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Volume 6, No. 8, August 2008
Hot Topics
Obstetrics | Gynecology | Child Health | Chronic Disease and Illness
Obstetrics
Improving neonatal outcome through practical shoulder dystocia training
OBJECTIVE: To compare the management of and neonatal injury associated with shoulder dystocia before and after introduction of mandatory shoulder dystocia simulation training. METHODS: This was a retrospective, observational study comparing the management and neonatal outcome of births complicated by shoulder dystocia before (January 1996 to December 1999) and after (January 2001 to December 2004) the introduction of shoulder dystocia training at Southmead Hospital, Bristol, United Kingdom. The management of shoulder dystocia and associated neonatal injuries were compared pretraining and posttraining through a review of intrapartum and postpartum records of term, cephalic, singleton births in which difficulty with the shoulders was recorded during the two study periods.
RESULTS: There were 15,908 and 13,117 eligible births pretraining and posttraining, respectively. The shoulder dystocia rates were similar: pretraining 324 (2.04%) and posttraining 262 (2.00%) (P=.813). After training was introduced, clinical management improved: McRoberts' position, pretraining 95/324 (29.3%) to 229/262 (87.4%) posttraining (P<.001); suprapubic pressure 90/324 (27.8%) to 119/262 (45.4%) (P<.001); internal rotational maneuver 22/324 (6.8%) to 29/262 (11.1%) (P=.020); delivery of posterior arm 24/324 (7.4%) to 52/262 (19.8%) (P<.001); no recognized maneuvers performed 174/324 (50.9%) to 21/262 (8.0%) (P<.001); documented excessive traction 54/324 (16.7%) to 24/262 (9.2%) (P=.010). There was a significant reduction in neonatal injury at birth after shoulder dystocia: 30/324 (9.3%) to 6/262 (2.3%) (relative risk 0.25 [confidence interval 0.11-0.57]).
CONCLUSION: The introduction of shoulder dystocia training for all maternity staff was associated with improved management and neonatal outcomes of births complicated by shoulder dystocia. LEVEL OF EVIDENCE: II.
Draycott TJ , Crofts JF, Ash JP, Wilson LV, Yard E, Sibanda T, Whitelaw A.
Improving neonatal outcome through practical shoulder dystocia training. Obstet
Gynecol. 2008 Jul;112(1):14-20.
http://www.ncbi.nlm.nih.gov/pubmed/18591302
Progesterone for the prevention of preterm birth: a systematic review
OBJECTIVE: We performed a systematic review to assess the benefits and harms of progesterone administration for the prevention of preterm birth in women and their infants. DATA SOURCES: The Cochrane Controlled Trials Register was searched, and reference lists of retrieved studies were searched by hand. No date or language restrictions were placed. METHODS OF STUDY SELECTION: Randomized trials comparing antenatal progesterone for women at risk of preterm birth were considered. Studies were evaluated for inclusion and methodological quality. Primary outcomes were perinatal death, preterm birth before 34 weeks, and neurodevelopmental handicap.
TABULATION, INTEGRATION AND RESULTS: Eleven randomized controlled trials (2,425 women and 3,187 infants) were included. For women with a history of spontaneous preterm birth, progesterone was associated with a significant reduction in preterm birth before 34 weeks (one study, 142 women, RR 0.15, 95% CI 0.04-0.64, number needed to treat 7, 95% CI 4-17), but no statistically significant differences were identified for the outcome of perinatal death. For women with a short cervix identified on ultrasound, progesterone was not associated with a significant difference in perinatal death (one study, 274 participants, RR 0.38, 95% CI 0.10-1.40), but there was a significant reduction in preterm birth before 34 weeks (one study, 250 women, RR 0.58, 95% CI 0.38-0.87, number needed to treat 7, 95% CI 4-25). For women with a multiple pregnancy, progesterone was associated with no significant difference in perinatal death (one study, 154 participants, RR 1.95, 95% CI 0.37-10.33). For women presenting after threatened preterm labor, no primary outcomes were reported. For women with "other" risk factors for preterm birth, progesterone was not associated with a significant difference in perinatal death (two studies, 264 participants, RR 1.10, 95% CI 0.23-5.29).
CONCLUSION: Progesterone is associated with some beneficial effects in pregnancy outcome for some women at increased risk of preterm birth.
Dodd JM , Flenady VJ, Cincotta R, Crowther CA. Progesterone for the prevention of preterm birth: a systematic review. Obstet Gynecol. 2008 Jul;112(1):127-34. http://www.ncbi.nlm.nih.gov/pubmed/18591318
Effect of Timing of Umbilical Cord Clamping at Birth of Term Infants on Mother and Baby Outcomes (Cochrane Update)
BACKGROUND: Policies for timing of cord clamping vary, with early cord clamping generally carried out in the first 60 seconds after birth, whereas later cord clamping usually involves clamping the umbilical cord greater than one minute after the birth or when cord pulsation has ceased.
OBJECTIVES: To determine the effects of different policies of timing of cord clamping at delivery of the placenta on maternal and neonatal outcomes.
