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Volume 5, No. 4, April 2007
Hot Topics
Obstetrics | Gynecology | Child Health | Chronic Disease and Illness
Obstetrics
GPRA Reporting: HIV Prenatal Screening
by Brigg Reilley* and Scott Giberson
Current national standards of care for prenatal care specifically recommend that all pregnant women be routinely screened for a variety of diseases for which early detection is critical for the mother and/or the child. Routine screening includes tests for HIV, syphilis, gonorrhea, chlamydia, and hepatitis B surface antigen. Furthermore, the Centers for Disease Control and Prevention (CDC) recently expanded recommendations for HIV screening so that more persons will be aware of their HIV status. Screening based on risk factors alone is no longer recommended for HIV (1, 2).
IHS considers prenatal HIV screening an important indicator of the quality of care provided by the Agency. As a result, HIV screening during prenatal care is one of the core Government Performance and Results Act (GPRA) measurements, and the IHS goal is to reach 100%. Nationally, IHS facilities have a collective prenatal HIV screening rate of 65%. For the most recent year, GPRA statistics show that levels of prenatal HIV care range by Area range from 17% to 84%. Although many facilities screen for HIV appropriately, there is room for improvement.
Editorial Comment
Site visits made by the IHS Division of Epidemiology and Disease Prevention to IHS clinical units have revealed some of the explanations for inconsistency in reported prenatal HIV screening rates. While the results are still preliminary, some patterns are emerging. In general, if the service unit has a screening rate <80%, there is generally a systemic clinical or data gap, often one that may be easily identified and fixed. If these gaps are addressed, the reported screening rates have the potential to increase substantially:
Clinical:
-Not using “opt-out” HIV testing. Opt-out means that HIV screening is treated like other routine infectious disease screenings, such as syphilis. A consent form for HIV testing is no longer recommended or required by CDC. (However, you must check with state regulations for specific testing requirements). Some service units in fact now ask prenatal patients to sign refusals if they wish to forgo HIV testing, so it is clear to the mother what risk she is taking for her and her baby if she has undetected HIV.
-Responsibility for performing HIV testing. Some small clinics simply do an HCG test, followed by basic metabolic blood work, and then refer the woman elsewhere for prenatal care. However, GPRA considers a service unit ‘responsible’ for HIV testing if a pregnant woman is seen more than once during pregnancy. Small clinics with the highest GPRA rates assume responsibility for the entire prenatal infectious disease screening, including HIV, and have integrated prenatal testing into a single prenatal lab panel.
-Transfer of patients. Women will often be referred from one clinic to another. Smaller clinics may assume that labs were done at the larger facility and vice versa, but sometimes, in reality, neither facility has ordered the test. This is a troublesome finding because it is a lost opportunity for prenatal care.
-Not testing. Some providers still decide whether or not to test a woman based on risk factor assessment. This strategy is no longer standard of care. In addition, some providers have extremely high refusal rates. Others have expressed a lack of time and that patients need to see an HIV counselor before testing. All of these perceived obstacles can be worked out. However, at some facilities, these difficulties persist.
Data:
-Not entering historical data. Again, if a woman has more than one visit during her pregnancy, we should know her HIV serostatus. If the test has been done at another facility, either prior to or after her appointments at your facility, GPRA finds the service unit responsible for obtaining and entering the HIV test.
-Not entering reference lab data. If the test is done by an outside lab, and the lab is not linked to RPMS, the service unit does not get ‘credit’ for the test unless it is entered. Some low GPRA rates are tied to lab slips not being entered in RPMS.
Other
The barriers to higher GPRA rates are mainly service unit-based, rather than patient-based. Patient-based difficulties are harder to resolve. Some women arrive very late in pregnancy (although rapid HIV tests can still be used). Some women never return after two appointments. Admittedly, these cases are difficult to follow up, although some reviewed charts showed multiple attempts by determined PHNs. While these types of patients can be the most challenging, they may also be the most important patients to screen for HIV.
How can we identify what is going wrong in our facility?
