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Volume 4, No. 8, August 2006
Features
American Family Physician**
Norethindrone More Effective for Menses Suppression
Clinical Question: Do oral contraceptives containing norethindrone acetate or levonorgestrel differ in their effect on suppression of menses with continuous use?
Synopsis: There were 139 women enrolled in this double-blind, four-arm trial of oral contraceptives used continuously for 180 days for the purpose of suppressing menstrual periods. The estrogen used in all study arms was ethinyl estradiol (E2), which could be at a dose of 20 mcg or 30 mcg. The progestin was 1 mg norethindrone acetate (Loestrin) or 100 mcg levonorgestrel (Seasonale). The four study arms included: (1) norethindrone acetate plus 20 mcg ethinyl E2; (2) norethindrone acetate plus 30 mcg ethinyl E2; (3) levonorgestrel plus 20 mcg ethinyl E2; and (4) levonorgestrel plus 30 mcg ethinyl E2.
All study participants had used cyclic oral contraceptives for at least three months before randomization. This study had an overall drop-out rate of 45 percent. More days of amenorrhea were recorded in the norethindrone acetate groups, with no difference between the lower versus higher estrogen dosing (mean days of amenorrhea during 180 days' use: norethindrone acetate plus 20 mcg ethinyl E2 = 164, levonorgestrel plus 20 mcg ethinyl E2 = 151; P = .02).
Bottom Line: In continuous dosing regimens, more days of amenorrhea can be achieved with oral contraceptives containing 1 mg norethindrone acetate than with oral contraceptives containing 100 mcg levonorgestrel. (Level of Evidence: 2b)
http://www.aafp.org/afp/20060715/tips/6.html
Fecal Occult Blood Testing in Healthy Patients Does Not Reduce Mortality
Clinical Question: Does fecal occult blood testing (FOBT) reduce all-cause mortality?
Synopsis: The idea behind screening tests is that they may detect something in otherwise healthy persons that will help them live longer, making all-cause mortality the most important outcome measure of any screening. This study tried to determine if FOBT reduces all-cause mortality. The authors combined data from three large published randomized trials of FOBT: one Danish, one British, and one American. All studies compared FOBT, performed every two years, with no screening.
The British and Danish studies used unrehydrated FOBT in adults 45 to 75 years of age; the American study used rehydrated FOBT in adults 50 to 80 years of age. All three studies monitored patients for a mean of 12 years; which means that 245,217 persons were followed up for more than 3 million patient years. Overall, there was a 13 percent relative reduction in colorectal cancer mortality. In absolute terms, dividing the total colorectal cancer deaths by total participants, that is 0.82 versus 0.94 percent (P = .002; number needed to treat = 833 for 12 years).
There was a 1.9 percent relative increase in noncolorectal cancer deaths in the nonscreened group, and no overall difference between groups in all-cause mortality (26.51 for screened and 26.46 for nonscreened patients). Potential explanations for this paradox include unintended consequences of screening (e.g., failure of the patient to adopt a healthier lifestyle because he or she has been screened, mortality from follow-up colonoscopy) and better identification of colorectal cancer as a cause of death in screened patients.
Bottom Line: Screening for colorectal cancer using FOBT does not reduce all-cause mortality. This is important when considering whether to screen healthy patients. (Level of Evidence: 1a)
http://www.aafp.org/afp/20060715/tips/1.html
Mammography Results in Overdiagnosis of Breast Cancers
Clinical Question: Does screening mammography result in the identification and treatment of breast cancers that would never be apparent clinically?
Synopsis: There are two possible harmful outcomes of screening for breast cancer. The first is a false-positive result, telling a woman she may have breast cancer only to find out on biopsy that she does not. A more subtle negative outcome is the risk of overdiagnosis, in which breast cancer is detected by mammography in a woman who would otherwise have lived her life never knowing that she had breast cancer. The authors conducting this analysis used the results of the Malmo mammographic screening trial. Over 10 years, 42,283 women were enrolled in the trial and randomized to receive mammography or no mammography. Follow-up continued for another 15 years.
As would be expected, significantly more women receiving mammography were identified as having breast cancer than were nonscreened women. However, there continued to be more diagnoses of breast cancer in the screened group than in the nonscreened group, even though during follow-up women in both groups had regular mammography. Because any woman diagnosed with breast cancer was no longer part of the screening group, the initially unscreened women should have caught up and had more breast cancers identified when they started regular mammography. That they did not indicates that overdiagnosis occurred in the women initially assigned to the screening group.
Overall, about 10 percent (95% confidence interval, 1 to 18 percent) of the women who had mammography and were diagnosed with breast cancer were overdiagnosed, meaning they would never have known they had breast cancer-or have received treatment-except for the screening program.
Bottom Line: In addition to the possibility of having a false-positive result on mammography sometime in her life, one in 10 women who has a real diagnosis of breast cancer undergoes treatment that, although seemingly curative, ultimately has no beneficial effect on her because she would never have developed clinically apparent breast cancer. (Level of Evidence: 2b)
http://www.aafp.org/afp/20060801/tips/6.html
Omega-3 Fats Do Not Affect Mortality Rates
Clinical Question: Does supplementation with omega-3 fatty acids decrease mortality, cardiovascular disease, or cancer in adults?
Setting: Various (meta-analysis)
Study Design: Systematic review
Synopsis: In this update of a previous Cochrane review, authors identified 48 randomized controlled trials and 41 cohort studies evaluating the effect of fish oil supplementation on overall mortality, cardiovascular disease, and cancer in adults. The authors identified these studies through the usual Cochrane methodology and analyzed the results from randomized trials separately from cohort data. The studies included patients with or without preexisting coronary heart disease. As a result, the authors combined primary and secondary prevention research.
Omega-3 fatty acids were given as supplements or a recommendation was made to eat more oily fish. In randomized trials enrolling more than 30,000 patients, omega-3 supplementation did not significantly reduce mortality (relative risk [RR] = 0.87; 95% confidence interval [CI], 0.73 to 1.03) or the likelihood of a cardiovascular event (RR = 1.09; CI, 0.87 to 1.37). Long-chain omega-3 fatty acids did not produce results different from short-chain fats. Cancer was neither increased nor decreased in clinical trials or cohort studies. The lack of benefit demonstrated in this study conflicts with the results of an earlier meta-analysis of the effect in patients with coronary heart disease (Bucher HC, et al. N-3 polyunsaturated fatty acids in coronary heart disease: a meta-analysis of randomized controlled trials. Am J Med 2002;112:298-304). However, this is the second study published after the meta-analysis that did not find a benefit overall.
Bottom Line: Overall, omega-3 fatty acid supplementation does not decrease mortality or cardiovascular disease compared with placebo. This study combined primary and secondary prevention; that is, it included persons with or without coronary heart disease.
(Level of Evidence: 1a) http://www.aafp.org/afp/20060801/tips/1.html
Screening for Iron Deficiency Anemia, Including Iron Supplementations for Children and Pregnant Women
U.S. Preventive Services Task Force Recommendation Statement
The USPSTF concludes that evidence is insufficient to recommend for or against routine screening for iron deficiency anemia in asymptomatic children six to 12 months of age.
I recommendation.
The USPSTF recommends routine screening for iron deficiency anemia in asymptomatic pregnant women.
