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Volume 4, No. 10, October 2006
Hot Topics
Obstetrics | Gynecology | Child Health | Chronic Disease and Illness
Obstetrics
Can a 29% Cesarean Delivery Rate Possibly Be Justified?
1.) Have there been measurable improvements in fetal outcome from the use of EFM and its associated increase in the cesarean delivery rate? There is a very high false-positive rate for "nonreassuring" heart rate patterns used to predict a depressed newborn.
It did not achieve its promise because it was designed to prevent intrapartum death, an event so rare that it was not possible to show a significant difference, and to prevent cerebral palsy, which we now know is attributable to birth asphyxia in term infants only about 6–17% of the time. In fact, although most labors are followed with EFM, there has been no reduction in the incidence of cerebral palsy over the last 3 decades.
2.) What about the maternal benefits of cesarean delivery? There is little argument that vaginal delivery is associated with a higher frequency of subsequent stress urinary incontinence and uterine and vaginal prolapse. However, it is also clear that nulliparous women and those who have had only cesarean delivery may also be symptomatic, suggesting that the aging process, pregnancy per se, genetic factors, and just walking upright for more than 50 years are significant contributors to the problem.
3.) In contrast, the risks of the current cesarean delivery rate are not difficult to discern. Getahun and co-workers (below) have reported a 50% increase in the risk of placenta previa and a doubling of the risk of abruptio placenta in the subsequent pregnancy after one previous cesarean delivery. These risks increased with multiple prior cesareans. Resnik R. Can a 29% Cesarean Delivery Rate Possibly Be Justified? Obstet Gynecol 2006 107:752-4
Stricter VBAC Guideline Does Not Improve Mortality
The incidence of vaginal birth after cesarean delivery (VBAC) in the United States has steadily declined after reaching a peak of 27.4 percent of all deliveries in 1997. The American College of Obstetricians and Gynecologists (ACOG) revised its VBAC guidelines in 1999, recommending for the first time that VBAC only be performed in "institutions equipped to respond to emergencies with physicians immediately available to provide emergency care." Rural hospitals may have been affected by this new guideline; however, it is uncertain if adverse maternal and neonatal outcomes were reduced after the revision. Zweifler and colleagues conducted a retrospective analysis of birth data to determine if the ACOG guideline change affected neonatal and maternal mortality.
The study population consisted of 386,232 women who previously had a cesarean delivery for a singleton birth in a California hospital between 1996 and 2002. Data were collected from the California Department of Health Services Birth Statistical Master Files. Data from before the guideline revision (1996 to 1999) were compared with data from after the revision (2000 to 2002). Neonatal deaths were defined as newborns living fewer than 28 days, and maternal deaths were defined as deaths within 72 hours of delivery. The total number of attempted VBAC deliveries (successful and unsuccessful) also was noted.
Although there was a significant decrease in attempted VBAC deliveries after the ACOG guideline revision (24 percent of all deliveries before the revision to 13.5 percent after), neonatal and maternal mortality rates did not change. During both periods, neonatal mortality rates for attempted VBAC deliveries were similar to those for repeat cesarean deliveries, except for infants with a very low birth weight (i.e., less than 1,500 g). Neonatal mortality rates for infants with a very low birth weight were higher for attempted VBAC than for repeat cesarean deliveries during both periods. Maternal death rates did not change significantly after the guideline revision, regardless of delivery type.
The authors conclude that the ACOG guideline revision resulted in a large decline in the percentage of women in California who attempted VBAC, but that it did not improve neonatal or maternal mortality rates. In addition, neonatal mortality in infants weighing more than 1,500 g was not related to delivery type. The authors suggest that pregnant women who have had a previous cesarean delivery be informed about these encouraging findings in addition to the risks associated with VBAC.
Zweifler J, et al. Vaginal birth after cesarean in California: before and after a change in guidelines. Ann Fam Med May/June 2006;4:228-34.
