Volume 4, No. 5, May 2006
Features
American Family Physician**
Patient-Oriented Evidence that Matters (POEMS)*
Immersion Exercise Reduces Leg Edema in Pregnancy
Clinical Question: Does immersion exercise reduce dependent edema in pregnant women?
Study Design: Cohort (prospective)
Synopsis: Dependent edema is common in pregnancy. In this study, nine women with marked edema and otherwise uncomplicated pregnancies participated in a 45-minute exercise session while immersed in water. Lower leg volumes were measured before and after the session, including the foot and 4 in (10 cm) of the lower leg. Mean volume decreased by 112 mL on the left leg and 84 mL on the right leg ( P = .007). The women also had a subjective impression of reduction in edema. The authors did not report the duration of the effect or other patient-oriented outcomes.
Bottom Line: Water immersion exercise is an option for managing leg edema in otherwise uncomplicated pregnancies. (Level of Evidence: 2b)
Hartmann S, Huch R. Response of pregnancy leg edema to a single immersion exercise session. Acta Obstet Gynecol Scand December 2005;84:1150-3 http://www.aafp.org/afp/20060415/tips/11.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.
American College of Obstetricians and Gynecologists
ACOG Recommends First Ob-Gyn Visit in Early Teens
Washington , DC -- The American College of Obstetricians and Gynecologists (ACOG) reaffirms its recommendation that teenage girls first visit an ob-gyn between the ages of 13 and 15 in a new committee opinion published in the May 2006 issue of Obstetrics & Gynecology. This initial reproductive health visit will help teens develop a relationship with their ob-gyn before they need to seek care for a specific health issue. The committee opinion details ACOG recommendations for the scope of the visit, discussion topics, and ways to address confidentiality concerns.
The early teen years are an ideal time for an initial ob-gyn office visit that focuses on screening and preventive health care. "During these years, young teens face new issues regarding sexual and reproductive health and development on a daily basis. It's important that they develop a relationship with their ob-gyn," says Marc Laufer, MD, chair of ACOG's Committee on Adolescent Health Care. "Interaction with an ob-gyn they trust allows teens to get answers to questions that they may be too embarrassed or afraid to raise with parents and friends. Ob-gyns also can encourage teens to adopt healthy lifestyle habits that they can carry into adulthood."
Physicians can discuss normal development, menstruation, sexuality, healthy eating habits, safety and injury prevention, and date rape prevention with teens. It also gives ob-gyns an opportunity to address problems that may require early intervention such as eating disorders and weight issues, blood pressure problems, and mental health issues such as anxiety, depression, and physical, sexual, and emotional abuse.
"Teens who are nervous about receiving a pelvic exam can rest easy. A pelvic exam is rarely necessary during the initial visit, unless indicated by medical history," Dr. Laufer adds. Because ACOG recommends that young women have their first Pap test approximately three years after vaginal intercourse but before age 21, teens may visit the ob-gyn several times before a speculum or pelvic exam is needed. However, ob-gyns may recommend a pelvic exam if the teen has had an abnormal puberty (pubertal aberrancy), abnormal bleeding, or abdominal or pelvic pain.
"The first reproductive health visit is an excellent time to discuss pregnancy prevention and sexually transmitted infections," says Lesley Breech, MD, vice chair of the Committee on Adolescent Health Care. Today, more than 85% of adolescents become sexually active during the teen years - nearly one-third of ninth graders and more than 60% of 12th graders report having had sexual intercourse, and the US has the highest teen pregnancy rate of any industrialized nation. "Physicians can use the visit as an opportunity to provide teens with early and accurate information about sex. We can talk about how to use condoms correctly and the various types of contraception that are available, such as emergency contraception, before they start having sex," Dr. Breech adds. If a teen is already sexually active at the time of her first visit, she can be screened for certain sexually transmitted infections through a urine sample.
Parents are encouraged to get involved. The first visit provides an opportunity for parents or guardians to meet the physician, alleviate fears, and develop trust. Parents also can encourage a positive relationship between their daughter and her ob-gyn. Ob-gyns can greet parents and teens together to give a thorough explanation of the visit and confidentiality issues. The exam and discussion should then continue between physician and teen alone to ensure privacy.
http://www.acog.org/from_home/publications/press_releases/nr05-09-06-2.cfm
Vaginitis
ACOG Practice Bulletin No. 72
Summary of Recommendations and Conclusions
The following recommendation and conclusion are based on good and consistent scientific evidence (Level A):
- Women with complicated vulvovaginal candidiasis should receive more aggressive treatment than women with an uncomplicated episode.
- To prevent reinfection, women with trichomoniasis should avoid intercourse until they and their partner have received treatment.
The following recommendation and conclusion are based on limited or inconsistent scientific evidence (Level B):
- Microscopy is the first line for diagnosing vulvovaginal candidiasis and trichomoniasis. In selected patients, culture for yeast and T vaginalis should be obtained in addition to standard office-based testing.
- Douching is not recommended for the prevention or treatment of vaginitis.
- Self-diagnosis of vaginitis is unreliable.
The following recommendation is based primarily on consensus and expert opinion (Level C):
- Clinical evaluation of women with vaginal symptoms should be encouraged, particularly for women who fail to respond to self-treatment with a nonprescription antifungal.
Vaginitis. ACOG Practice Bulletin No. 72. American College of Obstetricians and Gynecologists. Obstet Gynecol 2006;107:1195–206.
Hepatitis B and Hepatitis C Virus Infections in Obstetrics–Gynecology
ACOG Committee Opinion No. 332
ABSTRACT: Hepatitis B and hepatitis C may be transmitted from patients to health care workers and from health care workers to patients. To reduce the risk, all obstetrician–gynecologists who provide clinical care should receive hepatitis B virus vaccine. Obstetrician–gynecologists who are hepatitis B surface antigen positive and e antigen positive should not perform exposure prone procedures until they have sought counsel from an expert review panel. Because the risk of hepatitis C virus transmission is lower than that of hepatitis B virus transmission, routine testing of health care workers is not recommended, and hepatitis C virus-positive health care workers are not required to restrict professional activities.
Hepatitis B and Hepatitis C Virus Infections in Obstetrician–Gynecologists. ACOG Committee Opinion No. 332. American College of Obstetricians and Gynecologists. Obstet Gynecol 2005;106:1141–2.
The Apgar Score
ACOG Committee Opinion No. 333
ABSTRACT: The Apgar score provides a convenient shorthand for reporting the status of the newborn infant and the response to resuscitation. The Apgar score has been used inappropriately to predict specific neurologic outcome in the term infant. There are no consistent data on the significance of the Apgar score in preterm infants. The Apgar score has limitations, and it is inappropriate to use it alone to establish the diagnosis of asphyxia. An Apgar score assigned during resuscitation is not equivalent to a score assigned to a spontaneously breathing infant. An expanded Apgar score reporting form will account for concurrent resuscitative interventions and provide information to improve systems of perinatal and neonatal care.
The Apgar Score. ACOG Committee Opinion No. 333. American College of Obstetricians and Gynecologists. Obstet Gynecol 2005;106:1141–2.
