February 2005 CCC Corner > Hot Topics

Hot Topics:

• Obstetrics
• Gynecology
• Child Health
• Chronic Disease and Illness

Obstetrics

Severe Preeclampsia and Eclampsia: Systolic Hypertension Is Also Important

CONCLUSION: In contrast to severe systolic hypertension, severe diastolic hypertension does not develop before stroke in most patients with severe preeclampsia and eclampsia. A paradigm shift is needed toward considering antihypertensive therapy for severely preeclamptic and eclamptic patients when systolic blood pressure reaches or exceeds 155-160 mm Hg. LEVEL OF EVIDENCE: III. Martin JN  Stroke and severe preeclampsia and eclampsia: a paradigm shift focusing on systolic blood pressure. Obstet Gynecol. 2005 Feb;105(2):246-54.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15684147&dopt=Abstract

Editorial

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15684145&dopt=Abstract

Progesterone Treatment Decreases Preterm Birth Rate

CONCLUSION: Use of 17P could reduce preterm birth among eligible women, but would likely have a modest effect on the national preterm birth rate. Additional research is urgently needed to identify other populations who might benefit from 17P, evaluate new methods for early detection of women at risk, and develop additional prevention strategies. LEVEL OF EVIDENCE: III.

Petrini JR, et al Estimated effect of 17 alpha-hydroxyprogesterone caproate on preterm birth in the United States. Obstet Gynecol. 2005 Feb;105(2):267-72. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15684150&dopt=Abstract

and

CONCLUSION: The use of progestational agents and 17alpha-hydroxyprogesterone caproate reduced the incidence of preterm birth and low birth weight newborns.

Sanchez-Ramos L et al Progestational agents to prevent preterm birth: a meta-analysis of randomized controlled trials. Obstet Gynecol. 2005 Feb;105(2):273-9. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15684151&dopt=Abstract

and

ACOG: Progesterone Treatment Decreases Preterm Birth Rate

https://www.acog.com/from_home/publications/press_releases/nr01-31-05-1.cfm

Ripening of the Cervix and Risk for Later Preterm Birth

CONCLUSION: The use of the Foley catheter for preinduction cervical ripening does not appear to increase the risk of preterm birth in a subsequent pregnancy.

Sciscione A  et al Preinduction cervical ripening with the Foley catheter and the risk of subsequent preterm birth. Am J Obstet Gynecol. 2004 Mar;190(3):751-4. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15042009

Ginger May Relieve Nausea During Early Pregnancy

CONCLUSION: For women looking for relief from their nausea, dry retching, and vomiting, the use of ginger in early pregnancy will reduce their symptoms to an equivalent extent as vitamin B6. LEVEL OF EVIDENCE: I Smith C, et al. A randomized controlled trial of ginger to treat nausea and vomiting in pregnancy. Obstet Gynecol April 2004;103:639-45. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15051552

Effect of Episiotomy on Pelvic Floor Weakness

CONCLUSION: Mediolateral episiotomy does not protect against urinary and anal incontinence and genital prolapse and is associated with a lower pelvic floor muscle strength compared with spontaneous perineal lacerations and with more dyspareunia and perineal pain. LEVEL OF EVIDENCE: II-2  Sartore A, et al. The effects of mediolateral episiotomy on pelvic floor function after vaginal delivery. Obstet Gynecol April 2004;103:669-73.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15051557

Role of Regular Physical Activity in Preeclampsia Prevention

Abnormal placental development, predisposing maternal constitutional factors, oxidative stress, immune maladaptation, and genetic susceptibility have all been hypothesized to contribute to the development of preeclampsia. Physical conditioning and preeclampsia have opposite effects on critical physiological functions. This suggests that regular prenatal exercise may prevent or oppose the progression of the disease. Epidemiologic studies show that occupational and leisure-time physical activity is associated with a reduced incidence of preeclampsia.

Weissgerber TL  et al The role of regular physical activity in preeclampsia prevention. Med Sci Sports Exerc. 2004 Dec;36(12):2024-31.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15570135

Subclinical hypothyroidism: should all pregnant women be screened?

