Volume 5, No. 10, November 2007
Features
American College of Obstetricians and Gynecologists
Viral Hepatitis in Pregnancy
Summary of Recommendations and Conclusions
The following recommendations are based on good and consistent scientific evidence (Level A):
- Routine prenatal screening of all pregnant women by HBsAg testing is recommended.
- Newborns born to hepatitis B carriers should receive combined immunoprophylaxis consisting of HBIG and hepatitis B vaccine within 12 hours of birth.
- Hepatitis B infection is a preventable disease, and all at-risk individuals, particularly health care workers, should be vaccinated. All infants should receive the hepatitis B vaccine series as part of the recommended childhood immunization schedule.
- Breastfeeding is not contraindicated in women with HAV infection with appropriate hygienic precautions, in those chronically infected with hepatitis B if the infant receives HBIG passive prophylaxis and vaccine active prophylaxis, or in women with HCV infection.
The following recommendations are based on limited or inconsistent scientific evidence (Level B):
- Routine prenatal HCV screening is not recommended; however, women with significant risk factors for infection should be offered antibody screening.
- Route of delivery has not been shown to influence the risk of vertical HCV transmission, and cesarean delivery should be reserved for obstetric indications in women with HCV infection.
The following recommendations are based primarily on consensus and expert opinion (Level C):
- The risk of transmission of hepatitis B associated with amniocentesis is low.
- Susceptible pregnant women who are at risk for hepatitis B infections should be specifically targeted for vaccination.
Viral Hepatitis in Pregnancy. ACOG Practice Bulletin No. 86. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;110:941–55.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17906043
Disclosure and Discussion of Adverse Events
ABSTRACT: Disclosure and discussion of adverse events in health care is desired by patients and championed by safety experts and policy makers. Improving the disclosure process through policies, programmatic training, and accessible resources will enhance patient satisfaction, strengthen the physician–patient relationship, and most importantly, promote a higher quality of health care.
Disclosure and Discussion of Adverse Events. ACOG Committee Opinion No. 380. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;110:957–8
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17906044
Routine Thyroid Screening Not Recommended for Pregnant Women
ABSTRACT: Subclinical hypothyroidism is diagnosed in asymptomatic women when the thyroid-stimulating hormone level is elevated and the free thyroxine level is within the reference range. Thyroid hormones, specifically thyroxine, are essential for normal fetal brain development. However, data indicating fetal benefit from thyroxine supplementation in pregnant women with subclinical hypothyroidism currently are not available. Based on current literature, thyroid testing in pregnancy should be performed on symptomatic women and those with a personal history of thyroid disease or other medical conditions associated with thyroid disease (eg, diabetes mellitus). Without evidence that identification and treatment of pregnant women with subclinical hypothyroidism improves maternal or infant outcomes, routine screening for subclinical hypothyroidism currently is not recommended.
Subclinical Hypothyroidism in Pregnancy. ACOG Committee Opinion No. 381. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;110:959–60.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17906045
Fetal Monitoring Prior to Scheduled Cesarean Delivery
ABSTRACT: There are insufficient data to determine the value of fetal monitoring prior to scheduled cesarean delivery in patients without risk factors.
With the increasing rate of scheduled cesarean deliveries in the United States, clinicians and hospitals must decide whether there is need to determine fetal status prior to scheduled cesarean delivery. At the present time there are insufficient data to determine the value of fetal monitoring, either by electronic fetal heart rate monitoring or by ultrasound, prior to scheduled cesarean delivery in patients without risk factors. The decision to monitor the fetus prior to scheduled cesarean delivery should be individualized. Presence of fetal heart tones prior to surgery should be documented.
Fetal Monitoring Prior to Scheduled Cesarean Delivery. ACOG Committee Opinion No. 382. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;110:961.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17906046
Evaluation of Stillbirths and Neonatal Deaths
ABSTRACT: A complete evaluation of a stillbirth or neonatal death may explain the cause of death, direct further investigation of the family, and be particularly valuable in counseling parents about recurrence risks in future pregnancies. The results of the autopsy, placental examination, laboratory tests, and cytogenetic studies should be communicated to the involved clinicians and to the family of the deceased infant in a timely manner.
Evaluation of Stillbirths and Neonatal Deaths. ACOG Committee Opinion No. 383. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;110:963–6.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17906047
American Family Physician**
Repeat Cesarean Delivery vs. Planned Induction of Labor: Cochrane Briefs
Clinical Question
Should women who have had a previous low-transverse cesarean delivery and who require induction of labor be offered a trial of labor?
Evidence-Based Answer
There are no randomized controlled trials (RCTs) of labor induction in women with a low-transverse uterine scar. Observational studies indicate that there is a small increased risk of uterine rupture and adverse fetal outcomes, especially in women induced with prostaglandins. Although induction in these patients is common practice in other countries, based on these data, the American College of Obstetricians and Gynecologists (ACOG) recommends that patients be discouraged from induction of labor after a single previous low-transverse cesarean delivery.
Practice Pointers
Based on retrospective cohort studies, most women with one previous low-transverse cesarean delivery are candidates for vaginal birth and should be counseled and offered a trial of labor.1,2 In a retrospective, population-based review (including more than 20,000 total women), the overall rate of uterine rupture after a previous low-transverse cesarean delivery was 4.5 per 1,000; the rate was 1.6 per 1,000 with repeat cesarean delivery and no labor, 5.2 per 1,000 with spontaneous labor, 7.7 per 1,000 with nonprostaglandin induction, and 24.5 per 1,000 with prostaglandin induction.3
Another study showed that using oxytocin (Pitocin) to augment labor in women with a previous low-transverse cesearan delivery increases the risk of uterine rupture compared with spontaneous labor (8.7 versus 3.6 per 1,000); using oxytocin alone to induce labor increases the risk to 10.7 per 1,000. In women undergoing a trial of labor, the overall uterine rupture-related perinatal death was 0.11 per 1,000. The rate of perinatal hypoxic brain injury was 0.46 per 1,000 trials of labor compared with zero in women who had a repeat cesarean delivery.4
In Australia, New Zealand, and Canada, it is common practice to offer a trial of labor to women with a previous low-transverse cesarean delivery who require induction. Most physicians prefer oxytocin induction rather than cervical ripening with prostaglandins.
The authors of this Cochrane review found no RCTs to help further determine the safety of labor induction after previous cesarean delivery. In particular, it is not clear if prostaglandin use causes adverse outcomes in women attempting vaginal birth or if having an unfavorable cervix is simply a marker for complications.
The ACOG recommends that women who have had one previous low-transverse cesarean delivery be counseled and offered a trial of labor. However, because of limited and inconsistent evidence showing an increased risk of uterine rupture, the ACOG recommends that women who require cervical ripening or induction be discouraged from attempting a vaginal delivery. If a woman attempts a vaginal delivery after a previous low-transverse cesarean delivery, the ACOG recommends that her labor be managed in a hospital with immediate access to emergency obstetric care.
Because data are limited, the individual patient and her physician should make the ultimate decision. Vaginal birth after cesarean delivery should not be attempted in a woman with a classic uterine incision or history of transfundal surgery.2
Dodd JM, Crowther CA. Elective repeat caesarean section versus induction of labour for women with a previous caesarean birth. Cochrane Database Syst Rev 2006;(4):CD004906.
http://www.aafp.org/afp/20071001/cochrane.html
Hyperthyroidism
What are the effects of drug treatments for primary hyperthyroidism?
likely to be beneficial
Antithyroid Drugs (Carbimazole, Propylthiouracil, and Thiamazole). We found no randomized controlled trials (RCTs) comparing antithyroid drug treatment with placebo in persons with hyperthyroidism, although there is consensus that treatment is beneficial. We found no RCTs comparing antithyroid drugs (carbimazole, propylthiouracil, or thiamazole) with each other. One systematic review found that fewer persons relapsed with 18 months of higher-dose antithyroid drug treatments than with six months; however, it found no significant difference for more than 18 months compared with 12 to 18 months of lower-dose treatment. One systematic review found that a similar number of persons relapsed to hyperthyroidism with antithyroid drugs alone (titration) and antithyroid drugs plus thyroxine (block replace). One RCT found a similar proportion of persons who relapsed and who became euthyroid between high- and low-dose thiamazole. However, it found that adverse effects were lower with titration regimens. There have been concerns about bone marrow suppression, neutropenia, and agranulocytosis with antithyroid drugs. The doses of antithyroid drugs reported in the studies are higher than are generally used in practice. (Based on consensus because RCTs would be considered unethical.)
Radioactive Iodine (in Persons Without Ophthalmopathy; May Increase Ophthalmopathy in Persons with Graves' Disease) . We found no RCTs comparing radioiodine with placebo in persons with hyperthyroidism, although there is consensus that treatment is beneficial. Cohort studies found that radioiodine can increase some thyroid and extrathyroid cancers but not overall incidence of cancer. RCTs found that radioiodine can worsen ophthalmopathy in persons with Graves' disease compared with other treatments. (Based on consensus because RCTs would be considered unethical.)
unlikely to be beneficial
Adding Thyroxine to Antithyroid Drugs (Carbimazole, Propylthiouracil, and Thiamazole). One systematic review found that a similar number of persons relapsed to hyperthyroidism between antithyroid drugs plus thyroxine (block replace) and antithyroid drugs alone (titration). However, it found that adverse effects were higher with block replace regimens. Another systematic review found no significant difference in relapse between thyroxine and no treatment after antithyroid treatment.
What are the effects of surgical treatments for primary hyperthyroidism?
likely to be beneficial
Thyroidectomy. We found no RCTs comparing surgery with placebo in persons with hyperthyroidism, although there is consensus that treatment is beneficial. One systematic review and subsequent RCT found that total thyroidectomy decreased hyperthyroidism and increased euthyroidism and hypothyroidism compared with subtotal thyroidectomy. However, another subsequent RCT found no significant difference among bilateral subtotal, unilateral total, and contralateral subtotal, and total thyroidectomy in improvement in Graves' ophthalmopathy. The systematic review and RCTs did not find sufficient evidence that adverse effects were worse with total or subtotal thyroidectomy. (Based on consensus because RCTs would be considered unethical.)
What are the effects of treatments for subclinical hyperthyroidism?
likely to be beneficial
Any Antithyroid Treatment. One controlled clinical trial found that thyroid-stimulating hormone (TSH; also known as thyrotropin) and bone mineral density were higher in women given radioiodine compared with no treatment in women with no compression symptoms from a nodular goiter.
Definition
Hyperthyroidism is characterized by high levels of serum thyroxine (T4), high levels of serum triiodothyronine (T3), or both, and low levels of TSH. Subclinical hyperthyroidism is characterized by decreased levels of TSH (less than 0.1 mIU per L) but with levels of T4 and T3 within the normal range (total T4: 5 to 11 mcg per dL [64 to 142 nmol per L]; total T3: 65.19 to 162.97 ng per dL [1.0 to 2.5 nmol per L], depending on assay type). The terms hyperthyroidism and thyrotoxicosis are often used synonymously; however, they refer to slightly different conditions. Hyperthyroidism refers to overactivity of the thyroid gland leading to excessive production of thyroid hormones. Thyrotoxicosis refers to the clinical effects of unbound thyroid hormones, whether or not the thyroid gland is the primary source.
Secondary hyperthyroidism owing to pituitary adenomas, thyroiditis, iodine-induced hyperthyroiditis, and treatment of children and pregnant or lactating women are not covered in this review. Hyperthyroidism can be caused by Graves' disease (diffusely enlarged thyroid gland on palpation, ophthalmopathy, and dermopathy), toxic multinodular goiter (thyrotoxicosis and increased radioiodine uptake with multinodular goiter on palpation), or toxic adenoma (benign hyperfunctioning thyroid neoplasm presenting as a solitary thyroid nodule). We have not included treatment of Graves' ophthalmopathy in this review, although we do report on worsening of Graves' ophthalmopathy with radioiodine. We also have not included euthyroid sick syndrome (a condition occurring in persons with, for example, pneumonia, acute myocardial infarction, cancer, and depression; it is characterized by low levels of TSH and T3).
Diagnosis
The diagnosis of hyperthyroidism is established by a raised serum total or free T4 or T3 hormone levels, reduced TSH level, and high radioiodine uptake in the thyroid gland with features of thyrotoxicosis. The usual symptoms are irritability, heat intolerance and excessive sweating, palpitations, weight loss with increased appetite, increased bowel frequency, and oligomenorrhea. Persons with hyperthyroidism also often have tachycardia, fine tremors, warm and moist skin, muscle weakness, and eyelid retraction or lag.
Incidence and Prevalence
Hyperthyroidism is more common in women than in men. One study (2,779 persons in the United Kingdom; median age 58 years; 20 years' follow-up) found an incidence of clinical hyperthyroidism of 0.8 per 1,000 women a year (95% confidence interval [CI], 0.5 to 1.4 per 1,000 women a year). The study reported that the incidence was negligible in men.
In areas with low iodine intake, the incidence of hyperthyroidism is higher than in areas with high iodine intake because suboptimal iodine intake induces nodular goiter, and by the time the nodules become autonomic, hyperthyroidism develops. In Denmark, with moderate iodine insufficiency, the overall incidence of hyperthyroidism (defined as low levels of TSH) is 9.7 percent compared with 1.0 percent in Iceland with high iodine intake. The prevalence in the Danish study was 38.7 per 100,000 women a year and two per 100,000 men a year.
Etiology
Smoking is a risk factor, with an increased risk of Graves' disease (odds ratio [OR] = 2.5; 95% CI, 1.8 to 3.5) and toxic nodular goiter (OR = 1.7; 95% CI, 1.1 to 2.5). In areas with high iodine intake, the major cause is Graves' disease, whereas nodular goiter is the major cause in areas with low iodine intake. A correlation between diabetes mellitus and thyroid dysfunction has been described. In a Scottish population with diabetes, the overall prevalence of thyroid disease was 13 percent; the prevalence was highest in women with type 1 diabetes (31 percent). As a result of screening, new thyroid disease was diagnosed in 7 percent of persons with diabetes (hyperthyroidism in 1 percent).
Prognosis
Clinical hyperthyroidism can be complicated by severe cardiovascular or neuropsychiatry manifestations requiring hospital admission or urgent treatment.
Mortality
One population-based 10-year cohort study of 1,191 persons at least 60 years of age found a higher mortality among persons who had a low initial TSH level. The excess in mortality was attributable to cardiovascular diseases. However, the persons in this study who had a low TSH level may have had a higher prevalence of other illnesses, and adjustment was done only for age and sex, not for comorbidity. We found another population-based study evaluating 3,888 persons with hyperthyroidism. No increase was found in all-cause mortality or serious vascular events in persons whose hyperthyroidism was treated and stabilized, but an increased risk of dysrhythmias was found in persons treated for hyperthyroidism compared with the standard population (standardized incidence ratio = 2.71; 95% CI, 1.63 to 4.24).
Atrial fibrillation in persons with overt hyperthyroidism
We found one cohort study evaluating the incidence of atrial fibrillation in persons older than 60 years with low serum TSH concentrations (0.1 mIU per L or less). It found that low serum TSH concentrations were associated with an increased risk of atrial fibrillation (diagnosed by electrocardiography) at 10 years (61 persons with low TSH and 1,576 persons with normal TSH; incidence of atrial fibrillation was 28 per 1,000 person-years with low TSH values versus 11 per 1,000 person-years with normal TSH values; 13 out of 61 [21 percent] persons with low TSH values versus 133 out of 1,576 [8 percent] persons with normal TSH values; relative risk [as calculated by Clinical Evidence] = 2.53; 95% CI, 1.52 to 4.20). A population-based study including 40,628 persons diagnosed with hyperthyroidism in Denmark from 1977 to 1999 found that 8.3 percent were diagnosed with atrial fibrillation or flutter within 30 days from the date of diagnosis of hyperthyroidism.
