Volume 4, No. 6, June 2006
Features
American Family Physician**
Patient-Oriented Evidence that Matters (POEMS)*
Toremifene Is Effective Therapy for Mastalgia
Clinical Question: Is toremifene (Fareston) an effective treatment for mastalgia?
Study Design: Randomized controlled trial (double-blinded)
Synopsis: Mastalgia (i.e., painful symptoms of the breast) is the most common clinical complaint in women with benign breast disease. Toremifene is a new selective estrogen receptor modulator that is equally as effective as, but less toxic than, tamoxifen (Nolvadex) in the treatment of breast cancer. To evaluate the benefit of toremifene for the treatment of mastalgia, the investigators performed a randomized, double-blind (concealed allocation assignment) trial of 195 women with persistent (i.e., lasting longer than six months) mastalgia. They assigned patients to toremifene 30 mg daily or matched placebo for three menstrual cycles. Patients were recruited from a breast disease pain clinic, and from this group the authors included only the most severe cases. Thus, generalizability to routine practice is suspect.
Participants were blinded to treatment group assignment and self-reported the severity of breast pain using a visual analog scale from 0 (no pain) to 10 (worst pain). A 50 percent reduction in total pain score for the three months met criteria for a clinically significant treatment response. Follow-up occurred for all subjects at three months. Using intention-to-treat analysis, women receiving toremifene reported a significant reduction in total breast pain compared with those receiving placebo (69.2 versus 31.9 percent, respectively; number needed to treat = 3; 95% confidence interval, 2 to 4). Women with cyclical mastalgia had a higher response rate to toremifene than those with noncyclical pain. Adverse events in both groups included menses disturbance, dizziness, vaginal discharge, and nausea. Overall, the incidences of adverse events were the same in both groups.
Bottom Line: Toremifene effectively relieves moderate to severe mastalgia. Women with cyclical mastalgia received the greatest treatment benefit. (Level of Evidence: 1b)
http://www.aafp.org/afp/20060515/tips/14.html
Low-Fat, High-Carbohydrate Diet Does Not Cause Obesity
Clinical Question: Do low-fat, high-carbohydrate diets increase the risk of obesity among postmenopausal women?
Bottom Line: Following long-term recommendations to reduce dietary fat and increase consumption of fruits, vegetables, and whole grains does not cause weight gain among postmenopausal women. (Level of Evidence: 2b)
Howard BV , et al. Low-fat dietary pattern and weight change over 7 years: the Women's Health Initiative Dietary Modification Trial. JAMA January 4, 2006;295:39-49.
http://www.aafp.org/afp/20060501/tips/8.html
Duloxetine Is Effective for Fibromyalgia in Some Women
Clinical Question: Is duloxetine (Cymbalta) effective in controlling symptoms in women with fibromyalgia?
Bottom Line: Duloxetine is effective in some women with fibromyalgia, whether or not they are depressed. (Level of Evidence: 1b-)
Arnold LM, et al. A randomized, double-blind, placebo-controlled trial of duloxetine in the treatment of women with fibromyalgia with or without major depressive disorder. Pain December 15, 2005;119:5-15
http://www.aafp.org/afp/20060601/tips/18.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
Use of Hormonal Contraception in Women With Coexisting Medical Conditions
Practice Bulletin, No, 73
Summary of Recommendations and Conclusions
The following recommendations and conclusions are based on good and consistent scientific evidence (Level A):
- A history of benign breast disease or a positive family history of breast cancer should not be regarded as contraindications to oral contraceptive use.
- Combination oral contraceptives are safe for women with mild lupus who do not have antiphospholipid antibodies.
- Combination contraceptives are not recommended for women with a documented history of unexplained venous thromboembolism or venous thromboembolism associated with pregnancy or exogenous estrogen use, unless they are taking anticoagulants.
- Combination oral contraceptives should be prescribed with caution, if ever, to women who are older than 35 years and are smokers.
- Use of the levonorgestrel intrauterine system is appropriate for women with diabetes without retinopathy, nephropathy, or other vascular complications.
The following recommendations and conclusions are based on limited or inconsistent scientific evidence (Level B):
- Healthy, nonsmoking women doing well on a combination contraceptive can continue their method until the ages of 50–55 years, after weighing the risks and benefits.
- Progestin-only oral contraceptives and DMPA can be initiated safely at 6 weeks postpartum in lactating women and immediately postpartum in nonbreastfeeding women.
- Combination contraceptives are not recommended as the first choice for breastfeeding women because of the possible negative impact of contraceptive doses of estrogen on lactation. However, use of combination contraceptives by well-nourished breastfeeding women does not appear to result in infant development problems; therefore, their use can be considered once milk flow is well established.
- Women with well-controlled and monitored hypertension who are aged 35 years or younger are appropriate candidates for a trial of combination contraceptives, provided they are otherwise healthy, show no evidence of end-organ vascular disease, and do not smoke.
- The use of combination contraceptives by women with diabetes should be limited to such women who do not smoke, are younger than 35 years, and are otherwise healthy with no evidence of hypertension, nephropathy, retinopathy, or other vascular disease.
- The use of combination contraceptives may be considered for women with migraine headaches if they do not have focal neurologic signs, do not smoke, are otherwise healthy, and are younger than 35 years. Although cerebrovascular events rarely occur among women with migraines who use combination oral contraceptives, the impact of a stroke is so devastating that clinicians should consider the use of progestin-only, intrauterine, or barrier contraceptives in this setting.
- Because of the increased risk of venous thrombotic embolism, combination contraceptives should be used with caution in women older than 35 years who are obese.
- In women with depressive disorders, symptoms do not appear to worsen with use of hormonal methods of contraception.
- If oral contraceptives are continued before major surgery, heparin prophylaxis should be considered.
The following recommendations and conclusions are based primarily on consensus and expert opinion (Level C):
- Most women with controlled dyslipidemia can use combination oral contraceptives formulated with 35 mcg or less of estrogen. In women with uncontrolled LDL cholesterol greater than 160 mg/dL, a triglyceride level greater than 250 mg/dL, or multiple additional risk factors for coronary artery disease, alternative contraceptives should be considered.
- Depot medroxyprogesterone acetate has noncontraceptive benefits and is appropriate for women with sickle cell disease.
- Progestin-only contraceptives may be appropriate for women with coronary artery disease, congestive heart failure, or cerebrovascular disease. However, combination contraceptives are contraindicated in these women.
- Short- or long-term use of DMPA in healthy women should not be considered an indication for DXA or other tests that assess bone mineral density. In adolescents, the advantages of DMPA likely outweigh the theoretical safety concerns regarding bone mineral density and fractures. However, in the absence of long-term data in this population, consideration of long-term use should be individualized.
Use of hormonal contraception in women with coexisting medical conditions. ACOG Practice Bulletin No. 73. American College of Obstetricians and Gynecologists. Obstet Gynecol 2006:107:1453–72.
Noncontraceptive Uses of the Levonorgestrel Intrauterine System, Committee Opinion
ABSTRACT: The levonorgestrel intrauterine system, approved for contraceptive use for up to 5 years, also has noncontraceptive uses. It appears to reduce menstrual bleeding significantly in women with idiopathic menorrhagia. Current studies suggest that menopausal hormone therapy regimens combining the levonorgestrel intrauterine system with estradiol are effective in reducing climacteric symptoms and in inducing amenorrhea in most women after 1 year. Further studies are required before this device can be recommended as a treatment for endometriosis-associated pelvic pain, hyperplasia, or endometrial adenocarcinoma, or as adjuvant therapy with tamoxifen.
Noncontraceptive uses of the levonorgestrel intrauterine system. ACOG Committee Opinion No. 337. American College of Obstetricians and Gynecologists. Obstet Gynecol 2006;107:1479–82.
Analgesia and Cesarean Delivery Rates
ABSTRACT: Neuraxial analgesia techniques are the most effective and least depressant treatments for labor pain. The American College of Obstetricians and Gynecologists previously recommended that practitioners delay initiating epidural analgesia in nulliparous women until the cervical dilatation reached 4–5 cm. However, more recent studies have shown that epidural analgesia does not increase the risks of cesarean delivery. The choice of analgesic technique, agent, and dosage is based on many factors, including patient preference, medical status, and contraindications. The fear of unnecessary cesarean delivery should not influence the method of pain relief that women can choose during labor.
Analgesia and cesarean delivery rates. ACOG Committee Opinion No. 339. American College of Obstetricians and Gynecologists. Obstet Gynecol 2006;107:1487–8.
Tamoxifen and Uterine Cancer
ABSTRACT: Tamoxifen may be associated with endometrial proliferation, hyperplasia, polyp formation, invasive carcinoma, and uterine sarcoma. Any symptoms of endometrial hyperplasia or cancer reported by a postmeno-pausal woman taking tamoxifen should be evaluated. Premenopausal women treated with tamoxifen have no known increased risk of uterine cancer and as such require no additional monitoring beyond routine gynecologic care. If atypical endometrial hyperplasia develops, appropriate gynecologic management should be instituted, and the use of tamoxifen should be reassessed.