SEARCH STRATEGY: We searched the Cochrane Pregnancy and Child birth Group's Trials Register (December 2007).
SELECTION CRITERIA: Randomized controlled trials comparing early and late cord clamping.
DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial eligibility and quality and extracted data.
MAIN RESULTS: We included 11 trials of 2989 mothers and their babies. No significant differences between early and late cord clamping were seen for postpartum hemorrhage or severe postpartum hemorrhage in any of the five trials (2236 women) which measured this outcome (relative risk (RR) for postpartum hemorrhage 500 mls or more 1.22, 95% (CI) 0.96 to 1.55). For neonatal outcomes, our review showed both benefits and harms for late cord clamping. Following birth, there was a significant increase in infants needing phototherapy for jaundice (RR 0.59, 95% CI 0.38 to 0.92; five trials of 1762 infants) in the late compared with early clamping group. This was accompanied by significant increases in newborn hemoglobin levels in the late cord clamping group compared with early cord clamping (weighted mean difference 2.17 g/dL; 95% CI 0.28 to 4.06; three trials of 671 infants), although this effect did not persist past six months. Infant ferritin levels remained higher in the late clamping group than the early clamping group at six months.
AUTHORS' CONCLUSION: One definition of active management includes directions to administer an uterotonic with birth of the anterior shoulder of the baby and to clamp the umbilical cord within 30–60 seconds of birth of the baby (which is not always feasible in practice). In this review delaying clamping of the cord for at least two to three minutes seems not to increase the risk of postpartum hemorrhage. In addition, late cord clamping can be advantageous for the infant by improving iron status which may be of clinical value particularly in infants where access to good nutrition is poor, although delaying clamping increases the risk of jaundice requiring phototherapy.
McDonald SJ, Middleton P. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD004074. DOI: 10.1002/14651858.CD004074.pub2. Obstet Gynecol. 2008 Jul;112(1):177-8.
http://www.ncbi.nlm.nih.gov/pubmed/18591323
Length of rupture of membranes in the setting of premature rupture of membranes at term and infectious maternal morbidity
OBJECTIVE: This study was undertaken to define the time thresholds of increased risk for infectious maternal morbidities with relationship to length of ruptured membranes at term. STUDY DESIGN: We designed a retrospective cohort study of all women with premature rupture of membranes beyond 37 weeks' gestation at a single institution. Dichotomized time thresholds of length of ruptured membranes before delivery were examined in 2-hour increments using bivariate and multivariable analyses to assess the rates of chorioamnionitis and endomyometritis. RESULTS: Among the 3841 women meeting inclusion criteria, increased rates of chorioamnionitis and endomyometritis were noted at time thresholds of 12 hours (adjusted odds ratio 2.3 [95% confidence interval, 1.2-4.4]) and 16 hours (adjusted odds ratio 2.5 [95% confidence interval, 1.1-5.6]), respectively.
CONCLUSION: We found that when length of time of ruptured membranes before delivery is examined via dichotomized time thresholds, the risks of chorioamnionitis and endomyometritis are significantly increased at 12 hours and 16 hours, respectively. These time thresholds derived from dichotomized time analyses should be considered during risk-based counseling and labor management in the setting of term premature rupture of membranes.
Tran SH , Cheng YW, Kaimal AJ, Caughey AB. Length of rupture of membranes in the setting of premature rupture of membranes at term and infectious maternal morbidity. Am J Obstet Gynecol. 2008 Jun;198(6):700.e1-5. http://www.ncbi.nlm.nih.gov/pubmed/18538159
How physicians cope with stillbirth or neonatal death: a national survey of obstetricians
OBJECTIVE: To identify U.S. obstetricians' experiences and attitudes about perinatal death, their coping strategies, and their beliefs about the adequacy of their training on this topic.
METHODS: A total of 1,500 randomly selected U.S. obstetricians were mailed a self-administered survey about their experiences and attitudes in dealing with perinatal death. Physicians received up to three copies of the survey, a reminder card, and a $2 cash incentive. Eight hundred four physicians (54%) completed the entire survey.
RESULTS: Seventy-five percent of respondents reported that caring for a patient with a stillbirth took a large emotional toll on them personally, and nearly one in 10 obstetricians reported they had considered giving up obstetric practice because of the emotional difficulty in caring for a patient with a stillbirth. Talking informally with colleagues (87%) or friends and family (56%) were the most common strategies used by physicians to personally cope with these situations. CONCLUSION: Perinatal death has a profound effect on the delivering obstetrician, and a significant number of participants in our study have even considered giving up obstetrics altogether. Improved bereavement training may help obstetricians care for grieving families but also cope with their own emotions after this devastating event. LEVEL OF EVIDENCE: II.
Gold KJ , Kuznia AL, Hayward RA. How physicians cope with stillbirth or neonatal death: a national survey of obstetricians. Obstet Gynecol. 2008 Jul;112(1):29-34. http://www.ncbi.nlm.nih.gov/pubmed/18591304
Gynecology
The relationship of bleeding patterns to daily reproductive hormones in women approaching menopause
OBJECTIVE: To discover early hormonal predictors of menopause and the stages of the menopausal transition and to understand the hormonal basis behind the bleeding abnormalities common in the menopausal transition.