B recommendation.
http://www.aafp.org/afp/20060801/us.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
Induction of Labor for Vaginal Birth After Cesarean Delivery (see Abstract of the Month)
ABSTRACT: Induction of labor in women who have had cesarean deliveries may be necessary because of fetal or maternal indications. The potentially increased risk of uterine rupture should be discussed with the patient and documented in the medical record. Selecting women most likely to give birth vaginally and avoiding the sequential use of prostaglandins and oxytocin appear to offer the lowest risks. Misoprostol should not be used in patients who have had cesarean deliveries or major uterine surgery.
Induction of labor for vaginal birth after cesarean delivery. ACOG Committee Opinion No. 342. American College of Obstetricians and Gynecologists. Obstet Gynecol 2006;108:465–67.
Management of alloimmunization during pregnancy. ACOG Practice Bulletin
Recommendations and Conclusions
The following recommendations are based on good and consistent scientific evidence (Level A):
- In a center with trained personnel and when the fetus is at an appropriate gestational age, Doppler measurement of peak systolic velocity in the fetal middle cerebral artery is an appropriate noninvasive means to monitor pregnancies complicated by red cell alloimmunization.
- The initial management of a pregnancy involving an alloimmunized patient is determination of the paternal erythrocyte antigen status.
- Serial titers are not useful for monitoring fetal status when the mother has had a previously affected fetus or neonate.
- Antibody titers are not appropriate for monitoring Kell-sensitized patients because Kell antibodies do not correlate with fetal status.
- Anti-D immune globulin is indicated only in Rh-negative women who are not previously sensitized to D.
Management of alloimmunization during pregnancy. ACOG Practice Bulletin No. 75. American College of Obstetricians and Gynecologists. Obstet Gynecol 2006;108:457–64.
Psychosocial Risk Factors: Perinatal Screening and Intervention
ABSTRACT: The American College of Obstetricians and Gynecologists advocates assessing for psychosocial risk factors and helping women manage psychosocial stressors as part of comprehensive care for women. Psychosocial screening of all women seeking pregnancy evaluation or prenatal care should be performed regardless of social status, educational level, or race and ethnicity. Because problems may arise during the pregnancy that were not present at the initial visit, it is best to perform psychosocial screening at least once each trimester to increase the likelihood of identifying important issues and reducing poor birth outcomes. When screening is completed, every effort should be made to identify areas of concern, validate major issues with the patient, provide information, and, if indicated, make suggestions for possible changes. When necessary, the health care provider should refer the patient for further evaluation or intervention. Psychosocial risk factors also should be considered in discharge planning after delivery. Many of the psychosocial issues that increase the risk for poor pregnancy outcome also can affect the health and welfare of the newborn. Screening should include assessment of barriers to care, unstable housing, unintended pregnancy, communication barriers, nutrition, tobacco use, substance use, depression, safety, intimate partner violence, and stress.
Psychosocial risk factors: perinatal screening and intervention. ACOG Committee Opinion No. 343. American College of Obstetricians and Gynecologists. Obstet Gynecol 2006;108:469–77.
AHRQ
More data are needed to better identify health care disparities among American Indians and Alaska Natives
http://www.ahrq.gov/research/jun06/0606RA5.htm
Increasing cervical cancer screening intervals is cost-effective for women with three consecutive normal Pap smears
http://www.ahrq.gov/research/jun06/0606RA13.htm
Use of ACE inhibitors during the first trimester of pregnancy is related to an increased risk of birth defects
http://www.ahrq.gov/research/jun06/0606RA1.htm
Ask A Librarian: Diane Cooper, M.S.L.S. / NIH
New on Your Library Website
Daily Health Policy News Summaries
You might notice something different when you go to your HSR Library website. Headlines now appear at the top of the Features Panel. Click on the headline links and you will go to news summaries on the latest in women’s health policy, health policy in general, and HIV/AIDS news. These summaries provide further links to the actual full-text articles and papers on the subject.
These news summaries are called the Kaiser Daily Health Reports, and are written and published by a for-profit organization, The Advisory Board Company, for the Henry J. Kaiser Family Foundation. The Reports are free and we have a trial subscription. Take a look and give some feedback on rather this service is useful or not to you.
Filter Preferences in PubMed
When you conduct a literature search in PubMed, you can use LIMITS to limit your subject search to humans, English language only, publication years, age groups and other limits. After you enter GO, your retrieval page will now show two default tabs above the results, “All” and “Review”. The “All” tab includes all citations found on the subject you typed into the search box; the “Review” tab will show you only those citations in the “All” group that are review articles.
What’s new is this: Now you can group your search results further by areas of interest using Filter Preferences. To get to the Filter Preference page, click on the tiny hammer/wrench icon located next to the “Review” tab. You will now be in My NCBI (formerly “My Cubby”), where you will need to login using your user name and password. If you haven’t registered, you will need to create your user name and password.
On the Filter Preference page, you can click on Browse to further select areas of interest. For example in the Properties Group under Clinical Queries you may select “diagnosis” or “therapy” among many possibilities. Another example in the Properties Group under the category, Health Services Research Queries is “Outcomes Assessment.”
Here’s an example. Let’s look for articles on vitamin D and diet using the “Outcomes Assessment” filter. When you hit the Go, your search retrieval will now show 3 tabs:
“All” tab; “Review” tab; and “Outcomes Assessment” tab.
Tip: If you want to see citations that fit two or more categories (e.g., aged and outcomes assessment), use LIMIT to select “aged” and then go on to the FILTER PREFERENCE page and select the filter “Outcomes Assessment.” Using the LIMIT selection for “aged” will guarantee that the citations in the “Outcomes Assessment” tab are only “aged.” On the other hand, if you were to select “aged” in the FILTER PREFERENCE page, then you would see “aged” as a tab and all articles key-worded to “aged” are in this group of search results. Under the “Outcomes Assessment” tab will be “aged” and “not aged” in the citations.
Another Tip: Through the magic of cookies and central memory, your tab selections will stay with you for your next search. You can always delete a tab selection by checking on “My Selections.”
If you need help using this feature or any of the electronic resources available to you through the HSR Library, please email me at cooperd@mail.nih.gov
Breastfeeding - Suzan Murphy, PIMC
Early Milk Supply Issues
Providers who work with new families usually hear lots of versions about “not enough milk” concerns. Phrases like:
- I don’t think that I have enough milk
- I don’t think I have any milk because I didn’t leak while I was pregnant
- My breasts are flat
- There is nothing coming out
- The baby is hungry all the time
usually mean that the mom/family is worried, scared, and unaware of how to know if their baby is getting enough to eat. The following are ways to assess adequate intake and help guide families in the first weeks.
Reasonable expectations for intake and feeding behavior in a normal, healthy baby are:
- Birth – 24 hours
- Effective latch at birth, lots of sleep, and sleepy feeds. 2-3 feedings (including latch at birth) in the first 24 hours is success.
- 24 hours and until the white ("mature") milk comes in
- The first milk, colostrum is thick (like honey), hard to suck out, and harder to see. The average amount consumed at each feeding is 5 cc (1 tsp). The baby's stomach size is 5-10cc at birth, expanding to about 60 cc (2 oz) at 1 week. The mother's colostrum and white milk production increases as the baby's stomach expands.
