today from MedWatch, the FDA's safety information and adverse event reporting program. One of those two recent deaths of women taking the abortion pill RU-486 was unrelated to an abortion or use of the drug, but the second case is still under investigation,
Healthcare professionals are encouraged to report mifepristone-related adverse events to the FDA's MedWatch reporting program by phone at 1-800-FDA-1088, by fax at 1-800-FDA-0178, online at http://www.fda.gov/medwatch, or by mail to 5600 Fishers Lane, Rockville, MD 20852-9787.
Featured Website David Gahn, IHS Women’s Health Web Site Content Coordinator
I saw a blip in the May 2006 CCCC about the Utah website.
You think it is good? Well try Michigan’s site. It’s super!
http://www.michigan.gov/surgeongeneral/
From Barbara Stillwater Barbara_Stillwater@health.state.ak.us
Frequently asked questions
The Indian Health MCH Frequently Asked Question (FAQ) site
This site offers over 425 answers to common questions about the care of women and children in the unique settings found in Indian Country. Answers include both a quick answer and then significant background and multiple resources and links.
The site is maintained frequently (see section below) with 11 new FAQs this month and numerous existing FAQs being updated. There are 15 answers to questions on bilateral tubal ligation alone.
Go here to explore the frequently asked question page
http://www.ihs.gov/MedicalPrograms/MCH/M/mchFaqs.cfm
Indian Child Health Notes - Steve Holve, Pediatrics Chief Clinical Consultant
July 2006 – Highlights
- Free on-line full text journals and textbooks are available to all Indian Health and 638 sites. Read how to get this access at work and at home.
- Fever treatment - Motrin versus Tylenol and together
- Human Papillomavirus (HPV) vaccine approved
- Substance Abuse and AI/AN adolescents
- Find out who won the AAP Native American Child Advocacy Award
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ICHN706.doc
Information Technology
Hospital Computer Keyboards Should Be Disinfected Daily
CONCLUSIONS: Our data suggest that microbial contamination of keyboards is prevalent and that keyboards may be successfully decontaminated with disinfectants. Keyboards should be disinfected daily or when visibly soiled or if they become contaminated with blood.
Rutala WA, et al Bacterial contamination of keyboards: efficacy and functional impact of disinfectants. Infect Control Hosp Epidemiol. 2006 Apr;27(4):372-7.
Health Information Technology (HIT): A rural provider’s roadmap to quality
September 21-23, 2006 in Kansas City, MO.
The participation fee is waived for the first 300 rural health care providers to register. Space is limited! http://www.securemcking.com/hrsa/rural/ Registration deadline is August 1, 2006.
Kick-Start Your HIT Planning
Learn about the basic components of HIT
Focus on the initial steps of strategic planning for HIT investments
Explore the benefits of health information technology adoption and its link to quality improvement
Understand how to find appropriate technology to meet individual quality aims
Share best practices and lessons learned about HIT implementation.
UpToDate 14.2 is now available
on our web site at www.uptodateonline.com or by clicking on the UpToDate icon on your computer.
Since our previous release, more than 180 new topic reviews were added to the program and approximately 45% of existing topics were updated based on new information. A visit to the "What's New" section of the Table of Contents gives you a summary of updates thought to be of particular interest by our editors.
International Health Update: Claire Wendland, Madison, WI
Where There is No Doctor & A Book for Midwives
Most of us have likely seen or used Where There is No Doctor, the community health worker’s manual that is a staple of Peace Corps volunteers and others -- and that has had ninety translations and adaptations made to date! The Hesperian Foundation, a non-profit organization famous for its publication of this and other low-cost low-technology health manuals, has now made several manuals available on line in English-language versions. OB providers will be especially interested in A Book for Midwives, just named “Notable Book of 2006” by the American College of Nurse-Midwives. You can download it free at h ttp://www.hesperian.org/
Convenience makes a big difference in HIV testing: a Zimbabwe study
Voluntary HIV counseling and testing (VCT) is a crucial component of HIV/AIDS care and prevention plans, central to the scale-up of HIV treatment programs in Africa, but still only about 8% of African adults report ever having had an HIV test. Observational studies suggested that convenience of VCT may be a critical predictor of testing – outweighing individual client-related factors like age, gender, pregnancy status, or perceived risk of HIV. A trial in Harare, Zimbabwe, randomized area businesses with 100-600 employees to off-site or on-site VCT. At all sites, individual pre-test counseling, risk assessment and risk reduction plans were offered to all employees. At the on-site businesses, employees had tests, results, and post-test counseling on the same day. At the businesses randomized to the off-site protocol, which is current standard of care for workplace VCT in southern Africa, employees got vouchers for off-site testing redeemable at multiple nearby convenient locations, available after working hours and on weekends. Employees who didn’t use the vouchers were given three reminders. Any HIV-positive employees were given basic HIV care – not including antiretrovirals. Sites were followed up for two years, and VCT remained available for all employees through those two years. Key findings included:
with on-site testing, employees were much more likely to complete VCT (adjusted RR 12.5 [CI 8.2-16.8]) – in fact, in on-site businesses over half of employees got tested
demand for VCT outstripped capacity in the first few weeks, then declined slowly; most individuals who got tested did so during the first two months it was available to them
few employees (9.6% in the on-site arm, 5.1% in the off-site) got the recommended repeat tests if they were initially HIV-negative
This study confirms a high readiness to test for HIV, even in the absence of effective antiretroviral treatment, when testing is made readily available. Even minor differences in convenience translate into large differences in uptake of testing – a pattern also found, the authors note, in studies in the UK and the US.
