Women's Health Notes 02/10 by 5HzRgE5

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									Women’s Health Notes                                                February 2010

Introduction
The Women’s Health Notes is an electronic publication for those providing care for American Indian and
Alaska Native women and their families. The Chief Clinical Consultant for Obstetrics and Gynecology
serves as the editor for the newsletter. If you have suggestions or would like to contribute, please
contact jean.howe@ihs.gov.

If you have received this from a colleague and would like to subscribe (or to unsubscribe), please follow
this link: http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=87&startrow=1

If you would also like to receive the IHS Provider electronically, please follow this link:
http://www.ihs.gov/provider/index.cfm?module=listserv

Thank you for your interest in this publication, and for the work that you do.


Featured Issue:
This month the lead article for the Women’s Health Notes is from our Lactation correspondent, Sue
Murphy, of Phoenix Indian Medical Center. PIMC has been using breastfeeding support as a diabetes risk
intervention for over a decade. Ms. Murphy can be reached at: Suzan.Murphy@ihs.gov.

Breastfeeding as a SIDS Reduction Strategy
Sudden Infant Death, SIDS, is the leading cause of death in babies between 1 month and 1 year. SIDS is
nearly three times more common among American Indian/Alaska Native infants when compared to the
general population. Parents are encouraged to use the “back to sleep” sleeping position on a firm
sleeping surface for their baby, to not smoke around their baby, to eliminate soft items (toys, pillows,
thick blankets, etc) from their baby’s environment, and to not allow their baby to fall asleep on
recliners, sofas, or couches.

Now there is another way families can reduce their babies’ risk of SIDS. Choosing to breastfeed can
make a difference. While research has linked breastfeeding with less risk of SIDS, study methods have
improved and the evidence has become more compelling.

A recent summary by Ip, et al. of the Agency for Healthcare Research and Quality reviews evidence on
the effects of breastfeeding on term infant and on maternal health outcomes in developed countries.
They found that any breastfeeding reduced SIDS risk. The report looked for research that included an
objective definition of SIDS (autopsy confirmed SIDS in infants 1 week to 1 year, clear reporting of
breastfeeding data, and outcome adjustment for important confounders such as sleep positions,
maternal smoking, and socio-economic status. Six studies were included, 3 rated as good, and 3 rated as
fair. Ranking in the ratings was based on study design - systematic reviews, experimental (randomized
controlled trials), observational studies (prospective cohort and case-control studies only), population
(healthy term infants in developed countries) and the intervention being the use of breast milk
compared to formula. The meta-analysis of the studies showed the ever breastfeeding was linked with
a statistically significant reduction of SIDS for both crude and adjusted risk – crude OR 0.41, 95% CI
(0.28, 0.58) and adjusted OR 0.64, 95% CI (0.51, 0.81).
A study in Germany by Vennemann, et al. reviewed 333 infants who died of SIDS and 998 age-matched
controls. Strengths of this study included size, pre-existence of back-to-sleep type educational
campaign, standardized autopsy procedures using a multidisciplinary panel to determine cause of
death, and data collection of feeding patterns by month for most participants (exclusively breastfed,
partially breastfed, or not breastfed). The study found that after adjustment for potential confounders,
exclusive and partial breastfeeding reduced SIDS risk by 50% at all ages.

The study also found similarities to other SIDS studies regarding age distribution - 59% of SIDS victims
died between 2 and 5 months, and 73% died before 6 months. This pattern suggests that supporting
breastfeeding in the first few months when SIDS risk is highest and through 6 months as the risk lowers
could be especially promising for reducing SIDS.

Although research has not been able to identify what part of breastfeeding reduces risk, some
suggestions have been made. The unique and changing immunological properties of human milk may
be one factor. That breastfed infants are more easily aroused than formula fed babies has also been
noted. There may be other variables not yet found that also make a difference.

But at the end of the day, the reasons for why breastfeeding protects babies from SIDS is not nearly as
important to families as knowing that they are doing the best they can to prevent it. For information
about supporting breastfeeding, please see the resources section below.


References:
Ip S, Chung M, Raman G, Trikalinos TA, Lau J. A summary of the Agency for Healthcare Research and
Quality's evidence report on breastfeeding in developed countries. Breastfeed Med. 2009 Oct;4 Suppl
1:S17-30. http://www.ncbi.nlm.nih.gov/pubmed/19827919

U.S. Department of Health and Human Services. Regional Differences in Indian Health, 2002-2003
edition. March 2008.

