Volume 4, No. 6, June 2006
Hot Topics
Obstetrics
Point / Counterpoint: Not Yet Time to Use the P:C Ratio
The P:C ratio would at first glance seem to be an excellent short cut in the diagnosis and management of pre-eclampsia, but we have several concerns:
1) Because of the many physiologic changes that occur in pregnancy and the unique pathophysiology of pre-eclampsia, comparing the usefulness of the P:C ratio in pre-eclampsia to the management of chronic renal disease is, we feel, inappropriate.
2) The literature in pregnant women is incomplete and inconsistent but seems to indicate that P:C ratio can be used to rule OUT significant proteinuria, but is not reliable in quantifying the level of proteinuria in pregnant women with pre-eclampsia.
3) In regards to the pathophysiology of proteinuria in pre-eclampsia, we cannot assume that protein excretion from the glomerular endotheliosis is as constant as the creatinine excretion. Meaning that the excretion of protein can increase and decrease significantly over short periods of time, independent of the GFR, where the excretion of creatinine will not.
4) Despite all this, we would still endorse the use of the P:C ratio in certain clinical situations for ruling out pre-eclampsia if the cut-off is low enough to keep the sensitivity high. We might consider using the P:C ratio to make a transfer decision, but not to diagnose/treat a patient in house.(Can you imagine trying to transfer a 30 week EGA woman to a wary physician 200 miles away solely because of an elevated P:C ratio?) We suspect there would be enough other clinical information available to make the transfer decision.
5) Medico-legally, we are rolling the dice if ACOG hasn't endorsed the use of P:C ratios in diagnosing and managing pre-eclampsia.
6) In the article, we appreciated the comment about looking at the entire clinical picture. Pre-eclampsia is a sneaky disease and the appropriate treatment is typically based on the “weight of evidence”. We often hear ourselves and our colleagues after a lengthy discussion of a patient in whom we are trying to r/o pre-eclampsia say, "Does she look like she has pre-eclampsia?" It is often the most important piece of data when the diagnosis is questionable.
Overall, we are not convinced we can predict the 24-hour urine protein excretion reliably with the P:C ratio in both the 120 kg 40 y/o diabetic woman and the 45 kg 16 y/o woman. Also, the pursuit seems academic. We haven't seen a patient go from questionable pre-eclampsia to a disease state that doesn't allow for transfer while waiting for a 24-hour urine. We know that pre-eclampsia can progress rapidly and all of us have seen people go from mild to severe to seizures over a short period of time, but we are usually not surprised by the rapid progression. It would seem that the major reason for promoting the use of P:C ratio in pregnancy is simply to avoid the hassle (for patient and clinician) of collecting and waiting for the results of the venerable 24-hour urine protein quantification. Unfortunately, for the reasons outlined above, we do not believe that this is clinically appropriate or supported by the current data.
David Gahn, Hastings Indian Medical Center
Eric Manske, Gallup Indian Medical Center
OB/GYN CCC Editorial comment:
I want to thank David Gahn and Eric Mankse for this thoughtful counterpoint to the April CCCC Abstract of the Month, ‘Protein to Creatinine Ratio in Pre-eclampsia: Is the data preceding the U.S. benchmarks? ‘ with Comments by Jonathan Steinhart and Jean Howe.
http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0406_AOM.cfm
I would like to clarify two other points that were raised in the wake of that Abstract of the Month.
First, the original systematic review by Price et al, suggested that the P:C had it greatest value in the P:C’s ability to ‘rule out’ significant proteinuria, i.e. one were emphasizing the negative predictive value. “Most importantly, we have shown that the protein: creatinine ration for a random urine sample (particularly with adjustment of the test threshold to a lower value) might be used to rule out the presence of significant proteinuria as defined by a quantitative measure of the 24-h protein excretion. Use of the ration negates the uncertainty associated with the use of dilute or concentrated urine...When results above the cutoff value for the protein:creatinine ration are obtained, a full 24-h urine collection and quantification are indicated."
From a logistics viewpoint, there is enough evidence to use the P:C to rule out the disease. That way one can let the patient go home without the delay of being admitted and doing the collection, which as we agree gives very variable results. If the P:C value is over 0.2, then they should probably have further evaluation. Also, as Sibai has demonstrated in several papers, while the presence of proteinuria is what enables us to make the diagnosis, the amount of proteinuria is not associated with either maternal or infant outcome.