Corbett EL, Dauya E, Matambo R et al. Uptake of worplace HIV counselling and testing: a cluster-randomised trial in Zimbabwe. PLoS Medicine 3(7):e238, 4 July 2006 http://medicine.plosjournals.org/archive/1549-1676/3/7/pdf/10.1371_journal.pmed.0030238-p-S.pdf
A new way to develop reliable tests for neglected diseases: Doctors Without Borders
Among other problems associated with providing medical care in remote settings, availability of low-cost reliable diagnostic tests can be a serious issue. The problem is worsened when the disease is one – like sleeping sickness or malaria – that has been “neglected” by private companies because of expected low market returns. In Nature, Doctors Without Borders (MSF) staff report a new way of accelerating development of such tests. In desperate need of a simple and reliable field test for malaria usable in Africa, MSF brought together a group of scientists, field doctors and manufacturers who set the design goal: what precisely would be needed in the field. This group built on existing research to design a test for antibodies to pLDH (a malaria parasite enzyme), which rise with acute infection and drop quickly when parasites are cleared. The design was offered to three manufacturers who worked to develop actual test kits optimized for field use: the competition was intended to (and did) encourage development of a high-quality product at an accessible price. The entire process, from literature review all the way through field trials, cost about US$100,000 – a remarkably low total. This model of product development is very promising, and potentially applicable to many other medical diagnostics, devices and drugs.
Usdin M, Guillerm M, Chirac P. Neglected tests for neglected patients. Nature 441:283-4, 18 May 2006 http://www.nature.com/nature/journal/v441/n7091/full/441283a.html
MCH Alert
Summary of Adolescent Pregnancy Prevention Programs
What Works: Curriculum-Based Programs that Prevent Teen Pregnancy presents an overview of what is known about carefully evaluated interventions that help prevent adolescent pregnancy. The 19-page brochure, published by the National Campaign to Prevent Teen Pregnancy, summarizes program reviews contained in a number of detailed reports and publications produced and disseminated over the years. The brochure begins with information about the characteristics of effective programs and how to choose a program and then presents a list of programs for which evidence of success is strongest. A chart containing a description of each program, including the name, study setting and sample, selected effects, contact information, and additional resources is also provided. The brochure, intended for use by communities in finding programs that suit local values, opportunities, and budgets, is available at http://www.teenpregnancy.org/resources/reading/pdf/What_Works.pdf
Medical Mystery Tour
Copious post operative mucous secretions: The rest of the story
Let’s review last month’s case history….
A 60 year old female heavy smoker underwent a staging laparotomy that ultimately revealed bilateral hydrosalpinges without complication. The patient developed a left lung collapse due to tenacious secretions and had a successful re-inflation of her left lung by bronchoscopy. The afebrile patient was then noted to have several dry small fatty nodules between her midline staples, but she was otherwise tolerating an advancing diet, voiding, and had bowel movements. The patient was e ncouraged to stop smoking and the nature of chronic obstructive pulmonary was discussed with the patient. On the day of discharge the provider began to replace of the slightly prolapsed subcutaneous fat and to place Steristrips over the otherwise clean and dry incision.
Did you think of any further discharge / wound care instructions you would give this patient?
If you said something along the lines of…
-take two hydrocodone(s) and call me in the morning, then you would have been ½ correct.
If you had said take a little general anesthesia and call me in the morning, then you would have been closer. Let me explain.
The provider initially removed the lower one half of the staples at the bedside and was surprised to find that the adipose protruding through the staples for the last 3 days had actually been the omentum. The patient was then taken to the operating room and received general anesthesia. The subcutaneous tissue was opened. There was omentum in the subcutaneous tissue with some omentum that was dried indicating that it had been there for a while. Most of the tissue was fresh in appearance and moist. There was no odor, discharge or purulent material. There was no devitalized tissue. The skin edges and the subcutaneous tissues looked normal and without significant need for debridement. At the fascial edge, the suture was identified and was in place, but had pulled through the fascia in the upper 1/2 of the wound allowing the omentum to herniate through.
The total area of dried omentum is less than 2 square inches. This is immediately moved away from the incision and a small partial omentectomy was performed by sequentially clamping, dividing and ligating the omentum away from the bowel. There is no bowel extravasated from the abdominal cavity. The prolapsed omentum was excised and the abdomen explored without further findings. The fascia was closed with a mass closure technique. The patient did well and was discharged 5 days later without further complication. The patient was re-admitted 2 weeks later with a partial small bowel obstruction that resolved with conservative therapy.
Of note, the patient went home with inhalers an incentive spirometer, and a pulmonary appointment, but she did stop smoking.
What can we learn from this case?
There are a number of facets to this case, but to start let’s review some of what UpToDate says about ‘Surgical incisions: Prevention and treatment of complications’.
The incidence of fascial disruption is 1 percent overall and 0.4 percent in gynecologic surgery. By comparison, incisional hernia develops in approximately 1 percent of uncomplicated surgical cases, 10 percent of patients with wound infection, and 30 percent of patients who underwent repair of dehiscence. More than one-half of hernias appear within six months of the original operation, approximately three-quarters are present by two years, and 97 percent are present by five years.
Wound disruption results from increased intraabdominal pressure or abdominal wall muscle tension overcoming suture strength, knot security, and tissue strength or holding power. Factors that enable mature collagen to stretch and allow incisional hernia after apparently adequate healing remain obscure. Often no obvious cause or precipitating factors are identified.
Problems with slow or delayed healing are rare in young and healthy patients, while a number of factors contribute to the problem of fascial failure in other patients:
Underlying conditions — Risk factors for fascial disruption are numerous, but excessive coughing is listed along with poor nutrition, advanced age, pulmonary disease, obesity, and several others.