Role of the Obstetrician–Gynecologist in the Screening and Diagnosis of Breast Masses
ACOG Committee Opinion No. 334
ABSTRACT: Obstetrician–gynecologists are in a favorable position to diagnose breast disease in their patients. Obstetrician–gynecologists are more likely to encounter a patient with breast cancer than a patient with any gynecologic cancer. The American College of Obstetricians and Gynecologists (ACOG) has adopted the goals of assisting in educating obstetrician–gynecologists in the diagnosis and treatment of breast cancer and in reducing mortality from breast cancer. To help meet these goals, ACOG has developed recommendations for the early diagnosis of breast disease
Role of the Obstetrician–Gynecologist in the Screening and Diagnosis of Breast Masses. ACOG Committee Opinion No. 334. American College of Obstetricians and Gynecologists. Obstet Gynecol 2005;106:1141–2.
The Initial Reproductive Health Visit
ACOG Committee Opinion No. 335
ABSTRACT: The American College of Obstetricians and Gynecologists (ACOG) recommends that the first visit to the obstetrician–gynecologist take place between the ages of 13 and 15 years (1). This visit will provide health guidance, screening, and preventive health care services and provide an excellent opportunity for the obstetrician–gynecologist to start a physician–patient relationship. This visit generally does not include an internal pelvic examination.
The Initial Reproductive Health Visit. ACOG Committee Opinion No. 335. American College of Obstetricians and Gynecologists. Obstet Gynecol 2006;107:745-7.
AHRQ
Do-not-resuscitate orders for terminally ill children may not be honored by public schools
http://www.ahrq.gov/research/mar06/0306RA12.htm
Ectopic pregnancy rates are declining, but the decline is slower among black women
http://www.ahrq.gov/research/mar06/0306RA17.htm
Close-call reporting systems may be underutilized in identifying potential medical errors
http://www.ahrq.gov/research/mar06/0306RA3.htm
Doctors still prescribe antibiotics for over half of children with sore throats
http://www.ahrq.gov/research/mar06/0306RA13.htm
Ask A Librarian: Diane Cooper, M.S.L.S. / NIH
MCH Library launches redesigned web site
The MCH Library has launched a redesigned Web site that provides accurate, reliable, and timely information and resources for the maternal and child health (MCH) community. The Web site contains the MCH Alert weekly e-newsletter, resource guides, full text publications, databases, and links to quality MCH Web sites.
A search box, an A-Z topic index, and frequently asked questions are featured on the Web site home page. The home page also includes links to the MCH thesaurus, final reports produced by Maternal and Child Health Bureau grantees, an index to non-English-language materials and resources, and resources for families. The Healthy People 2010 Web page provides information related to MCH goals and objectives and library products related to leading health indicators. The Web site, intended for use by health professionals, policymakers, family advocates, community service professionals, MCH/public health faculty and students, and families: http://www.mchlibrary.info
Breastfeeding - Suzan Murphy, PIMC
Database provides information about drugs in breastfeeding mothers
The Drugs and Lactation Database (LactMed) is a peer-reviewed and fully referenced database of drugs to which breastfeeding mothers may be exposed. The database was produced by the National Library of Medicine as part of the Toxicology Data Network. Among the data included are maternal and infant levels of drugs, possible effects on breastfed infants and on lactation, and alternate drugs to consider. The database is searchable by drug name
http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT
CCC Corner Digest
Nicely laid out hard copy - A compact digest of last month’s CCC Corner
Highlights include:
- Protein to Creatinine Ratio in Pre-eclampsia: Is the data preceding the U.S. benchmarks?
- RCTs: Do they have external validity for patients with multiple co-morbidities ?
- Gestational Diabetes Mellitus Tracking Sheets and Case Management PPT
- Glyburide is at least as effective as insulin therapy in treating gestational diabetes
- Urinary incontinence: Substantial economic costs and decrement in quality of life
- Infant Mortality Reviews in the Aberdeen Area: Strategies and Outcomes
- Breast cancer study from PIMC
- Less Invasive Management of Cervical Cytology Abnormalities in Adolescents
- ACOG: New Guidelines Call for Restricted Use of Episiotomies
- Early feeding choice and obesity
- MCH Frequently Asked Question (FAQ) site
- What is the common theme?
- Hands off" versus "hands on" for decreasing perineal lacerations: No difference
- Methamphetamine abuse among women on Navajo, Part 1
- Journey to Magnet
- Peripartum Cardiomyopathy
- Vaginal breech < 3, 500 g - No increase risk in neurodevelopment at 2 years of age
- Adverse Childhood Events: Impact on chronic adult illness / Risk taking
- Announcing New Program Manager for the IHS National STD Program
- ”Clinical inertia" - Providers not intensifying diabetes therapy when indicated
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/06AprOL.pdf
If you want a copy of the CCC Digest mailed to you each month, please contact nmurphy@scf.cc
Domestic Violence
Grants Alert: Domestic Violence, Cultural Competence
Purpose: To provide for the distribution of credible and persuasive
information by community organizations to help break the cycle of family
violence. Support for these efforts will help ensure that individuals
are aware of available resources and alternative responses for the
intervention and prevention of violence.
Administration for Children and Families Community Awareness and Outreach Campaign Projects for the Prevention of Family Violence , Department of Health & Human Services
Application Deadline: 06/11/2006.
Estimated Available Funds: $750,000.
Maximum Award Size: $75,000 per project period.
Estimated Number of Awards: 5 to 10.
CFDA No.: 93.592.
For more information, contact: William D. Riley, Director
Email: wriley@acf.hhs.gov o r go to: http://tinyurl.com/zkmjj
Elder Care News
Maintenance treatment of major depression in old age
Depression is common in the elderly, and places them at increased risk of death and disability. Elders treated successfully for depression tend to have recurrences over time. This study evaluated whether long term antidepressant treatment with either medication or psychotherapy reduced the rate of recurrence in patients 70 and older with major depression who have responded to initial treatment with paroxetine (an SSRI antidepressant) and psychotherapy. Over a two year period those patients receiving maintenance medication, with or without psychotherapy, were roughly half as likely as those who did not receive medication to have recurrence of their depression. This study was not supported by the pharmaceutical industry.
The accompanying editorial points out that mild-moderate depression can often be treated by exercise and increased social activities. The author also suggests that elderly individuals who have had a significant depressive episode should have lifelong periodic reevaluation.
Elder Care Director Comments
I would now consider continuing treatment of an the older individual with depression who has responded to antidepressant therapy for up to two years and would plan to incorporate periodic reevaluation for depression into their plan of care.. We are reminded that depression in the elderly should be considered a chronic condition.
Reynolds CF III, et al. Maintenance treatment of major depression in old age.
N Engl J Med. 2006 Mar 16; 354(11):1130-8.
Reifler BV. Play it again, Sam--depression is recurring. N Engl J Med. 2006 Mar 16;354(11):1189-90.
Family Planning
31% of Sexually Active U.S. Teenage Girls Become Pregnant
Based on the National Survey of Family growth from the National Center for Health Statistics, CDC, and HHS, nearly 31% of girls ages 15 to 19 who have had sexual intercourse at least once become pregnant. In addition, more than 13% of sexually active teenage boys say they have been involved in a pregnancy. The analysis shows that more than one-third of sexually active girls who have had three or more sexual partners have been pregnant, compared with one in four who have had one or two partners. In addition, the report finds that 27% of girls who used a form of contraception when having sex for the first time said they became pregnant, compared with 43% of girls who did not use contraception during sexual debut.
http://www.teenpregnancy.org/press/pdf/ScienceSays23.pdf
Postpartum contraception: New Mexico Pregnancy Risk Assessment Monitoring System
OBJECTIVE: To examine factors associated with postpartum contraception, including the relationship between ethnicity and postpartum contraceptive use.