Secondly, here was another important comment from one of our readers….
“ You state in passing that “ as we currently recommend the use of daily aspirin therapy in patients with previous severe pre-eclampsia”; I am unaware that this is a currently endorsed strategy for prevention of preeclampsia in this country, given the large multicenter trials disproving this intervention (e.g., NEJM 1998; 338:701-05. Caritis et al “low-dose aspirin to prevent preeclampsia in women at high risk”). Though the Cochrane review of 42 trials does show a small benefit.
What source(s) do you have? “
Yes, we have been recommending low dose ASA on our Indian Health national guidelines website for a small group of high risk patients for a while now.
-Chronic HTN
-Past severe pre-eclampsia
-Renal disease
-Pre-existing Diabetes
IHS Guidelines page
http://www.ihs.gov/NonMedicalPrograms/nc4/index.cfm?module=clinguid
Hypertension in Pregnancy Guidelines
http://www.ihs.gov/NonMedicalPrograms/nc4/Documents/HYPERT12004.doc
Yes, it is based on the Cochrane Review below, though the content was actually brought to our attention by the IHS Nephrology Chief Clinical Consultant prior to that.
Knight M, Duley L, Henderson-Smart DJ, King JF. Antiplatelet agents for preventing and treating pre-eclampsia. The Cochrane Database of Systematic Reviews 2000, Issue 2. Art. No.: CD000492. DOI: 10.1002/14651858.CD000492.
http://www.update-software.com/publications/cochrane/
New campaign materials released to help GDM patients prevent or delay Type 2 Diabetes
It's Never Too Early to Prevent Diabetes, the latest diabetes prevention campaign message by the National Diabetes Education Program, is spreading the word about the risk of type 2 diabetes faced by women with a history of gestational diabetes mellitus (GDM) and their children.
The message is part of Small Steps. Big Rewards. Prevent type 2 Diabetes, the nation's first comprehensive multicultural type 2 diabetes prevention campaign. The campaign offers materials that can help women with a history of GDM take steps to prevent or delay type 2 diabetes and help their children lower their risk for the disease.
Available campaign materials include a tip sheet in English and Spanish for women who have had GDM, a tip sheet in English and Spanish for children at risk for type 2 diabetes, and a booklet for adults to help women and their families make healthy food choices and be more physically active to prevent or delay type 2 diabetes. These materials are available at http://www.ndep.nih.gov/campaigns/SmallSteps/SmallSteps_nevertooearly.htm
Prenatal Weight Gain Recommendations - Obesity in Pregnancy
One third of adult women in the United States are obese. During pregnancy, obese women are at increased risk for several adverse perinatal outcomes, including anesthetic, perioperative, and other maternal and fetal complications. Obstetricians should provide preconception counselling and education about the possible complications and should encourage obese patients to undertake a weight reduction program before attempting pregnancy. Obstetricians also should address prenatal and peripartum care considerations that may be especially relevant for obese patients, including those who have undergone bariatric surgery.
Women who are obese (i.e., those with a body mass index [BMI] of 30 kg per m2 or greater) are at increased risk of complications of pregnancy such as gestational hypertension and diabetes, preeclampsia, fetal macrosomia, spontaneous abortion, cesarean delivery, neural tube defects in the fetus, and stillbirth. Estimation of fetal weight and interpretation of external fetal heart rate and patterns of uterine contraction also may be problematic in women who are obese. Infants who are large for their gestational age are more common in mothers who are obese, and these infants subsequently are at increased risk of childhood obesity. In addition, operative and postoperative complications such as excessive blood loss, longer operative time, wound infection, endometritis, and anesthetic challenges are more common in obese patients.
ACOG strongly encourages preconception assessment and counseling of women who are obese, with provision of education about the risks and potential complications for mother and fetus. Nutrition advice should be provided, and patients should be encouraged to make changes in diet and exercise before pregnancy is attempted. Weight loss also should be encouraged before initiation of infertility treatment because of the increased risk of spontaneous abortion in obese women who undergo this therapy. Counseling and exercise programs should continue after delivery.
