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Volume 5, No. 11, December 2007
Hot Topics
Obstetrics | Gynecology | Child Health | Chronic Disease and Illness
Obstetrics
Cesarean delivery in Native American women: are low rates explained by practice style?
CONCLUSIONS: Despite a higher prevalence of medical risk factors for cesarean delivery, the rate at this hospital was well below New Mexico (16.4%, all races) and national (21.2%, all races) cesarean rates for 1998. Medical and practice-related factors were the only observed independent correlates of cesarean delivery. Implementation of institutional and practitioner policies common to the Indian Health Service may reduce cesarean deliveries in other populations
Mahoney SF, Malcoe LH. Cesarean delivery in Native American women: are low rates explained by practices common to the Indian health service? Birth. 2005 Sep;32(3):170-8.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=16128970
Multiple cesarean deliveries not associated with significant risk for uterine rupture
RESULTS: Uterine rupture occurred in 9 of 975 (0.9%) women with multiple prior cesarean compared with 115 of 16,915 (0.7%) women with a single prior operation (P = .37). Multivariable analysis confirmed that multiple prior cesarean delivery was not associated with an increased risk for uterine rupture. The rates of hysterectomy (0.6% versus 0.2%, P = .023) and transfusion (3.2% versus 1.6%, P < .001) were increased in women with multiple prior cesarean deliveries compared with women with a single prior cesarean delivery attempting trial of labor. Similarly, a composite of maternal morbidity was increased in women with multiple prior cesarean deliveries undergoing trial of labor compared with those having elective repeat cesarean delivery (odds ratio 1.41, 95% confidence interval 1.02-1.93).
CONCLUSION: A history of multiple cesarean deliveries is not associated with an increased rate of uterine rupture in women attempting vaginal birth compared with those with a single prior operation. Maternal morbidity is increased with trial of labor after multiple cesarean deliveries, compared with elective repeat cesarean delivery, but the absolute risk for complications is small. Vaginal birth after multiple cesarean deliveries should remain an option for eligible women. LEVEL OF EVIDENCE: II-2.
Landon MB et al Risk of uterine rupture with a trial of labor in women with multiple and single prior cesarean delivery. Obstet Gynecol. 2006 Jul;108(1):12-20.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=16816050
Trial of Labor Often Successful After Prior Cesarean Delivery for Multiple Gestation
CONCLUSION: Women with one previous cesarean delivery for a multifetal gestation have high trial of labor success rates and low complication rates.
Varner MW et al Risk of uterine rupture with a trial of labor in women with multiple and single prior cesarean delivery. Obstet Gynecol. 2006 Jul;108(1):12-20.
Neonatal mortality rates were higher among infants delivered by cesarean delivery
RESULTS: Neonatal mortality rates were higher among infants delivered by cesarean delivery (1.77 per 1,000 live births) than for those delivered vaginally (0.62). The magnitude of this difference was reduced only moderately on statistical adjustment for demographic and medical factors, and when deaths due to congenital malformations and events with Apgar scores less than 4 were excluded. The cesarean/vaginal mortality differential was widespread, and not confined to a few causes of death. CONCLUSIONS: Understanding the causes of these differentials is important, given the rapid growth in the number of primary cesareans without a reported medical indication.
MacDorman MF et al Infant and neonatal mortality for primary cesarean and vaginal births to women with "no indicated risk," United States, 1998-2001 birth cohorts. Birth. 2006 Sep;33(3):175-82.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=16948717
Rehospitalizations after giving birth were more likely in planned cesarean vs vaginal birth
RESULTS: Rehospitalizations in the first 30 days after giving birth were more likely in planned cesarean (19.2 in 1,000) when compared with planned vaginal births (7.5 in 1,000). After controlling for age, parity, and race or ethnicity, mothers with a planned primary cesarean were 2.3 (95% confidence interval [CI] 1.74-2.9) times more likely to require a rehospitalization in the first 30 days postpartum. The leading causes of rehospitalization after a planned cesarean were wound complications (6.6 in 1,000) (P<.001) and infection (3.3 in 1,000). The average initial hospital cost of a planned primary cesarean of US dollars 4,372 (95% C.I. US dollars 4,293-4,451) was 76% higher than the average for planned vaginal births of US dollars 2,487 (95% C.I. US dollars 2,481-2,493), and length of stay was 77% longer (4.3 days to 2.4 days). CONCLUSION: Clinicians should be aware of the increased risk for maternal rehospitalization after cesarean deliveries to low-risk mothers when counseling women about their choices. LEVEL OF EVIDENCE: II.
