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Volume 6, No. 10, October 2008
Hot Topics
Obstetrics | Gynecology | Child Health | Chronic Disease and Illness
Obstetrics
Electronic Fetal Monitoring: Update on Definitions and Interpretation
In April 2008, the Eunice Kennedy Shriver National Institute of Child Health
and Human Development, the American College of Obstetricians and Gynecologists,
and the Society for Maternal-Fetal Medicine partnered to sponsor a 2-day workshop
to revisit nomenclature, interpretation, and research recommendations for intrapartum
electronic fetal heart rate monitoring.
Participants included obstetric experts and representatives from relevant stakeholder groups and organizations. This article provides a summary of the discussions at the workshop. This includes a discussion of terminology and nomenclature for the description of fetal heart tracings and uterine contractions for use in clinical practice and research. A three-tier system for fetal heart rate tracing interpretation is also described. Lastly, prioritized topics for future research are provided.
Please see the Medical Mystery Tour in the Features section for a discussion of the Key Points from 2008 NICHD Electronic Fetal Monitoring Workshop.
Macones GA, Hankins GD, Spong CY, Hauth J, Moore T. The 2008 National Institute
of Child Health and Human Development Workshop Report on Electronic Fetal Monitoring:
Update on Definitions, Interpretation, and Research Guidelines. Obstet Gynecol.
2008 Sep;112(3):661-6.
http://www.ncbi.nlm.nih.gov/pubmed/18757666
Bariatric surgery linked to improved perinatal outcomes
OBJECTIVE: To compare the perinatal outcomes of women who delivered before
with women who delivered after bariatric surgery.
METHODS: A retrospective study was undertaken to compare perinatal outcomes of
women who delivered before with women who delivered after bariatric surgery in
a tertiary medical center between 1988 and 2006. A multivariate logistic regression
model was constructed to control for confounders.
RESULTS: During the study period, 301 deliveries preceded bariatric surgery and
507 followed surgery. A significant reduction in rates of diabetes mellitus (17.3%
vs 11.0; P=0.009), hypertensive disorders (23.6% vs 11.2%; P<0.001), and fetal
macrosomia (7.6% vs 3.2%; P=0.004) were noted after bariatric surgery. Bariatric
surgery was found to be independently associated with a reduction in diabetes
mellitus (OR 0.42, 95% CI 0.26-0.67; P<0.001), hypertensive disorders (OR
0.38, 95% CI 0.25-0.59; P<0.001), and fetal macrosomia (OR 0.45, 95% CI 0.21-0.94;
P=0.033).
CONCLUSION: A decrease in maternal complications, such as diabetes mellitus and
hypertensive disorders, as well as a decrease in the rate of fetal macrosomia
is achieved following bariatric surgery.
Weintraub AY, Levy A, Levi I, Mazor M, Wiznitzer A, Sheiner E. Effect of bariatric
surgery on pregnancy outcome. Int J Gynaecol Obstet. 2008 Sep 1. [Epub ahead
of print]
http://www.ncbi.nlm.nih.gov/pubmed/18768177
A randomized, controlled trial of magnesium sulfate for the prevention of cerebral palsy
BACKGROUND: Research suggests that fetal exposure to
magnesium sulfate before preterm birth might reduce the risk of cerebral palsy.
METHODS: In this multicenter, placebo-controlled, double-blind trial, we randomly
assigned women at imminent risk for delivery between 24 and 31 weeks of gestation
to receive magnesium sulfate, administered intravenously as a 6-g bolus followed
by a constant infusion of 2 g per hour, or matching placebo. The primary outcome
was the composite of stillbirth or infant death by 1 year of corrected age or
moderate or severe cerebral palsy at or beyond 2 years of corrected age.
RESULTS: A total of 2241 women underwent randomization. The baseline characteristics
were similar in the two groups. Follow-up was achieved for 95.6% of the children.
The rate of the primary outcome was not significantly different in the magnesium
sulfate group and the placebo group (11.3% and 11.7%, respectively; relative
risk, 0.97; 95% confidence interval [CI], 0.77 to 1.23). However, in a prespecified
secondary analysis, moderate or severe cerebral palsy occurred significantly
less frequently in the magnesium sulfate group (1.9% vs. 3.5%; relative risk,
0.55; 95% CI, 0.32 to 0.95). The risk of death did not differ significantly between
the groups (9.5% vs. 8.5%; relative risk, 1.12; 95% CI, 0.85 to 1.47). No woman
had a life-threatening event. CONCLUSIONS: Fetal exposure to magnesium sulfate
before anticipated early preterm delivery did not reduce the combined risk of
moderate or severe cerebral palsy or death, although the rate of cerebral palsy
was reduced among survivors.