Quality of life
The quality of life of persons with thyroid problems can be reduced in many ways if left untreated, and this can continue in the long term. In a long-term follow-up (179 persons, treated for 14 to 21 years before investigation), persons with Graves' disease had diminished vital and mental quality-of-life aspects even after years of treatment compared with a large Swedish reference population.
Fracture rate and bone mineral density
Hip and spine bone mineral density levels can decrease if hyperthyroidism is untreated. However, when treated, bone mineral density can increase to normal levels. The risk of hip fracture is also higher in persons with hyperthyroidism. Progression from subclinical to overt hyperthyroidism occurs in persons with nodular goiter but not in persons found by screening without other signs of thyroid disease. A meta-analysis (search date 1996), based on data from screening studies, estimated that each year 1.5 percent of women and 1.0 percent of men who had a low TSH level and normal free T4 and T3 levels developed an elevated free T4 or T3 level. Ophthalmopathy is a complication of Graves' hyperthyroidism. Treatment can be problematic and usually involves topical corticosteroids and external radiation of the eye muscles.
Thyroid volume and the nodularity of the gland influence the cure rate of hyperthyroidism
In a controlled study of 124 persons with newly diagnosed hyperthyroidism, remission rates were calculated after treatment with a combined antithyroid drug plus T4 for about two years. Persons with Graves' disease who did not have a goiter or had a small goiter had a significantly better outcome compared with persons with Graves' disease who had a medium- or large-sized goiter. Most persons with multinodular goiter had a relapse within the first year after stopping medication. http://www.aafp.org/afp/20071001/bmj.html
Clinical Evidence Concise,A Publication of BMJ Publishing Group
Bell's Palsy: Diagnosis and Management (See also Patient Education)
Bell's palsy is a peripheral palsy of the facial nerve that results in muscle weakness on one side of the face. Affected patients develop unilateral facial paralysis over one to three days with forehead involvement and no other neurologic abnormalities. Symptoms typically peak in the first week and then gradually resolve over three weeks to three months. Bell's palsy is more common in patients with diabetes, and although it can affect persons of any age, incidence peaks in the 40s. Bell's palsy has been traditionally defined as idiopathic; however, one possible etiology is infection with herpes simplex virus type 1. Laboratory evaluation, when indicated by history or risk factors, may include testing for diabetes mellitus and Lyme disease. A common short-term complication of Bell's palsy is incomplete eyelid closure with resultant dry eye. A less common long-term complication is permanent facial weakness with muscle contractures. Approximately 70 to 80 percent of patients will recover spontaneously; however, treatment with a seven-day course of acyclovir or valacyclovir and a tapering course of prednisone, initiated within three days of the onset of symptoms, is recommended to reduce the time to full recovery and increase the likelihood of complete recuperation. Am Fam Physician 2007;76:997-1002, 1004.
http://lyris.aafp.org/t/1935903/16249464/520268/0/
Peptic Ulcer Disease (See also Patient Education)
Peptic ulcer disease usually occurs in the stomach and proximal duodenum. The predominant causes in the United States are infection with Helicobacter pylori and use of nonsteroidal anti-inflammatory drugs. Symptoms of peptic ulcer disease include epigastric discomfort (specifically, pain relieved by food intake or antacids and pain that causes awakening at night or that occurs between meals), loss of appetite, and weight loss. Older patients and patients with alarm symptoms indicating a complication or malignancy should have prompt endoscopy. Patients taking nonsteroidal anti-inflammatory drugs should discontinue their use. For younger patients with no alarm symptoms, a test-and-treat strategy based on the results of H. pylori testing is recommended. If H. pylori infection is diagnosed, the infection should be eradicated and antisecretory therapy (preferably with a proton pump inhibitor) given for four weeks. Patients with persistent symptoms should be referred for endoscopy. Surgery is indicated if complications develop or if the ulcer is unresponsive to medications. Bleeding is the most common indication for surgery. Administration of proton pump inhibitors and endoscopic therapy control most bleeds. Perforation and gastric outlet obstruction are rare but serious complications. Peritonitis is a surgical emergency requiring patient resuscitation; laparotomy and peritoneal toilet; omental patch placement; and, in selected patients, surgery for ulcer control. (Am Fam Physician 2007;76:1005-12, 1013 http://www.aafp.org/afp/20071001/1005.html
Respiratory Distress in the Newborn
The most common etiology of neonatal respiratory distress is transient tachypnea of the newborn; this is triggered by excessive lung fluid, and symptoms usually resolve spontaneously. Respiratory distress syndrome can occur in premature infants as a result of surfactant deficiency and underdeveloped lung anatomy. Intervention with oxygenation, ventilation, and surfactant replacement is often necessary. Prenatal administration of corticosteroids between 24 and 34 weeks' gestation reduces the risk of respiratory distress syndrome of the newborn when the risk of preterm delivery is high. Meconium aspiration syndrome is thought to occur in utero as a result of fetal distress by hypoxia. The incidence is not reduced by use of amnioinfusion before delivery nor by suctioning of the infant during delivery. Treatment options are resuscitation, oxygenation, surfactant replacement, and ventilation. Other etiologies of respiratory distress include pneumonia, sepsis, pneumothorax, persistent pulmonary hypertension, and congenital malformations; treatment is disease specific. Initial evaluation for persistent or severe respiratory distress may include complete blood count with differential, chest radiography, and pulse oximetry. Am Fam Physician 2007;76:987-94 http://www.aafp.org/afp/20071001/987.html
AHRQ
Information women receive in pregnancy affects their childbirth preferences
after prior cesarean delivery
http://www.ahrq.gov/research/oct07/1007RA15.htm
Primary care doctors should encourage colorectal cancer screening
and clarify that screening is not just for those with symptoms
http://www.ahrq.gov/research/oct07/1007RA5.htm
Three clinical characteristics double the likelihood of hysterectomy
for women with common noncancerous pelvic conditions
http://www.ahrq.gov/research/sep07/0907RA13.htm
Three-fourths of low-income women are dissatisfied with their body
size 6 months after giving birth
http://www.ahrq.gov/research/oct07/1007RA14.htm
Women in Medicare and private managed care plans receive worse care
than men for cardiovascular disease and diabetes
http://www.ahrq.gov/research/sep07/0907RA7.htm
Ask A Librarian: Diane Cooper, M.S.L.S. / NIH
The HSR Library- a branch of the NIH Library Provides Access to Many Online Journals
The HSR Library's online journal collection continues to expand. Select from these options to access one of the titles now available:
- Click on the NIH Library button that appears when searching PubMed®, Scopus™, Web of Science®, and other HSR Library databases.
OR
- Go to the HSR Library website and select Online Journals under Quick Links.
- OR
- Search the HSR Library Online Catalog for a journal title.
If the Library does not subscribe to the journal you need, you may use the Order
a Document form to request electronic copies of articles.
Links:
HSR Library http://hsrl.nihlibrary.nih.gov/
Online Journals http://hsrl.nihlibrary.nih.gov/ResearchTools/default.htm?srchType=OnlineJournals
Online Catalog http://hsrl.nihlibrary.nih.gov/ResearchTools/Online+Catalog.htm
Order a Document http://hsrl.nihlibrary.nih.gov/LibraryServices/Order+a+Document.htm
For more information or help using your online library resources, contact me at cooperd@mail.nih.gov
Breastfeeding, Amy Patterson, California Area*
Breastfeeding Promotion: Good Public Health Policy
Why do we care about breastfeeding?
Babies, mothers, and society at large all benefit from breastfeeding. Breast milk is a complete form of nutrition for infants. Breast milk has just the right amount of fat, sugar, water, and protein needed for a baby's growth and development, and is easier to digest than formula. As a result, breastfed infants tend to gain less unnecessary weight. This may carry over into adulthood. A number of studies have shown that children and adults who were breastfed are less likely to be overweight compared to those who were never breastfed. Breastfeeding has the potential to help stem the epidemic of childhood and adult obesity in the United States.
Breastfeeding also promotes good health. Breast milk contains antibodies that can protect infants from bacterial and viral infections; formula does not contain these antibodies. Breastfed babies are less likely to be hospitalized for illness than formula-fed babies. 1 Breastfed infants also have lower rates of asthma and diabetes later in life. Research suggests that exclusive breastfeeding for at least the first 4 months is preventive for asthma and other allergies in children. 2 Breastfeeding has also been correlated with a lower prevalence of type 2 diabetes in adult American Indians. 3,4
By contrast, babies who are not breastfed are sick more often and have more doctor visits. They are more likely to develop a wide range of infectious diseases including ear infections, diarrhea, and respiratory illnesses. The difference in health status is stark: infants who are not breastfed are 21% more likely to die within their first year than breastfed babies in the in the U.S. 5 A few studies suggest that infants who are not breastfed have higher rates of sudden infant death syndrome (SIDS) in the first year of life. 6,7 The health disparities continue even after the first year; people who were not breastfed have higher rates of type 1 and type 2 diabetes, lymphoma, leukemia, Hodgkin's disease, overweight and obesity, high cholesterol and asthma. 8
The benefits of breastfeeding extend to nursing mothers as well. Nursing uses up extra calories, making it easier to lose weight gained during pregnancy. Breastfeeding lowers the long-term risk of breast and ovarian cancers, and possibly the risk of hip fractures and osteoporosis after menopause. Breastfeeding has also been linked with a reduced risk of type 2 diabetes, and the protective effect increases with exclusivity and duration. 9 Exclusive breastfeeding (meaning no supplementing with formula) also delays the return of normal ovulation and menstrual cycles, though it should not be relied upon as a fail-safe form of birth control.
Breastfeeding also makes a nursing mother’s life easier; it saves time and money, and is more convenient than bottle feeding. There are no bottles and nipples to sterilize, and no risk of contamination, as there is with formula. A mother can give her baby immediate satisfaction by providing breast milk when her baby is hungry. Breastfeeding requires a mother to take some quiet time for herself and her baby, and helps them bond. Physical contact is important to newborns and can help them feel more secure, warm and comforted.
- Ball TM, Wright AL. Health care costs of formula feeding in the first year of life. Pediatrics. 1999 Apr;103(4 Pt 2)870-6.
- Kull I, Wickman M, Lilja G, Nordvall SL, Pershagen G. Breastfeeding and allergic diseases in infnats - a prospective birth cohort study. Arch Dis Child. 2002 Dce;87(6):478-81.
- Pettitt DJ, Forman MR, Hanson RL, Knowler WC, Bennett PH. Breastfeeding and incidence of non-insulin-dependent diabetes mellitus in Pima Indians. Lancet. 1997Jul 19;350(9072):166-8.
- Young TK, Martens PJ, Taback SP, Sellers EA, Dean HG, Cheang M, Flatt B.Type 2 Diabetes mellitus in children:prenatal and early infancy risk factors among Native Canadians. Arch Pediatr Adolesc Med. 2002 Jul;156(7):651-5.
- Chen A, Rogan WJ. Breastfeeding and the risk of postneonatal death in the United States.Pediatrics. 2004 May;113(5):e435-9.
- Ford RP, Taylor BJ, Mitchell EA, Enright SA, Stewart AW, Becroft DM, Scraff R, Hassall IB, Barry DM, Allen EM, et al. Breastfeeding and the risk of sudden infant death syndrome. int J Epidemiol. 1993 Oct;22(5):885-90.
- Mitchell EA, Tuohy PG, Brunt JM, Thompson JM, Clements MS, Stewart AW,
Ford RP, Taylor BJ. Risk factos for sudden infant death syndrome following the prevention campaign in New Zealand. Pediatrics. 1997 Nov;100(5):835-40.
- Gartner LM, Morton J, Lawrence RA, Naylor AJ, O'Hare D, Schanler RJ, Eidelman AI; American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2005 Feb;115(2):496-506.
- Stuebe AM, Rich-Edwards JW, Willett WC, Manson JE, Michels KB. Duration of lactation and incidence of type 2 diabetes. JAMA. 2005 Nov 23;294(20):2601-10.
Note: Tune in next month for the next installment “Getting it Right”
If you would like more information and prefer to use one comprehensive article,
please consider:
Ips, Chung M. Raman G. Chew P, Magula N. De Vine D, Trikalinos T, Lau J. Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries. Evidence Report/Technology Assessment . 2007 Apr (153):1-186.
*by Amy Patterson (PhD, Public Health Analyst, California Area Indian Health Service)
Other
Early skin-to-skin contact for mothers and their newborn infants improves outcomes
BACKGROUND: Mother-infant separation postbirth is common in Western culture. Early skin-to-skin contact (SSC) begins ideally at birth and involves placing the naked baby, covered across the back with a warm blanket, prone on the mother's bare chest. According to mammalian neuroscience, the intimate contact inherent in this place (habitat) evokes neurobehaviors ensuring fulfillment of basic biological needs. This time may represent a psychophysiologically 'sensitive period' for programming future behavior.
CONCLUSIONS: The intervention may benefit breastfeeding outcomes, early mother-infant attachment, infant crying and cardio-respiratory stability, and has no apparent short or long-term negative effects.
Moore ER, et a; Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD003519
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17636727
Breast milk: Greater mental development and fewer re-hospitalizations
Extremely low birth weight premature infants who received breast milk shortly after birth, while still in intensive care units, had greater mental development scores at 30 months than did infants who were not fed breast milk, reported researchers in an NIH network. Moreover, infants fed breast milk were less likely to have been re-hospitalized after their initial discharge than were the infants not fed breast milk.
CONCLUSIONS: Beneficial effects of ingestion of breast milk in the NICU persist at 30 months' corrected age in this vulnerable extremely low birth weight population. Continued efforts must be made to offer breast milk to all extremely low birth weight infants both in the NICU and after discharge.
Vohr BR, et al Persistent beneficial effects of breast milk ingested in the neonatal intensive care unit on outcomes of extremely low birth weight infants at 30 months of age. Pediatrics. 2007 Oct;120(4):e953-9.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17908750
CCC Corner Digest
Nicely laid out hard copy - A compact digest of last month’s CCC Corner
October Highlights include:
- Group Prenatal Care Improves Pregnancy Outcomes at No Additional Cost
- Rebuilding Iraq one patient at a time: You can be part of the solution
- Do Unsutured Second-Degree Perineal Lacerations Affect Postpartum Outcomes?
- Cervical cancer differences disappear in rural women after controlling for poverty and race
- How to improve psychosocial problems at well child care visits?
- Why Hasn't This Patient Been Screened for Colon Cancer?
- Management of Delivery of a Newborn With Meconium-Stained Amniotic Fluid
- In Search of a Research Article?
- A pacifier by any other name….
- October is Domestic Violence Awareness Month: Materials available
- Advance Provision for Emergency Oral Contraception Reduces Post Coital Interval
- What's the first course of action for this couple that's trying to conceive?
- Bar code medication administration changes nurses' work
- Prevention of Mother-to-Child HIV Transmission: An Innovative Program in Cameroon
- AI / AN researchers on perinatal depression requesting names of interested individuals
- Endometriosis: Where is the real truth?