Vennemann MM, Bajanowski T, Brinkmann B, Jorch G, Yücesan K, Sauerland C, Mitchell EA; GeSID Study
Group. Does breastfeeding reduce the risk of sudden infant death syndrome? Pediatrics. 2009
Mar;123(3):e406-10. http://www.ncbi.nlm.nih.gov/pubmed/19254976


Resources:
IHS Breastfeeding Support Website: http://www.ihs.gov/MedicalPrograms/MCH/M/bf.cfm

IHS guidance on recording infant feeding choices in EHR:
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/FAQs-Infant%20Feeding%20Choice_110207.doc

Office of Women’s Health: http://www.womenshealth.gov/breastfeeding/index.cfm

NIH free web-based database for checking medication compatibility with breastfeeding:
http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT
(This can be added to the E.H.R. website links as a resource for E.H.R. users.)

WHO Baby-Friendly Hospitals Initiative: http://www.babyfriendlyusa.org/

WIC: http://www.fns.usda.gov/wic/breastfeeding/breastfeedingmainpage.htm
Maternity Care
“Preventing Maternal Death”; New Joint Commission Sentinel Event Alert Published
Pre-existing medical conditions such as high blood pressure are putting women at greater risk for death
during or shortly after pregnancy, according to Sentinel Event Alert #44 issued by The Joint Commission.
Current statistics from the CDC show that there are 13.3 maternal deaths per 100,000 live births; this is
significantly above the Healthy People 2010 target of 3.3 maternal deaths per 100,000 live births.

Common preventable causes that contribute to maternal deaths include uncontrolled high blood
pressure, undiagnosed fluid build-up in the lungs of women with pre-eclampsia, lack of careful
monitoring of vital signs after a cesarean delivery, and hemorrhage after cesarean delivery.

To improve maternal outcomes, the Joint Commission endorses formal maternal mortality reviews and
the following six steps:

    1. Educate physicians and other clinicians who care for women with underlying medical conditions
       about the additional risks that could be imposed if pregnancy were added; how to discuss these
       risks with patients; the use of appropriate and acceptable contraception; and pre-conceptual
       care and counseling. Communicate identified pregnancy risks to all members of the health care
       delivery team.
    2. Identify specific triggers for responding to changes in the mother’s vital signs and clinical
       condition and develop and use protocols and drills for responding to changes, such as
       hemorrhage and pre-eclampsia. Use the drills to train staff in the protocols, to refine local
       protocols, and to identify and fix systems problems that would prevent optimal care.
    3. Educate emergency room personnel about the possibility that a woman, whatever her
       presenting symptoms, may be pregnant or may have recently been pregnant. Many maternal
       deaths occur before the woman is hospitalized or after she delivers and is discharged. These
       deaths may occur in another hospital, away from the woman’s usual prenatal or obstetric care
       givers. Knowledge of pregnancy may affect the diagnosis or appropriate treatment.
    4. Refer high-risk patients to the care of experienced prenatal care providers with access to a
       broad range of specialized services.
    5. Make pneumatic compression devices available for patients undergoing Cesarean section who
       are at high risk for pulmonary embolism.
    6. Evaluate patients who are at high risk for thromboembolism for low molecular weight heparin
       for postpartum care.

Joint Commission, Preventing Maternal Death, Sentinel Event Alert Number 44, January 26, 2010.
http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_44.htm

The complete list and text of past issues of Sentinel Event Alert can be found at
http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/.

Additional Resources:
ACOG, Department of Patient Safety & Quality Improvement:
http://www.acog.org/departments/dept_web.cfm?recno=28
California Maternal Quality Care Collaborative (CMQCC), OB Hemorrhage Toolkit:
http://cmqcc.org/ob_hemorrhage/ob_hemorrhage_protocol_tools
ACOG District II and New York State Department of Health, Safe Motherhood Initiative:
http://www.acog.org/acog_districts/dist_notice.cfm?recno=1&bulletin=1551
Impact of Pregnancy-Induced Hypertension on Stillbirth and Neonatal Mortality
BACKGROUND: Hypertensive disorders of pregnancy are more frequent in primiparous women, but may
be more severe in multiparas. We examined trends in stillbirth and neonatal mortality related to
pregnancy-induced hypertension (PIH), and explored whether mortality varied by parity and maternal
race.
METHODS: We carried out a population-based study of 57 million singleton live births and stillbirths (24-
46 weeks' gestation) in the United States between 1990 and 2004. We estimated rates and adjusted
odds ratios (ORs) of stillbirth and neonatal death in relation to PIH, comparing births in 1990-1991 with
2003-2004.
RESULTS: PIH increased from 3.0% in 1990-1991 to 3.8% in 2003-2004. In both periods, PIH was
associated with a higher risk of stillbirth and neonatal death. We explored this in more detail in 2003-
2004, and observed that the increased risk of PIH-related stillbirth was higher in women having their
second or higher-order births (OR = 2.2 [95% confidence interval = 2.1-2.4]) compared with women
having their first birth (1.5 [1.4-1.6]). Patterns were similar for neonatal death (1.3 [1.2-1.4] in first and
1.6 [1.5-1.8] in second or higher-order births). Among multiparas, the association between PIH and
stillbirth was stronger in black women (2.9 [2.7-3.2]) than white women (2.0 [1.8-2.1]).
CONCLUSIONS: A substantial burden of stillbirth and neonatal mortality is associated with PIH, especially
among multiparous women, which may be due to more severe PIH, or to a higher burden of underlying
disease.