Run a simple patient list of women who are pregnant but not screened for HIV (Brigg Reilley, in the Division of Epidemiology and Disease Prevention, can email the program commands to anyone interested, courtesy of Audrey Lynch at PIMC). A quick chart review should reveal if the service unit has clinical gaps, data gaps, or both. If problems of the type we have discussed here are solved, the service unit can enjoy immediate improvement in GPRA rates for prenatal screening.
References
1. Advancing HIV prevention: new strategies for a changing epidemic— United States, 2003. MMWR April 18, 2003 / 52(15);329-332
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5215a1.htm
2. Voluntary HIV testing as part of routing medical care— Massachusetts, 2002. MWWR June 25, 2004 / 53(24);523-526.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5324a2.htm
*IHS Division of Epidemiology
Obstetric Causes of Cerebral Palsy Are Uncommon
Conclusion: The authors conclude that there is a high correlation between MRI findings and clinical findings and that MRI in patients with cerebral palsy might help predict future medical needs. A high rate of white matter damage suggests that genetic factors, nutritional factors, and infections damage the placenta and lead to ischemic events that are unrelated to management issues during labor and delivery.
The authors postulate a genetic cause of cerebral palsy in children with normal MRI findings. They indicate that in 19.9 percent of the children (those with cortical/subcortical damage or basal ganglia damage) the cerebral palsy could conceivably have had an obstetric cause. Of these children, at least one fourth were born by cesarean delivery, indicating that the obstetrician was responding to a problem in labor. In short, the authors find that malpractice is unlikely to be a cause of most cerebral palsy cases. In addition, urinary tract infection rates were higher in mothers with children who had cerebral palsy, and this may be an area where more aggressive intervention could have a preventive effect.
Bax M, et al. Clinical and MRI correlates of cerebral palsy: the European Cerebral Palsy Study. JAMA October 4, 2006;296:1602-8.
Significantly higher rehospitalization rates and costs with planned cesareans
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 $4,372 (95% C.I. $4,293-4,451) was 76% higher than the average for planned vaginal births of $2,487 (95% C.I. $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):669-677.
Fish During Pregnancy May Boost Childrens' IQ
INTERPRETATION: Maternal seafood consumption of less than 340 g per week in pregnancy did not protect children from adverse outcomes; rather, we recorded beneficial effects on child development with maternal seafood intakes of more than 340 g per week, suggesting that advice to limit seafood consumption could actually be detrimental. These results show that risks from the loss of nutrients were greater than the risks of harm from exposure to trace contaminants in 340 g seafood eaten weekly.
Hibbeln JR et al Maternal seafood consumption in pregnancy and neurodevelopmental outcomes in childhood (ALSPAC study): an observational cohort study. Lancet. 2007 Feb 17;369(9561):578-85
OB/GYN CCC Editorial comment:
Recommendations that seafood consumption should be limited in pregnancy contradicted
Women who eat seafood while pregnant may be boosting their children's IQ
in the process. The results of the study were surprising, and contradict American
and British recommendations that pregnant women should limit seafood and fish
consumption to avoid potentially high levels of mercury.
Mercury is found in small concentrations in fish and seafood, but can accumulate
in the body. High amounts of the metal can damage the human nervous system, particularly
those in developing fetuses. On the other hand, seafood - including fish - is
also a major source of omega-3 fatty acids, essential to brain development.
While experts believe further research is necessary to confirm these conclusions,
the study's failure to find evidence of increased harm from eating fish is significant.
Because seafood contain both nutrients and toxins, it remains a dilemma for regulatory
authorities what kinds of recommendations should exist for pregnant women.
At 32 weeks into their pregnancy, the women were asked to fill in a seafood consumption
questionnaire. They were subsequently sent questionnaires four times during their
pregnancy, and then up to eight years after the birth of their child. Researchers
examined issues including the children's social and communication skills, their
hand-eye coordination, and their IQ levels. As with any study based on self-reporting
methods, however, the results cannot be considered entirely definitive.
These results highlight the importance of including fish in the maternal diet
and lend support to the popular opinion that fish is brain food. Eating even
more than three portions of fish or seafood a week could be beneficial. Advice
that limits seafood consumption might reduce the intake of nutrients necessary
for optimum neurological development.
