Volume 4, No. 6, June 2006
From Your Colleagues
Carolyn Aoymana, HQE
Management of Eating Disorders Webcast on July 18, 2006 - Save the Date
This national webcast will feature presentations based on the April 2006 “Management of Eating Disorders Evidence Report” funded by the Agency for Healthcare, Research and Quality, National Institutes of Health, Office of Research on Women’s Health & the Health Resources and Services Administration, in collaboration with Research Triangle Institute (RTI)-UNC Evidence-Based Practice Center. The registration website www.mchcom.com can begin to take registrants now
Abstract for the full report http://www.ahrq.gov/clinic/tp/eatdistp.htm
National Conference on women, addiction, and recovery
July 12 – 14, 2006
Anaheim , CA
News You Can Use brings together so many women’s issues and perinatal exposure issues; discussed inside of research, treatment services and program evaluation including:
- gender specific applications
- trauma informed systems
- eating disorders
- justice system issues
- tobacco
- underage drinking
- hiv/aids prevention and testing
- family treatment models
- strengthening the treatment continuum and improving continuity of care
- Impact of parental AOD use on children and interventions for children.
http://conferences.jbs.biz/womensconference/
Burt Attico, Phoenix
Injectable Contraception and Skeletal Health: No fractures seen
Question
Should it be standard clinical practice to perform baseline bone density studies in young women starting Depo-Provera and to continue follow-up studies periodically thereafter?
Maj Joyce Fiedler, MD
Injectable contraception (depot medroxyprogesterone acetate [DMPA], Depo-Provera) is used by approximately 2 million women in the United States, including 4 million adolescents, and has been associated with declining rates of unintended pregnancy and abortion in teens. Contraceptive doses of DMPA suppress ovarian production of estradiol and, accordingly, lower bone mineral density (BMD) during use. Concern that long-term use of DMPA might increase future risk of osteoporotic fractures led the US Food and Drug Administration to add a black box warning to the package labeling for DMPA in 2004. The warning states that injectable contraception should be continued for more than 2 years only if other birth control methods are inadequate and suggests that dual x-ray absorptiometry (DXA) studies might be used to monitor BMD in DMPA users.
No studies have found evidence of osteoporosis or fractures in DMPA users. Cross-sectional studies have found no evidence of reduced BMD or osteoporosis years after use of DMPA. Cohort studies conducted in the United States in adolescent and adult women have shown complete recovery of BMD after discontinuation of DMPA. Supplementation with menopausal doses of estrogen (eg, conjugated equine estrogen 0.625 mg daily or transdermal estrogen 0.05 mg patches) during DMPA use prevents any loss of BMD during DMPA use.
Given the above observations, skeletal health concerns should not restrict use of DMPA. In very long-term users who may continue use of DMPA into menopause, supplemental estrogen as described in the previous paragraph can be considered. I do not believe that routine DXA testing in premenopausal women who use DMPA is appropriate because it is not likely to provide clinical benefit.
Kaunitz AM. Depo-Provera's Black Box: time to reconsider? Contraception. 2005;72:165-167
Donald Clark, Albuquerque
What is the rate of preterm birth in Native Americans?
Native Americans have the second highest rate of preterm birth, as per Peristats from March of Dimes. During 2001-2003 (average) in the United States, preterm birth rates were highest for black infants (17.7%), followed by Native Americans (13.2%), Hispanics (11.6%), whites (11.0%) and Asians (10.4%).
Here is a link to helpful graph from the March of Dimes Perinatal Stats site
http://www.marchofdimes.com/peristats/level1.aspx?
reg=99&slev=1&top=3&stop=63&obj=1&lev=1&dv=cg
(I just searched by race and the whole country)
OB/GYN CCC Editorial comment:
The Peristats is a great resource provided the March of Dimes. You can create your own search by various geographic or other demographic parameters. Go to the link below create your own queries to see its many dimensions. http://www.marchofdimes.com/peristats/default.aspx
In addition, as the AI/AN population has high rates of tobacco use, the additional information on periodontal disease may let us to better sculpt our effort to improve the AI/AN infant, neonatal, and postneonatal deaths and mortality rates shown below. (Table A)
Other resources on our MCH web site
Preterm labor resources, multiple
http://www.ihs.gov/medicalprograms/mch/M/Pr01.cfm#PretermLabor
Preterm labor and Preterm Rupture of membranes: CEU/CME module – or just a great resource
http://www.ihs.gov/MedicalPrograms/MCH/M/PretermLaborandPreterm.cfm
Impact of oral disease on preterm birth
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/oralsystemicMCH7-04.ppt
Infant Mortality Statistics from the 2003 Period Linked Birth/Infant Death Data Set
T.J. Mathews, M.S. and Marian F. MacDorman, Ph.D., Division of Vital Statistics http://www.cdc.gov/nchs
Data from Guise JM, McDonagh M, Hashima J, et al.
Vaginal birth after cesarean (VBAC). Evidence Report/Technological Asessment No. 71.