METHODS: We used data from the New Mexico Pregnancy Risk Assessment Monitoring System, which monitors selected maternal events occurring before, during and after pregnancy.
RESULTS: Our findings in 4096 women revealed that women who are aged >or=35 years, unmarried and lacking a postpartum visit have increased risk of no postpartum contraception. The odds of postpartum contraception were over three times greater in women with a postpartum visit [adjusted odds ratio (OR)=3.06, 95% confidence interval (CI): 2.17-4.31) and over 50% greater in married women(adjusted OR=1.57, 95% CI: 1.16-2.11). Hispanic women were more likely than were Native Americans to use postpartum contraception (OR=1.25, 95% CI: 0.95-1.64).
CONCLUSION: Focused contraception counseling, especially in the postpartum setting, is important to help ensure the well-being of women and children.
Depineres T, Blumenthal PD, Diener-West M. Postpartum contraception: the New Mexico Pregnancy Risk Assessment Monitoring System. Contraception. 72(6):422-5, 2005 Dec
http://www.contraceptionjournal.org/issues/contents
Featured Website David Gahn, IHS Women’s Health Web Site Content Coordinator
The 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
Finally, if the particular question you have is not already posted, then please contact the OB/GYN Chief Clinical Consultant directly. You can get an answer at nmurphy@scf.cc
Frequently asked questions
Q. Are there any cultural barriers/among Native Americans to becoming cord blood donors?
A. Yes, there are issues of the cost for long term cord blood storage, as well as cultural issues. Below are five resources about various aspects of cord blood and tissue donation. The MCH web page also has a Frequently Asked Question with a sample cord blood donation disclaimer and many other resources.
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/CordStem4206.doc
1.) Why should minorities be concerned about organ donation?
Some diseases of the kidney, heart, lung, pancreas, and liver are found more frequently in racial and ethnic minority populations than in the general population. For example, African Americans, Asian and Pacific Islanders, and Hispanics are three times more likely to suffer from end-stage renal disease than Caucasians. Native Americans are four times more likely than Caucasians to suffer from diabetes. Some of these diseases are best treated through transplantation; others can only be treated through transplantation.
Successful transplantation often is enhanced by the matching of organs between members of the same ethnic and racial group. For example, any patient is less likely to reject a kidney if it is donated by an individual who is genetically similar. Generally, people are genetically more similar to people of their own ethnicity or race than to people of other races. Therefore, a shortage of organs donated by minorities can contribute to death and longer waiting periods for transplants for minorities. http://www.unos.org/qa.asp
2.) Q: Why is there a need for women from all racial and ethnic groups to donate their baby's cord blood?
A: Because the tissue traits that are used to match a cord blood unit with a patient are inherited, a patient's most likely match will be cord blood donated by someone of the same heritage. American Indian and Alaska Native, Asian, Black and African American, Hispanic and Latino, Native Hawaiian and Other Pacific Islander, and multiple-race patients face a greater challenge in finding a match than White patients.
NMDP cord blood banks are working in local communities to increase the racial and ethnic diversity of NMDP cord blood listings. From 2001 to 2003, the likelihood of finding a matched cord blood unit has grown at least twofold for patients from all racial and ethnic groups. Still, some patients are unable to find a match because of the rarity of their tissue traits. Some tissue traits are more likely to be found among people of a particular racial or ethnic heritage. That is why a pressing need remains for more cord blood donations from American Indian and Alaska Native, Asian, Black and African American, Hispanic and Latino, Native Hawaiian and Other Pacific Islander, and multiple-race donors. http://www.marrow.org/DONOR/cord_blood_faqs.html#minority
National Marrow Donor Program http://www.marrow.org/DONOR/cord_blood_faqs.html
3.) Native Village: Youth and Education News: Umbilical Cord Blood Donation
Cryobanks International is a facility accepting umbilical cord blood donations throughout the United States. Umbilical cord blood is rich in stem cells used in place of bone marrow for transplants. Cryobanks is now working with Dave Jackson, a Native American Advocate and high-risk OB physician, to sponsor an umbilical cord blood donation program. Umbilical Cord Blood Donation is a painless, non-invasive process that utilizes cord blood that would otherwise be discarded as medical waste. Currently, Native Americans in life and death searches have little chance to find a stem cell match. Donations are accepted from anywhere in the Continental United States.
There is no charge to donate, but be sure to ask about storage charges. ipressler@cryo-intl.com
Native Village : Youth and Education News December 10, 2003 Issue 124, Volume 3
Learn more about Cryobanks: http://www.cryo-intl.com/
4.) Sacred symbolic value associated with the placenta, umbilical cord, and umbilical cord blood
Excerpt:
Yet, in many indigenous cultures, including Native American, the placenta, umbilical cord, and umbilical cord blood have sacred symbolic value associated ...
Abstract:. Religious discussion of human organs and tissues has concentrated largely on donation for therapeutic purposes. The retrieval and use of human tissue samples in diagnostic, research, and education contexts have, by contrast, received very little direct theological attention. Initially undertaken at the behest of the National Bioethics Advisory Commission, this essay seeks to explore the theological and religious questions embedded in nontherapeutic use of human tissue. It finds that the "donation paradigm" typically invoked in religious discourse to justify uses of the body for therapeutic reasons is inadequate in the context of nontherapeutic research, while the "resource paradigm" implicit in scientific discourse presumes a reductionist account of the body that runs contrary to important religious values about embodiment. The essay proposes a "contribution paradigm" that provides a religious perspective within which research on human tissue can be both justified and limited . http://muse.jhu.edu/
Campbell, Courtney S. 1956- "Religion and the Body in Medical Research"
Kennedy Institute of Ethics Journal - Volume 8, Number 3, September 1998, pp. 275-305
The Johns Hopkins University Press
5.) Ethical bases for the draft Indian Health Service's (IHS) Guidelines about the collection and use of research specimens
“34. People in some Tribes have traditional beliefs that the placenta, umbilical cord, and umbilical cord blood are sacred and must be handled in a special manner. IHS hospitals give such tissues back to the patient or family upon request. “
This paper presents the ethical bases for the DRAFT Indian Health Service's (IHS) Guidelines about the collection and use of research specimens (Appendix A). The Guidelines were designed to be a working document for American Indian and Alaska Native (AI/AN)(3) Tribal communities and people; its ethical rationale was not discussed. The Guidelines are relevant to most U.S. people, researchers, and policy makers; if researchers and ethicists are to them as relevant, however, that ethical rationale must be clarified and convincing…
For the proper perspective please view the entire paper at link below.
This was published in Weir R (ed.). Stored tissue samples: Ethical, legal, and public policy implications. U. Iowa Press; Iowa City, IA. 1998: 267-301. This file is the pre-edited next-to-final version. For the final, printed, version, please see the book.
This paper does not necessarily represent the views of the Indian Health Service
Frequently Asked Question: MCH website
Q. Is cord blood stem cell storage a viable option in Indian Country?
A. Cord blood stem cell storage can offer patients both advantages and disadvantages.
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/CordStem4206.doc
Indian Child Health Notes - Steve Holve, Pediatrics Chief Clinical Consultant
Highlights of May 2006
Remember when they told you in medical school that half of what they were teaching you was wrong, they must didn't know which half. Now we do...