Tamoxifen and uterine cancer. ACOG Committee Opinion No. 336. American College of Obstetricians and Gynecologists. Obstet Gynecol 2006;107:1475–8.
Patient-Requested Cesarean Update: Cesareans should be performed for medical reasons
Experts addressed the growing controversy of "patient-choice" cesarean, recently dubbed "cesarean delivery on maternal request (CDMR)," at a news briefing during The American College of Obstetricians and Gynecologists' (ACOG) 54th Annual Clinical Meeting in Washington, DC. The increasing number and rate of cesarean deliveries in the US over the past three decades has been of interest to ACOG, governmental agencies, and other health care entities. The issue of whether cesarean delivery should be allowed purely on the basis of maternal request in the absence of any medical indication has added yet another element of intense debate.
The total cesarean delivery rates increased rapidly in the 1970s and the 1980s, although the rates declined in the late 1980s through the mid-1990s. In 2004, 29.1% of all live births were delivered by cesarean, according to the National Center for Health Statistics (NCHS). One of the major drivers of the overall increase in cesarean delivery has been that, after a cesarean delivery, the likelihood of cesarean delivery increases in subsequent pregnancies. The increase in primary cesarean delivery parallels the total cesarean delivery rate, which cannot, therefore, be explained by the decreasing use of vaginal birth after cesarean (VBAC). "Some indications for cesarean delivery, whether planned or emergency, include breech presentation, poor fetal heart rate, uterine rupture, prolapsed umbilical cord, abruption placental, and placenta previa," says Stanley Zinberg, MD, MS, ACOG deputy executive vice president, and vice president of ACOG's Practice Activities division.
Mary E. D'Alton, MD, director of obstetrics and gynecology services at Columbia University Medical Center, College of Physicians and Surgeons in New York City, was the conference chair of the recent National Institutes of Health State-of-the-Science Conference on Cesarean Delivery on Maternal Request. "One of the key points that came out of the conference is that more research is needed. There just isn't sufficient evidence at this time to fully evaluate the benefits and risks of cesarean delivery based on maternal request compared to normal vaginal delivery." There was consensus, says Dr. D'Alton, that CDMR is not recommended for women who are planning on having several children since the risks of placenta previa and placenta accrete increase with each cesarean delivery. "While some data show an association between both vaginal and cesarean delivery with pelvic floor problems and incontinence later, the data are not definitive," according to Dr. D'Alton.
"Patient-requested cesarean is but one of the many factors that have converged over the years to produce the current cesarean rate," says Fredric D. Frigoletto Jr, MD, associate chief of staff and vice chair at Massachusetts General Hospital in Boston, and an ACOG past president. "At this time, the best delivery mode for any woman is best decided by her and her physician, considering her individual circumstances. A woman must be thoroughly and accurately informed about the risks and benefits of each option for her as she participates in the decision," Dr. Frigoletto added.
"ACOG continues to review all of the issues surrounding maternal-request cesarean, but at this time our position is that cesareans should be performed for medical reasons," says Dr. Zinberg. While the increase in cesarean deliveries over the years has been significant, it's important to understand that there has been a noticeable shift in the demographic of women at high risk for cesarean, Dr. Zinberg noted. Some of these high-risk groups include women carrying multiple fetuses conceived through fertility treatments, older women becoming pregnant, and overweight and obese women.
Both Dr. Zinberg and Dr. D'Alton stress that women who request cesarean delivery in the absence of any medical indication should be counseled on the risks associated with cesarean, including a higher risk of infection, adhesions (painful scar tissue under the skin), pulmonary embolisms (blood clots), complications from the use of anesthesia, and the potential need for future cesareans, which entail additional risk. They also pointed out that the decision to perform a CDMR should be carefully individualized and consistent with ethical principles. "There is also a growing concern of the increased risk of babies born before 39 weeks of gestation; therefore, CDMR should not be performed prior to 39 weeks of gestation or without verification of lung maturity," says Dr. Zinberg.
http://www.acog.org/from_home/publications/press_releases/nr05-09-06-1.cfm
Screening for Fragile X Syndrome
ABSTRACT: Fragile X syndrome is the most common inherited form of mental retardation, affecting approximately 1 in 4,000 males and 1 in 8,000 females. DNA-based molecular analysis is the preferred method of diagnosis for fragile X syndrome and its premutations. Prenatal testing for fragile X syndrome should be offered to known carriers of the premutation or mutation. Testing for fragile X syndrome should be considered for any child with developmental delay of uncertain etiology, autism, or autistic behavior or for any individual with mental retardation of uncertain etiology. Women with ovarian failure or an elevated follicle-stimulating hormone level before 40 years of age without a known cause should be screened to determine whether they have the fragile X premutation.
Screening for fragile X syndrome. ACOG Committee Opinion No. 338. American College of Obstetricians and Gynecologists. Obstet Gynecol 2006;107:1483–5.
AHRQ
AHRQ study finds wrong-site surgery is rare and preventable
http://www.ahrq.gov/research/apr06/0406RA1.htm
Patient responses to medical errors depend on the timeliness and quality of the physician's communication about the event
http://www.ahrq.gov/research/apr06/0406RA3.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
Early breastfeeding choice, GDM, and BMI
When a mother has diabetes during pregnancy, she has more to worry about. Among other diabetes related concerns, her baby has a greater risk for being large for gestational age, developing type 2 diabetes at an early age. Also, studies indicate that if are babies born large for gestational age, they are likely to stay over weight or obese as they grow.
But there is hope that more children born to mothers with gestational diabetes mellitus (GDM) can avoid early childhood obesity and its risk of later adult obesity, and so possibly diabetes. A study by Schaefer-Graf et al in Germany found that early feeding choice could change risk of overweight for children from mothers with GDM.
During 1995-2000, 2000 women with GDM were cared for at the Vivantes Medical Center in Berlin, Germany. Later, many returned for follow-up, including 354 children (54% males, 46% females) who were included in this study. The mean age was 5.4 + 1.6 years, 28.4% were overweight. Overweight prevalence by feeding choice was:
Children not breastfed . . . . . . . . . . . . . . . . . 37.3%
Children breastfed up to 3 months . . . . . . . .32.5%
Children breastfed more than 3 months . . . .22.0%
The impact of breastfeeding as a preventive measure was maintained after adjusting for confounding factors such as parental obesity and high birth weight. The authors concluded that “the risk of childhood overweight may be reduced by 40-50% when breastfeeding is >3 months.”
For more information about this study, please see the complete article by Schaefer-Graf UM et al, Association of Breast-feeding and Early Childhood Overweight in Children From Mothers With Gestational Diabetes Mellitus, Diabetes Care, Vol:29, Number 5, May 2006, pp 1105-1007.
Other
Intervention to Increase Breastfeeding Rates
Overall, the patients in the control group had a 90 percent greater risk of low breastfeeding rates at three months and a 150 percent greater risk at 12 months. Women in the intervention group maintained a 50 percent rate of breastfeeding at six months compared with 33 percent in the control group. Women born in the United States had much lower breastfeeding intensity than foreign-born women. The authors suggest that prenatal visits and postpartum home visits were important contributors to the intervention's success. They acknowledge, however, that the intervention was labor intensive.
CONCLUSIONS: This "best-practices" intervention was effective in increasing breastfeeding duration and intensity. Breastfeeding promotion should focus on US-born women and exclusive breastfeeding
Bonuck KA, et al. Randomized, controlled trial of a prenatal and postnatal lactation consultant intervention on duration and intensity of breastfeeding up to 12 months. Pediatrics December 2005;116:1413-26.
Study hints at link between breastfeeding and intelligence
http://www.ahrq.gov/research/apr06/0406RA12.htm
CCC Corner Digest
Nicely laid out hard copy - A compact digest of last month’s CCC Corner
May 2006 Highlights include
- Maternal periodontal disease in early pregnancy: Small-for-gestational-age infant
- Improve colorectal cancer screening: Contribute to this survey
- Counterpoint: Not Yet Time to Use the P:C Ratio for pre-eclampsia
- FDA: Vaccine to Prevent Cervical Cancer Is Safe, Effective
- Relationship between team sport participation and adolescent smoking
- Caring for Patients After Bariatric Surgery
- ACOG Recommends First Ob-Gyn Visit in Early Teens
-ACOG: Hepatitis B and Hepatitis C Virus Infections, Committee Opinion
- 31% of Sexually Active U.S. Teenage Girls Become Pregnant
- Are there any cultural barriers/among Native Americans to becoming cord blood donors?
