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Volume 5, No. 7, August 2007
Features
American College of Obstetricians and Gynecologists
Management of Herpes in Pregnancy: Practice Bulletin
Summary of Recommendations and Conclusions
The following recommendations and conclusions are based on limited or inconsistent scientific evidence (Level B):
- Women with active recurrent genital herpes should be offered suppressive viral therapy at or beyond 36 weeks of gestation.
- Cesarean delivery is indicated in women with active genital lesions or prodromal symptoms, such as vulvar pain or burning at delivery, because these symptoms may indicate an impending outbreak.
The following recommendations and conclusions are based primarily on consensus and expert opinion (Level C):
- In women with premature rupture of membranes, there is no consensus on the gestational age at which the risks of prematurity outweigh the risks of HSV.
- Cesarean delivery is not recommended for women with a history of HSV infection but no active genital disease during labor.
- Routine antepartum genital HSV cultures in asymptomatic patients with recurrent disease are not recommended.
- Routine HSV screening of pregnant women is not recommended
Management of Herpes in Pregnancy. ACOG Practice Bulletin No. 82. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007; 109:1233–48.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17569194
Management of Adnexal Masses: Practice Bulletin
Summary of Recommendations and Conclusions
The following recommendations and conclusions are based on limited or inconsistent scientific evidence (Level B):
- In asymptomatic women with pelvic masses, whether premenopausal or postmenopausal, transvaginal ultrasonography is the imaging modality of choice. No alternative imaging modality has demonstrated sufficient superiority to transvaginal ultrasonography to justify its routine use.
- Specificity and positive predictive value of CA 125 level measurements are consistently higher in postmenopausal women compared with premenopausal women. Any CA 125 elevation in a postmenopausal woman with a pelvic mass is highly suspicious for malignancy.
- Simple cysts up to 10 cm in diameter on ultrasound findings are almost universally benign and may safely be followed without intervention, even in postmenopausal patients.
- Unilateral salpingo-oophorectomy or ovarian cystectomy in patients with germ cell tumors, stage I stromal tumors, tumors of low malignant potential, and stage IA, grade 1–2 invasive cancer who undergo complete surgical staging and who wish to preserve fertility does not apper to be associated with compromised prognosis.
The following recommendations and conclusions are based primarily on consensus and expert opinion (Level C):
- Women with ovarian cancer whose care is managed by physicians who have advanced training and expertise in the treatment of women with ovarian cancer, such as gynecologic oncologists, have improved overall survival rates compared with those treated without such collaboration.
- Most masses in pregnancy appear to have a low risk for both malignancy and acute complications and, thus, may be considered for expectant management.
Management of Adnexal Masses ACOG Practice Bulletin No. 83. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007; 110:201–14.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17601923
Sterilization of Women, Including Those With Mental Disabilities
ABSTRACT: Sterilization, like any other surgical procedure, must be carried out under the general ethical principles of respect for autonomy, beneficence, and justice. Women requesting sterilization should be encouraged to discuss their decision and associated issues with their husbands or other appropriate intimate partners. The physician who objects to a patient’s request for sterilization solely as a matter of conscience has the obligation to inform the patient that sterilization services may be available elsewhere and should refer the patient to another caregiver. The presence of a mental disability does not, in itself, justify either sterilization or its denial. When a patient’s mental capacity is limited and sterilization is considered, the physician must consult with the patient’s family, agents, and other caregivers in an effort to adopt a plan that protects what the consulted group believes to be the patient’s best interests while, at the same time, preserving, to the maximum extent possible, the patient’s autonomy.
ACOG Committee Opinion No. 371: Sterilization of Women, Including Those With Mental Disabilities. Obstet Gynecol. 2007 Jul;110(1):217-20
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17601925
The Role of Cystourethroscopy in the Generalist Obstetrician Gynecologist Practice
ABSTRACT: Cystourethroscopy can be performed for diagnostic and a few operative indications by obstetrician–gynecologists to help improve patient care. Perhaps the most important indications for cystourethroscopy are to rule out cystotomy and intravesical or intraurethral suture or mesh placement and to verify bilateral ureteral patency during or after certain gynecologic surgical procedures. The granting of privileges for cystourethroscopy and other urogynecologic procedures should be based on training, experience, and demonstrated competence. Postgraduate education, including residency training programs in obstetrics and gynecology and continuing medical education, should include education in the instrumentation, technique, and evaluation of findings of cystourethroscopy, and in the pathophysiology of diseases of the lower urinary tract.
Although many of the pioneers of cystourethroscopy, most notably Howard Kelly, were gynecologists, for decades the procedure has been performed mainly by urologists. However, cystourethroscopy can be performed for diagnostic and a few operative indications by obstetrician–gynecologists to help improve patient care. This document reviews the definition and indications for cystourethroscopy and discusses the evidence and recommendations for its use in the generalist obstetrician–gynecologist practice. situations and be prepared to respond in a professional, ethical manner to patient requests for information and procedures.
ACOG Committee Opinion No. 372: The Role of Cystourethroscopy in the Generalist Obstetrician Gynecologist Practice. Obstet Gynecol. 2007 Jul;110(1):221
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17601926
Adoption
ABSTRACT: Obstetrician–gynecologists may find themselves at the center of adoption issues because of their expertise in the assessment and management of infertility, pregnancy, and childbirth. Physicians have a responsibility to provide information about adoption to all patients with unwanted pregnancies, to all patients with infertility concerns, and to same-sex partners seeking information on parenting. Unless physicians are truly expert in the field of adoption, they should guard against advocating for a particular action. Physicians should not serve as brokers in independent adoptions. When authorized by patients to fill out forms for adoption agencies, physicians should do so truthfully, with full disclosure to patients of what they intend to say.
Adoption. ACOG Committee Opinion No. 368. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007; 109:1507–10.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17569192
Communication Strategies for Patient Handoffs
ABSTRACT: Handoff communication, which includes up-to-date information regarding patient care, treatment and service, condition, and any recent or anticipated changes, should be interactive to allow for discussion between the giver and receiver of patient information. It requires a process for verification of the received information, including read-back or other methods as appropriate.
Communication Strategies for Patient Handoffs. ACOG Committee Opinion No. 367. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;109:1503–5.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17569191
Institutional Responsibility to Provide Legal Representation
ABSTRACT: Hospitals, academic institutions, professional corporations, and other health care organizations should have policies and procedures by which alleged violations of professional behavior can be reported and investigated. These institutions should adopt policies on legal representation and indemnification to protect those whose responsibilities in managing such investigations may expose them to potentially costly legal actions. The American College of Obstetricians and Gynecologists’ Committee on Ethics supports the position of the American Association of University Professors regarding institutional responsibility for legal demands on faculty.
ACOG Committee Opinion No. 370: Institutional Responsibility to Provide Legal Representation. Obstet Gynecol. 2007 Jul;110(1):215-6
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17601924
Multifetal Pregnancy Reduction
ABSTRACT: Counseling for treatment of infertility should include a discussion of the risks of multifetal pregnancy, and multifetal pregnancy reduction should be discussed with patients before the initiation of any treatment that could increase the risk of multifetal pregnancy. In almost all cases, it is preferable to terminate an ovulation induction cycle or limit the number of embryos to be transferred to prevent a situation in which fetal reduction will have to be considered. The best interests of the patient and the future child or children should be at the center of the risk–benefit equation. Although no physicians need to perform fetal reductions if they believe that such procedures are morally unacceptable, all obstetricians and gynecologists should be aware of the medical and ethical issues in these complex situations and be prepared to respond in a professional, ethical manner
Multifetal Pregnancy Reduction. ACOG Committee Opinion No. 369. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007; 109:1511–5.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17569193
American Family Physician**
Screening for Breast Cancer: Current Recommendations and Future Directions
Breast cancer is one of the most significant health concerns in the United States. Recent reviews have questioned the value of traditional breast cancer screening methods. Breast self-examination has been shown not to improve cancer-specific or all-cause mortality in large studies, but it is commonly advocated as a noninvasive screen. Patients who choose to perform self-examination should be trained in appropriate technique and follow-up. The contribution of the clinical breast examination to early detection is difficult to determine, but studies show that sensitivity is highly dependent on time taken to do the examination. Up to 10 percent of cancers are mammographically silent but evident on clinical breast examination. The U.S. Preventive Services Task Force recommends mammography for women older than 40 years who are in good health, but physicians should consider that sensitivity is lower for younger women. Digital mammography is somewhat more sensitive in younger women and women with dense breasts, but outcome studies are lacking. Although magnetic resonance imaging shows promise as a screening tool in some high-risk women, it is not currently recommended for general screening because of high false-positive rates and cost. The American Cancer Society recommends annual magnetic resonance imaging as an adjunct to screening mammography in high-risk women 30 years and older. Am Fam Physician 2007;5:1660-6
http://www.aafp.org/afp/20070601/1660.html
ACS Recommendations on MRI and Mammography for Breast Cancer Screening
Women at high risk of developing breast cancer should receive annual magnetic resonance imaging (MRI) as an adjunct to mammography, according to new guidelines from the American Cancer Society (ACS).