Induction after 41 completed weeks or later is associated with fewer perinatal deaths
AUTHORS' CONCLUSION: A policy of labour induction after 41 completed weeks or later compared to awaiting spontaneous labour either indefinitely or at least one week is associated with fewer perinatal deaths. However, the absolute risk is extremely small. Women should be appropriately counseled on both the relative and absolute risks.
Induction of labour for improving birth outcomes for women at or beyond term. Obstet Gynecol. 2007 Mar;109(3):753-4.
No support for oral betamimetics in treatment for threatened preterm labor
Clinical Scenario
A pregnant patient presents to the hospital at 31 weeks' gestation with preterm contractions. After the patient receives hydration and terbutaline (Brethine), the contractions stop.
Clinical Question
Should an oral betamimetic be used as maintenance therapy to prevent preterm delivery after treatment for threatened preterm labor?
Evidence-Based Answer
There is no evidence to support the use of oral betamimetics for maintenance therapy after treatment for threatened preterm labor, and there is a risk of adverse effects with these drugs.
Dodd JM, Crowther CA, Dare MR, Middleton P Oral betamimetics for maintenance therapy after threatened preterm labour. The Cochrane Database of Systematic Reviews 2007 Issue 1
http://www.cochrane.org/reviews/en/ab003927.html
Bleeding patterns after misoprostol vs surgical treatment of early pregnancy failure: RCT
CONCLUSION: Bleeding is heavier and more prolonged after medical treatment with misoprostol than with curettage for early pregnancy failure; however, bleeding rarely requires intervention.
Davis AR et al Bleeding patterns after misoprostol vs surgical treatment of early pregnancy failure: results from a randomized trial. Am J Obstet Gynecol. 2007; 196(1):31.e1-7
Controversy Over Keepsake Prenatal Ultrasound Images Without an Indication
Is providing expectant parents with an ultrasound "keepsake" image of their unborn child is justifiable without a medical indication? Many professionals frown on the practice of performing unnecessary ultrasound scans during pregnancy, out of safety concerns. Nonetheless, for those who offer "boutique ultrasonography," selling antenatal scans has become "a slick business transaction. The practice has expanded with technology improvements that now allow high definition 3D snapshots of the fetus and even '4D' video. Companies can make up to $490 from one CD or DVD.
There is no scientific evidence that 3D or 4D imaging offers any genuine medical utility, Watts points out. Also, many physicians wonder how commercial enterprises deal with the discovery of fetal abnormalities. The nub of the argument is whether or not medically unnecessary ultrasound exposure is safe. The US Food and Drug Administration states on its website, Although there is no evidence that these physical effects can harm the fetus, public health experts, clinicians and industry agree that casual exposure to ultrasound, especially during pregnancy, should be avoided. The agency considers commercial fetal imaging organizations unacceptable because they operate without medical supervision. In 2002, the FDA announced that "anyone administering ultrasound without a prescription is breaking the law."
Watts G. First pictures: One for the album. BMJ. 2007 Feb 3;334(7587):232-3.
AGA Releases Position Statement on Gastrointestinal Medication Use During Pregnancy
Drug treatment of gastrointestinal disease in pregnant women can be difficult, particularly because U.S. Food and Drug Administration classifications are not necessarily based on clinical experience or current literature. The American Gastroenterological Association (AGA) released a position statement on gastrointestinal medication use in pregnant women. The report was published in the July 2006 issue of Gastroenterology.
Treatment of gastrointestinal disease after pregnancy is usually preferred; however, waiting to treat some illnesses (e.g., irritable bowel syndrome [IBS]) could cause adverse outcomes. Because of the risk of adverse effects or teratogenicity, there are numerous medications that should never be taken during pregnancy. These include bismuth (Tritec), castor oil, doxycycline (Vibramycin), methotrexate, ribavirin (Virazole), sodium bicarbonate, tetracycline, and thalidomide (Thalomid). If drug treatment is needed, the AGA recommends using the lowest-risk medications possible, providing the most appropriate and effective dosage for the patient's condition, and evaluating pregnancy stage and possible dosing adjustments when making treatment decisions. It also recommends discussing treatment options with the patient before starting any drug therapy.