- Estrogen Protects Women’s Brains Prior to Menopause
- Piercing the veil: the marginalization of midwives in the United States
- Evaluation of the pregnant patient for non-obstetric surgery
- Memories, As a Public Health Nurse on the Navajo*
- Common Questions about HPV and Cervical Cancer: For Women Who Have HPV
- Fracture Outcomes in Women Discontinuing Alendronate
- Procedure-related complications of amniocentesis and CVS are small
- Chronic Renal Disease is Part of Primary Care
- Call for re-evaluation of gestational diabetes diagnosis and treatment criteria
- Ovarian Cancer: Pinn Point on Women’s Health
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/CCCC_v5_09.pdf
If you want a copy of the CCC Digest mailed to you each month, please contact nmurphy@scf.ccDomestic Violence – Denise Grenier, Rachel Locker
Coaching Boys Into Men AI/AN Poster - Available in PDF Only
The
FVPF launches two new posters for use in American Indian/Alaska Native (AI/AN)
communities! The posters, part of two current FVPF campaigns: Coaching Boys into
Men and Fathering After Violence, may be used in any community setting frequented
by men and boys. This may include tribal offices, schools, gyms, batter’s
intervention programs, health care facilities and visitation centers.
About the Coaching Boys Into Men Campaign
Men – as fathers, brothers, coaches, teachers, uncles and mentors – are
in a unique position to prevent domestic violence through action and conversation.
Over the past five years, the Family Violence Prevention Fund (FVPF) has refined
its public education strategy to focus on men and boys as a critical part of
the national movement to end violence against women and girls. Coaching Boys
into Men (CBIM) is the result of this shift - helping stop violence before it
starts. The campaign’s core goal is to inspire men to teach boys to respect
women and that violence never equals strength. Learn more about the Coaching
Boys Into Men Campaign. Alternate poster versions are available for diverse
communities.
The AI/AN CBIM poster was developed by a committee of leaders working in AI/AN
communities and on violence prevention and is co-sponsored by Mending
the Sacred Hoop Technical Assistance Project.
Download
and print this CBIM AI/AN poster
http://endabuse.org/programs/publiceducation/files/CBIM-AIAN.pdf
Resources
http://fvpfstore.stores.yahoo.net/coaching-boys-into-men-aian-poster.html
and
http://www.endabuse.org/programs/healthcare/
Aberdeen requesting DV and sexual assault pamphlets or CD-ROM resources
Willeen Druley MCH / WH coordinator at Aberdeen Area is requesting your assistance if you happen to have access to any DV and sexual assault pamphlets or CD-ROM resources.
Patient Self-Administered Report Effective to Screen for Domestic Violence
CONCLUSIONS: Domestic violence is common, and we found that most patients and clinicians are comfortable with domestic violence screening in urban family medicine settings. Patient self-administered domestic violence screening is as effective as clinician interview in terms of disclosure, comfort, and time spent screening.
Chen PH et al Randomized comparison of 3 methods to screen for domestic violence in family practice. Ann Fam Med. 2007 Sep-Oct;5(5):430-5.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17893385
Domestic violence victims have higher health care use and costs than other women, even long after the abuse has ended
http://www.ahrq.gov/research/sep07/0907RA11.htm
Elder Care News
Moderate- and High-Intensity Resistance Training Improves Cognitive Function in Elderly
CONCLUSIONS: Moderate- and high-intensity resistance exercise programs had equally beneficial effects on cognitive functioning.
Cassilhas
RC et al The impact of resistance exercise on the cognitive function of the
elderly.
Med Sci Sports Exerc. 2007 Aug;39(8):1401-7.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17762374
Fall Injury Episodes Among Noninstitutionalized Older Adults: United States, 2001–2003
The annualized rate of fall injury episodes for noninstitutionalized adults aged 65 years and over in 2001–2003 was 51 episodes per 1,000 population. Rates of fall injuries increased with age, and were higher for women compared with men. The most common cause of fall injuries among older adults was slipping, tripping, or stumbling, and most fall injuries occurred inside or around the outside of the home. Nearly 60 percent of older adults who experienced a fall injury visited an emergency room for treatment or advice. Nearly one-third of older adults experiencing a fall injury needed help with activities of daily living as a result, and over one-half of these persons expected to need this help for at least 6 months. A similar percentage experienced limitation in instrumental activities of daily living as a result of fall injuries. http://www.cdc.gov/nchs/data/ad/ad392.pdf
Maintenance Antidepressant Treatment Improves Well-Being in Late-Life Depression
CONCLUSION: Maintenance antidepressant pharmacotherapy is superior to placebo in preserving improvements in overall well-being achieved with treatment response in late-life depression. No such benefit was seen with interpersonal psychotherapy.
Dombrovski
AY, et al Maintenance treatment for old-age depression preserves health-related
quality of life: a randomized, controlled trial of paroxetine and interpersonal
psychotherapy.
J Am Geriatr Soc. 2007 Sep;55(9):1325-32.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17767673
The Last Hours of Living: Practical Advice for Clinicians (Medscape)
Preparing for the Last Hours of Life
Physiologic Changes and Symptom Management
Two Roads to Death
When Death Occurs
Notifying Others of the Death
Pronouncing Death
http://www.medscape.com/viewarticle/542262
Principles of Effective Pain Management at the End of Life
Case based CME module, Medscape
http://www.medscape.com/viewarticle/545562
Family Planning
Transdermal hormonal contraception: benefits and risks
Transdermal drug delivery systems have been available in the United States for >20 years. Since the introduction of the first transdermal patch (scopolamine) for the treatment of motion sickness, >35 transdermal patch products have been approved by the US Food and Drug Administration for a variety of indications that include hormone replacement therapy, nicotine replacement therapy, chronic pain (fentanyl), angina (nitroglycerin), hypertension (clonidine), and more recently, overactive bladder (oxybutynin), and contraception (ethinyl estradiol/norelgestromin). Clinical data demonstrated the efficacy and safety of the contraceptive patch; however, concerns regarding estrogen levels and reports of venous thromboembolism led to the development of 2 epidemiologic studies and, subsequently, revised product labeling. Despite this, the contraceptive patch may be an appropriate option for some patients
Burkman RT. Transdermal hormonal contraception: benefits and risks. Am J Obstet Gynecol. 2007 Aug;197(2):134.e1-6.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17689623
Oral Contraceptive Use Linked to Cancer Risk
The evidence suggests that current users of combined oral contraceptives have an increased risk of cancer of the breast, cervix, and liver compared with non-users. The risks of breast and cervical cancer decline after stopping oral contraception, returning to that of non-users within about 10 years. Current users of combined oral contraceptives, however, have a reduced risk of cancer of the endometrium, ovaries, and, possibly, colorectum
CONCLUSION: In this UK cohort, oral contraception was not associated with an overall increased risk of cancer; indeed it may even produce a net public health gain. The balance of cancer risks and benefits, however, may vary internationally, depending on patterns of oral contraception usage and the incidence of different cancers.
Hannaford PC et al Cancer risk among users of oral contraceptives: cohort data from the Royal College of General Practitioner's oral contraception study. BMJ. 2007 Sep 29;335(7621):651.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17855280
Featured Web Site David Gahn, IHS MCH Portal Web Site Content Coordinator
It was low hanging fruit before: Now it is even easier - Perinatology Corner
The Perinatology Corner, a great Indian Health resource on many obstetric topics, plus free CME, has just gotten easier to use. Once you create an IHS login username and password (which takes about 30 seconds) the system will remember you and make it easier each time you want to take another module.
Submitting a Posttest
To take a posttest, log in with an IHS login now
The link to log in is in the leftside menu of each module's posttest page. (You will only need to log in once to any page that provides the link in the IHS site.) Once you fill in the registration information on the posttest page of one module, the demographics will self populate all future modules, thereby saving you time and effort.
You can take and retake any posttest. Any time you take a posttest, an email will sent to you with answers. You only get credit for the first time you take a module's posttest.
You can change your contact information (except their email address, through this system) in the form of any module's posttest once you've submitted your contact information in the first posttest you take.
You can update your contact information on the form when you're submitting a new posttest, when retaking a test with or without retaking the posttest.
Here is how to complete the Posttest and Evaluation
It is easy. Ptease log in and the Posttest page will become available
-If you have logged into the to the Indian Health registration before, then go directly to Login (choose the "Login" link):
Hit Login or Register
-If haven't completed the Registration process before, it is easy, secure,
and relatively quick.
-It will also allow you to take future modules without having to repeat your
contact information each time.
Choose the "Register" link:
Once you have successfully logged into your web account, then hit the Return
button on the
Successful Login page and it will take you to the Posttest and Evaluation
Perinatology Corner
Frequently asked questions
Q. How can we best manage Jehovah’s Witnesses during pregnancy?
http://www.ihs.gov/MedicalPrograms/MCH/M/Jfaqs.cfm
Indian Child Health Notes - Steve Holve, Pediatrics Chief Clinical Consultant
November 2007 – Highlights
The latest in Child Health Info for those in Indian Health and Tribal Clinics
-A guest editorial on Pediatric Rheumatology by Dr. James Jarvis
-Viral etiologies in AI/AN children – what do our patients get?
-Privacy, property rights and cultural rights. Where tribal groups and American law clash
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/ICHN1107.doc
Information Technology
National Release - RPMS Electronic Health Record, Version 1.1
OIT is VERY pleased to announce the certification of the RPMS Electronic Health Record (EHR) graphical user interface (GUI) application, version 1.1.
The RPMS EHR GUI functionality was tested at the following alpha and beta test sites: Wind River Service Unit, Cherokee Indian Hospital, Carl Albert Indian Hospital, Warm Springs Health and Wellness Center, Fort Defiance Indian Hospital, Whiteriver Indian Hospital, and Phoenix Indian Medical Center. Each facility has endorsed the certification and release of EHR v1.1.
EHR v1.1 routines and documentation adhere to the 2006 RPMS Programming Standards and Conventions. A number of minor functional issues have been identified by users at test sites, and these will be addressed in upcoming application patches.
Release Criteria
EHR v1.1 should be installed ONLY at sites that are already running the RPMS EHR v1.0. Although v1.0 is not a technical prerequisite for v1.1, certain EHR infrastructure applications including Order Entry v3 and Outpatient Pharmacy v7, among others, are prerequisites. These applications continue to be released in a controlled manner by OIT to sites that have met specific preparation criteria.
It is very strongly recommended that all installations of EHR v1.1 be coordinated and scheduled with the Information Systems Coordinator (ISC) and other technical and support staff at your Area Office. This is to ensure availability of support at the Area level should issues be encountered during installation and configuration of the application. OIT has asked the ISCs to provide a schedule of planned installations so that OIT may anticipate v1.1 support calls.
Functionality
EHR v1.1 includes a wide variety of enhancements to the Electronic Health Record interface. The EHR configuration menus have been consolidated and greatly simplified to make EHR management easier for Clinical Application Coordinators. Functional enhancements include numerous changes to the medication management component, enhancements to the documentation of patient education, improvements in documenting refusals, and the ability to configure Web links to speed access to information and decision support, among many others. Errors and bugs identified since the release of v1.0 and not addressed in prior patches have been corrected, and previous exceptions to the Standards and Conventions have been resolved. A new EHR Technical Manual has been delivered and all prior guides and manuals have been updated.
The new release of this software is available from the IHS Website, http://www.ihs.gov/Cio/RPMS/index.cfm?module=home&option=software
National Release - BI Immunization System, Version 8.2
OIT is pleased to announce the release of a new version of the immunization package. Please contact your site manager for further information.
The BI Immunization Version 8.2 has the following new features.
Human Papillomavirus (HPV) vaccine Forecasting
Version 8.2 provides two forecasting options for HPV vaccine. Providers can choose to forecast HPV vaccine for 11 to 18-year-old or 11 to 26-year-old females.
New Adolescent Report
There is a new adolescent immunization report which provides immunization coverage rates for single vaccines (HepB, HepA, Td/Tdap, MMR, Varicella, MeningCV4,Influenza and HPV vaccines) and combinations (e.g., 3HepB, 2MMR, 1Var, 1Td/Tdap) for adolescents 11 to 17-years-old with 2 visits in the past 3 years. This report follows the logic and age groups that the Centers for Disease Control (CDC) is using for the new Adolescent National Immunization Survey.
New Lot Number Inventory Tracking
Version 8.2 contains a new Vaccine Inventory system that monitors vaccine stock by lot number. When the pharmacist/manager enters a new lot number, they will input the expiration date, source (VFC, non-VFC), starting number of doses, and unused doses. The “doses unused” decreases each time an immunization of that lot number is entered into RPMS. The provider will get an alert notice if they enter an expired vaccine lot, or if the supply is low.
Forecasting for Rotavirus (v8.1*1 patch )
There is a new rotavirus forecasting option that forecasts rotavirus (rota-pent, RotaTeq®) vaccine for all infants at 2 months (or 6 weeks), 4 months, and 6 months.
Influenza vaccine routinely forecast for children 6 - 59 months (v8.1*1 patch)
The routine influenza forecasting for children was changed from 6 - 23 months to 6 - 59 months to match recommendations from the Advisory Committee on Immunization Practices.
Second dose of Varicella Forecast at 4 - 18 Years (v8.1*1 patch)
A second dose of Varicella vaccine is forecast starting at age 4 years 0 months. The minimal interval between the first and second doses is 3 months; however, a second dose is valid if there are at least 4 weeks between the first and second doses.
MMR maximum age 18 years (v8.1*1 patch)
No forecasting option will forecast MMR vaccine after 18 years 364 days, regardless of previous vaccine history. Theresa.Cullen@ihs.gov
International Health Update: Claire Wendland, Madison, WI
Treating schizophrenia in poorer countries: Old dilemmas and new directions
Although for many years the conventional wisdom in international psychiatry held that schizophrenia had a better prognosis in the Third World than in the First, this belief has recently been called into question. Evidence suggests that conditions for the chronically mentally ill may be changing for the worse, in part because rapid social and economic change are undermining the family-based care that has traditionally provided for people with schizophrenia. (Interestingly, income inequality and urbanization are linked with poor outcomes even more strongly than poverty per se). Mental health has sometimes been called the Cinderella of international public health, and with good reason. Developing countries typically devote less than 1% of their already limited health budgets to mental health, and have on average one to two qualified mental health providers for every million population – a population that should include three to five thousand schizophrenics, as rates of schizophrenia appear to vary little among societies. Little or no community-based care for the chronically mentally ill exists, and psychiatric hospitals are few, large, and undersupplied with staff and therapies. Some evidence suggests that human rights abuses of the mentally ill are on the rise.
In a recent PLoS Medicine article, three psychiatrists with experience in India and Pakistan propose new models for treating schizophrenics. The director of a schizophrenia research foundation, R. Thara, argues that simply treating more people with antipsychotics will reduce stigma by pushing communities to accept medical (rather than magical or religious) explanations for psychotic disorders. National mental health programs can follow up with campaigns intended to destigmatize schizophrenia the way previous campaigns worked to destigmatize leprosy. Saeed Farooq, a psychiatrist from Pakistan, takes a similar approach, but one built on the model of tuberculosis. Farooq proposes that patients with schizophrenia be given free antipsychotic drugs under supervision for two years, echoing the “Directly Observed Therapy, Short-Course” (DOTS) used more-or-less successfully in many countries to control tuberculosis. Families already provide the most expensive care for these patients, Farooq argues; surely the state can shoulder a small part of the burden by paying for the drugs. Like Thara, he believes effective treatment will reduce stigma and insure that more sufferers will seek help. Vikram Patel proposes a more integrated model in which minimally trained community health workers act as case finders, referring patients to health practitioners who can make the diagnosis and initiate drug treatment. The patients are then referred back to the community health worker, who will follow up for medication adherence, refer to social welfare organizations, and help to strengthen employment options.