- Feedings averaging every 2-3 hours – 8-12 times in 24 hours are important - they help insure adequate intake and stimulate the mom's milk supply. Wake the baby as needed.
- Frequent feedings are normal. Babies often get fussy at feedings, perhaps because their mouths are tired from learning how to suck. They get stronger quickly. It will be easier once the white milk comes in.
- Expect one diaper change for every day of life. For example if the baby is 3 days old, 3 diaper changes tells the mom that the baby is getting enough.
- By 2-5 days, the white milk is in.
- Encourage the mom to feed every 2-3 hours to help prevent engorgement and insure adequate intake for the baby.
- Watch for one diaper change for every day of life – up to 6 or more in 24 hours – this tells that mom that the baby is getting enough.
- Once the baby is waking to eat, and diaper changes are 6 or more in 24 hours, the mom can relax a little and feed the baby on demand.
- Watch for:
- < 7% weight loss in the first several days.
- Birth weight re-gained by 2 weeks.
- Weight gain of ½ oz to 1 oz per day in the first 3-6 months to double birth weight at 4-6 months and triple by one year.
- Growth spurts happen every couple weeks. The baby will suddenly want to eat more, all the time. The feeding frenzy will last 1-2 days, the mom's milk supply will increase to meet the need, and things will be fine.
- If the family wants to supplement, encourage them to use caution. Supplementing in the first weeks can undermine the mom's body's ability to maintain her supply.
- By 6-8 weeks, the baby' stomach is bigger, and the suck is much more efficient. Also the mom's body has become accustomed to the milk being there. The feedings are much shorter and less frequent, the mom's breasts are softer, and the leaking is almost gone. Breastfeeding is much easier.
Schanler R et al. Breastfeeding Handbook for Physicians, American Academy of Pediatrics and American college of Obstetricians and Gynecologists. 2006
Biancuzzo M. Breastfeeding the Newborn: Clinical Strategies for Nurses, Mosby Publishing, 2003.
Other
Breastfeeding Basics: Generalist to Generalist
Date: August 31, 2006
Time: 1:00 pm Eastern, 12:00 pm Central, 11:00 am Mountain, 10:00 am Pacific
American Academy of Pediatrics Breastfeeding Promotion in Physicians’ Office Practices Program Phase III (BPPOP III) Teleconference
The BPPOP III Program is delighted to bring you a teleconference concerning breastfeeding support and management in your office setting. As physicians who have made breastfeeding support and management a priority in their practices, Sharon Mass, MD, FACOG, Liaison to the Section on Breastfeeding from the American College of Obstetricians and Gynecologists, Jenny Thomas, MD, IBCLC, FAAP, Wisconsin Chapter Breastfeeding Coordinator, and Margreete Johnston, MD, FAAP, Tennessee Chapter Breastfeeding Coordinator, will walk you through breastfeeding basics, generalist to generalist. These are busy practitioners making it work in their practice. If they can do it, so can you!
During this teleconference, participants will learn how to:
- encourage and support breastfeeding before and during pregnancy
- fit breastfeeding assessment and management into your office visits
- weave a web of breastfeeding support and resources in your community
Because the BPPOP III program is dedicated to serving racially/ethnically diverse populations, we would like to recruit participants to these teleconferences that serve these populations, however all health care providers are encouraged to sign-up if there is an interest. One week prior to the call you will receive call-in information and call materials.
If you are interested in participating in the teleconference please email Becky Ramsey, Breastfeeding Initiatives Program Coordinator, atbramsey@aap.org
CCC Corner Digest
Nicely laid out hard copy - A compact digest of last month’s CCC Corner
July 2006 Highlights include
- Refusals by pharmacists to dispense emergency contraception
- How to address health disparities? One story of success
- Pendulum swing: Vaginal breech delivery approved within guidelines
- CDC’s Advisory Committee Recommends Human Papillomavirus Virus Vaccination
- New Guidelines for Pediatric and Neonatal Emergency Cardiovascular Care
- Driving, Other Erratic Behaviors Reported After Taking Zolpidem (Ambien)
- Planned Early Birth vs. Expectant Management for PROM
- William H. J. Haffner American Indian / Alaska Native Women’s Health Award
- Pain is one the reasons that moms quit breastfeeding in the first 2 weeks
- Injectable Contraception and Skeletal Health
- Hospital Computer Keyboards Should Be Disinfected Daily
- Where There is No Doctor & A Book for Midwives
- Copious post operative mucous secretions: The rest of the story
- Nuchal cords, somersaults, and the value of a pulsing cord: Nuchal Cord Management
- Methamphetamine abuse among women on Navajo: Part IV - The “Drop- in” gravida
- The Association of Nurses in Aids Care
- IHS Division of Epidemiology and Disease Prevention Launches New Website
- Osteoporosis Guidelines Updated: North American Menopause Society
- Only 29% of ACOG recommendations are level A: Good and consistent scientific evidence
- September 1, 2006: Palliative Medicine's Role in the Continuity of Care
- Focus on adolescent sexual behavior this month
- Diabetes Is The Clinical Equivalent of Aging 15 Years
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/06JulOL.pdf
If you want a copy of the CCC Digest mailed to you each month, please contact nmurphy@scf.cc
Domestic Violence
Randomized trial assesses screening for intimate partner violence in health settings
The findings from this study examining 3 approaches to IPV [intimate partner violence] screening in health care settings suggest that the face-to-face approach is the least preferred by women, irrespective of instrument.
The authors found that
* Twelve-month prevalence of IPV ranged from 4.1% to 17.7%, depending on screening method, instrument, and health care setting.
* Prevalence was significantly lower on the written WAST than on the PVS.
* Lower levels of missing data occurred for the WAST vs. the PVS and for the written method vs. the face-to-face and computer-based methods combined.
* On all three evaluation indicators (easy, preferred, private), women chose computerized and written methods over face-to-face questioning.
* The positive predictive value of the WAST was minimally higher than that of the PVS, and the negative predictive values were almost the same, leading to very similar accuracies.
Prevalence, missing data, and preference are all important considerations for both clinical and research efforts in IPV screening.
MacMillan HL, Wathen CN, Jamieson E, et al. 2006. Approaches to screening for intimate partner violence in health care settings: A randomized trial. The Journal of the American Medical Association 296(5):530-536 http://jama.ama-assn.org/cgi/content/abstract/296/5/530?etoc
Physical Dating Violence Common Among Teens, Linked to Risky Behaviors
Nearly 1 out of 11 US high school students is subjected to physical violence from their boyfriend or girlfriend each year, the results of a nationwide survey suggest -- and boys are just as likely as girls to be the victim of such violence, according to a report in the May 19th issue of the Morbidity and Mortality Weekly Report . The study also confirms that these victims of violence have an increased prevalence of high-risk behaviors.
Physical Dating Violence Among High School Students --- United States, 2003 MMWR May 19, 2006 / 55(19);532-535 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5519a3.htm
After the Crisis - Resource Papers and Issue Briefs
As many of you are already aware, the National GAINS Center and the Center on Women, Violence and Trauma convened a highly successful expert panel meeting in Bethesda, Maryland on April 24 and 25, 2006. This meeting brought together approximately 50 individuals with professional and/or personal experience with trauma following disasters to help guide the activities of the After the Crisis disaster response initiative.
