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Volume 5, No. 2, February 2007
Hot Topics
Obstetrics | Gynecology | Child Health | Chronic Disease and Illness
Obstetrics
Teamwork Training: Decision to incision times significantly improved
RESULTS: One process measure, the time from the decision to perform an immediate cesarean delivery to the incision, differed significantly after team training (33.3 minutes versus 21.2 minutes, P=.03).
CONCLUSION: Training, as was conducted and implemented, did not transfer to a detectable impact in this study. The Adverse Outcome Index could be an important tool for comparing obstetric outcomes within and between institutions to help guide quality improvement. LEVEL OF EVIDENCE: I.
Nielsen PE, et al Effects of Teamwork Training on Adverse Outcomes and Process of Care in Labor and Delivery: A Randomized Controlled Trial. Obstet Gynecol. 2007 Jan;109(1):48-55
OB/GYN CCC Editorial comment:
Put innovation into motion:National Indian Health MCH and Women’s Health meeting
Another successful example is the 100,000 Lives Campaign, which is an initiative to engage US hospitals in a commitment to implement changes in care proven to improve patient care and prevent avoidable deaths. The Institute for Healthcare Improvement estimates that the lives saved as of June 14, 2006 was 122,300.
To that end, the National Indian Health MCH and Women’s Health meeting , August 15-17, 2007 in Albuquerque will highlight speakers from the Institute for Healthcare Improvement and others that have evaluated and treated various health care systems. The meeting has individual facility program review as well as many hours of CME/CEUs.
Your facility should send a team of staff to the above meeting, e. g., you and 2-3 other colleagues from different disciplines should start planning now.
National Indian Health MCH and Women’s Health meeting
http://www.ihs.gov/MedicalPrograms/MCH/F/CN01.cfm#Aug07
Physical activity in pregnancy: Important determinant of birth weight
Infants born to women in the highest quartile of physical activity weighed 608 g less than infants born to women in the lowest quartile. The inverse relationship between physical activity and fetal growth ratio was moderated by maternal height; virtually all the effect was seen in mothers taller than the sample median (1.65 m). Similar relationships were found across methods of physical activity measurement. CONCLUSION: Aerobic physical activity in pregnancy may be an important determinant of birth weight within the normal range, especially in taller mothers. LEVEL OF EVIDENCE: II. Perkins CC, et al Physical Activity and Fetal Growth During Pregnancy. Obstet Gynecol. 2007 Jan;109(1):81-87
Fetal injury and death twice as likely to have been born from 11 pm to 8 am
CONCLUSION: Fetuses sustaining injuries resulting in death were more than twice as likely as controls to have been born from 11 pm to 8 am. Further studies are needed to determine the factors that affect this association and what changes might need to be made to optimize care regardless of time of day or night
Urato AC, et al The association between time of birth and fetal injury resulting in death. Am J Obstet Gynecol. 2006 Dec;195(6):1521-6.
VBAC is safer
Among VBAC candidates who have had a prior vaginal delivery, those who attempt a VBAC trial have decreased risk for overall major maternal morbidities, as well as maternal fever and transfusion requirement compared with women who elect repeat cesarean delivery. Physicians should make this more favorable benefit-risk ratio explicit when counseling this patient subpopulation on a trial of labor.
Cahill AG, et al Is vaginal birth after cesarean (VBAC) or elective repeat cesarean safer in women with a prior vaginal delivery? Am J Obstet Gynecol. 2006 Oct;195(4):1143-7
Induction of labor at 41 completed weeks improves birth outcomes: Cochrane
Authors' conclusions : A policy of labour induction after 41 completed weeks or later compared to awaiting spontaneous labour either indefinitely or at least one week is associated with fewer perinatal deaths. However, the absolute risk is extremely small. Women should be appropriately counselled on both the relative and absolute risks.
Gülmezoglu AM, Crowther CA, Middleton P. Induction of labour for improving birth outcomes for women at or beyond term. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD004945. DOI: 10.1002/14651858.CD004945.pub2.
http://www.ihs.gov/MedicalPrograms/CIR/index.cfm?module=cir_answering_clinical_questions
Conservative management for pregnant women with carcinoma in situ of the uterine cervix
CONCLUSIONS: We recommend conservative management for women with carcinoma in situ of the uterine cervix. We found no difference for the route of delivery regarding postpartum regression and recommend a postpartum evaluation after the puerperium. Colposcopic guided biopsy should rule out an invasive process during pregnancy. Cesarean section as the mode of delivery should be considered, if invasion is suspected.
Ackermann S, et al Management and course of histologically verified cervical carcinoma in situ during pregnancy. Acta Obstet Gynecol Scand. 2006;85(9):1134-7.
Cerebral Palsy Linked With Preterm Birth, Maternal Age and Other Factors
Even if it is recognized that most cases of CP are due to antenatal events, our study revealed associations between various perinatal factors and cerebral palsy. CONCLUSION: Preterm birth entails a high risk for CP, but 65% of these children are born at term. Several obstetric factors and low Apgar scores are associated with CP. LEVEL OF EVIDENCE: II-2.
Thorngren-Jerneck K, et al Perinatal factors associated with cerebral palsy in children born in Sweden. Obstet Gynecol. 2006 Dec;108(6):1499-505
Controlled-release m isoprostol effectively induced labor in parous women at term
OBJECTIVE: To assess the ability of a controlled-release misoprostol vaginal insert to induce labor using dose reservoirs of 25, 50, 100, and 200 microg. CONCLUSION: Misoprostol vaginal inserts effectively induced labor in pregnant parous women at term. LEVEL OF EVIDENCE: I.