If endoscopy with sedation is needed in the third trimester, fetal monitoring may be necessary. For lighter sedation, a typical dose of meperidine (Demerol) seems to provide comfort at low risk, and a small dose of midazolam (Versed) can have a calming effect without causing drowsiness. Low doses of fentanyl (Duragesic) also can be used. Consultation with an anesthesiologist or obstetrician is recommended if deeper sedation is required. When performing colonic lavage, low-risk treatment options include tap water enemas and polyethylene glycol solutions. Bipolar cautery that does not require grounding pad placement should be used for therapeutic interventions.
When treating nausea, vomiting, or hyperemesis gravidarum during pregnancy, low-risk drug options include metoclopramide (Reglan), ondansetron (Zofran), prochlorperazine (Compazine), promethazine (Phenergan), and trimethobenzamide (Tigan). For heartburn, first-line treatment is over-the-counter calcium-based antacids. Antacids containing aluminum or magnesium are another low-risk option. Few data are available on the use of famotidine (Pepcid) and nizatidine (Axid) in pregnancy; the use of cimetidine (Tagamet) and ranitidine (Zantac) is preferred. Although omeprazole (Prilosec) has shown some fetal and embryonic toxicity, it is still a drug of choice because the risk remains low.
If hepatitis A or B vaccines are needed during pregnancy, both are considered low risk. For the management of hepatitis C, ribavirin and interferon are not recommended because they are contraindicated in pregnancy. Patients with Wilson's disease who need regular penicillamine (Cuprimine) therapy should have the dosage reduced to 250 mg per day by the third trimester; trientine (Syprine) appears to be a more low-risk option for managing this disease. For cholestasis of pregnancy, ursodiol (Actigall) has been used successfully without increasing adverse events. Because of impaired fetal growth, use of propranolol (Inderal) or any similar class of drugs to treat portal hypertension is not recommended after the first trimester. If a liver transplant is needed, cyclosporine (Sandimmune) and tacrolimus (Prograf) are low-risk options at dosages required for graft survival.
Dietary modifications (e.g., increased fiber intake, reduced fat and dairy consumption) are considered first-line therapy in the treatment of IBS. If medication use is necessary to treat constipation, osmotic laxatives, polyethylene glycol, docusate, senna, bisacodyl, and tegaserod (Zelnorm) are considered low-risk options. For diarrhea, loperamide (Imodium) and diphenoxylate with atropine (Lomotil) are low-risk options, but these agents are not recommended because of their possible fetal toxicity risk. There are no low-risk options for treating abdominal pain.
Although most infectious diarrhea episodes are self-limited, there still are some antibiotic treatment options for use in pregnancy. These include albendazole (Valbazen), ampicillin, vancomycin, azithromycin (Zithromax), furazolidone (Furoxone), tinidazole (Tindamax), and metronidazole (Flagyl). However, physicians should be aware that although these drugs may not cause an increased risk of birth defects, some have the potential to cause other adverse effects (e.g., gastrointestinal distress), and some recommendations are based on limited data. For women with IBS, the most favorable option would be to conceive while in remission. However, 5-aminosalicylates are considered low risk for maintenance of remission during pregnancy.
http://www.aafp.org/afp/20070301/practice.html#p2
Gynecology
Ultrasonography Detects Malignant Adnexal Masses
Results: At surgery, 144 masses (80 percent) were benign, 26 (14 percent) were malignant, and 11 (6 percent) were borderline. The 26 malignant masses included 16 serous adenocarcinomas, three clear cell carcinomas, and two mucinous adenocarcinomas. Median laparotomy was performed on 29 women who were found to have benign lesions. Benign, borderline, and malignant masses did not differ significantly in volume. Malignant masses had significantly higher density, as measured by mean gray index, and significantly higher flow index. The most striking difference between malignant and other masses was in central vessels, which were present in 69 percent of malignant masses and 15 percent of benign masses.
Conclusion: The authors conclude that the best parameters to distinguish benign from malignant adnexal masses are detection of central blood vessels, density (mean gray index), and
Geomini PM, et al. Evaluation of adnexal masses with three-dimensional ultrasonography. Obstet Gynecol November 2006;108:1167-75.