All three models use antipsychotics as a lever to change community perceptions of schizophrenia. All three are hazy on issues of cost and the possibility of coercion. At least one of these strategies (the DOTS analogue) is being tested in an RCT now. We should soon have better information on methods that work – or don’t work – for this serious problem in international health.
Patel V, Farooq S, Thara R. What is the best approach to treating schizophrenia in developing countries? PLoS Medicine 4(6):e159, June 2007
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17579508
MCH Alert
Having more family meals during adolescence is associated with improved diet quality
The article describes meal patterns of young adults and examines relationships between family meals during adolescence and dietary quality and meal patterns during early young adulthood. Results of this study indicate that having more family meals during adolescence is associated with improved diet quality during young adulthood.
The authors found that
* The frequency of family meals at Time 1 was as follows: 1-2 times per week for 22.1% of adolescents, 3-6 times per week for 41.9% of adolescents, and 7 or more times per week for 18.6% of adolescents. The prevalence of never having family meals was 17.4%.
* Time 1 family meal frequency was positively associated with Time 2 dietary intake as follows: among females, intakes of vegetables, magnesium, potassium, and fiber were directly associated and soft drinks inversely associated with Time 1 family meals; among males, intakes of fruit, vegetables, dark-green and orange vegetables, and potassium were directly associated with Time 1 family meals.
* Associations between Time 1 family meals and Time 2 meal patterns were significant only for dinner frequency among males. Among males, higher family meal frequency at Time 1 predicted a higher priority for social eating and meal structure at Time 2.
* Stratified analyses conducted according to residence showed few differences between young adults living with their parents or away from their parents, and differences did not follow a consistent pattern.
Based on the study findings, the authors conclude that food and nutrition professionals should encourage families to share meals as often as practically possible.
Larson NI, Neumark-Sztainer D, Hannan PJ, et al. 2007. Family meals during adolescence are associated with higher diet quality and healthful meal patterns during young adulthood. Journal of the American Dietetic Association 107(9):1502-1510. Abstract available at
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17761227
Telemedicine Meeting the Health Care Needs of Children
Telemedicine, when applied appropriately, can address the health care needs of children in California, particularly children from families with low incomes who live in medically underserved areas. The issue brief is the third in the Digital Opportunity for Youth series produced by The Children's Partnership. Content includes (1) an overview of the benefits of telemedicine for children and families, health systems, and communities;
(2) the challenges associated with the successful adoption of telemedicine; and (3) recommendations for ensuring that telemedicine reaches its full potential in meeting the health care needs of California's most vulnerable children. The use of telemedicine is specifically illustrated in the following areas: emergency and critical care, oral health, vision screening, mental health, children with special health care needs, home health care, telepharmacy, child abuse evaluations, educating families, supporting families, supporting rural health professionals, providing medical education, disease management, caring for children where they are located, and language translation. Information on the history of telemedicine and additional resources from the Children's Partnership are included .
Challenges in the prevention of mother to child HIV transmission
Much progress has been made in PMTCT [prevention of mother-to-child transmission] of HIV both in the United States and internationally.
However, the challenges of complete elimination of new perinatal HIV infections will depend on not only PMTCT interventions worldwide but also effective primary HIV prevention interventions among adolescents and young adults. PMTCT in the United States and Europe has been a major success story. However, translation of findings from research studies into successful national PMTCT programs and health policies has not been optimal. The supplement focuses on achievements, issues, and challenges in PMTCT in the United States and in settings where resources are limited. The article presents information on the experience and on remaining gaps and challenges in perinatal HIV prevention efforts in the United States, international experience in PMTCT, international trials aimed at reducing transmission among women with HIV who breastfeed, and current challenges and program gaps internationally. A table of the chronology of events in perinatal HIV prevention in the United States and PMTCT in international settings and future directions for PMTCT in the United States and internationally are also presented.
Future directions include the following:
* Efforts that led to the declines in perinatal HIV transmission need to continue, and ongoing surveillance of the scope and breadth of perinatal transmission in the United States needs to be strengthened.
* All women should be offered testing early in prenatal care for every pregnancy.
* Ongoing and expanded education and resources for obstetric clinicians are needed, especially as rapid HIV testing for women in labor with unknown HIV status becomes the standard of care.
[Note: The Health Resources and Services Administration and CDC jointly support the National Perinatal HIV Consultation and Referral Service's Perinatal Hotline at (888) 448-8765].
* In international settings, there is an urgent need for effective strategies to make breastfeeding safer for HIV-exposed infants through the first year of life. The authors assert that an infant HIV vaccine, if proven efficacious, would be an optimal approach to both reducing the risk of HIV transmission during the first year of life and providing the infant with adequate nutrition and the continued protection breastmilk provides against other infectious causes of morbidity and mortality.
Fowler MG, Lampe MA, Jamieson DJ, et al. 2007. Reducing the risk of mother-to-child human immunodeficiency virus transmission: Past successes, current progress and challenges, and future directions.
American Journal of Obstetrics and Gynecology 197(3, suppl. 1):S3-S9.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17825648
[Note: The Centers for Disease Control and Prevention (CDC) recently expanded recommendations for routine HIV testing to include all adults and adolescents in health care facilities as well as pregnant women in all antenatal settings and those women at labor and
delivery with unknown HIV status. http://www.cdc.gov/mmwR/preview/mmwrhtml/rr5514a1.htm ]
[Note: The CDC is launching the One Test, Two Lives campaign in the United States to encourage obstetrical professionals in all settings to offer early HIV testing as a routine, opt-out practice for their pregnant clients and to counsel clients who decline testing to accept an HIV test. More information is available at http://www.cdc.gov/1test2lives ]
Supplement examines influences on obesity and healthy adolescent behavior
The October 2007 supplement to the American Journal of Preventive Medicine examines the impact of the policies, programs, practices, and other environmental influences on obesity among adolescents. The supplement includes an introduction and 11 papers containing some of the first findings from research supported by the Robert Wood Johnson Foundation (RWJF) on the environmental determinants of obesity among adolescents and on the physical inactivity and poor dietary practices that contribute to the problem. The introduction to the supplement briefly describes RWJF's Bridging the Gap (BTG) initiative and the surveys and other data sets from which it has drawn its data; highlights some of the initiative's research on adolescent substance abuse to illustrate its potential for parallel contributions to the childhood obesity issue; and discusses the conceptual framework that underlies BTG's more recent work on youth physical activity, healthy eating, and obesity. The papers that follow emphasize the disparities that exist in these factors and outcomes among different racial and ethnic and socioeconomic groups. Two papers from the National Cancer Institute's related efforts to identify, rate, and track state policies potentially affecting these behaviors are also included.
Bridging the Gap. Chaloupka FJ et al (eds) American Journal of Preventive Medicine Volume 33, Issue 4, Supplement S (October 2007)
http://www.ajpm-online.net/issues/contents?issue_key=S0749-3797(07)X0129-6
MCH Headlines: Judy Thierry HQE
Child passengers are exposed to secondhand smoke
Similar to injuries to children from improperly installed car seats, childhood illness from secondhand smoke exposure in cars is preventable. The National Highway Traffic Safety Administration ( NHTSA) and the U.S. Environmental Protection Agency ( EPA) Indoor Environments Division are dedicated to protecting children from the heightened risk of injury and illness in cars. With your help, parents and caregivers can learn how to prevent child passengers from being injured and becoming ill from secondhand smoke in cars.
The U.S. Surgeon General has reported that secondhand smoke is a known cause of respiratory problems, ear infections, asthma attacks, and even sudden infant death syndrome in infants and children. While many smokers open a window or increase the ventilation in their cars, the child passenger is still exposed to secondhand smoke. When you are educating families about car seat safety, you may also want to give them written information, such as EPA’s Smoke-free Homes & Cars educational materials which are free and available for downloading and distribution.
What you can do to help:
- Share this information with your affiliates, colleagues, and others in the child passenger safety community.
- Download materials from EPA to give to parents and caregivers during car seat safety inspections or other car safety events.
- Talk to organizations in your community that reach parents and caregivers of young children about the effects of secondhand smoke.
To download, print and/or order Smoke free Homes and Cars materials, see www.epa.gov/smokefree/publications.html
For more information on EPA’s Smoke-free Homes and Cars Program, seewww.epa.gov/smokefree
or call Alexander Sinclair, U.S. Department of Transportation/NHTSA (202) 366-2723
26th Annual “Protecting Our Children”
- April 20-23, 2008
- Minneapolis , MN
- National American Indian Conference on Child Abuse and Neglect
- http://www.nicwa.org/
Child Poverty in Nonmetropolitan Areas by State including New Mexico
Key results include:
# The rural child poverty rate in 2006 ranges from a low of 9.1 percent in
Connecticut to a high of nearly 34.7 percent in Mississippi.
# Rural child poverty rates increased between 2000 and 2006 in 37 of the 47 states
where rural data was available (data were unavailable in 3 states and the District
of Columbia).
# In 19 states, the increase in the rural child poverty rate was higher than
the increase in the overall U.S. child poverty rate (3.0 percent) between 2000
and 2006.
# The state with the biggest percentage point increase in rural child poverty
between 2000 and 2006 was Ohio (+6.8 percentage points), followed by Indiana
(+6.4 percentage points), and Maine (+5.5 percentage points).
# Ten states showed a decrease in the rural child poverty rate, led by Maryland
with a 4.0 percentage point decrease.
# Five states ( Ohio, Indiana, Maine, Tennessee, and South Carolina) experienced
increases of 5 percentage points or more in rural child poverty between 2000
and 2006.
# Three states ( Mississippi, Louisiana, and New Mexico) all had rural child poverty rates above 30 percent in 2006, which reflects the pervasive child poverty problem in the rural South as well as areas with high percentages of minority populations.
http://carseyinstitute.unh.edu/FS_ruralchildpoverty_07.htm
Substance Use Treatment Among Women of Childrearing Age
A 3 page short report, based on SAMHSA's National Survey on Drug Use and Health (NSDUH), provides national data on the rates of substance use treatment needed and received as well as rates of unmet need and reasons for not receiving treatment among women aged 18 to 49.
Highlights: Combined data from SAMHSA's National Surveys on Drug Use & Health conducted from 2004 to 2006 indicate that an annual average of 6.3 million women (9.4%) aged 18 to 49 needed treatment for a substance use problem.
Of the women aged 18 to 49 who met criteria for needing substance use treatment in the past year, 84.2% neither received it nor perceived the need for substance use treatment. Only 5.5% of women in this age group had a perceived unmet treatment need (i.e., did not receive substance use treatment even though they thought they needed it).
The reasons for not receiving substance use treatment among the women with an unmet treatment need were as follows: 36.1% were not ready to stop using alcohol or illicit drugs, 34.4% could not cover their treatment costs because of no or inadequate health insurance coverage, and 28.9% did not seek substance use treatment because of social stigma.
To find OAS data on a specific topic, go to SAMHSA's Office of Applied Studies' topics website at http://www.oas.samhsa.gov/topics.cfm You can always get to the topics website by clicking on "Topics" on the OAS banner at the top of most OAS web pages. You can also get data on specific drugs by clicking on "Drugs" on the OAS banner. You can get to the treatment topics at the Topics page or by clicking on "Treatment" on the footer of most OAS web pages.
http://oas.samhsa.gov/2k7/womenTX/womenTX.cfm
For single or bulk orders of free copies of these reports or any OAS report for meetings, contact SAMHSA’s National Clearinghouse for Alcohol and Drug Information (NCADI) either on the web or by phone. Please allow sufficient time to process your request. NCADI : http://ncadi.samhsa.gov/
For children of all ages: Driving Safety Statistics, tips, and good slide (4 items)
#1
Number one killer of youth: MVAs - Great set of slides to pick and choose from
One hundred and forty nine slides for your information and use from NHTSA
More than half (55%) of passenger vehicle occupants killed were unrestrained (Unchanged from 2005)
Blood alcohol unchanged
Total alcohol-related fatalities and fatalities at BAC ≥ .08 g/dl essentially
remained the same
Young drivers
- The number of young drivers (age 16 to 20) killed increased slightly - 0.7 percent
- Fatal crash involvements of young drivers declined slightly - 0.3 percent
Contact Judith Thierry at Judith.Thierry@ihs.gov
#2
Primary Enforcement Laws Reach Groups Least Likely to Use Safety Belts
A recent study by researchers from CDC's Injury Center highlights primary enforcement safety belt laws as an effective strategy to increase overall safety belt use and to reduce disparities among subpopulations.
Primary vs. Secondary Enforcement Laws
Primary enforcement safety belt laws allow police to stop and ticket motorists solely for being unbelted. Secondary laws only allow police to issue a safety belt citation if the vehicle has been stopped for another reason (e.g., speeding). Primary laws more effectively increase safety belt use and reduce traffic fatalities and serious injuries than secondary laws.
Study Findings
Primary enforcement safety belt laws may have the greatest impact on groups least likely to wear safety belts. According to Injury Center researchers, these groups include males, young adults, those with limited education, Native Americans/Alaska Natives, the obese, and impaired drivers. For each of these groups, safety belt use was at least 13 percentage points higher in states with primary enforcement laws than those with secondary enforcement laws. Overall, safety belt use was 85% in primary enforcement states and 74% in secondary enforcement states.
Safety belt use is the single most effective way to prevent crash-related deaths. The study supports primary enforcement laws as an effective population-based strategy to increase overall safety belt use and to reduce disparities among subpopulations.
Beck LF, Shults RA, Mack KA, Ryan GW. Associations between sociodemographics and safety belt use in states with and without primary enforcement laws. American Journal of Public Health 2007; 97(9):1619-1624.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17666699
#3
NHTSA crash data for 2006
NHTSA has made available on its website the crash data files for 2006. Included in this release are the 2006 Fatality Analysis Reporting System (FARS) file, the final 2005 Fatality Analysis Reporting System file, the full 2006 Annual Assessment Report, the 2006 Traffic Safety Annual Assessment, the updated State Traffic Safety Information (STSI) and the 2006 National Automotive Sampling System General Estimates System (NASS GES) file.
The FARS files are a census of all motor vehicle crashes that resulted in a fatality within 30 days of the crash. The NASS GES is a nationally representative sample of the police-reported crashes of all severities, including those that result in a death, injury, or property damage.
#4
NHTSA booster seat data
Probability-based surveys of 1) booster seat use in the United States based on the observation of children in vehicles; 2) use of seat belts and child restraints by racial and ethnic groups; and 3) whether children in the United States are utilizing restraints appropriate for their height and weight.
http://www.nhtsa.gov/portal/site/nhtsa/menuitem.6a6eaf83cf719ad24ec86e10dba046a0/
Do you know is it 1 in 5, 7, 10, or 12 Americans that are living with a disability?
October is Disability Awareness Month.
Learn more about what CDC is doing to promote the health and well-being among people of all ages with disabilities.