Ewert K et al Controlled-release misoprostol vaginal insert in parous women for labor induction: a randomized controlled trial. Obstet Gynecol. 2006; 108(5):1130-7
No evidence to show regional anesthesia is superior for maternal or neonatal outcomes
AUTHORS' CONCLUSIONS: There is no evidence from this review to show that RA is superior to GA in terms of major maternal or neonatal outcomes. Further research to evaluate neonatal morbidity and maternal outcomes, such as satisfaction with technique, will be useful.
Afolabi BB, Lesi FEA, Merah NA. Regional versus general anaesthesia for caesarean section. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD004350. DOI: 10.1002/14651858.CD004350.pub2.
http://www.ihs.gov/MedicalPrograms/CIR/index.cfm?module
=cir_answering_clinical_questions
National recommendations for preconception care: Essential role of primary care
The Centers for Disease Control and Prevention have published national recommendations for improving preconception health and health care in response to unfavorable aspects of the health status of women and children in the United States. The publication explains that the national recommendations are part of a strategic plan for improving preconception health through the provision of clinical care as well as the promotion of changes in individual behaviors, health policy, and public health strategies. The concept of preconception care has been articulated for well over a decade but has not become part of the routine practice of family medicine. Because all women of reproductive age presenting to the primary care setting are candidates for preconception care, the essential and critical role of family physicians in the provision of preconception care is apparent. As a specialty, we are now challenged to devise ways to effectively translate the concept of preconception care into clinical reality.
Dunlop
AL, Jack
B, Frey
K. National recommendations for preconception care: the essential role of
the family physician. J
Am Board Fam Med. 2007 Jan-Feb;20(1):81-4.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db
=pubmed&list_uids=17204739&dopt=Abstract
Maternal Oxygen Affects Nonreassuring FHR Patterns
Results: The mean increase in fetal oxygen saturation was 4.9 percent for 40 percent F io2 and 6.5 percent for 100 percent F io2. In fetuses with an initial oxygen saturation of 30 to 40 percent, the increases in saturation were 7.0 percent for 40 percent F io2 and 12.6 percent for 100 percent F io2. Fetuses with the lowest initial oxygen saturation had the greatest improvement in their oximetry readings. All of these increases were statistically significant compared with room air oximetry levels. These results were consistent regardless of which of the five nonreassuring FHR patterns were present.
Conclusion: The authors conclude that providing supplemental oxygen to women in labor significantly increases fetal oxygen saturation in fetuses with nonreassuring FHR patterns. They add that those with the lowest oxygen saturation seem to benefit the most from maternal oxygen supplementation.
Haydon ML, et al. The effect of maternal oxygen administration on fetal pulse oximetry during labor in fetuses with nonreassuring fetal heart rate patterns. Am J Obstet Gynecol September 2006;195:735-8. http://www.aafp.org/afp/20070101/tips/5.html
Fetal death remains a significant and understudied problem
The death of a formed fetus is one of the most emotionally devastating events for parents and clinicians. With improved care for conditions such as RhD alloimmunization, diabetes, and preeclampsia, the rate of fetal death in the United States decreased substantially in the mid twentieth century. However, the past several decades have seen much greater reductions in neonatal death rates than in fetal death rates. As such, fetal death remains a significant and understudied problem that now accounts for almost 50% of all perinatal deaths. The availability of prostaglandins has greatly facilitated delivery options for patients with fetal death. Risk factors for fetal death include African American race, advanced maternal age, obesity, smoking, prior fetal death, maternal diseases, and fetal growth impairment. There are numerous causes of fetal death, including genetic conditions, infections, placental abnormalities, and fetal–maternal hemorrhage. Many cases of fetal death do not undergo adequate evaluation for possible causes. Perinatal autopsy and placental examination are perhaps the most valuable tests for the evaluation of fetal death. Antenatal surveillance and emotional support are the mainstays of subsequent pregnancy management. Outcomes may be improved in women with diabetes, hypertension, red cell alloimmunization, and antiphospholipid syndrome. However, there is considerable room for further reduction in the fetal death rate.
Gynecology
Outreach workers should follow women with the most severe PAP abnormalities
A health care system in which many women fail to get follow-up care for an abnormal Pap smear, outreach workers were more effective than usual care (mail or telephone reminders) at increasing follow-up rates. The results suggest that outreach workers should manage their effort based on the degree of abnormality; most effort should be placed on women with the most severe abnormality (high-grade squamous intraepithelial lesion).
Wagner TH, Engelstad LP, McPhee SJ, Pasick RJ. The costs of an outreach intervention for low-income women with abnormal Pap smears. Prev Chronic Dis 2007 Jan http://www.cdc.gov/pcd/issues/2007/jan/06_0058.htm
Pelvic Floor Muscle Therapy May Be Best Option for Urinary Incontinence
CONCLUSIONS: In women who have already had simple behavioural therapies (including advice on PFM exercises) for urinary dysfunction, the continuation of these behavioural therapies can lead to further improvement. The addition of vaginal cone therapy or intensive PFMT does not seem to contribute to further improvement. The improvement in pelvic floor function was significantly greater in the PFMT arm than in the control arm although this did not translate into changes in urinary symptoms.
Williams KS, et al A randomized controlled trial of the effectiveness of pelvic floor therapies for urodynamic stress and mixed incontinence. BJU Int. 2006 Nov;98(5):1043-50
Closing the vaginal cuff vertically is superior to horizontal closure for vaginal length
RESULTS: Preoperatively mean vaginal lengths in the horizontal and vertical groups were statistically similar (7.76 +/- 1.23 cm versus 8.28 +/- 1.39 cm, respectively; P = .21). Postoperatively the groups statistically differed (6.63 +/- 1.02 cm versus 7.93 +/- 1.18 cm, P < .001). The mean change in vaginal length was -1.13 +/- 1.15 cm and -0.35 +/- 0.91 cm, respectively (P = .01). CONCLUSION: Closing the vaginal cuff vertically is superior to horizontal closure for the purpose of preserving vaginal length.