High rates of complications after sling surgery suggest the need for quality improvement
CONCLUSION: Complication rates within 1 year after sling surgery among Medicare beneficiaries were found to be higher than those reported in the clinical literature. The high rates of postoperative urinary tract infections, prolapse, and outlet obstruction suggest the need for quality improvement measures in the management of women with incontinence and pelvic prolapse. LEVEL OF EVIDENCE: III.
Anger JT, et al Complications of sling surgery among female medicare beneficiaries. Obstet Gynecol. 2007 Mar;109(3):707-14.
Surgery versus medical therapy for heavy menstrual bleeding
AUTHORS' CONCLUSIONS: Surgery, especially hysterectomy, reduces menstrual bleeding at one year more than medical treatments but LNG-IUS appears equally effective in improving quality of life. The evidence for longer term comparisons is weak and inconsistent. Oral medication suits a minority of women long term.
Marjoribanks J; Lethaby A; Farquhar C Surgery versus medical therapy for heavy menstrual bleeding. Cochrane Database Syst Rev. 2006; (2):CD003855
Inside-out for transobturator tape placement was closer to neurovascular structures
CONCLUSION: The outside-in technique results in the mesh being placed farther from the obturator canal and closer to the ischiopubic ramus, theoretically reducing the risk of neurovascular injury. LEVEL OF EVIDENCE: II.
Zahn CM, et al Anatomic comparison of two transobturator tape procedures. Obstet Gynecol. 2007 Mar;109(3):701-6.
Monsel's paste and fulguration with ball electrode appear be equally effective
RESULTS: Six patients (2 Monsel's and 4 fulguration) required an alternate method of hemostasis. Patient demographics, postprocedural discharge, and recurrent dysplasia were comparable between the 2 groups. Visual analog scale scores and hemostasis time were significantly higher in the fulguration group. Estimated blood loss, although higher in the fulguration group, was not significant between groups.
CONCLUSION: Monsel's paste and fulguration with ball electrode appear be equally effective as hemostatic agents after loop electrosurgical excision procedure.
Lipscomb GH et al A trial that compares Monsel's paste with ball electrode
for hemostasis after loop electrosurgical excision procedure. Am
J Obstet Gynecol. 2006; 194(6):1591-4; discussion 1595 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd
=Retrieve&dopt=AbstractPlus&list_uids=16579924
Clipping better than shaving: Preoperative hair removal to reduce surgical site infection
AUTHORS' CONCLUSIONS: The evidence finds no difference in SSIs among patients who have had hair removed prior to surgery and those who have not. If it is necessary to remove hair then clipping results in fewer SSIs than shaving using a razor. There is insufficient evidence regarding depilatory cream compared with shaving using a razor. There is no difference in SSIs when patients are shaved or clipped one day before surgery or on the day of surgery
Tanner J et a; Preoperative hair removal to reduce surgical site infection. Cochrane Database Syst Rev. 2006; (2):CD004122
Closing the vaginal cuff vertically is superior to horizontal for preserving vaginal length
RESULTS: Preoperatively mean vaginal lengths in the horizontal and vertical groups were statistically similar (7.76 +/- 1.23 cm versus 8.28 +/- 1.39 cm, respectively; P = .21). Postoperatively the groups statistically differed (6.63 +/- 1.02 cm versus 7.93 +/- 1.18 cm, P < .001). The mean change in vaginal length was -1.13 +/- 1.15 cm and -0.35 +/- 0.91 cm, respectively (P = .01). Within-group comparisons revealed a statistical difference between pre- versus postmean vaginal length in the horizontal group (7.76 +/- 1.23 cm versus 6.63 +/- 1.02 cm; P < .001) and no difference within the vertical group (8.28 +/- 1.39 cm versus 7.93 +/- 1.18 cm; P = .11). CONCLUSION: Closing the vaginal cuff vertically is superior to horizontal closure for the purpose of preserving vaginal length.
Vassallo BJ, et al A randomized trial comparing methods of vaginal cuff closure at vaginal hysterectomy and the effect on vaginal length. Am J Obstet Gynecol. 2006; 195(6):1805-8
Management of vertical incisions with 3 or more centimeters of subcutaneous fat
CONCLUSION: Suture approximation or drainage of the subcutaneous tissues of women with 3 cm or more subcutaneous fat measured in midline vertical incisions resulted in no significant change in the incidence of overall wound complications or superficial wound disruption.