Today, about 50 million Americans, or one in five people, are living with at least one disability, and most Americans will experience a disability at some time during the course of their lives. Some disabilities are easy to see, such as when a person uses a wheelchair or when someone has lost an arm. Other disabilities, like a developmental disability such as autism or a chronic condition like arthritis, may not be as easy to see. Some people may live with a disability all their lives. Others may have a disability when they are young or as an older adult. Different kinds of disabilities affect people in different ways. And the same disability can affect each person differently. Send a Health-e card - http://www2a.cdc.gov/ecards/
CDC Health-e-Card from Judith Thierry to school based health care programs
Maternal and Child Health Program has sent you a CDC Health- e- Card.
http://www2a.cdc.gov/ecards/viewcard.asp?gid=A1dfC9DF367e17D79A5a102320200
FAS Prevention: Request for Proposals Released
Fetal Alcohol Spectrum Disorders Prevention or Diagnosis and Intervention
Juvenile Court Proposals Are Due November 1, 2007
Local Community Proposals Are Due November 8, 2007
State Proposals Are Due November 15, 2007
Questions Are Due October 11, 2007
Proposals are requested from State agencies; juvenile courts; and local public, private, or tribal non-profit organizations. There will be a full and open competition in each of these three categories – States, juvenile courts, and local communities. Please consider submitting a proposal and forward this to others who may be interested in the RFP’s.
Organizations are asked to organize, implement, and evaluate programs that will either:
· Decrease the incidence of FASD by implementing evidence-based programs to eliminate alcohol consumption by pregnant women. (The target audience will be pregnant women who drink or women of childbearing age in alcohol or substance abuse treatment.) Or
· Improve the functioning and quality of life of people with an FASD and their families by diagnosing those with an FASD and providing interventions based on the diagnosis.
Types of organizations invited to submit proposals:
· WIC programs serving pregnant women, maternity or prenatal care programs, and alcohol and substance abuse programs serving women. Additional organizations that provide services to women likely to drink during pregnancy may also submit proposals.
· Developmental disabilities, mental health, child welfare, juvenile justice, adult substance abuse, and vocational rehabilitation. Other organizations serving a population that likely has a higher prevalence of FASD than the general population may also submit proposals.
· Juvenile courts or those legally authorized to provide services to adjudicated youth on probation or dependent youth.
Those submitting proposals should have the authority to change the relevant policies and procedures of the service delivery organization(s) of interest.
Funded organizations will receive technical assistance to organize and conduct their FASD prevention or FASD intervention program. This request for proposals is an opportunity for those interested in preventing or addressing fetal alcohol spectrum disorders in the population they serve.
Northrop Grumman, Inc. will be funding and managing the FASD subcontractors. Northrop Grumman is the prime contractor with the Substance Abuse and Mental Health Service Administration (SAMHSA). SAMHSA is an agency of the U.S. Department of Health and Human Services. The RFP’s are posted on www.fasdcenter.com.Medical Mystery Tour
Endometriosis: Where is the real truth?
Here are the answers with discussions and references to last month’s questions
1.) Endometriosis virtually always progresses in severity without treatment
False
It appears that endometriosis is a dynamic process of chronic and constant remodeling, not one of linear growth, which was confirmed in studies with African monkeys. As such, determining where along the course, or continuum, any individual patient might be at any one time will better let us tailor treatment to the status of that woman.
D'Hooghe TM, et al Serial laparoscopies over 30 months show that endometriosis in captive baboons (Papio anubis, Papio cynocephalus) is a progressive disease. Fertil Steril. 1996 Mar;65(3):645-9
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=8774301
Having said that….
The degree of response to laparoscopy is parallel to the extent of the disease.
In the first trial (Sutton 1994), women with stage I disease (a large proportion of study participants) were less likely to improve after their surgical procedure, whereas 74 percent of stage II-IV disease patients achieved pain relief. Most of the women in the second trial (Abbott 2004) had stage II-IV disease, which may account, at least in part, for the higher surgical success rate reported in this study.
Sutton CJ, et al Prospective, randomized, double-blind, controlled trial of laser laparoscopy in the treatment of pelvic pain associated with minimal, mild, and moderate endometriosis. Fertil Steril. 1994 Oct;62(4):696-700
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=7926075
Abbott J, et al Laparoscopic excision of endometriosis: a randomized, placebo-controlled trial. Fertil Steril. 2004 Oct;82(4):878-84
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=15482763
2.) Postoperative medical therapy has been shown to produce significant benefit in reducing pain in women who have treated for endometriosis laparscopically
False
REVIEWERS' CONCLUSIONS: There is insufficient evidence from the studies identified to conclude that hormonal suppression in association with surgery for endometriosis is associated with a significant benefit with regard to any of the outcomes identified.
Yap C, et al Pre and post operative medical therapy for endometriosis surgery. Cochrane Database Syst Rev. 2004;(3):CD003678
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=15266496
3.) Appoximately 40% of women with endometriosis and pain will derive symptomatic benefit from treatment with placebo
True
The placebo response to any treatment in chronic pelvic pain is roughly 40% for a period of at least 3 months.
Abbott J, et al Laparoscopic excision of endometriosis: a randomized, placebo-controlled trial. Fertil Steril. 2004 Oct;82(4):878-84
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=15482763
Dlugi AM, et al Lupron depot (leuprolide acetate for depot suspension) in the treatment of endometriosis: a randomized, placebo-controlled, double-blind study. Lupron Study Group. Fertil Steril. 1990 Sep;54(3):419-27
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=2118858
Sutton CJ, et al Prospective, randomized, double-blind, controlled trial of laser laparoscopy in the treatment of pelvic pain associated with minimal, mild, and moderate endometriosis. Fertil Steril. 1994 Oct;62(4):696-700
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=7926075
4.) Surgical modalities, such as electrocautery, laser, or harmonic scalpel appear to be equally effective in treating endometriosis
True
Conservative surgery is typically accomplished by laparoscopy. Adequate treatment of endometriosis is usually possible, and desirable, at the initial diagnostic procedure. This offers the advantage of ablating the implants and adhesions while avoiding possible disease or symptom progression. The currently available methods of ablation appear to be equally effective and the choice of modality is dependent on the experience of the surgeon.
Early surgical therapy also avoids the expense and side effects of medical therapy. Potential disadvantages include inadvertent damage to adjacent organs (eg, bowel and bladder), infection, and mechanical trauma to pelvic structures that may result in greater adhesion formation.
Conservative surgery involves excision, fulguration, or laser vaporization of endometriotic implants and removal of associated adhesions. Its goal is restoration of normal pelvic anatomy. Laparoscopic treatment offers advantages over laparotomy, including shorter hospitalization, anesthetic, and recuperation times.
Laparotomy may be more advisable, however, when dealing with extensive adhesions or invasive endometriosis located near structures such as the uterine arteries, ureter, bladder, and bowel. Ancillary procedures to laparotomy may include presacral neurectomy, uterosacral interruption of sensory nerves innervating the pelvis, and uterine suspension to avoid adhesion formation from the cul-de-sac to the posterior surface of the uterus, tube, and ovaries.
Kennedy S et al ESHRE guideline for the diagnosis and treatment of endometriosis. Hum Reprod 2005 Oct;20(10):2698-704. Epub 2005 Jun 24.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=15980014
5.) Surgical aspiration is the preferred treatment method for women with ovarian endometrioma
False
CONCLUSION(S): Laparoscopic cystectomy of endometriomas is a better choice than fenestration and coagulation because the former technique leads to a lower recurrence of signs and symptoms and a lower rate of reoperation and a higher cumulative pregnancy rate than the latter.
Alborzi S, et al A prospective, randomized study comparing laparoscopic ovarian cystectomy versus fenestration and coagulation in patients with endometriomas. Fertil Steril. 2004 Dec;82(6):1633-7
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=15589870
6.) Treatment with a GnRH analog for 6 months is associated with an increased fracture risk in women with endometriosis
False
This study examined the effect of a low-dose E and pulsed progestogen hormone therapy (HT) regimen for add-back during long-term GnRH-agonist therapy on bone mineral density (BMD) in five patients with stage IV endometriosis. Bone mineral density was stable after initiation of HT for the entire follow-up period (up to 10 years). One patient stopped her treatment on two occasions to conceive and was successful each time with delivery of a normal baby. No patient had return of pelvic pain after HT add-back .
Bedaiwy MA, Casper RF.Treatment with leuprolide acetate and hormonal add-back for up to 10 years in stage IV endometriosis patients with chronic pelvic pain. Fertil Steril. 2006 Jul;86(1):220-2. Epub 2006 May 23 .
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=16716325
Zupi
E et al Add-back therapy in the treatment of endometriosis-associated pain.
Fertil Steril. 2004 Nov;82(5):1303-8.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=15533351
7.) Interstitial cystitis coexists with endometriosis in approximately 10 percent of cases
False
CONCLUSIONS: Results of this prospective study show that interstitial cystitis and endometriosis may frequently coexist in patients with chronic pelvic pain. A positive Potassium Sensitivity Test accurately predicted the presence of interstitial cystitis in 96% of these patients with chronic pelvic pain, as confirmed by cystoscopic hydrodistention. It is necessary to consider the diagnosis of endometriosis and interstitial cystitis concurrently in the evaluation of patients with chronic pelvic pain to avoid unnecessary delay in identifying either condition.
Chung
MK et al Interstitial cystitis and endometriosis in patients with chronic
pelvic pain: The "Evil Twins" syndrome.
JSLS. 2005 Jan-Mar;9(1):25-9.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=15791965
Extra credit
Promising therapies for endometriosis include:
-Aromatase inhibitors
-RU-486
-Levonorgestrel containing IUDs
-Antiangiogenic cancer therapy
Answer: All of the above
-Aromatase inhibitors
CONCLUSION(S): Fourteen of 15 patients with refractory endometriosis achieved significant pain relief using anastrazole and 20 microg ethinyl estradiol/0.1 mg levonorgestrel with minimal side effects. This treatment for endometriosis is a promising new modality that warrants further investigation.
Amsterdam LL et al Anastrazole and oral contraceptives: a novel treatment for endometriosis. Fertil Steril. 2005 Aug;84(2):300-4.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=16084868
-RU-486, Mifepristone, an antiprogestogen
Medical treatment of endometriosis relies on drugs that suppress ovarian steroids and induce an hypoestrogenic state that causes atrophy of ectopic endometrium. Gonadotrophin-releasing hormone (GnRH) analogues, danazol, progestogens and oestrogen-progestin combinations have all proven effective in relieving pain and reducing the extent of endometriotic implants. However, symptoms often recur after discontinuation of therapy and hypoestrogenism-related side effects limit the long-term use of most medications. Furthermore, these therapies are of limited value in patients with a desire to become pregnant because they inhibit ovulation. An important target for current research is to identify effective therapies that can be safely administered in the long term. GnRH analogues with add-back therapy, progestogens and continuous oral contraceptive are options available for a medium or long-term systemic treatment. Mifepristone, an antiprogestogen, may constitute an alternative if encouraging preliminary data on its effectiveness and tolerability are confirmed. A very appealing area of interest is the possibility of treating
Fedele L , Berlanda N . Emerging drugs for endometriosis. Expert Opin Emerg Drugs. 2004 May;9(1):167-77
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=15155142
-Levonorgestrel containing IUDs
CONCLUSIONS: One small study has shown that postoperative use of the LNG-IUS reduces the recurrence of painful periods in women who have had surgery for endometriosis. There is a need for further well-designed RCTs of this approach.
Abou-Setta
AM et al Levonorgestrel-releasing intrauterine device (LNG-IUD) for symptomatic
endometriosis following surgery.
Cochrane Database Syst Rev. 2006 Oct 18;(4):CD005072. Review.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17054236
-Antiangiogenic cancer therapy
In summary, antiangiogenic agents inhibited the growth of explants in an in vivo model of endometriosis by disrupting the vascular supply, and this effect is likely to apply to the human disease. These findings suggest that antiangiogenic agents may provide a novel therapeutic approach for the treatment of endometriosis.
Hull ML, et al Antiangiogenic agents are effective inhibitors of endometriosis. J Clin Endocrinol Metab. 2003 Jun;88(6):2889-99.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=12788903
Medscape*
Prevention and Management of Influenza in a Family Setting to Reduce
Transmission to Individuals at Risk
http://www.medscape.com/viewprogram/7693?src=mp
Mrs. Wilson, a 78-year-old woman, is seen in consultation for chronic
neck pain
http://www.medscape.com/viewarticle/562117
Epidemiology and Prevalence of Breast Cancer in the US
http://www.medscape.com/infosite/brcc/article-1?src=0_nl_sm_0
Important Considerations for Treating Epilepsy in a Woman of Middle
Age
http://medsitecme.com/(e024vi55quyrrmuk0axhf4ud)/IDetail/Default
_Campaign/Default_Program//261//sponsor.aspx
Individualized Preventive and Therapeutic Management of Hereditary
Breast Ovarian Cancer Syndrome
http://www.medscape.com/viewprogram/7811?src=nlcmealert
Hereditary Link to PMDD Identified
http://www.medscape.com/resource/pmdd?src=rcupdate#1
Ask the Experts topics in Women's Health and OB/GYN Index, by specialty,
Medscape
http://www.medscape.com/pages/editorial/public/ate/index-womenshealth
OB GYN & Women's Health Clinical Discussion Board Index, Medscape
http://boards.medscape.com/forums?14@@.ee6e57b
Clinical Discussion Board Index, Medscape
Hundreds of ongoing clinical discussions available
http://boards.medscape.com/forums?14@@.ee6e57b
Free CME: MedScape CME Index by specialty
http://www.medscape.com/cmecenterdirectory/Default
*NB: Medscape is free to all, but registration is required. It can be accessed from anywhere with Internet access. You just need to create a personal username and password.
Menopause Management
Hormone therapy has no effect on memory but increases sexual interest
Hormone therapy taken in the first few years after menopause does not appear to affect a woman’s memory, but may lead to increased sexual interest. The study also found an increase in sexual interest and thoughts in the women taking hormone therapy. The level of sexual interest reported by women on hormone therapy increased 44 percent and their number of sexual thoughts increased 32 percent compared to the placebo group
CONCLUSIONS: With the power to detect an effect size of >/=0.45, this study suggests potential modest negative effects on verbal memory that are consistent with previous hormone therapy trials in older women
Maki PM et al Hormone therapy in menopausal women with cognitive complaints: A randomized, double-blind trial. Neurology. 2007 Sep 25;69(13):1322-30
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17893293
Continuous HRT combined therapy vs sequential therapy and endometrial cancer risk
CONCLUSION: These results support the hypotheses that continuous combined therapy does not increase (and may decrease) endometrial cancer risk and that long-term sequential therapy can lead to a modest increased risk. However, the collective results of all studies of these questions and their clinical implications remain unclear.
Doherty JA, et al Long-term use of postmenopausal estrogen and progestin hormone therapies and the risk of endometrial cancer. Am J Obstet Gynecol. 2007 Aug;197(2):139.e1-7.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17689625
There are benefits to the introduction of hormone therapy on exercise
CONCLUSION: The peripheral circulation is the limiting system in postmenopausal women experiencing exercise intolerance, and there are benefits in introducing HT. LEVEL OF EVIDENCE: II.
Mercuro G, et al Effect of hormone therapy on exercise capacity in early postmenopausal women. Obstet Gynecol. 2007 Oct;110(4):780-7
Strength Training Helps Prevent Fat Gain in Overweight, Obese Premenopausal Women
CONCLUSION: This study suggests that strength training is an efficacious intervention for preventing percentage body fat increases and attenuating intraabdominal fat increases in overweight and obese premenopausal women. This is relevant to public health efforts for obesity prevention because most weight gain can be assumed to be fat, including abdominal fat.