Ananth CV, Basso O. Impact of pregnancy-induced hypertension on stillbirth and neonatal mortality.
Epidemiology. 2010 Jan;21(1):118-23. http://www.ncbi.nlm.nih.gov/pubmed/20010214


Routine Use of Internal Tocodynamometry for Monitoring Contractions Not Supported by
Results of Randomized Trial
BACKGROUND: It has been hypothesized that internal tocodynamometry, as compared with external
monitoring, may provide a more accurate assessment of contractions and thus improve the ability to
adjust the dose of oxytocin effectively, resulting in fewer operative deliveries and less fetal distress.
However, few data are available to test this hypothesis.
METHODS: We performed a randomized, controlled trial in six hospitals in The Netherlands to compare
internal tocodynamometry with external monitoring of uterine activity in women for whom induced or
augmented labor was required. The primary outcome was the rate of operative deliveries, including
both cesarean sections and instrumented vaginal deliveries. Secondary outcomes included the use of
antibiotics during labor, time from randomization to delivery, and adverse neonatal outcomes (defined
as any of the following: an Apgar score at 5 minutes of less than 7, umbilical-artery pH of less than 7.05,
and neonatal hospital stay of longer than 48 hours).
RESULTS: We randomly assigned 1456 women to either internal tocodynamometry (734) or external
monitoring (722). The operative-delivery rate was 31.3% in the internal-tocodynamometry group and
29.6% in the external-monitoring group (relative risk with internal monitoring, 1.1; 95% confidence
interval [CI], 0.91 to 1.2). Secondary outcomes did not differ significantly between the two groups. The
rate of adverse neonatal outcomes was 14.3% with internal monitoring and 15.0% with external
monitoring (relative risk, 0.95; 95% CI, 0.74 to 1.2). No serious adverse events associated with use of the
intrauterine pressure catheter were reported.
CONCLUSIONS: Internal tocodynamometry during induced or augmented labor, as compared with
external monitoring, did not significantly reduce the rate of operative deliveries or of adverse neonatal
outcomes.
Bakker JJ, Verhoeven CJ, Janssen PF, van Lith JM, van Oudgaarden ED, Bloemenkamp KW, Papatsonis
DN, Mol BW, van der Post JA. Outcomes after internal versus external tocodynamometry for monitoring
labor. N Engl J Med. 2010 Jan 28;362(4):306-13. http://www.ncbi.nlm.nih.gov/pubmed/20107216


Acetaminophen Safe in Pregnancy; May Prevent Some Birth Defects
OBJECTIVE: To investigate whether exposure during the first trimester of pregnancy to single-ingredient
acetaminophen increases the risk of major birth defects.
METHODS: Data from the National Birth Defects Prevention Study, a population-based, case-control
study, were used. Women who delivered between January 1, 1997, and December 31, 2004, and
participated in the telephone interview were included. Type and timing of acetaminophen use were
assigned based on maternal report. Women reporting first-trimester acetaminophen use in a
combination product were excluded, resulting in a total of 11,610 children in the case group and 4,500
children in the control group for analysis.
RESULTS: The prevalence of first-trimester single-ingredient-acetaminophen use was common: 46.9%
(n=5,440) among women in the case group and 45.8% (n=2,059) among women in the control group
(P=.21). Overall, acetaminophen was not associated with an increased risk of any birth defect. Among
women reporting a first-trimester infection and fever, use of acetaminophen was associated with a
statistically significantly decreased odds ratio (OR) for anencephaly or craniorachischisis (adjusted OR
0.35, 95% confidence interval [CI] 0.08-0.80), encephalocele (adjusted OR 0.17, 95% CI 0.03-0.87), anotia
or microtia (adjusted OR 0.25, 95% CI 0.07-0.86), cleft lip with or without cleft palate (adjusted OR 0.44,
95% CI 0.26-0.75), and gastroschisis (adjusted OR 0.41, 95% CI 0.18-0.94).
CONCLUSION: Single-ingredient-acetaminophen use during the first trimester does not appear to
increase the risk of major birth defects. It may decrease the risk of selected malformations when used
for a febrile illness.