METHODS: A cohort of 804 women aged 42-52 collected first void urine samples daily for one complete menstrual cycle or 50 days (whichever came first) once a year for 3 years. Urine was assayed for excreted levels of follicle-stimulating hormone, luteinizing hormone, estrogen metabolites, and progesterone metabolites, which were normalized for creatinine concentration. Anovulation was defined by an algorithm based on progesterone secretion. Menstrual bleeding parameters were derived from daily calendars. Correlations among bleeding characteristics, hormone concentrations, and other potential clinical predictors were analyzed using multivariable logistic regression models.
RESULTS: An ethnically diverse population of women (mean age of 47) with a majority in the early perimenopause was studied. Approximately 20% of all cycles were anovulatory. Short cycle intervals (fewer than 21 days) were common early in the menopause transition and were associated with anovulation (44%). Long cycle intervals (more than 36 days) also were associated with anovulatory cycles (65%). Both short (1-3 days) and long (more than 8 days) duration of menstrual bleeding were associated with anovulation (18% and 23%, respectively). Women with anovulatory cycles were less likely to report heavy menstrual bleeding as compared with those with ovulatory cycles. Heavy bleeding was not associated with steroid hormone concentrations but was associated with obesity and with the self-reported presence of leiomyomata.
CONCLUSIONS: Among women in the early menopause transition, abnormalities in timing of menstrual bleeding (cycle intervals or bleeding duration) have a hormonal basis and are frequently associated with anovulation. In contrast, abnormally heavy periods do not appear to have a steroid hormonal basis and are less likely after anovulatory cycles. Heavy periods are associated with obesity and leiomyomata. LEVEL OF EVIDENCE: II.
Van Voorhis BJ , Santoro N, Harlow S, Crawford SL, Randolph J. The relationship of bleeding patterns to daily reproductive hormones in women approaching menopause. Obstet Gynecol. 2008 Jul;112(1):101-8. http://www.ncbi.nlm.nih.gov/pubmed/18591314
Bilateral oophorectomy and depressive symptoms 12 months after hysterectomy
OBJECTIVE: This study was performed to examine whether bilateral oophorectomy is related to depressive symptoms.
STUDY DESIGN: A secondary analysis of data collected from a cohort study of 1047 premenopausal women undergoing hysterectomy with or without concomitant oophorectomy for benign indications was performed. Data on depressive symptoms, based on the Profile of Mood States survey, were collected presurgically and 12 months postoperatively.
RESULTS: The effect of bilateral oophorectomy on postoperative depressive symptoms varied, depending on the presence of baseline depressive symptoms. Bilateral oophorectomy was associated with a decrease in risk of depressive symptoms in women without baseline depressive symptoms (risk ratio [RR] 0.36 [95% confidence interval (CI), 0.17, 0.78]) and did not change significantly in those with baseline depressive symptoms (RR 1.21 [95% CI, 0.73, 2.00]). CONCLUSIONS: Bilateral oophorectomy, in comparison with unilateral or no oophorectomy, is associated with less risk of postoperative depressive symptoms in women without baseline depressive symptoms undergoing hysterectomy.
Rohl J , Kjerulff K, Langenberg P, Steege J. Bilateral oophorectomy and depressive symptoms 12 months after hysterectomy. Am J Obstet Gynecol. 2008 Jul;199(1):22.e1-5. Epub 2008 Mar 24.
http://www.ncbi.nlm.nih.gov/pubmed/18359477
Two-year outcomes after sacrocolpopexy with and without burch to
prevent stress urinary incontinence
OBJECTIVES: To report anatomic and functional outcomes 2 years after sacrocolpopexy
in stress-continent women with or without prophylactic Burch colposuspension.
METHODS: In the Colpopexy and Urinary Reduction Efforts ( CARE) trial, stress-continent women undergoing sacrocolpopexy were randomized to receive or not receive a Burch colposuspension. Outcomes included urinary symptoms, other pelvic symptoms, and pelvic support. Standardized pelvic organ prolapse quantification examinations and validated outcome measures including the Pelvic Floor Distress Inventory and the Pelvic Floor Impact Questionnaire were completed before surgery and at several postoperative intervals, including at 2 years.
RESULTS: This analysis is based on 302 of 322 randomized participants. Most were Caucasian (94%), with a mean age of 62+/-10 years (mean+/-standard deviation). Two years after surgery, 32.0% and 45.2% of women in the Burch and control groups, respectively, met the stress incontinence endpoint (presence of symptoms or positive cough stress test or interval treatment for stress incontinence, P=.026). The apex was well supported (point C within 2 cm of total vaginal length) in 95% of women, and this was not affected by concomitant Burch (P=.18). There was a trend toward fewer urgency symptoms in the Burch group (32.0% versus 44.5% no Burch, P=.085). Twenty participants experienced mesh or suture erosions.
