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Volume 5, No. 7, August 2007
Hot Topics
Obstetrics | Gynecology | Child Health | Chronic Disease and Illness
Obstetrics
VBAC: Smaller attributable risk than previously reported
OBJECTIVE: To compare pregnancy outcomes in women with one prior low-transverse cesarean delivery after induction of labor with pregnancy outcomes after spontaneous labor. METHODS: This study is an analysis of women with one prior low-transverse cesarean and a singleton gestation who underwent a trial of labor and who were enrolled in a 4-year prospective observational study. Pregnancy outcomes were evaluated according to whether a woman underwent spontaneous labor or labor induction
RESULTS: Among the 11,778 women studied, vaginal delivery was less likely after induction of labor both in women without and with a prior vaginal delivery (51% versus 65%, P<.001; and 83% versus 88%, P<.001). An increased risk of uterine rupture after labor induction was found only in women with no prior vaginal delivery (1.5% versus 0.8%, P=.02; and 0.6% versus 0.4%, P=.42). Blood transfusion, venous thromboembolism, and hysterectomy were also more common with induction among women without a prior vaginal delivery. No measure of perinatal morbidity was associated with labor induction. An unfavorable cervix at labor induction was not associated with any adverse outcomes except an increased risk of cesarean delivery. CONCLUSION: Induction of labor in the study population is associated with an increased risk of cesarean delivery in all women with an unfavorable cervix, a statistically significant, albeit clinically small, increase in maternal morbidity in women with no prior vaginal delivery, and no appreciable increase in perinatal morbidity. LEVEL OF EVIDENCE: II.
OB/GYN CCC Editorial comment:
VBAC: The pendulum is swinging back
After peaking in 1996, the vaginal birth after cesarean delivery (VBAC) rate has steadily declined to 13% in 2004. This decline has been accompanied by a number of articles that have questioned whether a trial of labor is equally suitable for all women with a prior low-transverse cesarean delivery. Correspondingly, investigators have tried to identify factors predictive of a lower chance of a successful trail of labor as well as a greater chance of uterine rupture, and thereby identify the specific women for whom a trial of labor is less safe and appropriate.
In contrast to the declining rate of VBAC, the rate of labor induction has been steadily increasing, more than doubling over the last decade to a frequency of more than 20%. Thus, the effect of induced versus spontaneous labor in women attempting VBAC is of particular interest. Initial reports suggested that women who underwent labor induction were no more likely than their spontaneously laboring counterparts to have a cesarean delivery or a uterine rupture. More recent studies, however, have challenged both conclusions, showing a higher rate of both cesarean delivery and uterine rupture among women undergoing labor induction with a prior cesarean delivery.
The 2001 Lydon-Rochelle et al in the NEJM raised questions about a possible higher rate of uterine rupture during induction of labor after previous cesarean delivery and temporally was related with a further erosion of the VBAC rate. The current prospective observation study above further illuminates the weakness of the Lydon-Rochelle et al article which was based on ICD 9 codes alone, a method known for ascertainment bias.
Women who desire a VBAC and are confronted with the decision to undergo labor induction can be counseled that their risk for most serious adverse outcomes is not significantly increased, the adverse outcomes that are increased have a small attributable risk associated with induction, and that even this small attributable risk appears limited to women without a prior vaginal birth.
Grobman WA, et al Outcomes of induction of labor after one prior cesarean. Obstet Gynecol. 2007 Feb;109(2 Pt 1):262-9.
Other Cesarean Delivery Resources:
Elective cesarean increases risk of respiratory morbidity after 37 completed weeks
CONCLUSION: Delivery by elective caesarean section was shown to increase the risk of respiratory morbidity in all studies eligible for inclusion. The magnitude of this relative risk seemed to depend on gestational age even in deliveries after 37 completed weeks of gestation.
Hansen AK et al Elective caesarean section and respiratory morbidity in the term and near-term neonate. Acta Obstet Gynecol Scand. 2007; 86(4):389-94
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17486457
Decision aids help women with previous cesarean section: May reduce cesarean rate
CONCLUSIONS: Decision aids can help women who have had a previous caesarean section to decide on mode of delivery in a subsequent pregnancy. The decision analysis approach might substantially affect national rates of caesarean section.
Montgomery AA, et al Two decision aids for mode of delivery among women with previous caesarean section: randomised controlled trial. BMJ. 2007 Jun 23;334(7607):1305
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17540908
Who will succeed with a trial of labor after VBAC?
RESULTS: Seven-thousand six hundred sixty women were available for analysis. The prediction model is based on a multivariable logistic regression, including the variables of maternal age, body mass index, ethnicity, prior vaginal delivery, the occurrence of a VBAC, and a potentially recurrent indication for the cesarean delivery. After analyzing the model with cross-validation techniques, it was found to be both accurate and discriminating.