Feldkamp ML, Meyer RE, Krikov S, Botto LD. Acetaminophen use in pregnancy and risk of birth defects:
findings from the National Birth Defects Prevention Study. Obstet Gynecol. 2010 Jan;115(1):109-15.
http://www.ncbi.nlm.nih.gov/pubmed/20027042



Gynecology and Well-Woman Care
Atypical Hyperplasia Associated with High Long-Term Risk of Endometrial Cancer
PURPOSE: The severity of endometrial hyperplasia (EH)-simple (SH), complex (CH), or atypical (AH)-
influences clinical management, but valid estimates of absolute risk of clinical progression to carcinoma
are lacking.
MATERIALS AND METHODS: We conducted a case-control study nested in a cohort of 7,947 women
diagnosed with EH (1970-2002) at one prepaid health plan who remained at risk for at least 1 year.
Patient cases (N = 138) were diagnosed with carcinoma, on average, 6 years later (range, 1 to 24 years).
Patient controls (N = 241) were matched to patient cases on age at EH, date of EH, and duration of
follow-up, and they were counter-matched to patient cases on EH severity. After we independently
reviewed original slides and medical records of patient controls and patient cases, we combined
progression relative risks (AH v SH, CH, or disordered proliferative endometrium [ie, equivocal EH]) from
the case-control analysis with clinical censoring information (ie, hysterectomy, death, or left the health
plan) on all cohort members to estimate interval-specific (ie, 1 to 4, 5 to 9, and 10 to 19 years) and
cumulative (ie, through 4, 9, and 19 years) progression risks.
RESULTS: For nonatypical EH, cumulative progression risk increased from 1.2% (95% CI, 0.6% to 1.9%)
through 4 years to 1.9% (95% CI, 1.2% to 2.6%) through 9 years to 4.6% (95% CI, 3.3% to 5.8%) through
19 years after EH diagnosis. For AH, cumulative risk increased from 8.2% (95% CI, 1.3% to 14.6%)
through 4 years to 12.4% (95% CI, 3.0% to 20.8%) through 9 years to 27.5% (95% CI, 8.6% to 42.5%)
through 19 years after AH.
CONCLUSION: Cumulative 20-year progression risk among women who remain at risk for at least 1 year
is less than 5% for nonatypical EH but is 28% for AH.

Lacey JV Jr, Sherman ME, Rush BB, Ronnett BM, Ioffe OB, Duggan MA, Glass AG, Richesson DA,
Chatterjee N, Langholz B. Absolute Risk of Endometrial Carcinoma During 20-Year Follow-Up Among
Women With Endometrial Hyperplasia. J Clin Oncol. 2010 Jan 11. [Epub ahead of print]
http://www.ncbi.nlm.nih.gov/pubmed/20065186



Abrupt or Tapered Stop to HRT; No impact on vasomotor symptoms
OBJECTIVE: The aim of this study was to investigate whether tapering down of combined estrogen plus
progestogen therapy (EPT) reduced the recurrence of hot flashes and resumption of therapy compared
with abrupt discontinuation. A secondary aim was to evaluate whether health-related quality of life
(HRQoL) was affected after discontinuation of EPT and to investigate the possible factors predicting
resumption of EPT.
METHODS: Eighty-one postmenopausal women undergoing EPT because of hot flashes were
randomized to tapering down or abrupt discontinuation of EPT. Vasomotor symptoms were recorded in
self-registered diaries, and resumption of hormone therapy (HT) was asked for at every follow-up. The
Psychological General Well-being Index was used to assess HRQoL.
RESULTS: Neither the number nor the severity of hot flashes or HRQoL or frequency of resumption of HT
differed between the two modes of discontinuation of EPT during up to 12 months of follow-up. About
every other woman had resumed HT within 1 year. Women who resumed HT after 4 or 12 months
reported more deteriorated HRQoL and more severe hot flashes after discontinuation of therapy than
did women who did not resume HT.
CONCLUSIONS: Women who initiate EPT because of hot flashes may experience recurrence of
vasomotor symptoms and impaired HRQoL after discontinuation of EPT regardless of the
discontinuation method used, abrupt or taper down. Because, in addition to severity of flashes,
decreased well-being was the main predictor of the risk to resume HT, it seems important to also discuss
quality of life in parallel with efforts to discontinue HT.