Dose-response pattern in the risk of previa, with increasing number of cesarean deliveries
CONCLUSION: A cesarean first birth is associated with increased risks of previa and abruption in the second pregnancy. There is a dose-response pattern in the risk of previa, with increasing number of prior cesarean deliveries. A short interpregnancy interval is associated with increased risks of previa and abruption. LEVEL OF EVIDENCE: II-2.
Getahun D et al Previous Cesarean Delivery and Risks of Placenta Previa and Placental Abruption Obstet Gynecol 2006 107:771-8
12 and 24 hours of MgSO4: Similar course in postpartum mild preeclampsia
CONCLUSION: Twelve hours of postpartum MgSO4 therapy for mild preeclampsia
is associated with infrequent disease progression and a clinical course similar
to that with 24-hour therapy. Patients with chronic hypertension and insulin-requiring
diabetes are at risk for progression to severe disease postpartum. CLINICAL TRIAL
REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00344058 LEVEL OF
EVIDENCE: I.
Ehrenberg
HM, Mercer
BM. Abbreviated postpartum magnesium sulfate therapy for women with mild
preeclampsia: a randomized controlled trial. Obstet
Gynecol. 2006 Oct;108(4):833-8.
Oral misoprostol Can Reduce PPH When Given Prophylactically
A single oral dose of 600 μg of misoprostol (three 200 μg tablets) or placebo (three tablets that were identical in appearance) was administered after delivery of the baby and within 5 min of clamping and cutting of the umbilical cord. After being given the drug, the women were monitored by the midwife for a minimum of 2 h according to the usual standard of care procedure to determine the need for transfer to a higher level facility. Blood loss, uterine tone, changes in blood pressure, pulse, and pallor, as well as possible maternal and neonatal side effects from the misoprostol were documented in the data collection form designed for the study
INTERPRETATION: Oral misoprostol was associated with significant decreases in the rate of acute postpartum haemorrhage and mean blood loss. The drug's low cost, ease of administration, stability, and a positive safety profile make it a good option in resource-poor settings Derman RJ, et al Oral misoprostol in preventing postpartum haemorrhage in resource-poor communities: a randomised controlled trial. Lancet. 2006 Oct 7;368(9543):1248-53
Obstetric outcomes in overweight and obese adolescents
CONCLUSION: Overweight adolescent women are at increased risk for adverse neonatal and perinatal outcomes. With rates of overweight increasing overall, overweight in the gravid adolescent is a pressing perinatal and public health concern.
Sukalich S, et al Obstetric outcomes in overweight and obese adolescents. Am J Obstet Gynecol. 2006 Sep;195(3):851-5
Operative vaginal delivery and midline episiotomy: A bad combination for the perineum
CONCLUSION: The use of operative vaginal delivery, particularly in combination with midline episiotomy, was associated with a significant increase in the risk of anal sphincter trauma in both primigravid and multigravid women. Given the reported substantial long-term adverse consequences for anal function, this combination of operative modalities should be avoided if possible.
Kudish B, et al Operative vaginal delivery and midline episiotomy: A bad combination for the perineum. Am J Obstet Gynecol. 2006 Sep;195(3):749-54
OB/GYNs follow recommendations for obesity when patients are likely to adhere
CONCLUSION: A majority of obstetrician-gynecologists appear to use BMI to screen for obesity and to counsel their patients about weight control, diet, and physical activity. Many, however, do not prescribe weight loss medications or refer patients to behavioral weight loss therapy. Obstetrician-gynecologists who believe they can help patients lose weight are more likely to follow recommendations for the treatment of obesity. LEVEL OF EVIDENCE: III.
Power
ML, et al Obesity Prevention and Treatment Practices of U.S. Obstetrician-Gynecologists.
Obstet Gynecol. 2006 Oct;108(4):961-968.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd
=retrieve&db=pubmed&list_uids=17012460&dopt=Abstract
All healthcare providers attending pregnancies must be prepared for shoulder dystocia
CONCLUSION: For many years, long-standing opinions based solely on empiric reasoning have dictated our understanding of the detailed aspects of shoulder dystocia prevention and management. Despite its infrequent occurrence, all healthcare providers attending pregnancies must be prepared to handle vaginal deliveries complicated by shoulder dystocia.