- What was the common theme in these 2 cases?
- Routine use of sweeping of membranes from 38 weeks of pregnancy onwards
- Methamphetamine abuse among women on Navajo (Part 2 of 4)
- Native American Scholarship Opportunities at the School of Nursing
- Female Sexual Dysfunction
- Factors Associated With Rise in Primary Cesarean Births in the United States
- Adverse Childhood Events: Impact on chronic adult illness / Risk taking
- Prediction of Pelvic Inflammatory Disease Among Young, Single, Sexually Active Women
- Long-term Dietary Intervention May Reduce Risk for Insulin Resistance in Children
http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0506.cfm
If you want a copy of the CCC Digest mailed to you each month, please contact nmurphy@scf.cc
Domestic Violence
DV: A cause of major morbidity and mortality, 4x more common than breast cancer, cannot be ignored
The present investigation focusing on intimate partner violence [IPV] prevalence in a cohort of insured, employed, educated, English-speaking U.S. women provides new knowledge on the high prevalence, several dimensions of chronicity, severity, and interrelatedness of IPV types.
The authors found that
- Over 14% of the women reported IPV of any type in the past 5 years, and 7.9% in the past year.
- Many women reported more than one IPV type. For example, among the 138 women with physical abuse (not sexual) in the past 5 years, 28 (20.3%) experienced physical abuse only, while 79.7% also experienced other types of IPV. Of the 138 women reporting physical abuse, 84 (60.9%) experienced a total of two to three types of IPV, and 26 (18.8%) experience four to five types.
- Between 10% and 21% (depending on IPV type) of the women who reported IPV reported abuse by two or more partners.
- The proportion of women with IPV rating it as moderately to extremely violent was 61% for physical violence, 45% for sexual intercourse, 36% for forced sexual contact, 63% for fear due to a partner's threats or anger, and 31% for controlling behavior.
- IPV risk was higher among younger women, women with lower incomes, women with less education, women who were single mothers, and women who had been exposed to any form of abuse as a child or who had witnessed IPV as a child.
From the present work, a picture emerges of both physical and non-physical IPV as very common, chronic, intergenerational, and present in highly overlapping forms. A cause of major morbidity and mortality, which is fourfold more common than breast cancer, cannot be ignored.
Thompson RS, Bonomi AE, Anderson M, et al. 2006. Intimate partner violence: Prevalence, types, and chronicity in adult women. American Journal of Preventive Medicine 30(6):447-457.
Readers: More information about domestic violence is available from the MCH Library's knowledge path at http://www.mchlibrary.info/KnowledgePaths/kp_domviolence.html
Physical Dating Violence Among High School Students – United States, 2003
CDC analyzed the prevalence of physical dating violence (PDV) victimization among high school students. The results indicated that 8.9% of students (8.9% of males and 8.8% of females) reported PDV victimization during the 12 months preceding the survey and that students reporting PDV victimization were more likely to engage in four of five risk behaviors.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5519a3.htm
50% with female cancers: History of violence correlates with advanced stage at diagnosis
CONCLUSION: A history of violence in breast, ovarian, endometrial, and ovarian cancer patients was extremely common and correlated with advanced stage at diagnosis.
LEVEL OF EVIDENCE: II-2
Modesitt et alAdverse Impact of a History of Violence for Women With Breast, Cervical, Endometrial, or Ovarian Cancer. Obstetrics & Gynecology 2006;107:1330-1336
Launch of Choose Respect Initiative!
Choose Respect is an initiative to help adolescents form healthy relationships to prevent dating abuse before it starts. Learn about this new initiative and what you can do to promote healthy relationships in your community. http://www.cdc.gov/ncipc/dvp/DatingViolence.htm
Elder Care News
September 1, 2006: Palliative Medicine's Role in the Continuity of Care
Moderator: Tim Domer, M.D.
- Management of acute vs chronic pain
- Quality of Life in chronic illness
- The meaning of "Code Status"
- Preparing for a "Good Death"
- End-of-Life Care as part of Continuity of Care and Prevention
Primary Care Discussion Forum
http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForum.cfm#
Family Planning
Refusals by pharmacists to dispense emergency contraception: a critique
Over the past several months, numerous instances have been reported in the United States media of pharmacists refusing to fill prescriptions written for emergency postcoital contraceptives. These pharmacists have asserted a "professional right of conscience" not to participate in what they interpret as an immoral act. In this commentary, we examine this assertion and conclude that it is not justifiable, for the following reasons: 1) postcoital contraception does not interfere with an implanted pregnancy and, therefore, does not cause an abortion; 2) because pharmacists do not control the therapeutic decision to prescribe medication but only exercise supervisory control over its dispensation, they do not possess the "professional right" to refuse to fill a legitimate prescription; 3) even if one were to grant pharmacists the "professional right" not to dispense prescriptions based on their own personal values and opinions, pharmacists "at the counter" lack the fundamental prerequisites necessary for making clinically sound ethical decisions, that is, they do not have access to the patient's complete medical background or the patient's own ethical preferences, have not discussed relevant quality-of-life issues with the patient, and do not understand the context in which the patient's clinical problem is occurring. We conclude that a policy that allows pharmacists to dispense or not dispense medications to patients on the basis of their personal values and opinions is inimical to the public welfare and should not be permitted.
Wall LL, Brown D. Refusals by pharmacists to dispense emergency contraception: a critique. Obstet Gynecol. 2006 May;107(5):1148-51.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=
retrieve&db=pubmed&list_uids=16648422&dopt=Abstract
Discussion needed: Reasons why women discontinue oral contraception
RESULTS: Most women who reported having discontinued OCs did so because of medical side effects, and most had switched to less effective methods. Among OC users, 26.4% had sexual intercourse on days they missed pills just before or after their placebo week. Nonadherence did not differ by socioeconomic factors or obesity. CONCLUSION: Clinicians may need to encourage their patients to discuss their reasons for wanting to discontinue the use of an effective contraceptive method and assist them with their concerns or to switch to other effective methods to protect themselves from unintended pregnancy.
Huber LR, et al Contraceptive use and discontinuation: findings from the contraceptive history, initiation, and choice study. Am J Obstet Gynecol. 2006 May;194(5):1290-5
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=
Retrieve&db=pubmed&dopt=Abstract&list_uids=16647912
Fertility, Contraception, and Fatherhood: 2002 National Survey of Family Growth
The Centers for Disease Control and Prevention has issued a comprehensive report on fertility, contraception, and fatherhood indicators among men 15-44 years of age in the United States. The data are from the National Survey of Family Growth conducted in 2002. It’s the latest survey of this type, and--for the first time--this large-scale, nationwide survey includes men. Whenever appropriate, the findings for men and women are contrasted. Men’s and women’s reproductive experiences vary significantly, and often sharply, by characteristics such as education, income, and Hispanic origin and race.
-Teen fathers - Among non-Hispanic black fathers, 25 percent fathered their first child before they were 20 years old; 19 percent of Hispanic fathers also became fathers as teenagers, and 11 percent of non-Hispanic white men became fathers while they were teens.
-Nonmarital childbearing – About one-half of the men without a high school education have fathered a child outside of marriage compared with about 6 percent among college graduates.
-Child support – About three-quarters of the 28 million men who have children (under age 19) live with those children. Among fathers who live apart from their children, 85 percent of fathers with higher incomes contributed to their children’s support on a regular basis, compared with 64 percent of fathers with income below the poverty level.
-Marriage and divorce - A third of men marry by age 25; almost two-thirds marry by age 30. Among women, one-half are married by the time they are 25 and three-quarters by age 30. Overall, men marry later in life than women. The average woman marries a man 2 years older than she. One-half of the men who married as teenagers were divorced or separated within 10 years, compared with 17 percent of men who married at 26 years or over.
-Sexual activity - Men who did not live with both parents at age 14 were more likely to have had sexual intercourse during the teenage years (19 or younger) compared with those who lived with both parents at age 14.
Fertility, Contraception, and Fatherhood: Data from the 2002 National Survey of Family Growth Martinez, GM, Chandra A, Abma J, Jones, J, Mosher W. http://www.cdc.gov/nchs
Levonorgestrel-Releasing Intrauterine System (Mirena) for Contraception
The levonorgestrel-releasing intrauterine system (Mirena) is a T-shaped intrauterine device (IUD), 1.3 inches (32 mm) in length and width, that releases levonorgestrel. It is labeled for use as a contraceptive agent for up to five years.