CONCLUSION: We speculate that the previously reported reduction in intelligence quotient of offspring of women with subclinical hypothyroidism may be related to the effects of prematurity. LEVEL OF EVIDENCE: II-2. Casey BM, et al Subclinical hypothyroidism and pregnancy outcomes. Obstet Gynecol. 2005 Feb;105(2):239-45. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15684146&dopt=Abstract

Editorial

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15684144&dopt=Abstract 

Diagnosis, Prevention, and Management of Eclampsia

The development of eclampsia is associated with increased risk of adverse outcome for both mother and fetus, particularly in the developing nations. Pregnancies complicated by eclampsia require a well-formulated management plan. Women with a history of eclampsia are at increased risk of eclampsia (1-2%) and preeclampsia (22-35%) in subsequent pregnancies. Recommendations for diagnosis, prevention, management, and counseling of these women are provided based on results of recent studies and my own clinical experience.

Sibai, BM. Diagnosis, Prevention, and Management of Eclampsia Obstet Gynecol. 2005 Feb;105(2):402-10. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15684172&dopt=Abstract

Pregnancy Outcomes Worsening for Diabetic Women

CONCLUSIONS: The perinatal outcome of pregnancies in women with type 2 diabetes during 1996-2001 is poor. It is worse than the outcome of pregnancies in women with type 1 diabetes and the background population in the same period, as well as in women with type 2 diabetes studied during 1982-1990. Clausen TD, et al Poor pregnancy outcome in women with type 2 diabetes. Diabetes Care. 2005 Feb;28(2):323-8

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15677787

Heavy mother, heavy child

CONCLUSION: Anthropometric measures were not significantly different between groups at year 2; weight and lean body mass were greater at years 4 and 6, and fat mass was greater at year 6 in high-risk children. Berkowitz RI, et al Growth of children at high risk of obesity during the first 6 years of life: implications for prevention. Am J Clin Nutr. 2005 Jan;81(1):140-6.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15640473

Substances Found in Blood May Predict Development of Preeclampsia

Abnormal levels of two molecules found in the blood appear to predict the development of preeclampsia.  When compared to women who did not have preeclampsia, women who later developed the condition had elevated blood levels of a substance known as soluble fms-like tyrosine kinase 1 (sFlt-1), before their preeclampsia occurred. Conversely, beginning early in their pregnancies, these women had lower levels of a substance known as placental growth factor (PlGF) in the blood than did women who did not develop preeclampsia.  

http://www.nichd.nih.gov/new/releases/preeclampsia.cfm#nejm

Pain Management After Cesarean Delivery

CONCLUSION: Pain relief was superior with the morphine regimens used and was positively associated with breastfeeding and infant rooming-in.

Yost NP, et al. A hospital-sponsored quality improvement study of pain management after cesarean delivery. Am J Obstet Gynecol May 2004;190:1341-6.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15167840

Neural Tube Defect Risk Persists in Babies of Overweight Mothers

CONCLUSION: These data emphasize the higher risk of NTD associated with increased maternal weight, even after universal folic acid flour fortification. Beyond periconceptional folic acid use, consideration should be given to testing whether prepregnancy weight reduction is an independent means of preventing NTD. Ray JG, et al Greater maternal weight and the ongoing risk of neural tube defects after folic acid flour fortification. Obstet Gynecol. 2005 Feb;105(2):261-5. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15684149&dopt=Abstract

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Gynecology

Sexual Function After Hysterectomy

CONCLUSION: Most patients expected and experienced no change in sexual desire, orgasm frequency, or orgasm intensity. Hysterectomy appears to result in decreased pain with sexual relations. Dragisic KG, Milad MP. Sexual functioning and patient expectations of sexual functioning after hysterectomy. Am J Obstet Gynecol May 2004;190:1416-8.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15167854

Screening for Ovarian Cancer: Recommendation Statement

U.S. PREVENTIVE SERVICES TASK FORCE: SUMMARY OF RECOMMENDATIONS

The USPSTF recommends against routine screening for ovarian cancer. D recommendation.