Women who have had bariatric surgery should be counseled to avoid pregnancy during the postsurgery phase of rapid weight loss. Pregnant women who have had bariatric surgery should have levels of vitamin B12, folate, iron, and calcium assessed to determine whether supplementation is necessary.
Prenatal weight gain recommendations should correspond to the Institute of Medicine guidelines: BMI below 25 kg per m 2 25 to 35 lb (11.4 to 15.9 kg)
BMI of 25 to 29 kg per m 2 15 to 25 lb (6.8 to 11.4 kg)
BMI of 30 or greater kg per m 2 15 lb (6.8 kg)
In pregnant women who are obese, screening for gestational diabetes should be considered at presentation or in the first trimester, with screenings repeated throughout pregnancy if the results are negative.
Because of the increased likelihood of cesarean delivery and complications of surgery, ACOG recommends that pregnant women who are obese have an anesthesiology consultation before delivery. Because of the increased risk of wound breakdowns and infections in obese patients, antibiotic prophylaxis should be given if cesarean delivery is required. The use of graduated compression stockings, hydration, and early mobilization may be helpful during and after cesarean delivery. http://www.aafp.org/afp/20060415/practice.html
ACOG Committee Opinion number 315, September 2005. Obesity in pregnancy. Obstet Gynecol. 2005 Sep;106(3):671-5.
Preconception Care: Recommendations to Improve Health of Babies and Moms, CDC
The Centers for Disease Control and Prevention (CDC), in collaboration with more than 35 federal, public and private partners, today released national recommendations designed to encourage women to take steps toward good health before becoming pregnant.
http://www.cdc.gov/od/oc/media/pressrel/r060420b.htm
The preparers of this report analyzed the National Ambulatory Medical Care Survey and demonstrated that diabetes affects approximately 1.85 million (21 per 1,000) women in the United States aged 18--44 years, and that
- Preconceptional diabetes management has the potential to reduce the risk for pregnancy loss and congenital malformation for approximately 113,000 births per year.
- Anti-epileptic/antiseizure drugs are prescribed for approximately 1 million women (19 per 1,000), potentially affecting an estimated 75,000 pregnancies.
- Approximately 7 million (125 per 1,000) women of childbearing age are frequent drinkers, and without preconception interventions, alcohol misuse might affect approximately 577,000 births per year.
- Women with chronic medical conditions and their specialty providers should take advantage of every opportunity to discuss preconception health and risks.
These conditions and risk factors affect substantial proportions of the approximately 4 million pregnancies that occur in the United States each year. (J Thierry Note: 42,000 AIAN)
Four goals
1) improve the knowledge and attitudes and behaviors of men and women related to preconception health
2) assure that all women of childbearing age in the United States receive preconception care services (i.e., evidence-based risk screening, health promotion, and interventions) that will enable them to enter pregnancy in optimal health
3) reduce risks indicated by a previous adverse pregnancy outcome through interventions during the interconception period, which can prevent or minimize health problems for a mother and her future children; and
4) reduce the disparities in adverse pregnancy outcomes.
Patients are exposed to chronic conditions and or consume substances that can have an adverse effect on pregnancy outcomes, leading to pregnancy loss, infant death, birth defects, or other complications for mothers and infants. For example, in 2002, approximately 6% of adult women aged 18--44 years had asthma, 50% were overweight or obese, 3% had cardiac disease, 3% were hypertensive, 9% had diabetes, and 1% had thyroid disorder (44). Dental caries and other oral diseases also are common (>80% of women aged 20--39 years) and associated with complications for women and infants. …..Social determinants of women's health also play a role in pregnancy outcomes. The health status of minority women with low incomes contributes to persistent, and sometimes increasing, disparities in birth outcomes. In one study, the reduced overall health status (including poorer physical and emotional health) of women with low income during the month before pregnancy was associated with an increased risk for preterm labor. Socioeconomic status directly and indirectly influences three major determinants of health: health-care access, environmental exposure, and health behavior. Racial inequalities in access to effective treatment also influence these determinants of pregnancy outcomes for women and infants Existing clinical practice guidelines (e.g., AAP and ACOG).
- Isotretinoins. Use of isotretinoins (e.g., Accutane®) in pregnancy to treat acne can result in miscarriage and birth defects. Effective pregnancy prevention should be implemented to avoid unintended pregnancies among women with childbearing potential who use this medication.