CONCLUSION: A predictive nomogram, which incorporates six variables easily ascertainable at the first prenatal visit, has been developed that allows the determination of a patient-specific chance for successful VBAC for those women who undertake trial of labor. LEVEL OF EVIDENCE: II.
Grobman WA et al Development of a nomogram for prediction of vaginal birth after cesarean delivery. Obstet Gynecol. 2007; 109(4):806-12
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17400840
Postcesarean delivery adhesions associated with delayed delivery of infant
CONCLUSION: A high percentage of cesarean deliveries result in adhesive disease, which delays repeat cesarean delivery of the fetus. The potential for adhesive disease should be included in counseling regarding primary elective cesarean births.
Morales KJ, et al Postcesarean delivery adhesions associated with delayed delivery of infant Am J Obstet Gynecol. 2007 May;196(5):461
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17466702
New CDC / ACIP Recommendation for Varicella Vaccination in Women
Prenatal Assessment and Postpartum Vaccination
Prenatal assessment of women for evidence of varicella immunity is recommended. Birth before 1980 is not considered evidence of immunity for pregnant women because of potential severe consequences of varicella infection during pregnancy, including infection of the fetus. Upon completion or termination of their pregnancies, women who do not have evidence of varicella immunity should receive the first dose of vaccine before discharge from the health-care facility. The second dose should be administered 4--8 weeks later, which coincides with the postpartum visit (6--8 weeks after delivery). For women who gave birth, the second dose should be administered at the postpartum visit. Women should be counseled to avoid conception for 1 month after each dose of varicella vaccine. Health-care settings in which completion or termination of pregnancy occurs should use standing orders to ensure the administration of varicella vaccine to women without evidence of immunity. …”
Prevention of Varicella: Recommendations of the Advisory Committee on Immunization
Practices (ACIP
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5604a1.htm?s_cid=rr5604a1_e
OB/GYN CCC Editorial comment:
Update the clinical guidelines at your hospital to include the above recommendations
Please add prenatal screening and postpartum vaccination as per the CDC / ACIP recommendations to your practice and facility guidelines
Postpartum Labial Adhesions
Background: Labial adhesions are common in young girls and menopausal women. Topical estrogen is the first line of therapy for these adhesions. Based on a systematic literature review, postpartum labial adhesions are uncommon in clinical practice. They are not painful but can prevent patients from resuming normal sexual activity. Topical estrogen therapy is an ineffective treatment option for adhesions in this setting. Surgical division under local anesthesia is usually effective.
Case: A 29-year-old women presented at 6 weeks after an uncomplicated vacuum-assisted delivery for a routine postpartum evaluation. Examination revealed a 5-mm labial adhesion connecting her left and right labia minora. Division under local anesthetic resulted in a complete recovery within 3 days.
Conclusion: Postpartum labial adhesions can usually be surgically divided under local anesthetic with complete and rapid recovery.
Seehusen, DA, Earwood, JS. Postpartum Labial Adhesions Journal of the American Board of Family Medicine 20 (4): 408-410 (2007)
http://www.jabfm.org/cgi/content/abstract/20/4/408?etoc
Administration of cefazolin prior to skin incision is superior to cefazolin at cord clamping
CONCLUSION: Administration of prophylactic cefazolin 15-60 minutes prior to incision prior to skin incision resulted in a decrease in both endomyometritis and total postcesarean infectious morbidity, compared with administration at the time of cord clamping. This dosing did not result in increased neonatal septic workups or complications.
Sullivan SA, et al Administration of cefazolin prior to skin incision is superior to cefazolin at cord clamping in preventing postcesarean infectious morbidity: a randomized, controlled trial. Am J Obstet Gynecol. 2007 May;196(5):455.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17466699
Simulation-based, hands-on training can identify recurring errors in emergencies
CONCLUSION: A curricular unit based on simulation of obstetric emergencies can identify pitfalls of management in labor and delivery rooms that need to be addressed.
Maslovitz S et al Recurrent obstetric management mistakes identified by simulation. Obstet Gynecol. 2007 Jun;109(6):1295-300.
http://www.ncbi.nlm.nih.gov/sites/entrez?cmd
=retrieve&db=pubmed&list_uids=17540800&dopt=Abstract
Dystocia in Nulliparous Women (ALSO Serialization)
Dystocia is common in nulliparous women and is responsible for more than 50 percent of primary cesarean deliveries. Because cesarean delivery rates continue to rise, physicians providing maternity care should be skilled in the diagnosis, management, and prevention of dystocia. If labor is not progressing, inadequate uterine contractions, fetal malposition, or cephalopelvic disproportion may be the cause. Before resorting to operative delivery for arrested labor, physicians should ensure that the patient has had adequate uterine contractions for four hours, using oxytocin infusion for augmentation as needed. For nulliparous women, high-dose oxytocin-infusion protocols for labor augmentation decrease the time to delivery compared with low-dose protocols without causing adverse outcomes. The second stage of labor can be permitted to continue for longer than traditional time limits if fetal monitoring is reassuring and there is progress in descent. Prevention of dystocia includes encouraging the use of trained labor support companions, deferring hospital admission until the active phase of labor when possible, avoiding elective labor induction before 41 weeks' gestation, and using epidural analgesia judiciously. Am Fam Physician 2007;75:1671-8.