Groups for whom MRI screening is recommended include the following:
- Women with a BRCA mutation
- Women with a first-degree relative who has a BRCA mutation
- Women with a 20 to 25 percent or greater lifetime risk for breast cancer, based on BRCAPRO or other risk models that depend largely on family history
- Women exposed to chest radiation between the ages of 10 and 30 years
- Women with Li-Fraumeni syndrome, and first-degree relatives of women with this syndrome
- Women with Cowden and Bannayan-Riley-Ruvalcaba syndromes, and first-degree relatives of women with these syndromes
MRI screening has been proven to detect cancer with early-stage tumors, which are associated with better outcomes. Studies have found high sensitivity for MRI, ranging from 71 to 100 percent versus 16 to 40 percent for mammography alone in high-risk populations. MRI also finds smaller tumors compared with mammography, and the types of cancers found with MRI contribute to reduced mortality rates.
Three approaches are available for identifying women with a high risk for breast cancer: family history, genetic testing, and clinical history. Although many women have at least one relative with breast cancer, most of these women are not at increased risk. Only 1 to 2 percent of women have a family history suggestive of the inheritance of an autosomal-dominant, high-penetrance gene that confers up to an 80 percent lifetime risk of breast cancer. In some families, there is also a high risk of ovarian cancer. Family history findings that suggest the presence of such a high-penetrance gene include two or more close relatives (i.e., first- or second-degree) with breast or ovarian cancer; breast cancer occurring before 50 years of age in a close relative; a family history of breast and ovarian cancers; one or more relatives with two cancers (breast and ovarian cancers or two independent breast cancers); and male relatives with breast cancer.
Inherited mutations in the two breast and ovarian cancer susceptibility genes, BRCA1 and BRCA2, are present in approximately one half of families in which an inherited risk is strongly suspected. Several models can help physicians determine risk estimates: the Gail, Claus, and Tyrer-Cuzick models are based on family history, and BRCAPRO and the Breast and Ovarian Analysis of Disease Incidence and Carrier Estimation Algorithm (BOADICEA) estimate the likelihood of BRCA mutations.
Genetic testing for BRCA mutations usually is offered to adult members of families with a known mutation and to women with a 10 percent or greater likelihood of carrying such a mutation. If a woman from a family in which a BRCA mutation has been identified does not have that mutation, her breast cancer risk is no higher than it would have been if she did not have a family history of breast cancer. However, in women from high-risk families without a known mutation, failure to find a mutation does not reduce risk.
http://caonline.amcancersoc.org/cgi/content/full/57/2/75
Ginger: An Overview
Ginger (Zingiber officinale) is one of the more commonly used herbal supplements. Although often consumed for culinary purposes, it is taken by many patients to treat a variety of conditions. Ginger has been shown to be effective for pregnancy-induced and postoperative nausea and vomiting. There is less evidence to support its use for motion sickness or other types of nausea and vomiting. Mixed results have been found in limited studies of ginger for the treatment of arthritis symptoms. Am Fam Physician 2007;75:1689-91.
http://www.aafp.org/afp/20070601/1689.html
CDC Changes Treatment Guidelines for Gonorrhea
Fluoroquinolones (i.e., ciprofloxacin [Cipro], ofloxacin [Floxin], and levofloxacin [Levaquin]) have been used since 1993 for the treatment of gonorrhea because of their effectiveness, availability, and convenience as a single-dose oral therapy. However, the prevalence of fluoroquinolone resistance in Neisseria gonorrhoeae has been increasing in the United States, necessitating changes in treatment regimens. Since 1999, increasing resistance of N. gonorrhoeae to fluoroquinolones has been reported, first in Hawaii, then in California and other Western states, then among men who have sex with men, and now in other populations and regions. Data from 2005 and 2006 show that the prevalence of fluoroquinolone-resistant N. gonorrhoeae has continued to increase among heterosexual men and is present in all regions of the United States.
Because fluoroquinolones are no longer recommended for the treatment of gonorrhea, treatment options are limited. For the treatment of uncomplicated urogenital and anorectal gonorrhea, the CDC now recommends a single 125-mg intramuscular dose of ceftriaxone (Rocephin) or a single 400-mg oral dose of cefixime (Suprax). Alternative regimens include a single 400-mg oral dose of cefpodoxime (Vantin) or a 1-g dose of cefuroxime (Ceftin).
For pharyngeal gonorrhea, the CDC now recommends a single 125-mg intramuscular dose of ceftriaxone. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5614a3.htm
Headache (Chronic Tension-Type)
What are the effects of drug treatments for chronic tension-type headache?
beneficial
Amitriptyline. One systematic review and three small, short duration randomized controlled trials (RCTs) found that amitriptyline reduced the duration and frequency of chronic tension-type headache compared with placebo. One RCT found that amitriptyline was more effective than citalopram in improving headache duration, frequency, and severity. Another RCT found comparable effectiveness between amitriptyline and mirtazapine for the treatment of chronic tension-type headache, although amitriptyline was associated with a less favorable adverse effect profile. One RCT found no significant difference between amitriptyline and cognitive behavior therapy in headache scores or frequency of clinically important improvement after six months.
Mirtazapine (Only Short-term Evidence). One small RCT found that mirtazapine reduced the duration, frequency, and intensity of chronic tension-type headache compared with placebo. One RCT found comparable effectiveness between mirtazapine and amitriptyline for the treatment of chronic tension-type headache, although mirtazapine was associated with a more favorable adverse effect profile.
unknown effectiveness
SSRI Antidepressants. One systematic review and one additional RCT provided insufficient evidence about the effects of selective serotonin reuptake inhibitors (SSRIs) on symptoms of chronic tension-type headache compared with placebo. One systematic review found no significant difference between SSRIs compared with amitriptyline for treatment of chronic tension-type headache; however, more adverse effects occurred in the amitriptyline group.
Tricyclic Antidepressants (Other Than Amitriptyline). We found insufficient evidence about the effects of tricyclic antidepressants other than amitriptyline.
likely to be ineffective or harmful
Benzodiazepines. Two RCTs provided insufficient evidence about the effects of benzodiazepines compared with placebo or other treatments. Benzodiazepines are commonly associated with adverse effects if taken regularly.
Botulinum Toxin. One systematic review and one subsequent RCT provided no evidence that botulinum toxin improved the symptoms of chronic tension-type headache compared with placebo. However, botulinum toxin is associated with important adverse effects.
Regular Acute Pain Relief Medication. We found no systematic review or RCTs. One nonsystematic review of observational studies provided insufficient evidence about the benefits of common analgesics in persons with chronic tension-type headache. It found that sustained and frequent use of some analgesics was associated with chronic headache and reduced the effectiveness of prophylactic treatment.
What are the effects of nondrug treatments for chronic tension-type headache?
likely to be beneficial
Cognitive Behavior Therapy. One systematic review and one subsequent RCT found limited evidence that cognitive behavior therapy reduced the symptoms of chronic tension-type headache at six months compared with placebo. One RCT found no significant difference between cognitive behavior therapy and amitriptyline or in headache scores or frequency of clinically important improvement after six months. One systematic review provided insufficient evidence to compare cognitive behavior therapy versus relaxation or electromyographic biofeedback therapy.
uknown effectiveness
Acupuncture. Two systematic reviews and one subsequent RCT provided insufficient evidence about the effects of acupuncture compared with sham acupuncture in persons with chronic tension-type headache. A second subsequent RCT found that low-power laser acupuncture improved headache intensity, duration, and frequency compared with placebo.