Rockville (MD): Agency for Healthcare Research and Quality; March 2003. p. 31 Table 2.
| Table A. Infant, neonatal, and postneonatal deaths and mortality rates by race and mother: U.S., 2003 linked file | |||||
|---|---|---|---|---|---|
| Race of mother | All races | White | Black | Am. Indian * | Asian/Pacific Islander |
| Live births | 4,090,007 | 3,225,990 | 599,860 | 43,054 | 221,203 |
| Number of deaths | |||||
| Infant | 27,995 | 18,458 | 8,094 | 376 | 1,068 |
| Neonatal | 18,935 | 12,457 | 5,530 | 196 | 752 |
| Postneonatal | 9,060 | 6,000 | 2,563 | 180 | 316 |
| Mortality rate per 1,000 live births | |||||
| Infant | 6.84 | 5.72 | 13.49 | 8.73 | 4.83 |
| Neonatal | 4.63 | 3.86 | 9.22 | 4.55 | 3.40 |
| Postneonatal | 2.22 | 1.86 | 4.27 | 4.18 | 1.43 |
|
* Includes Aleuts and Eskimos NOTES: Infant deaths are weighted so numbers may not exactly add to totals due to rounding. Neonatal is less than 28 days and postneonatal is 28 days to under 1 year. Race and Hispanic origin are reported separately on birth certificates. Race categories are consistent with the 1977 Office of Management and Budget standards. In this table all women (including Hispanic women) are classified only according to their race. See reference 3. |
|||||
Rich Dickson, MFM, Tucson
Protein to Creatinine Ratio in Pre-eclampsia: Is the data preceding the U.S. benchmarks?
Here is more follow-up on this topic (see prior postings below)
Some opinions: We agree with the letter that your colleagues Gahn and Manske wrote: we are not ready to recommend or work with the P:C ratio.
Some references, conclusions:
This might have all started with Rodriquez-Thompson's paper from Harvard of all places (Use of random urine P:C ratio for diagnosis of Significant proteinuria during pregnancy: AJOG, 2001, Oct;185(4):808-811. They had a positive conclusion, used a cut-off of .19 for high, .14 for "negative". This was confirmed by a study in Thailand in '03 by Yamasmit (J Med Assoc Thai, 2003 Jan;86(1):69-71. They found a strong correlation with random urine P:C ratio and quantification of 24-hr collect in Hospitalized pts.
However in our country: Durnwald found that P;C Ratio does not exclude adequately the presence of significant proteinuria or predict severe PIH, and "should not be used as an alternative to 24-hr total protein evaluation". (AJOG, 2003 Sept;189(3):848-52. Additionally, Hass found that the Ratio does NOT predict total urine protein reliably in the 2nd and 3rd trimester, but did in the 1st trimester and post partum period (J Matern Fetal Neonat Med.2003 Oct;14(4):233-6.
This evidence, along with the fact that proteinuria itself is only one marker, makes this a moot point to determine if a patient should be transferred to a higher level of care or not.
So there you go . . .
Warm Regards, Rich D
May CCC Corner - Abstract of the month
Protein to Creatinine Ratio in Pre-eclampsia: Is the data preceding the U.S. benchmarks?
http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0406_AOM.cfm
June CCC Corner – Obstetric Hot Topics
Counterpoint: Not Yet Time to Use the P:C Ratio ( Gahn and Manske)
http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0506_HT.cfm#ob
Steve Heath, Albuquerque
Risk Management and Medical Liability, 2 nd Edition, Indian Health
The Second Edition of the IHS publication, Risk Management and Medical Liability, A Manual for Indian Health Service and Tribal Health Care Professionals, by Stephen W. Heath, MD, MPH has been posted on the IHS website at the National Council of Chief Clinical Consultants (NC4) homepage. The button labeled “Credentials/Risk Management” will take you to Manual site.
This current edition of the Manual describes the medical malpractice tort claim process changes that have taken place, updates data on tort claims, describes the IHS role in National Practitioner Data Bank reporting, and provides additional risk management guidance for local programs and health care professionals. It has been posted on the IHS website to allow access to as many individuals as possible. Users are encouraged to print the Manual for hard-copy use, if desired.. http://www.ihs.gov/NonMedicalPrograms/nc4/Documents/RM2_a.pdf
Sunnah Kim, IH-Special Interest Group, AAP
Access to Mental Health Services
Below is the link from the recent IH-SIG and Rural Health SIG listserv discussion on Access to Mental Health Services. In response to many of the comments and concerns, the summary lists a series of 9 possible strategies that could be adopted to address the identified systemic deficiencies regarding mental health services in rural and AI/AN communities. These strategies could be initiated locally, regionally, or nationally by various agencies and groups.