The USPSTF found fair evidence that screening with serum CA-125 level or transvaginal ultrasound can detect ovarian cancer at an earlier stage than it can be detected in the absence of screening; however, the USPSTF found fair evidence that earlier detection would likely have a small effect, at best, on mortality from ovarian cancer. Because of the low prevalence of ovarian cancer and the invasive nature of diagnostic testing after a positive screening test, there is fair evidence that screening could likely lead to important harms. The USPSTF concluded that the potential harms outweigh the potential benefits.

HTTP://WWW.AAFP.ORG/AFP/20050215/US.HTML

Limitations of Screening Tests for Asymptomatic Chlamydia

CONCLUSION: When C. trachomatis infection was defined by multiple tests from different specimen sources, the sensitivity of any 1 test from a single specimen source was lower than generally reported. The limitations of the use of a single test to identify C. trachomatis infection should be considered when test type, specimen source, and collection method for screening young women is being determined.  

Shrier LA, et al. Limitations of screening tests for the detection of Chlamydia trachomatis in asymptomatic adolescent and young adult women. Am J Obstet Gynecol March 2004;190:654-62. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15041995

Abnormal Uterine Bleeding: Surgical or Medical Therapy?

CONCLUSIONS: Among women with abnormal uterine bleeding and dissatisfaction with medroxyprogesterone, hysterectomy was superior to expanded medical treatment for improving health-related quality-of-life after 6 months. With longer follow-up, half the women randomized to medicine elected to undergo hysterectomy, with similar and lasting quality-of-life improvements; those who continued medical treatment also reported some improvements.

Kuppermann M, et al., for the Ms Research Group. Effect of hysterectomy vs medical treatment on health-related quality of life and sexual functioning. The medicine or surgery (Ms) randomized trial. JAMA March 24/31, 2004;291:1447-55.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15039411

Endometriosis and Subfertility: Is the Relationship Resolved?

Conclusion: Based on the evidence presented in this article, many arguments support the hypothesis that endometriosis causes subfertility. D'Hooghe TM et al Endometriosis and subfertility: is the relationship resolved? Semin Reprod Med. 2003 May;21(2):243-54.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12917793

Selecting Medications for the Treatment of Urinary Incontinence (also Patient Education)

http://www.aafp.org/afp/20050115/315.html

Dysmenorrhea  (also see Patient Education)

http://www.aafp.org/afp/20050115/285.html

Procedural Sedation in the Acute Care Setting

http://www.aafp.org/afp/20050101/85.html

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Child Health

Gender bias in child growth evaluations may miss disease in girls

CONCLUSIONS: Sex differences in short stature referrals may delay diagnosis of diseases in girls while promoting overzealous evaluations of healthy boys who do not appear to be tall enough.  Grimberg A, et al Sex differences in patients referred for evaluation of poor growth. J Pediatr. 2005 Feb;146(2):212-6.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15689911

Recommended Childhood and Adolescent Immunization Schedule, United States, 2005

CDC National Immunization Program Web site   (http://www.cdc.gov/nip) 

AAFP Web site       (http://www.aafp.org/x10615.xml)

Society of Teachers of Family Medicine   (http://www.immunizationed.org), 

Immunization Action Coalition Web site   (http://www.immunize.org);

National Network for Immunization Information Web site  (http://www.immunizationinfo.org).

Protective effects of firearm storage practices for children

The 4 specific practices of keeping a gun locked, unloaded, and storing ammunition locked and in a separate location were associated with a protective effect and suggest feasible strategies to reduce these types of injuries in homes with children and adolescents where guns are stored.

Grossman DC, Mueller BA, Riedy C, et al. 2005. Gun storage practices and risk of youth suicide and unintentional firearm injuries. JAMA, The Journal of the American Medical Association 293(6):707-714. http://jama.ama-assn.org/cgi/content/abstract/293/6/707?etoc.