http://www.aafp.org/afp/20070601/1671.html
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17329511
Postterm pregnancy: No difference - Induction versus serial antenatal fetal monitoring
CONCLUSION: No differences were found between the induced and monitored groups regarding neonatal morbidity or mode of delivery, and the outcomes were generally good.
Heimstad R; et al Induction of labor or serial antenatal fetal monitoring in postterm pregnancy: a randomized controlled trial. Obstet Gynecol. 2007; 109(3):609-17
Uterine compression sutures effective: Outcome of subsequent pregnancy is reassuring
CONCLUSION: Uterine compression sutures for severe postpartum hemorrhage may obviate the need for hysterectomy and appear not to jeopardize subsequent pregnancy. LEVEL OF EVIDENCE: III.
Baskett TF. Uterine compression sutures for postpartum hemorrhage: efficacy, morbidity, and subsequent pregnancy. Obstet Gynecol. 2007 Jul;110(1):68-71
http://www.ncbi.nlm.nih.gov/sites/entrez?cmd
=retrieve&db=pubmed&list_uids=17601898&dopt=Abstract
Usefulness of Knowledge of Occiput Posterior Position Prior to Labor is Limited
CONCLUSION: Two thirds of OP positions at delivery after induction of labor occur due to a mal-rotation in labor from a non-OP position. Ultrasonography is an easy method of assessing fetal head position before induction of labor. In clinical practice, its usefulness is limited by the fact that, contrary to conventional teaching, OP position before induction of labor does not appear to be associated with an increased risk of cesarean delivery. LEVEL OF EVIDENCE: II.
Peregrine E; O'Brien P; Jauniaux E Impact on delivery outcome of ultrasonographic fetal head position prior to induction of labor. Obstet Gynecol. 2007; 109(3):618-25
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17329512
HSV-1 appears more readily transmissible to the neonate than HSV-2
CONCLUSION: Our results suggest that maternal HSV-1 antibody offers little, if any, protection against neonatal HSV-2 infection. During reactivation, HSV-1 appears more readily transmissible to the neonate than HSV-2, a concerning finding given the rising frequency of genital HSV-1 infection.
Brown EL et al Effect of maternal herpes simplex virus (HSV) serostatus and HSV type on risk of neonatal herpes. Acta Obstet Gynecol Scand. 2007;86(5):523-9
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17464578
Women with previous episode of chorioamnionitis have a twofold risk of recurrence
CONCLUSION: Women delivering vaginally who were diagnosed with chorioamnionitis during their first pregnancy are at increased risk for chorioamnionitis in a subsequent pregnancy. This supports the concept that there may be a predisposition to chorioamnionitis that should be further investigated. LEVEL OF EVIDENCE: II-2.
Laibl VR, et al Recurrence of clinical chorioamnionitis in subsequent pregnancies. Obstet Gynecol. 2006 Dec;108(6):1493-7
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17138785
Active Management of the Third Stage of Labor
AUTHORS' CONCLUSIONS: Prophylactic intramuscular or intravenous injections of ergot alkaloids are effective in reducing blood loss and postpartum hemorrhage, but adverse effects include vomiting, elevation of blood pressure and pain after birth requiring analgesia, particularly with the intravenous route of administration.
Liabsuetrakul T et al Prophylactic use of ergot alkaloids in the third stage of labour. Cochrane Database Syst Rev. 2007; (2):CD005456
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17443592
Nephrolithiasis requiring hospital admission increases risk of preterm delivery
CONCLUSION: Although the incidence of nephrolithiasis requiring hospital admission during pregnancy is relatively low, these women have an increased risk of preterm delivery. This has potential implications for counseling of pregnant women with kidney stones requiring hospital admission. Additionally, it may prompt definitive treatment of small, asymptomatic stones in women during reproductive years.
Swartz MA et al Admission for nephrolithiasis in pregnancy and risk of adverse birth outcomes. Obstet Gynecol. 2007; 109(5):1099-104
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17470589
Gynecology
LEEP doubles risk of preterm delivery: Patients need to be informed
CONCLUSION: Our study showed an almost 2-fold increase in the risk of preterm delivery after LEEP treatment. Thus, women in their reproductive age should be informed about the increased risk of preterm delivery, if treated with LEEP.