Vassallo BJ et al A randomized trial comparing methods of vaginal cuff closure at vaginal hysterectomy and the effect on vaginal length Am J Obstet Gynecol. 2006; 195(6):1805-8
TVT and the transobturator tension- free vaginal tape procedures perform equally
CONCLUSION: The TVT and the TVT-O procedures perform equally in terms of objective and subjective cure. The statistically significant higher complication rate in the TVT-O group is not regarded as clinically significant. LEVEL OF EVIDENCE: I.
Laurikainen E, et al Retropubic Compared With Transobturator Tape Placement in Treatment of Urinary Incontinence: A Randomized Controlled Trial. Obstet Gynecol. 2007 Jan;109(1):4-11.
Prophylactic Oophorectomy in Young Women Carries Increased Mortality Risk
We aimed to investigate survival patterns in a population-based sample of women who had received an oophorectomy and compare these with women who had not received an oophorectomy. CONCLUSION: Although prophylactic bilateral oophorectomy undertaken before age 45 years is associated with increased mortality, whether it is causal or merely a marker of underlying risk is uncertain.
Rocca WA, et al Survival patterns after oophorectomy in premenopausal women: a population-based cohort study. Lancet Oncol. 2006 Oct;7(10):821-8.
Less complications for transobturator tape than TVT
Conclusion Transobturator tape is associated with a lower rate of bladder injury, a decreased incidence of postoperative anticholinergic medication use, and fewer urethrolyses for postoperative voiding dysfunction or urinary urgency than tension-free vaginal tape.
Barber
MD, et al Perioperative complications and adverse events of the MONARC transobturator
tape, compared with the tension-free vaginal tape. Am
J Obstet Gynecol. 2006 Dec;195(6):1820-5 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd
=Retrieve&dopt=AbstractPlus&list_uids=17027591
The VI-SENSE-vaginal discharge self-test to facilitate management of vaginal symptoms
OBJECTIVE: This study was undertaken to evaluate a diagnostic panty liner (VI-SENSE) (Common Sense, Caesarea, Israel) developed to facilitate diagnosis of vaginal infections by detecting disordered acidity level. CONCLUSION: The VI-SENSE test was found to be superior to traditional individual tests in facilitating preliminary diagnosis of vaginal infections.
Geva A, et al The VI-SENSE-vaginal discharge self-test to facilitate management of vaginal symptoms. Am J Obstet Gynecol. 2006 Nov;195(5):1351-6
Age-Based Ovarian Stimulation Yields High Pregnancy Rates
CONCLUSION(S): Women with diminished ovarian reserve, if treated with an ovarian age-based rather than chronological age-based ovarian stimulation protocols, will demonstrate surprisingly good pregnancy rate with IVF in comparison to women with normal ovarian function.
Gleicher N, Barad D. "Ovarian age-based" stimulation of young women with diminished ovarian reserve results in excellent pregnancy rates with in vitro fertilization. Fertil Steril. 2006 Dec;86(6):1621-5
Specific Symptoms May Assist in Early Detection of Ovarian Cancer
RESULTS.: Symptoms that were associated significantly with ovarian cancer were pelvic/abdominal pain, urinary urgency/frequency, increased abdominal size/bloating, and difficulty eating/feeling full when they were present for <1 year and occurred >12 days per month. In a logistic regression analysis, symptoms that were associated independently with cancer were pelvic/abdominal pain (P < .001), increased abdominal size/bloating (P<.001), and difficulty eating/feeling full (P = .010). A symptom index was considered positive if any of those 6 symptoms occurred >12 times per month but were present for <1 year. In the confirmatory sample, the index had a sensitivity of 56.7 for early-stage disease and 79.5% for advanced-stage disease. Specificity was 90% for women age >50 years and 86.7% for women age <50 years. CONCLUSIONS.: Specific symptoms in conjunction with their frequency and duration were useful in identifying women with ovarian cancer. A symptom index may be useful for identifying women who are at risk.
Goff BA, et al Development of an ovarian cancer symptom index: possibilities for earlier detection. Cancer. 2006 Dec 11
Intravaginal slingplasty effective for stress incontinence, but 9% removed for erosions
CONCLUSION: Both procedures were effective for stress incontinence, but 9% of women treated with the IVS required removal of the tape for erosions.
Meschia M et al Tension-free vaginal tape (TVT) and intravaginal slingplasty (IVS) for stress urinary incontinence: a multicenter randomized trial. Am J Obstet Gynecol. 2006; 195(5):1338-42
Vulvar vestibulitis: Electromyographic biofeedback and topical lidocaine both effective
CONCLUSIONS: Four months' treatment with electromyographic biofeedback and topical lidocaine gave statistically significant improvements on vestibular pain measurements, sexual functioning, and psychosocial adjustments at the 12-month follow-up. No differences in outcome between the two treatments were observed but a larger sample may be needed to obtain significance. The treatments were well tolerated but the compliance to the electromyographic biofeedback training program was low. A combination of both treatments could potentially benefit many women with vulvar vestibulitis.
Danielsson I et al EMG biofeedback versus topical lidocaine gel: a randomized study for the treatment of women with vulvar vestibulitis. Acta Obstet Gynecol Scand. 2006; 85(11):1360-7
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17091418
Child Health
Are you interested in acquiring HPV vaccine to provide to 9 – 18 year olds?
Please see note below from CDC regarding the entitlement for all VFC eligible females 9 – 18 years of age to receive HPV vaccine. This email was sent to all state immunization program managers and IHS Immunization coordinators.