- Humidification doesn't benefit croup
- Fluoroquinolones can be used in children < 12 years
However our editors Drs. Singleton and Esposito do know some things and will share them...
- Which Haemophilus influenzae type b vaccine is the best for AI/AN infants?
- Helicobacter pylori and anemia in AI/AN children
- Lessons from New Zealand - access to care for indigenous Maori http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ICHN5706.doc
Information Technology
Annual IHS Technology Conference
We are pleased to announce the IHS Technology Conference, June 19-23, 2006, to be held in the Albuquerque Convention Center, Albuquerque, New Mexico. The theme is "Native Communities Sharing Information through Technology". Please register for the conference using the website, and refer to the site for conference tracks, agenda, and presentations.
International Health Update
Special Journal Issue Features Articles on Women, Gender, and Health Care Disparities
The March-April issue of the Journal of Women's Health features seven articles on women, gender, and health care disparities coauthored by AHRQ's Director of Women's Health and Gender-Based Research, Rosaly Correa-de-Araujo, M.D. The articles are as follows:
- Introduction to the theme issue: Women, gender, and health care disparities, by Correa-de-Araujo R.
- Commentary: Catalyzing quality of care improvements for women, by Correa-de-Araujo R and Clancy C.
- Gender differences across racial and ethnic groups in the quality of care for acute myocardial infarction and heart failure associated with comorbidities, by Correa-de-Araujo R, Stevens B, Moy E, Nilasena D, Chesley F, and McDermott K.
- Gender differences across racial and ethnic groups in the quality of care for diabetes, by Correa-de-Araujo R, McDermott K , and Moy E.
- Women's health care utilization and expenditures, by Taylor AT, Larson S, and Correa-de-Araujo R.
- Preventive health examinations: A comparison along the rural-urban continuum, by Larson S and Correa-de-Araujo R.
- Quality of health care for older women: What do we know,? by Kosiak B, Sangl J, and Correa-de-Araujo R.
A copy is available by sending an e-mail to ahrqpubs@ahrq.hhs.gov. Limited copies are available. Journal of Women's Health http://www.liebertpub.com/publication.aspx?pub_id=42
MCH Alert
Dieting behavior among overweight and non-overweight adolescents
Findings from the present study show that the risks associated with dieting appear similar for overweight and non-overweight teens. Dieting behavior has been shown to co-occur with a variety of negative correlates in adolescents. Dieting could be a reasonable, health-promoting behavior for adolescents who are overweight, while simultaneously carrying health risks for those not overweight. Alternatively, dieting could carry similar risks for all adolescents, regardless of their weight status
The authors found that
* The majority (68.2%) of the students were classified as non-overweight, with 31.8% classified as overweight.
* Student report of dieting was common (55.2% of girls and 25.9% of boys).
* Students classified as overweight were roughly 1.5 to 3 times as likely as students classified as non-overweight to report dieting, EWCBs, and body dissatisfaction.
* Girls who reported dieting had elevated odds ratios for EWCBs, low self-esteem, body dissatisfaction, and depressive symptoms, and tobacco use and alcohol use; boys who reported dieting had elevated odds for EWCBs, low self-esteem, body dissatisfaction, and depressive symptoms.
* Increased risks associated with dieting were similar for overweight and non-overweight students, with the exception of body dissatisfaction in non-overweight girls (5.26) vs. overweight girls (3.19).
"The psychosocial and behavioral risks of dieting . . . may outweigh the potential benefits, even for overweight teens," conclude the authors.
Crow S, Eisenberg ME, Story M, et al. 2006. Psychosocial and behavioral correlates of dieting among overweight and non-overweight adolescents.
Journal of Adolescent Health 38(5):569-574.
Medical Mystery Tour
What was the common theme in these 2 cases?
Let’s recap what we learned last month
Patient #1
This 35 year old G 2 P1001 was originally scheduled for elective repeat cesarean delivery at 36 2/7 pending results of fetal lung maturity studies. The patient’s prenatal course was significant for a first visit at 8 weeks. The gestational age was confirmed by a 10 week ultrasound. The patient was offered a quad screen and /or amniocentesis and declined both. The patient had gastroesophageal reflux disease and received omeprazole 20 mg per day orally.
The patient’s previous delivery was significant for a low transverse cesarean delivery for an abruption placenta at term. The infant did well and she had an unremarkable course. She otherwise had a history of mild endometriosis and laparoscopy for an ovarian cystectomy.
Patient #2
This 20 year old G 3 P 0020 at 40 2/7 presented with good early dating for an outpatient cervical ripening regimen. The patient had uncomplicated Class A 1 gestational diabetes mellitus. The patient weighed 193 lbs and her fetus was in a cephalic presentation. Her cervical exam was 50% effaced, 1 cm dilation at the external os, firm, and posterior with the presenting part at -3 station.
The question was: What do these two patients have in common?
First, let me tell you a little more about our patients
Patient #1 received an amniocentesis that revealed a fluorescence polarization (FP) of 30 mg / g, which is immature. One reference laboratory’s FP ranges include
IMMATURE <= 39 MG/G
MATURE >= 55 MG/G
Results between 40-54 mg/G cannot be declared "Mature" or "Immature with the same level of confidence and should be considered "Inconclusive".
The reflex follow up test was a phosphatidyglyscerol (PG)
%PGL Trace
%Ppt.Lec. 65
%PI 27.0
LS ratio 2.4
Comment: Interpretation: Lungs are - Mature with caution if not Diabetic or 36 weeks
Soon after the PG level result returned (NB: the patient had been 36 2/7 when the amniocentesis was performed) the patient underwent a cesarean delivery for what was termed ‘extreme maternal anxiety’.
The patient delivered a 7 lb. 5 oz. with Apgars of 8 and 9. The infant developed respiratory distress and required additional respiratory support and was transferred to the neonatal intensive care unit. The mother did well and was discharged on the third post-operative day. The infant remained hospitalized in the special care nursery and was discharged on the 5 th hospital day.
Patient #2 was functional a primipara who received a 3 day cervical ripening process followed by a prolonged 2 day induction of labor. This process culminated in a cesarean delivery for prolonged 1 st stage of labor as the patient did not progress beyond 8-9 cm despite adequate contractions with oxytocin augmentation. The patient delivered a 6 lb. 15 oz. infant with Apgars of 7/8. The mother and infant initially had an unremarkable post-operative course and were both discharged afebrile on post-operative day 2.
The mother had to be re-admitted for wound care on post-operative day #6 for wound cellulitus. The patient was started on ampicillin, clindamycin, and gentamicin intravenously and spontaneously began draining purulent material from her wound. The patient remained hospitalized until post-operative day #10. At the time of this review the patient was still being followed in outpatient clinic for continued wound care 5 weeks after her surgery.
Let me summarize the clinical scenarios:
The first patient received an elective cesarean delivery for ‘extreme maternal anxiety’ with an immature lung profile at 36 weeks. (Please recall it was reported a ‘Mature with caution if not Diabetic or 36 weeks and the patient had been 36 2/7 at the time of amniocentesis) Her infant developed respiratory distress and required neonatal intensive care. The infant remained hospitalized after the mother was discharged.
The second patient underwent a cervical ripening and subsequent prolonged induction of labor with an unripe cervix. The patient ultimately received a cesarean delivery with a less than 7 lb. infant for a prolonged 1 st stage of labor. The patient developed a wound infection and required re-admission to the hospital. The patient required prolonged outpatient wound care that was not complete at the time of this review.