Bottom Line
The levonorgestrel-releasing intrauterine system is a reliable, reversible, low-maintenance method of long-term contraception. Rates of failure are similar to those of female sterilization, and the risk of expulsion is minimal for most users. http://www.aafp.org/afp/20060515/steps.html
Featured Website David Gahn, IHS Women’s Health Web Site Content Coordinator
From Candace Jones, HQE and Terry Cullen, Tucson
This is a GREAT site for Health Promotion Disease Prevention Utah Department of Health http://www.ibis.health.utah.gov/
Frequently asked questions
The Indian Health MCH Frequently Asked Question (FAQ) site
This site offers over 425 answers to common questions about the care of women and children in the unique settings found in Indian Country. Answers include both a quick answer and then significant background and multiple resources and links.
The site is maintained frequently (see section below) with 11 new FAQs this month and numerous existing FAQs being updated. There are 15 answers to questions on bilateral tubal ligation alone.
Go here to explore the frequently asked question page
http://www.ihs.gov/MedicalPrograms/MCH/M/mchFaqs.cfm
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
Indian Child Health Notes - Steve Holve, Pediatrics Chief Clinical Consultant
June 2006 Highlights
- Wrist Fractures in children - All those kids who sawed off their own casts were right
- Developmental Dyslplasia of the Hip - US Preventive Task Force and AAP differ over value of screening
- Watch out for mumps. It is spreading out of Iowa
- Doug Esposito weighs in on health disparities for urban Indians
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ICHN606.doc
Information Technology
RPMS Behavioral Health System Patch Release Announcement, June 1, 2006
The Indian Health Service Office of Information Technology and the Division of Behavioral Health announce the following application patch releases:
Significant changes in the current patches include:
- New 2006 ICD codes
- Updated DSM-ICD code mapping as appropriate for 2006 ICD codes
- Addition of new RPMS Alcohol and Depression Screening Exam Codes
- Addition of Goal and Goal Status to Patient Education
- Most Recently Used functionality is now patient-specific not user-specific where applicable
- Sensitive Patient Tracking functionality
- Minimize capability
- Name of Group displays on all printed encounters
- All printed forms include date and time of printing
- Technical modifications to accommodate the future release of the Patient Chart behavioral health component in the RPMS Electronic Health Record
Further information including application documentation and training opportunities can be found at the IHS RPMS website: http://www.ihs.gov/Cio/RPMS/index.cfm
International Health Update
Nothing defines us better than providing service to colleagues less fortunate than we
As citizens of the United States, we have the opportunity and means to volunteer our time and skills to assist our colleagues in less-developed areas of the world to achieve higher quality of care for their patients. As obstetricians and gynecologists, we have a special interest in such humanitarian efforts. Whether it be offering emergency aid or bringing care and expertise to clinics and hospitals in the developing world, there are many opportunities for physicians to make a difference in the global community.
Americans have a tradition of being generous with their time, money, and services. Witness the recent response of the American people to the victims of the 2004 tsunami and 2005 hurricanes. Our philanthropic outpouring was enormous, with over $3 billion raised by private nonprofits for hurricane Katrina relief alone. But that should not be surprising, because for many decades the United States has been quietly and effectively combating disease and suffering throughout the world. We have assisted in bringing education, medicine, and infrastructure to developing countries worldwide.
The United States Agency for International Development (USAID) has programs in approximately 100 countries. This agency strives to provide education to eliminate illiteracy, agriculture to help eliminate hunger, and know-how to produce economic growth and has made major efforts toward improving global health. The USAID budgetary resources exceeded $13 billion for fiscal year 2005; these funds allow USAID to promote a broad-based sustainable effort and provide humanitarian assistance in the developing world.
The United States is also the major contributor to the World Health Organization, which provides critical health measures globally. The World Health Organization plays an extremely important role in fighting the acquired immunodeficiency syndrome (AIDS) scourge, detecting outbreaks of epidemics, and combating many other diseases worldwide.
There are myriad nongovernmental organizations through which Americans participate with donations and services. Nongovernmental organizations work predominantly in the developing world as well as anywhere a disaster occurs. Many foundations are directed toward bringing medicine and public health to people in need. Most notably, the Bill & Melinda Gates Foundation has made major strides in worldwide immunizations, AIDS prevention, and recently, prevention of prematurity. Rotary Clubs worldwide have helped to wipe out poliomyelitis by ensuring immunizations even in the remotest parts of the globe. They are now considering their role in alleviating the avian influenza threat.
In all of these efforts, physicians have played a vital role. From the American College of Obstetricians and Gynecologists (ACOG) Fellows volunteering their surgical skills to repair fistulae (ACOG Today, April 2005) to Dr. Brown's 2-year volunteer effort combating the human immunodeficiency virus (HIV)/AIDS epidemic in western Kenya (ACOG Today, January 2006), many are giving the benefit of their skills worldwide. Through organizations such as Doctors Without Borders/Médecins Sans Frontières, for instance, physicians are able to aid people in underserved areas of the globe, many of whom are affected by wars or natural disasters.
The American College of Obstetricians and Gynecologists played a major role in helping our neighbors in Central America decrease maternal mortality in the Save the Mothers Initiative of FIGO. The College paired up with 4 Central American countries: Honduras, Nicaragua, El Salvador and Guatemala. As an outgrowth of this collaboration, the 7 Central American countries have become a Central American Section of ACOG.
Certainly, it is not possible for everyone to pick up and travel to remote areas to volunteer, but Fellows should develop interests in certain projects, local or international or both, and offer support. Moreover, Fellows are encouraged to become familiar with the local, regional, or national organizations that are responsible for implementing the kinds of programs in which a Fellow develops an interest. Even letting your local congressional representative know of your interests can aid in the establishment of worthwhile programs. While monetary contributions are always welcome, when the propitious time arrives, the Fellow can volunteer. What we do defines who we are in this global community, and nothing defines us better than providing service or support to colleagues less fortunate than we are.
Queenan JT. Worldwide involvement. Obstet Gynecol. 2006 May;107(5):974-5.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=
retrieve&db=pubmed&list_uids=16648397&dopt=Abstract
The College maintains a list of religious and secular organizations that sponsor volunteers in developing countries
Religious organizations: http://www.acog.org/from_home/departments/international/religiousorganizations.pdf
Secular organizations:
http://www.acog.org/from_home/departments/international/organizationdatabase.pdf
Chlorhexidine: Potential to improve maternal /newborn outcomes - Developing countries
TABULATION, INTEGRATION AND RESULTS: Chlorhexidine is a highly effective killer of most bacteria, has an excellent safety profile, rarely is associated with bacterial resistance, is easy to administer, and costs a few cents per application. When used as a vaginal or newborn disinfectant, it clearly reduces bacterial load, including transmission of Group B Streptococcus from the mother to the fetus. Nevertheless, in developed countries, chlorhexidine generally has not been shown to significantly reduce life-threatening maternal or neonatal infections. However, 2 large but not randomized studies, one in Malawi and the other in Egypt, suggest that important reductions in maternal and neonatal sepsis and neonatal mortality may be achievable with vaginal or neonatal chlorhexidine treatment.
CONCLUSION: With 4 million neonates and about 700,000 pregnant or recently pregnant women–mostly in developing countries–dying each year, many from infections originating in the vagina, further study of this highly promising treatment is indicated.
Goldenberg RL et al Use of vaginally administered chlorhexidine during labor to improve pregnancy outcomes. Obstet Gynecol. 2006 May;107(5):1139-46.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd
=retrieve&db=pubmed&list_uids=16648420&dopt=Abstract
Report on Children and Families Displaced by Hurricanes Katrina and Rita
The findings from the first comprehensive face-to-face field survey of residents living in FEMA-subsidized shelters following Hurricanes Katrina and Rita reveal a host of under-or untreated medical and mental health conditions affecting adults and children. The study was part of an ongoing needs assessment by Operation Assist, a collaborative effort of the Children’s Health Fund and The National Center for Disaster Preparedness at the Columbia University Mailman School of Public Health. The purpose of the study was to gather information that could inform local, state, and Federal policymakers about the health and social service needs of displaced populations living in transitional community-based settings, such as trailer parks and hotels with FEMA-subsidized housing units. Key findings include poor access to care, high rates of chronic illness, mental health issues, and gaps in children/family welfare (decreases in stability, income and security). www.hrsa.gov/womenshealth
MCH Alert
Association of poverty with overweight among adolescents, 1971 - 2004
A widening disparity in overweight that disadvantages adolescents in poor families has emerged in the 15- to 17-year-old age group in recent years. The prevalence of overweight among adolescents in the United States has more than doubled during the past three decades. Whether this increasing prevalence is characterized by larger, smaller, or unchanged disparities in overweight status across socioeconomic strata is not known but is important for evaluating the success of recent efforts by the Department of Health and Human Services to reduce health disparities.
The authors found that
- In general, at no year of the surveys did the prevalence of overweight status differ significantly across poor and nonpoor families among all adolescents ages 12-14, or within any of the racial and ethnic subsamples. An exception was found, however, among Hispanic black adolescents ages 12-14, for whom a disparity in adolescent overweight reversed over time so that the prevalence of overweight was higher among nonpoor families compared with poor families by the last years of the surveys.