If your Area/facilities are interested in acquiring HPV vaccine to provide to 9 – 18 year olds, but you are unable to get the vaccine through your state VFC program or are limited to certain age groups, please let Amy Groom amy.groom@ihs.gov know so she can follow up with CDC. Please cc Judy Thierry. Judith.Thierry@ihs.gov
Response requested : From Amy Groom, IHS Immunization Program Manager / CDC Field Assignee: As you begin planning for implementation of the new HPV vaccine, please keep in mind that VFC is an entitlement program. In the case of HPV vaccine, this means that all VFC-eligible females 9 through 18 years of age are entitled to the vaccine. It also means that VFC-enrolled providers must have access to the vaccine and may provide it to all VFC-eligible females between 9 through 18 years of age. While you may target your outreach efforts to certain age groups or types of providers, requests for the vaccine from VFC-enrolled providers must be honored. A copy of the VFC resolution is attached for your reference.
South Dakota becomes 2nd State in the Nation to Offer Girls Free Cancer Vaccine
Governor Rounds his plan to provide the HPV vaccine, Gardasil to every girl
in South Dakota between the ages of 11-18. SOUX FALLS, SD. – January 9,
2007 – The Women’s Cancer Network – the breast and cervical
cancer statewide coalition -- applauded the Governor’s decision today to
make South Dakota the 2nd state in the nation to offer the new cervical-cancer
vaccine free to girls. The vaccine against the human papilloma virus, or
HPV, will be available to all girls ages 11 through 18 as part of a state program
that offers immunizations to youth at no cost. FOR MORE INFORMATION, COTACT:
Jill Ireland, Women's Cancer Network
Jill.Ireland@cancer.org
Rapid flu test trims further tests, treatment
CONCLUSIONS: The inclusion of rapid influenza testing for the evaluation of febrile young infants without signs of focal infection during influenza season decreases the need for additional studies and reduces the length of stay in the ED, the use of antibiotic treatment and unnecessary hospitalizations. Benito-Fernandez J, et al Impact of rapid viral testing for influenza A and B viruses on management of febrile infants without signs of focal infection. Pediatr Infect Dis J. 2006 Dec;25(12):1153-7
Training Available: The Stanford Pediatric Weight Control Program
What is the Training Institute?
The Training Institute is a four-day program at Stanford University to train and certify you to deliver the Stanford Pediatric Weight Control Program at your own organization. Successful completion of the Institute will certify your organization to use the Stanford Pediatric Weight Control Program and materials.
What is the Stanford Pediatric Weight Control Program? The Stanford Pediatric Weight Control Program is available in versions for families with 8-12 year old children (English and culturally-tailored Spanish versions) or 13-15 year old teens (English only). The Program is extremely well received by participating families. More than 400 families have completed the program to date at Stanford Medical School and Lucile Packard Children’s Hospital. The Program is not designed for large, rapid, short-term weight loss.
Successful completion of the Institute will provide initial certification as a Stanford Pediatric Weight Control Program provider.
Training Institute for the Stanford Pediatric Weight Control Program – cost $5,000 for first participant and 1250 for subsequent persons.
Hepatitis B Vaccine for Infants of HBsAg-Positive Mothers: Cochrane Briefs
Clinical Question
Do hepatitis B vaccine and immune globulin prevent hepatitis B infection in newborns of mothers who are positive for hepatitis B surface antigen (HBsAg)?
Evidence-Based Answer
Hepatitis B vaccine, hepatis B immune globulin, and the combination of both reduce the risk of transmission of hepatitis B virus from mother to newborn, especially in newborns of mothers positive for hepatitis B e antigen (HBeAg). The combination of vaccine and immune globulin is more effective than vaccine alone.
Practice Pointers
Without intervention, 70 to 90 percent of infants born to women who are positive for both HBsAg and HBeAg will have chronic hepatitis B infection by six months of age.1 This Cochrane review of 29 clinical trials demonstrates that vaccine and immune globulin each are effective in preventing infection and that they are more effective in combination.
The reviewers found that compared with no intervention, hepatitis B immune globulin alone and the combination of immune globulin and vaccine reduced transmission of hepatitis B virus by 50 percent. The combination of vaccine and hepatitis B immune globulin also reduced transmission compared with vaccine alone (relative risk = 0.54; 95% confidence interval [CI], 0.41 to 0.73; 10 trials). Recombinant and plasma-derived vaccines were comparable in effectiveness, as were high-dose and low-dose vaccines.
Most of the trials included only mothers who tested positive for HBsAg and HBeAg. The number needed to treat to prevent transmission of hepatitis B from mothers who are positive for HBsAg but negative for HBeAg is likely to be much lower, but data for this population are limited.
The Advisory Committee on Immunization Practices recommends that all pregnant women be screened for HBsAg during routine prenatal care and that they be reevaluated and the results recorded when they report to the hospital in labor. Patients with positive results should be reported to local or state prenatal hepatitis B prevention programs and case-management tracking programs. Women who present in labor who are at high risk of infection or do not have HBsAg results should be tested as soon as possible. Newborns of mothers who are positive for HBsAg should receive single-antigen hepatitis B vaccine and hepatitis B immune globulin within 12 hours of birth. Thimerosal has been removed from vaccines, so neonatal vaccination can be performed.