Gherman RB, et al Shoulder dystocia: the unpreventable obstetric emergency with empiric management guidelines. Am J Obstet Gynecol. 2006 Sep;195(3):657-72.
Induction of labor may not increase a woman's risk of cesarean delivery at 41 weeks
CONCLUSION: Our findings suggest that IOL may not increase a woman's risk of CD when compared to expectant management. While this question has been addressed prospectively at 41 weeks gestation, it requires further examination at earlier gestations and among various subgroups.
Caughey AB, et al Induction of labor and cesarean delivery by gestational age. Am J Obstet Gynecol. 2006 Sep;195(3):700-5
Risk factors for cervical insufficiency after term delivery
CONCLUSION: Multiparous women who experience cervical insufficiency after a term birth are more likely to have had a previous precipitous delivery, a prolonged second stage of labor, or a previous curettage compared with multiparous women who experience a repeat term birth with no cervical insufficiency.
Vyas NA, et al Risk factors for cervical insufficiency after term delivery. Am J Obstet Gynecol. 2006 Sep;195(3):787-91
Risk factors for the breakdown of perineal laceration repair after vaginal delivery
CONCLUSION: The most significant events were mediolateral episiotomy, especially in conjunction with operative vaginal delivery, third- and fourth-degree lacerations, and meconium.
Williams MK, Chames MC. Risk factors for the breakdown of perineal laceration repair after vaginal delivery Am J Obstet Gynecol. 2006 Sep;195(3):755-9
Gynecology
A new era in ovula tion induction: Aromatase inhibitors
CONCLUSION(S): Aromatase inhibitors are as effective as or superior to clomiphene citrate in ovulation induction and in superovulation. Unlike CC, they do not carry an antiestrogenic effect on the endometrium. Given the advantages of aromatase inhibitors, they can be used to replace CC as ovulation-inducing drugs. Their role in IVF remains to be determined.
Holzer H et al A new era in ovulation induction. Fertility and Sterility 2006 85(2): 277-85
Preventing Postoperative Nausea and Vomiting
Up to 30 percent of patients vomit after surgery. As well as being distressing for the patient and those nearby, postoperative nausea and vomiting stresses sutures, drains, and intravenous lines; promotes bleeding and venous hypertension; and increases the risk of pulmonary aspiration. Layeeque and colleagues studied the ability of the combination of dronabinol (Marinol; an anticannabinoid) and prochlorperazine (Compazine; an anticholinergic) to prevent postoperative nausea and vomiting in patients who had breast surgery.
The control cohort of 127 women had standard care that did not routinely include antiemetic medications. The 115 women in the intervention cohort received standard administration of prophylactic oral dronabinol (5 mg) before anesthesia plus rectal prochlorperazine (25 mg) after anesthesia. Cardiovascular and neurologic statuses were monitored in all patients, and women in the intervention group were asked about possible medication side effects. Episodes of postoperative nausea and vomiting and use of antiemetic medications were measured for both groups.
Six patients in the intervention group did not receive prophylactic therapy, and 20 patients in the control group received prophylactic antiemetic treatment. Nevertheless, by intention-to-treat analysis, the rate of postoperative nausea was significantly lower in the intervention group (15 percent) than in the control group (59 percent). The rate of postoperative vomiting also was significantly different: 3 percent in the intervention group and 29 percent in the control group. Additional antiemetic treatment was given to 60 percent of control patients but to only 11 percent of the intervention group.
Postoperative nausea was significantly more prevalent in patients with cancer (47 percent) than in women with a benign diagnosis (19 percent). Similarly, rates of postoperative vomiting were significantly higher in patients with cancer (22 percent compared with 5 percent in those without cancer). The diagnosis of cancer had odds ratios of 3.88 for likelihood of nausea after surgery and 7.49 for likelihood of vomiting; but the most significant factor in multivariate analysis was being in the intervention group, which had odds ratios of 7.79 for reduction in nausea and 14.65 for reduction in vomiting. No significant side effects were documented during the study.
The authors conclude that routine prophylaxis using drugs targeting two stimulating mechanisms of the emetic center provided effective, inexpensive, and easily administered antiemetic therapy during common surgeries.