Nøhr B et al Loop electrosurgical excision of the cervix and the subsequent risk of preterm delivery. Acta Obstet Gynecol Scand. 2007;86(5):596-603
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17464590
Treatment of bleeding irregularities induced by progestin only contraceptives: Effective
AUTHORS' CONCLUSIONS: Some women may benefit from the interventions described, particularly with cessation of an ongoing bleeding episode. Several regimens offer promise in regulating bleeding, but findings need to be reproduced in larger scale trials. Intermittent treatment with an agent may help some women to continue the use of a progestin-only contraceptive. The results of this review do not support routine clinical use of any of the regimens included in the trials, particularly for long-term effect.
Abdel-Aleem H et al Treatment of vaginal bleeding irregularities induced by progestin only contraceptives. Cochrane Database Syst Rev. 2007; (2):CD003449
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17443526
Clinic management of early pregnancy failure: Safe, cost-effective
Early pregnancy failure and induced abortion are often managed differently, even though safe uterine evacuation is the goal in both. Early pregnancy failure is commonly treated by curettage in operating room settings in anesthetized patients. Induced abortion is most commonly managed by office vacuum aspiration in awake or sedated patients. Medical evidence does not support routine operating room management of early pregnancy failure. The University of Michigan initiated office uterine evacuations for early pregnancy failure treatment. Patients previously went to the operating room. These changes required faculty, staff, and resident education. Our efforts blurred the lines between spontaneous and induced abortion management, improved patient care and better utilized hospital resources
Harris LH, et a; Surgical management of early pregnancy failure: history, politics, and safe, cost-effective care Am J Obstet Gynecol. 2007 May;196(5):445.e1-5
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17466695
Short-term superiority of effectiveness of transobturator tape reported
AUTHOR'S CONCLUSIONS: The evidence for short-term superiority of effectiveness of transobturator and retropubic tape procedures ( TOT) is currently limited. Bladder injuries and voiding difficulties are lower, but the risk of vaginal erosions and groin pain is higher with TVTO/TOT. Methodologically sound and sufficiently powered RCTs with long-term follow up are needed, and the results of continuing trials are
Latthe PM et al Transobturator and retropubic tape procedures in stress urinary incontinence: a systematic review and meta-analysis of effectiveness and complications.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17362484
Women in their 50s: fecal incontinence not associated with parity or mode of delivery
CONCLUSION: In our population of women in their 50s, fecal incontinence was not associated with either parity or mode of delivery. LEVEL OF EVIDENCE: III.
Fritel X, et al Mode of Delivery and Fecal Incontinence at Midlife: A Study of 2,640 Women in the Gazel Cohort. Obstet Gynecol. 2007 Jul;110(1):31-38
http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db
=pubmed&list_uids=17601893&dopt=Abstract
Hysterectomy or levonorgestrel-releasing intrauterine system on sexual functioning
RESULTS: Among women treated by hysterectomy, sexual satisfaction increased and sexual problems decreased. Among LNG-IUS users, satisfaction with partner decreased. In addition to treatment modality (P = 0.02), estrogen therapy (P = 0.01), smoking (P = 0.001), night sweats (P = 0.03), vaginal dryness (P = 0.04), hot flushes (P = 0.01), and having someone to ask for advice (P = 0.03) and to share worries (P = 0.01) explained changes in sexual functioning. CONCLUSIONS: Among women with menorrhagia, hysterectomy improves sexual functioning, whereas LNG-IUS does not have such a positive effect.
Halmesmäki K et al The effect of hysterectomy or levonorgestrel-releasing intrauterine system on sexual functioning among women with menorrhagia: a 5-year randomised controlled trial. BJOG. 2007; 114(5):563-8
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17439564
Radiotherapy for stage I endometrial cancer reduces local disease: May extend survival
AUTHORS' CONCLUSIONS: Patients with stage I endometrial carcinoma have different risks of local and distant recurrence depending on the presence of risk factors including stage 1c, grade 3, lymphovascular space invasion and age. Though external beam pelvic radiotherapy reduced locoregional recurrence by 72%, there is no evidence to suggest that it reduced the risk of death. In patients with multiple high risk factors, including stage 1c and grade 3, there was a trend towards a survival benefit and adjuvant external beam radiotherapy may be justified. For patients with only one risk factor, grade 3 or stage 1c, no definite conclusion can be made and data from ongoing studies ( ASTEC; Lukka) are awaited. External beam radiotherapy carries a risk of toxicity and should be avoided in stage 1 endometrial cancer patients with no high risk factors
Kong A et al Adjuvant radiotherapy for stage I endometrial cancer. Cochrane Database Syst Rev. 2007; (2):CD003916
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17443533
Daily record of severity of problems: Screening instrument for premenstrual syndrome
CONCLUSION: The DRSP administered on the first day of menses is an acceptable screening instrument to identify women who may have PMS.