Indian Head Massage. We found no systematic review or RCTs about the effects of Indian head massage in persons with chronic tension-type headache.
Relaxation and Electromyographic Biofeedback. Two systematic reviews and one subsequent RCT provided insufficient evidence about the effects of relaxation and electromyographic biofeedback on symptoms of chronic tension-type headache.
Definition
Chronic tension-type headache is a disorder that evolves from episodic tension-type headache, with daily or very frequent episodes lasting minutes to days. The 2004 International Headache Society criteria for chronic tension-type headache includes having headaches for 15 or more days a month (180 days per year) for at least three months; pain that is bilateral, pressing, or tightening in quality and that is nonpulsating, of mild or moderate intensity, and that does not worsen with routine physical activity such as walking or climbing stairs; presence of no more than one additional clinical feature (e.g., mild nausea, photophobia, phonophobia); and without moderate or severe nausea or vomiting. Chronic tension-type headache is generally regarded as a featureless headache. Not all experts agree that mild features more typically seen in migraine (e.g., photophobia, phonophobia) should be included in the operational definition of chronic tension-type headache, and it is often difficult to distinguish mild migraine headache from tension-type headache.
Chronic tension-type headache is to be distinguished from other causes of chronic daily headache that require different treatment strategies (e.g., new daily persistent headache, medication overuse headache, chronic migraine, hemicrania continua). Many persons who develop chronic daily headache owing to chronic migraine or medication overuse also develop mild migrainous "background" headaches that might be mistaken for coincidental chronic tension-type headache. It is therefore extremely important to take a full headache history to elicit the individual features of the headache and to look for prodromal or accompanying features that might indicate an alternative diagnosis.
In contrast to chronic tension-type headache, episodic tension-type headache can last for 30 minutes to seven days and occurs for fewer than 180 days a year. The greatest obstacle to studying tension-type headache is the lack of any single proven specific or reliable, clinical, or biological defining characteristic of the disorder. Terms based on assumed mechanisms (e.g., muscle contraction headache, tension headache) are not operationally defined. Older studies that used these terms may have included persons with many different types of headache.
Incidence and Prevalence
The prevalence of chronic daily headache from a survey of the general population in the United States was 4.1 percent; one half met the International Headache Society criteria for chronic tension-type headache. In a survey of 2,500 U.S. undergraduate students, the prevalence of chronic tension-type headache was 2 percent. The prevalence was 2.5 percent in a Danish population-based survey of 975 persons. One community-based survey in Singapore (2,096 persons from the general population) found that the prevalence was 1.8 percent in women and 0.9 percent in men.
Etiology
Tension-type headache is more prevalent in women (65 percent of cases in one survey). Symptoms begin before 10 years of age in 15 percent of persons.7 There is a family history of some form of headache in 40 percent of persons with chronic tension-type headache,8 although a twin study found that the risk of headache was similar for identical and nonidentical twins.
Prognosis
The prevalence of chronic tension-type headache declines with age.
Clinical Evidence Concise, A Publication of BMJ Publishing Group
http://www.aafp.org/afp/20070701/bmj.html
Exercise for Older Patients Who Are Acutely Hospitalized
Clinical Question
What are the effects of exercise interventions for patients older than 65 years who are acutely hospitalized?
Evidence-Based Answer
The effects of exercise interventions on functional outcomes are unclear, but there is a trend toward functional improvement. Multidisciplinary interventions that include exercise also show several other benefits, including reduction in length of hospitalization and hospital costs; these benefits have not been shown with exercise-only interventions, however.
Practice Pointers
Older adults experience declines in physical strength, mobility, and functioning during and after acute hospitalization.1 Exercise training can improve functional outcomes in these patients.2
In this Cochrane review, the authors searched for studies evaluating the effectiveness of inpatient exercise programs for older patients admitted to the hospital with general medical problems. Nine studies with 4,223 total patients were included. Patients in specialized stroke, intensive care, or rehabilitation units or those with primarily orthopedic diagnoses were excluded. Interventions were started within three days of admission and were compared with usual hospital care. The exercise interventions ranged from increased physical activity to individually tailored walking and strengthening programs.
The review found that older patients benefited from a multidisciplinary intervention program that incorporated exercise. The benefits included a decrease in hospital costs of about $300 per hospital stay, an average one-day reduction in length of hospitalization, and a 6 percent increase in the proportion of patients discharged to home rather than to a nursing home or other facility (number needed to treat = 16). It is important to note that exercise-only programs did not demonstrate these outcomes. In addition, the exercise portion of the multidisciplinary interventions was not explained in detail, thus limiting the practical implication of the studies. The authors conclude that the benefits may be from the multidisciplinary effort rather than the exercise itself.
These data support including exercise in multidisciplinary programs initiated as early as hospital admission and continuing until discharge. Multidisciplinary programs generally include individually designed patient exercise plans, a specialized geriatric inpatient unit, and evaluation and treatment by physical and occupational therapists and a physician or nurse trained as a geriatrician. Small but important clinical outcomes can be expected with this multidisciplinary approach. Cochrane Brief
de Morton NA, Keating JL, Jeffs K. Exercise for acutely hospitalised older medical patients. Cochrane Database Syst Rev 2007(1):CD005955.
http://www.aafp.org/afp/20070701/cochrane.html
Evaluation of Nausea and Vomiting
A comprehensive history and physical examination can often reveal the cause of nausea and vomiting, making further evaluation unnecessary. Acute symptoms generally are the result of infectious, inflammatory, or iatrogenic causes. Most infections are self-limiting and require minimal intervention; iatrogenic causes can be resolved by removing the offending agent. Chronic symptoms are usually a pathologic response to any of a variety of conditions. Gastrointestinal etiologies include obstruction, functional disorders, and organic diseases. Central nervous system etiologies are primarily related to conditions that increase intracranial pressure, and typically cause other neurologic signs. Pregnancy is the most common endocrinologic cause of nausea and must be considered in any woman of childbearing age. Numerous metabolic abnormalities and psychiatric diagnoses also may cause nausea and vomiting. Evaluation should first focus on detecting any emergencies or complications that require hospitalization. Attention should then turn to identifying the underlying cause and providing specific therapies. When the cause cannot be determined, empiric therapy with an antiemetic is appropriate. Initial diagnostic testing should generally be limited to basic laboratory tests and plain radiography. Further testing, such as upper endoscopy or computed tomography of the abdomen, should be determined by clinical suspicion based on a complete history and physical examination. Am Fam Physician 2007;76:76-84.
http://www.aafp.org/afp/20070701/76.html
AHRQ
Use of high-risk medications by pregnant women is not uncommon
http://www.ahrq.gov/research/may07/0507RA19.htm
Gastrointestinal complaints in young women of low to normal weight
may indicate possible eating disorders
http://www.ahrq.gov/research/apr07/0407RA11.htm
Model shows contribution of mammography screening and adjuvant therapy
to reducing breast cancer deaths from 1975 to 2000
http://www.ahrq.gov/research/apr07/0407RA13.htm
Pediatricians with more knowledge of and confidence in identifying
and managing child abuse are more likely to identify abuse
http://www.ahrq.gov/research/may07/0507RA10.htm
Oncologists appear to communicate differently with breast cancer
patients depending on women's age, race, education, and income
http://www.ahrq.gov/research/apr07/0407RA12.htm
Clinic-based and community-based strategies can promote the use of
key preventive services by Latina women
http://www.ahrq.gov/research/apr07/0407RA14.htm
Ask A Librarian: Diane Cooper, M.S.L.S. / NIH
Scopus ™ : A New Database
Scopus ™ is an interdisciplinary, bibliographic database that indexes the contents of more than 15,000 journals in the physical sciences, engineering, earth and environmental sciences, life and health sciences, social sciences, psychology, business, and management. Scopus coverage includes 535 open access journals, 12,850 academic journals, conference proceedings, trade publications, 13 million patents, and more than 200 million scientific web pages. The coverage of Scopus is strongest from 1996 to the present and it is updated daily.