Schmitz KH et al Strength training and adiposity in premenopausal women: Strong, Healthy, and Empowered study. Am J Clin Nutr. 2007 Sep;86(3):566-72.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17823418
Midwives Corner - Lisa Allee, CNM
If you gotta use something, nitrous oxide might be better than narcotics and epidurals
Judith Rooks and Judith Bishop, two well known midwives in the United States, present information about nitrous oxide—a labor pain medication available to women in many countries, but used very little in the US. Rooks presents the evidence that self administered nitrous oxide is safe and effective. It is safe for mother and baby because it is eliminated by the lungs rather than the liver, so it has transient effects rather than cumulative. It is more effective than opioids and does not have the negative effects on babies that narcotics are well known for nor the maternal side effects of epidurals. She stresses that self administration is crucial for safety and efficacy and has the added benefit of giving women the real sense of control over their pain management. Rooks also covers the occupational and environmental concerns about nitrous oxide that are largely unfounded. Bishop shares the standardized procedure for nitrous oxide administration by CNMs at University of California San Francisco.
As I am sure you all have realized I am a staunch supporter of natural, non-medicated birth. I really think it is the gold standard. So, when I saw this article my initial reaction was “oh no, not another drug.” But I am also fully grounded in reality and have been with enough women in labor to know that medication for pain is needed and/or desired by some women. As I read on about nitrous oxide for labor, I could see that it is superior in many ways to the narcotics we usually use. The speed at which it takes effect (a minute or less) and wears off (also really quick), the lack of sleepiness in the babies, the self administration giving women complete control, and the fact that it does not slow labor and that continuous EFM nor IV fluids are needed are all huge pluses for nitrous. I was also fascinated that Rooks’ description of the experience of nitrous oxide—“diminished pain, or a continued awareness of pain without feeling bothered by it…a kind of strange sensation of feeling the pain while feeling a sense of bliss…so the pain may still exist for some women, but the gas may create a feeling of: “Painful contraction? Who cares?!””—was exactly my experience when I was trained in hypnobirthing. When deeply relaxed (hypnotized) I didn’t care that someone was squeezing my ankle as hard as they could, but when I was no longer in that alpha state I rapidly pulled my ankle away yelling “Ow!” I have guided laboring women to that state and seen it have wonderful results. One young woman said “That wasn’t so bad” right after she had her first baby! So, I can see nitrous as a great tool in our bag of tricks if, for whatever reason, deep relaxation is not happening for a laboring woman. Unfortunately, however, most women in the US do not have, or even know about, this option. This is something that the midwifery community needs to explore and change. If you have experience with nitrous, are working to bring nitrous oxide to your practice, or are interested in doing so, please email me and the listserve with your observations and thoughts.
Rooks, JP Use of nitrous oxide in midwifery practice--complementary, synergistic, and needed in the United States. Journal of Midwifery & Women’s Health 2007 May-Jun;52(3):186-9
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17467584
Bishop, JT Administration of nitrous oxide in labor: expanding the options for women. Journal of Midwifery & Women’s Health 2007 May-Jun;52(3):308- 9
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17467598
Other
Repeat HIV testing in pregnancy identifies opportunities for antiretroviral prophylaxis
RESULTS: Fifty-four HIV-infected women were identified. Four primary HIV infections were recognized, with median estimated seroconversion at 22 weeks of gestation. All 4 women denied new sex partners, alcohol, and illegal drug use during pregnancy. Three of the 4 mother-infant pairs received antiretroviral medications. One infant was infected perinatally, with positive HIV DNA polymerase chain reaction at birth. Questionnaire data identified 2 additional women with HIV that was likely acquired during pregnancy (identified by rapid testing at labor and delivery), which suggests that 6 of 54 HIV-infected women (11%) in the MIRIAD study had primary infection during pregnancy.
CONCLUSION: Repeat HIV testing in pregnancy can identify opportunities for antiretroviral prophylaxis and should be used in areas of high HIV prevalence.
Nesheim S, et al Primary human immunodeficiency virus infection during pregnancy detected by repeat testing. Am J Obstet Gynecol. 2007 Aug;197(2):149.e1-5.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17689629
Nei-Guan point acupressure is a useful treatment for relieving hyperemesis gravidarum
RESULTS: The degree of nausea and vomiting was statistically significantly lower in the Nei-Guan point acupressure group in comparison with the placebo and control groups. Ketonuria levels were reduced over time and, on days three and four of hospitalization, levels in the treatment group were statistically significantly lower than in the placebo or control groups (P < 0.05).
CONCLUSION: Nei-Guan point acupressure is a useful treatment for relieving symptoms experienced by women with hyperemesis gravidarum
Shin HS et al Effect of Nei-Guan point (P6) acupressure on ketonuria levels, nausea and vomiting in women with hyperemesis gravidarum. J Adv Nurs. 2007 Sep;59(5):510-9. Epub 2007 Jul 20
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17645494
One in Seven Women are Depressed Before, During, or After Pregnancy
The first integrated survey of maternal depression, shows that more than one in seven women are depressed at some time during the nine months before becoming pregnant, during pregnancy, or in the nine months after childbirth.
CONCLUSIONS: Approximately one in seven women was identified with and treated for depression during 39 weeks before through 39 weeks after pregnancy, and more than half of these women had recurring indicators for depression.
Dietz PM et al Clinically identified maternal depression before, during, and after pregnancies ending in live births. Am J Psychiatry. 2007 Oct;164(10):1515-20.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17898342
Advice on fish intake during pregnancy sparks controversy
For Pregnant Women, Benefits of Eating Ocean Fish Outweigh Concerns from Trace Levels of Mercury: Experts in Obstetrics and Nutrition Unveil Seafood Consumption Recommendations During Pregnancy
A coalition that advocates for healthy pregnancies came under criticism after issuing an advisory urging pregnant women to eat more fish, based on an evidence review that received financial support from the fisheries industry. In its advisory, however, the National Healthy Mothers, Healthy Babies (HMHB) Coalition stated that “consumption of ocean fish rather than ingestion of fish oil supplements is the best public health approach,” and added that “whole fish itself rather than fish oil supplements has been linked to reductions in preterm labor.”
http://www.hmhb.org/oceanfishpr.html
Navajo News, John Balintona, Shiprock
Acute Appendicitis and Pregnancy
Appendicitis occurs in about 1 in 5000 pregnancies making it the most common nonobstetric surgical event during pregnancy. This condition can occur in any trimester but seems to be more common in the second trimester. Obstetric providers should have high clinical suspicion and be prepared to start a treatment regimen for the patient.
Acute appendicitis during pregnancy is a potentially life-threatening condition for the mother and could possibly affect the well being of the fetus. Delay in making the diagnosis and initiating intervention contributes to increased morbidity and mortality.
Because the uterus displaces the omentum into the upper abdomen, the infectious process may not be confined and disseminate more rapidly. The increase in vasculatrity during pregnancy may make the inflammatory response more intense. The acuity of this response tends to increase as gestation increases and therefore maternal morbidity and mortality is highest in the third trimester. Effects on the fetus are mainly due to premature delivery and if there is peritonitis present. Fetal loss rates in uncomplicated appendicitis are about 1%, rising to about 30% if peritonitis occurs.
Diagnosis
The diagnosis of appendicitis during pregnancy can be difficult for several reasons: including the anatomic changes that naturally occur and the similarity of many signs and symptoms of appendicitis and normal pregnancy. The most common clinical signs of acute appendicitis are right lower quadrant abdominal tenderness and vague abdominal pain. Due to the migration of the appendix in the second and third trimester, the pain may be found in the right upper quadrant or right flank. Rebound tenderness and guarding may not be effective diagnostic tools during pregnancy due to the laxity of the abdominal muscles. Anorexia with nausea and vomiting are common, especially in the first and early second trimester, but nevertheless should be evaluated. An elevated leukocyte count associated with appendicitis ranges from 5 – 25,000, which incorporates the normal mild leukocytosis seen in pregnancy. Studies have shown that there is no known distinguishing temperature that separates appendicitis from those that turned out to be falsely positive and therefore fever is only of limited benefit. The use of imaging techniques has proven to be a valuable diagnostic tool in the diagnosis of appendicitis during pregnancy and should be considered in the evaluation of these patients. Both ultrasound and CT have been shown to have acceptable sensitivity and specificity in the diagnosis of appendicitis. Many sources do suggest that due to radiation exposure, ultrasound should be the first imaging modality that is attempted with CT reserved for unsure findings on ultrasound.
Obstetric providers should be cognizant of other medical conditions that may mimic the signs and symptoms of appendicitis. Ectopic pregnancy can present with unilateral lower quadrant pain. Ovarian cysts and torsion can also cause pain and an inflammatory response. Degenerating fibroids have been found in patients with suspected appendicitis, as well as, gall bladder disease and hepatitis. The most common misdiagnosis is pyelonephritis.
Treatment
Many surgeons accept a 15% false positive rate for surgical intervention for suspected appendicitis in nonpregnant patients. Due to the difficulty in diagnosis and the issues related to delay in diagnosis some suggest that a 30% false positive rate is appropriate for pregnant patients. The treatment of appendicitis is surgical. Laparotomy is viewed as the most common mode, but laparoscopy may be considered especially in the first trimester. Perioperative prophylactic antibiotics may be considered in cases of suspected appendicitis, but appropriate broad-spectrum antibiotics are indicated in cases of gangrene, perforation, or peritonitis. Surgeons should also consider placement of operative site drains especially in scenarios involving perforation and peritonitis. Prophylactic tocolysis may be considered if preterm contractions occur, however, there is no conclusive evidence that this intervention is effective.
Morbidity and mortality from appendicitis during pregnancy occurs with uncertainty in diagnosis and delay in treatment. Obstetric providers have a responsibility in providing an expeditious evaluation and treatment plan for patients with suspected appendicitis.
References
- Williams Obstetrics. 22nd Edition. 2002. Chapter 50. Gastrointestinal Disorders.
- Erilmaz R, et al. Acute Appendicitis During Pregnancy. Digestive Surgery. 2002. Vol 19. 40-44
- Mourad J, et al. Appendicitis in Pregnancy. American Journal of Obstetrics and Gynecology. 2000. Vol. 182. 1027-9
- Williams R and Shaw, J. Ultrasound Scanning in the Diagnosis of Acute Appendicitis in Pregnancy. Emergency Medicine Journal. 2007. Vol 24. 359-360
Nurses Corner - Sandra Haldane, HQE
Nurses and physicians have different perspectives in medical decisions
Nurses and physicians are both very involved in the care of nursing home residents. However, their roles in and perspectives on medical decisionmaking for residents can be very different, concludes a new study. Jiska Cohen-Mansfield, Ph.D., A.B.P.P., and colleagues interviewed nurses and physicians involved in the care of 28 cognitively impaired nursing home residents who were unable to communicate their own wishes. In these cases, the resident either had a change in health status, change in a nonchronic condition that required medical followup by a doctor, or died from a nonchronic illness.
Five male physicians and two female nurse practitioners answered the medical staff questionnaire. The nurses who answered the nursing staff questionnaire included 1 nurse manager and 17 primary charge nurses (3 RNs and 15 LPNs).
Compared with physicians, nurses reported a greater degree of familiarity with the family's and resident's wishes. Physicians reported considering more treatment options and choosing more treatments for residents than nurses, probably because nurses did not see this as part of their role in some of the cases. In 65 percent of cases, doctors estimated that the condition was likely to improve with the treatment, while the nurses predicted improvement in only 48 percent of cases.
Both physicians and nurses agreed that physicians had a major role in decisionmaking that nurses did not. However, the gap in reported roles was greater based on physicians' reports compared with nurses' reports. Both physicians and nurses were generally comfortable with their medical decisions and had similar perceptions of the families' reactions to the decisions. However, the involvement of the nurse as a partner in these decisions was reported to be minor. In a third of the reported cases, physicians and nurses disagreed about whether advance directives had been followed.
Medical decision-making in the nursing home: A comparison of physician and nurse perspectives," by Dr. Cohen-Mansfield, Steven Lipson, M.D., and Debra Horton, R.N., in the December 2006 Journal of Gerontological Nursing 32(12), pp. 14-21
http://www.ahrq.gov/research/sep07/0907RA15.htm
Office of Women's Health, CDC
Church-Based Breast Cancer Screening Education: Impact of Two Approaches
The Tepeyac Project is a church-based health promotion project that was conducted from 1999 through 2005 to increase breast cancer screening rates in Colorado. In this report, an evaluation is done on the program among enrollees in the state’s five major insurance plans. The mammogram rate for Latinas in the Printed Intervention remained the same from baseline to follow-up. In the Promotora Intervention, the rate was 59% at baseline and 61% at follow-up. Rates increased modestly over time and varied widely by insurance type. After adjusting for age, income, urban versus rural location, disability, and insurance type, women exposed to the Promotora Intervention had a significantly higher increase in biennial mammograms than did women exposed to the Printed Intervention. http://www.cdc.gov/pcd/issues/2007/oct/06_0150.htm
Oklahoma Perspective - Nathan Tillotson, DO, – Hastings Indian Medical Center
Training for Shoulder Dystocia
Shoulder dystocia is an obstetric emergency with serious potential risks for both mother and fetus. The reported incidence ranges from 0.6% to 1.4% among vaginal deliveries. It is an unpredictable event with no cost-effective means of prevention for the large majority of women at higher risk. A study of 236 shoulder dystocia cases reported an 11% rate of postpartum hemorrhage and a 3.8% rate of fourth-degree lacerations. Neonates can experience brachial plexus injuries and fractures of the clavicle and humerus with shoulder dystocia. Fortunately, fewer than 10% of all cases of shoulder dystocia result in a persistent brachial plexus injury.
Training for shoulder dystocia among midwives and obstetricians using low and high-fidelity mannequins has been shown to improve performance: use of basic maneuvers 114 of 140 (81.4%) to 125 of 132 (94.7%), successful deliveries 60 of 140 (42.9%) to 110 of 132 (83.3%), good communication with the patient 79 of 139 (56.8%) to 109 of 132 (82.6%), pre- and posttraining, respectively. Training with the high-fidelity mannequin was associated with a higher successful delivery rate than training with traditional devices: 94% compared with 72% (odds ratio 6.53, P=.002). A delivery was considered successful if performed within 5 minutes.
ACOG Practice Bulletin Number 40, Shoulder Dystocia: November 2002.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17138783
Osteoporosis
Ordinary Doses of Vitamin D Linked to Lower Mortality
CONCLUSIONS: Intake of ordinary doses of vitamin D supplements seems to be associated with decreases in total mortality rates. The relationship between baseline vitamin D status, dose of vitamin D supplements, and total mortality rates remains to be investigated. Population-based, placebo-controlled randomized trials with total mortality as the main end point should be organized for confirming these findings.