Cardosi RJ et al Subcutaneous management of vertical incisions with
3 or more centimeters of subcutaneous fat. Am
J Obstet Gynecol. 2006; 195(2):607-14; discussion 614-6 (ISSN:
1097-6868) http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd
=Retrieve&dopt=AbstractPlus&list_uids=16796988
Distension of painful structures in the treatment for chronic pelvic pain in women
CONCLUSION: In this open, randomized study, distension of painful pelvic structures in women with CPP resulted in significant relief of pain and improvement in quality of life measures.
Heyman J et al Distension of painful structures in the treatment for chronic pelvic pain in women. Acta Obstet Gynecol Scand. 2006; 85(5):599-603
Tension-free vaginal tape: Less complications than intravaginal slingplasty
CONCLUSION: Both procedures were effective for stress incontinence, but 9% of women treated with the IVS required removal of the tape for erosions.Meschia M et al Tension-free vaginal tape (TVT) and intravaginal slingplasty (IVS) for stress urinary incontinence: a multicenter randomized trial. Am J Obstet Gynecol. 2006; 195(5):1338-42 (ISSN: 1097-6868)
The use of herbs and dietary supplements in gynecology: an evidence-based review
Consumers frequently use herbs and dietary supplements to treat chronic conditions that are poorly responsive to prescription drugs or when prescription drugs carry a high side effect burden. Women may use herbs and supplements for chronic gynecologic conditions, such as menopause, premenstrual syndrome, dysmenorrhea, cyclic mastalgia, and infertility. This review is an evidence-based evaluation of herbs and supplements for these conditions. Therapies that carry a higher level of support from randomized controlled trial evidence include black cohosh for menopause; vitamins B(1) and E for dysmenorrhea; calcium, vitamin B(6), and chasteberry for premenstrual syndrome; and chasteberry for cyclic mastalgia. There were too few trials involving herbs and supplements in infertility to warrant a solid recommendation, but chasteberry, antioxidants, and Fertility Blend have some preliminary support. Midwives may want to consider these alternatives in addition to more traditional treatment options when meeting with patients.
Dennehy CE. The use of herbs and dietary supplements in gynecology: an evidence-based review. J Midwifery Womens Health. 2006;51(6):402-409
No evidence that spinal manipulation is effective for dysmenorrhoea
CONCLUSIONS: Overall there is no evidence to suggest that spinal manipulation is effective in the treatment of primary and secondary dysmenorrhoea. There is no greater risk of adverse effects with spinal manipulation than there is with sham manipulation.
Proctor ML et al Spinal manipulation for primary and secondary dysmenorrhoea. Cochrane Database Syst Rev. 2006; 3:CD002119
Child Health
Newborn male circumcision: Improved outcomes with pediatric hospitalists
In 2004, the Department of Obstetrics and Gynecology at the University of Michigan decided to stop offering routine circumcision for specialty and disciplinary, logistic, and educational reasons. The Pediatric Hospitalist Service assumed responsibility for the procedures and the educational process with resultant patient and staff satisfaction, educational, logistical and economic benefits.
Johnson TR et al Why and how a department of obstetrics and gynecology stopped doing routine newborn male circumcision. Obstet Gynecol. 2007 Mar;109(3):750-2.
Eleven medications account for one-third of medication errors that harm hospitalized children http://www.ahrq.gov/research/feb07/0207RA11.htm
Croup: Single dose of prednisolone less effective than single dose of dexamethasone
RESULTS: Children treated with prednisolone were more likely to re-present: 19 of 65 children (29%) reattended medical care compared with 5 of 68 (7%) from the dexamethasone group. The confidence intervals around this 22% difference in outcome were 8% to 35%, outside the 0% to 7.5% range of equivalence. There were no significant differences in other outcome measures. CONCLUSION: A single oral dose of prednisolone is less effective than a single oral dose of dexamethasone in reducing unscheduled re-presentation to medical care in children with mild to moderate croup.