Infants of mothers whose HBsAg status is unknown should receive single-antigen hepatitis B vaccine within 12 hours of birth. If the results of subsequent HBsAg testing of the mother are positive, the infant should receive hepatitis B immune globulin within seven days of birth. A complete hepatitis B vaccine series should be completed on all infants regardless of newborn vaccinations. At the end of the vaccination series at nine to 18 months, the infant should be tested for HBsAg and hepatitis B surface antibody.2
Lee C, et al. Hepatitis B immunisation for newborn infants of hepatitis B surface antigen-positive mothers. Cochrane Database Syst Rev 2006;(2):CD004790.
http://www.aafp.org/afp/20070101/cochrane.html
2007 Childhood and Adolescent Immunization Schedules: Evolution or Intelligent Design?
The recent expansion of the recommended vaccines includes 14 additional vaccine doses as follows:
-Meningococcal vaccine (one dose at 11 or 12 years of age)
-Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine (one dose at 11 or 12 years of age)
-Hepatitis A vaccine (two doses six months apart at one to two years of age)
-Three additional doses of influenza vaccine (starting at six months of age; two doses in the first
season, then one dose annually through 59 months of age)
-Rotavirus vaccine (three doses at two, four, and six months of age)
-Human papillomavirus vaccine (three doses at 11 or 12 years of age)
-Second dose of varicella vaccine (at four to six years of age)
Such changes present a challenge to the clinically active primary care provider; the complicated array of antigens and timing for administration can make one's head swim. Fortunately, this expansion also has shaped the evolution of the recommended schedules. This is where the recommended immunization schedules become essential clinical tools.
http://www.aafp.org/afp/20070101/practice.html
Size Does Matter: Childhood Immunization Needle
Results: Of the 696 infants enrolled, 240 were randomized to wide, long needles; 230 to narrow, short needles; and 226 to narrow, long needles. The infants in each group did not differ in any significant variables. Although immunogenicity was not significantly different, the average immune response was higher in infants in the wide, long needle group, and it was lowest in the narrow, short needle group. The differences in immunogenicity were greatest for the meningococcal C vaccine. Overall, local reactions at the injection site were reported for 61 percent of infants. Significantly fewer local reactions were reported in the wide, long needle group. Over the three-dose series, the relative reduction ranged from 22 to 54 percent. The size of the reaction also was smaller, but this difference was not statistically significant. Differences in reactivity were only apparent for the first vaccine dose. Eleven infants were withdrawn from the study because they had injection site reactions; 10 of these infants were in the narrow, short needle group.
The three groups of infants did not differ in reported systemic reactions or use of analgesics, and the infants in the long needle groups did not differ significantly in immunogenicity. The narrow, long needle was associated with lower local reactivity compared with the wide, long needle; however, both had similar systemic reactivity. Conclusion: The authors conclude that local reactions from routine childhood immunizations are significantly reduced with no change in immunogenicity or increase in systemic reactions when wide, long needles are used. This may be because the longer needle more consistently reaches the muscle layer.
Diggle L, et al. Effect of needle size on immunogenicity and reactogenicity of vaccines in infants: randomised controlled trial. BMJ September 16, 2006; 333:571-4.
http://www.aafp.org/afp/20070101/tips/3.html
Chronic Disease and Illness
Sleepiness and sleep deprivation are associated with injury
Results: Better sleep quality in the past 7 days was associated with a lower risk of injury (odds ratio (OR) 0.88, 95% confidence interval (CI) 0.80 to 0.97). Self-reported sleepiness just before injury compared with control time was associated with a lower risk of injury, with ORs of 0.82 per unit on a 0-to-12 scale (95% CI 0.78 to 0.86) in case-control analysis and 0.76 (0.73 to 0.80) in case-crossover analysis. In case-crossover analysis, additional sleep in the 24 hours before injury compared with the 24 hours before that was associated with an increased risk of injury (OR 1.06 per hour, 95% CI 1.03 to 1.09), but this effect disappeared when we controlled for activity, location, and recent alcohol consumption. Conclusions: Better recent sleep quality was associated with a lower risk of injury, but surprisingly, feeling sleepy was also.
Edmonds
JN, Vinson
DC.Three measures of sleep, sleepiness, and sleep deprivation and the risk
of injury: a case-control and case-crossover study. J
Am Board Fam Med. 2007 Jan-Feb;20(1):16-22.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd
=retrieve&db=pubmed&list_uids=17204730&dopt=Abstract
Discourage scheduled work beyond 16 consecutive hours
Companies today glorify the executive who logs 100-hour workweeks, the road warrior who lives out of a suitcase in multiple time zones, and the negotiator who takes a red-eye to make an 8 A.M. meeting. But to Dr. Charles A. Czeisler, the Baldino Professor of Sleep Medicine at Harvard Medical School, this kind of corporate behavior is the antithesis of high performance. In fact, he says, it endangers employees and puts their companies at risk. In this interview, Czeisler describes four neurobiological functions that affect sleep duration and quality as well as individual performance. When these functions fall out of alignment because of sleep deprivation, people operate at a far lower level of performance than they would if they were well rested. Czeisler goes on to observe that corporations have all kinds of policies designed to protect employees- rules against smoking, sexual harassment, and so on-but they push people to the brink of self-destruction by expecting them to work too hard, too long, and with too little sleep. The negative effects on cognitive performance, Czeisler says, can be similar to those that occur after drinking too much alcohol: "We now know that 24 hours without sleep or a week of sleeping four or five hours a night induces an impairment equivalent to a blood alcohol level of .1%. We would never say, 'This person is a great worker! He's drunk all the time!' yet we continue to celebrate people who sacrifice sleep for work." Czeisler recommends that companies institute corporate sleep policies that discourage scheduled work beyond 16 consecutive hours as well as working or driving immediately after late-night or overnight flights. A sidebar to this article summarizes the latest developments in sleep research.
Czeisler CA. Sleep deficit: the performance killer. Harv Bus Rev. 2006 Oct;84(10):53-9, 148
Making and Keeping New Year's Resolutions: Nine Modifiable Cancer Risk Factors
More Than One Third of Cancer Deaths May Be Attributable to Nine Modifiable Risk Factors
INTERPRETATION: Reduction of exposure to key behavioural and environmental risk factors would prevent a substantial proportion of deaths from cancer.