Borenstein JE et al Using the daily record of severity of problems as a screening instrument for premenstrual syndrome. Obstet Gynecol. 2007; 109(5):1068-75
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17470584
New cervical cancer test increases the detection rate of abnormal cells
CONCLUSION: The ThinPrep Imager detects 1.29 more cases of histological high grade squamous disease per 1000 women screened than conventional cytology, with cervical intraepithelial neoplasia grade 1 as the threshold for referral to colposcopy. More imager read slides than conventional slides were satisfactory for examination and more contained low grade cytological abnormalities.
Davey E, et al Accuracy of reading liquid based cytology slides using the ThinPrep Imager compared with conventional cytology: prospective study. BMJ. 2007 Jun 29;
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17604301
Higher circulating CRP concentrations in women who developed ovarian cancer
CONCLUSION: Higher circulating CRP concentrations in women who subsequently developed ovarian cancer support the hypothesized role of chronic inflammation in ovarian carcinogenesis. LEVEL OF EVIDENCE: II.
McSorley MA et al C-reactive protein concentrations and subsequent ovarian cancer risk. Obstet Gynecol. 2007 Apr;109(4):933-41
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17400857
Pain relief in hysterosalpingography
AUTHORS' CONCLUSIONS: There is little evidence of benefit in terms of pain relief of any of the interventions considered in this study during or immediately after HSG. However, there is limited evidence of pain reduction 30 minutes after the procedure. Further RCTs should consider the role of non steroidal antiinflammatories (NSAIDs) and intrauterine anaesthetic during HSG.
Ahmad G; Duffy J; Watson AJ Pain relief in hysterosalpingography. Cochrane Database Syst Rev. 2007; (2):CD006106
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17443612
Treatment of Menorrhagia
Menorrhagia is defined as excessive uterine bleeding occurring at regular intervals or prolonged uterine bleeding lasting more than seven days. The classic definition of menorrhagia (i.e., greater than 80 mL of blood loss per cycle) is rarely used clinically. Women describe the loss or reduction of daily activities as more important than the actual volume of bleeding. Routine testing of all women with menorrhagia for inherited coagulation disorders is unnecessary. Saline infusion sonohysteroscopy detects intracavitary abnormalities such as endometrial polyps or uterine leiomyoma and is less expensive and invasive than hysteroscopy. Endometrial biopsy is effective for diagnosing precancerous lesions and adenocarcinoma but not for intracavitary lesions. Except for continuous progestin, medical therapies are limited. The levonorgestrel-releasing intrauterine device is an effective therapy for women who want to preserve fertility and avoid surgery. Surgical therapies include endometrial ablation methods that preserve the uterus; and hysterectomy, which results in high satisfaction rates but with potential surgical morbidity. Overall, hysterectomy and endometrial ablation result in the greatest satisfaction rates if future childbearing is not desired. Treatment of menorrhagia results in substantial improvement in quality of life. Am Fam Physician 2007;75:1813-9,1820. http://www.aafp.org/afp/20070615/1813.html
Child Health
Physical Activity Alone May Not Reduce Obesity in Children
Conclusion: The authors conclude that this program to increase physical activity resulted in improvement in motor skills of children four to five years of age but had no demonstrable impact on obesity. They suggest that the program may have provided inadequate levels of physical activity to produce a measurable effect, and that several factors may need to be addressed simultaneously to impact body mass index. They suggest that future intervention programs for obesity in early childhood should incorporate attention to diet, more behavioral approaches, and greater involvement of parents.
Reilly JJ, et al. Physical activity to prevent obesity in young children: cluster randomised controlled trial. BMJ November 18, 2006;333:1041-3.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17028105
Obese Young Adults Face High Diabetes Risk
People who are obese at age 18 will more likely than not develop type 2 diabetes at some point.
CONCLUSIONS: Cardiometabolic abnormalities are present in nearly 68% of young, healthy, Asian-Indian adolescents and even among those with normal weight. Insulin resistance is associated with individual cardiometabolic factors, and plasma insulin showed association with clustering of some variables
Ramachandran A, Insulin resistance and clustering of cardiometabolic risk factors in urban teenagers in southern India. Diabetes Care. 2007 Jul;30(7):1828-33.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17416794
Increased risk of autism: associated with parental age and obstetric conditions
CONCLUSIONS: Evidence to suggest that parental age and obstetric conditions are associated with an increased risk of autism and autism spectrum disorders is accumulating. Although not proven as independent risk factors for autism, these variables should be examined in future studies that use large, population-based birth cohorts with precise assessments of exposures and potential confounders.