So, back to the question: What do these cases have in common?
The cases have two things in common:
First, the patients developed common complications of common procedures
-prolonged neonatal intensive care after premature delivery
(though in this case, iatrogenic prematurity)
-prolonged wound care after a cesarean delivery for a failed induction
(though in this case, for a non-acute indication with an unripe cervix)
Second, these both happened the during the same holiday week.
The first patient received her amniocentesis on Christmas day and second patient had the decision to begin cervical ripening made on the day before Christmas Eve.
A couple thoughts come to mind. As some move toward cesarean delivery on demand and increasingly patient directed care, we may want to reflect that at one point that our predecessors followed this dictum, in Greek "First, do no harm" becomes "Primum non nocere" in Latin.*
One could argue that in an effort to comply with these patient’s wishes to be at home with their family for the holidays, that our health system may have failed to uphold the spirit of one of its most basic principles.
OB/GYN CCC Editorial comment:
Is it ‘poor datism’ or post datism, and other issues
Considering the 2 cases above, let’s muse about elective induction of labor. In 2002, the last year for which full natality statistics were available, the labor induction rate was 20.6%. This reflects a 64% increase since 1989. Demographics reveal that induction of labor is more common in insured patients, but is rising in all groups. As more than 60% of women are in the formal work force, some degree of scheduling is desirable on economic grounds alone. The challenge is to balance patient autonomy with resource utilization and health care concerns as illustrated above.
Other positive aspects of labor induction is that is allows us to smooth the L/D work flow and as increasing number of indications for induction of labor are developing rapidly, e.g., post term vs post datism. The key calibrate our patients expectations and not to allow ourselves to misguide patients about their chance of timely delivery with an unfavorable cervix. Or put another way, to what extent do we need to allow our patient’s mother in law’s frequent flyer ticket affect our clinical practice. We should also be aware that in many cases we are inducing patients for what amounts to ‘poor datism’, rather than true post datism.
Throughout this increase in induction of labor, ACOG has not changed its criteria for elective delivery, e.g., 39 weeks by good dating parameters.**
Other issues
Elective induction: an analysis of economic and health consequences
Kaufman et al concluded: Elective induction of labor at term is not cost saving and results in a large excess of cesarean deliveries. Costs are significantly altered by the timing of the induction, parity, and cervical ripeness.
Specifically, Kaufman showed that induction of primiparas with unfavorable cervices at 39 weeks would result in an additional annual health expenditure of $ 84,000,000 and lead to another 11,000 cesarean deliveries. Depending on that primipara’s desired ultimate family size, many issues arise about future uterine rupture, scar dehiscence, and neonatal compromise. In addition, depending on the patient’s physical location, she may or may not be offered a vaginal birth after cesarean with her next pregnancy. This may have the effect of increasing her chances of subsequent placenta accreta, plus other operative complications that could lead to cesarean hysterectomy.
Routine use of sweeping of membranes from 38 weeks of pregnancy onwards
(See Midwives Corner below)
Resources:
Frequently Asked Question
Q. When should we change the estimated date of delivery (EDD) based on ultrasound?
A. There are various criteria, but once you determine an EDD, stick with it. See these helpful tips
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/USdating4606.doc
Perinatology Corner CME/CEU Modules (also just full of good resources)
Post-term Pregnancy and Induction of Labor
http://www.ihs.gov/MedicalPrograms/MCH/M/DP61.cfm#top
Vaginal Birth After Cesarean
http://www.ihs.gov/MedicalPrograms/MCH/M/VB01.cfm
** Confirmation of Term Gestation, ACOG Practice Bulletin, No. 10
- Fetal heart tones have been documented for 20 weeks by nonelectronic fetoscope or for 30 weeks by Doppler.
- It has been 36 weeks since a positive serum or urine human chorionic gonadotropin pregnancy test was performed by a reliable laboratory.
- An ultrasound measurement of the crown. rump length, obtained at 6-12 weeks, supports a gestational age of at least 39 weeks.
- An ultrasound obtained at 13-20 weeks confirms the gestational age of at least 39 weeks determined by clinical history and physical examination.
Induction of Labor ACOG Practice Bulletin NUMBER 10, NOVEMBER 1999. American College of Obstetricians and Gynecologists, Washington, D.C.
American College of Obstetricians and Gynecologists. Assessment of fetal lung maturity. ACOG Educational Bulletin 230. Washington DC: ACOG, 1996
Kaufman KE, Bailit JL, Grobman W. Elective induction: an analysis of economic and health consequences. Am J Obstet Gynecol. 2002 Oct;187(4):858-63.
*A translation of the original perhaps, but some sources attribute "Primum non nocere" to the Roman physician, Galen. http://www.geocities.com/everwild7/noharm.html
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)
Effects of Conjugated Equine Estrogen on Quality of Life
The authors conclude that oral conjugated equine estrogen does not have a clinically significant effect on health-related quality of life in women who have had a hysterectomy. They add that in the WHI study, the risks and benefits of conjugated equine estrogen use were relatively balanced at six years. They note that vasomotor symptoms will improve in some women, but this is offset by the adverse effects of hormone therapy. http://www.aafp.org/afp/20060415/tips/12.html
Brunner RL, et al. Effects of conjugated equine estrogen on health-related quality of life in postmenopausal women with hysterectomy. Arch Intern Med September 26, 2005;165:1976-86
Midwives Corner - Rosemary Bolza, CNM and Marsha L. Tahquechi, CNM
Routine use of sweeping of membranes from 38 weeks of pregnancy onwards
Cochrane Database of Systematic Review
Risk of caesarean section was similar between groups (relative risk (RR) 0.90, 95% confidence interval (CI) 0.70 to 1.15). Sweeping of the membranes, performed as a general policy in women at term, was associated with reduced duration of pregnancy and reduced frequency of pregnancy continuing beyond 41 weeks (RR 0.59, 95% CI 0.46 to 0.74) and 42 weeks (RR 0.28, 95% CI 0.15 to 0.50). To avoid one formal induction of labour, sweeping of membranes must be performed in eight women (NNT = 8). There was no evidence of a difference in the risk of maternal or neonatal infection. Discomfort during vaginal examination and other adverse effects (bleeding, irregular contractions) were more frequently reported by women allocated to sweeping. Studies comparing sweeping with prostaglandin administration are of limited sample size and do not provide evidence of benefit.
Authors' conclusions: Routine use of sweeping of membranes from 38 weeks of pregnancy onwards does not seem to produce clinically important benefits. When used as a means for induction of labour, the reduction in the use of more formal methods of induction needs to be balanced against women's discomfort and other adverse effects.
Boulvain M, Stan C, Irion O. Membrane sweeping for induction of labour. The Cochrane Database of Systematic Reviews 2005, Issue 1. Art. No.: CD000451.pub2. DOI: 10.1002/14651858.CD000451.pub2
http://www.update-software.com/publications/cochrane/
Navajo Corner, Kathleen Harner, Tuba City
Methamphetamine abuse among women on Navajo
PART II
Recognizing methamphetamine (MA) abuse is not always simple. A few weeks ago, I saw a lovely multigravid woman in the ER, at TCRHCC, bleeding with an incomplete abortion. Her husband was with her and she was clearly grieving about the pregnancy loss. He was appropriately concerned about her and attentive to her grief. When he left the ER to check on their children at home, she confided to me that he had been “doing meth” and it was affecting their marriage. She asked me if I would talk to him and urge him, for the sake of their family, to stop. Although I routinely ask patients about illicit drug use, I would never have guessed that this family had a problem. The first challenge for the practitioner is identifying the patients with a problem. Once this is done, how best to help the Gravida and her family?