Rouse DJ, Hirtz DG, Thom E, Varner MW, Spong CY, Mercer BM, et al. A randomized, controlled trial of magnesium sulfate for the prevention of cerebral palsy. N Engl J Med. 2008 Aug 28;359(9):895-905. http://www.ncbi.nlm.nih.gov/pubmed/18753646
Gestational weight gain and risk of overweight in the offspring at age 7 y in a multicenter, multiethnic cohort study
BACKGROUND: The earliest determinants of obesity may operate during intrauterine life, and gestational weight gain may influence the intrauterine environment in a way that may affect the risk of overweight in the offspring. OBJECTIVE: The purpose of this study was to examine the association of gestational weight gain with offspring overweight. DESIGN: This was a retrospective cohort study of 10,226 participants from the Collaborative Perinatal Project (1959-1972). Anthropometric and sociodemographic variables were assessed during gestation, at birth, and at age 7 y. The association between gestational weight gain and offspring overweight at 7 y was examined after adjustment for important confounding factors. RESULTS: The odds of overweight in offspring at age 7 y increased by 3% for every 1 kg of gestational weight gain (adjusted odds ratio: 1.03; 95% CI: 1.02, 1.05). When gestational weight gain was examined using Institute of Medicine guidelines, the odds of overweight was 48% greater for children of mothers who gained more than the weight gain recommendations than for children of mothers who met the weight gain guidelines (adjusted OR: 1.48; 95% CI: 1.06, 2.06). The association remained significant after additional adjustment for birth weight. The association between gestational weight gain and overweight in the offspring was strongest for women who were underweight before pregnancy (P for interaction < 0.01). CONCLUSION: Helping pregnant women to meet the recommended weight gain during pregnancy may be an important and novel strategy for preventing pediatric obesity.
Wrotniak BH, Shults J, Butts S, Stettler N. Gestational weight gain and risk of overweight in the offspring at age 7 y in a multicenter, multiethnic cohort study. Am J Clin Nutr. 2008 Jun;87(6):1818-24. http://www.ncbi.nlm.nih.gov/pubmed/18541573
Gynecology
Methicillin-resistant Staphylococcus aureus as a common cause of vulvar abscesses
OBJECTIVE: To estimate the incidence of methicillin-resistant
Staphylococcus aureus (MRSA) among women with vulvar abscesses and to describe
clinical factors associated with inpatient compared with outpatient treatment.
METHODS: We reviewed all women with a vulvar abscess who were treated with incision
and drainage between October 2006 to March 2008. We reviewed the abscess cultures
and evaluated clinical and laboratory variables associated with inpatient compared
with outpatient treatment.
RESULTS: During the 80-week study period, 162 women were treated for a vulvar
abscess. Methicillin-resistant S aureus was isolated from 85 of 133 (64%) cultured
vulvar abscesses. No presenting signs or symptoms were more common among patients
with MRSA abscesses. Women with an MRSA vulvar abscess were not more likely to
require inpatient admission or experience treatment complications. Inpatient
treatment occurred in 64 of 162 (40%) patients and was predicted by medical comorbidities:
diabetes (45.3%, odds ratio [OR] 2.29, 95% confidence interval [CI] 1.12-4.72),
hypertension (34.4%, OR 2.33, 95% CI 1.06-5.13), initial serum glucose greater
than 200 (37.5%, OR 3.32, 95% CI 1.48-7.51), and signs of worse infection, i.e.,
larger abscesses (mean 5.2 cm) (P<.001) and elevated white blood cell count
of at least 12,000/mm3 (45.3%, OR 3.04, 95% CI 1.44-6.43).
CONCLUSION: Methicillin-resistant S aureus was the most common organism isolated
from vulvar abscesses. Inpatient treatment is more common in women with medical
comorbidities, larger abscesses, and signs of systemic illness. An antibiotic
regimen with activity against MRSA, such as trimethoprim-sulfamethoxazole, should
be considered in similar populations with vulvar abscesses.
Thurman AR, Satterfield TM, Soper DE. Methicillin-resistant Staphylococcus aureus as a common cause of vulvar abscesses. Obstet Gynecol. 2008 Sep;112(3):538-44. http://www.ncbi.nlm.nih.gov/pubmed/18757650
Hysterectomy Complication Rates Decline Significantly
OBJECTIVE:
To assess the utilization rates of and complications associated with inpatient
hysterectomy in California between 1991 and 2004.