CONCLUSION: The early advantage of prophylactic Burch colposuspension for stress incontinence that was seen at 3 months remains at 2 years. Apical anatomic success rates are high and not affected by concomitant Burch. LEVEL OF EVIDENCE: I.
Brubaker L , et al. Two-year outcomes after sacrocolpopexy with and without burch to prevent stress urinary incontinence. Obstet Gynecol. 2008 Jul;112(1):49-55. http://www.ncbi.nlm.nih.gov/pubmed/18591307
Comparison of the treatment outcome of pubovaginal sling, tension-free vaginal tape, and transobturator tape for stress urinary incontinence with intrinsic sphincter deficiency
OBJECTIVE: The aim of this study was to compare the treatment outcome of 3 sling procedures for stress urinary incontinence with intrinsic sphincter deficiency.
STUDY DESIGN: This retrospective study included 253 patients who underwent incontinence surgery (pubovaginal sling [PVS] = 87, tension-free vaginal tape [TVT] = 94, and transobturator tape [TOT] = 72) for urodynamic stress incontinence with intrinsic sphincter deficiency. Analysis of variance, chi(2) test, Fisher's exact test, Kaplan-Meier survival analysis, and Cox proportional hazard regression were used for statistical analysis.
RESULTS: Overall complication rates were not significantly different. At 2 years postoperatively, the cumulative cure rates of the PVS, TVT, and TOT groups were significantly different (87.25%, 86.94%, and 34.89%, respectively; P < .0001). The risk of treatment failure in women who received TOT was 4.6 times higher than in women who underwent PVS. The 7-year cumulative cure rates of PVS and TVT groups were 59.10% and 55.09%, respectively.
CONCLUSION: PVS and TVT were more efficacious, but the long-term cure rates were low.
Jeon MJ , Jung HJ, Chung SM, Kim SK, Bai SW. Comparison of the treatment outcome of pubovaginal sling, tension-free vaginal tape, and transobturator tape for stress urinary incontinence with intrinsic sphincter deficiency. Am J Obstet Gynecol. 2008 Jul;199(1):76.e1-4. Epub 2008 Jan 25. http://www.ncbi.nlm.nih.gov/pubmed/18221934Child Health
Universal newborn hearing screening: systematic review to update the 2001 US Preventive Services Task Force Recommendation
OBJECTIVE: This review is an update for the US Preventive Services Task Force on universal newborn hearing screening to detect moderate-to-severe permanent, bilateral congenital hearing loss. We focus on 3 key questions: (1) Among infants identified by universal screening who would not be identified by targeted screening, does initiating treatment before 6 months of age improve language and communication outcomes? (2) Compared with targeted screening, does universal screening increase the chance that treatment will be initiated by 6 months of age for infants at average risk or for those at high risk? (3) What are the adverse effects of screening and early treatment?
METHODS: Medline and Cochrane databases were searched to identify articles published since the 2002 recommendation. Data from studies that met inclusion criteria were abstracted, and studies were rated for quality with predetermined criteria.
RESULTS: A good-quality retrospective study of children with hearing loss indicates that those who had early versus late confirmation and those who had undergone universal newborn screening versus none had better receptive language at 8 years of age but not better expressive language or speech. A good-quality nonrandomized trial of a large birth cohort indicates that infants identified with hearing loss through universal newborn screening have earlier referral, diagnosis, and treatment than those not screened. These findings are corroborated by multiple descriptive studies of ages of referral, diagnosis, and treatment. Usual parental reactions to an initial nonpass on a hearing screen include worry, questioning, and distress that resolve for most parents. Cochlear implants have been associated with higher risks for bacterial meningitis in young children.
CONCLUSIONS: Children with hearing loss who had universal newborn hearing screening have better language outcomes at school age than those not screened. Infants identified with hearing loss through universal screening have significantly earlier referral, diagnosis, and treatment than those identified in other ways.
Nelson HD , Bougatsos C, Nygren P; 2001 US Preventive Services Task Force. Universal newborn hearing screening: systematic review to update the 2001 US Preventive Services Task Force Recommendation. Pediatrics. 2008 Jul;122(1):e266-76. http://www.ncbi.nlm.nih.gov/pubmed/18595973
Children at High Risk Should Be Screened for Elevated Cholesterol
This clinical report replaces the 1998 policy statement from the American Academy of Pediatrics on cholesterol in childhood, which has been retired. This report has taken on new urgency given the current epidemic of childhood obesity with the subsequent increasing risk of type 2 diabetes mellitus, hypertension, and cardiovascular disease in older children and adults. The approach to screening children and adolescents with a fasting lipid profile remains a targeted approach. Overweight children belong to a special risk category of children and are in need of cholesterol screening regardless of family history or other risk factors. This report reemphasizes the need for prevention of cardiovascular disease by following Dietary Guidelines for Americans and increasing physical activity and also includes a review of the pharmacologic agents and indications for treating dyslipidemia in children.