Sparrow A, Geelhoed G. Prednisolone versus dexamethasone in croup: a randomised equivalence trial. Arch Dis Child. 2006; 91(7):580-3
Use of Child Restraints in 2006: New NHTSA Research Note
NHTSA has published its latest observational survey findings on the use of child restraints in a Research Note entitled, The survey, a core component of NHTSA’s annual National Occupant Protection Use Survey (NOPUS), analyzes the use of child restraints among children from birth 1 through age 7. This is the only probability-based observational survey of child restraint use in the U.S.
The majority of young children riding in motor vehicles in the United States continued to be restrained by some type of child safety seat or seat belt, with 98 percent of infants and 89percent of children ages 1 to 3 so restrained in 2006. This result is from the National Occupant Protection Use Survey (NOPUS), which provides the only probability-based observed data on child restraint use in the United States. The NOPUS is conducted annually by the National Center for Statistics and Analysis of the National Highway Traffic Safety Administration (NHTSA).
The 2006 survey also found the following:
• Children between the ages of 4 and 7 continued to be restrained at somewhat lower rates than younger children, with 78 percent of these children restrained by a safety seat or seat belt in 2006.
• Most children continued to ride in the rear seat of vehicles. In 2006, 93 percent of infants, 94 percent of children ages 1 to 3, and 91 percent of children ages 4 to 7 rode in the rear seat.
• Child restraint use continued to be higher in the West than other parts of the country in 2006.
• Child restraint use continued to be lower when the driver was unbelted than for belted drivers in 2006.
“Child Restraint Use in 2006 – Overall Results”
http://www-nrd.nhtsa.dot.gov/pdf/nrd-30/NCSA/RNotes/2007/810737.pdf
Failure to thrive: No associations found with social class or parental education
CONCLUSIONS: The most important postnatal factors associated with growth faltering are the type and efficiency of feeding: no associations were found with social class or parental education. In the first 8 weeks of life, weak sucking is the most important symptom for both breastfed and bottle-fed babies. After 8 weeks, the duration of breast feeding, the quantity of milk taken and difficulties in weaning are the most important influences
Emond A et al Postnatal factors associated with failure to thrive in term infants in the Avon Longitudinal Study of Parents and Children. Arch Dis Child. 2007; 92(2):115-9
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16905563
Chronic Disease and Illness
New Findings Support Fetal Overnutrition Hypothesis
Findings from an epidemiologic study lend further support to the fetal overnutrition hypothesis: subjects overexposed to glucose, free fatty acids, and amino acids in utero are at increased risk for obesity later in life.
According to this hypothesis, it is the mother's weight status that determines the degree of fetal overnutrition. Thus, the hypothesis helps explain why obesity is often passed from parent to offspring.
Dr. Debbie A. Lawlor and colleagues correlated the maternal body mass index (BMI) with offspring BMI in 3340 parent-offspring trios drawn from an Australian birth cohort.
Maternal BMI was assessed at the first antenatal clinic visit and offspring BMI was determined at age 14. In addition, paternal BMI was calculated from the mother's report of the father's height and weight.
The offspring's BMI was more closely linked to the mother's BMI than the father's, Dr. Lawlor, from the University of Bristol in the UK, and colleagues note. For a one-standard-deviation increase in maternal and paternal BMI, offspring BMI increased by 0.362 and 0.239 standard deviations.
"There is currently an epidemic of obesity in Western societies," the authors conclude. "The potential importance of the suggestion, from our study, that greater maternal size during pregnancy, either through programming of neuroendocrine pathways or through epigenetic or other mechanisms, results in greater offspring BMI in later life means that this issue warrants further investigation."
Am J Epidemiol 2007;165:418-424. http://www.medscape.com/viewarticle/552903?src=mp
Obesity surgeries have jumped dramatically since 1998, AHRQ
Obesity surgeries for patients between the ages of 55 and 64 in the United States soared from 772 procedures in 1998 to 15,086 surgeries in 2004—a nearly 2,000 percent increase, according to a new report by the Agency for Healthcare Research and Quality (AHRQ). The report, the latest of several studies that AHRQ has done on obesity surgery, also found a 726 percent increase in surgeries among patients age 18 to 54. There were a total of 121,055 surgeries performed on patients of all ages in 2004.
Among the reasons for the dramatic increases is that the mortality outcomes from obesity surgery have improved greatly. The national death rate for patients hospitalized for bariatric surgery declined 78 percent, from 0.9 percent in 1998 to 0.2 percent in 2004.