Dramatic decline in varicella related mortality: Impact of vaccine

After the universal childhood varicella vaccination program was implemented in 1995, the incidence of disease in the United States declined by 71% to 84% by 2000 in areas of active surveillance and by 67% to 82% by 2001 in areas of passive surveillance

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15689583&dopt=Abstract

Oral health is looking to better capture the topical fluoride applications

Are you and or your non-dental provider staff using this code? If not which one are you using? Please email Patrick Blahut Patrick.Blahut@ihs.gov 

ICD-9 Code ICD-9 Code Description

V07.31  NEED FOR PROPHYLACTIC FLUORIDE ADMINISTRATION

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Chronic disease and Illness

Quality of Care May Decline as Physicians Age

CONCLUSIONS: Physicians who have been in practice longer may be at risk for providing lower-quality care. Therefore, this subgroup of physicians may need quality improvement interventions. Choudhry NK, et  al Systematic review: the relationship between clinical experience and quality of health care. Ann Intern Med. 2005 Feb 15;142(4):260-73.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15710959

Chronic disease antecedents arise in utero and infancy: The Barker Hypothesis

Fetal Infant Mortality (NFIMR) conference in August plenary session by Dr. Michael Lu presented birth outcomes that you will find provocative and insightful.  It focuses primarily on White and African American differences and includes AI/AN population in the graphs to a certain extent.   

 Dr. Lu introduces a model of life trajactory, "the weathering factor", and the Barker Hypothesis calling attention to the multifactoral nature of birth outcomes and that there is no one easy fix.  http://128.248.232.90/archives/mchb/dpswh/august2004/dpswhaugust2004slides.pdf

Medscape article on the Barker Hypothesis:

http://www.medscape.com/viewarticle/453242_print

JAMA Editorialist recommends the "low fad" approach

CONCLUSIONS: Each popular diet modestly reduced body weight and several cardiac risk factors at 1 year. Overall dietary adherence rates were low, although increased adherence was associated with greater weight loss and cardiac risk factor reductions for each diet group.

Dansinger ML et al Comparison of the Atkins, Ornish, Weight Watchers, and Zone diets for weight loss and heart disease risk reduction: a randomized trial. JAMA. 2005 Jan 5;293(1):43-53. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15632335

The dietary approach to obesity: is it the diet or the disorder?

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15632342

Book Review

Diabetes Mellitus in Women: Adolescence Through Pregnancy and Menopause

Third edition. Edited by E. Albert Reece, Donald R. Coustan, and Steven G. Gabbe. 492 pp., illustrated. Philadelphia, Lippincott Williams & Wilkins, 2004. $99. ISBN 0-7817-3861-X.

http://content.nejm.org/cgi/content/extract/352/6/638

Irritable Bowel Syndrome: What are the effects of treatments in people with irritable bowel syndrome (IBS)? Clinical Evidence Concise: A Publication of BMJ Publishing Group

A. Likely to be beneficial

Antidepressants (Amitriptyline, Clomipramine, Desipramine, Doxepin, Mianserin, Trimipramine). One systematic review found limited evidence from low to moderate quality randomized controlled trials (RCTs) that antidepressants (amitriptyline, clomipramine, desipramine, doxepin, mianserin, trimipramine) reduced symptoms of IBS compared with placebo in the short term. It was not clear whether the effects on IBS were independent of the effects on psychological symptoms.

Smooth Muscle Relaxants (Cimetropium Bromide, Hyoscine Butyl Bromide, Mebeverine Hydrochloride, Otilonium Bromide, Pinaverium Bromide, Trimebutine). One systematic review found limited evidence that smooth muscle relaxants (cimetropium bromide, hyoscine butyl bromide, mebeverine hydrochloride, otilonium bromide, pinaverium bromide, trimebutine) improved symptoms compared with placebo. One subsequent RCT found no significant difference between alverine and placebo in improvement in abdominal pain, although the study may have lacked power to exclude a clinically important effect. One RCT identified by a systematic review found that mebeverine was less effective for symptoms than alosetron in women with diarrhea-predominant IBS, although there are concerns that alosetron may be associated with ischemic colitis.

B. Trade-off between benefits and harms

5HT4 Receptor Agonists (Tegaserod). One systematic review found that in women with constipation-predominant IBS, tegaserod improved symptoms compared with placebo. It found insufficient evidence about the effects of tegaserod in men. Tegaserod was more likely to cause diarrhea than placebo.