- Differences in the prevalence of adolescent overweight were most evident among respondents ages 15-17 in the last two surveys. In general, the prevalence of overweight increased over the period of the surveys at a faster rate among these adolescents from poor families compared with their counterparts in nonpoor families.
- A disparity in physical inactivity by family poverty was more pronounced for older compared with younger adolescents in the cross-sectional NHANES 1999-2004.
- A disparity across poverty status in percentage of calories from sweetened beverages was more pronounced for older vs. younger adolescents in the cross-sectional NHANES 1999-2002.
These results suggest that efforts to reduce health disparities in the United States require monitoring of population health, so that emergent disparities and their underlying causes can be detected and addressed at early stages of their development.
Miech RA, Kumanyika SK, Stettler NS. 2006. Trends in the association of poverty with overweight among US adolescents, 1971-2004. JAMA, The Journal of the American Medical Association 295(20):2385-2395. http://jama.ama-assn.org/cgi/content/abstract/295/20/2385?etoc
Medical Mystery Tour
Copious post operative mucous secretions
A 60 year old female presented to her primary care provider with lower abdominal discomfort. The patient did not complain of increasing weight or abdominal girth, and noted no change in her appetite. The patient was s/p vaginal hysterectomy for a history of irregular bleeding with normal pap smears. Imaging studies revealed a complex cystic pelvic mass with no evidence of ascites. Other medical issues included hypertension, controlled with oral medication, and smoking one pack a day of tobacco without current respiratory symptoms. The patient was well nourished had no previous history of abdominal surgery.
The patient underwent a staging laparotomy that revealed bilateral hydrosalpinges, and was otherwise without complications. On post op day one, the patient was afebrile and tolerated an advancing diet, but had coarse breath sounds. On the second day post-op the patient developed increased mucous production and had periods of desaturation. Examination revealed rhonchi and continued coarse breath sounds. Chest X-ray revealed complete opacification of the left hemithorax. The patient was transferred to the Intensive Care Unit and received an urgent bronchoscopy and was found to have tenacious mucous plugging. Her left lung was easily reinflated. The patient rapidly improved and was returned to the medical surgical ward the following day. The patient continued to produce copious mucous secretions and she received vigorous pulmonary toilet with bronchodilators and incentive spirometry.
On the day the following the bronchoscopy the patient was noted to have several small fatty spots between her midline staples, but she was otherwise tolerating an advancing diet, voiding, and had bowel movements. It was felt the prolapsed subcutaneous fat was a result of the patient’s coughing due to the copious secretions. On the fourth postoperative day, there was no wound discharge. In fact the subcutaneous fat was becoming dehydrated so moist gauze was placed on the wound to facilitate replacement of the slightly prolapsed subcutaneous fat the next day. The patient was prepared for discharge on the fifth post-operative day and it was elected to remove the staples, replace the slightly prolapsed subcutaneous fat and then place steristrips over the otherwise clean and dry incision. In anticipation of discharge the patient was encouraged to stop smoking and the nature of chronic obstructive pulmonary was discussed with the patient.
Can you think of any further discharge or wound care instructions you would give this patient?
Stay tuned to next month’s CCCC Newsletter for the rest of the story
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)
Testosterone Treatments: Why, When, and How? (see also Patient Education)
Testosterone treatment is controversial for men and even more so for women. Although long-term outcome data are not available, prescriptions for testosterone are becoming more common. Testosterone is used primarily to treat symptoms of sexual dysfunction in men and women and hot flashes in women. Potential benefits include improved libido, increased bone mass, and increased sense of well-being. In individuals with human immunodeficiency virus infection or other chronic diseases, testosterone has been shown to improve mood and energy levels, even in patients with normal testosterone levels. Testosterone can be administered by injection, patch, topical gel, pill, or implant. Side effects in men include polycythemia and acne. Side effects in women include acne, hepatotoxicity, and virilization and usually only occur when testosterone is used in supraphysiologic doses. Long-term studies of the effects of testosterone on prostate cancer, breast cancer, and heart disease have not been completed. Mammograms and monitoring of prostate-specific antigen, hematocrit, and lipid levels are recommended for patients taking testosterone. Am Fam Physician 2006;73:1591-8, 1603.
http://www.aafp.org/afp/20060501/1591.html
Midwives Corner - Lisa Allee, CNM
Empowering women to find the power of birth is of great value
The effect of labor pain relief medication on neonatal suckling and breastfeeding duration.
This study by Jan Riordan and colleagues is unique in that they had a true control group of women who delivered without any pain medication. Previous studies had compared groups of women with different types of medications. They also used a tool to assess breastfeeding specifically, whereas other studies used tools that assessed general neonatal behaviors. The study was prospective, multisite, and involved 129 mother-baby dyads with vaginal births at term, 29% of which occurred after unmedicated labors and 71% had some form of pain medication. The results showed significant differences in breastfeeding ability between the non-medicated group and those receiving pain medications. The babies who were not exposed to any pain medication had significantly higher scores, meaning more vigorous and effective suckling, than the other three groups. The IV-analgesia-only group and the epidural-only group had similar scores, significantly lower than the non-med group, and the IV and epidural group had the lowest scores. The results did not show a difference in duration of breastfeeding, but the dyads with low scores weaned earlier than those with medium or high scores.
The authors conclude that pain medication during labor, including epidurals (and I think we can easily extrapolate to intrathecals) clearly hinder breastfeeding. They make the following points for consideration in clinical care:
- Nonpharmacological comfort measures are effective and do not compromise early neonatal suckling and breastfeeding.
- Informed consent includes telling women that their infant’s ability to breastfeed is diminished with IV analgesics and epidurals (intrathecals.)
- If epidurals (intrathecals) are used, it appears the best choice is medication that does not include a narcotic.
- Breastfeeding mothers who have had pain medication during labor may become discouraged and babies with poor breastfeeding behaviors are at greater risk for dehydration, jaundice, and poor weight gain.
Riordan J, Gross A, Angeron J, Krumwiede B, Melin J. 2000. The Effect of Labor Pain Relief Medication on Neonatal Suckling and Breastfeeding Duration. Journal of Human Lactation 16(1): 7-12 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=
Retrieve&db=pubmed&dopt=Abstract&list_uids=11138228
Full article is available at: http://jhl.sagepub.com/cgi/reprint/16/1/7
Midwives Corner Editorial comment: Lisa Allee, CNM
I find this article to be yet another affirmation that empowering women to find the power of birth is of great value. When we teach, support, encourage, cajole, advocate, and do whatever else is necessary to assist women through the intense, life-altering experience of labor and birth without using narcotics, there are profound benefits for the woman, the baby, and, with this article, society when you consider the far-reaching effects of breastfeeding success. This article also points out that when women do use narcotics during labor that we must be very attentive to breastfeeding support initially and ongoing.
Other topics
Multiparous women with induced labor: Shorter active phase of labor than spontaneous
CONCLUSION: The pattern of labor progression differs for women with an electively induced labor without cervical ripening compared with those who present with spontaneous onset of labor.
Hoffman MK, et al Comparison of labor progression between induced and noninduced multiparous women. Obstet Gynecol. 2006 May;107(5):1029-34.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=
retrieve&db=pubmed&list_uids=16648407&dopt=Abstract
Pushing During Second-Stage Labor Is Matter of Preference
Clinical Question: During the second stage of labor, is coaching to push more beneficial than not coaching to push?
Study Design: Randomized controlled trial (nonblinded)
Allocation: Concealed
Synopsis: The benefit of the routine practice of coaching to push during the second stage of labor is debated. In this study, 325 women with uncomplicated term pregnancies in spontaneous active labor for the first time were randomized to coached pushing or uncoached pushing during the second stage of labor. Women were excluded if the estimated fetal weight was more than 8.2 lb (4,000 g), if they had a diagnosis of chorioamnionitis, or if oxytocin (Pitocin) or epidural analgesia was used.
Coaching consisted of asking women to bear down with a closed glottis and legs pulled back for 10-second intervals during contractions. Women who were not coached to push were told to "do what comes naturally." All women were asked to assume a recumbent or lateral position and were attended by certified nurse-midwives. The midwives were trained to be compliant with the instructions for the corresponding arm of the study. Forceps delivery was considered only if there was a prolonged second stage (more than two hours) or a fetal heart rate abnormality.
Mean duration of second-stage labor was 46 minutes in the coached group and 59 in the uncoached group (P = .014). There were no differences in mode of delivery, perineal trauma, or episiotomy use. There were no differences in neonatal Apgar scores, need for resuscitation, sepsis work-up, or neonatal intensive care unit admission. There were more infants with meconium-stained fluid in the coached group, but in most cases, it was noted before the second stage of labor. It also appears unlikely that a larger study would have detected clinically important differences.