Layeeque R, et al. Prevention of nausea and vomiting following breast surgery. Am J Surg June 2006;191:767-72.
Flexible-dosing with anticholinergics: Simple and effective for overactive bladder
Dose adjustment may improve the therapeutic outcome, facilitating a balance between efficacy and anticholinergic side effects such as dry mouth. Flexible-dosing studies indicate that dry mouth, the adverse effect most frequently seen with the use of anticholinergic agents, seldom leads to study withdrawal. Patient-initiated control of OAB symptoms may be achieved in 1 month by following established protocols.
Staskin DR, MacDiarmid SA. Pharmacologic Management of Overactive Bladder: Practical Options for the Primary Care Physician American Journal of Medicine 2006 119(3A):245-285
HPV and HPV Vaccine: Information for Healthcare and for the general public
This three page fact sheet provides information on provisional recommendations, HPV vaccine safety, HPV vaccine efficacy, duration of vaccine protection, HPV vaccine delivery, cost effectiveness, policies, other vaccines in development, genital HPV infection, natural history of HPV, HPV-associated disease, prevention of cervical cancer, and additional sources of information. (Revised) http://www.cdc.gov/std/HPV/hpv-vacc-hcp-3-pages.pdf
Other
CDC’s HPV website: 2 items
The Advisory Committee on Immunization Practices (ACIP) provisional recommendations for the use of the quadrivalent HPV vaccine .
www.cdc.gov/nip/recs/provisional_recs/hpv.pdf
Q&A for the general public
www.cdc.gov/std/hpv/STDFact-HPV-vaccine.htm
MR imaging: Excellent at excluding appendicitis in pregnancy when not visualized at US
CONCLUSION: MR imaging is an excellent modality for use in excluding acute appendicitis in pregnant women who present with acute abdominal pain and in whom a normal appendix is not visualized at US.
Pedrosa I et al MR Imaging Evaluation of Acute Appendicitis in Pregnancy Radiology 2006 238(3):891-99
Child Health
Fetal injury at cesarean delivery: Related to the indication and type of uterine incision
RESULTS: A total of 37,110 cesarean deliveries were included in the registry, and 418 (1.1%) had an identified fetal injury. The most common injury was skin laceration (n=272, 0.7%). Other injuries included cephalohematoma (n=88), clavicular fracture (n=11), brachial plexus (n=9), skull fracture (n=6), and facial nerve palsy (n=11). Among primary cesarean deliveries, deliveries with a failed forceps or vacuum attempt had the highest rate of injuries (6.9%). In women with a prior cesarean delivery, the highest rate of injury also occurred in the unsuccessful trial of forceps or vacuum (1.7%), and the lowest rate occurred in the elective repeat cesarean group (0.5%). The type of uterine incision was associated with fetal injury, 3.4% "T" or "J" incision, 1.4% for vertical incision, and 1.1% for a low transverse (P=.003), as was a skin incision–to–delivery time of 3 minutes or less. Fetal injury did not vary in frequency with the type of skin incision, preterm delivery, maternal body mass index, or infant birth weight greater than 4,000 g.
CONCLUSION: Fetal injuries complicate 1.1% of cesarean deliveries. The frequency of fetal injury at cesarean delivery varies with the indication for surgery as well as with the duration of the skin incision–to–delivery interval and the type of uterine incision.
Alexander JM, et al Fetal injury associated with cesarean delivery. Obstet Gynecol. 2006 Oct;108(4):885-90.