In terms of functionality, Scopus:
- provides the ability to view search results and refine them to the most relevant hits,
- offers an email alerting service that notifies you when a new publication matches your search terms, and when a new publication cites a selected publication,
- presents patent search results from four patent offices,
- includes seamless links to full-text articles and other library resources.
| Search Functions | ||
| Function | Symbol/Method | Example |
| Freetext searching | Select "All fields" | |
| Spelling | Use all variations | colour, color |
| Phrases | use quotation marks - " " | "avian flu" |
| Truncation | * | arter* gives artery or arteries |
| Wildcard | * | wom*n gives woman or women |
| Optional wildcard | ? | p?ediatric gives pediatric or paediatric |
| Controlled vocabulary | none | |
| Boolean | AND, OR, AND NOT | human AND NOT rat |
You can access Scopus via Research Tools Databases on the green menu bar on the HSR Library webpage. For more information about using Scopus email me at cooperd@mail.nih.gov
Breastfeeding - Suzan Murphy, PIMC
What to do when: Mom says, “My newborn likes the bottle better.”
Why does it happen?
In a normal, healthy newborn, bottle preference is usually from overuse of a bottle and/or pacifier. However, it is helpful to rule out unusual newborn issues that can effect sucking like a short frenulum or thrush.
What is the cause?
Formula or breast milk comes out of the bottle quickly, just a little tug. Also, the plastic nipple can rub the roof of the mouth, stimulating the suck. It is not much work for the baby - and there is no waiting for let down. It is easy. Breastfeeding takes more work. Often, but not always, a baby will begin to favor the bottle and avoid breastfeeding. Unfortunately, it is hard to know which baby will be influenced by frequent bottles/pacifiers.
In the first couple weeks, there is probably still time for the mom’s supply to bounce back. To get mom and baby back to breastfeeding:
Assure the mom that her baby is getting enough:
Have her count diaper changes - if her baby has least 6 in 24 hours, her baby is probably has an adequate intake.
Check her baby’s weight gain – ½ oz – 1 oz per day, 3.5 - 7 oz per week is normal
Tell the mom to breastfeed about 2 hours – 8 to 12 times in 24 hours. The baby’s suck muscles and mom’s milk supply will get up to speed together and the frequency will slow down within a couple days.
Discourage the “pump and feed” method – it has a near 100% burn out rate.
Tell the mom to praise her baby for sucking well. The baby knows mom’s happier voice and will respond appropriately.
Recommend less use of the bottle. If the bottle can be weaned down to once or twice a day, the mom’s milk supply will probably be protected. Less is best in the first 4-6 weeks.
Suggest that the pacifier be avoided – and saved for difficult times like car trips with screaming a baby or challenging moments.
If it looks like it really is a supply issue, or the “bounce back” is not happening, consider medication. Clinical studies indicate that metoclopromide can increase milk supply in difficult situations. For more information, refer to Thomas Hales’ text, Medications and Mother’s Milk or sources like the San Diego Breastfeeding Coalition web page.
If the baby won’t latch, refer the mom to WIC or a Lactation Consultant. It is OK to call us for over-the-phone-ideas at 1- 877-868-9473. It is toll-free - best times are 7 am – 10 pm, Mountain Standard Time.
What about extra fluids?
Clinical studies have not agreed with the common practice of encouraging fluids to increase milk supply. Unfortunately the studies were small, each with less than 30 participants, and did not correct for climate issues – such as excessive heat/cold, or the typical amount of outdoor exposure the mother experienced. So while encouraging water is a healthy practice, excessive fluids are not necessary. A reasonable recommendation is to keep water nearby and drink to thirst.
Please note: If it is believed that a specific (safe) beverage will help, it probably will. Confidence is a powerful tool with parenting, especially breastfeeding.
References
Dusdieker LB et al. Prolonged maternal fluid supplementation in breast-feeding. Pediatrics,
1990 Nov;86(5):737-40.
Morse JM et al. The effect of maternal fluid intake on breast milk supply: a pilot study.
Canadian Journal of Public Health, 1992 May-Jun;83(3):213-6.
Other
New IHS Breast feeding Family Support web page: Have pictures to share?
When family and friends support breastfeeding,
it makes the challenges easier.
Your encouragement will touch a lifetime.
Tell mom that she is doing great.
Let dad know that his patience is beautiful.
Let the new family how proud you are of them.
Praise grandparents/aunts/uncles/cousins/friends
for their wonderful care and wisdom.
Give the new family a boost:
- Tackle some household chores
- Bring a meal over
- Change some diapers
- Make the trip to the grocery store
- Give the baby a bath
- Take the new siblings to the park
- Read a book or watch TV with the new siblings
- Keep mom resting, bring the baby to her
If you have pictures to share, please email them to suzan.murphy@ihs.gov
http://www.ihs.gov/MedicalPrograms/MCH/M/bfFamily.cfm
Cup feeding not be recommended over bottle feeding as a supplement to breastfeeding
AUTHORS' CONCLUSIONS: Cup feeding cannot be recommended over bottle feeding as a supplement to breastfeeding because it confers no significant benefit in maintaining breastfeeding beyond hospital discharge and carries the unacceptable consequence of a longer stay in hospital.
Flint A, et al Cup feeding versus other forms of supplemental enteral feeding for newborn infants unable to fully breastfeed. Cochrane Database Syst Rev. 2007 Apr 18;(2):CD005092
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17443570
CCC Corner Digest
Nicely laid out hard copy - A compact digest of last month’s CCC Corner
June / July Highlights include:
-A new management category: ‘First Trimester GDM’
-Control over schedule: Most important predictor of staff work-life balance / burnout
-Placental problems with previous caesarean delivery: Abruptio, previa
-Discharge 24 Hours After Vaginal Hysterectomy Safe, Acceptable
-Guidelines for School-Based STD Screening in Indian Country
-Malabsorption of Oral Antibiotics in Pregnancy after Gastric Bypass Surgery
-Seeking and Giving Consultation
-Long-Term Breastfeeding among Native American Women
-The failure to protect Indigenous women from sexual violence in the USA
-Reasons for unprotected intercourse
-What are the Unnecessary Tests?
-Improve HIV screening in pregnancy? Preliminary GPRA Related Results
-Social context of maternal deaths and morbidity
-Improve the system - Improve the care: Underpinnings
-Which Indian Health facilities lead the U.S. in national benchmarks?
-Earlier hormone therapy closer to menopause tended to have reduced CHD risk
-Adjustable Urethral Slings: Hope for Patients with Complex Incontinence
-Personal Digital Assistants: Practical Advice for Nurses in 2007
-Placental cultures and histology poor predictors of infectious amniotic fluid
-Electronic Health Record (EHR) Implementation: Worth the effort?
-Fluoroquinolones No Longer Recommended for Gonococcal Infections
-High rate of DM among indigenous people ?not due to thrifty gene
-Women’s Early Drinking Problems More Likely to Escape Diagnosis
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/CCCC_v5_06.pdf
If you want a copy of the CCC Digest mailed to you each month, please contact nmurphy@scf.cc
Domestic Violence – Denise Grenier, Rachel Locker
IHS-ACF DV Project: Conference CD
I want to make you aware that you can obtain a copy of the National Conference on Health and Domestic Violence Conference – Presenter CD by clicking on the URL:
http://fvpfstore.stores.yahoo.net/2007-conference-presentation2008.html
You may find the CD content helpful as you work towards improving your DV screening, patient education and patient safety planning
Carolyn Aoyama Carolyn.Aoyama@ihs.gov
Family Violence Prevention Funds Screen to End Abuse Video
IHS-ACF DV Project: Free online DV training video and CME: The Family Violence Prevention Funds Screen to End Abuse video is now up on Medscape with a free 1 hour CEU. People may view the video and then take a CME test to receive credit.
Now Available on Medscape with CME: Screen to End Abuse
Screen to End Abuse, a 30 minute training video produced by the Family Violence Prevention Fund (FVPF) includes five clinical vignettes demonstrating techniques for screening and responding to domestic violence in primary care settings. The FVPF partnered with Medscape, an internet provider of educational tools for health care professionals and students to develop the Screen to End Abuse video into a Continuing Education activity. The free 1 hour activity includes the five vignettes, learning objectives and statistics from Screen to End Abuse and incorporates Pre and Post-test questions to facilitate the user’s learning experience.