Autier P, Gandini S. Vitamin D Supplementation and Total Mortality: A Meta-analysis of Randomized Controlled Trials. Arch Intern Med. 2007 Sep 10;167(16):1730-7
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17846391
Home health care following hospitalization for hip fracture may provide an opportunity to limit osteoporosis progression
http://www.ahrq.gov/research/sep07/0907RA14.htmPatient Information
Unsafe drugs during pregnancy: Frequency of birth control services
with prescriptions
Summaries for patients. Frequency of birth control services with prescriptions
for unsafe drugs during pregnancy.Ann Intern Med. 2007 Sep 18;147(6):I38.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17876016
Strategies to improve health literacy for diverse populations should
address literacy, language, and cultural barriers
http://www.ahrq.gov/research/oct07/1007RA6.htm
Health literacy is not associated with how minorities perceive their
physical or mental health status
http://www.ahrq.gov/research/oct07/1007RA7.htm
Bell's Palsy: What You Should Know
http://www.aafp.org/afp/20071001/1004ph.html
Peptic Ulcers: What You Should Know
http://www.aafp.org/afp/20071001/1013ph.html
Perinatology Picks - George Gilson, Maternal Fetal Medicine, ANMC
No, I don’t mean THAT Dating Game
“….THE DATING GAME was and still is by all accounts, the premiere game show for singles. It was the forerunner for many imitators such as "Love Connection", MTV's "Singled Out" and numerous others. But they all have the same influence: Chuck Barris, the creator of the one that started it all! "THE DATING GAME" first premiered on December 20-24, 1965 on ABC-TV and remained a fixture on the...”
No, I don’t mean the above Dating Game.
I mean Ultrasound Dating - Update 2007
We continuously play “the dating game” in obstetrics. A reliable estimation of when a woman is at term is critically important information for us to have in order to be able to plan for delivery, especially if complications of pregnancy develop later. Women and their families also want to be able to plan for the birth by having a reliable date. We often argue about the importance of “listening to women” (menstrual dates) versus “technology” (ultrasound dates) in making our decisions about when due dates will fall, but, considering the following information, this really should not be an issue.
Women who undergo ovulation induction and/or artificial insemination may have gestational age estimates of +3 days. However, for the vast majority of women, a major problem in using menstrual dates to determine fetal age is the biologic variability in the length of the follicular phase, which is not a normally distributed variable. A higher number of women ovulate late in the cycle (after day 21) than early in the cycle (earlier than day 11). In a large recent study, 3% of the gestational ages by ultrasound evaluation were greater than expected from an optimal menstrual history (indicating early ovulation), and 17% were less (indicating late ovulation). The “pregnancy wheels” we all carry in our pockets (or PalmPilots!) are not able to predict the exact due date because they are set up only for those women (about 52%) who ovulate on cycle day 14.
Early ultrasound therefore has an advantage over even “good” dates. The accuracy of first trimester (6-12 weeks) ultrasounds is also critically influenced by the caliber of the machine and the expertise of the ultrasonographer. These are variables that are usually not uniform from service unit to service unit, and it is important to know your unit’s capabilities in order to be able to trust the results they generate. That said, with current equipment, and a capable sonographer, the accuracy of first trimester scans should be +3 days, not the +7 days values generated from data accrued with the older instrumentation. This result takes precedence over menstrual dates, and over first trimester pelvic exams (which are only accurate to +2 weeks). At this stage of pregnancy there is minimal biologic size variability as estimated from crown-rump length (CRL), and it remains the most reliable biometric parameter for estimation of the due date.
Measurement of crown-rump length is generally considerably more accurate than measurement of gestational sac dimensions, so, if no fetal pole is identified (<6 weeks), the exam should ideally be repeated in 1-2 weeks to document both dates, viability, and the location of the pregnancy. The gestational age established by the CRL in the first trimester should be used for the due date, and not changed based on biometric measurements made later in pregnancy.
In the first half of the second trimester (13-20 weeks), fetal biometry remains quite accurate. The composite parameters used (BPD, HC, AC, FL) to derive the average ultrasound age (AUA) should be accurate to within +7 days at this stage of pregnancy. The machine’s computational software uses a regression equation to derive a predicted gestational age from the combined measurements, so one shouldn’t just add up the values obtained and divide by 4. Later in the second trimester (21-28 weeks), because of the more pronounced biologic variability in fetal growth, the most recent evidence seems to indicate that the standard deviation of the composite measurements is +14 days. This difference becomes even more pronounced in the third trimester (29-42 weeks) when the accuracy is now reduced to +21 days. These latter values are unfortunately no different from those obtained in the early 1980’s with the older equipment, again because of the biologic variability in fetal size as term approaches.
What can you do with the patient who presents late for prenatal care in the early third trimester, with no or “poor” dates? If her fundal height is not congruent with the dates she gives, the question arises whether she is growth restricted, or just premature, or if she is actually farther along than suspected. In a recent WHO study in developing nations, measurement of fundal height proved to be the best screening tool for intrauterine growth restriction, but it was just that, a screening, not a diagnostic, test. Third trimester physical exam has been found to be as inaccurate as +6 weeks, again because of the “bell curve” of fetal size, as normal term infants can weigh 5 ½ pounds or 9 pounds, and everything in between. Ethnicity and parental size are also important variables to take into consideration.
The best strategy here, time permitting, is to do serial ultrasounds 3 weeks apart. The normal fetus should follow a normal growth curve. Thus, if the first ultrasound gave a gestational age of 29+3 weeks, the subsequent scan in 3 weeks should demonstrate a gestational age of 32+3 weeks. The two estimated dates of delivery (EDD) generated should be comparable, and can then be used to set the anticipated due date, again with the known standard deviations. Scans obtained sooner than 3 weeks apart may be misleading, because of that +3 week standard deviation.
Another “quick and dirty” practical point for patients who present close to term with unknown, or unclear, dates, and who are not diabetic, but in whom an expeditious decision about gestational age needs to be made, is to rely on the biparietal diameter. This assumes the fetal head is not engaged, and a satisfactory BPD can be obtained. As a rough “rule of thumb”, if the BPD is >92 mm, the infant is most likely at term. Sonographic estimated fetal weights obtained in the late trimester are no more reliable than clinical estimates however, with a margin of error of at least 20% in either direction (that could be almost 2 pounds for a suspected macrosomic fetus...).
Summary
In order to optimize our care, it would be ideal if all our service units were to use the same standards. This is especially important for regional centers and the individual outlying sites that refer women for delivery to them. From the best available evidence I have found, I would like to recommend that CRL obtained between 6-12 weeks is the most accurate parameter for establishing a due date, and supersedes menstrual dates.
In order to make this a reality, the following assumptions need to be true:
there is a capable sonographer available on a stable basis, as well up to date equipment that is well maintained with an ongoing quality assurance program. If those assumptions are the case, then our service units should use the same standards, listed below.
Average Ultrasound Age Accuracy
6-12 weeks +3 days
13-20 weeks +7 days
21-28 weeks +14 days
29-42 weeks +21 days
References
- Callen PW. Ultrasonography in Obstetrics and Gynecology. (5th ed.) 2007. W. B. Saunders Co., Philadelphia, PA.
- Goldberg BB, McGahan JP. Atlas of Ultrasound Measurements. (2nd ed.) 2006. Mosby, Inc., Philadelphia, PA.
- Altman DG, Chitty LS. New charts for ultrasound dating of pregnancy. Ultrasound Obstet Gynecol 1997; 10:174-9.
- Royston P, Wright EM. How to construct ‘normal ranges’ for fetal variables. Ultrasound Obstet Gynecol 1998; 11:30-8.
- ACOG. Ultrasonography in pregnancy. ACOG Practice Bulletin #58, December
2004.
http://www.acog.com/
Others
Prevention is the most effective evidence-based management to avoid recurrence of FGR
Fetal growth restriction is associated with multiple short- and long-term consequences for the infant. A woman with a prior gestation complicated by fetal growth restriction has nearly a 20% risk of recurrence. Strategies to predict and prevent the recurrence are critical in obstetric management. Effective interventions for prevention of recurrent fetal growth restriction include the following: a reproductive plan because spacing of pregnancies impacts their outcome, optimization of maternal medical conditions, smoking cessation, accurate dating by first-trimester sonography and monitoring of fetal growth with serial sonograms, and low-dose aspirin (80–160 mg) started before 20 weeks. In women with nutritional deficiencies, optimizing caloric intake with low-protein (less than 25%) supplementation of 500–1,000 calories may prevent recurrent fetal growth restriction. In women living in areas endemic for malaria, antimalarial prophylaxis diminishes risk of recurrent fetal growth restriction.
Berghella V. Prevention of recurrent fetal growth restriction. Obstet Gynecol. 2007 Oct;110(4):904-12
3 criteria of oligohydramnios in identifying peripartum complications
Study Design The 3 definitions of oligohydramnios were amniotic fluid index (AFI) 5.0 cm or less and AFI <5% for gestational age (GA) using nomograms by Moore and Cayle or Magann et al. Likelihood ratio (LR) and guidelines by the Evidence-Based Medicine Working Group were used in the secondary analysis of previously published reports. AFI obtained during antepartum and intrapartum periods were analyzed separately.
Results The 95% confidence intervals for the prevalence of oligohydramnios using the 3 criteria are significantly different in the antepartum or intrapartum analysis. The LR was <6 for ante- and intrapartum AFI to identify cesarean delivery for nonreassuring fetal heart rate tracing, Apgar score 3 or less at 5 minutes, umbilical arterial pH <7.00, and newborns’ weight 5% or less for GA.
Conclusion The 3 criteria for determining the adequacy of amniotic fluid are not fungible, and they are not useful diagnostic tests for identifying peripartum complications because LR is <10.
Johnson JM, et al A comparison of 3 criteria of oligohydramnios in identifying peripartum complications: a secondary analysis. Am J Obstet Gynecol. 2007 Aug;197(2):207.e1-7; discussion 207.e7-8.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17689653
Oxytocin agonists for preventing postpartum haemorrhage
AUTHORS' CONCLUSIONS: There is insufficient evidence that 100 micrograms of intravenous carbetocin is as effective as oxytocin to prevent PPH. In comparison to oxytocin, carbetocin was associated with reduced need for additional uterotonic agents, and uterine massage. There was limited comparative evidence on adverse events.
Su L et al Oxytocin agonists for preventing postpartum haemorrhage. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD005457
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17636798
Features of metabolic syndrome increase risk of a child with a NTD
CONCLUSIONS: We found about 2-fold and 6-fold higher risk for NTD in the presence 1, and 2 or more features, of the metabolic syndrome, respectively. It is not clear whether this risk is altered by the presence of a high serum hsCRP concentration.
Ray
JG, et al Metabolic Syndrome features and risk of neural tube defects.
BMC Pregnancy Childbirth. 2007 Sep 19;7(1):21
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17880716
Pregnant women who have very low cholesterol may face a greater risk of preterm delivery
Pregnant women who have very low cholesterol may face a greater risk of delivering their babies prematurely than women with more moderate cholesterol levels
CONCLUSIONS: Total serum cholesterol <10th population percentile was strongly associated with preterm delivery among otherwise low-risk white mothers in this pilot study population. Term infants of mothers with low total cholesterol weighed less than control infants among both racial groups.
Edison
RJ, et al Adverse birth outcome among mothers with low serum cholesterol.
Pediatrics. 2007 Oct;120(4):723-33.
=ShowDetailView&TermToSearch=17908758
Primary Care Discussion Forum - Ann Bullock, Cherokee, NC
Chronic Kidney Disease: CKD is Part of Primary Care !
Moderator: Andrew Narva, MD
Ongoing now
- What is the burden of CKD in AI/AN?
- How should CKD patients be identified and followed?
- What should we be doing for CKD patients in the primary setting?
- When should patients be referred?
How to subscribe / unsubscribe to the Primary Care Discussion Forum?
Subscribe to the Primary Care listserv
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STD Corner - Lori de Ravello, National IHS STD Program
American Indian women, HIV/AIDS, and health disparity
Data are presented regarding the prevalence of HIV/AIDS among American Indian women. Health disparities found among American Indians are discussed and biological, economic, social, and behavioral risk factors associated with HIV are detailed. Recommendations are suggested to alleviate the spread of HIV among American Indian women and, in the process, to diminish a culture of treatment malpractice and a weakening of treatment ethics, racism, and genderism.
Vernon IS. American Indian women, HIV/AIDS, and health disparity. Subst Use Misuse. 2007;42(4):741-52
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17558961
Adolescents’ Discussions About Contraception Or STDs with Partners Before First Sex
RESULTS: Fifty-three percent of females and 45% of males discussed contraception or STDs before having first sex. The greater respondents’ perceived condom knowledge and the greater their communication with their parents about everyday life, the higher their odds of discussing contraception or STDs before first sex (odds ratio, 1.2 for each). Being black was positively associated with sexual communication before first sex (1.9); as the number of dating activities and score on a test of verbal ability increased, so did the odds of such communication (1.6 and 1.02, respectively). The predictors of discussions about contraception or STDs did not differ by gender.
CONCLUSIONS: By increasing teenagers’ knowledge about condoms and other methods of contraception, pregnancy and STD prevention programs can help to encourage communication among teenage partners before the initiation of sexual intercourse. Programs should also encourage conversations between parents and teenagers, even when not about sex.
Ryan S et al Adolescents’ Discussions About Contraception Or STDs with Partners Before First Sex Perspectives on Sexual and Reproductive Health, Volume 39 Issue 3 Page 149-157, September 2007
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17845526
Using clinical classifcation trees to identify risk of STDs during pregnancy
RESULTS: Nineteen percent of women had an incident STD during pregnancy. Classification tree analysis identified three subgroups with a high STD incidence (33–61%), one with a moderate incidence (16%) and three with a low incidence (6–11%).Women in subgroups with high STD incidence included those not living with the partner with whom they conceived and those who had a moderate or a high level of depression, a history of STDs and a low level of social support. A logistic regression model using groups defined by the classification tree analysis had better predictive ability than one using common demographic and sexual risk predictors.
CONCLUSION: This classification tree identified risk factors not captured by traditional risk screenings, and could be used to guide STD treatment, care and prevention within the prenatal care setting.
Kershaw TS et al Using Clinical Classification Trees to Identify Individuals at Risk of STDs During PregnancyPerspectives on Sexual and Reproductive Health, Volume 39, Number 3, September 2007, p. 141–148
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17845525
Exam room reminders and physician feedback can improve screening for chlamydia in young women during preventive care visits
http://www.ahrq.gov/research/sep07/0907RA12.htm
Genital Herpes: Framing the Problem, Diagnosing the Disease
http://www.medscape.com/viewprogram/7905?src=nlcmealert
Sexual Behaviors of Opposite-Sex Couples Through Emerging Adulthood
RESULTS: Eighty percent of respondents had engaged in cunnilingus and fellatio as well as vaginal intercourse in their current relationship; this group included 22% who also had engaged in anal sex. Compared with their peers who reported that they and their partner did not love each other a lot, both males and females who reported mutually loving relationships had significantly higher odds of having given oral sex (odds ratios, 3.9 and 2.6, respectively) and having received oral sex (1.8 and 3.3); males in mutually loving relationships also had elevated odds of having had anal sex (3.1).
CONCLUSIONS: Most young adult couples in long-term relationships engage in a variety of sexual practices with loving partners; the direction of causality in this association and its implications for relationship building require exploration. Furthermore, programs and interventions that address health and well-being during emerging adulthood should cover issues relevant to a broad range of sexual activities, including oral and anal sex.
Kaestle CE, Halpern TC What’s Love Got to Do with It? Sexual Behaviors of Opposite-Sex Couples Through Emerging Adulthood Perspectives on Sexual and Reproductive Health Volume 39 Issue 3 Page 134-140, September 2007
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17845524
Barbara Stillwater, Alaska State Diabetes Program
Magic Pill Improves Glycemic Control and Decreases Death by 25% for Type 2's
Imagine an inexpensive pill that could decrease the hemoglobin A1c value by 1 percentage point, reduce cardiovascular death by 25%, and substantially improve functional capacity (strength, endurance, and bone density). Diabetes experts would be quick to incorporate this pill into practice guidelines and performance measures for diabetes.