Kolevzon A et al Prenatal and perinatal risk factors for autism: a review and integration of findings. Arch Pediatr Adolesc Med. 2007; 161(4):326-33
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17404128
Physician Prompting Improves Asthma Preventive Care
Conclusion: The authors conclude that use of a physician prompt that includes severity of the disease and care guidelines at an office visit can improve the delivery of preventive asthma care. They add that because urban children have the highest risk of asthma morbidity, this intervention has the potential to reduce morbidity in this population.
Halterman JS, et al. Improved preventive care for asthma. A randomized trial of clinician prompting in pediatric offices. Arch Pediatr Adolesc Med October 2006;160:1018-25.
http://www.aafp.org/afp/20070615/tips/6.html
Child adiposity at 3 years: New recommendations for gestational weight gain required?
RESULTS: Greater weight gain was associated with higher child body mass index z-score (0.13 units per 5 kg [95% CI, 0.08, 0.19]), sum of subscapular and triceps skinfold thicknesses (0.26 mm [95% CI, 0.02, 0.51]), and systolic blood pressure (0.60 mm Hg [95% CI, 0.06, 1.13]).
CONCLUSION: New recommendations for gestational weight gain may be required in this era of epidemic obesity.
Oken E et al Gestational weight gain and child adiposity at age 3 years. Am J Obstet Gynecol. 2007; 196(4):322.e1-8
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17403405
Outcome of infants with an Apgar score of zero at 10 minutes is almost universally poor
Results: death or severe disability occurred in 8 of 9 infants. Combining the results of metaanalysis of published data with our results of 94 infants, 88 infants (94%) either died or were handicapped severely; 2 infants (2%) were handicapped moderately, and 1 infant (1%) was handicapped mildly. For 3 infants (3%), the long-term outcome could not be determined.
CONCLUSION: The outcome of infants with an Apgar score of zero at 10 minutes is almost universally poor.
Harrington DJ, et al The long-term outcome in surviving infants with Apgar zero at 10 minutes: a systematic review of the literature and hospital-based cohort
Am J Obstet Gynecol. 2007 May;196(5):463
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17466703
Chronic Disease and Illness
Teratogenicity of SSRIs--serious concern or much ado about little?
Researchers from Boston University’s Slone Epidemiology Center have found that certain selective serotonin reuptake inhibitors (SSRIs) antidepressants do not appear to increase the risk for most kinds of birth defects. CONCLUSIONS: Our findings do not show that there are significantly increased risks of craniosynostosis, omphalocele, or heart defects associated with SSRI use overall. They suggest that individual SSRIs may confer increased risks for some specific defects, but it should be recognized that the specific defects implicated are rare and the absolute risks are small.
Louik C, et al First-trimester use of selective serotonin-reuptake inhibitors and the risk of birth defects. N Engl J Med. 2007 Jun 28;356(26):2675-83
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17596601
Maternal use of SSRIs was not associated with significantly increased risks
CONCLUSIONS: Maternal use of SSRIs during early pregnancy was not associated with significantly increased risks of congenital heart defects or of most other categories of birth defects. Associations were observed between SSRI use and three types of birth defects, but the absolute risks were small, and these observations require confirmation by other studies
Alwan S, et al Use of selective serotonin-reuptake inhibitors in pregnancy and the risk of birth defects. N Engl J Med. 2007 Jun 28;356(26):2684-92
http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db
=pubmed&list_uids=17596602&dopt=Abstract
Editorial
Teratogenicity of SSRIs--serious concern or much ado about little?
“…..Patients and physicians alike would prefer it if there were clear lines separating "risk" and "no risk" and if all studies gave consistent results pointing in the same direction. Unfortunately, this is often not the case, and the data to inform potential risks of SSRIs are no exception. The two reports in this issue of the Journal, together with other available information, do suggest that any increased risks of these malformations in association with the use of SSRIs are likely to be small in terms of absolute risks. “
Greene
MF. Teratogenicity of SSRIs--serious concern or much ado about little? N
Engl J Med. 2007 Jun 28;356(26):2732-3.
http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db
=pubmed&list_uids=17596609&dopt=Abstract
Two Other Depression Related Resources:
American Native Suicide
Following the Depression theme in the last issue, I wanted to look at suicide, the tragic outcome of acute untreated depression. You don’t have to look far to realize that while Alaska’s suicide rate is far worse that the national, Alaska Native Suicide is three times as high here as non-native! This issue explores why this is so, and more importantly what is needed to turn this around. I have included one website for help in dealing with suicidal behavior in general – because this is prime time and the more we know, the greater our chances of averting tragedy!
http://consortiumlibrary.org/hsis/about/newsletters/May07.pdf
Health Sciences Information Service Newsletter, University of Alaska, Anchorage
Depression: Deadlier in the Spring
This issue is about depression, a critically important topic for this time of year. The take-home message is that all of us need to be aware of the symptoms of depression and alert for them in ourselves and in those around us. Please take time to explore the excellent websites which provide good coverage of all aspects of depression, including research news. Depression is a very treatable medical condition! I’ve seen this demonstrated in my own family.