-To view the video visit : www.medscape.com
(log in free and search: “ Domestic Violence and Your Patient's Health: Asking the Right Questions” )
Perceptions of Adult Patients’ History of Child Abuse
The providers in our exploratory study seemed to lack awareness and strategies about how and when to incorporate inquiry into a history of child abuse in their clinical assessment. Contradictory discourses exist among them about the potential significance of routine inclusion of child abuse history in the initial and/or ongoing assessment of adult patients. Despite the fact that primary care providers are in an ideal position to identify and treat the physical and emotional sequelae of early abuse, and that patients, including those with abuse histories, favor screening about childhood physical and sexual abuse, these family physicians expressed reluctance to enter these troubled waters.
The potential benefits of a patient's disclosure of a history of childhood abuse to his or her family physician are many: A survivor might feel relief from the burden of the secret and might finally hear that the abuse was not his or her fault. The patient might be able to make a connection between current emotional and physical symptoms with past abuse and might take the opportunity to engage in counseling or psychotherapy around these painful issues. The patient might realize that his or her own body is not shameful and start to be able to take better care of it and make healthier lifestyle choices. 9 Finally, a caring relationship with a nonabusive adult such as a family physician may facilitate healing and speed a survivor's journey to recovery. 10 The potential for such inquiry to have a therapeutic effect deserves further investigation.
Weinreb, L et al Perceptions of Adult Patients’ History of Child Abuse in Family Medicine Settings Journal of the American Board of Family Medicine 20 (4): 417-419 (2007)
http://www.jabfm.org/cgi/content/full/20/4/417?etoc
Study finds connection between teenage violence and domestic violence
Researchers tracing the development of violent behavior have found a link between teenage violence and domestic violence.
Adolescents who engaged in violent behavior at a relatively steady rate through their teenage years and those whose violence began in their mid teens and increased over the years are significantly more likely to engage in domestic violence in their mid 20s than other young adults, according to a new University of Washington study.
"Most people think youth violence and domestic violence are separate problems, but this study shows that they are intertwined," said Todd Herrenkohl, lead author of the study and a UW associate professor of social work.
The study also found no independent link between an individual's use of alcohol or drugs and committing domestic violence. In addition it showed that nearly twice as many women as men said they perpetrated domestic violence in the past year including kicking, biting or punching their partner, threatening to hit or throw something at their partner, and pushing, grabbing or shoving their partner.
Data from the study came from the on-going Seattle Social Development Project which has been tracing youth development and the social and antisocial behavior of more than 800 participants. It began when they were in the fifth grade and continues to follow them into adulthood.
That project earlier showed four patterns of youth violence taken by teens between the ages of 13 and 18.
- Non-offenders, the largest group (60 percent), did not engage in violent behavior in adolescence.
- Desisters (15 percent) engaged in violence early on but stopped by age 16.
- Chronic offenders (16 percent) began violent behavior early and it persisted at a moderate level up to age 18.
- Late increasers (9 percent) became involved with violence in mid adolescence with the behavior increasing up to age 18.
The new study found that individuals from the last two groups were significantly more likely than non-offenders to have committed moderately severe forms of domestic violence when they were 24 years old. At that age, nearly 650 of the original students had a partner and about 19 percent of them, or 117 individuals, reported having committed domestic violence in the past year.
The finding that a perpetrator's use of alcohol is not significantly related to domestic violence was somewhat surprising since other studies have shown such an association. The reasons for this are unclear, according to Herrenkohl, who speculated such a relationship may have shown up if more severe forms of domestic violence, such as those requiring hospitalization had been measured.
The study also showed a number of personal characteristics, partner characteristics and neighborhood conditions that increased an individual's chances of being involved in domestic violence as a young adult. Being diagnosed with a major episode of depression or receiving welfare were significantly related to committing domestic violence, as were having a partner who used drugs heavily, sold drugs, had a history of violence toward others, had an arrest record or was unemployed.
Disorganized neighborhoods where attitudes toward drug sales and violence were favorable also increased a person's likelihood of committing domestic violence.
"Individuals who have a history of anti-social behavior may be more likely to find a partner with a similar history and re-create what they experienced as children. They may also be more likely to be in places in their communities where they interact with people with the same types of behavior," said Herrenkohl.
"The take-home message from this study is that it may be possible to prevent some forms of domestic violence by acting early to address youth violence. Our research suggests the earlier we begin prevention programs the better, because youth violence appears to be a precursor to other problems including domestic violence."
http://uwnews.washington.edu/ni/article.asp?articleID=34626
Co-authors of the study were Rick Kosterman, a research scientist; W. Alex Mason, a research analyst; and J. David Hawkins, professor of social work. All are affiliated with the UW's Social Development Research Group. The paper appears in the current issue of the journal Violence and Victims and the research was funded by the National Institute on Drug Abuse and the National Institute of Mental Health.
SANE: Is there a center near you?
From the International Association of Forensic Nurses "Beyond Tradition, Advancing Humanity"
Web site - US Map with state-by-state links to local sites. http://www.iafn.org/registry/reghome.cfm
Frequently Asked Questions:
-Standards of Practice: Domestic Violence Is there any source available for standards for care of domestic violence victims?
http://www.iafn.org/about/aboutFAQ.cfm?nav=registry#29
-Publications on line at the following link:
https://www.iafn.org/store/storeHome.cfm
-Standards of Practice: Forensic Nursing Where can I find Forensic Nursing Standards of Practice?
http://www.iafn.org/about/aboutFAQ.cfm?nav=registry#20
-Website Tools: Listing Tools How can I make changes to our program on line?
http://www.iafn.org/about/aboutFAQ.cfm?nav=registry#90
Certification chapters committees education events jobs membership projects publications registry (includes Canadian provinces)
Elder Care News
AAN Guidelines on Reporting Medical Conditions That May Affect Driving Competency
Driving laws for persons with medical conditions that affect cognition, consciousness, vision, or motor skills vary from state to state. Physicians are expected to report a patient's driving-related condition to authorities if the condition might pose a safety risk, especially when the patient does not comply with requests to be tested or stop driving. Requiring mandatory reporting, however, may negatively affect the patient-physician relationship. Reporting also may not result in safety benefits to the public or the patient, who may consequently withhold important medical information.
Poorly designed reporting laws may also expose physicians to liability for a patient's driving outcomes, even when a physician has followed all applicable laws. Most states have full legal immunity for physicians who follow applicable laws in good faith. However, physicians in some states (e.g., Arkansas, Georgia) may be sued for reporting a patient with questionable driving abilities, resulting in a suggested violation of patient-physician privilege. In other states (e.g., Michigan, Montana), a physician who does not report a patient who appears to be a sound driver is at risk of being sued if that patient later causes an accident.
The American Academy of Neurology (AAN) encourages physicians to review applicable driving laws with their patients and to discuss and document their medical recommendations with their patients. The AAN also supports optional reporting of persons with medical conditions that may affect their ability to drive safety, especially for cases in which public safety has already been compromised or when the person clearly no longer has the skills to drive safely.
Physician immunity policies should be clarified so that physicians are granted immunity for reporting or not reporting a patient's condition when such action is taken in good faith, when the patient is reasonably informed of his or her driving risks, and when such actions are documented by the physician in good faith.