Daniels SR , Greer FR; Committee on Nutrition Collaborators (13). Lipid screening and cardiovascular health in childhood. Pediatrics. 2008 Jul;122(1):198-208.
http://www.ncbi.nlm.nih.gov/pubmed/18596007
Cardiovascular Risk Factors and the Metabolic Syndrome in Pediatric Nonalcoholic Fatty Liver Disease
BACKGROUND: Nonalcoholic fatty liver disease (NAFLD), the most common cause of liver disease in children, is associated with obesity and insulin resistance. However, the relationship between NAFLD and cardiovascular risk factors in children is not fully understood. The objective of this study was to determine the association between NAFLD and the presence of metabolic syndrome in overweight and obese children.
METHODS AND RESULTS: This case-control study of 150 overweight children with biopsy-proven NAFLD and 150 overweight children without NAFLD compared rates of metabolic syndrome using Adult Treatment Panel III criteria. Cases and controls were well matched in age, sex, and severity of obesity. Children with NAFLD had significantly higher fasting glucose, insulin, total cholesterol, low-density lipoprotein cholesterol, triglycerides, systolic blood pressure, and diastolic blood pressure than overweight and obese children without NAFLD. Subjects with NAFLD also had significantly lower high-density lipoprotein cholesterol than controls. After adjustment for age, sex, race, ethnicity, body mass index, and hyperinsulinemia, children with metabolic syndrome had 5.0 (95% confidence interval, 2.6 to 9.7) times the odds of having NAFLD as overweight and obese children without metabolic syndrome.
CONCLUSIONS: NAFLD in overweight and obese children is strongly associated with multiple cardiovascular risk factors. The identification of NAFLD in a child should prompt global counseling to address nutrition, physical activity, and avoidance of smoking to prevent the development of cardiovascular disease and type 2 diabetes.
Schwimmer JB , Pardee PE, Lavine JE, Blumkin AK, Cook S. Cardiovascular Risk Factors and the Metabolic Syndrome in Pediatric Nonalcoholic Fatty Liver Disease. Circulation. 2008 Jun 30. [Epub ahead of print] http://www.ncbi.nlm.nih.gov/pubmed/18591439
Epidemiology and treatment of painful procedures in neonates in intensive care units
CONTEXT: Effective strategies to improve pain management in neonates require a clear understanding of the epidemiology and management of procedural pain.
OBJECTIVE: To report epidemiological data on neonatal pain collected from a geographically defined region, based on direct bedside observation of neonates.
DESIGN, SETTING, AND PATIENTS: Between September 2005 and January 2006, data on all painful and stressful procedures and corresponding analgesic therapy from the first 14 days of admission were prospectively collected within a 6-week period from 430 neonates admitted to tertiary care centers in the Paris region of France (11.3 millions inhabitants) for the Epidemiology of Procedural Pain in Neonates (EPIPPAIN) study.
MAIN OUTCOME MEASURE: Number of procedures considered painful or stressful by health personnel and corresponding analgesic therapy. RESULTS: The mean (SD) gestational age and intensive care unit stay were 33.0 (4.6) weeks and 8.4 (4.6) calendar days, respectively. Neonates experienced 60,969 first-attempt procedures, with 42,413 (69.6%) painful and 18,556 (30.4%) stressful procedures; 11,546 supplemental attempts were performed during procedures including 10,366 (89.8%) for painful and 1180 (10.2%) for stressful procedures. Each neonate experienced a median of 115 (range, 4-613) procedures during the study period and 16 (range, 0-62) procedures per day of hospitalization. Of these, each neonate experienced a median of 75 (range, 3-364) painful procedures during the study period and 10 (range, 0-51) painful procedures per day of hospitalization. Of the 42,413 painful procedures, 2.1% were performed with pharmacological-only therapy; 18.2% with nonpharmacological-only interventions, 20.8% with pharmacological, nonpharmacological, or both types of therapy; and 79.2% without specific analgesia, and 34.2% were performed while the neonate was receiving concurrent analgesic or anesthetic infusions for other reasons. Prematurity, category of procedure, parental presence, surgery, daytime, and day of procedure after the first day of admission were associated with greater use of specific preprocedural analgesia, whereas mechanical ventilation, noninvasive ventilation and administration of nonspecific concurrent analgesia were associated with lower use of specific preprocedural analgesia.
CONCLUSION: During neonatal intensive care in the Paris region, large numbers of painful and stressful procedures were performed, the majority of which were not accompanied by analgesia.
Carbajal R , et al. Epidemiology and treatment of painful procedures in neonates in intensive care units. JAMA. 2008 Jul 2;300(1):60-70. http://www.ncbi.nlm.nih.gov/pubmed/18594041Chronic Disease and Illness
Prevalence and Correlates of Subclinical Atherosclerosis in Alaska Eskimos. The GOCADAN Study
BACKGROUND AND PURPOSE: The recent increase in clinical cardiovascular disease in Alaska Eskimos suggests that changes in traditional lifestyle may have adverse public health consequences. This study examines the prevalence of subclinical vascular disease and its relation to risk factors in Alaska Eskimos.
METHODS: Participants in the population-based Genetics of Coronary Artery Disease in Alaska Natives (GOCADAN) Study underwent evaluation of cardiovascular disease risk factors and carotid ultrasound. Outcome variables were carotid intimal-medial thickness and presence and extent of atherosclerosis.