- Alcohol misuse. No time during pregnancy is safe to drink alcohol, and harm can occur early, before a woman has realized that she is or might be pregnant. Fetal alcohol syndrome and other alcohol-related birth defects can be prevented if women cease intake of alcohol before conception.
- Anti-epileptic drugs. Certain anti-epileptic drugs are known teratogens (e.g., valproic acid). Recommendations suggest that before conception, women who are on a regimen of these drugs and who are contemplating pregnancy should be prescribed a lower dosage of these drugs.
- Diabetes (preconception). The three-fold increase in the prevalence of birth defects among infants of women with type 1 and type 2 diabetes is substantially reduced through proper management of diabetes.
- Folic acid deficiency. Daily use of vitamin supplements containing folic acid has been demonstrated to reduce the occurrence of neural tube defects by two thirds ( 83--88).
- Hepatitis B. Vaccination is recommended for men and women who are at risk for acquiring hepatitis B virus (HBV) infection. Preventing HBV infection in women of childbearing age prevents transmission of infection to infants and eliminates risk to the woman of HBV infection and sequelae, including hepatic failure, liver carcinoma, cirrhosis, and death.
- HIV/AIDS. If HIV infection is identified before conception, timely antiretroviral treatment can be administered, and women (or couples) can be given additional information that can help prevent mother-to-child transmission.
- Hypothyroidism. The dosages of Levothyroxine® required for treatment of hypothyroidism increase during early pregnancy. Levothyroxine® dosage needs to be adjusted for proper neurologic development of the fetus.
- Maternal phenylketonurea (PKU). Women diagnosed with PKU as infants have an increased risk for delivering neonates/infants with mental retardation. However, this adverse outcome can be prevented when mothers adhere to a low phenylalanine diet before conception and continue it throughout their pregnancy.
- Rubella seronegativity. Rubella vaccination provides protective seropositivity and prevents congenital rubella syndrome.
- Obesity. Adverse perinatal outcomes associated with maternal obesity include neural tube defects, preterm delivery, diabetes, cesarean section, and hypertensive and thromboembolic disease. Weight loss before pregnancy reduces these risks). Appropriate weight loss and nutritional intake before pregnancy reduces these risks.
- Oral anticoagulant. Warfarin, which is used for the control of blood clotting, has been demonstrated to be a teratogen. To avoid exposure to warfarin during early pregnancy, medications can be changed to a nonteratogenic anticoagulant before the onset of pregnancy.
- STD. Chlamydia trachomatis and Neisseria gonorrhoeae have been strongly associated with ectopic pregnancy, infertility, and chronic pelvic pain. STDs during pregnancy might result in fetal death or substantial physical and developmental disabilities, including mental retardation and blindness. Early screening and treatment prevents these adverse outcomes.
- Smoking. Preterm birth, low birthweight, and other adverse perinatal outcomes associated with maternal smoking in pregnancy can be prevented if women stop smoking before or during early pregnancy. Because only 20% of women successfully control tobacco dependence during pregnancy, cessation of smoking is recommended before pregnancy. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5506a1.htm
Preconception care - Patient and provider education CDC website
http://www.cdc.gov/ncbddd/preconception/default.htm
Strategies and outcome of Infant Mortality Reviews in the Aberdeen Area of the IHS
The authors set out to determine the cause and manner of deaths in the Aberdeen Area of the Indian Health Service from 1998 to 2002 and identify risk markers for infant mortality. They found that Sudden Infant Death Syndrome was the leading cause of infant death and accounted for 33% of infant deaths. Prematurity was the second leading cause and accounted for 22% of infants. The authors also found that infant mortality was recurrent; 32% of mothers of a deceased infant had another infant death.
The authors note that participation of tribal team members provides an important cultural and community perspective. The authors conclude that the reviews have been very helpful in public education. They say that quality improvement actions are underway on substance abuse, mental health/bereavement issues and reviews of fetal deaths.
Eaglestaff, ML et al. Infant Mortality Reviews in the Aberdeen Area of the Indian Health Service: Strategies and Outcomes. Public Health Reports. Volume 121 (March/April 2006) pp 140 - 148.
OB/GYN CCC Editorial comment:
Kudos to the Aberdeen Area Perinatal and Infant Mortality Review (PIMR) Team!