Incisional factors — Tension on an incision is proportional to its length. Herniation is more common when the incision is in excess of 18 cm. It was thought that longitudinal incisions were at greater risk of dehiscence than transverse incisions. However, it is difficult to make legitimate comparisons since longitudinal incisions are more likely to be performed in cases of hemorrhage, trauma, sepsis, multiorgan disease, previous surgery, previous radiation therapy, and malignancy. Randomized trials comparing paramedian, transverse, and midline incisions reported no significant differences in the frequency of dehiscence or herniation when confounding factors were considered.
Suture — The main causes of wound separation are failure of suture to remain anchored in the fascia, suture breakage, knot failure, and excessive stitch interval which allows protrusion of viscera. In up to 95 percent of abdominal wound dehiscences, the sutures and knots are intact, but the suture has pulled through the fascia. This is usually the result of fascial necrosis from sutures being placed too close to the edge or under too much tension. Since tissue is weak 1 cm from the incision, sutures should be placed more than 1 cm from the wound edge to ensure that the tissue is strong enough to hold the suture. For continuous closure, the total length of the suture should be approximately four times the length of the incision.
Suture breakage and knot failure uncommon causes of wound separation. Absorbable suture material has an increased risk of dehiscence and herniation because up to 80 percent of tensile strength is lost within two weeks. Chromic catgut suture closure, which is rapidly degraded, is associated with an 11 percent dehiscence rate; therefore, catgut suture should not be used on the fascia, whether as a layered or mass closure. Polyglycolic acid and polyglactin 910, which are degraded more slowly, give better results, similar to permanent sutures in healthy patients who have no unusual risk of dehiscence. In high-risk patients, polyglycolic acid and polyglactin are inferior to a permanent suture, such as nylon.
Monofilament sutures should be used for closure of most longitudinal incisions or if prolonged healing is anticipated, such as in an infected wound. The smallest suture caliber that will adequately support the fascia should be selected.
Clinical manifestations and diagnosis — Signs and symptoms of a complete dehiscence include profuse serosanguinous drainage, often preceded by a popping sensation and an incisional bulge exacerbated by Valsalva maneuvers. The absence of a healing ridge in a laparotomy incision by postoperative day 5 can be a sign of impaired healing and impending disruption. In one series, none of 17 patients with dehiscence had a palpable ridge prior to rupture whereas 1,240 of 1,249 patients without dehiscence had a palpable ridge.
Most dehiscences occur 4 to 14 days after surgery, with a mean of 8 days. The diagnosis can be made based upon clinical grounds in the majority of cases. Imaging studies, such as ultrasonography, magnetic resonance imaging, or computed tomography, have been used when the diagnosis was unclear.
Treatment — When fascial integrity is in question, wound exploration should be performed in the operating room. Complete abdominal dehiscence is associated with a mortality rate of 10 percent, and is a surgical emergency. At the bedside, a moist dressing should be placed over the wound and a binder placed around the patient's abdomen. These steps will protect the patient from potential evisceration on the way to the operating theater.
Once opened, the wound must be thoroughly debrided. A mass closure with continuous or retention sutures should be performed with 2-caliber permanent suture. If the skin is left open, it may be closed when granulation tissue is present.
Prevention — The method of fascial closure is a critical aspect of incision closure, as this provides the majority of wound strength during healing. The minimum components of good technique are:
-Wide tissue bites (
1 cm)
-A short stitch interval (
1 cm)
-Nonstrangulating tension on the suture
-Use of delayed absorbable or permanent suture material
Continuous mass closure or interrupted Smead-Jones closure with permanent or delayed absorbable suture are both safe and effective. A study in rats comparing simple mass closure to continuous Smead-Jones closure showed that, while simple mass closure was significantly faster, incisions closed with the continuous Smead-Jones technique had substantially higher bursting pressures.
The use of retention sutures provides the most secure closure, and is often used to reinforce other closures. Retention sutures will decrease the number of wound dehiscences, but not eliminate them entirely]. Retention sutures may be placed 2 cm from the incision in a through and through, vertical mattress, vertical parallel, or double retention fashion. Permanent suture of 2-caliber or greater should be used and left in place for at least 21 days. For patients at risk for wound dehiscence a running mass closure, Smead-Jones closure or the placement of retention sutures are all appropriate options.
OB/GYN CCC Editorial comment:
Appropriate wound reclosure will improve the care of our AI/AN patients
While the above wound dehiscence is a relatively uncommon event, superficial wound disruption is much more common. The American Board of Obstetricians and Gynecologists Annual Board Certification materials recently referenced a systematic reviewed on the reclosure of the disrupted laparotomy wound by Wechter et al 2005.
The review found that reclosure of disrupted laparotomy wounds was successful in over 80% of patients. Failed reclosure resulted in no life-threatening complications. Reclosure of disrupted laparotomy wounds is safe and decreases healing times. Compared with healing by secondary intention, reclosure resulted in faster healing times (16-23 days versus 61-72 days), and in the one study that evaluated it, 6.4 fewer office visits. The optimal timing and technique for reclosure and the utility of antibiotics were inconclusive.
Reference:
Wechter ME, et al Reclosure of the disrupted laparotomy wound: a systematic review. Obstet Gynecol. 2005 Aug;106(2):376-83.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db
=pubmed&list_uids=16055590&dopt=Abstract
Surgical incisions: Prevention and treatment of complications : UpToDate
http://www.uptodateonline.com/utd/content/topic.do?topicKey
=gyn_surg/12238&type=A&selectedTitle=1~7
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.
Menopause Management (see also Abstract of the Month)
Conjugated Equine Estrogen Treatment May Not Increase Breast Cancer Risk
CONCLUSIONS: Treatment with CEE alone for 7.1 years does not increase breast cancer incidence in postmenopausal women with prior hysterectomy. However, treatment with CEE increases the frequency of mammography screening requiring short interval follow-up. Initiation of CEE should be based on consideration of the individual woman's potential risks and benefits.