The expert panel meeting focused on the development of practical recommendations, strategies, and program concepts for providing technical assistance to states, communities, and individuals following disasters, setting the stage for planning and organizing a more effective collective response to future disasters. The overarching goal of these activities was to address what we know about how individuals, particularly those who have histories of mental health issues, justice involvement and/or previous trauma, respond to traumatic experiences.
You will find resource papers that were originally distributed at the expert panel meeting, and which have been subsequently revised to incorporate additional knowledge and recommendations from the panel at the link below. These papers, on the topics of Retraumatization, Revictimization, Peer Support, and Criminal Justice Issues, provide an overview of each of these topics as they relate to disaster response. A series of four Issue Briefs, also attached, was developed from the resource papers. The Issue Briefs provide an overview of each topic, key recommendations from the expert panel meeting and resources on the topic. Please feel free to distribute these materials. Contact Carolyn.Aoyama@ihs.gov
http://www.mentalhealth.samhsa.gov/newsroom/speeches/042406.asp
AHRQ: Primary care assessment of intimate partner violence and referrals may prevent its recurrence http://www.ahrq.gov/research/jun06/0606RA10.htm
Elder Care News
Is 75 Years an Appropriate Upper Age Limit for Mammography?
A major finding of this study is that the screening participation among elderly women is high. The outcomes of our study suggest a steadily increasing sojourn time of breast tumours beyond the age of 69, leading to a strong increase in detection of cancers, and therefore, disfavouring the balance with the benefits of screening. At present, 75 years of age can be regarded as an appropriate upper age limit for the Dutch programme.
Fracheboud J, et al Seventy-five years is an appropriate upper age limit for population-based mammography screening. Int J Cancer. 2006 Apr 15;118(8):2020-5
Elder Care Initiative Director: Editorial comment:
Fracheboud J, et al set out to better understand the risk / benefit ratio of screening mammography in women aged 70-75 when the Dutch breast cancer screening program raised its upper age limit from 69 to 75 based on models suggesting benefit to these older women. It is well known that breast cancer incidence increases with increasing age, but that cancers in older women tend to progress more slowly and that death from other causes also increases with age.
While a screening program is more likely to detect cancer in these older women than in women younger than 69, the cancers detected are less likely, without early detection, to cause death. This study (by the authors' own admission) adds little to the existing understanding, but it certainly provides no evidence to argue against screening in these older women and does point out that screening was well accepted (65.6% of women aged 70-75 accepted appointments for screening mailed to them).
An upper limit of mammography screening is supportable on a population basis but much less so when faced with the particulars of an individual patient. Walter and Covinsky provide an approach mimics (in a more formal way) the thought processes of many clinicians. They calculate the number needed to screen for women in the highest, middle, and lowest quartiles of life expectancy for selected age groups. The results can be quite striking: the number needed to screen to prevent one cancer death in an 80 year old in the highest quartile of life expectancy is quite close to that for a 50 year old woman in the lowest quartile (240 and 226 respectively). Women unlikely to benefit from mammography should not be subjected to the test or the inevitable cascade of medical events that follow, but age is not, by itself, a satisfactory indicator of likelihood of benefit. Walter and Covinsky provide an evidence-based approach for better advising our older patients.
Walter LC, Covinsky KE. Cancer screening in elderly patients: a framework for individualized decision making. JAMA. 2001 Jun 6;285(21):2750-6
Performance by Elderly on 400-Meter Walk Predicts Disability and Death
CONCLUSIONS: Older adults in the community who reported no difficulty walking had a wide range of performance on this extended walking test. Ability to do the test and performance were important prognostic factors for total mortality, cardiovascular disease, mobility limitation, and mobility disability in persons in their eighth decade.
Newman AB, et al Association of long-distance corridor walk performance with mortality, cardiovascular disease, mobility limitation, and disability. JAMA. 2006 May 3;295(17):2018-26
Second Annual American Indian and Alaska Native Long Term Care Conference
Honoring Our Elders: Best Practices in Long Term Care 2006
September 18 & 19, 2006
Tulsa , Oklahoma
This conference is designed to support the development of long term care services for Elders throughout Indian Country. Highlights include an intensive overview of the first Tribal PACE (Program of All-Inclusive Care for the Elderly) and the presentation of other promising practices in AI/AN Long Term Care.
www.aianlongtermcare.org or contact Alvin Rafaelito atAlvin@nicoa.org, 505-292-2001
Family Planning
Addressing Depression in Family Planning Services
This policy brief explores family planning programs as a possible site for incorporating interventions around depression, including screening and treatment, in reproductive age women. The brief looks at the opportunities to reach women who otherwise may have little contact with the health care system, as well as the challenges of locating these services within family planning programs, and offers a list of potential interventions and recommendations for further action for FP programs, state and local public health agencies, and mental health providers. http://www.jhsph.edu/wchpc/publications/ConsiderIntervenDepressionWomenFPP.pdf
Featured Website David Gahn, IHS Women’s Health Web Site Content Coordinator
I saw a blip in the May 2006 CCCC about the Utah website .
You think it is good? Well try Michigan’s site. It’s super!
http://www.michigan.gov/surgeongeneral/
From Barbara Stillwater Barbara_Stillwater@health.state.ak.us
Frequently asked questions
The Indian Health MCH Frequently Asked Question (FAQ) site
This site offers over 425 answers to common questions about the care of women and children in the unique settings found in Indian Country. Answers include both a quick answer and then significant background and multiple resources and links.
The site is maintained frequently (see section below) with 11 new FAQs this month and numerous existing FAQs being updated. There are 15 answers to questions on bilateral tubal ligation alone.
Go here to explore the frequently asked question page
http://www.ihs.gov/MedicalPrograms/MCH/M/mchFaqs.cfm
Indian Child Health Notes - Steve Holve, Pediatrics Chief Clinical Consultant
August 2006 Highlights
- High levels of bilirubin in newborns - more good than bad news
- The elevated risk of jaundice in AI/AN infants
- A round up of new vaccines for 2006 by Ros Singleton
- Mental Health disorders in parents of AI/AN adolescents
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ICHn806.doc
Information Technology
Hospital Computer Keyboards Should Be Disinfected Daily
CONCLUSIONS: Our data suggest that microbial contamination of keyboards is prevalent and that keyboards may be successfully decontaminated with disinfectants. Keyboards should be disinfected daily or when visibly soiled or if they become contaminated with blood.
Rutala WA, et al Bacterial contamination of keyboards: efficacy and functional impact of disinfectants. Infect Control Hosp Epidemiol. 2006 Apr;27(4):372-7.