Sally J. Bremner, Health Sciences Librarian
http://consortiumlibrary.org/hsis/about/newsletters/Apr07.pdf
Rosiglitazone: seeking a balanced perspective
CONCLUSIONS: Rosiglitazone was associated with a significant increase in the risk of myocardial infarction and with an increase in the risk of death from cardiovascular causes that had borderline significance. Our study was limited by a lack of access to original source data, which would have enabled time-to-event analysis. Despite these limitations, patients and providers should consider the potential for serious adverse cardiovascular effects of treatment with rosiglitazone for type 2 diabetes
Nissen SE, Wolski K. Effect of rosiglitazone on the risk of myocardial infarction and death from cardiovascular causes. N Engl J Med. 2007 Jun 14;356(24):2457-71.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17517853
Editorial Comments:
British Analysis Does Not Confirm Rosiglitazone (Avandia) MI Risk
After weighing all options and reviewing data from both the NEJM article and information sent out from GlaxoSmithKline, most do not presently believe it rational to have a blanket policy of taking patients off of rosiglitazone. No other major professional entity has recommended that up to this time. Rather, we recommend three possible options in consultation with the patient either by phone or at an appointed clinic visit.
- The patient and provider may choose to continue rosiglitazone with careful attention to possible symptoms of either ischemia or congestive heart failure.
- The patient and provider may negotiate a change in medication to pioglitazone if that is available on the pharmacy formulary. 15 to 30 mg of pioglitazone is roughly equivalent to 4 mg of rosiglitazone and 45 mg roughly corresponds to the 8mg dose.
- The patient and provider may choose to take the patient off rosiglitazone. This requires careful blood glucose monitoring for 2- 3 months as the effect of the TZD class is not lost immediately on discontinuing this medicine. Titration of insulin or adding another agent may be necessary depending on the response to discontinuing the medicine.
Recall that pioglitazone is in the same family as rosiglitazone and we have no guarantee this is not a class effect, nor do we understand the mechanism for this yet. While pioglitazone showed some modest cardiovascular benefits in secondary outcomes in the “PROACTIVE” study, there was also a significant side effect of CHF in 3.3% of the participants, not always predictable based on risk for CHF. We will remain vigilant for follow up information on this issue.
“….Taken together, these results, although based on very small numbers of events, certainly raise a signal of concern and indicate the need for more reliable information about rosiglitazone’s safety. But the FDA, physicians, and patients can reasonably await the results of RECORD, a phase III trial designed specifically to study cardiovascular outcomes. Until the results of RECORD are in, it would be premature to over interpret a meta-analysis that the authors and NEJM editorialists all acknowledge contains important weaknesses.
To avoid unnecessary panic among patients, a calmer and more considered approach to the safety of rosiglitazone is needed. Alarmist headlines and confident declarations help nobody. ■ The Lancet…” http://www.medpagetoday.com/
Q. How much does exercise help in weight loss?
A. There is a clear dose-response relationship between physical activity and weight
The majority of randomized, controlled trials (RCTs) show only modest weight loss with exercise intervention alone, and slight increases in weight loss when exercise intervention is added to dietary restriction. In most RCTs, the energy deficit produced by the prescribed exercise is far smaller than that usually produced by dietary restriction. In prospective studies that prescribed high levels of exercise, enrolled individuals achieved substantially greater weight loss–comparable to that obtained after similar energy deficits were produced by caloric restriction. High levels of exercise might, however, be difficult for overweight or obese adults to achieve and sustain. RCTs examining exercise and its effect on weight-loss maintenance demonstrated mixed results; however, weight maintenance interventions were usually of limited duration and long-term adherence to exercise was problematic. Epidemiologic, cross-sectional, and prospective correlation studies suggest an essential role for physical activity in weight-loss maintenance, and post hoc analysis of prospective trials shows a clear dose-response relationship between physical activity and weight maintenance.
Evidence from existing RCTs is relatively consistent with regard to the role of exercise in producing weight loss, either when used alone or in combination with dietary modification. Although the majority of RCTs show only modest weight loss with exercise alone, in most of these studies the level of exercise prescribed was relatively low and would have produced an energy deficit far smaller than that usually recommended for weight loss by caloric restriction. The resulting weight-loss findings from these studies are, therefore, consistent with the amount of exercise prescribed. Although other studies demonstrate that it is possible to achieve significant weight loss with high levels of physical activity alone (when the volume of exercise prescribed is equivalent to the energy deficit usually recommended for weight loss by caloric restriction and energy intake is held constant), producing the amount of activity needed is challenging given the difficulty of getting sedentary people to achieve and consistently adhere to increased physical activity.