Declercq E et al Maternal outcomes associated with planned primary cesarean births compared with planned vaginal births. Obstet Gynecol. 2007 Mar;109(3):669-77.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17329519
Exteriorization of uterus at cesarean delivery: Patient discomfort - Should not be routine
CONCLUSION: Exteriorization of the uterus for repair is associated with an increased incidence of nausea and vomiting and tachycardia during cesarean delivery under spinal anesthesia. Uterine repair should be done in situ where possible. LEVEL OF EVIDENCE: I.
Siddiqui M, et al Complications of exteriorized compared with in situ uterine repair at cesarean delivery under spinal anesthesia: a randomized controlled trial. Obstet Gynecol. 2007 Sep;110(3):570-5.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17766602
Other
Clear liquids in limited quantities does not increase labor complications
Revised Guidelines for Obstetric Anesthesia Issued
The American Society of Anesthesiologists (ASA) has issued revised, evidence-based practice guidelines for anesthetic management of women during labor, including operative and nonoperative deliveries, postpartum care and pain control.
The guidelines update guidelines issued in 1998 and "include data and recommendations on a wider range of techniques than was previously addressed."
The guidelines also provide information for women to consider before receiving anesthetics during childbirth.
"Not all women require anesthetic care during labor and delivery," Dr. Joy L. Hawkins, from University of Colorado, Denver, and chair of the ASA Task Force on Practice Guidelines for Obstetric Anesthesia said in a statement.
If a woman does request pain relief during labor and delivery, there are many options available, Dr. Hawkins said, depending on the patient's medical status, progress of labor and the resources available at the healthcare facility.
"The revised practice guidelines do not guarantee specific outcomes, but provide basic recommendations based on a synthesis of expert research and recommendations," Dr. Hawkins continued.
Among the revised recommendations:
* Women in early labor should be offered the option of spinal or epidural analgesia when available and it should not be withheld to meet arbitrary standards for cervical dilation. Women should be reassured that neuraxial analgesia does not increase the incidence of cesarean section.
* The use of spinals or epidurals is preferred over general anesthesia for most cesarean sections.
* To minimize post dural (spinal) headache, pencil-point spinal needles should be used instead of cutting-bevel spinal needles for spinal anesthesia.
* Drinking clear liquids in limited quantities has been found to bring comfort to women in labor and does not increase labor complications. Women with uncomplicated labor may drink small amounts of clear liquid, while those scheduled for nonemergency cesarean section may drink small amounts of clear liquids up to 2 hours before anesthesia administration.
* Solid foods should be avoided by patients during labor. Women scheduled for elective cesarean section or tubal ligation should fast for 6 to 8 hours prior to anesthesia administration.
Practice guidelines for obstetric anesthesia:An updated report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia. American Society of Anesthesiologists Task Force on Obstetric Anesthesia. Anesthesiology. 2007 Apr;106(4):843-63
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17413923
For more information on the revised practice guidelines for obstetric anesthesia, visit
www.anesthesiology.org or www.asahq.org.
Preterm birth and its recurrence increases with short interpregnancy intervals
CONCLUSION: The risk of preterm birth and its recurrence increases with short interpregnancy intervals, even after adjustment for coexisting risk factors. This highlights the importance of counseling women with either an initial term or preterm birth to wait at least 12 months between delivery and subsequent conception.
DeFranco EA, A short interpregnancy interval is a risk factor for preterm birth and its recurrence.
Am J Obstet Gynecol. 2007 Sep;197(3):264.e1-6.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17826413
Maternal obesity is associated with an increased risk of stillbirth
We conducted this metaanalysis to summarize the available epidemiologic evidence on the relationship between maternal overweight and obesity and the risk of stillbirth.