Lindh-Astrand L, Bixo M, Hirschberg AL, Sundström-Poromaa I, Hammar M. A randomized controlled
study of taper-down or abrupt discontinuation of hormone therapy in women treated for vasomotor
symptoms. Menopause. 2010 Jan-Feb;17(1):72-9. http://www.ncbi.nlm.nih.gov/pubmed/19675505


Mother’s Milk        Suzan Murphy, Phoenix Indian Medical Center
(see lead article)


International Women’s Health                  Claire Wendland; Madison, Wisconsin
Can common childhood diseases really be managed “globally”?
A well-known bumper sticker exhorts us to “think globally, act locally.” Now two health policy
researchers are suggesting that it’s time to think globally, but develop guidelines locally, for the
management of childhood diseases. Over several decades, the World Health Organization developed
case management guidelines for the simple, cheap, and safe diagnoses and treatment of common
childhood illnesses. These guidelines were intended to be readily applicable in all low-income settings,
and in fact they are used in hundreds of millions of cases of diarrhea, pneumonia, and malaria across the
poorer parts of the world every year. The fourth Millennium Development Goal calls for a reduction of
child mortality by two-thirds by 2015; in a recent PLoS Medicine article, two researchers with long-term
experience in Kenya argue that if that goal is to be met, case management guidelines are going to need
some serious work.

Current guidelines have a number of limitations. Many lean heavily on expert opinion rather than
evidence. What evidence there is often comes from 1980s studies, a handful of which are made to
generalize for very different local settings around the world. The authors note that changes in disease
patterns, the extreme heterogeneity in health systems, and the use and misuse of new diagnostic
technologies (such as point-of-care malaria tests) mean that both the effectiveness and cost-
effectiveness of guidelines are now questionable. Appropriate diagnosis and management of childhood
pneumonia, for instance, may be profoundly altered by patients’ vaccination histories, by the likelihood
of HIV seropositivity, by the ability of families and clinicians to ensure that follow-up will happen. All of
these can be assessed probabilistically with good local-level data, but “global” guidelines will inevitably
work better for some conditions than others. Any clinician devising or using case management
protocols will recognize some of the dilemmas these authors discuss: does this protocol really reflect the
unique needs and vulnerabilities of my patient population, the unique limitations and strengths of our
health care system, the practicalities of diagnosis and treatment here?

The authors do not recommend abandoning the WHO guidelines, nor waiting for local data in order to
devise new guidelines. They do propose that data collection and clinical decision-tree modeling should
become higher priorities in ministries of health worldwide. Population-based models can help guide
decision-making, but to make these models we need basic data on disease burden, treatment efficacy,
and cost. If models crafted as well as possible for local circumstances were available to clinicians and to
policy-makers, they would very likely stimulate demand for better data that would in turn improve the
models. Even before good-quality local-level data is available, sharing data and models across regions
will help to keep case management guidelines evolving and strengthening, and help to minimize
unnecessary childhood deaths.

English M, Scott JA. What is the future for global case management guidelines for common childhood
diseases? PLoS Med. 2008 Dec 9;5(12):e241. http://www.ncbi.nlm.nih.gov/pubmed/19071957


ACOG Update
ACOG Committee on American Indian Health Update
The ACOG/IHS 2010 Postgraduate Course, affectionately known as “The Denver Course”, (although now
conducted in Salt Lake City), will be held on August 15 – 18, 2010. This year the popular review course
on women’s health and maternity care will include options for supplemental certification. The AAFP-
sponsored, Advanced Life Support in Obstetrics (ALSO) course will be available to participants. The
Neonatal Resuscitation Program (NRP) and Implanon training will also be available.

For further information about this fun and educational conference, please contact Yvonne Malloy at
202-863-2580 or ymalloy@acog.org.


ACOG Guidelines
To help make current guidelines available to those working in women’s health, ACOG also permits
access to summaries and abstracts of their Committee Opinions and Practice Bulletins for those at I/T/U
sites.
Health Care for Homeless Women, ACOG Committee Opinion Number 454, February 2010
Abstract: Homelessness continues to be a growing problem in the United States. With increasing
unemployment and home foreclosures, the recent recession and current economic difficulties are
estimated to result in more than 1 million Americans experiencing homelessness through 2011. Women
and families represent the fastest growing segment of the homeless population. Health care for these
women is a challenge but an issue that needs to be addressed. Homeless women are at higher risk for
injury and illness and are less likely to obtain needed health care than women who are not homeless. It
is essential to undertake efforts to prevent homelessness, to expand community-based services for the
homeless, and provide adequate health care for this underserved population. Health care providers can
help address the needs of homeless individuals by identifying their own patients who may be homeless
or at risk of becoming homeless, educating these patients about available resources in the community,
treating their health problems, and offering preventive care.