American Academy of Neurology http://www.neurology.org/content/vol68/issue15/#SPECIAL_ARTICLES
AFP Practice Guideline Briefs http://www.aafp.org/afp/20070701/practice.html
Elderly Medicare patients with low health literacy receive little tangible support for their health care needs
http://www.ahrq.gov/research/may07/0507RA20.htm
Family Planning
Waiting until the menses to start hormonal contraceptives: Needless Obstacle
CONCLUSION: Protocols that require a woman to wait until the next menses to start hormonal contraceptives are an obstacle to contraceptive initiation. Directly observed, immediate initiation of the pill improves short-term continuation
Westhoff C, et al Initiation of oral contraceptives using a quick start compared with a conventional start: a randomized controlled trial. Obstet Gynecol. 2007 Jun;109(6):1270-6.
http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db
=pubmed&list_uids=17540797&dopt=Abstract
One In Four with Unplanned Pregnancy Experience Gaps In BCM Or Do Not Use A Method
Fifteen percent of U.S. women in a recent survey who were at risk of unplanned pregnancy had had a gap in contraceptive use of one or more months during the previous year, while 8% had not used any method
CONCLUSIONS: Providers could better help women avoid unintended pregnancy by initiating regular assessments of method use difficulties, improving counseling on method choice and pregnancy risk, and identifying and assisting women at higher risk for inconsistent method use because of disadvantage, relationship characteristics or ambivalence about pregnancy prevention. In addition to providers' efforts, broader societal commitment is critical for increasing contraceptive knowledge and expanding access to contraceptive care for all women who are at risk of having an unintended pregnancy
Frost J et al Factors associated with contraceptive use and nonuse, United States, 2004. Perspect Sex Reprod Health. 2007 Jun;39(2):90-9
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17565622
Little variation in the frequency of reported symptoms among oral contraceptive pills
CONCLUSION: In the absence of sufficient evidence-based data to support the existence of differences in the tolerance profile of low-dose combined OCPs, future well-designed randomized trials are needed to guide providers in their choice of OCPs. However, research should also assess the effectiveness of counseling on the tolerance of OCPs, an intervention that may prove to be more rewarding than basing the choice of OCPs on their theoretical properties.
Moreau, C et al Does the Type of Pill Matter? Oral Contraceptive Tolerance. Obstet Gynecol. 2007 Jun;109(6):1277-85.
http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db
=pubmed&list_uids=17540798&dopt=Abstract
FDA Approves Contraceptive for Continuous Use
The Food and Drug Administration (FDA) approved Lybrel, the first continuous use drug product for prevention of pregnancy on May 22, 2007
The new contraceptive, Lybrel, comes in a 28 day-pill pack with low-dose combination tablets that contain 90 micrograms of a progestin, levonorgestrel, and 20 micrograms of an estrogen, ethinyl estradiol, which are active ingredients available in other approved oral contraceptives. Continuous contraception works the same way as the 21 days on-seven days off cycle. It stops the body's monthly preparation for pregnancy by lowering the production of hormones that make pregnancy possible.
Other contraceptive pill regimens have placebo or pill-free intervals lasting four to seven days that stimulate a menstrual cycle. Lybrel is designed to be taken without the placebo or pill-free time interval. Women who use Lybrel would not have a scheduled menstrual period, but will most likely have unplanned, breakthrough, unscheduled bleeding or spotting.
The safety and efficacy of Lybrel as a contraceptive method were supported by two one-year clinical studies, enrolling more than 2,400 women, ages 18 to 49. Health care professionals and patients are advised that when considering the use of Lybrel, the convenience of having no scheduled menstruation should be weighed against the inconvenience of unscheduled bleeding or spotting. The occurrence of unscheduled bleeding decreases over time in most women who continue to take Lybrel for a full year. In the primary clinical study, 59 percent of the women who took Lybrel for one year had no bleeding or spotting during the last month of the study.
Like other available oral contraceptives, Lybrel is effective for prevention of pregnancy when used as directed. The risks of using Lybrel are similar to the risks of other conventional oral contraceptives and include an increased risk of blood clots, heart attacks, and strokes. The labeling also carries a warning that cigarette smoking increases the risk of serious cardiovascular side effects from the use of combination estrogen and progestin-containing contraceptives. Birth control pills do not protect against HIV infection (AIDS) or other sexually transmitted diseases.
Because Lybrel users will eliminate their regular periods, it may be difficult for women to recognize if they have become pregnant. Women should take a pregnancy test if they believe they may be pregnant. Women should also discuss contraceptive use, and the precautions and warnings for use of the drug product, with their doctors or other health care professional.
The approval of Lybrel concludes a comprehensive review process that included expert advice from a meeting of an FDA's Reproductive Health Drugs advisory committee and an opportunity for public comment on issues regarding hormonal contraception.
Lybrel is manufactured by Wyeth of Philadelphia, PA.
http://www.fda.gov/bbs/topics/NEWS/2007/NEW01637.html
Implanon and bone mineral density: Two Articles
BMD during long-term use of the progestagen contraceptive implant
An open, prospective, comparative study was done in healthy women, aged between 18 and 40 years, to study the effects of long-term etonogestrel treatment on bone mineral density (BMD). The control group used a non-hormone-medicated intrauterine device (IUD). The BMD was measured using a dual energy X-ray absorptiometry instrument. Measurements included the lumbar spine (L(2)-L(4)), the proximal femur (femoral neck, Ward's triangle, trochanter) and distal radius. The period of treatment was 2 years and 44 women in the Implanon group and 29 in the IUD group provided data. Groups were comparable at baseline with respect to age, weight, body mass index, BMD and 17beta-oestradiol status. Changes from baseline in BMD in the Implanon group were not essentially different from those in the IUD group. There was no relationship between 17beta-oestradiol concentrations and changes in BMD in this study population. The results of the present study indicate that Implanon((R)) can safely be used in young women who have not yet achieved their peak bone mass.
Beerthuizen R, et al Bone mineral density during long-term use of the progestagen contraceptive implant Implanon compared to a non-hormonal method of contraception. Hum Reprod. 2000 Jan;15(1):118-22
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=10611199
and
BMD with Implanon (etonorgestrel- and levonorgestrel-releasing contraceptive implants)
CONCLUSIONS: Women of 19-43 years of age using either one of the implants showed lower BMD at 18 months of use at the midshaft of the ulna, however, without a difference at the distal radius.
Bahamondes l et al A prospective study of the forearm bone density of users of etonorgestrel- and levonorgestrel-releasing contraceptive implants. Human Reproduction. 21(2):466-470, February 2006.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=16253974
Oral Contraceptives - Individualized Treatment -- Optimal Results (Slides with Audio)
http://www.medscape.com/viewarticle/557225
Featured Web Site David Gahn, IHS MCH Portal Web Site Content Coordinator
From Roberta Ward, CNM, ANMC
In case you didn't know about this website: +++
A couple of good handouts from Contraception Online that you may want to use with your patients are:
-Implantable Rod
-Extended Dosing
There are other handouts on that website also.
Contraception Online http://www.contraceptiononline.org/index.cfm
Last Special Issue on Methamphetamine in Indian Country: Now online
This is to let you know that the third (and last) special issue on meth in the IHS Primary Care
Provider is now available on-line at this link below
Thanks again to everyone who contributed to this important series.
Lori de Ravello, MPH lori.deravello@ihs.gov
Methamphetamine in Indian Country: Part 3
http://www.ihs.gov/PublicInfo/Publications/HealthProvider/issues/PROV0407.pdf
Wrong link for National Sexual Violence Resource Center
www.nsvrc.org is the CORRECT link for National Sexual Assault Resource Center NOT www.ncvrc.org
From Yohanah B LeivaYohanah.Leiva@ihs.gov
Frequently asked questions
Q. Can oral or sublingual misoprostol be used for postpartum hemorrhage?
A. Yes and both have a more rapid onset of action than rectal adminstraion
The doses are smaller than some of the rectal doses that are being used. The sublingual and oral doses of misoprostol mentioned below are: 400, and 600 microg.
Sublingual and oral doses reach a peak concentration much more rapidly, so sublingual or oral dosing may have more of a role in the acute management of PPH, rather the mid and long term management as with rectal misoprostol. (The time to peak concentration (Tmax) was similar in both the sublingual (26.0 +/- 11.5 min) and oral groups (27.5 +/- 14.8 min) and was significantly shorter than those in both vaginal groups.)
Here are a few articles on sublingual and oral doses of misoprostol used in postpartum hemorrhage.
Effect of sublingual misoprostol on severe postpartum haemorrhage in a primary health centre in Guinea-Bissau: randomised double blind clinical trial.
CONCLUSION: Sublingual misoprostol reduces the frequency of severe postpartum haemorrhage.
Høj L, et al Effect of sublingual misoprostol on severe postpartum haemorrhage in a primary health centre in Guinea-Bissau: randomised double blind clinical trial. BMJ. 2005 Oct 1;331(7519):723.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=16195287
Sublingual misoprostol versus methylergometrine for active management of the third stage of labor
CONCLUSION: Sublingual misoprostol appears to be as effective as intravenous methylergometrine in the prevention of postpartum hemorrhage. However, larger randomized studies are needed to advocate its routine use.