Alosetron. One systematic review found that alosetron (a 5HT3 receptor antagonist) improved symptoms in women with diarrhea-predominant IBS compared with placebo or mebeverine. However, alosetron is associated with adverse effects, particularly constipation, and has been restricted in some countries because of concerns that it may be associated with ischemic colitis. The systematic review provided insufficient evidence about the effects of alosetron in men.

unknown effectiveness

5HT3 Receptor Antagonists Other Than Alosetron. We found no RCTs examining 5HT3 receptor antagonists other than alosetron.

Fiber Supplementation. Small RCTs provided insufficient evidence on the effects of fiber supplementation on the symptoms of IBS. http://www.aafp.org/afp/20050201/bmj.html

Definition of Metabolic Syndrome

There has been disagreement in the medical community over the definition of the metabolic syndrome. The National Heart, Lung, and Blood Institute collaborated with the American Heart Association to examine the issues associated with the definition. 

The metabolic syndrome seems to have three potential etiologies: obesity and disorders of adipose tissue; insulin resistance; and a constellation of independent factors (e.g., molecules of hepatic, vascular, and immunologic origin) that mediate specific components of the metabolic syndrome. Other factors such as aging, proinflammatory state, and hormonal changes also have been implicated.

The clinical criteria for the diagnosis of metabolic syndrome, as defined in the National Cholesterol Education Program's Adult Treatment Panel III (ATP III) report, include waist circumference of more than 102 cm (40 in) in men and more than 88 cm (35 in) in women; triglyceride levels of at least 150 mg per dL (1.70 mmol per L); high-density lipoprotein cholesterol levels of less than 40 mg per dL (1.04 mmol per L) in men and less than 50 mg per dL (1.30 mmol per L) in women; blood pressure of at least 130/85 mm Hg; and fasting glucose levels of at least 110 mg per dL (6.10 mmol per L).

ATP III did not include impaired glucose tolerance, as detected by an oral glucose tolerance test (OGTT) or two-hour postglucose challenge, in the risk factors for metabolic syndrome. Its added value for determining cardiovascular risk appears small, and the benefit did not outweigh the inconvenience and cost of administering the OGTT in clinical practice. However, conference participants suggested adding OGTT at the physician's discretion in patients without diabetes with ATP III-defined metabolic syndrome or two or more metabolic risk factors. In the absence of impaired fasting glucose, impaired glucose tolerance could count as a risk factor to define metabolic syndrome. Their report is available online at http://www.circulationaha.org

Benefits of Omega-3 Fatty Acids

Consumption of fish oil can help reduce deaths from heart disease, but its effects on other outcomes are inconclusive, according to evidence reports from the Agency for Healthcare Research and Quality (AHRQ).  http://www.ahrq.gov/clinic/epcindex.htm#dietsup.

An analysis of 10 randomized controlled trials (RCTs) and nine other studies addressed the effects of omega-3 fatty acids on respiratory outcomes. The AHRQ could not conclude whether omega-3 fatty acids are an efficacious adjuvant or monotherapy in improving respiratory outcomes in adults or children. 

Overall, strong evidence shows that fish oils have a strong, dose-dependent beneficial effect on triglyceride levels. There also is evidence of possible small beneficial effects on blood pressure and coronary artery restenosis after angioplasty, exercise capacity in patients with coronary atherosclerosis, and heart rate variability, particularly in patients with recent MI. Omega-3 fatty acids do not appear to affect total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, fasting blood sugar, or glycosylated hemoglobin levels, and they had no effect on plasma insulin levels and insulin resistance in patients with type 2 diabetes.

http://www.aafp.org/afp/20050115/practice.html

Red meat consumption linked to colorectal cancer

CONCLUSIONS: Our results demonstrate the potential value of examining long-term meat consumption in assessing cancer risk and strengthen the evidence that prolonged high consumption of red and processed meat may increase the risk of cancer in the distal portion of the large intestine.