Bottom Line: Pushing time is reduced by an average of 13 minutes when women are coached to push during the expulsive phase of labor. Other than that, coached pushing demonstrated neither benefit nor harm. The choice is a matter of preference. This study included only women who were not receiving epidural analgesia or oxytocin. (Level of Evidence: 1b)
http://www.aafp.org/afp/20060515/tips/13.html
Navajo Corner, Kathleen Harner, Chinle
METHAMPHETAMINE ABUSE AMONG WOMEN ON NAVAJO (Part 3 of 4)
Phoenix Indian Medical Center (PIMC) has developed a program designed specifically for the special needs of substance abusers and women with mental health disorders. Their goal was to: protect the unborn from toxic drug exposure, assist the mother in successfully abstaining from drugs and alcohol, and to prevent repeat pregnancies with drug affected newborns. Beginning in October of 2003, the midwives at PIMC staff a “Special Care Clinic” devoted to pregnant drug users, victims of domestic violence and women with mental health disorders. The clinic meets one afternoon a week and has longer appointments than the normal prenatal care visits. Social workers and substance abuse counselors are in the clinic and available for same time appointments. At the first prenatal care visit problems are identified, a routine prenatal workup and sexually transmitted disease (STD) testing is performed. If substance abuse is identified it is discussed thoroughly and a drug contract is created and the patient is asked to sign it. A urine drug screen (UDS) is obtained if the patient agrees.
PIMC has created a wide network of referrals for the women in their “Special Care Clinic”. These include Mental Health, Public Health Nursing, Home Health, Case Management and some Community Support Groups (e.g. Twelve Step Programs). Social services and substance abuse counseling are as accessible as possible because they are in the clinic with the midwives. The patient sees the same counselor and midwife at each visit whenever practical. The patient need never explain the purpose of her visit to the admitting clerk, which avoids embarrassment. A UDS is obtained at each visit if the patient has agreed and the drug contract is signed at each visit as well. Patients are seen weekly if needed and otherwise are on a routine prenatal care schedule.
Patients receive gifts and incentives for participating in the “Special Care Clinic”. At each visit the pregnant woman is given a gift for herself and her baby. These gifts include make-up, hair care products, inexpensive jewelry and lotions for the mother. Baby gifts are blankets, clothing, pacifiers, and baby picture frames. Patients seem to particularly like the “Fetus Models” of a 12-week fetus. When a patient has had three negative UDS in a row she is rewarded with a $15.00 gift certificate for Wal-Mart, Target or Food City. If she tests positive for drugs there is no punitive action but she is usually seen more frequently.
If a patient is abusing MA heavily, residential treatment is offered. If she is positive for drugs, in addition to her weekly visit with the midwife and mental health counselor she also sees the social worker two or more times a week. Once several drug screens have been negative, she may be seen on a weekly schedule.
As of January 15, 2005 the program had been operating for 15 months. Over ninety women participated with a total of 275 midwife visits. Their diagnosis included substance abuse, anxiety/depressive disorders, bipolar disease, homelessness, severe congenital anomalies incompatible with life and domestic violence. Some patients are still lost to follow up. Many are drug free or have only occasional lapses. The midwives and patients are happy with the program. At PIMC every success is celebrated.
The PIMC program uses contingency management very effectively in their program. Contingency management (CM) treatments are based on a simple behavioral principle, if a behavior is reinforced or rewarded it is more likely to occur in the future. Reinforcement of good behaviors such as negative urine screens and attending prenatal or therapy appointments encourage women to stay abstinent. Rewards need not be large to be effective.
Cognitive behavioral therapy (CBT) has been widely used for treating cocaine abusers. CBT attempts to help patients recognize, avoid and cope with problematic behaviors associated with substance abuse. It has many advantages over other more traditional therapies such as twelve step programs and traditional psychotherapy. It is a short-term therapy that creates skills the patient can use after therapy is over. It has been studied extensively in clinical trials and has been proven very effective. It is flexible and can be individualized and it is compatible with other treatments.
MA abuse among women of childbearing age is a complicated problem. Using a multifaceted and multidisciplinary approach to helping pregnant women stop abusing MA provides the best opportunity for success. Kathleen Harner kathleen.harner@tcimc.ihs.gov
Next Month: The ‘drop in’ meth abusing gravida
References:
Hunter, F What we did about Prenatal Substance Abuse Special Care clinic. A Power Point presentation 2005.
Check out these sites for messaging for children and adolescents created in Montana.
Montana Meth ads
http://www.montanameth.org/ads_television.aspx
Meth, not even once
Nurses Corner - Sandra Haldane, HQE
SANE/SAFE training and capacity
Dear nursing colleagues:
I am gathering information on IHS and tribal capacity to conduct sexual assault examinations for adults and children. Specifically, I need to know which IHS and tribal facilities currently have a trained forensic nurse examiner on staff.
Please send me the following information:
- For each area, which hospitals and health centers have one or more nurses or APNs trained to perform a forensic examination and which do not?
- Please let me know if SANE or SAFE training has been offered in the past year, and where
Thank you very much for your help in getting me this information!
Carolyn Aoyama Carolyn.Aoyama@ihs.gov
Office of Women's Health, CDC
Recommendations to Improve Preconception Health and Health Care - United States
This report provides recommendations to improve both preconception health and care. The goal of these recommendations is to improve the health of women and couples, before conception of a first or subsequent pregnancy. The recommendations focus on changes in consumer knowledge, clinical practice, public health programs, health-care financing, and data and research activities. Each recommendation is accompanied by a series of specific action steps and, when implemented, can yield results within 2-5 years. Based on implementation of the recommendations, improvements in access to care, continuity of care, risk screening, appropriate delivery of interventions, and changes in health behaviors of men and women of childbearing age are expected to occur.
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5506a1.htm?s_cid=rr5506a1_e
Preconception Care website
http://www.cdc.gov/ncbddd/preconception/default.htm
USPSTF: Recommendations on Screening / Supplementation for Iron Deficiency Anemia
The U.S. Preventive Services Task Force issued new recommendations on routine screening for iron deficiency anemia and iron supplementation in pregnant women and children.
The Task Force recommends routine screening for iron deficiency anemia in asymptomatic pregnant women (B recommendation).
The Task Force recommends routine iron supplementation for asymptomatic children ages 6 to 12 months who are at increased risk for iron deficiency anemia (B recommendation).
The Task Force concludes that evidence is insufficient to recommend for or against routine iron supplementation for non-anemic pregnant women (I recommendation).
The Task Force concludes that evidence is insufficient to recommend for or against routine iron supplementation for asymptomatic children ages 6 to 12 months who are at average risk for iron deficiency anemia (I recommendation).
http://www.ahrq.gov/clinic/uspstf/uspsiron.htm#top
Oklahoma Perspective Greggory Woitte – Hastings Indian Medical Center
Elective Cesarean Delivery
When asked the question in your office about an elective primary cesarean delivery, how do you respond? Do you defer to the patient’s right to determine her birthing method or do you respond that you don’t perform one without an indication? As the media popularizes elective cesareans for the famous, where do we stand as a profession? The NIH convened a consensus conference March 27-29 to review the available evidence.
Here is a summary of their conclusions:
Cesarean deliveries without medical or obstetrical indications are on the rise and a component of this is due to elective maternal request.
Insufficient evidence to fully evaluate
There is insufficient evidence to evaluate fully the benefits and risks of cesarean delivery on maternal request as compared to planned vaginal delivery, and more research is needed.
Until quality evidence becomes available, any decision to perform a cesarean delivery on maternal request should be carefully individualized and consistent with ethical principles.
Given that the risks of placenta previa and accreta rise with each cesarean delivery, cesarean delivery on maternal request is not recommended for women desiring several children.
Cesarean delivery on maternal request should not be performed prior to 39 weeks of gestation or without verification of lung maturity, because of the significant danger of neonatal respiratory complications.
Maternal request for cesarean delivery should not be motivated by unavailability of effective pain management. Efforts must be made to assure availability of pain management services for all women.
NIH or another appropriate Federal agency should establish and maintain a Web site to provide up-to-date information on the benefits and risks of all modes of delivery.
http://consensus.nih.gov/2006 /2006CesareanSOS027html.htm
Osteoporosis
Calcium Plus Vitamin D for Fracture Prevention: POEM
Clinical Question: Does supplementation with 1,000 mg of calcium and 400 IU of vitamin D reduce the risk of fracture in healthy women?