Stefanick ML et al Effects of conjugated equine estrogens on breast cancer and mammography screening in postmenopausal women with hysterectomy. JAMA. 2006 Apr 12;295(14):1647-57
Changes in U.S. Prescribing patterns of menopausal hormone therapy
CONCLUSION: These nationally representative data indicate substantial declines in menopausal hormone prescriptions coinciding with clinical trial results on HT. These declines occurred among all types of therapy and patient characteristics. LEVEL OF EVIDENCE: II-3.
Hing E, Brett KM. Changes in U.S.. Prescribing patterns of menopausal hormone therapy, 2001-2003. Obstet Gynecol. 2006 Jul;108(1):33-40.
ACOG Reports on Compounded Bioidentical Hormones
Compounded bioidentical hormones are plant-derived hormones, biologically similar or identical to those produced by the body, that can be custom prepared by a pharmacist based on physician specifications. These agents are controversial, however, because of concerns related to quality, purity, potency, and effectiveness. A committee of the American College of Obstetricians and Gynecologists (ACOG) has released a report on compounded bioidentical hormones, which was published in the November 2005 issue of Obstetrics & Gynecology.
No rigorous clinical trials have tested the safety or effectiveness of bioidentical hormone regimens. However, 10 out of 29 other compounded products failed one or more quality tests when analyzed by the U.S. Food and Drug Administration (FDA) compared with the 2 percent failure rate of FDA-approved agents. Because bioidentical hormones are not FDA approved, manufacturers are not required to provide official labeling that would list warnings or contraindications.
ACOG considers bioidentical hormones to have the same safety issues as the drugs that require approval by the FDA, along with possible additional risks associated with compounding. ACOG also concludes that there is no scientific evidence to support claims that these agents are safer or more effective than individualized estrogen or progesteronetherapy.
http://www.aafp.org/afp/20060615/practice.html
Midwives Corner - Lisa Allee, CNM
Nuchal cords, somersaults, and the value of a pulsing cord: Nuchal Cord Management
Abstract : Nuchal cord, or cord around the neck of an infant at birth, is a common finding that has implications for labor, management at birth, and subsequent neonatal status. A nuchal cord occurs in 20% to 30% of births. All obstetric providers need to learn management techniques to handle the birth of an infant with a nuchal cord. Management of a nuchal cord can vary from clamping the cord immediately after the birth of the head and before the shoulders to not clamping at all, depending on the provider's learned practices. Evidence for specific management techniques is lacking. Cutting the umbilical cord before birth is an intervention that has been associated with hypovolemia, anemia, shock, hypoxic-ischemic encephalopathy, and cerebral palsy. This article proposes use of the somersault maneuver followed by delayed cord clamping for management of nuchal cord at birth and presents a new rationale based on the available current evidence.
Mercer, J, Skovgaard, R, Peareara-Eaves, J, Bowman, T. 2005. Nuchal Cord Management and Nurse-Midwifery Practice. Journal of Midwifery & Women’s Health 50(5): 373-379
Editorial Comment: Lisa Allee, CNM
Judith Mercer, et al, present excellent evidence that leaving a nuchal cord alone and delivering the baby by the somersault maneuver is preferred over clamping and cutting the cord before the shoulders deliver. They also provide nice drawings showing how to do the somersault. I first learned the somersault many years ago from a locums midwife while I was working as an RN. Soon after, on a very, very busy shift, I walked into a room where two nurses were busily getting gloves on, but the head was crowning, so I stepped in and caught the baby noting a nuchal cord as he came out. I pointed him toward his mother’s thigh and out he somersaulted! First baby I ever caught. I have used the somersault ever since except once when I mistakenly thought that a baby was slow to deliver due to the nuchal cord and clamped and cut it—it wasn’t the cord it was the shoulders. Needless to say the seconds it took to get that baby out were long and the baby needed some help getting going. Lesson learned—the baby needs the cord intact. Mercer, et al, present research that shows cutting a nuchal cord can lead to problems (see above) and that in a survey of nurse-midwives 40% selected somersaulting as their best option for nuchal cords and 96% avoid immediate clamping and cutting of nuchal cords. They also provide a clearly stated description of cord anatomy and physiology and the “blood volume model of neonatal transition” that not only supports the suggested management of nuchal cords, but also the benefits of delayed cord clamping in general. Judith Mercer has written elsewhere about delayed cord clamping and its beneficial role in neonatal resuscitation. This is based on the blood volume the baby gets from the placenta preventing hypovolemia and this thinking is consistent with the new changes in CPR that emphasize circulation, circulation, circulation (who else just took the new class with all those compressions?) She proposes letting the cord pulse while giving PPV with baby between mom’s legs. I know this is very different than the rush to the warmer and change is hard, but read and think about it—it makes sense. I highly recommend her chapter, Fetal to neonatal transition: First, do no harm, in Normal Childbirth: Evidence and debate, edited by Su Downe. Actually, read the whole book.
Other
Midwives in IHS- Choose Midwifery: A Perfect Match
An attractive and informative 5 page pamphlet on the roles of midwives in Indian Health.
http://www.midwife.org/siteFiles/education/IHS_booklet_revised_11_05.pdf
Short and Long Pregnancy Spacing Impairs Perinatal Outcomes
CONCLUSIONS: Interpregnancy intervals shorter than 18 months and longer than 59 months are significantly associated with increased risk of adverse perinatal outcomes. These data suggest that spacing pregnancies appropriately could help prevent such adverse perinatal outcomes.
Conde-Agudelo A et al Birth spacing and risk of adverse perinatal outcomes: a meta-analysis. JAMA. 2006 Apr 19;295(15):1809-23.
Coitus is associated with reduced requirement for labor induction at 41 weeks
CONCLUSION: Reported sexual intercourse at term was associated with earlier onset of labor and reduced requirement for labor induction at 41 weeks. LEVEL OF EVIDENCE: II-2.