International Health Update: Claire Wendland, Madison, WI
HIV/AIDS in Latin America and the Caribbean
This month the sixteenth international AIDS conference will be held in Toronto. In a fascinating series of articles, Science reporter Jon Cohen documents the state of the epidemic in Latin America and the Caribbean, where typical modes of transmission, economic and social conditions, and government response vary dramatically from country to country. (In Puerto Rico, for instance, injection drug use is a major vector of HIV transmission; in the Caribbean sex tourism is a significant part of the problem. In Argentina, it’s a primarily heterosexual epidemic, while in Mexico and much of the rest of Central America, men who have sex with men are the major group at risk.) Check out the stories and photographs at www.sciencemag.org/sciext/aidsamericas
Cohen’s look at Brazil is particularly interesting. When expensive multi-drug regimens first proved effective at controlling HIV in 1996, Brazil’s government inspired activists and troubled corporate leaders around the world by not only mounting a strong prevention campaign, but by promising free antiretrovirals to any citizen who needed them – in part by negotiating aggressively with BigPharma, in part by manufacturing cheap knockoffs of drugs domestically. At the time, Brazil had the worst epidemic in the region. Ten years later, HIV prevalence rates are less than half of what had been predicted, and the Ministry of Health says 90,000 deaths have been averted. But increasing drug resistance among patients on long-term antiretroviral treatment means the country is spending more and more on second-line patented medications. Many critics, both on the left and the right, believe Brazil’s universal access program will not be sustainable for much longer. Will the country be the first to break patent restrictions under the so-called “compulsory licensing” clause of the World Trade Organization’s intellectual property rights act? Though this clause was meant to ensure that countries could manufacture affordable medications in a public health emergency, no government has yet invoked it for fear of the trade sanctions that would likely follow. HIV-infected Brazilians, and health workers in poor and middle-income countries around the world, watched the Brazilian government take the lead on universal access ten years ago; they – and we – are now waiting to see what the next move will be.
Reference:
Cohen J. Brazil: ten years after. Science 313:484-7, 28 July 2006 www.sciencemag.org/cgi/content/full/313/5786/484b
The next influenza pandemic: what public health measures might help?
The “basic reproductive number” (R0) of any given virus is the average number of people infected by a single typical infected person. The higher R0, the more rapidly an epidemic will typically spread, while clearly, if R0 is less than one a disease will tend to die out. R0 depends not only on the virus itself, but on host behavior. (Body-washing burial customs in Congo significantly boosted the R0 of Ebola virus there, for instance, as did inability to sterilize medical equipment due to a devastated public health sector.) Wu and colleagues modeled mathematically which measures might mitigate the spread of the next influenza pandemic (avian or otherwise). Their goal was to help public health workers with pandemic preparedness by evaluating various strategies that have been suggested for reducing initial “first-wave” influenza attack rates. Using transmissibility data from the 1918 influenza pandemic, demographic and epidemiologic data from the present-day city of Hong Kong, and published efficacy studies of oseltamivir, the authors modeled effects of four public health measures: voluntary segregation of household contacts of a suspected case (a.k.a. quarantine); voluntary isolation of symptomatic patients – including those not ill enough to require hospitalization – in separate facilities; antiviral administration for known household exposures; and contact tracing with subsequent quarantine and antiviral administration in school, peer and work networks. None of these policies stopped the modeled epidemic, but even with only moderate (50%) compliance assumed, all improved transmission rates substantially. Voluntary household quarantine was the most effective measure modeled in reducing R0, followed by individual isolation and targeted antiviral use, while contact tracing did not add much and dramatically increased the proportion of the population in quarantine. The combination of household quarantine, isolation, and targeted antivirals was predicted to reduce the proportion of the population who became ill from 49 to 27% in the first year of epidemic influenza, while preventing about 16,000 deaths in a city the size of Hong Kong (6.8m). Modeling showed that populations with large stockpiles and effective delivery of antivirals could do almost as well without imposing isolation (but with quarantine); for those without, isolation was a vital control measure.
Reference:
Wu, JT, S Riley, C Fraser and GM Leung. Reducing the impact of the next influenza pandemic using household-based public health interventions. PLoS Medicine 3(9):e361
MCH Alert
AAP encourages implementation of new shopping cart standards to prevent child injury
The current US standard for shopping carts should be revised to include clear and effective performance criteria for shopping cart child-restraint systems and cart stability to prevent falls from carts and cart tip-overs.
AAP recommendations outlined in the policy statement include the following:
* Incorporate an effective performance standard in existing and future state and federal laws on shopping cart safety; transport children only in carts that meet this minimum safety standard.
* Encourage businesses that provide customers with shopping carts to adopt safety strategies to help prevent shopping-cart-related injuries to children.
* Educate families about the risks of transporting children in shopping carts.
* Inform the public through the media about shopping cart hazards.
* Evaluate the effectiveness of education programs and public-awareness initiatives focused on shopping cart safety.
* Until an effective revised performance standard for shopping cart safety is implemented in the United States, seek alternatives to transporting children in shopping carts.
American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention. 2006. Shopping cart-related injuries to children. Pediatrics 118(2):825-827 http://pediatrics.aappublications.org/cgi/content/abstract/pediatrics;118/2/825
Medical Mystery Tour
First trimester screening: How would you counsel this patient?
Ms. L. is a 40 y/o G1P0 at 9 weeks gestation (by a 6 week ultrasound) and is aware of her age-related risks for fetal aneuploidy. She inquires about the possibility of early screening.
Which ONE of the statements below is the most accurate way to counsel her:
A. Ultrasonic measurement of fetal nuchal translucency combined with biochemical tests between 11 and 13 weeks may detect close to 90% of chromosomally abnormal fetuses
B. Early trimester screening has a better detection rate, but a higher false positive rate, than midtrimester screening
C. Women who have first trimester screening that is negative will not need further testing
Stay tuned till next month to find out more
(or see comment below)
OB/GYN CCC Editorial comment:
For more background on this and other Prenatal genetic screening questions, please go to this free CME module which is also just a great resource
Prenatal genetic screening: Serum and ultrasound
http://www.ihs.gov/MedicalPrograms/MCH/M/TM01.cfm
Medscape*
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)
Gabapentin is an effective alternative to estrogen for the treatment of hot flushes
CONCLUSION: Despite the small scale of this study, gabapentin appears to be as effective as estrogen in the treatment of postmenopausal hot flushes. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov, NCT 00276081. LEVEL OF EVIDENCE: I.
Reddy SY, et al Gabapentin, estrogen, and placebo for treating hot flushes: a randomized controlled trial. Obstet Gynecol. 2006 Jul;108(1):41-8.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd
=retrieve&db=pubmed&list_uids=16816054
AHRQ: Menopausal hormone therapy declined after published WHI trial results
http://www.ahrq.gov/research/jun06/0606RA14.htm
Midwives Corner - Lisa Allee, CNM
VBAC: Pendulums and Ecstasy
The first article I’ll review is yet another nudge for the pendulum to swing back to sanity for VBACs in this country and the second article has some thought-provoking information on ways to enhance the natural birth process, VBAC or not, but certainly incredibly relevant to supporting women in achieving successful VBACs.
Landon, et al, in a large multi-center prospective observational study found that women with histories of multiple cesarean deliveries are not at higher risk for uterine rupture than women with single prior cesarean deliveries, 0.9% and 0.7% respectively. (Also notice how low these rates are—less than 1%, less than 1 in a hundred!!) They also found that while having had a prior vaginal delivery was protective for uterine rupture, it was not significant enough to warrant requiring this in order to be a VBAC candidate.