METHODS: We used the California Patient Discharge Database to analyze International
Classification of Diseases, 9th Revision, Clinical Modification diagnostic and
procedure codes for 649,758 women undergoing inpatient hysterectomy in California
between 1991 and 2004 using multiple logistic regression models.
RESULTS: Between 1991 and 2004, the incidence of any type of inpatient hysterectomy
for benign gynecologic conditions declined 17.6%. The rates of laparoscopically
assisted vaginal hysterectomy and subtotal hysterectomy increased substantially.
The year of hysterectomy was a factor associated with both medical and surgical
complications; the odds of inpatient complications between 1991 and 2004 steadily
declined.
CONCLUSION: In California between 1991 and 2004, the incidence of inpatient hysterectomy
for benign gynecological conditions and the adjusted odds of complications declined
substantially. Changes in practice and shorter hospital stays may have affected
the changes in inpatient hysterectomy rates and associated inpatient complications.
Smith
LH, Waetjen LE, Paik CK, Xing G. Trends in the safety of inpatient hysterectomy
for benign conditions in California, 1991-2004. Obstet Gynecol. 2008 Sep;112(3):553-61.
http://www.ncbi.nlm.nih.gov/pubmed/18757652
Prevalence of symptomatic pelvic floor disorders in U.S. women
CONTEXT:
Pelvic floor disorders (urinary incontinence, fecal incontinence, and pelvic
organ prolapse) affect many women. No national prevalence estimates derived from
the same population-based sample exists for multiple pelvic floor disorders in
women in the United States. OBJECTIVE: To provide national prevalence estimates
of symptomatic pelvic floor disorders in US women.
DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional analysis of 1961 nonpregnant
women (>or=20 years) who participated in the 2005-2006 National Health and
Nutrition Examination Survey, a nationally representative survey of the US noninstitutionalized
population. Women were interviewed in their homes and then underwent standardized
physical examinations in a mobile examination center. Urinary incontinence (score
of >or=3 on a validated incontinence severity index, constituting moderate
to severe leakage), fecal incontinence (at least monthly leakage of solid, liquid,
or mucous stool), and pelvic organ prolapse (seeing/feeling a bulge in or outside
the vagina) symptoms were assessed.
MAIN OUTCOME MEASURES: Weighted prevalence estimates of urinary incontinence,
fecal incontinence, and pelvic organ prolapse symptoms.
RESULTS: The weighted prevalence of at least 1 pelvic floor disorder was 23.7%
(95% confidence interval [CI], 21.2%-26.2%), with 15.7% of women (95% CI, 13.2%-18.2%)
experiencing urinary incontinence, 9.0% of women (95% CI, 7.3%-10.7%) experiencing
fecal incontinence, and 2.9% of women (95% CI, 2.1%-3.7%) experiencing pelvic
organ prolapse. The proportion of women reporting at least 1 disorder increased
incrementally with age, ranging from 9.7% (95% CI, 7.8%-11.7%) in women between
ages 20 and 39 years to 49.7% (95% CI, 40.3%-59.1%) in those aged 80 years or
older (P < .001), and parity (12.8% [95% CI, 9.0%-16.6%], 18.4% [95% CI, 12.9%-23.9%],
24.6% [95% CI, 19.5%-29.8%], and 32.4% [95% CI, 27.8%-37.1%] for 0, 1, 2, and
3 or more deliveries, respectively; P < .001). Overweight and obese women
were more likely to report at least 1 pelvic floor disorder than normal weight
women (26.3% [95% CI, 21.7%-30.9%], 30.4% [95% CI, 25.8%-35.0%], and 15.1% [95%
CI, 11.6%-18.7%], respectively; P < .001). We detected no differences in prevalence
by racial/ethnic group. CONCLUSION: Pelvic floor disorders affect a substantial
proportion of women and increase with age.
Nygaard I, Barber MD, Burgio KL, Kenton
K, Meikle S, Schaffer J, et al. Prevalence of symptomatic pelvic floor disorders
in U.S. women. JAMA, 2008 Sep 17;300(11):1311-6.
http://www.ncbi.nlm.nih.gov/pubmed/18799443
Behavioral therapy to enable women with urge incontinence to discontinue drug treatment: a randomized trial
BACKGROUND: Women with urge urinary
incontinence are commonly treated with antimuscarinic medications, but many discontinue
therapy.
OBJECTIVE: To determine whether combining antimuscarinic drug therapy with supervised
behavioral training, compared with drug therapy alone, improves the ability of
women with urge incontinence to achieve clinically important reductions in incontinence
episodes and to sustain these improvements after discontinuing drug therapy.