Tan PC, et al Effect of coitus at term on length of gestation, induction of labor, and mode of delivery. Obstet Gynecol. 2006 Jul;108(1):134-40.
Coitus During Early Pregnancy Not Linked to Recurrent Preterm Birth
CONCLUSION: Self-reported coitus during early pregnancy was not associated with an increased risk of recurrent preterm delivery. There was an association between increasing number of sexual partners in a woman's lifetime and recurrent preterm delivery.
Yost NP, et al Effect of coitus on recurrent preterm birth. Obstet Gynecol. 2006 Apr;107(4):793-7
Navajo Corner, Kathleen Harner, Tuba City
Methamphetamine abuse among women on Navajo: Part IV - The “Drop- in” gravida
A 24yo G3A2 presents to labor and delivery at 34 weeks gestation having received no prenatal care. She is contracting every 5 – 6 minutes and is complaining of excruciating pain. She is very dramatic. She denies health problems or surgeries; she has had one elective and one spontaneous abortion. She denies drug or alcohol use and does not use any medications regularly. Her fetal monitoring strip is reactive and without decelerations. You order routine prenatal labs and a urine toxicology screen and it is positive for methamphetamine. Her fetal fibronectin test is negative, ultrasound confirms her dating, and her contractions stop with hydration. Now what are you to do with her?
This is the “drop-in” gravida, positive for methamphetamine and having had no prenatal care. You are far more likely to see a gravida positive for meth in labor and delivery than in your prenatal care clinic. She comes in, not because she is concerned about her pregnancy but because she is in excruciating pain. Meth abusers do not perceive pain, joy or sadness the same way non abusers do. At TCRHCC this patient would be immediately identified as being at risk for drug or alcohol abuse and she would be informed that a urine toxicology screen would be performed.
Our clinical guideline on drug screening in labor and delivery includes the following conditions:
- Positive Substance Abuse Questionnaire
- No Prenatal Care
- Late Prenatal Care
- Scant Prenatal Care
- Multiple DNKA’s (missed appointments)
- Abruptio Placenta
- Intrauterine Fetal Demise
- Prior History of Substance Abuse
- Preterm Labor
- Intrauterine Growth Restriction
- Unexplained Congenital Abnormalities
- Current Sign and Symptoms of acute intoxication
- Domestic Violence
Patients should be informed that screening will be performed based on clinical guidelines. Written consent is not required. Providers should strive to protect the integrity of the provider-patient relationship treating patients with dignity and respect. Providers should communicate honestly and directly about what information can and cannot be protected. Positive screens are reported to child protective services and the staff pediatricians are notified.
The patients are offered counseling services prior to discharge from the hospital. If the patient is undelivered at discharge she is offered the same combination of regular drug screening, continuity of prenatal care, and mental health counseling that drug dependant mothers identified in the clinic setting are offered. If the patient is delivered and either she or the baby have a positive urine drug screen, child protective services are notified and they determine the appropriate disposition of the infant. The mother is still offered counseling services and close follow-up.
Unfortunately, we often don’t see these moms until late in their prenatal course, as with the gravida in the example. Ideally, these patients should receive extra support from their prenatal care providers but this is impossible when they are not identified until late in pregnancy. But, however and whenever they are identified, they must be offered comfort, hope and support.
References:
Buchi KF, Zone S, Langheinrich K, and Varner MW. Changing Prevalence of Prenatal Substance Abuse in Utah. The American College of Obstetricians and Gynecologists, Vol.102, No 1 July 2003 Pages 27 – 30.
The DASIS Report. Pregnant Women in Substance Abuse Treatment: 2002. September 3 2004. Accessed September 29, 2005http://www.oas.samhsa.gov/2k4/pregTX/pregTX.htm
Guidelines for obtaining maternal and neonatal UDM. Accessed September 30, 2005 http://aia.berkeley.edu/media/pdf/nm_sen_guidelines.doc
Healthy People 2010. Increase abstinence from alcohol, cigarettes and illicit drugs among pregnant women. Accessed October 4, 2005
http://www.healthypeople.gov/document/html/objectives/16-17.htm
Slutsker L, Smith R, Higginson G, Fleming D. Recognizing Illicit Drug Use by Pregnant Women: Reports from Oregon Birth Attendants. American Journal of Public Health 1993 Jan; 83 (1): 61-4
OB/GYN CCC Editorial comment:
I want to offer special thanks to Kathleen Harner, MD, from Tuba City for this very helpful 4 part series on Methamphetamine abuse among women on Navajo. The previous 3 editions can be found in the CCCC dating from April 2006.
http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN01.cfm
In addition, the Primary Care Discussion Forum had a particularly helpful discussion on the topic of Methamphetamine Abuse in Indian Country moderated by Steve Holve, MD, also from Tuba City. Please find that captured discussion, as well as many other resources at this site
http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForumMod.cfm#meth
In the meantime here is a set of recommendations to improve the child welfare system's ability to counteract the impact of methamphetamine (meth) use on children, families, and communities
Impact of Methamphetamine on Family Well Being
Meth and Child Welfare: Promising Solutions for Children, Parents, and Grandparents provides a set of recommendations to improve the child welfare system's ability to counteract the impact of methamphetamine (meth) use on children, families, and communities. The report, produced by Generations United with support from the Pew Charitable Trusts, discusses the unique problems faced by child welfare agencies and others as they respond to increased meth use. The report then presents information about new knowledge, models, and best practices emerging from states about how to keep children safe, promote family reunification, and find children permanent homes when they cannot live with their parents. The report concludes with six policy recommendations for federal support in helping child welfare agencies capitalize on the inherent resiliency of the families and communities with which they work . http://ipath.gu.org/documents/A0/Meth_Child_Welfare_Final_cover.pdf
Nurses Corner - Sandra Haldane, HQE
The Association of Nurses in Aids Care
This nursing organization offers many services including educational offerings that you may be interested in taking advantage of. www.anacnet.org
Are you aware of a school curriculum dealing with STI/HIV prevention activities?