The discussion and summary were coordinated by Mick Storck, MD, AACAP Liaison to CONACH and Douglas H. Esposito, MD, MPH, FAAP http://www.aap.org/nach/AccesstoMentalHealthSummary.htm
Chris Lamer, Cherokee
Three new additions to the Indian Health National Guidelines websites
Tobacco assessment algorithm, Cherokee (PDF)
Tobacco cessation documentation and treatment, Cherokee (PDF)
Elder, Medication/ Beers Criteria, Cherokee (WORD)
Ron Pust, Tucson
Prenatal setting: Missed opportunity to link tuberculin skin test–positive and Tx
RESULTS: Among 678 women with known tuberculin skin test (TST) status, 341 (50.3%) had a TST-positive result, including 200 who were newly diagnosed. Of 291 TST-positive women with no previous LTBI treatment or history of TB, 27 (9.3%) completed > or =6 months of INH. In a subset with detailed follow-up, the most important reasons for not completing treatment were nonreferral for evaluation of a TST-positive result (30.9%), not keeping the appointment (17.9%), and nonadherence with prescribed treatment (34.6%). CONCLUSION: The prenatal setting represents a missed opportunity to link TST-positive non-US-born women with LTBI treatment and support for treatment completion.
Sackoff JE, Tuberculosis prevention for non-US-born pregnant women. Am J Obstet Gynecol. 2006 Feb;194(2):451-6.
Ty Reidhead, Whiteriver
Towards a better Patient Education webpage for Indian Health
Ty Reidhead, the Internal Medicine Chief Clinical Consultant is helping build our Indian Health Patient Education Resource page. http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-patEd.cfm
Ty asks that you forward him any electronic educational materials that you may have at your facility or know of from elsewhere
Please send them directly to Ty at Charles.Reidhead@ihs.gov
Judy Thierry, HQE
Achievements in Public Health: Reduction in Perinatal Transmission of HIV Infection
Implementation of recommendations for universal prenatal HIV testing, ARV prophylaxis, elective cesarean delivery, and avoidance of breastfeeding has resulted in a 95% decrease in the number of perinatal AIDS cases in the United States since 1992 and a decline in the risk for perinatal HIV transmission from an HIV-infected mother to less than 2%. However, barriers to the elimination of perinatal HIV infection remain, as the number of HIV infections continues to rise among women, and health-care services are not universally accessed by women in need of these services. Finally, the success in reducing perinatal HIV transmission observed in the United States contrasts with the situations in poorer countries, particularly in sub-Saharan Africa, where perinatal HIV transmission remains largely unabated. Continued success in the United States and reduction of perinatal HIV transmission in areas where such transmission remains common will require sustained commitment to prevention of HIV infection among women and to treatment for women affected by HIV/AIDS.
Achievements in Public Health: Reduction in Perinatal Transmission of HIV Infection --- United States, 1985—2005 MMWR June 2, 2006 / 55(21);592-597
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5521a3.htm?s_cid=mm5521a3_e
Editorial comment: George J. Gilson, MD
Reduction in Perinatal Transmission of HIV Infection
Since the first pediatric cases of HIV were reported in the early 80’s, significant progress has occurred in the prevention of vertical transmission of the infection in the United States. Prior to the era of anti-retroviral therapy (ARV), perinatal transmission was as high as 30%, but is currently under 2 per cent. Nevertheless, transmission continues to occur, mostly to infants who are born to women who have had no prenatal care (16%), or who have had prenatal care, but who have not been tested (26%), or who had been recognized as infected, but who had not been adequately treated (41% had not received zidovudine during labor). These are the areas where we should be able to make improvements in our care. Utilization of the “opt-out” approach to prenatal HIV screening, testing with the rapid, point of care, “OraQuick” test in labor for women with undocumented HIV status, and re-testing in the third trimester of high-risk women (history of a sexually transmitted infection or illicit drug use in the current pregnancy, or women from high prevalence areas), are all areas where the primary provider can play an important role in reducing transmission. Increased awareness among women of the need for testing, and case management to insure adequate prenatal care and adherence to ARV treatment for women identified as infected, are also crucial in preventing new infant infections. HIV infection in women is increasing rapidly, currently accounting for over a quarter of the total cases in the United States, and underscores the need for increased vigilance on the part of all of us who care for pregnant clients.
Safety belts: Single most effective means of preventing death and serious injury in a crash
. . . 45% effective in preventing death in passenger cars and 60% effective in preventing death in light trucks.
Child restraint Use: How do you add up compared to the NHTSA aggregate data?
Infants . . . . . . . . 98%
Toddlers . . . . . . . 83%
4 – 7 year old . . . 73%
MUST VIEW CHILD safety short video "UNTIL THEY ARE 4' 9"
Plus maps of states with booster seat requirements. List and maps of states with booster seat requirements. Go to www.boosterseat.gov and Enter
- CHILD’S AGE
- WEIGHT
- HEIGHT
Erica Streit-Kaplan, MPH, MSW estreit-kaplan@edc.org
Connected Kids: Safe, Strong, Secure is a new set of resources developed by VIPP
The Violence Intervention and Prevention Program. Connected Kids provides pediatricians with guidance and patient-oriented materials to take an asset-based approach to violence prevention from birth through 21 years of age. BUILD your query with age/ audience/ category/ key words – liking bullying or dating violence: http://www.aap.org/vipp/
Then a great list of links to sites and contact info and links to their specific programs comes up
As part of this program, more than 20 Connected Kids handouts are included. Some of the important topics covered are: Bullying, Discipline, Interpersonal Skills, Parenting, Suicide, Television Violence and more... please contact connectedkids@aap.org
Abstract Of The Month ‹ Previous | Next › Hot Topics
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.