DESIGN: 2-stage, multicenter, randomized clinical trial conducted from July 2004
to January 2006.
SETTING: 9 university-affiliated outpatient clinics.
PATIENTS: 307 women with urge-predominant incontinence.
INTERVENTION: 10 weeks of open-label, extended-release tolterodine alone (n =
153) or combined with behavioral training (n = 154), followed by discontinuation
of therapy and follow-up at 8 months.
MEASUREMENTS: The primary outcome, measured at 8 months, was no receipt of drugs
or other therapy for urge incontinence and a 70% or greater reduction in frequency
of incontinence episodes. Secondary outcomes were reduction in incontinence,
self-reported satisfaction and improvement, and scores on validated questionnaires
measuring symptom distress and bother and health-related quality of life. Study
staff who performed outcome evaluations, but not participants and interventionists,
were blinded to group assignment.
RESULTS: 237 participants completed the trial. According to life-table estimates,
the rate of successful discontinuation of therapy at 8 months was the same in
the combination therapy and drug therapy alone groups (41% in both groups; difference,
0 percentage points [95% CI, -12 to 12 percentage points]). A higher proportion
of participants who received combination therapy than drug therapy alone achieved
a 70% or greater reduction in incontinence at 10 weeks (69% vs. 58%; difference,
11 percentage points [CI, -0.3 to 22.1 percentage points]). Combination therapy
yielded better outcomes over time on the Urogenital Distress Inventory and the
Overactive Bladder Questionnaire (both P <0.001) at both time points for patient
satisfaction and perceived improvement but not health-related quality of life.
Adverse events were uncommon (12 events in 6 participants [3 in each group]).
LIMITATIONS: Behavioral therapy components (daily bladder diary and recommendations
for fluid management) in the group receiving drug therapy alone may have attenuated
between-group differences. Assigned treatment was completed by 68% of participants,
whereas 8-month outcome status was assessed on 77%.
CONCLUSION: The addition of behavioral training to drug therapy may reduce incontinence
frequency during active treatment but does not improve the ability to discontinue
drug therapy and maintain improvement in urinary incontinence. Combination therapy
has a beneficial effect on patient satisfaction, perceived improvement, and reduction
of other bladder symptoms.
Burgio KL, Kraus SR, Menefee S, Borello-France D, Corton M, Johnson HW, et al. Behavioral therapy to enable women with urge incontinence to discontinue drug treatment: a randomized trial. Ann Intern Med. 2008 Aug 5;149(3):161-9. http://www.ncbi.nlm.nih.gov/pubmed/18678843
Success rates <1% following fresh assisted reproduction treatment in women aged 45 years and older
BACKGROUND: The aim of this study was
to calculate assisted reproductive technology (ART) success rates for fresh autologous
and donor cycles in women aged > or
= 45 and the resultant cost per live birth.
METHODS: We performed a retrospective population-based study of 2339 ART cycles
conducted in Australia, 2002-2004 to women aged > or = 45 years. The cost-outcome
study was performed on fresh autologous treatment cycles.
RESULTS: There were 1101 fresh autologous cycles initiated in women aged > or
= 45, with a pregnancy rate of 1.9 per 100 initiated cycles. There were 21 women
who achieved a clinical pregnancy with 15 (71%) ending in early pregnancy loss
and 6 in live singleton births. The live birth rate following fresh autologous
initiated cycles was 0.5% [95% confidence interval (CI): 0.1-1.0%]. Fresh donor
recipients had an higher live birth rate of 19.1% (95% CI: 15.1-23.2) (odds ratio
43.2; 95% CI: 18.6-100.3) compared with women having fresh autologous cycles.
The average cost of a live birth following fresh autologous cycles was 753,107
euros. CONCLUSIONS: The success rate of fresh autologous treatment for women
aged > or = 45 years was < 1%. The very high cost of a live birth reflects
a treatment failure rate of > 99%. The ART profession should counsel patients
of the reality of the technology before the patients consent to treatment.
Sullivan E, Wang Y, Chapman M, Chambers G. Success rates and cost of a live birth following fresh assisted reproduction treatment in women aged 45 years and older, Australia 2002-2004. Hum Reprod. 2008 Jul;23(7):1639-43. Epub 2008 Apr 15. http://www.ncbi.nlm.nih.gov/pubmed/18417497
Child Health
Randomized controlled trial of a pictogram-based intervention to reduce liquid medication dosing errors and improve adherence among caregivers of young children.