Vimala N, et al Sublingual misoprostol versus methylergometrine for active management of the third stage of labor. Int J Gynaecol Obstet. 2004 Oct;87(1):1-5
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=15464767
A pilot-randomized comparison of sublingual misoprostol with syntometrine on the blood loss in third stage of labor
CONCLUSION: The use of sublingual misoprostol or intravenous syntometrine in spontaneous vaginal delivery resulted in a comparable amount of blood loss. Transient side effect such as fever and shivering which resolved within a day occurred more frequent to those who received sublingual misoprostol.
Lam H, et al A pilot-randomized comparison of sublingual misoprostol with syntometrine on the blood loss in third stage of labor. Acta Obstet Gynecol Scand. 2004 Jul;83(7):647-50
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=15225189
A multicentre randomized controlled trial of oral misoprostol and i.m. syntometrine in the management of the third stage of labour
Oral misoprostol might be used in the management of the third stage, especially in situations where the use of syntometrine is contraindicated and facilities for storage and parenteral administration of oxytocics are limited.
Ng PS, et al A multicentre randomized controlled trial of oral misoprostol and i.m. syntometrine in the management of the third stage of labour. Hum Reprod. 2001 Jan;16(1):31-35
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=11139532
A double-blind randomized controlled trial of oral misoprostol and intramuscular syntometrine in the management of the third stage of labor.
CONCLUSION: Orally administered misoprostol at a dose of 400 mug is an acceptable alternative in preventing post-partum blood loss, as measured by the peri-partum change in hemoglobin level and was not associated with an increased incidence of side effects.
Ng PS, et al A double-blind randomized controlled trial of oral misoprostol and intramuscular syntometrine in the management of the third stage of labor. Gynecol Obstet Invest. 2007;63(1):55-60
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=16940738
Oral misoprostol in preventing postpartum haemorrhage in resource-poor communities: a randomised controlled trial
INTERPRETATION: Oral misoprostol was associated with significant decreases in the rate of acute postpartum haemorrhage and mean blood loss. The drug's low cost, ease of administration, stability, and a positive safety profile make it a good option in resource-poor settings.
Derman RJ, et al Oral misoprostol in preventing postpartum haemorrhage in resource-poor communities: a randomised controlled trial. Lancet. 2006 Oct 7;368(9543):1248-53
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17027730
A randomised placebo controlled trial of oral misoprostol in the third stage of labour.
CONCLUSIONS: Shivering has been shown in this study to be a specific side effect of misoprostol administered orally in the puerperium. No serious side effects were noted. Misoprostol shows promise as a method of preventing postpartum haemorrhage. Because of the potential benefits for childbearing women, particularly those in developing countries, further research to determine its effects with greater certainty should be expedited.
Hofmeyr GJ, et al A randomised placebo controlled trial of oral misoprostol in the third stage of labour. Br J Obstet Gynaecol. 1998 Sep;105(9):971-5
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=9763047
A double-blind placebo controlled randomised trial of misoprostol and oxytocin in the management of the third stage of labour
CONCLUSIONS: In low risk women oral misoprostol appears to be as effective in minimising blood loss in the third stage of labour as intramuscular oxytocin. Shivering was noted more frequently with misoprostol use, but no other side effects were noted. Misoprostol has great potential for use in the third stage of labour especially in developing countries.
Walley RL, et al A double-blind placebo controlled randomised trial of misoprostol and oxytocin in the management of the third stage of labour. BJOG. 2000 Sep;107(9):1111-5
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=11002954
Pharmacokinetics of different routes of administration of misoprostol.
CONCLUSION: The new sublingual route of administration of misoprostol demonstrated a great potential to be developed into a method of medical abortion.
Tang OS, et al Pharmacokinetics of different routes of administration of misoprostol. Hum Reprod. 2002 Feb;17(2):332-6
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=11821273
Q. How should you greet your patients?
A. Most Patients Prefer Their Physicians to Greet Them With a Handshake and Introduction
CONCLUSIONS: Physicians should be encouraged to shake hands with patients but remain sensitive to nonverbal cues that might indicate whether patients are open to this behavior. Given the diversity of opinion regarding the use of names, coupled with national patient safety recommendations concerning patient identification, we suggest that physicians initially use patients' first and last names and introduce themselves using their own first and last names.
Makoul G, et al An evidence-based perspective on greetings in medical encounters. Arch Intern Med. 2007 Jun 11;167(11):1172-6
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17563026
Q. How can I better counsel my patient to adhere to therapy?
A. Treatment effects expressed in terms of number needed to treat (NNT) yielded higher consent rates than did those expressed as equivalent postponements.
Background: Ways to communicate the benefits of risk-reducing drug therapies include the number needed to treat (NNT) to prevent adverse events, such as heart attacks or hip fractures, and gains in disease-free life expectancy or postponement of adverse events.
Methods: Respondents were randomized to a scenario with 1 of 3 outcomes after 5 years of treatment. For the drug to prevent heart attacks, the outcomes were postponement by 2 months for all patients, postponement by 8 months for 1 of 4 patients, or an NNT of 13 patients to prevent 1 heart attack.For the drug to prevent hip fractures, the outcomes were postponement by 16 days for all patients, postponement by 16 months for 3 of 100 patients, or an NNT of 57 patients to prevent 1 fracture. Study endpoints were consent to receive the intervention and perceived ease of understanding the treatment effect.
CONCLUSIONS: Treatment effects expressed in terms of NNT yielded higher consent rates than did those expressed as equivalent postponements. This result suggests that the description of the anticipated outcome may influence the patient's willingness to accept a recommended intervention.
Halvorsen PA, et al Different ways to describe the benefits of risk-reducing treatments: a randomized trial Ann Intern Med. 2007 Jun 19;146(12):848-56
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17577004
Q. Should patients use sweat lodges during pregnancy?
A. A sweat lodge that does not elevate the maternal core temperature would be acceptable
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/SweatLodge7607.doc
Q. What is recommended about peyote use in pregnancy?
A. Use of hallucinogens are not recommended in pregnancy
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/Peyote7607.doc
Indian Child Health Notes - Steve Holve, Pediatrics Chief Clinical Consultant
August 2007 – Highlights
-Lactose intolerance in infants, children, and adolescents.
-Influenza activity, 2006-7
-Inhalant abuse
-Fatal Injuries Among Children by Race and Ethnicity
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ICHN807.doc
Information Technology
Integrated case management software application release
The IHS Office of Information Technology (OIT) is pleased to announce the release of iCare, the next generation of RPMS Population Management software. We would like to thank Cherokee Indian Hospital, Phoenix Indian Medical Center, Red Lake Hospital Service Unit; Sells Service Unit, and SouthEast Alaska Regional Health Consortium for testing this application.
IHS Office of Information Technology initiated this population health care software application to provide an easy-to –use tool with multiple uses to a wide variety of providers. iCare is a Windows-based graphical user interface (GUI) component of the IHS Resource and Patient Management System (RPMS) that presents diverse patient data in a user-friendly perspective.
This initial version of iCare will provide IHS providers the ability to view patient data from an individual patient as well as a "population-centric" perspective. The application will assist the user in identifying trends in care for individuals and populations as well as increase awareness of the services that patients need by highlighting the status of key clinical prevention and treatment measures.
User-defined patient lists (panels) can be created, sorted and filtered in a variety of ways to form the core functionality of iCare. Additionally, auto-tagging" of patients with one or more clinical diagnoses and facilitating provider review of clinical quality of care measures for their own patients should enable improvement in the quality of healthcare delivery.
iCARE can be used by sites that are on RPMS-EHR as well as those that are not on RPMS-EHR. We encourage all sites to start using this software.
To encourage use, OIT is pleased to offer WebEx training for the new iCare (Population Management) software application. You will be able to participate in the training from your office or conference room and will not be required to travel to obtain this training. For more information on these training sessions, please visit our website: http://www.ihs.gov/CIO/ca/icare/index.asp and download the training schedule.
The new release of this software is available on the IHS Web site: http://www.ihs.gov/Cio/RPMS/index.cfm?module=home&option=software
or ITSC system, cmbsyb, in the /usr/spool/uucppublic/DIST/2006cert directory
iCare Training
The IHS Office of Information Technology is pleased to continue offering WebEx training for the new iCare (Population Management) software application. You will be able to participate in the training from the comfort of your office or conference room and will not be required to travel to obtain this training.
iCare is a tool with multiple uses for a wide variety of providers that presents diverse RPMS data through an easy to use graphical user interface (GUI).