#1
FromChristine Benally, SHC, Coordinated School Health Education, Ft. Defiance Service Unit
There is a Curriculum developed out of the University of New Mexico specifically for Native Americans. The Circle of Life: Native American HIV Prevention Curriculum. Contact info below
http://hsc.unm.edu/chpdp/projects/croflife.htm
University of New Mexico
Center for Health Promotion and Disease Prevention
MSC 11 6145
Albuquerque, NM 87131
For more information about the Center's activities, projects, community outreach or employment,
please contact Leslie Trickey at 505-272-4462, or email her at LETrickey@salud.unm.edu
#2
From Mary Wachacha, Lead Consultant IHS Health Education
Here is information on the Be Proud, Be Responsible curriculum. I am still waiting to hear where the electronic version of the Native American specific "Circle of Life HIV/AIDS" curriculum is physically located. ‘Be Proud, Be Responsible’ can be ordered from Select Media at the website below
ETR has a great website of evidence-based programs. For each program they include-
Overview of the Curriculum
Unique Features of the Curriculum
Theoretical Framework
Costs and Training Information
Evaluation Fact Sheet
http://www.selectmedia.org/curriculum.asp?curid=4
2006 ANAC 19th Annual Conference: Scaling the Heights of HIV/AIDS Nursing
October 26-29th, 2006
Las Vegas , Nevada
https://secure.ar51.net/anacnet/confreg_onlineapp.htm
2007 Evidence-Based Practice Conference
February 22 -23, 2007
Phoenix , AZ
Center for the Advancement of Evidence-Based Practice at the Arizona State University
http://nursing.asu.edu/caep/conference/index.htm
Important for sites to promote height and weight standardization
The HT WT standardization web training is available at the link below. The training is based on the WIC Program HT WT training. www.ihs.gov/medicalprograms/anthropometrics
Office of Women's Health, CDC
New Data on Priority Health Risk Behaviors among Adolescents and Young Adults
Many high school students continue to engage in behaviors that place them at risk for the leading causes of mortality and morbidity. Priority health-risk behaviors, which contribute to the leading causes of morbidity and mortality among adolescents and adults, often are established during childhood and adolescence, extend into adulthood, are interrelated, and are preventable.
* Seventy-one percent of all deaths among children, adolescents, and young adults ages 10-24 result from four causes: motor-vehicle crashes, other unintentional injuries, homicide, and suicide.
* During the 30 days preceding the survey, 9.9% of respondents had driven a car or other vehicle when they had been drinking alcohol, 18.5% had carried a weapon, 43.4% had consumed alcohol, and 20.2% had used marijuana.
* During the 12 months preceding the survey, 35.9% of high school students had been in a physical fight, and 8.4% had attempted suicide.
* A total of 46.8% of high school students had ever had sexual intercourse; 37.2% of sexually active high school students had not used a condom at last sexual intercourse; and 2.1% had ever injected an illegal drug.
* Risk behaviors associated with the two leading causes of death among adults ages 25 or older (cardiovascular disease and cancer) were initiated during adolescence: a total of 23% of high school students had smoked cigarettes during the 30 days preceding the survey, 79.9% had not eaten five or more servings of fruits and vegetables per day during the 7 days preceding the survey, 67% did not attend physical education classes daily, and 13.1 % were overweight.
Centers for Disease Control and Prevention. 2006. Youth Risk Behavior Surveillance -- United States, 2005. MMWR 55(No. SS-5). http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5505a1.htm
Oklahoma Perspective Greggory Woitte – Hastings Indian Medical Center
IHS Division of Epidemiology and Disease Prevention Launches New Website
The IHS Division of Epidemiology and Disease Prevention, located in Albuquerque, has launched a new website.
The Division of Epidemiology functions as the leading office in IHS for disease epidemiology, prevention and control activities for general infectious and chronic diseases as well as the following specific health conditions: cancer, tobacco use, breast and cervical cancer, vaccine-preventable diseases, sexually-transmitted diseases, and disease outbreaks. Additional activities of the Division include providing high level, responsive expertise on public health subject matter and methods, and strengthening the capacity for, and practice of, public health through mentoring, training and development of a network of proactive, responsive tribally-operated epidemiology centers for tribes and regions.
The mission of the Division of Epidemiology is to improve the health of AI/ANs by:
- Identifying and understanding health problems and disease risks
- Strengthening public health capacity
- Developing solutions for disease prevention and control
The new website contains a wealth of information on cancer, smoking, vaccines, viral hepatitis, and the STD program. Within each section are links to numerous resources for clinicians as well as program managers. I encourage you to the browse through the new website to become familiar with the information available. Congratulations to the Division of Epidemiology and the Web Development Team from OIT. http://www.ihs.gov/medicalprograms/epi/index.cfm.
CCC Editorial comment
This month’s Oklahoma Perspective was brought to us by David Gahn at Tahlequah while Gregg Woitte was performing a TDY in Rosebud
Thanks to both Gregg and David for the extra efforts.
Osteoporosis
Osteoporosis Guidelines Updated: North American Menopause Society
Specific recommendations for evaluation focus on assessment of risk factors for bone mineral density–defined osteoporosis and osteoporotic fracture are as follows:
- Lifestyle practices should be reviewed regularly, and those that reduce the risk for bone loss and osteoporotic fractures should be encouraged in all women. These include maintaining a healthy weight, eating a balanced diet, obtaining adequate calcium and vitamin D, participating in appropriate exercise, avoiding excessive alcohol consumption, not smoking, and using measures to prevent falls. Periodic reviews of calcium and vitamin D intake and lifestyle behaviors are useful in all adult women.