RESULTS: In multivariate analyses, intimal-medial thickness and presence and extent of atherosclerosis were all associated with traditional cardiovascular disease risk factors but not dietary intake of omega-3 fatty acids. Rates of carotid atherosclerosis were higher than those reported in 2 large population-based US studies.
CONCLUSIONS: Alaska Eskimos have similar traditional risk factors for carotid atherosclerosis as other ethnic and racial populations but have higher prevalences of atherosclerosis, possibly attributable to higher rates of smoking.
Cutchins A , Roman MJ , Devereux RB , Ebbesson SO , Umans JG , Zhu J , Weissman NJ , Howard BV . Prevalence and Correlates of Subclinical Atherosclerosis in Alaska Eskimos. The GOCADAN Study. Stroke. 2008 Jul 10. [Epub ahead of print] http://www.ncbi.nlm.nih.gov/pubmed/18617652
Diabetes and Depression Linked
CONTEXT: Depressive symptoms are associated with development of type 2 diabetes, but it is unclear whether type 2 diabetes is a risk factor for elevated depressive symptoms.
OBJECTIVE: To examine the bidirectional association between depressive symptoms and type 2 diabetes.
DESIGN, SETTING, AND PARTICIPANTS: Multi-Ethnic Study of Atherosclerosis, a longitudinal, ethnically diverse cohort study of US men and women aged 45 to 84 years enrolled in 2000-2002 and followed up until 2004-2005.
MAIN OUTCOME MEASURES: Elevated depressive symptoms defined by Center for Epidemiologic Studies Depression Scale (CES-D) score of 16 or higher, use of antidepressant medications, or both. The CES-D score was also modeled continuously. Participants were categorized as normal fasting glucose (< 100 mg/dL), impaired fasting glucose (100-125 mg/dL), or type 2 diabetes (> or = 126 mg/dL or receiving treatment). Analysis 1 included 5201 participants without type 2 diabetes at baseline and estimated the relative hazard of incident type 2 diabetes over 3.2 years for those with and without depressive symptoms. Analysis 2 included 4847 participants without depressive symptoms at baseline and calculated the relative odds of developing depressive symptoms over 3.1 years for those with and without type 2 diabetes. RESULTS: In analysis 1, the incidence rate of type 2 diabetes was 22.0 and 16.6 per 1000 person-years for those with and without elevated depressive symptoms, respectively. The risk of incident type 2 diabetes was 1.10 times higher for each 5-unit increment in CES-D score (95% confidence interval [CI], 1.02-1.19) after adjustment for demographic factors and body mass index. This association persisted following adjustment for metabolic, inflammatory, socioeconomic, or lifestyle factors, although it was no longer statistically significant following adjustment for the latter (relative hazard, 1.08; 95% CI, 0.99-1.19). In analysis 2, the incidence rates of elevated depressive symptoms per 1000-person years were 36.8 for participants with normal fasting glucose; 27.9 for impaired fasting glucose; 31.2 for untreated type 2 diabetes, and 61.9 for treated type 2 diabetes. Compared with normal fasting glucose, the demographic-adjusted odds ratios of developing elevated depressive symptoms were 0.79 (95% CI, 0.63-0.99) for impaired fasting glucose, 0.75 (95% CI, 0.44-1.27) for untreated type 2 diabetes, and 1.54 (95% CI, 1.13-2.09) for treated type 2 diabetes. None of these associations with incident depressive symptoms were materially altered with adjustment for body mass index, socioeconomic and lifestyle factors, and comorbidities. Findings in both analyses were comparable across ethnic groups.
CONCLUSIONS: A modest association of baseline depressive symptoms with incident type 2 diabetes existed that was partially explained by lifestyle factors. Impaired fasting glucose and untreated type 2 diabetes were inversely associated with incident depressive symptoms, whereas treated type 2 diabetes showed a positive association with depressive symptoms. These associations were not substantively affected by adjustment for potential confounding or mediating factors.
Golden SH , et al., Examining a bidirectional association between depressive symptoms and diabetes. JAMA. 2008 Jun 18;299(23):2751-9. http://www.ncbi.nlm.nih.gov/pubmed/18560002
Full text article at JAMA website: http://jama.ama-assn.org/cgi/content/full/299/23/2751
Hearing Loss More Common with Diabetes
BACKGROUND: Diabetes might affect the vasculature and neural system of the inner ear, leading to hearing impairment.
OBJECTIVE: To determine whether hearing impairment is more prevalent among U.S. adults with diabetes.
DESIGN: Cross-sectional analysis of nationally representative data. SETTING: National Health and Nutrition Examination Survey, 1999 to 2004.
PARTICIPANTS: 5140 noninstitutionalized adults age 20 to 69 years who had audiometric testing.