Health care for homeless women. Committee Opinion No. 454. American College of Obstetricians and
Gynecologists. Obstet Gynecol 2010;115:396–9.


Screening for Depression During and After Pregnancy, ACOG Committee Opinion Number 453,
February 2010
Abstract: Depression is very common during pregnancy and the postpartum period. At this time, there is
insufficient evidence to support a firm recommendation for universal antepartum or postpartum
screening. There are also insufficient data to recommend how often screening should be done. There
are multiple depression screening tools available for use.

Screening for depression during and after pregnancy. Committee Opinion No. 453. American College of
Obstetricians and Gynecologists. Obstet Gynecol 2010;115:394–5.


Also, please follow this link to highlights from previous documents:
http://www.ihs.gov/medicalprograms/mch/index.cfm?module=acog_pb


IHS Headquarters Updates
Carolyn Aoyama, IHS Women’s Health Consultant
Please review the following article on the impact of adverse childhood experiences on adult health:
Adverse childhood experiences and adult risk factors for age-related disease: depression,
inflammation, and clustering of metabolic risk markers
OBJECTIVE: To understand why children exposed to adverse psychosocial experiences are at elevated
risk for age-related disease, such as cardiovascular disease, by testing whether adverse childhood
experiences predict enduring abnormalities in stress-sensitive biological systems, namely, the nervous,
immune, and endocrine/metabolic systems.
DESIGN: A 32-year prospective longitudinal study of a representative birth cohort.
SETTING: New Zealand.
PARTICIPANTS: A total of 1037 members of the Dunedin Multidisciplinary Health and Development
Study. Main Exposures During their first decade of life, study members were assessed for exposure to 3
adverse psychosocial experiences: socioeconomic disadvantage, maltreatment, and social isolation.
MAIN OUTCOME MEASURES: At age 32 years, study members were assessed for the presence of 3 age-
related-disease risks: major depression, high inflammation levels (high-sensitivity C-reactive protein
level >3 mg/L), and the clustering of metabolic risk biomarkers (overweight, high blood pressure, high
total cholesterol, low high-density lipoprotein cholesterol, high glycated hemoglobin, and low maximum
oxygen consumption levels.
RESULTS: Children exposed to adverse psychosocial experiences were at elevated risk of depression,
high inflammation levels, and clustering of metabolic risk markers. Children who had experienced
socioeconomic disadvantage (incidence rate ratio, 1.89; 95% confidence interval, 1.36-2.62),
maltreatment (1.81; 1.38-2.38), or social isolation (1.87; 1.38-2.51) had elevated age-related-disease
risks in adulthood. The effects of adverse childhood experiences on age-related-disease risks in
adulthood were nonredundant, cumulative, and independent of the influence of established
developmental and concurrent risk factors.
CONCLUSIONS: Children exposed to adverse psychosocial experiences have enduring emotional,
immune, and metabolic abnormalities that contribute to explaining their elevated risk for age-related
disease. The promotion of healthy psychosocial experiences for children is a necessary and potentially
cost-effective target for the prevention of age-related disease.
Danese A, Moffitt TE, Harrington H, Milne BJ, Polanczyk G, Pariante CM, Poulton R, Caspi A. Adverse
childhood experiences and adult risk factors for age-related disease: depression, inflammation, and
clustering of metabolic risk markers. Arch Pediatr Adolesc Med. 2009 Dec;163(12):1135-43.
http://www.ncbi.nlm.nih.gov/pubmed/19996051

For more information on the ACE study (the basis of the study described above):
http://www.cdc.gov/nccdphp/ACE/


Attorney General Announces Significant Reforms to Improve Public Safety in Indian Country
Read the full press release at: http://www.justice.gov/dag/dag-memo-indian-country.html


Scott Giberson, IHS HIV/AIDS Principal Consultant
Preparation for National Native HIV/AIDS Awareness Day—March 20, 2010
The National Native HIV/AIDS Awareness Day Committee would like to announce the release of this
year’s Community Events Map (www.happ.colostate.edu/nnhaad). This online map was created to
publicize events taking place across the country in recognition of National Native HIV/AIDS Awareness
Day.

Event information will include details of the event, time and location. To submit your event, please
complete the attached form and send to andrea.israel@colostate.edu or fax to (970) 491-2717, Attn:
Andrea Israel. Please provide information in all of the required fields as incomplete entries will not be
included on the map. Deadline submission is March 13, 2010.