Youth Exposure to Alcohol Advertising on Radio
To determine the proportion of radio advertisements that occurred on radio programs with audiences composed disproportionately of underage youth and the proportion of total youth exposure to alcohol advertising that occurs as a result of such advertising, researchers evaluated the placement of individual radio advertisements for the most advertised U.S. alcohol brands and the composition of audiences in the largest 104 markets in the United States. This report summarizes the results of that study, which indicate that alcohol advertising is common on radio programs which have disproportionately large youth audiences and that this advertising accounts for a substantial proportion of all alcohol radio advertising heard by underage youth. These results further indicate that 1) the current voluntary standards limiting alcohol marketing to youth should be enforced and ultimately strengthened, and 2) ongoing monitoring of youth exposure to alcohol advertising should continue. Brand-specific exposure to radio advertising also varied by the sex and racial/ethnic composition of the audience. Compared with boys, underage girls had higher levels of exposure to 11 alcohol brands and in 41 of the 104 markets and less exposure to 13 brands and in 63 markets
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5534a3.htm?s_cid=mm5534a3_e
YOUTH: 3 complementary resources: Needs based…asset mapping…resiliency…
1.) Resilience Project
The purpose of the IRP is to develop a better, more culturally sensitive understanding of how youth around the world effectively cope with the adversities that they face in life. The IRP uses a unique cross-cultural approach that employs both quantitative and qualitative research methods to examine individual, interpersonal, family, community and cultural factors associated with building resilience in youth around the world. The IRP is currently bringing to a close the first 3-year phase of the research, in which the IRP piloted and integrated innovative quantitative and qualitative research methods and collected data with over 1500 children worldwide.
http://www.resilienceproject.org/cmp_text/
http://www.resilienceproject.org/documents/2006_reports/northerncanada.pdf
2.) Resilience Net
ResilienceNet provides the single, most comprehensive world-wide source of current, reviewed information about human resilience. The Web sites with resilience resources that are cited in ResilienceNet have been reviewed by a panel of experts according to a set of criteria for assuring the relevance and quality of the sites. If there is a Web site that you would like to submit for review by the ResilienceNet review panel for possible inclusion on ResilienceNet, please send a note with the name and URL of the site to the ResilienceNet Webmaster. If you think that any site listed on ResilienceNet is no longer appropriate or of sufficient quality to be included, please inform the ResilienceNet Webmaster.Resilience is defined as the "human capacity and ability to face, overcome, be strengthened by, and even be transformed by experiences of adversity." ResilienceNet brings together information available through the Internet and conventional published sources about the development and expression of human resilience. Although we endeavor to cover all aspects of resilience, ResilienceNet focuses on resilience in children, youth, and families. Additional topics, especially as they impact on children, youth, and families, are included as well, such as:
- resilience of communities
- resilience and life-long physical and mental health
- resilience related to culture, ethnicity, and gender
- children and adults at risk
3.) SEARCH Institute
There is an early childhood piece from SEARCH below: While the focus of the Institute began with school age youth this piece is on early childhood.
Search Institute's 40 Developmental Assets are concrete, common sense, positive experiences and qualities essential to raising successful young people. These assets have the power during critical adolescent years to influence choices young people make and help them become caring, responsible adults. http://www.search-institute.org/
http://www.searchinstitutestore.org/product.php?productid=16460
TeenScreen Conference: Second Annual
March 14 and 15, 2007
Washington D.C.
Bringing together TeenScreen champions for youth mental health from across the country to explore…
- The latest research in youth mental health and suicide prevention
- Practical skills for your entire screening team
- Tools to expand your TeenScreen Program
- Increasing government and local support for mental health screening
Contact TSConference@childpsych.columbia.edu
Adolescent Death Rates by Race/Ethnicity and Sex
During 2001--2003, AI/AN and non-Hispanic black male adolescents had higher average annual death rates than males in other racial/ethnic populations. Among female adolescents, AI/ANs had a higher death rate than any other population. In each racial/ethnic population, males had higher adolescent death rates than females.
* Aged 15--17 years.
† Average annual rate per 100,000 population.
§ Includes persons of Hispanic origin.
¶ Death rates are known to be underestimated.