They did find that “the risks of other adverse maternal events (hysterectomy and transfusion) is increased in women with multiple prior cesarean deliveries, but the absolute level of these risks is small” (3.2% and 0.6% respectively.) Another finding was that pitocin induction or augmentation, epidural, and less than 2 years since the cesarean delivery were associated with higher rates of uterine rupture. Perinatal outcomes of term infants were no different in women with one or multiple prior cesarean deliveries and in women with trials of labor or elective repeat cesarean.
Ecstatic Birth
In the second article Ecstatic Birth, Sarah Buckley, MD writes eloquently and informatively about the hormonal aspects of labor, birth, postpartum, and breastfeeding. She covers oxytocin, the love hormone and mediator of all the ejection reflexes—sperm, baby, placenta, and milk; beta-endorphins, our naturally occurring analgesics levels of which rise and rise during labor; catecholamines that inhibit oxytocin and blood flow to the uterus when stimulated by fear and anxiety; and prolactin the milk and protection hormone. She discusses the ways in which this hormonal mix is essential to the normal processes of giving birth, breastfeeding, and bonding and ways that it can be supported and enhanced. She draws the parallel of the hormones of birthing a baby being the ones involved in making the baby and, thus, the possibility of ecstatic birth. She also reviews the ways in which interventions such as induction or augmentation of labor, analgesia or anesthesia, cesarean delivery, and early separation can wreak havoc on this beautifully crafted hormonal milieu.
She closes the article with a beautiful quote from Dutch professor of obstetrics G. Kloosterman:
Spontaneous labour in a normal woman is an event marked by a number of processes so complicated and so perfectly attuned to each other that any interference will only detract from the optimal character. The only thing required from the bystanders is that they show respect for this awe-inspiring process by complying with the first rule of medicine--nil nocere [do no harm].
Buckley, S Ecstatic Birth: The hormonal blueprint of labor. Mothering. 2002 March-April; 111: 51-61.
Editorial Comment Lisa Allee, CNM
Landon’s article is yet more evidence that VBAC should be available and encouraged for most women with a prior cesarean delivery, or cesarean deliveries. This research was reported in USA Today and in the article the chairman of the ACOG practice committee was quoted as saying that he expects his group to revise their VBAC recommendations. Hallelujah! Let’s hope they even change that fateful wording “immediately available” back to the much more helpful “readily available” so even women in rural and small towns and cities can have VBACs again!
The second article is not from a peer reviewed journal, but check out the references and see that many of them are. This article gives scientific backing to the ancient art of midwifery--supporting women in their natural processes of giving birth. I included it here because while all women deserve us knowing and thinking about ways we can support, enhance, and, hopefully, not trample on their hormonal cascade for birth, women having a VBAC need us to do so even more. I fully admit that creating truly undisturbed births in most of our practice settings is difficult, if not impossible, but there are many, many things that we can do to move closer to that goal—speak softly and gently; make the surroundings comforting and soothing to all the senses; use words that induce calm and confidence, not fear and doubt; keep the sounds of other women giving birth to a minimum (close the door); turn down the lights; turn down the monitor; use touch and voice for relaxation; use relaxation, movement, water, massage, heat/cold, etc. for helping with pain instead of medications; welcome the people the woman loves; keep mothers and babies together…..
These oxytocin-friendly procedures can help women VBAC successfully and decrease (dare I say prevent?) the need for the interventions Landon and others have found to increase the risk of uterine rupture, namely pitocin and epidurals. Our own hormones rock, let them flow!
References:
Landon, M, et al , Risk of uterine rupture with a trial of labor in women with multiple and single prior cesarean delivery. Obstetrics & Gynecology.2006 Jul;108(1):12-20.
Buckley, S Ecstatic Birth: The hormonal blueprint of labor. Mothering. 2002 March-April; 111: 51-61. http://www.mothering.com/articles/pregnancy_birth/birth_preparation/ecstatic.html
Navajo Corner, Kathleen Harner, Tuba City
Please See Abstract of the Month
Nurses Corner - Sandra Haldane, HQE
Native Alaskan and American Indian Nurses Scholarship Opportunity
I am writing to you about a scholarship opportunity for American Indian and Native Alaskan (AI/NA) Commission Corps Officers through the Native Nurses Career Opportunity Program. We are a small grant-based scholarship program funded by IHS at the University of Minnesota - School of Nursing. We award scholarships to AI/NA registered nurses pursuing their Master degree at the University of Minnesota School of Nursing. It is our goal to increase the number of Masters prepared AI/NA nurses. We have several scholarship recipients who are currently Commission Corps Officers and would like to get the word out to other Officers who might also benefit from our program.
The U of MN offers courses online and we encourage our students to stay and serve in their current communities. We also understand the nature of being a Commission Corps Officer and understand that our students need to respond when called to duty.
I would appreciate it if you would forward this e-mail to the appropriate person. We would like to send your office information regarding our scholarship program and would appreciate it if you could share the information with any American Indian and Native Alaskan officers looking to increase further their education . NativeRN@umn.edu or www.nursing.umn.edu/NNCOP
Office of Women's Health, CDC
This report from the CDC summarizes the 2004 final births and birth rates for the United States. The number of births rose very slightly, the birth rate for teenagers declined 1 percent in 2004, and for the second consecutive year, all measures of childbearing by unmarried women rose sharply. http://www.cdc.gov/nchs/products/pubs/pubd/hestats/finalbirths04/finalbirths04.htm
Oklahoma Perspective Greggory Woitte – Hastings Indian Medical Center
The indications for IUD use have vastly expanded
Intrauterine devices are the most common reversible method of contraception worldwide. However, here in the US, less than 1% of contraceptive users use an IUD. Due to the Dalkon Shield controversy, many different forms of IUDs were removed from the market. Today, there are only two IUDs on the market here in the US, the copper T380A (Paraguard) and the Levonorgesterel intrauterine system (Mirena). Today’s IUDs have corrected a design flaw that was unique to the Dalkon Shield and recent research has shown that they are safe and very effective, with pregnancy rates approaching that of tubal sterilization. The Levonorgesterel intrauterine system offers the non-contraceptive benefit of reducing menstrual flow and can be used for idiopathic menorrhagia. Recent evidence suggests that IUDs can be used in the Adolescent population and that 75% of adolescents that had IUDs placed were very happy with their contraceptive choice at 1 year. IUD use in the properly selected adolescent could be a useful weapon in the prevention of teenage pregnancy. One of the largest concerns with IUD use is the increased risk of pelvic infections which appears to be greatest at the time of insertion but returns to the background rate 1 month after insertion. Candidates for IUDs include:
Multiparous and nulliparous women at low risk for STDs
Women who desire long-term reversible contraception
Women with the following medical conditions:
Diabetes, Thromboembolism, Menorrhagia / dysmenorrhea, breastfeeding,
breast cancer, and liver disease
When your next patient is searching for a contraceptive option, and isn’t absolutely certain she does not want to have more children, an IUD is an excellent option.
Resources:
ACOG practice bulletin. Number 59, January 2005. Intrauterine device. Obstet Gynecol. 2005 Jan;105(1):223-32
ACOG committee opinion. No. 337: Noncontraceptive uses of the levonorgestrel intrauterine system. Obstet Gynecol. 2006 Jun;107(6):1479-82.
Revisiting the intrauterine contraceptive device in adolescents. J Pediatr Adolesc Gynecol. 2006 Aug;19(4):291-6.