One of the best opportunities to approach and intervene with the substance abusing woman is when she is pregnant. The pregnancy or the child’s birth may give her a powerful motive to seek treatment for her addiction. Early intervention efforts during the prenatal period increase the likelihood that she will successfully recover from drug abuse. It is equally important to provide the pregnant, substance abusing woman with optimal, comprehensive obstetrical care to avoid the complications of pregnancy that can occur in the abusing gravida. A continuum of follow up services is a critical element for an improved quality of life for the substance abusing woman and her family. She often lives in a stressful environment that may include physical and sexual abuse, single parenthood, and limited financial and social support. Interventions during the postnatal period are needed to help her successfully parent her child, abstain from the use of drugs, and address complex social needs.
It is a good assumption, that if a pregnant MA abuser seeks prenatal care, she is interested in ending her drug use. Health care providers have a unique opportunity during pregnancy to identify drug abusers and help them stop abusing. For a treatment program to effectively meet the needs of MA abusers, it is essential to understand the perspective of the "customer" as she approaches, enters, and participates in treatment. There are a number of entry points in the system for women who might not present directly for treatment, including:
Pediatricians (mothers will take children to the doctor even when they will not go for their own problems)
Child protective agencies
Social service agencies
Primary care providers
Criminal justice system
Two types of barriers must often be addressed concerning outreach to women who use MA. First, internal barriers to seeking treatment for substance use disorders that include guilt, depression, fear of children being taken away, and fear of partners who are using or dealing drugs must be identified and mitigated. Second, external barriers to be examined include lack of accessibility to treatment programs, need for childcare, or lack of community-based programs that prevent women from seeking treatment. Often, reducing just one barrier is enough to bring a woman into treatment. For example, treatment programs that provide childcare may have higher participation levels than those that do not. Treatment for women should involve a holistic approach.
According to the National Institute on Drug Abuse the most effective treatments for MA addiction are cognitive behavioral interventions. These approaches are designed to help modify the patient’s thinking, expectations and behaviors and to increase skill in coping with life stressors. Methamphetimine support groups are also effective adjuncts to behavioral interventions. There are no pharmacological treatments for MA abuse although antidepressant medications can be helpful in combating the depressive symptoms seen in the first few months of abstinence from the drug.
Incentives, contingent on drug abstinence are a powerful intervention tool for facilitating abstinence in cocaine and methadone maintained cocaine abusers. There is evidence that MA dependent individuals respond similarly. The aim is to decrease behaviors maintained by drug reinforcers and increase behaviors maintained by nondrug enforcers by presenting rewards.
Although some traditional drug abuse treatment elements are appropriate for MA abusers, many treatment staff feels ill prepared to address the challenges presented by MA abusers. Poor treatment engagement rates, high drop out rates, severe paranoia, high relapse rates, ongoing episodes of psychosis severe craving and anhydonia are clinical challenges that are frequently more problematic than seen with standard treatment populations. In small communities, it is often only law enforcement which has the proper skills to deal with the needs of MA abusers. Several of the clinical problems encountered by the staff working with MA abusers occur because the staff has primarily been trained in alcoholism treatment and the severe psychiatric symptomatology of MA abusers is simply beyond their scope of practice. Providing extra training to this staff is part of the solution. Involving mental health experts also helps to meet these clinical challenges.
Pregnant women pose additional challenges; in addition to intensive outpatient treatment attention must be given to providing prenatal care. It is important that the clinical staff working with pregnant women is capable of dealing with their relapses. Often there is a lack of empathy to pregnant women who are using drugs. Additionally, women with small children require an increased level of support while in treatment. The combined burdens of work, home care, childcare and family responsibilities in addition to attending treatment frequently can lead to a fatigue so profound the MA abuse may reoccur in an effort to combat exhaustion.
Stimulant users, which include MA abusers, respond well to contingency procedures and this includes drug court strategies. Drug courts are based upon the rapid and certain application of contingent consequences based upon the behavior of the drug user. Drug court participants who successfully exhibit desired behaviors can earn their way to progressively less demanding treatment regimens. Those unable to maintain a contract of desired behaviors move to more intensive levels of care or incarceration. The National Institute of Drug Abuse has demonstrated that once women enter a treatment program, the motivation to stay drug free is their children.
Next Month: The Phoenix Indian Medical Center’s approach to the substance abusing gravida
References:
The DASIS Report. Pregnant Women in Substance Abuse Treatment:2002. September 3 2004. http://www.oas.samhsa.gov/2k4/pregTX/pregTX.htm
HSTAT. SAMHSA/CSAT Treatment Improvement Protocols. http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.chapter.22442#top
Milne, D.January 2003. Experts Desperately Seeking Meth Abuse Prevention, Treatment. Psychiatric News. Vol 38 number 1. http://pn.psychiatryonline.org/cgi/content/full/psychnews;38/1/12
National Institute on Drug Abuse Research Report Series. Methamphetamine Abuse and Addiction. http://www.nida.nih.gov/ResearchReports/Methamph/Methamph.html
Principles of Drug Addiction Treatment A Research-Based Guide. NIH Publication Umber 99-4180 Printed October 1999. http://www.nida.nih.gov/PODAT/PODATindex.html
Rawson RA, Anglin MD, Ling W. Will the Methamphetamine Problem Go Away?. Journal of Addictive Diseases, Vol 21 (1) 2002.
Rawson RA, Gonzales R, Brethen P. Treatment of methamphetamine use disorders: an update. Journal of Substance Abuse Treatment 23 (2002) 145-50.
Nurses Corner - Sandra Haldane, HQE
Native American Scholarship Opportunities at the School of Nursing
Dear Colleagues:
We wished to share this important information about expanded scholarship activities for Native American nurses wishing to further their nursing education at The Catholic University of America (CUA).
Scholarship opportunities are available for BSN, MSN, RN to BSN, RN to MSN and PhD studies. The attached announcement may be circulated and reproduced on web-sites. Our goal is to have this information distributed as widely as possible so that qualified individuals may apply.
"CUA Receives $420K for Native American Scholarships
The Catholic University of America has been awarded $420,000 to use for scholarships for Catholic Native Americans who are studying nursing at the graduate level.The grant was made by the Bureau of Catholic Indian Missions, a Washington, D.C.-based Roman Catholic organization founded in 1874 for the protection and promotion of Catholic Indian missions in the United States. The money will be added to previous funds donated by the group for "The Cardinal Terence Cooke/ Bureau of Catholic Indian Missions Scholarship Fund," an endowed fund that provides tuition scholarships for academically qualified Catholic Native American applicants who belong to a tribe or have a formal association with one.