Danaei G, et al Causes of cancer in the world: comparative risk assessment of nine behavioural and environmental risk factors. Lancet. 2005 Nov 19;366(9499):1784-93
High blood glucose is a leading cause of cardiovascular mortality in most world regions
INTERPRETATION: Higher-than-optimum blood glucose is a leading cause of cardiovascular mortality in most world regions. Programmes for cardiovascular risk and diabetes management and control at the population level need to be more closely integrated.
Danaei G, et al Global and regional mortality from ischaemic heart disease and stroke attributable to higher-than-optimum blood glucose concentration: comparative risk assessment. Lancet. 2006 Nov 11;368(9548):1651-9
Meta-Analysis Confirms Red Meat Consumption Linked to Colorectal Cancer Risk
Consumption of red meat and processed meat was positively associated with risk of both colon and rectal cancer, although the association with red meat appeared to be stronger for rectal cancer. In 3 studies that reported results for subsites in the colon, high consumption of processed meat was associated with an increased risk of distal colon cancer but not of proximal colon cancer. The results of this meta-analysis of prospective studies support the hypothesis that high consumption of red meat and of processed meat is associated with an increased risk of colorectal cancer
Larsson SC, Wolk A. Meat consumption and risk of colorectal cancer: a meta-analysis of prospective studies. Int J Cancer. 2006 Dec 1;119(11):2657-64
Mastectomy vs. Breast-Conserving Therapy for DCIS
Background: The incidence of ductal carcinoma in situ (DCIS) of the breast
has dramatically increased over the past 25 years. Most cases initially were
treated with mastectomy; however, breast-conserving therapy (with or without
radiation) has become more common. Although breast-conserving therapy provides
a better cosmetic result, it is associated with a higher rate of local recurrence,
distant spread, and cancer-related mortality. Lee and colleagues studied outcomes
in women treated for DCIS between 1972 and 2005 and compared the outcomes of
mastectomy versus breast-conserving treatment strategies. Conclusion: The authors
emphasize that patients with DCIS have a good prognosis regardless of treatment
strategy. They also note that treatments have evolved considerably since their
data collection, and the current prognosis may be better than reported. Although
breast preservation treatment strategies were associated with somewhat worse
outcomes in this series, many of the differences were not statistically significant
and there was no survival advantage following mastectomy. The authors encourage
physicians to remind their patients that the breast cancer survival rates for
DCIS are
99 percent or more. Lee LA, et al. Breast cancer-specific mortality after invasive
local recurrence in patients with ductal carcinoma-in-situ of the breast. Am
J Surg October 2006;192;416-9.
http://www.aafp.org/afp/20070101/tips/4.html
Delay in Diagnosis of Diabetes Mellitus Due to Inaccurate Use of Hemoglobin A1C Levels
Testing of hemoglobin A1C (HbA1C) levels has become widespread in the management of patients with diabetes mellitus. Since the 1980s, it has proven to be an invaluable tool correlating with a patient’s average blood glucose levels as well as with their disease morbidity. Clinicians often base treatment decisions and make adjustments depending on a patient’s HbA1C level. As useful as the HbA1C is, it does have notable limitations. A number of conditions can lead to a falsely elevated or a falsely low HbA1C level. When one of these conditions is present, it is important to recognize the inaccuracy of the HbA1C test to prevent a delay or error in the diagnosis or care of patients with diabetes mellitus. It is also important to be aware of alternative methods of monitoring a patient’s diabetes such as a fructosamine assay or home and office blood glucose measurements. Presented is the case of a patient with diabetes mellitus and hereditary spherocytosis, a condition that interfered with her HbA1C value and resulted in a delay in her care.
Arnold
JG, McGowan
HJ. Delay in Diagnosis of Diabetes Mellitus Due to Inaccurate Use of Hemoglobin
A1C Levels. J
Am Board Fam Med. 2007 Jan-Feb;20(1):93-6.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=
retrieve&db=pubmed&list_uids=17204741&dopt=Abstract
New Guidelines Issued for Tdap Vaccine for Adults
The Advisory Committee on Immunization Practices (ACIP) has issued guidelines for tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) vaccine for adults which are published in the December 15, 2006, issue of the Morbidity and Mortality Weekly Report.
ACIP recommendations to reduce pertussis morbidity among adults, to maintain the standard of care for tetanus and diphtheria prevention, and to reduce the transmission of pertussis to infants and in healthcare settings are as follows:
- Adults aged 19 to 64 years should receive a single dose of Tdap to replace Td for booster immunization against tetanus, diphtheria, and pertussis if they received their last dose of Td more than 10 years earlier and if they have not previously received Tdap.
- For booster protection against pertussis, intervals shorter than 10 years since the last Td may be used.
- To reduce the risk for transmitting pertussis, adults who have or who anticipate having close contact with an infant younger than 12 months, such as parents, grandparents younger than 65 years, child care providers, and healthcare personnel, should receive a single dose of Tdap. The guidelines suggest an interval as short as 2 years from the last Td, but shorter intervals can be used. Whenever possible, women should receive Tdap before becoming pregnant, but women who have not previously received Tdap should receive a dose of Tdap in the immediate postpartum period.
- Healthcare personnel who have direct patient contact working in hospitals or ambulatory care settings should receive a single dose of Tdap as soon as possible if they have not previously received Tdap. The guidelines recommend an interval as short as 2 years from the last dose of Td, but shorter intervals may be used. HICPAC supports these recommendations for use of Tdap in healthcare personnel.
In addition to recommendations for the use of Tdap among adults aged 19 to 64 years, other issues highlighted in this ACIP report include a review of US pertussis, tetanus, and diphtheria vaccination policy, of the clinical features and epidemiology of pertussis in adults, and of immunogenicity, efficacy, and safety data for Tdap.