Above is another article published in a national peer review journal that illustrates the excellent work the PIMR team is accomplishing. All Indian Health Areas and tribes should use the success of the Aberdeen Area as benchmark for best practice.
An important outcome of the PIMR has been the routine examination of infant deaths and the realization that patterns of risk factors are present," conclude the authors, adding that "additional research is urgently needed to determine why the rate of SIDS remains high in the AAIHS."
"By examining the data by cause of and age at death, we found significant differences that may be useful to other groups who are considering development of an infant death review committee," state the authors of an article published in the March-April 2006 issue of Public Health Reports. The Aberdeen Area Indian Health Service (AAIHS) has higher rates of infant mortality, especially of post-neonatal infant mortality, when compared to the overall U.S. rate and the overall Indian Health Service (IHS) rate. To improve the classification of the cause and manner of infant death and to identify preventable causes of infant death, the Aberdeen Area Perinatal and Infant Mortality Review (PIMR) was established. The article reports data on 5 consecutive years of infant death reviews from the AAIHS PIMR. A discussion of the benefits of a systematic infant mortality review in communities with high infant mortality rates is also included.
Data for the review were drawn from death certificates sent by the four states in the AAIHS and from information that IHS service units and committee members identified by reviewing obituaries from multiple regional newspapers, death certificates by race, and reports from regional referral centers. Case reviews for 148 consecutive infant deaths from 1998 to 2002 were examined as summary data for the total group, by mortality category, and by three age-of-death categories.
The authors found that
* Nearly two-thirds of the infants who died were males (ratio: 1.8 to 1).
* Nearly one-third of the infants (32%) had a previous sibling death.
* The PIMR attributed 22% of the deaths to prematurity and 33% to SIDS.
* Infants who died from prematurity had significantly lower birthweights, shorter gestation, and younger age at death than infants who died from SIDS or other causes. Mothers of infants who died from prematurity had significantly fewer prenatal visits than mothers of infants who died from SIDS or other causes.
* Mothers of infants who died from SIDS were more likely to have begun prenatal care after the first trimester than mothers of infants who died from prematurity or other causes.
* Birthweights were significantly lower and gestation significantly shorter for infants who died in the first 3 weeks of life, compared with infants who died at older ages. Mothers of infants who died in the first 3 weeks of life had significantly fewer prenatal visits.
* Autopsies and death scene investigations were more likely to have been completed for older infants.
Eaglestaff ML, Klug MG, Burd L. 2006. Infant mortality reviews in the AAIHS. Public Health Reports (121(2):140-147.
Full text available to subscribers at http://www.publichealthreports.org/userfiles/121_2/121140.pdf
Early Glucose Challenge Testing Identifies Diabetes Versus Gestational Diabetes
In women in whom prenatal care is the first medical care they receive, screening for gestational diabetes before they are 24 weeks pregnant could help identify those with pre-gestational diabetes mellitus.
A 1-hour glucose challenge test was performed at the first visit in women obtaining prenatal and delivery care. If the test was positive, further appropriate testing was undertaken, then subsequent testing at 24 to 28 gestational weeks, if necessary.
Data collected included age, parity, ethnicity, body mass index, gestational age at delivery, fetal weight and mode of delivery.
A total of 756 patients were eligible for enrollment, and average gestational age at first visit was 14 2/7 weeks. Subjects were predominantly Hispanic or South Asian.
Gestational diabetes was diagnosed in 6.7%. Of these patients, 64.7% had an abnormal first visit test (P <.05) and 45% were diagnosed with gestational diabetes based on their early screening test alone.
Maternal ages were significantly higher and birth weights lower in women with abnormal first-visit glucose challenge tests than screen-negative controls (P <.04). Almost 50% of gestational diabetics were South Asian, and more South Asians were diagnosed with gestational diabetes based on early screening tests alone.
Certain populations are at increased risk of pre-gestational diabetes mellitus. In pregnancy, it's important to know whether this is the case because the mothers are at higher risk of preterm labor, and newborns [are at risk] of fetal demise or congenital abnormalities. Gestational diabetes does not carry such a serious risk profile."