Bottom Line: The ability of a small dose of calcium and vitamin D to prevent fractures in healthy community-dwelling women is modest at best. This study used a relatively low dose of vitamin D (less than the 700 to 800 IU found most beneficial in previous studies), and the patients were generally at low risk of fracture. Perhaps that explains the discordance of these findings with the bulk of the literature on this topic. (Level of Evidence: 1b)
Jackson RD , et al., for the Women's Health Initiative Investigators. Calcium plus vitamin D supplementation and the risk of fractures [Published correction appears in N Engl J Med 2006;354:1102]. N Engl J Med February 16, 2006;354:669-83.
http://www.aafp.org/afp/20060601/tips/19.html
Patient Information
Testosterone Therapy: What You Should Know
http://www.aafp.org/afp/20060501/1591.html
Microscopic Hematuria: What You Should Know
http://www.aafp.org/afp/20060515/1759ph.html
Is a Low-Carbohydrate Diet Right for Me?
http://www.aafp.org/afp/20060601/1951ph.html
Gonorrhea: What You Should Know
http://www.aafp.org/afp/20060515/1786ph.html
Opioid Addiction: What You Should Know
http://www.aafp.org/afp/20060501/1580ph.html
High Blood Pressure: What You Should Know
http://www.aafp.org/afp/20060601/1957ph.html
Perinatology Picks - George Gilson, Maternal Fetal Medicine, ANMC
Cesarean delivery rate: Continues to increase without improving population outcomes
Attempts to define, or enforce, an "ideal" cesarean delivery rate are futile, and should be abandoned. The cesarean rate is a consequence of individual value-laden clinical decisions, and is not amenable to the methods of evidence-based medicine. The influence of academic authority figures on the cesarean rate in the US is placed in historic context. Like other population health indices, the cesarean deliver rate is an indirect result of American public policy during the last century. Without major changes in the way health and maternity care are delivered in the US, the rate will continue to increase without improving population outcomes.
An RCT requires a hypothesis that is testable in the real world: it should be simple, specific, and stated in advance. On those grounds, there is no direct way to test the hypothesis that there is an ideal cesarean delivery rate. Because the cesarean rate is calculated post-hoc, it is also impossible to design a prospective trial comparing specific cesarean rates. Conceptually, one might set up a large RCT with multiple arms, each having a different proportion of women by intended method of delivery, e. g., 100% elective cesarean versus 0% planned vaginal birth, 80/20, 50/50, etc. For specified outcome variables, an ideal cesarean rate could then be estimated retrospectively. It is clear that the ideal rate will depend on which women are studied, and how much weight is given to maternal versus fetal morbidity—all subjective criteria.
Cyr RM. Myth of the ideal cesarean section rate: commentary and historic perspective. Am J Obstet Gynecol. 2006 Apr;194(4):932-6.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=
Retrieve&db=pubmed&dopt=Abstract&list_uids=16580278
OB/GYN CCC Editorial comment:
Patient-choice vaginal delivery? (See also the Oklahoma Perspective)
As Dr. Gilson points out the rapidly increasing cesarean rate does not improve commonly measured patient outcomes. Zweifler et al confirm that trend in this 1996 through 2002 California study of the Birth Statistical Master Files were used to identify 386,232 California residents who previously gave birth by cesarean delivery and had a singleton birth planned in a California hospital. (Results below)
Here is an excerpt from a Reflection by Dr. Larry Leeman and Dr. Lauren Plante from the May/June Annals of Family Medicine:
Patient-choice cesarean delivery is increasing in the United States. The American College of Obstetricians and Gynecologists supports this option, citing ethical premises of autonomy and informed consent, despite a lack of evidence for its safety. This increase in patient-choice cesarean delivery occurs during a time when women with a breech-presenting fetus or a previous cesarean deliver have fewer choices as to vaginal birth. Patient-choice cesarean delivery may become widely disseminated before the potential risks to women and their children have been well analyzed. The growing pressure for cesarean delivery in the absence of a medical indication may ultimately result in a decrease of women’s childbirth options. Advocacy of patient-choice requires preserving vaginal birth options as well as cesarean delivery.
Leeman LM, Plante LA. Patient-choice vaginal delivery? Ann Fam Med. 2006 May-Jun;4(3):265-8. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=
Retrieve&db=pubmed&dopt=Abstract&list_uids=16735530
CONCLUSIONS: Neonatal and maternal mortality rates did not improve despite increasing rates of repeat cesarean delivery during the years after the ACOG 1999 VBAC guideline revision. Women with infants weighing > or =1,500 g encountered similar neonatal and maternal mortality rates with VBAC or repeat cesarean delivery.
Zweifler J, et al Vaginal birth after cesarean in California: before and after a change in guidelines. Ann Fam Med. 2006 May-Jun;4(3):228-34.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd
=Retrieve&db=pubmed&dopt=Abstract&list_uids=16735524
Shifts in primary cesarean rates were not related to shifts in maternal risk profiles
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/530788
Tocolysis after 32 weeks gestation does not reduce neonatal hospital stay
RESULTS: The 2 groups had similar mean cervical dilation and gestational age at enrollment. There were no statistically significant differences in total neonatal hospital stay (5.8 +/- 7.2 days; median of 3 days in the no tocolysis vs. 7.5 +/- 8.6 days; median of 3 days in the tocolysis group), rate of preterm delivery (57% vs. 75%) or need for oxygen supplementation (7% vs. 21%, p < 0.23). The neonatal complications were similar in each group. CONCLUSION: Tocolysis after 32 weeks gestation does not reduce neonatal hospital stay.
How HY, et al Tocolysis in women with preterm labor between 32 0/7 and 34 6/7 weeks of gestation: a randomized controlled pilot study. Am J Obstet Gynecol. 2006 Apr;194(4):976-81.
Vaginal delivery of singleton fetuses in breech presentation at term remains a safeoption
RESULTS: Cesarean delivery was planned for 5579 women (68.8%) and vaginal delivery for 2526 (31.2%). Of the women with planned vaginal deliveries, 1796 delivered vaginally (71.0%). The rate of the combined neonatal outcome measure was low in the overall population (1.59%; 95% CI [1.33-1.89]) and in the planned vaginal delivery group (1.60%; 95% CI [1.14-2.17]). It did not differ significantly between the planned vaginal and cesarean delivery groups (unadjusted odds ratio = 1.10, 95% CI [0.75-1.61]), even after controlling for confounding variables (adjusted odds ratio = 1.40, 95% CI [0.89-2.23]).
CONCLUSION: In places where planned vaginal delivery is a common practice and when strict criteria are met before and during labor, planned vaginal delivery of singleton fetuses in breech presentation at term remains a safe option that can be offered to women.
Goffinet F, et al Is planned vaginal delivery for breech presentation at term still an option? Results of an observational prospective survey in France and Belgium. Am J Obstet Gynecol. 2006 Apr;194(4):1002-11.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=
Retrieve&db=pubmed&dopt=Abstract&list_uids=16580289
Glyburide and insulin: Equally efficient for treatment of GDM in all levels of severity
STUDY DESIGN: In a secondary analysis of our previous randomized study, 404 women were analyzed. The association among glyburide dose, severity of GDM, and selected maternal and neonatal factors was evaluated. Severity levels of GDM were stratified by fasting plasma glucose (FPG) from the oral glucose tolerance test (OGTT). Infants with birth weight at or above the 90th percentile were considered large-for-gestational age (LGA). Macrosomia was defined as birth weight > or =4000 g. Well-controlled was defined as mean blood glucose < or =95 mg/dL. The association between glyburide- and insulin-treated patients by severity of GDM and neonatal outcome was evaluated.
CONCLUSION: Glyburide and insulin are equally efficient for treatment of GDM in all levels of disease severity. Achieving the established level of glycemic control, not the mode of pharmacologic therapy, is the key to improving the outcome in GDM
Langer O et al Insulin and glyburide therapy: dosage, severity level of gestational diabetes, and pregnancy outcome. Am J Obstet Gynecol. 2005 Jan;192(1):134-9.
Improve patient safety, prevent medical errors and resolve the professional liability crisis
The current professional liability crisis is the third in the last 30 years. Similarities of the 3 crises are the rising cost of professional liability insurance and a diminishing number of sources available to purchase coverage. Proposed tort reform with caps on noneconomic damages and attorney contingency fees is a back end approach and will do little to solve this crisis or prevent future ones. The current situation can only be solved by placing an increased emphasis on improving patient safety and elimination of all preventable medical errors. A national electronic medical record must be developed and rapid response teams need to be available in most hospitals. The protective devices of privileged communication and peer review are counterproductive and must be eliminated. Full and prompt disclosure of any medical error or injury needs to be made. Physicians must be taught proper communication skills and the importance of teamwork. Providers with frequent patient, nursing or medical staff complaints must be critically reviewed. The present system of risk management needs to move from a reactive position to a role of being proactive for both patient and physician. Claims management should offer the patient early compensation when appropriate and pursue a vigorous defense when medical care is adequate. Experts should be identified who will render fair, unbiased reviews of medical care with all of their findings being disclosed. Similar experts need to devise clear, concise, evidenced based standards of care for common medical conditions.