Results : Nine studies were included in the metaanalysis. The unadjusted odds ratios of a stillbirth were 1.47 (95% CI, 1.08-1.94) and 2.07 (95% CI, 1.59-2.74) among overweight and obese pregnant women, respectively, compared with normal-weight pregnant women. The metaregression analysis found no evidence that these estimates were affected by selected study characteristics. Maternal obesity is associated with an increased risk of stillbirth, although the mechanisms to explain this association are not clear.
Chu SY, Maternal obesity and risk of stillbirth: a metaanalysis. Am J Obstet Gynecol. 2007 Sep;197(3):223-8. Review.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17826400
Optimal Gestational Weight Gain Improves Obstetric and Neonatal Outcomes
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
Cedergren MI. et al Optimal gestational weight gain for body mass index categories.
Obstet Gynecol. 2007 Oct;110(4):759-64.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17906006
Little basis for offering combined spinal-epidural over epidurals in labour
CONCLUSIONS: There appears to be little basis for offering combined spinal-epidural (CSE) over epidurals in labour with no difference in overall maternal satisfaction despite a slightly faster onset with CSE and less pruritus with epidurals. There is no difference in ability to mobilise, obstetric outcome or neonatal outcome. However, the significantly higher incidence of urinary retention and rescue interventions with traditional techniques would favour the use of low-dose epidurals. It is not possible to draw any meaningful conclusions regarding rare complications such as nerve injury and meningitis.
Simmons
SW, et al Combined spinal-epidural versus epidural analgesia in labour.
Cochrane Database Syst Rev. 2007 Jul 18;(3):CD003401. Review.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17636721
Adding extraamniotic saline infusion to Foley catheter does not improve labor induction
CONCLUSION: In women with an unfavorable cervix, the addition of extraamniotic saline infusion to a transcervical Foley catheter does not improve efficacy for labor induction. LEVEL OF EVIDENCE: I.
Lin MG et al Transcervical Foley catheter with and without extraamniotic saline infusion for labor induction: a randomized controlled trial. Obstet Gynecol. 2007 Sep;110(3):558-65.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17766600
Oral health for pregnant women discussion clinical setting and dental home for children
Preventive activities and education and awareness University of Albany School of Public Health 1 hour 13 minute video – This could be used as a group CEU
Oral Health during Pregnancy (video and discussion) moves into Early Childhood (full pediatric assessment and parent education visit on video)
The program Oral Health during Pregnancy and Early Childhood is now available online at: http://media.albany.edu:8080/ramgen/cellar/sph/oral_health_during_pregnancy.rm
MUST view CEU VIDEO, 73 minutes
1.25 CEU’s Continuing Education credits are available by filling out the evaluation and post-test on the University at Albany School of Public Health Web site. www.albany.edu/sph/coned/oralhealth.htm For questions, call Sue Brooks at 518/486-6453 or E-mail coned@albany.edu.
Gynecology
HPV test beats Pap in detecting cervical cancer
A new study led by McGill University researchers shows that the human papillomavirus (HPV) screening test is far more accurate than the traditional Pap test in detecting cervical cancer.
Moreover, because of its higher sensitivity and only slightly lower specificity, patients would only require an HPV test once every three years instead of annually, as is necessary with the Pap test.
CONCLUSIONS: As compared with Pap testing, HPV testing has greater sensitivity for the detection of cervical intraepithelial neoplasia
Mayrand
MH, et al Human papillomavirus DNA versus Papanicolaou screening tests for
cervical cancer.N Engl J Med. 2007 Oct 18;357(16):1579-88. http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17942871
OB/GYN CCC Editorial comment:
We still use the new 2006 ASCCP Consensus Guidelines
CCCaST is the first randomized controlled trial in North America of HPV testing as a stand-alone screening test for cervical cancer. The first round followed 10,154 women aged 30 to 69 in Montreal, Quebec and St. John's, Newfoundland who were enrolled in the study from 2002 to 2005.