OBJECTIVE: To evaluate the efficacy of a pictogram-based health
literacy intervention to decrease liquid medication administration errors by
caregivers of young children.
DESIGN: Randomized controlled trial. SETTING: Urban public hospital pediatric
emergency department.
PARTICIPANTS: Parents and caregivers (N = 245) of children aged 30 days to 8
years who were prescribed liquid medications (daily dose or "as needed").
INTERVENTION: Medication counseling using plain language, pictogram-based medication
instruction sheets. Control subjects received standard medication counseling.
OUTCOME MEASURES: Medication knowledge and practice, dosing accuracy, and adherence.
RESULTS: Of 245 randomized caregivers, 227 underwent follow-up assessments (intervention
group, 113; control group, 114). Of these, 99 were prescribed a daily dose medication,
and 158 were prescribed medication taken as needed. Intervention caregivers had
fewer errors in observed dosing accuracy (>20% deviation from prescribed dose)
compared with caregivers who received routine counseling (daily dose: 5.4% vs
47.8%; absolute risk reduction [ARR], 42.4% [95% confidence interval, 24.0%-57.0%];
number needed to treat [NNT], 2 [2-4]; as needed: 15.6% vs 40.0%; ARR, 24.4%
(8.7%-38.8%); NNT, 4 [3-12]). Of intervention caregivers, 9.3% were nonadherent
(i.e., did not give within 20% of the total prescribed doses) compared with 38.0%
of controls (ARR, 28.7% [11.4%-43.7%]; NNT, 3 [2-9]). Improvements were also
seen for knowledge of appropriate preparation for both medication types, as well
as knowledge of frequency for those prescribed daily dose medications.
CONCLUSION: A plain language, pictogram-based intervention used as part of medication
counseling resulted in decreased medication dosing errors and improved adherence
among multiethnic, low socioeconomic status caregivers whose children were treated
at an urban pediatric emergency department.
Yin HS, Dreyer BP, van Schaick L, Foltin GL, Dinglas C, Mendelsohn AL. Randomized controlled trial of a pictogram-based intervention to reduce liquid medication dosing errors and improve adherence among caregivers of young children. Arch Pediatr Adolesc Med. 2008 Sep;162(9):814-22. http://www.ncbi.nlm.nih.gov/pubmed/18762597
Ibuprofen more effective than acetaminophen for treating fever in children
OBJECTIVE: To investigate whether paracetamol (acetaminophen)
plus ibuprofen are superior to either drug alone for increasing time without
fever and the relief of fever associated discomfort in febrile children managed
at home.
DESIGN: Individually randomised, blinded, three arm trial.
SETTING: Primary care and households in England.
PARTICIPANTS: Children aged between 6 months and 6 years with axillary temperatures
of at least 37.8 degrees C and up to 41.0 degrees C.
INTERVENTION: Advice on physical measures to reduce temperature and the provision
of, and advice to give, paracetamol plus ibuprofen, paracetamol alone, or ibuprofen
alone.
MAIN OUTCOME MEASURES: Primary outcomes were the time without fever (<37.2
degrees C) in the first four hours after the first dose was given and the proportion
of children reported as being normal on the discomfort scale at 48 hours. Secondary
outcomes were time to first occurrence of normal temperature (fever clearance),
time without fever over 24 hours, fever associated symptoms, and adverse effects.
RESULTS: On an intention to treat basis, paracetamol plus ibuprofen were superior
to paracetamol for less time with fever in the first four hours (adjusted difference
55 minutes, 95% confidence interval 33 to 77; P<0.001) and may have been as
good as ibuprofen (16 minutes, -7 to 39; P=0.2). For less time with fever over
24 hours, paracetamol plus ibuprofen were superior to paracetamol (4.4 hours,
2.4 to 6.3; P<0.001) and to ibuprofen (2.5 hours, 0.6 to 4.4; P=0.008). Combined
therapy cleared fever 23 minutes (2 to 45; P=0.025) faster than paracetamol alone
but no faster than ibuprofen alone (-3 minutes, 18 to -24; P=0.8). No benefit
was found for discomfort or other symptoms, although power was low for these
outcomes. Adverse effects did not differ between groups.
CONCLUSION: Parents, nurses, pharmacists, and doctors wanting to use medicines
to supplement physical measures to maximise the time that children spend without
fever should use ibuprofen first and consider the relative benefits and risks
of using paracetamol plus ibuprofen over 24 hours.