Although adding physical activity to dietary modification increases initial weight loss, only a small advantage was gained in most of the RCTs. The daily energy deficit produced by short-term food restriction usually greatly exceeds that produced by physical activity and thus the contribution of additional physical activity (in the levels prescribed in many of these studies) to negative energy balance was minimal.
RCTs that have investigated the role of physical activity in weight-loss maintenance have reported mixed findings; however, limitations in existing RCTs include poor adherence to the physical activity prescribed, notable variability in the amount of exercise prescribed, and the limited duration of the exercise interventions. Few RCTs truly address the role of activity in weight-loss maintenance by providing a long term, sustained-activity intervention and there is a need for well-designed, prospective, randomized trials to assess such regimens. Studies in which activity is measured by observation or retrospective analysis illustrate a strong relation ship between physical activity and success in weight-loss maintenance.
Future research should focus on the impact of physical activity on other components of energy balance, why physical activity appears to be so critical for successful weight maintenance, individual specific determinants of how much activity is required for weight-loss maintenance, and how to motivate people to achieve and sustain the levels of activity that seem to be required for weight loss and weight-loss maintenance.
Catenacci VA, Wyatt HR. The role of physical activity in producing and maintaining weight loss. Nat Clin Pract Endocrinol Metab. 2007 Jul;3(7):518-29
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17581621
and
The Role of Physical Activity in Producing and Maintaining Weight Loss: CME
http://www.medscape.com/viewarticle/557969
Rizatriptan was effective for the treatment of menstrual migraine
Rizatriptan 10 mg was effective for the treatment of ICHD-II menstrual migraine, as measured by 2-h pain relief and 24-h sustained pain relief.
Mannix LK et al Rizatriptan for the acute treatment of ICHD-II proposed menstrual migraine: two prospective, randomized, placebo-controlled, double-blind studies. Cephalalgia. 2007 May;27(5):414-21
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17448179
Prehospital and Hospital Delays After Stroke Onset - United States, 2005-2006
To assess prehospital delays from onset of stroke symptoms to emergency department (ED) arrival and hospital delays from ED arrival to receipt of brain imaging, CDC analyzed data from the four states participating in the national stroke registry. Among the 3,795 patients who arrived at the ED within 2 hours of symptom onset, 3,491 had data recorded regarding the interval from ED arrival to receipt of brain imaging. A total of 2,275 (65.2%) received imaging within 1 hour of ED arrival. Significantly fewer women received imaging within 1 hour of ED arrival than men (62.9% versus 67.6%, p=0.004), and fewer nonambulance patients received imaging within 1 hour compared with patients transported by ambulance (56.3% versus 69.2%, p=0.001). No disparities among racial groups were observed regarding receipt of imaging within 1 hour of ED arrival. Among those patients who arrived at the ED within 2 hours, the median time from ED arrival to brain imaging was 0.73 hours (43.8 minutes).
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5619a3.htm
CDC Releases Report on Prevalence of Adult Obesity
Obesity is linked with a higher risk of hypertension, dyslipidemia, type 2 diabetes, coronary heart disease, stroke, and some cancers. One goal is to reduce the prevalence of obesity in adults by 15 percent. To analyze the prevalence of obesity by state, the Centers for Disease Control and Prevention (CDC) evaluated data from the 1995, 2000, and 2005 Behavioral Risk Factor Surveillance System surveys.
Adults with a body mass index (BMI) of 25 kg per m2 or more were classified as as overweight, a BMI of 30 or more as obese, and a BMI of 40 or more as extremely obese. In 2005, approximately 60 percent of adults were overweight, 24 percent were obese, and 3 percent were extremely obese. Overall, 24.2 percent of men and 23.5 percent of women were obese, and 17.7 percent of persons 18 to 29 years of age and 29.5 percent of persons 50 to 59 years of age were obese. The highest obesity rate (33.9 percent) was in non-Hispanic blacks. After adjusting for age, obesity prevalence was 15.6 percent in 1995, 19.8 percent in 2000, and 23.7 percent in 2005.
The CDC found that the prevalence of obesity increased significantly (P < .01) from 1995 to 2005 in all states. From 1995 to 2000, the number of states with a less than 20 percent obesity rate dropped from 50 to 28 (Figure 1). In 2005, only four states had an obesity rate of less than 20 percent. Seventeen states had an obesity rate of 25 percent or more, and three of these had a rate of 30 percent or more. To reverse this trend, an effective public health response is needed, including programs aimed at improving environmental factors, increasing awareness, and changing behaviors.
CDC http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5536a1.htm?s_cid=mm5536a1_e
Practice Guideline Briefs http://www.aafp.org/afp/20070701/practice.html
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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.