While the above results are of interest, we will adhere to the new 2006 ASCCP Consensus Guidelines which can be found here: http://www.asccp.org/consensus.shtml
Other Cervical Cancer Screening Articles
Value of HPV testing in LGSIL treated with LEEP per ASCCP guidelines
OBJECTIVE: This study was undertaken to evaluate the value of high-risk human papillomavirus (HPV) testing in the follow-up of cervical intraepithelial neoplasia grade low-grade squamous intraepithelial lesion treated by loop electrosurgical excision procedure because of the risk criteria established by the American Society for Colposcopy and Cervical Pathology (ie, unsatisfactory colposcopy or positive endocervical curettage, persistence of cervical intraepithelial neoplasia grade 1/low-grade squamous intraepithelial lesion, or high-risk HPV infection for longer than 2 years and older than 40 years).
CONCLUSION: Patients with low-grade squamous intraepithelial lesion/cervical intraepithelial neoplasia grade 1 and risk factors have a significant risk of harboring a cervical intraepithelial neoplasia grade 2-3 lesion. A conservative approach should be considered when basal high-risk HPV test is negative. High pretreatment high-risk HPV loads should be considered a risk factor for developing residual/recurrent disease. Posttreatment Hybrid Capture II has an extremely high sensitivity for detecting recurrences.
Alonso I, High-risk cervical epithelial neoplasia grade 1 treated by loop electrosurgical excision: follow-up and value of HPV testing. Am J Obstet Gynecol. 2007 Oct;197(4):359.e1-6
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17714678
Risk assessment to guide the prevention of cervical cancer
Advances in screening and diagnosis make it increasingly possible to prevent cervical cancer. However, if misused or poorly understood, these new tools will only increase costs and potentially harm patients without benefit. As a framework for standardized care that maximizes patient safety and well-being, we propose that a risk model be adopted to guide clinical management now and in the future. The model would use thresholds of increasing risk for cervical precancer and treatable cancer to guide clinical decision making for screening intensity, diagnostic evaluation, or treatment. Experts would decide on these risk thresholds and stratum based on the patient risk to benefit, independent of current (eg, cytology, carcinogenic HPV testing, and colposcopy) and future methods of measuring risk. A risk management model for cervical cancer prevention, based on appropriate clinical actions that correspond to risk stratum, can result in better allocation of resources to and increased safety for women at the greatest risk and increased well-being for women at the lowest risk.
Castle PE, et al Risk assessment to guide the prevention of cervical cancer.
Am J Obstet Gynecol. 2007 Oct;197(4):356.e1-6. Review.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17904958
Other topics
New Guidelines for Assessing Gynecologic Cancer Predispositions
Women with germline mutations in the cancer susceptibility genes, BRCA1 or BRCA2, associated with Hereditary Breast/Ovarian Cancer syndrome, have up to an 85% lifetime risk of breast cancer and up to a 46% lifetime risk ovarian cancer. Similarly, women with mutations in the DNA mismatch repair genes, MLH1, MSH2 or MSH6, associated with the Lynch/Hereditary Non-Polyposis Colorectal Cancer (HNPCC) syndrome, have up to a 40-60% lifetime risk of both endometrial and colorectal cancer as well as a 9-12% lifetime risk of ovarian cancer. Genetic risk assessment enables physicians to provide individualized evaluation of the likelihood of having one of these gynecologic cancer predisposition syndromes, as well the opportunity to provide tailored screening and prevention strategies such as surveillance, chemoprevention, and prophylactic surgery that may reduce the morbidity and mortality associated with these syndromes. Hereditary cancer risk assessment is a process that includes assessment of risk, education and counseling conducted by a provider with expertise in cancer genetics, and may include genetic testing after appropriate consent is obtained. This commentary provides guidance on identification of patients who may benefit from hereditary cancer risk assessment for Hereditary Breast/Ovarian Cancer and the Lynch/Hereditary Non-Polyposis Colorectal Cancer syndrome.
Lancaster JM et al Society of gynecologic oncologists education committee statement on risk assessment for inherited gynecologic cancer predispositions.
Gynecol Oncol. 2007 Nov;107(2):159-62.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17950381
Which Factors Influence Progression of Pelvic Prolapse?
Conclusion: The authors conclude that vaginal descent is common in postmenopausal women, but that the rate of progression is variable and the condition can regress. Only one in 10 women had descent of 2 cm or more, and the risk of descent was related to obesity and a history of at least five vaginal births. Clinically significant progression over the three-year study was rare. The authors believe that women with evidence of vaginal descent can be reassured that they are at low risk of significant progression over three years.