Venkatachalam S. Utility of the 1-Hour Glucose Challenge Test at the First Prenatal Visit to Screen for Pregestational Diabetes. Abstract p. 37S, 54th Annual Clinical Meeting of the American College of Obstetricians and Gynecologists (ACOG).
http://www.acog.com/acm/program/welcome.cfm
OB/GYN CCC Editorial comment:
These results from a retrospective review performed at an inner-city public hospital confirm the Indian Health procedure that recommends that certain high risk groups may benefit from earlier screening. As part of the 1993 ACOG Consultation* it was discussed that AI/AN women be screened at their first visit and again at 24- 28 weeks. Another aspect is that in certain high risk AI/AN populations, e.g., over 7 % diabetes in pregnancy, may consider one step screening / diagnostic test with a 3 hour OGTT.
*GDM: Can we proceed directly to one step screening / diagnosis in AI / AN women?
http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0306_HT.cfm#ob
Vitamins C and E does not reduce preeclampsia, IUGR, restriction, or death
CONCLUSIONS: Supplementation with vitamins C and E during pregnancy does not reduce the risk of preeclampsia in nulliparous women, the risk of intrauterine growth restriction, or the risk of death or other serious outcomes in their infants.
Rumbold AR, et al Vitamins C and E and the risks of preeclampsia and perinatal complications. N Engl J Med. 2006 Apr 27;354(17):1796-806.
Editorial
Antioxidants and the prevention of preeclampsia--unresolved issues. Jeyabalan A
Grants Being Distributed: Methamphetamine Pregnancy/Postpartum
See grant announcement. For additional information and to apply, you may access
Gynecology
FDA: Vaccine to Prevent Cervical Cancer Is Safe, Effective
The U.S. Food and Drug Administration Advisory Panel endorsed Merck's Gardasil vaccine against the four strains of human papillomavirus (HPV) responsible for 70 percent of cervical cancer cases. Questions remain as to whether the vaccine's effectiveness could be "offset" by the fact that it does not protect against all cervical cancer-causing HPV strains and congenital anomalies found in some infants born to women who received the vaccine near the time of conception. If approved as expected, the vaccine will be the first to protect against cervical cancer.
The American Cancer Society predicts that about 9,710 new cases of invasive cervical cancer will occur in the United States in 2006 and calculate that about 3,700 women will die from this disease this year. Globally, HPV causes about 470,000 cases of cervical cancer per year, according to the World Health Organization. Many adolescents, adults and health care providers have a limited understanding of HPV infections, particularly those that are sexually transmitted. Individuals must understand these issues to make informed decisions about the new vaccines. The media will play an exceptionally important role in the public's understanding of the issues surrounding HPV and the vaccines.
National Network for Immunization Information
http://www.immunizationinfo.org/
CDC Facts HPV accine
http://www.cdc.gov/std/hpv/STDFact-HPV-vaccine.htm
Amenorrhea: Evaluation and Treatment (also see Patient Education)
A thorough history and physical examination as well as laboratory testing can help narrow the differential diagnosis of amenorrhea. In patients with primary amenorrhea, the presence or absence of sexual development should direct the evaluation. Constitutional delay of growth and puberty commonly causes primary amenorrhea in patients with no sexual development. If the patient has normal pubertal development and a uterus, the most common etiology is congenital outflow tract obstruction with a transverse vaginal septum or imperforate hymen. If the patient has abnormal uterine development, müllerian agenesis is the likely cause and a karyotype analysis should confirm that the patient is 46,XX. If a patient has secondary amenorrhea, pregnancy should be ruled out. The treatment of primary and secondary amenorrhea is based on the causative factor. Treatment goals include prevention of complications such as osteoporosis, endometrial hyperplasia, and heart disease; preservation of fertility; and, in primary amenorrhea, progression of normal pubertal development. Am Fam Physician 2006;73:1374-82, 1387
http://www.aafp.org/afp/20060415/1374.html
Child Health
Relationship between team sport participation and adolescent smoking
The present study provides the first evidence of interacting effects of environmental influences with specific genetic variants on adolescent smoking progression. Experimentation with cigarette smoking usually begins in adolescence. Some, although not all, adolescents who experiment with cigarettes progress to a regular smoking habit. Environmental or behavioral factors, such as physical activity, seem to account for some of the variability in adolescent smoking progression.
* Physical activity had a significant negative effect on smoking, but only for adolescents with team sport participation. The between-group difference in the effect of physical activity on smoking was significant.