Aerobic and resistance training each improve glycemic control for patients with type 2 diabetes, but the improvement is greatest when both forms of exercise are combined,
CONCLUSION: Either aerobic or resistance training alone improves glycemic control in type 2 diabetes, but the improvements are greatest with combined aerobic and resistance training.
Sigal RJ et al Effects of aerobic training, resistance training, or both on glycemic control in type 2 diabetes: a randomized trial. Ann Intern Med. 2007 Sep 18;147(6):357-69
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17876019
Laugh Your Way to Normal Blood Sugars
People with type 2 diabetes may be better able to process sugar from meals if they laugh, according to a small study. Researchers found that diabetics who watched a comedy show had a smaller rise in post-meal blood sugar than when they listed to a non-humorous lecture. The effect occurred in people without diabetes as well. Stress is known to raise the risk of elevated blood sugar, and poorly controlled blood sugar can increase the risk of diabetes complications such as heart disease, kidney failure and blindness. Past studies have found that positive emotions such as laughter may lower blood pressure, release endorphins, improve circulation, stimulate the nervous system, heighten the immune system and strengthen the heart. Researchers are not certain why laughter appears to reduce blood sugar, but suggested that it might increase the consumption of energy by using the abdominal muscles, or might affect the neuroendocrine system, which controls glucose levels in the blood.
Hayashi K, et al Laughter lowered the increase in postprandial blood glucose. Diabetes Care May 2003;26:1651-1652
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=12716853
Maternal Weight Gain Series (Six articles)
Fat mum hastens path to childhood obesity
An overweight mother, watching TV and being a girl increase your odds of being an obese child.
CONCLUSIONS: Many primary school aged children start on the trajectory of obesity in the preschool years, which suggests interventions need to start early. Maternal overweight/obesity, television watching, sedentary activity time and rapid weight gain in infancy, early and middle childhood are risk factors for childhood obesity, and are all potentially modifiable.
Blair NJ et al Risk factors for obesity in 7-year-old European children: the Auckland Birthweight Collaborative Study. Arch Dis Child. 2007 Oct;92(10):866-71.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17855436
Optimal gestational weight gain for BMI categories: Outcome based
CONCLUSION: The gestational weight gain limits for BMI categories determined in this large population-based cohort study from Swedish Medical Registers showed that a decreased risk of adverse obstetric and neonatal outcomes was associated with lower gestational weight gain limits than was earlier recommended, especially among obese women. LEVEL OF EVIDENCE: II.
Cedergren MI. Optimal gestational weight gain for body mass index categories. Obstet Gynecol. 2007 Oct;110(4):759-64
Editorial
Catalano PM. Increasing maternal obesity and weight gain during pregnancy: the obstetric problems of plentitude. Obstet Gynecol. 2007 Oct;110(4):743-4
Diet or exercise, or both, for weight reduction in women after childbirth.
CONCLUSIONS: Preliminary evidence from this review suggests that dieting and exercise together appear to be more effective than diet alone at helping women to lose weight after childbirth, because the former improves maternal cardiorespiratory fitness level and preserves fat-free mass, while diet alone reduces fat-free mass. For women who are breastfeeding, more evidence is required to confirm whether diet or exercise, or both, is not detrimental for either mother or baby. Due to insufficient available data, additional research, with larger sample size, is needed to confirm the results.
Diet or exercise, or both, for weight reduction in women after childbirth. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD005627.
http://www.medscape.com/medline/abstract/17636810?cid=med&src=nlbest
Obese Pregnant Women Should Limit Weight Gain
Severely obese women should lose weight during pregnancy, while obese women who are pregnant should gain less weight than currently recommended
RESULTS: Gestational weight gain incidence for overweight or obese pregnant women, less than the currently recommended 15 lb, was associated with a significantly lower risk of preeclampsia, cesarean delivery, and large for gestational age birth and higher risk of small for gestational age birth. These results were similar for each National Institutes of Health obesity class (30-34.9, 35-35.9, and 40.0 kg/m(2)), but at different amounts of gestational weight gain. CONCLUSION: Limited or no weight gain in obese pregnant women has favorable pregnancy outcomes. LEVEL OF EVIDENCE: II.
Kiel DW, et al Gestational weight gain and pregnancy outcomes in obese women: how much is enough? Obstet Gynecol. 2007 Oct;110(4):752-8 .
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17906005
Normal pre-pregnancy BMI and weight gain: Low risk of adverse outcomes if full-term
CONCLUSION: Our study shows that adherence to the current Institute of Medicine guidelines results in lower risks for adverse pregnancy, labor, and delivery outcomes when comparing all outcomes collectively.
Devader
SR, et al Evaluation of gestational weight gain guidelines for women with
normal prepregnancy body mass index. Obstet Gynecol. 2007 Oct;110(4):745-51. http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db
=pubmed&list_uids=17906004&dopt=AbstractPlus
Maternal Weight Tied to Child's Body Composition at Age 9
Conclusions: Mothers with a higher pre-pregnant body mass index or a larger mid-upper arm circumference during pregnancy tend to have children with greater adiposity at age nine. The extent to which this is attributable to genetic factors, the influence of maternal lifestyle on that of her child, or maternal adiposity acting specifically during pregnancy on the child's fat mass cannot be determined in this study.
Gale CR et al Maternal Size in Pregnancy and Body Composition in Children. J Clin Endocrinol Metab. 2007 Aug 7
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17684051
Other
Sleep Deprivation Series: (3 articles)
True or False: The largest at-risk group for sleep-related crashes is commercial drivers.
November 5-11, 2007 in your state and with local health departments. Teen drowsy driving is an emerging issue. Consider the following annual facts:
- Drowsiness impairs judgment, vision, hand-eye coordination, and reaction times just like alcohol and other drugs. Being awake for 17 hours is equivalent to someone with a blood alcohol concentration (BAC) of 0.05.
- The National Highway Traffic Safety Administration estimates that 100,000 police-reported crashes are caused by fatigued drivers, resulting in more than 1,550 deaths and 71,000 injuries annually.
- According to National Sleep Foundation surveys half of Americans consistently report that they have driven drowsy and approximately 20% admit that they have fallen asleep at the wheel in the past year.
The CSN and National Center for Child Death Review Policy and Practice are proud co-sponsors with the National Sleep Foundation (NSF) of the Drowsy Driving Prevention Week campaign. The campaign is designed to educate young drivers (and everyone on the road!) about the dangers of driving while sleepy. This Toolkit provides resources about healthy sleep and drowsy driving prevention during DDPW and beyond for states and communities.
NSF's Drowsy Driving Prevention Week campaign includes:
- The newly redesigned Web site offers extensive resources about drowsy driving toolkit that include public policy, fact sheets, human interest stories, and news features. http://www.drowsydriving.org
- Presentations and online educational tools
- Parent/Teen Safe Driver Contract
- Resources to support drowsy driving advocates in their communities
- A "State of the States" survey to be released later this month
ANSWER Not commercial drivers – it is the kids! - Sleep-related crashes are most common in young people who tend to stay up late - sleep too little and drive at night.
Sleepy young drivers? Elevate your sleep IQ
Check out the Doze family dynamic 3-D animations of the Doze family members depicting effects of age and sleep and alertness influencers such as shift work, caffeine, alcohol, stress and "Monday morning blues."
A must see web site – 20 minutes with the doze will have you awake.
Young, elderly, teen, night shift, stressed worker what is your sleep pattern and what lifestyle adjustments CAN you make!
National Sleep Foundation is a real find Take the Quiz. Elevate your sleep IQ
http://www.sleepfoundation.org/site/c.huIXKjM0IxF/b.2418861/k.B1A8/
Tools_and_Quizzes.htm
Sleep for all ages – section on children – “sleep deprived… obstructive sleep apnea… Sleeping should be refreshing… Teachers should look for children who are frequently yawning or falling asleep in class… behavior/mood problems… in clinical history taking sleep is often overlooked” [Spring 2004, Volume 6, Issue 2 of sleepmatters.]
http://www.resisoftip.com/resisoft/nsf/flash_content/preloader.htm
Losing Sleep Triggers Abnormal Glucose Metabolism
According to a new study, Even a small amount of sleep loss can cause changes in hormonal glucose regulation, with a strong effect on pancreatic islet secretion, a decrease in glucagon levels and a slight reduction in C-peptide levels.
CONCLUSION: Short-term SD distinctly alters hormonal glucose regulation, affecting especially pancreatic islet secretion, and also increases hunger. Immediate perturbations in the dynamic regulation of energy metabolism caused by acute sleep curtailment may contribute to the association between chronic sleep loss and metabolic disorders.
Schmid SM , et al Sleep loss alters basal metabolic hormone secretion and modulates the dynamic counterregulatory response to hypoglycemia. J Clin Endocrinol Metab. 2007 Aug;92(8):3044-51
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17519315
Women’s Health Much More at Risk from Sleep Deprivation
New research led by researchers at Warwick Medical School at the University of Warwick reveals that women’s health is much more at risk from sleep deprivation than men’s. Professor Francesco Cappuccio from the University of Warwick’s Warwick Medical School led the research he declared that women sleeping les than 5 hours a night should try to get more sleep as:
"Sustained sleep curtailment, ensuing excessive daytime sleepiness, and the higher cardiovascular risk are causes for concern. Emerging evidence also suggests a potential role for sleep deprivation as a predictor or risk factor for conditions like obesity and diabetes."
Cappuccio FP, et al Gender-specific associations of short sleep duration with prevalent and incident hypertension: the Whitehall II Study. Hypertension. 2007 Oct;50(4):693-700.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17785629
Other
PRESENT Diabetes, an Online Clinical Conference any time day or night
On this web site, we will provide you with a quick look at PRESENT Diabetes, revealing it's innovative features and showing your how it will connect you to diabetes care givers around the world and provide an unparalleled opportunity to improve your knowledge and skills.
An Online Clinical Conference
Imagine a robust clinical conference, with cutting edge lectures with FREE CME,
focus groups, break out sessions and other forms of professional networking -
all available to you online 24/7/365 for free. http://presentdiabetes.com/#top
Women less likely than men to change habits that increase heart-disease risk
Smoking, eating fattening foods and not getting enough exercise are all lifestyle habits that can lead to poor health and cardiovascular disease – more so if you have a family history. But researchers at UT Southwestern Medical Center have found that women don’t change these habits as often as men, even when they have relatives with heart disease.
CONCLUSIONS: Despite a stronger association with CVD risk factors and atherosclerosis prevalence with FHMI among young women compared with men, young women with FHMI demonstrated less CVD risk awareness and worse lifestyle choices. Family history of premature MI may be an especially useful risk assessment tool in young women, and greater efforts are needed to promote CVD risk awareness among young women with FHMI.
Patel MJ et al Implications of family history of myocardial infarction in young women Am Heart J. 2007 Sep;154(3):454-60
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17719289
Strong link between a mother's hip size and the risk of breast cancer in her daughters
We conclude that the intercristal width, and the roundness of the iliac crests, are markers of mothers' sex hormones, and postulate that high concentrations cause genetic instability in differentiating breast cells in their daughters in utero
Barker DJ, et al A possible link between the pubertal growth of girls and breast cancer in their daughters. Am J Hum Biol. 2007 Oct 5;
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17922483
Cholesterol-Related Compound Can Block Estrogen From Helping To Prevent Heart Disease in Some Women
New research suggests that higher risk may be partially explained by the presence of a naturally occurring chemical that blocks estrogen's protective effects on the heart.
A molecule related to cholesterol can block the hormone estrogen from performing functions in blood vessels that keep them healthy and protected against heart disease
The researchers theorize that women taking hormone replacement therapy may be at greater risk of developing heart disease because the chemical 27-hydroxycholesterol (27HC) inhibits the activity of estrogens circulating in the blood. 27-hydroxycholesterol is produced when the body breaks down cholesterol. Decreased estrogen, when combined with high cholesterol, atherosclerosis, or both, could lead to an increased risk of cardiovascular disease.
Before this work, it was well known that estrogen may be cardioprotective. But the evidence was nil that there might be some endogenous antagonist to this protective system
Umetani M et al 27-Hydroxycholesterol is an endogenous SERM that inhibits the cardiovascular effects of estrogen Nature Medicine Published online: 16 September 2007
http://www.nature.com/nm/journal/vaop/ncurrent/abs/nm1641.html
Women's Health Headlines, Carolyn Aoyama, HQE
Planning Group - conference on midwifery models of care
Over the next 5 years, Indian Health Service and Health Canada, First Nations Inuit Health Branch (FNIHB) will be collaborating on various maternal and child health issues. The first topic to be explored will be midwifery care of AI/AN and First National/Inuit people.
A group has been formed and planning has begun. We have begun our discussions with differences in midwifery education, credentialing and licensure and the health care delivery systems between the US and Canada. We’ve had three calls over three months and more frequent follow-up conversations in between.
The planning group needs to be expanded. Please email me if you are an AI/AN midwife working in a IHS, Tribal, or Urban site. I would also like to hear from midwives who have developed one or more models of care to address a specific health disparity, or to improve cultural acceptability. And I would also like to hear from midwives who have significant midwifery experience in I/T/U settings.
Please remember that this activity requires time and commitment. We may not be able to add everyone who expresses an interest, but the idea is to be as inclusive as possible. Please contact me.
M. Carolyn Aoyama, CNM, MPH
Senior Consultant Women's Health & Advanced Practice Nursing
301-443-1028 Carolyn.Aoyama@ihs.gov
Are women being scared away from math, science, and engineering fields?
Female academic performance lies in the (gender) balance
This study examined the cues hypothesis, which holds that situational cues, such as a setting's features and organization, can make potential targets vulnerable to social identity threat. Objective and subjective measures of identity threat were collected from male and female math, science, and engineering (MSE) majors who watched an MSE conference video depicting either an unbalanced ratio of men to women or a balanced ratio. Women who viewed the unbalanced video exhibited more cognitive and physiological vigilance, and reported a lower sense of belonging and less desire to participate in the conference, than did women who viewed the gender-balanced video. Men were unaffected by this situational cue. The implications for understanding vulnerability to social identity threat, particularly among women in MSE settings, are discussed.
Murphy MC, et al Signaling threat: how situational cues affect women in math, science, and engineering settings. Psychol Sci. 2007 Oct;18(10):879-85 .
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17894605
What's new on the ITU MCH web pages?
How can we best manage Jehovah’s Witnesses during pregnancy?
There are several upcoming Conferences
and Online CME/CEU resources, etc….
…or just take a look at the What’s New page
Save the dates
2007 National HIV Prevention Conference
- December 2-5, 2007
- Atlanta , Georgia
- Center for Disease Control and Prevention
- http://www.2007nhpc.org/conferenceinfo.asp
23nd Annual Midwinter Indian Health OB/PEDS Conference
- February 8 - 10, 2008
- For providers caring for Native women and children
- Telluride, CO
- Contact AWaxman@salud.unm.edu
26th Annual “Protecting Our Children”
- April 20-23, 2008
- Minneapolis , MN
- National American Indian Conference on Child Abuse and Neglect
- http://www.nicwa.org/
Did you miss something in the last Chief Clinical Consultant Corner?
The October 2007 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.