Bradley CS, et al. Natural history of pelvic organ prolapse in postmenopausal women. Obstet Gynecol April 2007;109:848-54
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17400845
Despite shorter length of stay TVH / LAVH far less common than TAH for benign disease
CONCLUSION: Despite a shorter length of stay, vaginal and laparoscopic hysterectomies remain far less common than abdominal hysterectomy for benign disease. LEVEL OF EVIDENCE: III.
Wu JM, et al Hysterectomy rates in the United States, 2003. Obstet Gynecol. 2007 Nov;110(5):1091-5.
Abdominal sacrocolpopexy: Lower rate of recurrent vault prolapse than SSLS
AUTHORS' CONCLUSIONS: Abdominal sacrocolpopexy is associated with a lower rate of recurrent vault prolapse and dyspareunia than the vaginal sacrospinous colpopexy. These benefits must be balanced against a longer operating time, longer time to return to activities of daily living and increased cost of the abdominal approach. The use of mesh or graft inlays at the time of anterior vaginal wall repair may reduce the risk of recurrent cystocele. Posterior vaginal wall repair may be better than transanal repair in the management of rectoceles in terms of recurrence of prolapse. The addition of a continence procedure to a prolapse repair operation may reduce the incidence of postoperative urinary incontinence but this benefit needs to be balanced against possible differences in costs and adverse effects. Adequately powered randomised controlled clinical trials are urgently needed.
Maher C et al Surgical management of pelvic organ prolapse in women. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD004014. Review.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17636742
Tubal flushing with oil-soluble contrast media in increasing the odds of pregnancy
AUTHORS' CONCLUSIONS: There is evidence of effectiveness of tubal flushing with oil-soluble contrast media in increasing the odds of pregnancy and live birth versus no intervention. Future robust randomised trials, comparing oil-soluble versus water-soluble media, water-soluble media versus no intervention and tubal flushing versus established treatments for infertility would be a useful further guide to clinical practice.
Luttjeboer F, et al Tubal flushing for subfertility. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD003718. Review.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17636730
Urocortin plasma levels may differentiate endometrioma from other benign ovarian cysts
CONCLUSION: Plasma urocortin is increased in women with endometriomas, and its measurement may be useful for the differential diagnosis of endometrioma compared with other benign ovarian cysts. LEVEL OF EVIDENCE: II.
Florio P; et al Plasma urocortin levels in the diagnosis of ovarian endometriosis.Obstet Gynecol. 2007 Sep;110(3):594-600.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17766605
Laparoscopic 'drilling' by diathermy or laser for ovulation induction in anovulatory PCOS
CONCLUSIONS: There was no evidence of a difference in the live birth rate and miscarriage rate in women with clomiphene-resistant PCOS undergoing LOD compared to gonadotrophin treatment. The reduction in multiple pregnancy rates in women undergoing LOD makes this option attractive. However, there are ongoing concerns about long-term effects of LOD on ovarian function
Farquhar C et al Laparoscopic 'drilling' by diathermy or laser for ovulation induction in anovulatory polycystic ovary syndrome. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD001122. Review.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17636653
Child Health
Long-term prognosis for infants after massive fetomaternal hemorrhage
RESULTS: During the study period, 48 patients had massive fetomaternal hemorrhage (crude incidence 1.1 per 1,000; corrected incidence for Rh-negative women 4.6 per 1,000). Six fetal deaths were observed, representing 1.6% of all fetal deaths during the period. Nine newborns (18.7%) were transferred to neonatal intensive care unit (NICU) and five (10.4%) had transfusions. Fetomaternal hemorrhages of 20 mL/kg or more significantly increased the risk of fetal death, induced preterm delivery, transfer to NICU, and neonatal anemia requiring transfusion. Long-term follow-up was not associated with neurological sequelae (0%, 95% confidence interval 0.0-11.6%).
CONCLUSION: When the transfused volume equals or exceeds 20 mL/kg, massive fetomaternal hemorrhage may lead to severe prenatal or neonatal complications. LEVEL OF EVIDENCE: III.