Safety considerations for adult vaccination with Tdap include the proper spacing and administration sequence of vaccines containing tetanus toxoid, diphtheria toxoid, and pertussis antigens. Potential adverse neurologic and systemic events related to use of vaccines with pertussis or tetanus toxoid components may include Guillain-Barré syndrome, encephalopathy, or Arthus reaction.
The guidelines also discuss economic considerations for adult Tdap use and suggestions for implementing these recommendations for routine adult Tdap vaccination, vaccination of adults in contact with infants, vaccination of pregnant women, and vaccination of healthcare personnel.
Also highlighted are contraindications and precautions for use of Tdap, special situations for Tdap use, reporting of adverse events after vaccination, vaccine injury compensation, and areas of future research related to Tdap and adults.
Tdap is contraindicated for people with a history of serious allergic reaction, defined as anaphylaxis, to any component of the vaccine. These individuals should be referred to an allergist to determine whether they have a specific allergy to tetanus toxoid and whether they can safely receive tetanus toxoid vaccinations.
Tdap is contraindicated for adults with a history of encephalopathy, defined as coma or prolonged seizures, not attributable to an identifiable cause within 7 days of administration of a vaccine with pertussis components. These adults should receive Td instead of Tdap.
"Progressive neurological disorders are not considered a contraindication as indicated in the package insert, and unstable neurological disorders (e.g., cerebrovascular events, acute encephalopathic conditions) are considered precautions and a reason to defer Tdap and/or Td," the authors conclude. "Tdap may be used as part of the primary series for tetanus and diphtheria."
CDC, their planners, and their content experts have disclosed that they have no financial relationships with the makers of commercial products, suppliers of commercial services, or commercial supporters. Morbid Mortal Wkly Rep . 2006;55(RR-17):1-33.
http://www.cdc.gov/mmwr/weekcvol.html
What are the effects of surgical interventions for hip fracture?
unlikely to be beneficial
Conservative vs. Operative Treatment for Most Types of Hip Fracture. One small randomized controlled trial (RCT) identified by a systematic review showed limited evidence that conservative treatment of undisplaced intracapsular fractures increased the risk of nonunion compared with internal fixation of the fracture. The review provided limited evidence that, compared with operative treatment, conservative treatment of extracapsular fractures increased the proportion of persons who remained hospitalized after 12 weeks and the occurrence of leg shortening and varus deformity. The review identified no RCTs including persons with displaced intracapsular fracture. The review provided insufficient evidence to assess whether significant differences exist between conservative and operative treatment in medical complications, mortality, long-term pain, or loss of independence.
Short Cephalocondylic Nail (e.g., Gamma Nail) vs. Sliding Hip Screw for Extracapsular Hip Fracture. One systematic review showed no significant difference between intramedullary fixation with a short cephalocondylic nail (e.g., Gamma nail) and extramedullary fixation with a sliding hip screw in mortality, pain at follow-up, ability to return to a previous residence, and ability to walk after three to 12 months. The review also showed no significant difference between treatments in wound infection or cutout of the implant, but the review showed that cephalocondylic intramedullary fixation increased intraoperative and later femoral fractures and reoperation rates.
likely to be ineffective or harmful
Older Fixed Nail Plates vs. Sliding Hip Screws for Extramedullary Fixation of Extracapsular Fracture. One systematic review showed no significant difference between older fixed nail plates and sliding hip screws in mortality, pain at follow-up, or mobility. The review showed that sliding hip screws reduced the risk of fixation failure in persons with extracapsular hip fracture.
Intramedullary Fixation with Condylocephalic Nails (e.g., Ender Nails) vs. Extramedullary Fixation for Extracapsular Fracture. One systematic review showed that intramedullary fixation with condylocephalic nails increased reoperation rates and the incidence of leg shortening and external rotation deformity compared with extramedullary fixation. However, the review showed that condylocephalic nails reduced length of surgery, the incidence of deep wound sepsis, and operative blood loss.
trade-off between benefits and harms
Internal Fixation vs. Arthroplasty for Intracapsular Hip Fracture. Two systematic reviews and two subsequent RCTs including older persons with displaced intracapsular fractures showed that internal fixation increased the need for subsequent revision surgery compared with arthroplasty. Internal fixation, however, was associated with less operative trauma, including reduced operative blood loss and transfusion requirements, and reduced deep wound sepsis. There were no clear differences in mortality or long-term functional outcome.
unknown effectiveness
Choice of Implant for Internal Fixation of Intracapsular Hip Fracture. One systematic review provided insufficient evidence to determine the best implant for internal fixation of intracapsular fracture.
Different Types of Arthroplasty for Intracapsular Hip Fracture. One systematic review provided insufficient evidence to determine the best type of arthroplasty (cemented and uncemented prostheses; unipolar and bipolar hemiarthroplasty; or hemiarthroplasty and total hip replacement) for persons with intracapsular fracture.
Arthroplasty vs. Internal Fixation for Extracapsular Fracture. One RCT with weak methods identified by a systematic review provided insufficient evidence to compare arthroplasty with internal fixation in persons with extracapsular fracture.
Extramedullary Implants Other Than Older Fixed Nail Plates vs. Sliding Hip Screw for Extracapsular Fracture. One systematic review provided insufficient evidence on the relative effects of sliding and fixed extramedullary implants other than older fixed nail plates in persons with extracapsular hip fracture.
External Fixation for Extracapsular Fracture. One RCT identified by a systematic review provided insufficient evidence on the relative effects of external fixation compared with the sliding hip screw in persons with extracapsular hip fracture.