Hay AD, Costelloe C, Redmond NM, Montgomery AA, Fletcher M, Hollinghurst S, Peters TJ. Paracetamol plus ibuprofen for the treatment of fever in children (PITCH): randomised controlled trial. BMJ. 2008 Sep 2;337:a1302. doi: 10.1136/bmj.a1302. http://www.ncbi.nlm.nih.gov/pubmed/18765450
Identifying postpartum depression: are 3 questions as good as 10?
BACKGROUND:
Postpartum depression is the most common medical problem that new mothers face.
Anxiety is a more prominent feature of postpartum depression than of depression
that occurs at other times in life. Routine, universal screening significantly
improves detection in primary health care settings. Thus, an ultrabrief scale
that could be incorporated into a general health survey or interview would be
useful.
OBJECTIVE: We tested the hypothesis that, during the first 6 postpartum months,
the 3-item anxiety subscale of the Edinburgh Postpartum Depression Scale is a
better ultrabrief depression screener than 2 Edinburgh Postpartum Depression
Scale questions that are almost identical to the widely used Patient Health Questionnaire.
METHODS: A cohort of 199 14- to 26-year-old participants in an adolescent-oriented
maternity program completed the Edinburgh Postpartum Depression Scale at well-child
visits during the first 6 postpartum months. Three subscales of the Edinburgh
Postpartum Depression Scale were examined as ultrabrief alternatives: the anxiety
subscale (3 items; Edinburgh Postpartum Depression Scale-3), the depressive symptoms
subscale (7 items; Edinburgh Postpartum Depression Scale-7), and 2 questions
that resemble the Patient Health Questionnaire (Edinburgh Postpartum Depression
Scale-2). The reliability, stability, and construct validity of the Edinburgh
Postpartum Depression Scale and 3 subscales were compared. Criterion validity
was assessed by comparison with a score of >/=10 on the full, 10-item Edinburgh
Postpartum Depression Scale. RESULTS: A total of 41 mothers (20.6%) met study
criteria for referral for evaluation of depression (Edinburgh Postpartum Depression
Scale-10 score >/= 10). The Edinburgh Postpartum Depression Scale-3 exhibited
the best screening performance characteristics, with sensitivity at 95% and negative
predictive value at 98%. It identified 16% more mothers as depressed than the
Edinburgh Postpartum Depression Scale did. The performance of the Edinburgh Postpartum
Depression Scale-2 was markedly inferior, with sensitivity at 48% to 80%. Moreover,
the Edinburgh Postpartum Depression Scale-2 was unreliable for mothers who had
not been depressed in the past.
CONCLUSION: The brevity, reliability, and operating characteristics of the Edinburgh
Postpartum Depression Scale-3 make it an attractive postpartum depression screening
tool for primary health care settings in which the goal is to detect depression,
not to assess its severity. Validation by diagnostic psychiatric interview is
needed.
Kabir K, Sheeder J, Kelly LS. Identifying postpartum depression: are 3 questions as good as 10? Pediatrics. 2008 Sep;122(3):e696-702. http://www.ncbi.nlm.nih.gov/pubmed/18762505
Chronic Disease and Illness
Incidence and Risk Factors for Stroke in American Indians; The Strong Heart Study
BACKGROUND: There are few published data on the incidence of fatal and nonfatal
stroke in American Indians. The aims of this observational study were to determine
the incidence of stroke and to elucidate stroke risk factors among American Indians.
METHODS AND RESULTS: This report is based on 4549 participants aged 45 to 74
years at enrollment in the Strong Heart Study, the largest longitudinal, population-based
study of cardiovascular disease and its risk factors in a diverse group of American
Indians. At baseline examination in 1989 to 1992, 42 participants (age- and sex-adjusted
prevalence proportion 1132/100 000, adjusted to the age and sex distribution
of the US adult population in 1990) had prevalent stroke. Through December 2004,
306 (6.8%) of 4507 participants without prior stroke suffered a first stroke
at a mean age of 66.5 years. The age- and sex-adjusted incidence was 679/100
000 person-years. Nonhemorrhagic cerebral infarction occurred in 86% of participants
with incident strokes; 14% had hemorrhagic stroke. The overall age-adjusted 30-day
case-fatality rate from first stroke was 18%, with a 1-year case-fatality rate
of 32%. Age, diastolic blood pressure, fasting glucose, hemoglobin A1c, smoking,
albuminuria, hypertension, prehypertension, and diabetes mellitus were risk factors
for incident stroke.
CONCLUSIONS: Compared with US white and black populations, American Indians have
a higher incidence of stroke. The case-fatality rate for first stroke is also
higher in American Indians than in the US white or black population in the same
age range. Our findings suggest that blood pressure and glucose control and smoking
avoidance may be important avenues for stroke prevention in this population.