** Might be of any race.
National Vital Statistics System, 2001--2003 mortality files; Health Data for All Ages, http://www.cdc.gov/nchs/health_data_for_all_ages.htm
Chronic Disease and Illness
Aspirin to Prevent Heart Attack and Stroke: What’s the Right Dose? 160 mg/day
Despite hundreds of clinical trials, the appropriate dose of aspirin to prevent myocardial infarction (MI) and stroke is uncertain. In the US, the doses most frequently recommended are 80, 160, or 325 mg per day. Because aspirin can cause major bleeding, the appropriate dose is the lowest dose that is effective in preventing both MI and stroke because these two diseases frequently co-exist. Five randomized clinical trials have compared aspirin with placebo or no therapy for the prevention of stroke and MI. These trials varied with regard to the dose of aspirin, the duration of treatment, and, most important, the populations selected for study varied in their baseline risk of stroke and MI. These studies indicate that the most appropriate dose for the primary and secondary prevention of stroke and MI is 160 mg/day.
Dalen J. Aspirin to Prevent Heart Attack and Stroke: What’s the Right Dose? American Journal of Medicine 2006 119: 198-202
Benefits of Eating Fish Greatly Outweigh the Risks
The benefits of eating one to two servings of fish a week greatly outweigh the risks among adults and, except for a few species of fish, women of child-bearing age. “It is striking how much greater both the amount of the evidence and the size of the health effect are for health benefits, compared with health risks. Seafood is likely the single most important food one can consume for good health
Conclusions For major health outcomes among adults, based on both the strength of the evidence and the potential magnitudes of effect, the benefits of fish intake exceed the potential risks. For women of childbearing age, benefits of modest fish intake, excepting a few selected species, also outweigh risks.
Mozaffarian, D, Rimm, EB Fish Intake, Contaminants, and Human Health Evaluating the Risks and the Benefits JAMA. 2006;296:1885-1899.
http://jama.ama-assn.org/cgi/content/short/296/15/1885
Daily Weighing and Quick Action Keeps Pounds Off, Study Shows
Most successful dieters regain the weight they lost. But new research shows that a daily weigh-in – and quick adjustments to diet and exercise – can significantly help dieters maintain weight loss. The clinical trial, conducted by researchers at The Miriam Hospital and Brown Medical School, reports results of the first program designed specifically for weight loss maintenance.
Stepping on the scale every day, then cutting calories and boosting exercise if the numbers run too high, can significantly help dieters maintain weight loss, according to results of the first program designed specifically for weight loss maintenance.
Self-regulation is the core of STOP Regain
Unlike other obesity studies, which focus on how to lose weight, the “STOP Regain” trial tested a method that taught participants how to keep those pounds from coming back – regardless of the method they used to lose the weight in the first place.
Wing RR, et al A self-regulation program for maintenance of weight loss N Engl J Med. 2006 Oct 12;355(15):1563-71.
F as in Fat and Failing: How Obesity Policies are Failing in America, 2006
Adult obesity rates increased in 31 states during the past year, leaving an estimated two-thirds of Americans vulnerable to fatal diseases such as diabetes, stroke and cancer.
This, despite federal and state government efforts to curb the overweight epidemic, according to a new report from the Trust for America's Health.
The report, titled F as in Fat: How Obesity Policies Are Failing America, 2006 is the third in a series of annual reports by the trust detailing state obesity rates as well as the effectiveness of government policies to fight the problem.
According to official figures, the adult obesity rate rose from 15 percent in 1980 to 32 percent in 2004. Combine that with the number of Americans who are overweight but not obese, and the figure stands at 64 percent. And the childhood obesity rate more than tripled between 1980 and 2004, from 5 percent to 17 percent.
Among the report's other findings:
- The percentage of adults who are obese or overweight exceeds 60 percent in 28 states.
- West Virginia has the highest rate of type 2 diabetes among adults (10.4 percent) while Alaska has the lowest rate (4.5 percent).
- Mississippi has the highest rate of adult hypertension (32.7 percent) and Utah the lowest (19.8 percent).
- Seven states now have body mass index screening requirements in schools.
- All states except South Dakota have school physical education requirements, while 44 states plus Washington, D.C., have school health education requirements. There is little enforcement capability in either of these cases, however.
- Seventeen states plus Washington, D.C., have passed taxes on junk food or sodas.
Efforts to combat the obesity epidemic have failed to meet their goals, Nonas said. "I don't think they're going far enough," she said. "The perfect example of this is the physical-education and health-education requirements, where states have very little ability to enforce it. It's good that people are doing this, but it's not enough."