Weinstein L. A multifacited approach to improve patient safety, prevent medical errors and resolve the professional liability crisis. Am J Obstet Gynecol. 2006 Apr;194(4):1160-5; discussion 1165-7.
Progestational agents in second trimester may reduce preterm birth in women at risk
RESULTS: Three trials were eligible for inclusion. There was a significant reduction in risk of delivery less than 37 weeks with progestational agents (relative risk [95% CI] = 0.57 [0.36-0.90]). There was no significant effect on perinatal mortality or serious neonatal morbidity.
CONCLUSION: Progestational agents, initiated in the second trimester of pregnancy, may reduce the risk of delivery less than 37 weeks' gestation, among women at increased risk of spontaneous preterm birth, but the effect on neonatal outcome is uncertain. Larger randomized controlled trials are required to determine whether this treatment reduces perinatal mortality or serious neonatal morbidity.
Mackenzie R, et al Progesterone for the prevention of preterm birth among women at increased risk: a systematic review and meta-analysis of randomized controlled trials. Am J Obstet Gynecol. 2006 May;194(5):1234-42
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=
Retrieve&db=pubmed&dopt=Abstract&list_uids=16647905
SSRIs in pregnancy increase low birth weight, preterm birth, fetal death, and seizures
RESULTS: The risks of low birth weight (adjusted odds ratio, 1.58; 95% CI, 1.19, 2.11), preterm birth (adjusted odds ratio, 1.57; 95% CI, 1.28, 1.92), fetal death (adjusted odds ratio, 2.23; 95% CI, 1.01, 4.93), and seizures (adjusted odds ratio, 3.87; 95% CI, 1.00, 14.99) were increased in infants who were born to mothers who had received selective serotonin reuptake inhibitor therapy.
CONCLUSION: The use of selective serotonin reuptake inhibitors in pregnancy may increase the risks of low birth weight, preterm birth, fetal death, and seizures.
Wen SW et al Selective serotonin reuptake inhibitors and adverse pregnancy outcomes. Am J Obstet Gynecol. 2006 Apr;194(4):961-6.,
Primary Care Discussion Forum
September 1, 2006: Palliative Medicine's Role in the Continuity of Care
Moderator: Tim Domer, M.D.
- Management of acute vs chronic pain
- Quality of Life in chronic illness
- The meaning of "Code Status"
- Preparing for a "Good Death"
- End-of-Life Care as part of Continuity of Care and Prevention
http://www.ihs.gov/MedicalPrograms/MCH/F/PCdiscForum.cfm#
Thanks very much to Andy Hsi for his hard work and thoughtful approach to the Adverse Events of Childhood discussion. The captured discussion and summary are 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
HIV Testing and Additional Analysis of National Survey on HIV/AIDS
The Centers for Disease Control and Prevention (CDC)’s reported plans to
recommend routine HIV testing for patients in health care settings will mark
a major change in the way HIV testing is conducted in the United States
and is intended to increase testing nationwide. Given that an estimated one
in four of the more than one million people living with HIV/AIDS in the U.S.
do not know they are infected, increased testing could help more people learn
they are HIV positive, linking them to necessary care and services and
leading to reduced risk behaviors. In order to help inform discussions about
expanded testing, the Kaiser Family Foundation is releasing additional data
from its "2006 Survey of Americans on HIV/AIDS"
http://www.kff.org/kaiserpolls/pomr050806pkg.cfm
"HIV Testing: 2006 Kaiser Family Foundation Survey of Americans on HIV/AIDS"
-- New public opinion data finds that two-thirds of the public (65%) say HIV
testing should be treated just like routine screening for other diseases,
while about one-quarter (27%) say it should require special procedures, such
as written permission from the patient. The survey also found that most
people (65%) think rapid home HIV-testing is a good idea, but when asked
their personal preference, most (62%) would still prefer to get tested in a
doctor’s office rather than use a home test. http://www.kff.org/kaiserpolls/7521.cfm
"Opinions and Experiences of 18-25 Year Olds: 2006 Kaiser Family Foundation
Survey of Americans on HIV/AIDS" -- New analysis of public opinion data finds
that large shares of 18-25 year olds would like to have more information
about the different kinds of HIV tests available (60%); where to go to get
tested (54%); how to protect their privacy when getting an HIV test (51%);
and how to bring up the topic of getting tested with a partner (43%). This
report also examines young peoples' views on a wide variety of issues related
to HIV in addition to testing. http://www.kff.org/kaiserpolls/7522.cfm
" HIV Testing in the U.S." -- An updated fact sheet that provides key testing
statistics and outlines testing recommendations and requirements, state-by-
state policies, and different testing techniques.
The fact sheet is available athttp://www.kff.org/hivaids/6094.cfm
State-by-state data on HIV testingwww.statehealthfacts.org/r/hivtesting.cfm
These two new reports are based on subsets of the full survey. http://www.kff.org/kaiserpolls/pomr050806pkg.cfm
Most teenagers with chlamydial infections receive appropriate antibiotics, but fewer receive other recommended care
http://www.ahrq.gov/research/apr06/0406RA14.htm
Social Networks Testing: Strategy for Identifying Persons with Undiagnosed HIV Infection
One strategy for reaching and providing HIV CTR to persons with undiagnosed HIV infection is the use of social networks. Enlisting HIV-positive or high-risk HIV-negative persons (i.e., recruiters) to encourage people in their network (i.e., network associates) to be tested for HIV may provide an efficient and effective route to accessing individuals who are infected, or at very high risk for becoming infected, with HIV and linking them to services. The social network approach has proven to be a viable recruitment strategy for reaching people beyond current partners. http://www.cdc.gov/hiv/resources/guidelines/snt/index.htm
Diagnosis and Treatment of Neisseria gonorrhoeae Infections (see Patient Education)
The most common site of Neisseria gonorrhoeae infection is the urogenital tract. Men with this infection may experience dysuria with penile discharge, and women may have mild vaginal mucopurulent discharge, severe pelvic pain, or no symptoms. Other N. gonorrhoeae infections include anorectal, conjunctival, pharyngeal, and ovarian/uterine. Infections that occur in the neonatal period may cause ophthalmia neonatorum. If left untreated, N. gonorrhoeae infections can disseminate to other areas of the body, which commonly causes synovium and skin infections. Disseminated gonococcal infection presents as a few skin lesions that are limited to the extremities. These legions start as papules and progress into bullae, petechiae, and necrotic lesions. The most commonly infected joints include wrists, ankles, and the joints of the hands and feet. Urogenital N. gonorrhoeae infections can be diagnosed using culture or nonculture (e.g., the nucleic acid amplification test) techniques. When multiple sites are potentially infected, culture is the only approved diagnostic test. Treatments for uncomplicated urogenital, anorectal, or pharyngeal gonococcal infections include cephalosporins and fluoroquinolones. Fluoroquinolones should not be used in patients who live in or may have contracted gonorrhea in Asia, the Pacific islands, or California, or in men who have sex with men. Gonorrhea infection should prompt physicians to test for other sexually transmitted diseases, including human immunodeficiency virus. Am Fam Physician 2006;73:1779-84, 1786.
http://www.aafp.org/afp/20060515/1779.html
Barbara Stillwater, Alaska State Diabetes Program
Women Who Don't Snooze Enough Gain Weight
Not enough sleep for women may lead to extra pounds over the years, researchers reported.
Women who slept five hours or less per night gained 1.14 kg (2.5 lb) more than women who got in at least seven hours each night. The investigators found that weight gain appeared to have something of a dose-dependent effect. Women who slept six hours gained 0.71 1 kg (1.6 lbs) compared with women who slept for seven hours or more. The average weight gain in the women who slept the least may not sound like much, but it is an average amount. Some women gained much more than that, and even a small difference in weight can increase a person's risk of health problems such as diabetes and hypertension. Less sleep may also affect the basal metabolism rate to lower energy expenditures in those who get less rest. NB: This study was published as an abstract and presented orally at a conference. These data and conclusions should be considered to be preliminary as they have not yet been reviewed and published in a peer-reviewed publication.
Practice Pearl:
- Those who slept only five hours per night gained significantly more weight, and gained weight at a more rapid pace over 16 years, than women who slept seven or more hours per night.
2006 American Thoracic Society Annual Meeting: Patel SR et al. "Short Sleep is a Risk Factor for Weight Gain" Presented May 23, 2006 http://www.thoracic.org/
What's new on the ITU MCH web pages?
Is a fetal ultrasound survey indicated for all patients routinely?
Impromptu Discussion – Primary Care Forum
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
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
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
- 14 months away and counting
- Want a topic discussed? Contact nmurphy@scf.cc
Did you miss something in the last OB/GYN Chief Clinical Consultant Corner?
The May 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.