Zhang Y, Galloway JM, Welty TK, Wiebers DO, Whisnant JP, Devereux RB, et al. Incidence and Risk Factors for Stroke in American Indians. The Strong Heart Study. Circulation. 2008 Sep 22. [Epub ahead of print] http://www.ncbi.nlm.nih.gov/pubmed/18809797
Expanded Recommendations for Hepatitis B Screening
Serologic testing for hepatitis B surface antigen (HBsAg) is the primary way to identify persons with chronic hepatitis B virus (HBV) infection. Testing has been recommended previously for pregnant women, infants born to HBsAg-positive mothers, household contacts and sex partners of HBV-infected persons, persons born in countries with HBsAg prevalence of >8%, persons who are the source of blood or body fluid exposures that might warrant postexposure prophylaxis (e.g., needlestick injury to a health-care worker or sexual assault), and persons infected with human immunodeficiency virus. This report updates and expands previous CDC guidelines for HBsAg testing and includes new recommendations for public health evaluation and management for chronically infected persons and their contacts. Routine testing for HBsAg now is recommended for additional populations with HBsAg prevalence of >2%: persons born in geographic regions with HBsAg prevalence of >2%, men who have sex with men, and injection-drug users. Implementation of these recommendations will require expertise and resources to integrate HBsAg screening in prevention and care settings serving populations recommended for HBsAg testing. This report is intended to serve as a resource for public health officials, organizations, and health-care professionals involved in the development, delivery, and evaluation of prevention and clinical services.
Centers for Disease Control and Prevention. Recommendations for Identification and Public Health Management of Persons with Chronic Hepatitis B Virus Infection. MMWR 2008;57(No. RR-8):1-16. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5708a1.htm?s_cid=rr5708a1_e
Association of Urinary Bisphenol A Concentration With Medical Disorders and Laboratory Abnormalities in Adults
CONTEXT: Bisphenol A (BPA) is
widely used in epoxy resins lining food and beverage containers. Evidence of
effects in animals has generated concern over low-level chronic exposures in
humans.
OBJECTIVE: To examine associations between urinary BPA concentrations and
adult health status.
DESIGN, SETTING, and PARTICIPANTS: Cross-sectional analysis of BPA concentrations
and health status in the general adult population of the United States, using
data from the National Health and Nutrition Examination Survey 2003-2004. Participants
were 1455 adults aged 18 through 74 years with measured urinary BPA and urine
creatinine concentrations. Regression models were adjusted for age, sex, race/ethnicity,
education, income, smoking, body mass index, waist circumference, and urinary
creatinine concentration. The sample provided 80% power to detect unadjusted
odds ratios (ORs) of 1.4 for diagnoses of 5% prevalence per 1-SD change in BPA
concentration, or standardized regression coefficients of 0.075 for liver enzyme
concentrations, at a significance level of P < .05.
MAIN OUTCOME MEASURES: Chronic disease diagnoses plus blood markers of liver
function, glucose homeostasis, inflammation, and lipid changes.
RESULTS: Higher urinary BPA concentrations were associated with cardiovascular
diagnoses in age-, sex-, and fully adjusted models (OR per 1-SD increase in BPA
concentration, 1.39; 95% confidence interval [CI], 1.18-1.63; P = .001
with full adjustment). Higher BPA concentrations were also associated with diabetes
(OR per 1-SD increase in BPA concentration, 1.39; 95% confidence interval [CI],
1.21-1.60; P < .001) but not with other studied common
diseases. In addition, higher BPA concentrations were associated with clinically
abnormal concentrations of the liver enzymes 
-glutamyltransferase
(OR per 1-SD increase in BPA concentration, 1.29; 95% CI, 1.14-1.46; P < .001)
and alkaline phosphatase (OR per 1-SD increase in BPA concentration, 1.48; 95%
CI, 1.18-1.85; P = .002).
CONCLUSION: Higher BPA exposure, reflected in higher urinary concentrations of
BPA, may be associated with avoidable morbidity in the community-dwelling adult
population.