The report also offered a 20-step action plan to address the obesity crisis. Recommendations include improved nutritional labeling on foods; community-driven efforts to increase access to healthy foods in low-income areas; improved nutritional content on foods and beverages served and sold in schools; an improved physical environment with more and better sidewalks, parks and bike paths; better physical fitness curricula in schools; and employer-sponsored programs to increase physical activity and provide better insurance coverage for preventive services.
http://healthyamericans.org/reports/obesity2006/
Regular exercise and keeping weight in check decreases breast-cancer risk factors
Postmenopausal women who want to significantly decrease their breast-cancer risk would be wise to exercise regularly and keep their weight within a normal range for their height, according to new findings from the Women's Health Initiative.
Specifically, they found a significant decrease in the two most common, biologically active forms of estrogen, estrone and estradiol, among the most active, lean women studied. The researchers found that women with high BMI and low physical-activity had mean estrogen concentrations that were 50 percent to 100 percent higher than that of women with low BMI and high activity levels.
McTiernan A et al Relation of BMI and Physical Activity to Sex Hormones in Postmenopausal Women. Obesity (Silver Spring). 2006 Sep;14(9):1662-77
Management of Common Opioid-Induced Adverse Effects
Opioid analgesics are useful agents for treating pain of various etiologies; however, adverse effects are potential limitations to their use. Strategies to minimize adverse effects of opioids include dose reduction, symptomatic management, opioid rotation, and changing the route of administration. Nausea occurs in approximately 25 percent of patients; prophylactic measures may not be required. Patients who do develop nausea will require antiemetic treatment with an antipsychotic, prokinetic agent, or serotonin antagonist. Understanding the mechanism for opioid-induced nausea will aid in the selection of appropriate agents. Constipation is considered an expected side effect with chronic opioid use. Physicians should minimize the development of constipation using prophylactic measures. Monotherapy with stool softeners often is not effective; a stool softener combined with a stimulant laxative is preferred. Sedation and cognitive changes occur with initiation of therapy or dose escalation. Underlying disease states or other centrally acting medications often will compound the opioid's adverse effects. Minimizing unnecessary medications and judicious use of stimulants and antipsychotics are used to manage the central nervous system side effects. Pruritus may develop, but it is generally not considered an allergic reaction. Antihistamines are the preferred management option should pharmacotherapy treatment be required. Am Fam Physician 2006;74:1347-54.
http://www.aafp.org/afp/20061015/1347.html
Preventing Cardiovascular Disease in Women (also see Patient Education)
Cardiovascular disease (CVD) has been the primary cause of death in women for almost a century, and more women than men have died of CVD every year since 1984. Although CVD incidence can be reduced by adherence to a heart-healthy lifestyle and detection and treatment of major risk factors, preventive recommendations have not been consistently or optimally applied to women. The American Heart Association guidelines for CVD prevention in women provide physicians with a clear plan for assessment and treatment of CVD risk and personalization of treatment recommendations. The emphasis of preventive efforts has shifted away from treatment of individual CVD risk factors in isolation toward assessment of a woman's overall or "global" CVD risk. In addition to accounting for the presence or absence of preexisting coronary heart disease or its equivalents (e.g., diabetes, chronic kidney disease), cardiovascular risk can be further calculated with the Framingham risk score, which is based on age, sex, smoking history, and lipid and blood pressure levels. Intervention intensity and treatment goals are tailored to overall risk, with those at highest risk receiving the most intense risk-lowering interventions. Women at high risk for CVD and without contraindications should receive aspirin, beta blockers, and an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in addition to pharmacologic therapy for hyperlipidemia, hypertension, and diabetes. Women who already are at optimal or low risk for CVD should be encouraged to maintain or further improve their healthy lifestyle practices. Optimal application of these preventive practices significantly reduces the burden of death and disability caused by heart attack and stroke in women. Am Fam Physician 2006;74:1331-40, 1342. http://www.aafp.org/afp/20061015/1331.html
From Your Colleagues ‹ Previous | Next › Features
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.