- A woman's risk for falls should be evaluated at least annually after menopause.
- The physical examination should include an annual measurement of height and weight, as well as an assessment for kyphosis and back pain.
- Bone mineral density testing is indicated for all postmenopausal women with medical causes of bone loss and for all postmenopausal women aged 65 years and older. The preferred technique is dual energy x-ray absorptiometry (DXA). The total hip, femoral neck, and posterior-anterior lumbar spine should be measured, using the lowest of the 3 bone mineral density scores.
- Bone mineral density testing should be considered for healthy postmenopausal women younger than age 65 years with at least one of the following risk factors: previous fracture (other than skull, facial bone, ankle, finger, and toe) after menopause; thinness (body weight < 127 lb [57.7 kg] or body mass index < 21 kg/m2); history of hip fracture in a parent; or current smoking.
- Routine use of biochemical markers of bone turnover is not generally recommended in clinical practice.
- If osteoporosis is diagnosed clinically or by bone mineral density, any secondary causes should be identified. However, there are limited data to define the most thorough or cost-effective workup.
- Vertebral fracture must be confirmed, either by a vertebral fracture assessment with DXA measurement of the spine or height loss greater than 20% (or 4 mm) of a vertebra on spinal radiograph.
Specific recommendations for treatment are as follows:
- The need for prescription osteoporosis therapy is determined based on a combination of bone mineral density and risk factors. Drug treatment of osteoporosis is recommended for all postmenopausal women who have had an osteoporotic vertebral fracture; who have bone mineral density values consistent with osteoporosis (ie, T-score worse than or equal to -2.5); who have a T-score from -2.0 to -2.5 plus at least one of the following risk factors for fracture: thinness, history of fragility fracture (other than skull, facial bone, ankle, finger, and toe) since menopause, and history of hip fracture in a parent.
- Treatment recommendations should be based on both efficacy data and clinical parameters. These include magnitude of fracture risk, adverse effect profile, tolerability of specific drugs, extraskeletal risks and potential benefits, confounding diseases, cost, and patient preference, including choice of dosing. Because head-to-head trials comparing the effectiveness of pharmacologic therapies to reduce fracture risk have not been conducted, selection of one therapy over another cannot be on the basis of clinical evidence.
- Bisphosphonates are the first-line drugs for treating postmenopausal women with osteoporosis. Alendronate and risedronate reduce the risk for both vertebral and nonvertebral fractures, but whether there are differences in fracture protection among the bisphosphonates is uncertain. It is probable that all bisphosphonates produce greater relative and absolute fracture risk reductions in women with more severe osteoporosis.
- The selective estrogen-receptor modulator raloxifene should be considered most often in postmenopausal women with low bone mass or in younger postmenopausal women with osteoporosis who are at greater risk for spine fracture than hip fracture. Although raloxifene prevents bone loss and reduces the risk for vertebral fractures, its effectiveness in reducing other fractures is uncertain. When considering raloxifene therapy, extraskeletal risks and benefits are important.
- Teriparatide (parathyroid hormone 1 - 34) should be reserved for treating women at high fracture risk, including those with very low bone mineral density (T-score worse than -3.0) with a previous vertebral fracture. Parathyroid hormone improves bone mineral density and reduces the risk for new vertebral and nonvertebral fractures, but dosage requirements of daily subcutaneous injections may limit use.
- The primary indication for systemic ET/EPT is to treat moderate to severe menopause symptoms, such as vasomotor symptoms. When these symptoms abate, continued hormone therapy can still be considered for bone effects, weighing its benefits and risks against those of other treatment options.
- Calcitonin is not a first-line drug for postmenopausal osteoporosis treatment because its fracture efficacy is not strong and its bone mineral density effects are less than those of other agents. However, it can be considered in women with osteoporosis who are more than 5 years beyond menopause. Although calcitonin may reduce vertebral fracture risk in women with osteoporosis, the evidence documenting fracture protection is not strong. Calcitonin is not recommended for treating bone pain other than that resulting from acute vertebral compression fractures.
- At present, available data do not allow making definitive recommendations concerning combination or serial antiresorptive and anabolic drug therapy.
- Treatment goals and the choice of medication should be reevaluated on an ongoing basis through periodic medical examination and follow-up bone mineral density testing during therapy. Measuring bone mineral density has limited use in predicting the effectiveness of antiresorptive therapies for reducing fracture risk; an appropriate interval for repeat bone mineral density testing is 2 years. Adherence to the treatment plan should be encouraged, in part by providing clear information to women regarding their risk for fracture and the purpose of osteoporosis therapy.
- Drug-related adverse effects may require switching to another agent.
- In most women, treatment of osteoporosis needs to be long term.
North American Menopause Society. Management of osteoporosis in postmenopausal women: 2006 position statement of The North American Menopause Society. Menopause. 2006 May-Jun;13(3):340-67
Patient Information
Do you need a Native oriented sex education resource in your clinic?
Try this which was forwarded by Cliff O'Callahan MD, PhD, FAAP
No Place Like Home
http://www.noplacelikehome.org/contentsimages/NPLHNative.pdf
Kidney Stones: What You Should Know
http://www.aafp.org/afp/20060701/99ph.html
Recovering from a Hip Fracture: What You Should Know
http://www.aafp.org/afp/20060615/2201ph.html
Perinatology Picks - George Gilson, Maternal Fetal Medicine, ANMC
Only 29% of ACOG recommendations are level A: Good and consistent scientific evidence
Results: The 55 practice bulletins contained 438 recommendations of which 29% are level A, 33% level B, and 38% level C. The 55 bulletins cite 3953 references of which 17% are level I, 46% level II, 34% level III, and 3% others. Level A recommendations were significantly more likely among the 23 gynecologic than 32 obstetric bulletins (37% versus 23%, odds ratios 1.95, 95% confidence intervals 1.28, 2.96). The study types referenced in obstetric and gynecologic bulletins were similar (P > .05 for comparison of levels I, II, and III and meta-analysis references).