*For adolescents participating in at least one team sport, having one and two risk genotypes had a positive effect on physical activity.
* For adolescents with no team sport participation, neither risk genotype had a significant effect on physical activity.
* The difference in the effect of smoking risk genotype on physical activity between the groups was significant for one and two risk genotypes.
* For adolescents involved in at least one team sport, neither smoking risk genotype had a significant direct effect on smoking; the effect was indirect through physical activity. The indirect effect of one and two smoking risk genotypes on smoking progression through physical activity was significant.
* There was not a significant indirect effect of one and two smoking risk genotypes on smoking progression through physical activity for adolescents without team sport participation, although a direct effect approached significance, indicating an increased risk of smoking progression by the end of 12th grade for adolescents with one and two risk genotypes.
….because adolescent smoking often results in long-term smoking in adulthood, the medical and economic impact of preventing and reducing youth smoking could be significant.
Audrain-McGovern J, Rodriguez D, Wileyto EP, et al. 2006. Effect of team sport participation on genetic predisposition to adolescent smoking progression. Archives of General Psychiatry 63(4):433-441. http://archpsyc.ama-assn.org/cgi/content/abstract/63/4/433
Prevalence of diabetes and impaired fasting glucose levels among U.S. adolescents
This study does provide evidence that the prevalence of type 2 diabetes and impaired fasting glucose level is substantial among U.S. adolescents. Nationally representative data to monitor diabetes trends among adolescents (ages 12-19) are not available.
* In the full sample, 18 adolescents (0.5%) reported having diabetes, equivalent to a population-based weighted sample of 134,071 adolescents.
* Among adolescents who reported having diabetes, approximately 8 (29%) were categorized as having type 2 diabetes, equivalent to a population-based weighted sample of 39,005 adolescents.
* In the subsample (adolescents without self-reported diabetes who had fasted for at least 8 hours), approximately 178 adolescents (11%) were categorized as having impaired fasting glucose levels, equivalent to a population-based weighted sample of 2,769,736 adolescents.
These findings have important implications for public health because of the high rate of conversion from impaired fasting glucose level to type 2 diabetes in adults, and the increased risk of cardiovascular disease among adults with type 2 diabetes," states the author. The author concludes that "these data provide a compelling rationale for prevention of diabetes and impaired fasting glucose levels among adolescents in the U.S. population."
Duncan GE. 2006. Prevalence of diabetes and impaired fasting glucose levels among U.S. adolescents: National Health and Nutrition Examination Survey, 1999-2002. Archives of Pediatrics and Adolescent Medicine 160(5):523-528 http://archpedi.ama-assn.org/cgi/content/abstract/160/5/523
Sudden, Unexplained Infant Death Initiative
Summary
- Rates of SIDS among American Indian infants are almost three times higher than SIDS rates among white infants.
- CDC’s Division of Reproductive Health, in collaboration with partners, launched the Sudden, Unexplained Infant Death Initiative in 2004 to address these problems and to improve and standardize infant death scene investigations and cause-of-death reporting. Its objectives are to revise the 1996 Sudden, Unexplained Infant Death Investigation Reporting Form (SUIDIRF) and to develop a standard training curriculum and materials for those who investigate and determine causes of death.
- Revision of the 1996 SUIDIRF: In 2004, a work group that included medical examiners, coroners, death scene investigators, researchers, and groups of SIDS parents worked with CDC to revise the 1996 SUIDIRF. Two key members of this team -- a forensic pathologist and a Federal Bureau of Investigation (FBI) agent who coordinates infant death investigations – have experience working in AI/AN communities.
- At the October 2005 NIHB Tribal Public Health Workshop in Phoenix, Arizona, Dr. Terry Davis of CDC provided information to attendees about CDC’s SUID Initiative and plans to offer training for infant death scene investigators in AI/AN communities.
- Plan is to develop training vignettes that address issues specific to infant death scene investigations in AI/AN communities. CDC is seeking assistance and input on these from the AI/AN community. http://www.cdc.gov/SIDS/SUIDactivites.htm
- (if you submit any vignettes to Terry – please cc jthierry@ihs.gov )
Dr. Terry Davis at email: ddu8@cdc.gov or phone:770-488-6259 directly
Terry can answer any and all questions on the logistics of the regional training for state teams and approaches being considered for AIAN Tribes and communities and their jurisdictions.