Bariatric surgery has been proven beneficial in obese persons who have tried and failed to lose excess weight by diet, exercise, and other means. The various bariatric surgical procedures include gastric bypass operations, vertical-banded gastroplasty, and gastric banding or "lapband." Doctors may recommend bariatric surgery for patients who have a Body Mass Index (BMI) of 40 or greater (an example would be a person who is 5 feet 2 inches tall and weighs 276 pounds) or a BMI of 35 or more for patients who have serious, obesity-related medical conditions such as type 2 diabetes or severe sleep apnea.
http://www.ahrq.gov/research/jan07/0107RA29.htm
High BP in Pregnancy Increases Risk for Future Atherosclerosis
Women with a history of high blood pressure during pregnancy had a 57% increased risk of having coronary calcification compared with those women without this condition (OR: 1.57; 95% CI: 1.04 to 2.37). After adjusting for age, the relation did not change (OR: 1.64; 95% CI: 1.07 to 2.53). We concluded that high blood pressure during pregnancy is associated with an increased risk of coronary calcification later in life.
Sabour S, et al High Blood Pressure in Pregnancy and Coronary Calcification. Hypertension. 2007 Feb 5;
Switching from tamoxifen to aromatase inhibitor improves survival in breast cancer
CONCLUSIONS: Switching to an aromatase inhibitor after 2 or 3 years of tamoxifen therapy significantly improves survival compared with continuing 2 or 3 years of additional tamoxifen treatment.
Boccardo F, et al Switching to an aromatase inhibitor provides mortality benefit in early breast carcinoma : pooled analysis of 2 consecutive trials. Cancer. 2007 Feb 12
Telephone Counseling Improves Smoking Cessation Rates
Clinical Question
Does telephone counseling help smokers quit?
Evidence-Based Answer
Telephone counseling can improve long-term smoking cessation rates. Multiple proactive calls are more effective than a single reactive call.
Practice Pointers
Telephone counseling services (called quitlines, helplines, or hotlines) may offer counseling for smoking cessation. Telephone counseling can be a single session in response to a smoker's call (i.e., reactive), multiple sessions initiated by a counselor (i.e., proactive), or a combination of these types. Telephone counseling services are readily available to smokers who are planning a quit attempt or to former smokers trying to avoid a relapse. These services reach an estimated 1 to 6 percent of adult smokers each year, and some target specific at-risk populations such as pregnant, adolescent, or low-income smokers.
Proactive telephone counseling for smoking cessation helps motivated quitters stay abstinent. Three or more calls significantly increase the odds of smoking cessation compared with standard self-help materials or brief physician advice. Clinicians should identify proactive telephone counseling services for smoking cessation and provide this information to patients who want to quit smoking.
Stead LF, et al. Telephone counseling for smoking cessation. Cochrane Database Syst Rev 2006;(3):CD002850 . http://www.cochrane.org/index.htm
Alternative Therapies Worsen Breast Cancer Outcomes
Results: The authors calculated mean 10-year mortality rates for patients who eventually used standard therapy and for patients who substituted alternative therapy for standard therapy. For patients who delayed surgery, the 10-year relative risk of mortality associated with alternative therapy was estimated at 1.58. For those who refused chemotherapy, the relative risk was 1.54.
Conclusion: The authors conclude that, despite the many assumptions in the study, the results indicate that substituting alternative therapy for standard therapy adversely affects outcomes in patients with breast cancer.
Chang EY, et al. Outcomes of breast cancer in patients who use alternative therapies as primary treatment. Am J Surg October 2006;192:471-3.
CT screening for lung cancer didn’t improve mortality
CONCLUSIONS: Screening for lung cancer with low-dose CT may increase the rate of lung cancer diagnosis and treatment, but may not meaningfully reduce the risk of advanced lung cancer or death from lung cancer. Until more conclusive data are available, asymptomatic individuals should not be screened outside of clinical research studies that have a reasonable likelihood of further clarifying the potential benefits and risks.
Bach PB, et al Computed tomography screening and lung cancer outcomes. JAMA. 2007 Mar 7;297(9):953-61
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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.