Rubod C et al Long-term prognosis for infants after massive fetomaternal hemorrhage. Obstet Gynecol. 2007 Aug;110(2 Pt 1):256-60.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17666598
Increasing hyperglycemia in pregnancy associated with increased childhood obesity
CONCLUSIONS: Our results in a multiethnic U.S. population suggest that increasing hyperglycemia in pregnancy is associated with an increased risk of childhood obesity. More research is needed to determine whether treatment of GDM may be a modifiable risk factor for childhood obesity.
Hillier TA, et al Childhood obesity and metabolic imprinting: the ongoing effects of maternal hyperglycemia. Diabetes Care. 2007 Sep;30(9):2287-92. Epub 2007 May 22.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17519427
Family-Based Strategies for Controlling Childhood Obesity
Discussion: In this study of a family-based program involving parenting skills and lifestyle modification, all groups lost weight, but there were no significant differences in BMI z scores among the three groups. More children in the P+DA group had lower BMI z scores after 12 months compared with the other two groups. Waist circumference z scores were lower in the intervention groups compared with the control group at 12 months, and boys appear to benefit from intervention more than girls. Overall, the benefits of family training and involvement in reducing adiposity were modest. Because the control group also lost weight, the study might not have been adequately powered to detect greater differences. The authors conclude that further studies exploring a sex differential are warranted.
Source: Golley RK, et al. Twelve-month effectiveness of a parent-led, family-focused weight-management program for prepubertal children: a randomized, controlled trial. Pediatrics March 2007;119:517-25.
AFP EDITOR'S NOTE: A BMI z score reflects each person's BMI relative to the general population. One review observes that reference measurements, such as z score and centile measurements, are adequate for single BMI measurements, but do not assess within-child BMI changes over time. However, if a raw BMI score is used, adult obesity definitions do not apply because BMI is lower in children than in adults.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17332205
Effectiveness of a Novel Infant Tooth Wipe in High Caries-risk Babies 8 to 15 Months Old
Purpose : The purpose of this study was to assess baby and parental satisfaction and plaque-removal efficacy of a novel infant tooth wipe (Spiffies) in high caries-risk babies.
Methods: Thirty-five healthy and caries-free infants were selected. Babies had never had their teeth cleaned and no primary molars were yet present. Subjects were identified with the risk factor of nightly feeding behaviors. Pre- and postcleaning oral hygiene plaque measurements were recorded and then analyzed by a blinded examiner. A manual ing toothbrush (Ultra Kids) was used as the control method. Infants’ caregivers used their randomly assigned cleaning method without instruction. Babies returned to the clinic after a 48- to 72-hour washout period, and the procedures were repeated before and after use of the alternate method. Parental satisfaction and baby perceived acceptance were evaluated by a questionnaire and were analyzed at the time of the visit and at bedtime.
Results: Both the infant tooth wipe and conventional brushing significantly reduced plaque levels (P<.001). Parents were more satisfied with the wipes when compared to toothbrushing, particularly after nightly feeding habits (P<.001). Similarly, infant’s acceptance was higher with the wipes at daytime and significantly higher at night-time (P=.002). Conclusions: The Novel Infant Tooth Wipe provides an effective method of plaque removal before the eruption of primary molars.
Galganny-Almeida, A et al The Effectiveness of a Novel Infant Tooth Wipe in High Caries-risk Babies 8 to 15 Months Old (Pediatr. Dent. 2007;29:337-42)
http://www.aapd.org/searcharticles/article.asp?ARTICLE_ID=2183
ACIP Recommendations for the Prevention of Varicella
Routine Vaccination
Although one-dose vaccination coverage has been high and varicella morbidity and mortality has diminished, the one-dose program did not prevent varicella outbreaks completely. Therefore, two 0.5-mL doses of varicella vaccine administered subcutaneously are recommended for children 12 months and older, adolescents, and adults without evidence of immunity.
The second dose should provide improved protection to children who do not respond adequately to the first dose, and it should lower the risk for breakthrough disease. In a follow-up from 1993 to 2003 of healthy children 12 months to 12 years of age who were given one or two doses of varicella vaccine, the annual risk for varicella after community exposure was 0.8 percent in children who received one dose and 0.2 percent in children who received two doses (number needed to treat = 167). The rate in children without immunity is estimated at about 14 percent.