Conclusion : Only 29% of the American College of Obstetricians and Gynecologists recommendations are level A, based on good and consistent scientific evidence.
Chauhan SP et al American College of Obstetricians and Gynecologists practice bulletins: an overview. Am J Obstet Gynecol 2006 Jun;194(6):1564-72; discussion 1072-5.
Editorial comment:
Please note this article is not meant to criticize ACOG’s Practice Bulletin process, which is actually quite robust and we all appreciate. Rather, it is a reflection of what level of studies are available in the literature for ACOG to review.
When in doubt, remember the Cochrane Library was initially a maternity oriented database and only reviews randomized clinical trials. http://www.update-software.com/publications/cochrane/
Evidence-based surgery for cesarean delivery
RESULTS: US Preventive Services Task Force recommendations favor blunt uterine incision expansion, prophylactic antibiotics (either ampicillin or first-generation cephalosporin for just 1 dose), spontaneous placental removal, non-closure of both visceral and parietal peritoneum, and suture closure or drain of the subcutaneous tissue when thickness is > or =2 cm. CONCLUSION: Cesarean delivery techniques that are supported by good quality recommendations should be performed routinely. All technical aspects that have recommendations with lower quality should be researched with adequately powered and designed trials.
Berghella V, et al Evidence-based surgery for cesarean delivery. Am J Obstet Gynecol. 2005 Nov;193(5):1607-17
Higher rate of pain-free coitus at 6 weeks after delivery: Fast-absorbing polyglactin
CONCLUSION: Fast-absorbing polyglactin 910 for perineal repair is associated with earlier resumption of sexual intercourse when compared with chromic catgut.
Leroux N et al Impact of chromic catgut versus polyglactin 910 versus fast-absorbing polyglactin 910 sutures for perineal repair: a randomized, controlled trial. Am J Obstet Gynecol. 2006 Jun;194(6):1585-90; discussion 1590.
Progestational agents, initiated in the second trimester, reduce preterm delivery
CONCLUSION: Progestational agents, initiated in the second trimester of pregnancy, may reduce the risk of delivery less than 37 weeks' gestation, among women at increased risk of spontaneous preterm birth, but the effect on neonatal outcome is uncertain. Larger randomized controlled trials are required to determine whether this treatment reduces perinatal mortality or serious neonatal morbidity. Mackenzie R, et al Progesterone for the prevention of preterm birth among women at increased risk: a systematic review and meta-analysis of randomized controlled trials. Am J Obstet Gynecol. 2006 May;194(5):1234-42.
Calcium reduced preeclampsia severity, maternal morbidity, and neonatal mortality
CONCLUSION: A 1.5-g calcium/day supplement did not prevent preeclampsia but did reduce its severity, maternal morbidity, and neonatal mortality, albeit these were secondary outcomes.
Villar J, et al World Health Organization randomized trial of calcium supplementation among low calcium intake pregnant women. Am J Obstet Gynecol. 2006 Mar;194(3):639-49.
Primary Care Discussion Forum
September 1, 2006: Palliative Medicine's Role in the Continuity of Care
Moderator: Tim Domer, M.D.
- Management of acute vs chronic pain
- Quality of Life in chronic illness
- The meaning of "Code Status"
- Preparing for a "Good Death"
- End-of-Life Care as part of Continuity of Care and Prevention
http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForum.cfm#
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STD Corner - Lori de Ravello, National IHS STD Program
Focus on adolescent sexual behavior this month
Boyfriends, Girlfriends and Teenagers' Risk of Sexual Involvement
CONCLUSIONS: To reduce the risk of adolescent sexual activity, parents and communities should encourage youth in middle school, especially females who experience early menarche, to delay serious romantic relationships.
Marin BV et al Perspectives on Sexual and Reproductive Health Volume 38, Number 2, June 2006 pages 76-83 http://www.guttmacher.org/pubs/journals/3807606.pdf
Early Predictors of Sexual Behavior: Implications for Young Adolescents and Parents
Marín and colleagues examine sixth-, seventh- and eighth-grade characteristics as predictors of sexual activity in ninth grade among roughly 2,500 students in California (page 76). The study provides empirical evidence of the independent contribution of nonsexual romantic relationships in the seventh grade to the onset of sexual intercourse by the ninth grade for both males and females. In addition, it shows that among females, seventh graders in serious relationships with older teenagers—uniquely defined as those two or more years older—have an increased likelihood of sex in the ninth grade. Finally, the study demonstrates that seventh graders of both genders who have had serious romantic relationships were already significantly different in the sixth grade from those who have not: They had peers who were more accepting of sexual activity, they had experienced more unwanted sexual advances and situations that could lead to sex (i.e., where parental monitoring is limited) and, for females, they had undergone earlier menarche. The findings suggest important aspects of the pathways to early sexual intercourse that have not typically been addressed in either school- or parent-based sex education programs.
Lieberman LD Perspectives on Sexual and Reproductive Health Volume 38, Number 2, June 2006 pages: 112-114 http://www.guttmacher.org/pubs/journals/3811206.pdf
Greater Expectations: Adolescents' Positive Motivations for Sex
CONCLUSIONS: Adolescents view intimacy, sexual pleasure and social status as important goals in a relationship. Many have strong positive expectations that sex would satisfy these goals. Prevention programs and providers should address the risks of sex in the context of expected benefits.
Ott MA et al. Persp