There are two types of training offered:
- iCare Technical Overview
- iCare – Nuts and Bolts
The target audience is any provider who cares for patients (e.g. physicians, mid-level providers, nurses, case managers, public health personnel, pharmacists etc.)
NOTE:You must register for these classes. They are NOT limited to participants in a particular Area; they are open to all, however, space is limited so be sure to register right away. Below are the agendas and date/times for both classes. It is recommended that you attend them sequentially.
Each session is limited to 30 participants. Therefore, if there is a group of people who would like to attend at your facility, our recommendation is that you attend as a group and have only one person register for the session. For the group, you will need a conference room, conference phone, computer and projector. Please ensure someone at your facility is responsible for taking care of these arrangements.
Please note this is a live, internet-based training, not a recorded session, and people will be able to ask questions and actively participate in the class.
NOTE: All training times shown above are for the Pacific Daylight Time zone. Please ensure you adjust the time for your particular time zone.
Training Schedule
- iCare – Nuts and Bolts
Target Audience – Patient Care Providers (e.g. physicians, mid-level providers, nurses, case managers, public health personnel, pharmacists etc.)
Agenda
- Introductions and Context
- Set Up and Background (Server) Processes
- Establishing and Changing User Preferences
- Panel Creation
- Panel Modification
- Flags
- Diagnostic Tags
- National Performance Measures
- Patient Record
- Question and Answer Session
| Session | Date and Time | Reg Password | |
| iCare Nuts and Bolts | Mon 07/16/2007 | 12:00-14:00 PDT | coyote |
| Tue 07/31/2007 | 11:00-13:00 PDT | coyote | |
| Thur 08/23/2007 | 09:00-11:00 PDT | coyote | |
| Mon 08/27/2007 | 13:30-15:30 PDT | coyote | |
| Fri 09/14/2007 | 10:30-12:30 PDT | coyote |
- The Practical Use of iCare
Target Audience – Patient Care Providers (e.g. physicians, mid-level providers, nurses, case managers, public health personnel, pharmacists etc.)
Agenda
- Introductions and Context
- Scenarios
- Tips
- Using the Performance Measure views to improve outcomes
- Questions and Answers
| Session | Date and Time | Reg Password | |
| The Practical Use of iCare | Wed 07/18/2007 | 09:00-10:30 PDT | coyote |
| Thur 08/02/2007 | 09:30-11:00 PDT | coyote | |
| Fri 08/24/2007 | 10:00-11:30 PDT | coyote | |
| Thur 08/30/2007 | 12:00-13:30 PDT | coyote | |
| Wed 09/19/2007 | 11:00-12:30 PCT | coyote |
Registration Information
- Click this link:https://ihs-training.webex.com/
- At the Search For box, type in "iCare" (do not type in the quotation marks) and click the Go button. NOTE: If you do not see the Search For box, ensure the Training Center tab is selected at the top of the WebEx window, immediately under “webex.”
- All of the scheduled sessions will then be displayed in the window below. Choose the one you want to attend and click “Registration” in the Status column.
- Enter the Registration password that is shown above that corresponds to the class you want to attend.
- Click the OK button.
- Complete the registration form.
- Click the Register button.
- A Registration confirmation is displayed that contains all of the information for the training session, including the link for the session and the password to enter when you are ready to attend the session. Click the OK button to finish.
Setup (Software Install) Information:
You must have the WebEx software installed on your computer prior to attending the WebEx session. You should setup the software at least a day before the training session. You should not need anyone such as the Site Manager to install it for you. Below are the instructions.
- Click this link:
https://ihs-training.webex.com/ihs-training/mywebex/
default.php?Rnd0969=0.20680128403018566
- On the left side of the window, click Set Up.
- Immediately under Set Up you will see two options: Training Manager, Preferences.
- Click Training Manager.
- A message is displaying giving you information about the setup process. Click the Set Up button.
- After the software is installed, click the OK button.
Attending the Session:
When you are ready to attend the session, connect to the WebEx session first using the information contained in your registration confirmation e-mail and then connect to the conference line. The dial information for the conference line is shown below and is also included in your registration confirmation message.
Phone Number: (877) 781-4791
Passcode: 135963#
Questions? Contact Cynthia Gebremariam at Cynthia.Gebremariam@ihs.gov
International Health Update: Claire Wendland, Madison, WI
Maternal survival redux: a view from Malawi - Failure of justice
Last November this column reviewed the Lancet’s recent series on maternal survival, which assessed the progress and pitfalls of the Safe Motherhood movement. This month I want to revisit the issue of maternal survival from a more personal perspective. I spent the first five months of 2007 in Blantyre, Malawi, the largest city in a country in which a woman’s lifetime chance of dying from childbirth complications is around one in eight. While there I spent part of each week working clinically in a busy public referral and teaching hospital, alongside many of the nation’s new nurse midwives- and doctors-in-training. During these five months we averaged two to three maternal deaths every week in the hospital. I also spent time out in the community, interviewing nurse midwives at area health centers, and speaking with traditional midwives (TBAs in the biomedical lexicon). Many health workers – both within and outside of the formal medical sector -- shared their perceptions of maternal risk in Malawi. Some thoughts based on these experiences:
- Birth in a safe facility, attended by a skilled health worker, is just a start. And it doesn’t necessarily equate with “birth in a hospital with a biomedically trained doctor or nurse midwife.” Can a referral hospital be considered a “safe facility” if it has no sutures, runs out of all antibiotics except penicillin G, or has such poor staffing that one nurse covers a ward of eighty patients? Can a government health center be considered safe if there is no equipment to start an IV, nor any blood pressure cuff? What if the “skilled health worker” is demoralized and apathetic because he hasn’t been paid in two months? What if she is a brand new intern – poorly trained and supervised – who learned how to do a Cesarean from another intern and isn’t too sure how to use oxytocin? Making motherhood safer won’t happen simply by bringing women into the hospital. It is going to require detailed attention to sector-wide issues like supply chains, health sector funding, training and brain drain.
- Infection is playing a huge role in maternal deaths, at least in countries with high HIV prevalence, and the role of Cesarean section needs to be investigated carefully in these settings. Since I first worked in Malawi, the pattern of maternal deaths has shifted. In 1990, deaths from septic unsafe abortion were common, as was death from hemorrhage. In 2007, both of these have declined, but postpartum – and especially postoperative – infection deaths have skyrocketed. HIV-positive women are especially (but not exclusively) at risk. HIV treatment and prevention are crucial. And in this setting, the increased morbidity and mortality attendant upon surgical intervention should affect the risk/benefit analysis for Cesarean: the adoption of First World standards like surgical delivery for breech needs careful re-evaluation.
- We should rethink -- AGAIN -- the question of traditional birth attendant training. TBA training has all but vanished from international funders’ priorities, based on conflicting data on effectiveness. This despite the fact that TBAs continue to be the attendants at many births in the developing world; half of Malawi’s births are outside of formal-sector health facilities. TBAs I spoke with in Malawi very strongly advocated for a restoration of training programs that they felt provided them not only with valuable information and skills, but perhaps even more importantly enabled them to forge mutually respectful connections with district health offices and staff at local hospitals. These proved invaluable when it came time to manage difficult cases together.
- Women’s empowerment is more than a buzzword. In too many families, a woman’s value is in her capacity to bear children. In too many places, a girl’s ability to access schooling or employment depends on her willingness to trade sex for the patronage of an older male. In too many countries, women do not make the policy decisions that affect their lives. When a fifteen-year-old dies after an unsafe abortion, when a woman who knows she has AIDS dies of postpartum sepsis after her third attempt in three years to bear a son, maternal death is not just a biomedical problem, remediable by technical interventions. It is a failure of justice.
November 2006 International Health Update
http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn1106_Feat.cfm#ih
Other
Q. How about these two malarial drugs in early pregnancy?
Mefloquine Hydrochloride
Sulfadoxine and pyrimethamine (Fansidar)
Response from George Gilson, MFM
The above two drugs are not known to be teratogenic to human pregnancy. There has been
extensive experience with their use for malaria prophylaxis in developing co