MEASUREMENTS: Hearing impairment was assessed from the pure tone average of thresholds over low or mid-frequencies (500, 1000, and 2000 Hz) and high frequencies (3000, 4000, 6000, and 8000 Hz) and was defined as mild or greater severity (pure tone average >25 decibels hearing level [dB HL]) and moderate or greater severity (pure tone average >40 dB HL). RESULTS: Hearing impairment was more prevalent among adults with diabetes. Age-adjusted prevalence of low- or mid-frequency hearing impairment of mild or greater severity in the worse ear was 21.3% (95% CI, 15.0% to 27.5%) among 399 adults with diabetes compared with 9.4% (CI, 8.2% to 10.5%) among 4741 adults without diabetes. Similarly, age-adjusted prevalence of high-frequency hearing impairment of mild or greater severity in the worse ear was 54.1% (CI, 45.9% to 62.3%) among those with diabetes compared with 32.0% (CI, 30.5% to 33.5%) among those without diabetes. The association between diabetes and hearing impairment was independent of known risk factors for hearing impairment, such as noise exposure, ototoxic medication use, and smoking (adjusted odds ratios for low- or mid-frequency and high-frequency hearing impairment were 1.82 [CI, 1.27 to 2.60] and 2.16 [CI, 1.47 to 3.18], respectively). LIMITATIONS: The diagnosis of diabetes was based on self-report. The investigators could not distinguish between type 1 and type 2 diabetes. Noise exposure was based on participant recall. CONCLUSION: Hearing impairment is common in adults with diabetes, and diabetes seems to be an independent risk factor for the condition.
Bainbridge KE , Hoffman HJ, Cowie CC. Diabetes and hearing impairment in the United States: audiometric evidence from the National Health and Nutrition Examination Survey, 1999 to 2004. Ann Intern Med. 2008 Jul 1;149(1):1-10. Epub 2008 Jun 16. http://www.annals.org/cgi/content/full/0000605-200807010-00231v1
Hirose K . Hearing Loss and Diabetes: You Might Not Know What You're Missing. Ann Intern Med. 2008 Jul 1;149(1):54-5. Epub 2008 Jun 16. http://www.annals.org/cgi/content/full/149/1/54
Summary for Patients: http://www.annals.org/cgi/content/full/149/1/I-20
Management of Non–ST-Elevation Acute Coronary Syndromes in Men vs. Women; A role for conservative management in low risk women
CONTEXT: Although an invasive strategy is frequently used in patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS), data from some trials suggest that this strategy may not benefit women.
OBJECTIVE: To conduct a meta-analysis of randomized trials to compare the effects of an invasive vs conservative strategy in women and men with NSTE ACS. DATA SOURCES: Trials were identified through a computerized literature search of the MEDLINE and Cochrane databases (1970-April 2008) using the search terms invasive strategy, conservative strategy, selective invasive strategy, acute coronary syndromes, non-ST-elevation myocardial infarction, and unstable angina.
STUDY SELECTION: Randomized clinical trials comparing an invasive vs conservative treatment strategy in patients with NSTE ACS.
DATA EXTRACTION: The principal investigators for each trial provided the sex-specific incidences of death, myocardial infarction (MI), and rehospitalization with ACS through 12 months of follow-up.
DATA SYNTHESIS: Data were combined across 8 trials (3075 women and 7075 men). The odds ratio (OR) for the composite of death, MI, or ACS for invasive vs conservative strategy in women was 0.81 (95% confidence interval [CI], 0.65-1.01; 21.1% vs 25.0%) and in men was 0.73 (95% CI, 0.55-0.98; 21.2% vs 26.3%) without significant heterogeneity between sexes (P for interaction = .26). Among biomarker-positive women, an invasive strategy was associated with a 33% lower odds of death, MI, or ACS (OR, 0.67; 95% CI, 0.50-0.88) and a nonsignificant 23% lower odds of death or MI (OR, 0.77; 95% CI, 0.47-1.25). In contrast, an invasive strategy was not associated with a significant reduction in the triple composite end point in biomarker-negative women (OR, 0.94; 95% CI, 0.61-1.44; P for interaction = .36) and was associated with a nonsignificant 35% higher odds of death or MI (OR, 1.35; 95% CI, 0.78-2.35; P for interaction = .08). Among men, the OR for death, MI, or ACS was 0.56 (95% CI, 0.46-0.67) if biomarker-positive and 0.72 (95% CI, 0.51-1.01) if biomarker-negative (P for interaction = .09).
CONCLUSIONS: In NSTE ACS, an invasive strategy has a comparable benefit in men and high-risk women for reducing the composite end point of death, MI, or rehospitalization with ACS. In contrast, our data provide evidence supporting the new guideline recommendation for a conservative strategy in low-risk women.
O'Donoghue M , et al. Early invasive vs conservative treatment strategies in women and men with unstable angina and non-ST-segment elevation myocardial infarction: a meta-analysis. JAMA. 2008 Jul 2;300(1):71-80. http://www.ncbi.nlm.nih.gov/pubmed/18594042
ACC/AHA 2007 Guidelines for the Management of Patients with Unstable Angina/Non–ST-Elevation Myocardial Infarction:
http://content.onlinejacc.org/cgi/content/full/50/7/e1
Topiramate Improves Quality of Life and Physical Health in Alcohol-Dependent Adults
BACKGROUND: Topiramate can improve drinking outcomes via a hypothesized mechanism of facilitating gamma-aminobutyric acid function and inhibiting glutaminergic pathways in the corticomesolimbic system. We sought to determine whether topiramate's antidrinking effects are bolstered by improvements in physical and psychosocial well-being.