Lang IA, Galloway TS, Scarlett A, Henley WE, Depledge M, Wallace RB, Melzer D. Association of Urinary Bisphenol A Concentration With Medical Disorders and Laboratory Abnormalities in Adults. JAMA. 2008;300(11):1303-1310. Published online September 16, 2008 (doi:10.1001/jama.300.11.1303). http://jama.ama-assn.org/cgi/content/full/300/11/1303
JAMA Editorial:
vom Saal FS, Myers JP. Bisphenol A and Risk of Metabolic Disorders. JAMA. 2008;300(11):1353-1355. Published online September 16, 2008. http://jama.ama-assn.org/cgi/content/full/300/11/1353
Alcohol-Attributable Deaths and Years of Potential Life Lost Among American Indians and Alaska Natives --- United States, 2001--2005
Excessive alcohol consumption is a leading preventable cause of death in the United States (1) and has substantial public health impact on American Indian and Alaska Native (AI/AN) populations (2). To estimate the average annual number of alcohol-attributable deaths (AADs) and years of potential life lost (YPLLs) among AI/ANs in the United States, CDC analyzed 2001--2005 data (the most recent data available), using death certificate data and CDC Alcohol-Related Disease Impact (ARDI) software.* This report summarizes the results of that analysis, which indicated that AADs accounted for 11.7% of all AI/AN deaths, that the age-adjusted AAD rate for AI/ANs was approximately twice that of the U.S. general population, and that AI/ANs lose 6.4 more years of potential life per AAD compared with persons in the U.S. general population (36.3 versus 29.9 years). These findings underscore the importance of implementing effective population-based interventions to prevent excessive alcohol consumption and to reduce alcohol-attributable morbidity and mortality among AI/ANs.
Centers for Disease Control. Alcohol-Attributable Deaths and Years of Potential Life Lost Among American Indians and Alaska Natives --- United States, 2001--2005. MMWR. August 29, 2008 / 57(34);938-941 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5734a3.htm?s_cid=mm5734a3_e
Should the window for thrombolytic use be extended for stroke?
BACKGROUND:
Intravenous thrombolysis with alteplase is the only approved treatment for acute
ischemic stroke, but its efficacy and safety when administered more than 3 hours
after the onset of symptoms have not been established. We tested the efficacy
and safety of alteplase administered between 3 and 4.5 hours after the onset
of a stroke.
METHODS: After exclusion of patients with a brain hemorrhage or major infarction,
as detected on a computed tomographic scan, we randomly assigned patients with
acute ischemic stroke in a 1:1 double-blind fashion to receive treatment with
intravenous alteplase (0.9 mg per kilogram of body weight) or placebo. The primary
end point was disability at 90 days, dichotomized as a favorable outcome (a score
of 0 or 1 on the modified Rankin scale, which has a range of 0 to 6, with 0 indicating
no symptoms at all and 6 indicating death) or an unfavorable outcome (a score
of 2 to 6 on the modified Rankin scale). The secondary end point was a global
outcome analysis of four neurologic and disability scores combined. Safety end
points included death, symptomatic intracranial hemorrhage, and other serious
adverse events.
RESULTS: We enrolled a total of 821 patients in the study and randomly assigned
418 to the alteplase group and 403 to the placebo group. The median time for
the administration of alteplase was 3 hours 59 minutes. More patients had a favorable
outcome with alteplase than with placebo (52.4% vs. 45.2%; odds ratio, 1.34;
95% confidence interval [CI], 1.02 to 1.76; P=0.04). In the global analysis,
the outcome was also improved with alteplase as compared with placebo (odds ratio,
1.28; 95% CI, 1.00 to 1.65; P<0.05). The incidence of intracranial hemorrhage
was higher with alteplase than with placebo (for any intracranial hemorrhage,
27.0% vs. 17.6%; P=0.001; for symptomatic intracranial hemorrhage, 2.4% vs. 0.2%;
P=0.008). Mortality did not differ significantly between the alteplase and placebo
groups (7.7% and 8.4%, respectively; P=0.68). There was no significant difference
in the rate of other serious adverse events.
CONCLUSIONS: As compared with placebo, intravenous alteplase administered between
3 and 4.5 hours after the onset of symptoms significantly improved clinical outcomes
in patients with acute ischemic stroke; alteplase was more frequently associated
with symptomatic intracranial hemorrhage.
Hacke W, Kaste M, Bluhmki E, Brozman M, Davalos A, Guidetti D, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 2008 Sep 25;359(13):1317-29. http://www.ncbi.nlm.nih.gov/pubmed/18815396
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OB/GYN
Jean Howe, MD, MPH is the Obstetrics and Gynecology Chief Clinical Consultant (OB/GYN C.C.C.). Dr. Howe 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 American Indian and Alaska Native women and also indigenous peoples around the world. Please don't hesitate to contact her by e-mail (jean.howe@ihs.gov) or phone at (928) 674-7422.