Tool Kit on Teaching and Assessment children with Special needs
This Tool Kit … current and relevant information about practices that will improve and enhance education opportunities for students with disabilities throughout the nation. Office of Special Education and Rehabilitative Services (OSERS), U.S. Department of Education
http://www.osepideasthatwork.org/toolkit/ovr_intro.asp
SIDS/Infant Death Resource Center is looking for materials
The Health Resources and Services Administration (HRSA), Maternal and Child Health Bureau (MCHB), National SIDS/Infant Death Resource Center is developing a searchable electronic resource compendium where professionals and consumers can access information on sudden infant death syndrome (SIDS), other infant death, miscarriage, and stillbirth, in the areas of risk reduction and bereavement support. The resource compendium will be available on the NSIDRC Web site at www.sidscenter.org . The compendium includes links to electronic versions of publications such as fact sheets, brochures, booklets, posters, order forms, and electronic materials in CD/DVD/video format (including foreign-language materials). The Resource Compendium offers professionals and consumers a topical index that is sorted and searchable by keyword and by organization.
The Resource Compendium can assist you to increase the visibility of your publications. As a result, participating organizations may see an opportunity for collaboration with the author of a certain publication of interest.
If you would like to contribute your organization’s publications to the compendium, the materials must currently be online in either HTML, PDF, or Word format.
8280 Greensboro Drive, Suite 300
McLean , VA 22102
866.866.7437 (toll-free) Fax: 703.821.2098
703.902.1249 http://www.sidscenter.org
National Asthma Education and Prevention Program recommend inhaled corticosteroids
Guidelines from the National Asthma Education and Prevention Program recommend inhaled corticosteroids or another daily long-term control medication in older children and adults with persistent asthma to prevent symptoms and quick-relief medication such as inhaled bronchodilator to treat acute asthma symptoms if they occur. The results of the PEAK study provide strong support for extending the use of inhaled corticosteroids, for the same reasons, to pre-school children at high risk for asthma.
Resources
Guidelines for the Diagnosis and Management of Asthma -- Update on Selected Topics 2002,
http://www.nhlbi.nih.gov/guidelines/asthma/index.htm
National Asthma Education and Prevention Program
http://www.nhlbi.nih.gov/about/naepp/index.htm
Asthma Information for Patients and the General Public
http://www.nhlbi.nih.gov/health/public/lung/index.htm
Prevention of Early Asthma in Kids
http://www.asthma-carenet.org/clinicaltrials/peak.html
Inhaled Steroids Safe and Effective for Children with Asthma, NHLBI
http://www.nhlbi.nih.gov/new/press/oct11-00.htm
Chronic Disease and Illness
Caring for Patients After Bariatric Surgery
Bariatric surgery leads to sustainable long-term weight loss and may be curative for such obesity-related comorbidities as diabetes and obstructive sleep apnea in severely obese patients. The Roux-en-Y gastric bypass has become the most common procedure for patients undergoing bariatric surgery. The procedure carries a mortality risk of up to 1 percent and a serious complication risk of up to 10 percent. Indications include body mass index of 40 kg per m2 or greater, or 35 kg per m2 or greater with serious obesity-related comorbidities (e.g., diabetes, obstructive sleep apnea, coronary artery disease, debilitating arthritis). Pulmonary emboli, anastomotic leaks, and respiratory failure account for 80 percent of all deaths 30 days after bariatric surgery; therefore, appropriate prophylaxis for venous thromboembolism (including, in most cases, low-molecular-weight heparin) and awareness of the symptoms of common complications are important. Some of the common short-term complications of bariatric surgery are wound infection, stomal stenosis, marginal ulceration, and constipation. Symptomatic cholelithiasis, dumping syndrome, persistent vomiting, and nutritional deficiencies may present as long-term complications. Am Fam Physician 2006;73:1403-8 http://www.aafp.org/afp/20060415/1403.html
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OB/GYN
Dr. Neil Murphy is the Obstetrics and Gynecology Chief Clinical Consultant (OB/GYN C.C.C.). Dr. Murphy is very interested in establishing a dialogue and/or networking with anyone involved in women's health or maternal child health, especially as it applies to Native or indigenous peoples around the world. Please don't hesitate to contact him by e-mail or phone at 907-729-3154.