Judy Thierry, IHS MCH Coordinator
Youth regional treatment centers in Indian country video available
Experts from the Youth Regional Treatment Centers discuss a range of topics, including YRTC services
provided to American Indian and Alaska Native youth, success stories, challenges encountered, and
recommended solutions. Presenters include: David Nolley, CMS, Office of External Affairs; Tom Eagle
Staff, Nevada Skies YRTC; Anthony Yepa, New Sunrise YRTC; Angie Wilson, Wemble House YRTC; Zella
Weaver, Shiprock YRTC; Albert Long, Shiprock YRTC; Parcae Soule, Raven's Way YRTC; Vickie Claymore
LaHammer, IHS Aberdeen Area.

http://videocast.nih.gov/ram/cms121609.ram
Robert Wood Johnson Foundation Releases First Ever County Health Rankings
The County Health Rankings—the first set of reports to rank the overall health of every county in all
50 states—are now available on www.countyhealthrankings.org. The 50-state report, released by the
University of Wisconsin’s Population Health Institute and the Robert Wood Johnson Foundation, help
public health and community leaders, policy-makers, consumers and others to see how healthy their
county is, compare it with others within their state and find ways to improve the health of their
community.
Each county is ranked within the state on how healthy people are and how long they live. They also
are ranked on key factors that affect health such as: smoking, obesity, binge drinking, access to
primary care providers, rates of high school graduation, rates of violent crime, air pollution levels,
liquor store density, unemployment rates and number of children living in poverty.
Other studies have ranked states on health factors, but this is the first time researchers have
examined the multiple factors that affect health in each county in all 50 states.

RWJ Foundation: http://www.rwjf.org/publichealth/product.jsp?id=55508

State by State Views: http://www.countyhealthrankings.org/

USA Today article with 5 healthiest and 5 least healthy counties in each state:
http://www.usatoday.com/news/health/2010-02-17-countyhealth17_ST_N.htm



Megan Wohr, IHS Tobacco Control Specialist
Tobacco Dependence Treatment Medications Added to the National Core Formulary
Commercial tobacco abuse is the single most preventable cause of disease disability, and death within
tribal communities. Commercial tobacco abuse significantly increases the burden of every chronic
disease suffered within AI/AN communities. The smoking prevalence of the AI/AN population is the
highest of the U.S. Adult Ethic/Racial Groups, 32.0%, (37.5% of men and 26.8% of women); compared to
the National rate of 20.8%.

At the September National Pharmacy & Therapeutics Committee meeting, a presentation was given on
“Treating Tobacco Dependence”, and a request for the addition of cessation medications to the IHS
National Core Formulary was made on behalf of the IHS Tobacco Control Task Force (TCTF).

The IHS NPTC voted on and accepted the following recommendations from the TCTF:
Add NRT’s to National Core Formulary (any one (or more)):
        Nicotine Gum
        Nicotine Patch
        Nicotine Inhaler
        Nicotine Nasal Spray
        Nicotine Lozenge
Add Bupropion to National Core Formulary

US Public Health Service Guidelines, “Treating Tobacco Use and Dependence”, state that the use of
medications can double or triple patient’s long term quit rates. By adding Nicotine Cessation
Medications to IHS Core formulary, we can increase success rates and abstinence rates, decrease
hospital visits for tobacco related illness, increase the health and longevity of our patients, and increase
the Quality of Life for patients and their families.
The Tobacco Control Task Force (TCTF) is a multidisciplinary team consisting of volunteer
representatives from across the Indian Health System as well as partners from tobacco control
organizations. If you are interested in joining the IHS Tobacco Control Task Force, or in learning more
about our work, please contact the Tobacco Control Specialist: Megan Wohr at megan.wohr@ihs.gov,
or the Chair: Dr. Nat Cobb at nathaniel.cobb@ihs.gov.

Technical assistance and resources for clinical interventions and treatment are available from the IHS
Tobacco Control Task Force (TCTF): http://www.ihs.gov/medicalprograms/epi/tobacco
TCTF Provider and patient intervention tools are available at:
http://bandura.sbs.arizona.edu/hcp/IHS/external_downloads.htm



Announcements, Etc.
Surgeon General Releases Report To Help Americans Lead Healthier Lives
The Surgeon General's Vision for a Healthy and Fit Nation focuses on opportunities to prevent obesity by
implementing interventions in multiple settings. The report, released by the Surgeon General on January
28, 2010, strengthens and expands the Surgeon General's 2001 Call to Action, addressing personal
behaviors and biological traits, as well as characteristics of the social and physical environments that
offer or limit opportunities for positive health outcomes. Contents include background information on
obesity, including trends, disparities, measurement, consequences, and causes. Opportunities for
creating healthy home environments, child care settings, schools, and work sites; mobilizing the medical
community; and improving communities are also discussed.