Osteoporosis
Soy Isoflavones Protect Postmenopausal Women From Bone Loss
CONCLUSION: There is a significantly dose-dependent effect of soy isoflavones on attenuating bone loss at the spine and femoral neck possibly via the inhibition of bone resorption in non-obese postmenopausal Chinese women with high Kuppermann Scale
Ye YB, et al Soy isoflavones attenuate bone loss in early postmenopausal Chinese women : A single-blind randomized, placebo-controlled trial. Eur J Nutr. 2006 Jun 8
Patient Information
Antidepressant Discontinuation Syndrome: What You Should Know
http://www.aafp.org/afp/20060801/457ph.html
Tips to Help You Quit Smoking
http://www.aafp.org/afp/20060715/276ph.html
Health Care for Lesbians and Bisexual Women
http://www.aafp.org/afp/20060715/287ph.html
Perinatology Picks - George Gilson, Maternal Fetal Medicine, ANMC
Glyburide flows from fetus to mother by placental transport system
RESULTS: There was highly significant transfer of glyburide against concentration gradient from the fetal to the maternal circulation. Fetal-to-maternal concentration ratio was 0.92 +/- 0.23 at the start of the experimental period and 0.31 +/- 0.47 3 hours later (P = .01) (n = 5). Verapamil did not modify glyburide transport. CONCLUSION: This is the first direct evidence of active glyburide transport from the fetus to the mother and, in general, of any medicinal drug used during pregnancy. These experiments suggest that glyburide is actively efflux by a transporter other than P-glycoprotein. Alternatively, it is possible that a minority of glyburide is carried by P-glycoprotein, but most of the fetal load is pumped to the mother by a yet-unidentified placental transport system.
Kraemer J et al Perfusion studies of glyburide transfer across the human placenta: implications for fetal safety. Am J Obstet Gynecol. 2006 Jul;195(1):270-4.
Inappropriate Discontinuation of Asthma Medication Common in Early Pregnancy
CONCLUSIONS: Utilization of all categories of asthma medications decreased in early pregnancy, with the largest declines occurring for inhaled and rescue corticosteroids.
Enriquez R, et al Cessation of asthma medication in early pregnancy. Am J Obstet Gynecol. 2006 Jul;195(1):149-53.
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#
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
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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
Condom Use and the Risk of Genital Human Papillomavirus Infection in Young Women
Results The incidence of genital HPV infection was 37.8 per 100 patient-years at risk among women whose partners used condoms for all instances of intercourse during the eight months before testing, as compared with 89.3 per 100 patient-years at risk in women whose partners used condoms less than 5 percent of the time (adjusted hazard ratio, 0.3; 95 percent confidence interval, 0.1 to 0.6, adjusted for the number of new partners and the number of previous partners of the male partner). Similar associations were observed when the analysis was restricted to high-risk and low-risk types of HPV and HPV types 6, 11, 16, and 18. In women reporting 100 percent condom use by their partners, no cervical squamous intraepithelial lesions were detected in 32 patient-years at risk, whereas 14 incident lesions were detected during 97 patient-years at risk among women whose partners did not use condoms or used them less consistently. Conclusions Among newly sexually active women, consistent condom use by their partners appears to reduce the risk of cervical and vulvovaginal HPV infection.
Winer RL et al Condom Use and the Risk of Genital Human Papillomavirus Infection in Young Women New England Journal of Medicine June 22, 2006 Volume 354: pages 2645-2654
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db
=pubmed&list_uids=16790697
COMMENTARY: Condoms and Sexually-Transmitted Infections
Steiner MJ et al New England Journal of Medicine June 22, 2006 Volume 354: pages 2642-2643 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd
=Retrieve&dopt=AbstractPlus&list_uids=16790696
Other:
Latest STD Treatment Guidelines Just Released, 2006, CDC
Summary
These guidelines for the treatment of persons who have sexually transmitted diseases (STDs) were developed by CDC after consultation with a group of professionals knowledgeable in the field of STDs who met in Atlanta, Georgia, during April 19–21, 2005. The information in this report updates the Sexually Transmitted Diseases Treatment Guidelines, 2002 (MMWR 2002;51[No. RR-6]).
Included in these updated guidelines are an expanded diagnostic evaluation for cervicitis and trichomoniasis; new antimicrobial recommendations for trichomoniasis; additional data on the clinical efficacy of azithromycin for chlamydial infections in pregnancy; discussion of the role of Mycoplasma genitalium and trichomoniasis in urethritis / cervicitis and treatment-related implications; emergence of lymphogranuloma venereum protocolitis among men who have sex with men (MSM); expanded discussion of the criteria for spinal fluid examination to evaluate for neurosyphilis; the emergence of azithromycin resistant Treponema pallidum; increasing prevalence of quinolone-resistant Neisseria gonorrhoeae in MSM; revised discussion concerning the sexual transmission of hepatitis C; postexposure prophylaxis after sexual assault; and an expanded discussion of STD prevention approaches .
http://www.cdc.gov/std/treatment/default.htm
Rapid HIV Test Distribution Picks up Thousands of Infections in US
The distribution of 372,960 rapid HIV tests by the Centers for Disease Control and Prevention from September 2003 to December 2005 resulted in the identification of 4650 infections. The findings in this report suggest that HIV testing might be increased by using rapid tests and that RTDP might have enabled diagnosis of HIV infection in persons who would not have known their HIV status otherwise.
Rapid HIV Test Distribution --- United States, 2003—2005 MMWR June 23, 2006 / 55(24);673-676 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5524a2.htm
Barbara Stillwater, Alaska State Diabetes Program
Obese Girls: Threefold Risk for Early Death than Slim Counterparts
Among more than 100,000 women in the Nurses' Health Study II, those with a body mass index (BMI) greater than 30 kg/m2 when age 18 had a nearly threefold risk for premature death compared with women with BMIs below 18.5 kg/m2 at age 18.
Effects of childhood overweight on quality of life at younger ages may be substantial, and higher mortality rates in middle age may represent 'the tip of the iceberg' of detrimental health consequences. Our findings support preventive action in children aimed at reducing their risk for becoming overweight.
Women with higher BMIs in their late teens were at greater risk of premature death. Compared with women who had a BMI between 18.5 and 21.9 kg/m2 at age 18, the hazard ratio for premature death for women between the ages of 22 and 44 at baseline was 0.98, for those with a BMI less than 18.5 kg/m2, 1.18 for a BMI of 22.0 to 24.9 kg/m2, 1.66 for a BMI of 25.0 to 29.9 kg/m2 , and 2. for a BMI of 30 kg/m2 or greater.
During adolescence, women with a higher BMI at age 18 years had higher levels of alcohol consumption, were more likely to smoke cigarettes, and were less likely to engage in physical activity or use oral contraceptives.
This paper underscores the importance of efforts to prevent excessive weight gain in children, not only to prevent obesity but also to prevent moderate overweight.
Given the prevalence of overweight, large-scale preventive strategies aimed at increasing physical activity and stimulating healthy eating habits in U.S. children and adolescents are warranted.
Practice Pearl:
Explain to interested patients that this study adds to the substantial body of evidence indicating that excessive weight in childhood is associated with significant negative health consequences later in life, including increased risk for premature death.
van Dam RN et al. The Relationship between Overweight in Adolescence and Premature Death in Women. Ann Intern Med. 2006 Jul 18;145(2):91-7.