What are the effects of perioperative medical interventions on surgical outcome and prevention of complications?
beneficial
Perioperative Prophylaxis with Antibiotics. One systematic review showed that multiple-dose perioperative and single-dose preoperative antibiotic prophylaxis reduced deep and superficial wound infection after hip surgery compared with control or no antibiotics.
likely to be beneficial
Perioperative Prophylaxis with Antiplatelet Agents. One systematic review and one subsequent large RCT showed that perioperative and postoperative antiplatelet prophylaxis reduced the incidence of deep venous thrombosis (DVT) and pulmonary embolism compared with placebo or no prophylaxis. There was no significant effect on mortality. The review and subsequent RCT showed that more persons who received antiplatelet treatment had bleeding complications.
Cyclical Compression of the Foot or Calf to Reduce Venous Thromboembolism. One systematic review showed that cyclical compression devices (i.e., foot or calf pumps) reduced DVT and pulmonary embolism compared with no compression. However, compression devices were associated with noncompliance to therapy and skin abrasion.
Oral Multinutrient Feeds as Nutritional Supplementation After Hip Fracture. One systematic review including persons who had had hip fracture surgery showed limited evidence that nutritional supplementation consisting of oral protein and energy feeds reduced unfavorable outcomes (i.e., postoperative complications or death) compared with control.
unlikely to be beneficial
Preoperative Traction to the Injured Leg. One systematic review showed no significant difference in preoperative pain relief or subsequent ease and fracture reduction at the time of surgery between routine preoperative traction and control.
trade-off between benefits and harms
Perioperative Prophylaxis with Heparin to Reduce Venous Thromboembolism. One systematic review showed that perioperative prophylaxis with unfractionated heparin or low-molecular-weight heparin (LMWH) reduced the incidence of DVT compared with placebo or no treatment. The review provided insufficient evidence to determine whether heparin reduced pulmonary embolism risk or mortality. It also provided insufficient evidence to determine whether heparin increased bleeding and other complications, although another systematic review of unfractionated heparin in persons undergoing general, orthopedic, and urologic surgery showed that, overall, heparin increased excessive bleeding or the need for transfusion compared with control.
unknown effectiveness
Regional vs. General Anesthesia for Hip Fracture Surgery. One systematic review of persons after hip fracture surgery provided limited evidence that regional anesthesia reduced the risk of acute postoperative confusion compared with general anesthesia. The review provided insufficient evidence to draw conclusions about mortality or other outcomes.
Nerve Blocks for Pain Control Before and After Hip Fracture. One systematic review of small RCTs showed that nerve blocks reduced total analgesic intake compared with no nerve block.
Operative Day (Less Than 24 Hours) vs. Extended Multiple-Dose Antibiotic Regimens. Two systematic reviews provided limited evidence, from two and three RCTs, respectively, that there is no significant difference in wound infection between operative day and extended multiple-dose antibiotic regimens in persons undergoing hip fracture surgery.
Single-Dose (Long-Acting) vs. Multiple-Dose Antibiotic Regimens. Two systematic reviews provided limited evidence that there is no significant difference in wound infection between some single- and some multiple-dose antibiotic regimens in persons undergoing hip fracture surgery.
LMWH vs. Unfractionated Heparin to Reduce Venous Thromboembolism After Hip Fracture Surgery. Five weak RCTs identified by a systematic review provided insufficient evidence to establish whether LMWH reduced DVT compared with unfractionated heparin. A second systematic review including persons undergoing orthopedic surgery provided no evidence that there is a difference in bleeding complications between LMWH and unfractionated heparin.
Graduated Elastic Compression to Prevent Venous Thromboembolism. We found no RCTs of thromboembolism stockings for prevention of thrombotic complications in persons with hip fracture. Two systematic reviews of persons undergoing surgery, including elective total hip replacement, showed that graduated elastic compression reduced the risk of DVT compared with control.
Nasogastric Feeds for Nutritional Supplementation After Hip Fracture. One systematic review provided no evidence that nasogastric feeding tubes for nutritional supplementation reduced mortality compared with control. However, the four RCTs were small, had flawed methods, and included persons with differing nutritional status. There was insufficient evidence to assess other outcomes.
What are the effects of rehabilitation interventions and programs after hip fracture?
likely to be beneficial
Coordinated Multidisciplinary Approaches for Inpatient Rehabilitation of Older Persons. One systematic review comparing coordinated multidisciplinary care for inpatient rehabilitation with usual care (often orthopedic) in older persons showed no significant difference in mortality or the combined outcomes of death or institutional care, death or deterioration in functional status, or death or rehospitalization. However, more persons receiving multidisciplinary care tended to have better outcomes, and there was limited evidence that multidisciplinary care resulted in fewer complications. It was not possible to define the best method of multidisciplinary care from the various models assessed in the review.
unknown effectiveness
Mobilization Strategies Initiated Soon After Hip Fracture Surgery. One systematic review and one subsequent RCT provided insufficient evidence to determine the effects of various mobilization strategies initiated soon after hip fracture surgery.
Early Supported Discharge Followed by Home-Based Rehabilitation. Two RCTs showed no significant difference in overall quality of life, mortality, falls, or rehospitalization between early supported discharge (followed by home-based rehabilitation) and hospital-based rehabilitation in less-disabled persons with a favorable home situation. One RCT showed that early supported discharge reduced caregiver burden at 12 months compared with hospital-based rehabilitation. Both RCTs showed that early supported discharge reduced length of hospital stay but increased the overall length of rehabilitative care.
Systematic, Multicomponent Home-Based Rehabilitation. One RCT comparing a systematic, multicomponent home-based rehabilitation program with usual care showed no significant difference in recovery to prefracture self-care levels, home management, social activity, balance, or lower extremity strength after 12 months. http://www.aafp.org/afp/20070101/bmj.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.