Chao A et al Meat consumption and risk of colorectal cancer. JAMA. 2005 Jan 12;293(2):172-82. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15644544

Comment

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15644551

Sugar-Sweetened Soft Drinks, Obesity, and Type 2 Diabetes

CONCLUSION: Higher consumption of sugar-sweetened beverages is associated with a greater magnitude of weight gain and an increased risk for development of type 2 diabetes in women, possibly by providing excessive calories and large amounts of rapidly absorbable sugars.

Schulze MB  et al Sugar-sweetened beverages, weight gain, and incidence of type 2 diabetes in young and middle-aged women. JAMA. 2004 Aug 25;292(8):927-34. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15328324

Comment: 

Sugar-sweetened soft drinks contribute 7.1% of total energy intake and represent the largest single food source of calories in the US diet. The article by Schulze and colleagues in this issue of JAMA represents another link in the chain of evidence. This study provides additional evidence that excess calories from sugar-sweetened soft drinks are responsible for the increasing prevalence of obesity among adults and also implicates sugar-sweetened soft drinks as a cause of type 2 diabetes.  Apovian CM. Sugar-sweetened soft drinks, obesity, and type 2 diabetes. JAMA. 2004 Aug 25;292(8):978-9 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15328331

Nevirapine Alert (Viramune) - Serious liver toxicity with CD4+cell counts greater than 250

FDA issued a public health advisory to inform health care providers and patients about recent

safety-related changes to the nevirapine (Viramune) label and about appropriate use of HIV triple combination therapy containing nevirapine. The Indications and Usage section now recommends

against starting nevirapine treatment in women with CD4+cell counts greater than 250 cells/mm3 unless benefits clearly outweigh risks. This recommendation is based on a higher observed risk of serious liver toxicity in patients with higher CD4 cell counts prior to initiation of therapy.

http://www.fda.gov/medwatch/SAFETY/2005/safety05.htm#viramune

Mayo Clinic discovers a key to low metabolism -- and major factor in obesity

Obesity occurs when energy intake exceeds energy expenditure. Humans expend energy through purposeful exercise and through changes in posture and movement that are associated with the routines of daily life [called nonexercise activity thermogenesis (NEAT)]. To examine NEAT's role in obesity, we recruited 10 lean and 10 mildly obese sedentary volunteers and measured their body postures and movements every half-second for 10 days. Obese individuals were seated, on average, 2 hours longer per day than lean individuals. Posture allocation did not change when the obese individuals lost weight or when lean individuals gained weight, suggesting that it is biologically determined. If obese individuals adopted the NEAT-enhanced behaviors of their lean counterparts, they might expend an additional 350 calories (kcal) per day.

Levine JA, et al Interindividual variation in posture allocation: possible role in human obesity. Science. 2005 Jan 28;307(5709):584-6.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15681386

C-Reactive Protein Comparable to LDL as an Indicator 

CONCLUSIONS: Patients who have low CRP levels after statin therapy have better clinical outcomes than those with higher CRP levels, regardless of the resultant level of LDL cholesterol. Strategies to lower cardiovascular risk with statins should include monitoring CRP as well as cholesterol.  Ridker PM, et al C-reactive protein levels and outcomes after statin therapy. N Engl J Med. 2005 Jan 6;352(1):20-8. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15635109

Diagnostic Approach to Palpitations (See Patient Education)

http://www.aafp.org/afp/20050215/743.html

ACG Releases Updated Practice Guidelines for Ulcerative Colitis in Adults

http://www.aafp.org/afp/20050201/practice.html

Guidelines for Cardiovascular Disease Prevention in Women

http://www.aafp.org/afp/20050201/practice.html

Antidepressants and Antiepileptic Drugs for Chronic Non-Cancer Pain

http://www.aafp.org/afp/20050201/483.html

Ambulatory Detoxification of Patients with Alcohol Dependence (See Patient Education)

http://www.aafp.org/afp/20050201/495.html

Treatment of Panic Disorder (See Patient Education)

http://www.aafp.org/afp/20050215/733.html

Care of Cancer Survivors (See Patient Education)

http://www.aafp.org/afp/20050215/699.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.