Because of the risk for transmission of VZV in schools, all children entering school should receive two doses of varicella-containing vaccine or have other evidence of immunity. All states should require that students at all grade levels (including college) and those in child care centers receive varicella vaccine unless they have evidence of immunity.
CHILDREN 12 MONTHS TO 12 YEARS OF AGE
All healthy children should receive their first dose of varicella-containing vaccine at 12 to 15 months of age, and a second dose between the ages of four and six years (i.e., before entering prekindergarten, kindergarten, or first grade). The second dose may be administered earlier if the first dose was given more than three months previously. These recommended ages are harmonized with the recommendations for measles, mumps, and rubella vaccination and are intended to limit the period when children have no varicella antibody. Although the recommended minimum interval between the two doses for children 12 months to 12 years of age is three months, if the second dose was administered 28 days or more after the first dose, the second dose is considered valid and need not be repeated.
Whenever any components of the combination vaccine are indicated and the other components are not contraindicated, the use of licensed combination vaccines, such as MMRV vaccine, is preferred over separate injection of equivalent component vaccines. Single-antigen and combination MMRV vaccines may be administered simultaneously with other vaccines recommended for children 12 to 15 months of age and those four to six years of age. Simultaneous administration is particularly important if it is suspected a child will not return for subsequent vaccination.
PERSONS 13 YEARS AND OLDER
Persons 13 years and older without evidence of varicella immunity should receive two doses of single-antigen varicella vaccine administered four to eight weeks apart. However, if more than eight weeks elapse after the first dose, the second dose may be administered without restarting the schedule. Because the risk for transmission can be high among students in schools, colleges, and other educational institutions, students without evidence of immunity should routinely receive two doses of vaccine.
Special consideration for vaccination should be given to persons without evidence of immunity who have an increased risk of transmission to persons at high risk for severe disease or who have an increased risk for exposure. These include health care professionals; household contacts of immunocompromised persons; those who live or work in environments in which transmission of VZV is likely (e.g., teachers, child care workers, residents and staff in institutional settings) or has been reported (e.g., college students, inmates and staff members of correctional institutions, military personnel); nonpregnant women of childbearing age; adolescents and adults who live in households with children; and international travelers.
Catch-up Vaccination
A second dose is recommended for children, adolescents, and adults who previously received one dose. The recommended minimum interval between the first and second doses is three months for children 12 years or younger and four weeks for persons 13 years or older. However, the catch-up dose may be administered at any interval longer than the minimum recommended.
Physicians should use the recommended health maintenance visit at 11 to 12 years of age and other routine visits to ensure that all children without evidence of immunity have received two doses of varicella vaccine.
Prenatal Assessment and Postpartum Vaccination
Prenatal assessment of women for evidence of varicella immunity is recommended. Varicella in pregnant women is associated with a risk of VZV transmission to the child, which may cause congenital varicella syndrome, neonatal varicella, or herpes zoster during infancy or early childhood. Birth before 1980 is not considered evidence of immunity in pregnant women because of the potential severe consequences of infection.
Because the effects of the varicella vaccine on the fetus are unknown, pregnant women should not be vaccinated. Women without evidence of immunity should be vaccinated on completion or termination of pregnancy. The first dose of vaccine should be administered before discharge from the health care facility, and the second dose should be given four to eight weeks later. Women should be counseled to avoid conception for one month after each dose, but they may continue to breastfeed.
Health Care Professionals
Health care institutions should ensure that all health care professionals have evidence of immunity to varicella. Birth before 1980 is not considered evidence of immunity in this group because of the possibility of nosocomial transmission to high-risk patients. Health care professionals who have received two doses of vaccine and who are exposed to VZV should be monitored daily during days 10 to 21 after exposure and should be instructed to report fever, headache, or other constitutional symptoms and any atypical skin lesions immediately.