METHODS: In a 17-site, 14-week, double-blind, randomized controlled trial, we compared the effects of topiramate (up to 300 mg/d) vs placebo on physical health, obsessional thoughts and compulsions about using alcohol, and psychosocial well-being among 371 alcohol-dependent subjects who received weekly adherence enhancement therapy.
RESULTS: Topiramate was more efficacious than placebo in reducing body mass index (calculated as weight in kilograms divided by height in meters squared) (mean difference, 1.08; 95% confidence interval [CI], 0.81-1.34; P < .001), all liver enzyme levels (P < .01 for all comparisons), plasma cholesterol level (mean difference, 13.30 mg/dL; 95% CI, 5.09-21.44 mg/dL; P = .002), and systolic (mean difference, 9.70 mm Hg; 95% CI, 6.81-12.60 mm Hg; P < .001) and diastolic (mean difference, 6.74 mm Hg; 95% CI, 4.57-8.90 mm Hg; P < .001) blood pressure to about prehypertension levels-effects that might lower the risk of fatty liver degeneration and cirrhosis as well as cardiovascular disease. Topiramate compared with placebo significantly (P < .05 for all comparisons) decreased obsessional thoughts and compulsions about using alcohol, increased subjects' psychosocial well-being, and improved some aspects of quality of life, thereby diminishing the risk of relapse and longer-term negative outcomes. Paresthesia, taste perversion, anorexia, and difficulty with concentration were reported more frequently for topiramate than for placebo.
CONCLUSION: Topiramate appears to be generally effective at improving the drinking outcomes and physical and psychosocial well-being of alcoholic subjects.
Johnson BA , et al. Improvement of physical health and quality of life of alcohol-dependent individuals with topiramate treatment: US multisite randomized controlled trial. Arch Intern Med. 2008 Jun 9;168(11):1188-99. http://www.ncbi.nlm.nih.gov/pubmed/18541827
Noninvasive ventilation in acute cardiogenic pulmonary edema
BACKGROUND: Noninvasive ventilation (continuous positive airway pressure [CPAP] or noninvasive intermittent positive-pressure ventilation [NIPPV]) appears to be of benefit in the immediate treatment of patients with acute cardiogenic pulmonary edema and may reduce mortality. We conducted a study to determine whether noninvasive ventilation reduces mortality and whether there are important differences in outcome associated with the method of treatment (CPAP or NIPPV).
METHODS: In a multicenter, open, prospective, randomized, controlled trial, patients were assigned to standard oxygen therapy, CPAP (5 to 15 cm of water), or NIPPV (inspiratory pressure, 8 to 20 cm of water; expiratory pressure, 4 to 10 cm of water). The primary end point for the comparison between noninvasive ventilation and standard oxygen therapy was death within 7 days after the initiation of treatment, and the primary end point for the comparison between NIPPV and CPAP was death or intubation within 7 days.
RESULTS: A total of 1069 patients (mean [±SD] age, 77.7±9.7 years; female sex, 56.9%) were assigned to standard oxygen therapy (367 patients), CPAP (346 patients), or NIPPV (356 patients). There was no significant difference in 7-day mortality between patients receiving standard oxygen therapy (9.8%) and those undergoing noninvasive ventilation (9.5%, P=0.87). There was no significant difference in the combined end point of death or intubation within 7 days between the two groups of patients undergoing noninvasive ventilation (11.7% for CPAP and 11.1% for NIPPV, P=0.81). As compared with standard oxygen therapy, noninvasive ventilation was associated with greater mean improvements at 1 hour after the beginning of treatment in patient-reported dyspnea (treatment difference, 0.7 on a visual-analogue scale ranging from 1 to 10; 95% confidence interval [CI], 0.2 to 1.3; P=0.008), heart rate (treatment difference, 4 beats per minute; 95% CI, 1 to 6; P=0.004), acidosis (treatment difference, pH 0.03; 95% CI, 0.02 to 0.04; P<0.001), and hypercapnia (treatment difference, 0.7 kPa [5.2 mm Hg]; 95% CI, 0.4 to 0.9; P<0.001). There were no treatment-related adverse events.
CONCLUSIONS: In patients with acute cardiogenic pulmonary edema, noninvasive ventilation induces a more rapid improvement in respiratory distress and metabolic disturbance than does standard oxygen therapy but has no effect on short-term mortality.
Gray A , Goodacre S, Newby DE, Masson M, Sampson F, Nicholl J; 3 CPO Trialists.Noninvasive ventilation in acute cardiogenic pulmonary edema.
N Engl J Med. 2008 Jul 10;359(2):142-51. http://www.ncbi.nlm.nih.gov/pubmed/18614781
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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.