New Recommendations Regarding Exercise and Type 2 Diabetes Issued
Recommended lifestyle measures for prevention of type 2 diabetes are as follows:
- People with impaired glucose tolerance should begin and continue a program of weight control, including at least 150 minutes per week of moderate to vigorous physical activity and a healthful diet with modest energy restriction (Level of evidence: A).
- The amount and intensity of recommended aerobic exercise vary according to goals. To improve glycemic control, assist with weight maintenance, and reduce risk for cardiovascular disease (CVD), the panel recommends 150 minutes per week or more of moderate-intensity aerobic physical activity (40% - 60% of oxygen consumption per unit time [VO2max] or 50% - 70% of maximum heart rate), and/or 90 minutes per week or more of vigorous aerobic exercise (> 60% of VO2max or > 70% of maximum heart rate). The physical activity should be distributed over at least 3 days per week, with no more than 2 consecutive days without physical activity (Level of evidence: A).
- Compared with lower volumes of activity, performing at least 4 hours per week of moderate to vigorous aerobic and/or resistance exercise physical activity is associated with greater CVD risk reduction (Level of evidence: B).
- For long-term maintenance of major weight loss (≥ 13.6 kg or 30 lb), larger volumes of exercise (7 hours per week of moderate or vigorous aerobic physical activity) may be helpful (Level of evidence: B).
- Unless contraindicated, people with type 2 diabetes should be encouraged to perform resistance exercise 3 times per week, targeting all major muscle groups. This should progress to 3 sets of 8 to 10 repetitions at a weight that cannot be lifted more than 8 to 10 times (level of evidence: A). Initial supervision and periodic reassessments by a qualified exercise specialist are recommended to ensure that resistance exercises are performed correctly, to maximize health benefits, and to minimize the risk of injury.
The most successful programs for long-term weight control have involved combinations of diet, exercise, and behavior modification. Exercise alone, without concomitant dietary caloric restriction and behavior modification, tends to produce only modest weight loss of [approximately] 2 kg. Weight loss is typically this small primarily because obese people often have difficulty performing sufficient exercise to create a large energy deficit, and it is relatively easy to counterbalance increased energy expenditure through exercise by eating more or becoming less active outside of exercise sessions.
Sigal RJ, et al Physical activity/exercise and type 2 diabetes: a consensus statement from the American Diabetes Association. Diabetes Care. 2006 Jun;29(6):1433-8
Just how effective are diabetes management programs?
The answer, according to UCLA researchers, is that they lead to better examination and testing—but not to better control of key factors associated with diabetes complications, such as blood pressure, cholesterol or blood sugar levels.
A new study, finds that health care providers’ use of management programs resulted in higher rates among their patients of recommended examinations, such as eye and foot exams, testing for kidney function or damage due to the disease, cholesterol checks, and getting influenza vaccinations.
These management strategies, however, had no impact on good medication management and were not linked to improved sugar, blood pressure or cholesterol levels.
The three disease-management strategies include physician reminders (reminders that health plans or physician groups can send to their clinicians, including preprinted guidelines, flow sheets, and flags or customized alerts for medical records); regular feedback from physician groups to their doctors on the care they provide; and structured care management, which is when patients also see case managers, attend diabetes education classes and/or receive reminders about the care they need, such as eye examinations or flu shots, between doctor visits.
“The good news is that physician groups that are investing in care-management strategies are doing a better job of delivering eye care, screening for kidney problems and high cholesterol, and providing regular foot exams to more of their patients with diabetes,” said Dr. Carol Mangione, professor of medicine in the department of medicine at the David Geffen School of Medicine at UCLA and in the department of health services at the UCLA School of Public Health. “These results also suggest that it is much more challenging to achieve better control of the factors that are most strongly associated with the long-term complications of diabetes that patients care about, such as heart attacks and strokes. To prevent these serious complications, disease management programs may need to directly monitor the levels of blood pressure, cholesterol and glucose, and the treatments used to control them.”
The researchers studied 8,661 patients from 63 physician groups in several health plans, seven of them sponsored by Translating Research Into Action for Diabetes (TRIAD), a multi-center study of diabetes care within managed care systems, and four plans with individual physician contracts. The patients were recruited between July 2000 and October 2001.
The study shows that use of any of the three disease-management strategies resulted in higher rates of retinal screening, kidney checks, foot examinations and hemoglobin measurements. These are important because diabetes can lead to blindness, kidney failure and loss of limbs when not properly controlled.
Additionally, the researchers found that greater use of structured care management and performance feedback were linked with serum lipid level testing and influenza vaccine administration. They also found a correlation between the use of performance feedback and increased rates of foot examinations, and between physician reminders and increased rates for microalbuminuria checks, which test for small but abnormal amounts of the protein albumin in the urine.
Over the past 10 years, disease-management programs have focused on improving processes of care rather than outcomes. The study’s findings suggest that to achieve better control of blood pressure, cholesterol and sugar—and ultimately reduce the risk of complications such as heart attacks and strokes—these programs will need to actively engage the participation of doctors and patients and will need to measure and report on the levels of these outcomes on a regular basis.
Mangione CM, et al The association between quality of care and the intensity of diabetes disease management programs. Ann Intern Med. 2006 Jul 18;145(2):107-16.
http://ezproxyhhs.nihlibrary.nih.gov:2067/entrez/query.fcgi?cmd
=retrieve&db=pubmed&list_uids=16847293
What's new on the ITU MCH web pages?
New Deputy CCC for Family Practice, Ann Bullock, MD
http://www.ihs.gov/NonMedicalPrograms/nc4/nc4-fmDep.asp
There are several upcoming Conferences
and Online CME/CEU resources, etc….
and the latest Perinatology Corners (free online CME from IHS)
…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 Malloy at 202-863-2580
- Neonatal Resuscitation Program available
- Brochure
http://www.ihs.gov/MedicalPrograms/MCH/F/documents/ACOG_06brochR1_1.pdf
Second Annual AI / AN Long Term Care Conference
- September 18 & 19, 2006
- Tulsa , Oklahoma
- www.aianlongtermcare.org
- Contact Alvin Rafaelito atAlvin@nicoa.org, 505-292-2001
- Honoring Our Elders: Best Practices in Long Term Care 2006
Best Practices and GPRA Tracking
- Nov 1-2, 2006
- Sacramento CA
- California IHS Area Office, Contact Elaine.brinn@ihs.gov
- http://www.ihs.gov/MedicalPrograms/MCH/F/documents/BestPracticesFlyer1.pdf
22nd Annual Midwinter Indian Health OB/PEDS Conference
- For providers caring for Native women and children
- January 26-26, 2007
- Telluride, CO
- Contact Alan Waxman awaxman@salud.unm.edu
2nd International Meeting on Indigenous Child Health
- April 20-22, 2007
- Montreal , Quebec, Canada
- Solutions, not Problems
- Joint meeting of IHS, AAP-CONACH, First Nations and several other stakeholders
- http://www.aap.org/nach/2InternationalMeeting.htm
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 AI/AN women, children
- Internationally recognized speakers
- Save the dates. Details to follow
- 12 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 July 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.