"I am grateful to the Bureau of Catholic Indian Missions and to its executive director, Monsignor Paul Lenz, for this generous grant and for the important graduate and undergraduate scholarship support it has provided to Catholic University in the past," said the Very Rev. David M. O'Connell, C.M., university president. "We share the bureau's commitment to providing an excellent university education to deserving Native American students," he added. "We're very pleased to be able to offer more scholarship money to CUA where we hope it will be used for the education of Native Americans, and Catholic Native Americans in particular," Monsignor Lenz said. "We've looked forward to this and are delighted we were able to make it happen." The Bureau of Catholic Indian Missions' board of directors includes Cardinal William Keeler of Baltimore, president; Cardinal Edward Egan of New York and Cardinal Justin Rigali of Philadelphia. In 1985 the Bureau of Catholic Indian Missions first began giving annual grants of $25,000 or $50,000 to Catholic University. In 2003, the Bureau gave a $1 million scholarship grant to CUA to support qualified undergraduates. With the most current donation, the bureau is now funding two $1 million scholarships at Catholic University - one for graduate students and the other for undergraduates."
Nalini Jairath RN PhD
Dean, School of Nursing
The Catholic University of America
202-319-5403 jairath@cua.edu
Success stories of American Indian people throughout the US needed
I would like to feature success stories on each of the handout "backs". It seems that there are many doom and gloom health stories and we're likely to capture attention and generate behavior change by featuring positive stories of success that make people feel good and inspire them to change.
If you agree with this approach, perhaps we can talk about ways to find success stories of American Indian people throughout the US.
I will call and interview people you select, probing to get the "good stuff" for a powerful testimony. After writing their story, I always call back and read the entire story to them to confirm the facts and make sure they are comfortable with what will be said about them. I also arrange to have their picture taken for the handout back, often with their family, if appropriate. Here the type of people I would like to talk to:
1. Person who l ived on soda, drinking many a day. Something happened to make him/her switch to fresh, natural, cool and inviting water. They now prefer the taste of water and enjoy saving money previously wasted on soda. (Of course, there won't be anyone with this exact story--just someone who switched from soda to water.)
2. Someone who lost weight simply by eating less food. Not dramatic changes in the type of food, but the amount.
3. Mother (or anyone) who deliberately chooses to give her family fruit rather than candy. This change could be spurred by anything--family illness, awareness, etc.
4. Someone who was raised on meat and potatoes and rarely ate vegetables but now loves them. She/he may have influenced his/her family or co-workers
to eat more veggies too. Now they crave veggies and use meat only as a compliment to the rest of the meal rather than the main plate filler.
5. Someone who used too eat super sized meals (or served super sized food to his/her children) but found that they didn't like that too full feeling. Perhaps they have a way of knowing when to stop eating and use how they feel as the gauge of when to stop eating rather than what's on the plate.
6. Someone who previously ate candy, cookies, and other extras as main fare. Veggies and fruit were eaten only occasionally. They "saw the light" and now choose to eat "treats" only occasionally, much preferring how they feel when the focus on the "good stuff" first.
Thanks. Pam McCarthy pammccarthy2@comcast.net
Office of Women's Health, CDC
April was National Child Abuse Prevention Month –MMWR article
This year's theme was Safe Children and Healthy Families are a Shared Responsibility. Communities throughout the United States held blue ribbon campaigns to promote healthy families, organizing educational fairs, and honoring parenting heroes.
Many cases of child maltreatment go unreported to authorities. However, approximately:
- 906,000 children in the United States were confirmed by child protective services as being abused or neglected in 2003, a rate of 12.4 per 1,000 children.
- Of the reported cases,
- 5% involved emotional or psychological abuse,
- 10% involved sexual abuse,
- 9% involved physical abuse, and
- 61% involved neglect
- Persistent stress … impairs development of the nervous and immune response systems
- Adverse health effects throughout their lives (e.g., suicide, obesity, smoking, alcoholism, drug abuse, depression, eating disorders, sexual promiscuity, and certain chronic diseases)
- In addition, persons who are abused as children are twice as likely to be assaulted as adults
NCAPM is an opportunity to raise awareness about child maltreatment and its devastating effects.http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5513a6.htm
Information about child maltreatment is available online from CDC at http://www.cdc.gov/injury .
NCAPM materials are available online from the U.S. Department of Health and Human Services, Administration for Children and Families, at: http://nccanch.acf.hhs.gov
IHS National Child Abuse Project http://www.ovccap.ihs.gov /
Karen CookKaren.cook@ihs.gov 505-368-6818 contact info
Oklahoma Perspective Greggory Woitte – Hastings Indian Medical Center
Female Sexual Dysfunction
Female sexual dysfunction is a common problem affecting an estimated 50-80% of postmenopausal women as well as a significant number or premenopausal women. Sexual dysfunction can take on several variations from an absence of sexual fantasies and desire for sexual activity (hypoactive sexual desire disorder) to an absence of orgasm after normal sexual excitement phase (female orgasmic disorder). As with many topics in our specialty, this taboo subject is often only discussed when asked about. Getting a good history and providing the patient with information can often alleviate some of the problems. Medications such as testosterone and hormone replacement therapy can be used but, there is limited evidence supporting widespread use of these medications. Here are a few articles that will make you more comfortable approaching this topic with your patients.
Reference:
Basson R. Clinical practice. Sexual desire and arousal disorders in women. N Engl J Med. 2006 Apr 6;354(14):1497-506.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db
=pubmed&list_uids=16598046&dopt=Abstract
Modelska K, Cummings S. Female sexual dysfunction in postmenopausal women: systematic review of placebo-controlled trials. Am J Obstet Gynecol. 2003 Jan;188(1):286-93.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=
Retrieve&db=pubmed&dopt=Abstract&list_uids=12548231
Sarrel PM. Sexual dysfunction: treat or refer. Obstet Gynecol. 2005 Oct;106(4):834-9.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd
=Retrieve&db=pubmed&dopt=Abstract&list_uids=16199644
Osteoporosis
Women need information about alternatives, risks, and benefits of hormone therapy for osteoporosis to make an informed decision, AHRQ
http://www.ahrq.gov/research/mar06/0306RA16.htm
Patient Information
Amenorrhea: What You Should Know
http://www.aafp.org/afp/20060415/1387ph.html
Perinatology Picks - George Gilson, Maternal Fetal Medicine, ANMC
Factors Associated With Rise in Primary Cesarean Births in the United States, 1991-2002
Objectives: We examined factors contributing to shifts in primary cesarean rates in the United States between 1991 and 2002.
Methods: US national birth certificate data were used to assess changes in primary cesarean rates stratified according to maternal age, parity, and race/ethnicity. Trends in the occurrence of medical risk factors or complications of labor or delivery listed on birth certificates and the corresponding primary cesarean rates for such conditions were examined.
Results: More than half (53%) of the recent increase in overall cesarean rates resulted from rising primary cesarean rates. There was a steady decrease in the primary cesarean rate from 1991 to 1996, followed by a rapid increase from 1996 to 2002. In 2002, more than one fourth of first-time mothers delivered their infants via cesarean. Changing primary cesarean rates were not related to general shifts in mothers’ medical risk profiles. However, rates for virtually every condition listed on birth certificates shifted in the same pattern as with the overall rates.
Conclusions: Our results showed that shifts in primary cesarean rates during the study period were not related to shifts in maternal risk profiles.
Declercq E, Menacker F, MacDorman M. Factors Associated With the Rise in Primary Cesarean Births in the United States, 1991-2002 Am. J Public Health. 2006; 96(5):867-872)
http://www.medscape.com/viewarticle/530786
Recurrence of hypertensive disorder in second pregnancy
CONCLUSION: Recurrence of hypertensive disorders in pregnancy is common, but not specified by type of disorder in first pregnancy. Overweight and weight gain between pregnancies are associated with recurrent hypertensive disorders in pregnancy in women with gestational hypertension. Early onset of hypertension is a risk factor, independent of body weight.