Health care institutions should establish protocols and recommendations for screening and vaccinating health care professionals and for management after exposures in the workplace. Health care professionals in whom a vaccine-related rash occurs should avoid contact with persons without evidence of immunity who are at risk for severe disease and complications until all lesions resolve (i.e., are crusted over or fade away) or until no new lesions appear within 24 hours.
Special Considerations
Vaccination with the single-antigen vaccine should be considered in children who have HIV infection with an age-specific CD4 T-lymphocyte percentage of 15 percent or more, and may be considered in adolescents and adults with a CD4 T-lymphocyte count of 200 cells per µL or greater. Persons with impaired humoral immunity may be vaccinated. Single-antigen varicella vaccine should be used for persons with some degree of immunodeficiency.
Outbreak Control and Postexposure Prophylaxis
A two-dose varicella vaccination policy is recommended for outbreak control. In outbreaks among preschool-age children, two-dose vaccination is recommended, and children vaccinated with one dose should receive a second dose if three months have elapsed since the first. Although outbreak control efforts should be implemented as soon as an outbreak is identified, vaccination should still be offered when the outbreak is identified late.
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5604a1.htm
Chronic Disease and Illness
Heart Disease Kills More Younger Women
For decades, heart disease death rates have been falling. But a new study shows a troubling turn: more women under 45 are dying of heart disease due to clogged arteries, and the death rate for men that age has leveled off. Many aren't sure what went wrong, but they think increasing rates of obesity and other risk factors are to blame.
Conclusions: The mortality rates for CHD among younger adults may serve as a sentinel event. Unfavorable trends in several risk factors for CHD provide a likely explanation for the observed mortality rates.
Ford ES,Capewell S. Coronary Heart Disease Mortality Among Young Adults in the U.S. From 1980 Through 2002 J Am Coll Cardiol, 2007; 50:2128-2132,
http://content.onlinejacc.org/cgi/content/abstract/50/22/2128
Low-Carbohydrate Diet Effective in Women
Conclusion: The authors conclude that patients on the Atkins diet have greater weight loss at two and six months than those on the Zone, Ornish, or LEARN diets and have greater weight loss at one year than those on the Zone diet. Atkins dieters also have more favorable lipid profiles and blood pressures at various measurements, suggesting that concerns about how low-carbohydrate diets affect cardiac risk factors are unfounded.
Gardner CD, et al. Comparison of the Atkins, Zone, Ornish, and LEARN diets for change in weight and related risk factors among overweight premenopausal women. The A to Z weight loss study: a randomized trial. JAMA March 7, 2007;297:969-77.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17341711
Does Aspirin Use Affect Mortality in Women?
Results: Of the 79,439 participants, 9,477 died during the study. Women who regularly used aspirin had a relative risk of death from any cause of 0.75 (95% confidence interval, 0.71 to 0.81), compared with women who did not take aspirin. In aspirin users, the relative risk of death related to cardiovascular disease was less than that of cancer-related death (0.62 versus 0.88). A significant reduction in cardiovascular disease-related deaths occurred one to five years after initiating aspirin therapy, whereas the reduction in cancer-related deaths occurred after 10 years of aspirin use. Low and moderate doses of aspirin were equally effective in reducing mortality. The greatest benefit of aspirin use occurred in older participants and in those with more cardiac risk factors.
Conclusion: Low and moderate doses of aspirin were associated with a reduction in death from any cause in women, particularly in older women and those with more cardiac risk factors. The reduction in cardiovascular deaths occurred within five years, whereas the reduction in cancer deaths occurred after 10 years of aspirin use.
Chan AT, et al. Long-term aspirin use and mortality in women. Arch Intern Med March 26, 2007;167:562-72.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17389287
High suicide and heart disease deaths with bariatric surgery
CONCLUSIONS: There was a substantial excess of deaths owing to suicide and coronary heart disease. Careful monitoring of bariatric surgical procedures and more intense follow-up could likely reduce the long-term case fatality rate in this patient population.
Omalu BI et al Death rates and causes of death after bariatric surgery for Pennsylvania residents, 1995 to 2004. Arch Surg. 2007 Oct;142(10):923-8; discussion 929
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17938303
Hypertension in Pregnancy: An Emerging Risk Factor for Cardiovascular Disease
http://www.medscape.com/viewarticle/564295
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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.