The report is broken into sections which include breastfeeding as an important obesity prevention
strategy. Exclusive breastfeeding for 6 months is identified as one of the healthy choices for obesity
prevention. Breastfeeding is addressed in the child care, worksite, medical providers and community
support sections. Emphasis is placed on child care settings, school, and worksite and community
interventions.

U.S. Department of Health and Human Services. The Surgeon General’s Vision for a Healthy and Fit
Nation. Rockville, MD: U.S. Department of Health and Human Services, Office of the Surgeon General,
January 2010.

Press release: http://www.hhs.gov/news/press/2010pres/01/20100128c.html

The link to the 21 page full report: http://www.surgeongeneral.gov/library/obesityvision/obesityvision2010.pdf


NHSC Loan Repayment Program Expanded
More than $175 million in American Reinvestment and Recovery Act and FY2010 funds is providing
unprecedented opportunities for the NHSC and approved sites to expand the number of participating
clinicians. As many as 4,000 new NHSC clinicians are going to be placed in underserved communities by
September 2010. Your site can take advantage of this opportunity immediately. Up to $145,000 is
available in loan repayment for qualifying clinicians choosing a five year commitment to the NHSC.
Shorter two year service awards for $50,000 are also available.

There has never been a better time to recruit and retain clinicians through the National Health Service
Corps (NHSC). Clinicians working in NHSC‐approved sites with HPSA scores as low as zero have greater
opportunities and access to funding than ever before in the history of the program. Visit
http://www.nhsc.hrsa.gov for more details and for an online application.

NHSC Loan Repayment Website: http://nhsc.hrsa.gov/loanrepayment/

Site Outreach: http://www.nhchc.org/NHSCSiteOutreachFINALJan262010.pdf


Upcoming Events

2010 Indian Health/Tribal/Urban Basic and Refresher Colposcopy Courses
    March 10 – 12, 2010
    Albuquerque, NM
    More Info: Catherine Wood, UNM Office of Continuing Medical Education,
       http://hsc.unm.edu/som/cme/2010/Colposcopy/Colposcopy2010.shtml
       505-272-6569 or catwood@salud.unm.edu

Advances in Indian Health
   April 27 – 30, 2010
   Albuquerque, NM
   Up to 28 hours of CME
   More Info: Ann Bullock, 828-497-7455, annbull@nc-cherokee.com or
     Kathy Breckenridge, UNM Office of Continuing Medical Education,
     505-272-3942 or http://hsc.unm.edu/som/cme/2010/AIH/AIH.shtml

Centering Parenting/Lifecycle Training
    June 4 – 5, 2010
    Zuni, NM
    Led by Sharon Schindler Rising, founder of the Centering Healthcare Institute
    More Info: Nerissa Koehn, 505-782-7541, Nerissa.Koehn@ihs.gov

ACOG/IHS Postgraduate Course
(AKA “The Denver Course” – Official Title TBA)
    August 15 – 18, 2010
    Salt Lake City, Utah
    Advanced Life Support in Obstetrics (ALSO), Neonatal Resuscitation Program (NRP), and
       Implanon Training options for course participants
    More Info: Yvonne Malloy, 202-863-2580, ymalloy@acog.org

Spirit of Eagles; American Indian/Alaska Native Leadership Initiative on Cancer
     September 11 – 14, 2010
     Seattle, Washington
     8th National Conference; “Changing Patterns of Cancer in Native Communities:
        Strength through Tradition and Science”
     http://www.nativeamericanprograms.org
Thanks for taking the time to read the Women’s Health Notes. If you have comments or suggestions,
or would like to contribute to a future issue, please contact jean.howe@ihs.gov.

The Women’s Health Notes, an online newsletter for those working in women’s health at IHS, Tribal, and
Urban sites, is available for subscription through the IHS listserv:
http://www.ihs.gov/cio/listserver/index.cfm?module=list&option=list&num=87&startrow=76

Current and past issues, and many other resources, are available at the IHS MCH website:
http://www.ihs.gov/MedicalPrograms/MCH/index.cfm?module=whn_home


Looking for the Child Health Notes?
http://www.ihs.gov/MedicalPrograms/MCH/M/ChPedNotes.cfm

								
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