Hjartardottir S, et al Recurrence of hypertensive disorder in second pregnancy. Am J Obstet Gynecol. 2006 Apr;194(4):916-20.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd
=Retrieve&db=pubmed&dopt=Abstract&list_uids=16580276
Despite "inadequate placentation" hypothesis, preeclampsia and IUGR do not seem to be related as different aspects of the same disorder
Preeclampsia and gestational hypertension shared many risk factors, although there are differences that need further evaluation. Both conditions significantly increased morbidity and mortality. Conversely, preeclampsia and unexplained intrauterine growth restriction, often assumed to be related to placental insufficiency, seem to be independent biologic entities.
Preeclampsia, gestational hypertension and intrauterine growth restriction, related or independent conditions? Am J Obstet Gynecol. 2006 Apr;194(4):921-31
http://www.ajog.org/article/PIIS0002937805024361/abstract
Primary Care Discussion Forum
Adverse Childhood Events: Impact on chronic adult illness / Risk taking
Moderator: Andrew Hsi, M.D, University of New Mexico
Ongoing right now
Have you ever wondered where some untoward adult behaviors and chronic illness(s) come from?….perhaps they have roots in childhood?
We are lucky to have Andrew Hsi M.D., University of New Mexico, moderate a discussion on:
-Parental obesity and inactivity: Impact on childhood obesity
-Past sexual abuse: Effect on adult obesity
-Many other examples will be discussed
We will also be joined by the Indian Health Special Interest Group, AAP for this discussion
Go here:
http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForumMod.cfm#adverseEvents
How to subscribe / unsubscribe to the Primary Care Discussion Forum?
Subscribe to the Primary Care listserv
http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=51
Unsubscribe from the Primary Care listserv
http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=46&startrow=51
Questions on how to subscribe, contact nmurphy@scf.cc directly
STD Corner - Lori de Ravello, National IHS STD Program
Prediction of Pelvic Inflammatory Disease Among Young, Single, Sexually Active Women
Objectives: To assess prediction strategies for pelvic inflammatory disease (PID).
Study Design: One thousand one hundred seventy women were enrolled based on a high chlamydial risk score. Incident PID over a median of 3 years was diagnosed by either histologic endometritis or Centers for Disease Control and Prevention criteria. A multivariable prediction model for PID was assessed.
Results: Women enrolled using the risk score were young, single, sexually active, and often had prior sexually transmitted infections. Incident PID was common (8.6%). From 24 potential predictors, significant factors included age at first sex, gonococcal/chlamydial cervicitis, history of PID, family income, smoking, medroxyprogesterone acetate use, and sex with menses. The model correctly predicted 74% of incident PID; in validation models, correct prediction was only 69%.
Conclusions: Our data validate a modified chlamydial risk factor scoring system for prediction of PID. Additional multivariable modeling contributed little to prediction. Women identified by a threshold value on the chlamydial risk score should undergo intensive education and screening.
Ness RB et al. Prediction of Pelvic Inflammatory Disease Among Young, Single, Sexually Active Women. Sexually Transmitted Diseases. 33(3):137-142, March 2006.
Diagnosis and Treatment of Chlamydia trachomatis Infection
Chlamydia trachomatis infection most commonly affects the urogenital tract. In men, the infection usually is symptomatic, with dysuria and a discharge from the penis. Untreated chlamydial infection in men can spread to the epididymis. Most women with chlamydial infection have minimal or no symptoms, but some develop pelvic inflammatory disease. Chlamydial infection in newborns can cause ophthalmia neonatorum. Chlamydial pneumonia can occur at one to three months of age, manifesting as a protracted onset of staccato cough, usually without wheezing or fever. Treatment options for uncomplicated urogenital infections include a single 1-g dose of azithromycin orally, or doxycycline at a dosage of 100 mg orally twice per day for seven days. The recommended treatment during pregnancy is erythromycin base or amoxicillin. The Centers for Disease Control and Prevention and the U.S. Preventive Services Task Force recommend screening for chlamydial infection in women at increased risk of infection and in all women younger than 25 years. Am Fam Physician 2006;73:1411-6 http://www.aafp.org/afp/20060415/1411.html
Barbara Stillwater, Alaska State Diabetes Program
Long-term Dietary Intervention May Reduce Risk for Insulin Resistance in Children
Long-term, biannual dietary intervention reduces risk for insulin resistance in children, according to the results of a randomized study.
CONCLUSIONS: The long-term biannual dietary intervention decreases the intake of total and saturated fat and has a positive effect on insulin resistance index in 9-year-old children.
Kaitosaari T, et al Low-saturated fat dietary counseling starting in infancy improves insulin sensitivity in 9-year-old healthy children: the Special Turku Coronary Risk Factor Intervention Project for Children (STRIP) study. Diabetes Care. 2006 Apr;29(4):781-5.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=
Retrieve&db=pubmed&dopt=Abstract&list_uids=16567815
Insulin Sensitivity Measures Predict Preeclampsia
Conclusions: Judging from our findings, insulin sensitivity indexes (fasting homeostasis model assessment and quantitative insulin sensitivity check index are simple tests that can pinpoint impaired insulin sensitivity early in the pregnancy. Given their high sensitivity and specificity, these indexes could be useful in predicting the development of preeclampsia in early pregnancy, before the disease become clinically evident.
Parretti E, et al Preeclampsia in lean normotensive normotolerant pregnant women can be predicted by simple insulin sensitivity indexes. Hypertension. 2006 Mar;47(3):449-53.
What's new on the ITU MCH web pages?
Is a fetal ultrasound survey indicated for all patients routinely?
http://www.ihs.gov/MedicalPrograms/MCH/F/documents/USsurvey42406.doc
There are several upcoming Conferences
and Online CME/CEU resources, etc….
…or just take a look at the What’s New page
Save the dates
PUBLIC’S HEALTH & THE LAW IN THE 21 ST CENTURY
- June 12-14, 2006
- Atlanta , Georgia
http://www2a.cdc.gov/phlp/conference2006.asp
I.H.S. / A.C.O.G. Obstetric, Neonatal, and Gynecologic Care Course
- September 17 – 21, 2006
- Denver , CO
- Contact YMalloy@acog.orgor call Yvonne Malloy at 202-863-2580
- Neonatal Resuscitation Program available
- Brochure
http://www.ihs.gov/MedicalPrograms/MCH/F/documents/ACOG_06brochR1_1.pdf
2007 Indian Health MCH and Women’s Health National Conference
- August 15 -17, 2007
- Albuquerque , NM
- THE place to be for anyone involved in care of women, children
- Internationally recognized speakers
- Save the dates. Details to follow
Did you miss something in the last OB/GYN Chief Clinical Consultant Corner?
The April 2006 OB/GYN CCC Corner is available.
Hot Topics ‹ Previous
OB/GYN
Dr. Neil Murphy is the Obstetrics and Gynecology Chief Clinical Consultant (OB/GYN C.C.C.). Dr. Murphy is very interested in establishing a dialogue and/or networking with anyone involved in women's health or maternal child health, especially as it applies to Native or indigenous peoples around the world. Please don't hesitate to contact him by e-mail or phone at 907-729-3154.
