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Volume 4, No. 2, February 2006
Hot Topics
Obstetrics
Term breech trial: The original term breech trial recommendations should be re-evaluated
OBJECTIVE: On the basis of the end points of neonatal morbidity and death, the authors of the term breech trial concluded unequivocally that cesarean delivery was safer for breech babies.
STUDY DESIGN: Analysis of the original and new data gives rise to serious concerns as far as study design, methods, and conclusions are concerned. In a substantial number of cases, there was a lack of adherence to the inclusion criteria. There was a large interinstitutional variation of standard of care; inadequate methods of antepartum and intrapartum fetal assessment were used, and a large proportion of women were recruited during active labor. In many instances of planned vaginal delivery, there was no attendance of a clinician with adequate expertise.
RESULTS: Most cases of neonatal death and morbidity in the term breech trial cannot be attributed to the mode of delivery. Moreover, analysis of outcome after 2 years has shown no difference between vaginal and abdominal deliveries of breech babies.
CONCLUSION: The original term breech trial recommendations should be withdrawn.
Glezerman M. Five years to the term breech trial: the rise and fall of a randomized controlled trial. Am J Obstet Gynecol. 2006 Jan;194(1):20-5
OB/GYN CCC Editorial comment:
This review joins a growing body of literature that raises serious questions about the Hannah term breech trial that concluded unequivocally that cesarean delivery was safer for breech babies. One of the major questions is the reasons for the Hannah results may have been the short term nature of their follow-up. Other studies have shown outcomes after 2 years that show no difference between vaginal and abdominal deliveries of breech babies. We all need to critically follow this growing body of literature so that we can adequately counsel our patients.
Late postpartum eclampsia: a preventable disease?
CONCLUSION: Current obstetric treatment in the United States has resulted in a shift of eclampsia toward the postpartum period, with most cases being seen as late post partum. To reduce the rate of late postpartum eclampsia, efforts should be directed to the education of the health care providers and patients regarding the importance of prompt reporting and evaluation of symptoms of preeclampsia during the postpartum period
Chames MC et al Late postpartum eclampsia: a preventable disease? Am J Obstet Gynecol. 2002 Jun;186(6):1174-7.
Ensure that newborn infants are protected from hepatitis B virus (HBV) infection, CDC
Recommendations for Prenatal Care Providers
Management of all pregnant women:
·Test all pregnant women for hepatitis B surface antigen (HBsAg) during each pregnancy.
·Transfer a copy of the original laboratory report of the pregnant woman’s HBsAg test result to the patient’s medical record in the delivery hospital.
·Inform pregnant women of the importance of newborn hepatitis B vaccination.
·Vaccinate pregnant women who are at risk for HBV infection.
Management of pregnant women with chronic HBV infection:
·Inform HBsAg-positive women of HBV transmission risks and ways to prevent HBV infection, including the importance of postexposure prophylaxis for newborn infants and hepatitis B vaccination of household, sexual, and needle-sharing contacts.
·Refer HBsAg-positive women to an appropriate case-management program to ensure that their newborn infants receive timely postexposure prophylaxis and follow-up.
·Provide or refer HBsAg-positive women for appropriate medical management of their chronic HBV infection.
Recommendations for Delivery Hospitals
·Implement standing orders to ensure that, except in rare circumstances (see statement for additional details), all newborns with birth weights of greater than or equal to 2 kilograms receive hepatitis B vaccine before discharge.
·Implement policies and procedures to ensure that all infants born to HBsAg-positive mothers and all infants born to mothers with unknown HBsAg status are identified and receive appropriate immunoprophylaxis. These policies and procedures should include the following standing orders:
-Review HBsAg test results for all pregnant women at the time of admission for labor and delivery.
-Conduct HBsAg testing as soon as possible after admission for pregnant women who do not have a documented HBsAg result and for pregnant women identified as being at risk for HBV infection during pregnancy (e.g., >1 sex partner in the previous 6 months, evaluation or treatment for a sexually transmitted disease, recent or current injection-drug use, HBsAg-positive sex partner).
- Administer hepatitis B vaccine and hepatitis B immune globulin within12 hours of birth to all infants born to HBsAg-positive mothers.
- Administer hepatitis B vaccine within 12 hours of birth to all infants born to mothers with unknown HBsAg status.
- Document on the infant’s medical record the maternal HBsAg test results and the infant’s hepatitis B immunization.
Recommendations for Health Departments
·Provide or assure case-management services to ensure that 1) all pregnant women are tested for HBsAg during each pregnancy, and 2) infants born to HBsAg-positive women and infants born to women with unknown HBsAg status receive recommended immunoprophlaxis and follow-up.
Before hepatitis B vaccination became routine in the United States, transmission of HBV infection perinatally and during early childhood caused an estimated 30%-40% of chronic HBV infections. Approximately 25% of chronically infected children die prematurely from cirrhosis or liver cancer. The majority of chronically infected persons remain asymptomatic until the onset of cirrhosis or end-stage liver disease.
These recommendations update the ACIP strategy to eliminate HBV transmission in the United States. This strategy has been implemented with considerable success and has resulted in a substantial decline in hepatitis B incidence in the United States. However, challenges remain to eliminate perinatal and childhood HBV transmission. In particular, CDC estimates that only about half of expected births to HBsAg-positive mothers are identified for case management, which is needed to maximize on-time delivery of postexposure immunoprophylaxis. In addition, errors in management of infants born to HBsAg-positive mothers and infants born to mothers with unknown HBsAg status have kept many of these infants from receiving appropriate immunoprophylaxis to prevent HBV infection. http://www.cdc.gov/mmwr/PDF/rr/rr5416.pdf
Centers for Disease Control and Prevention Centers for Disease Control and Prevention
Ginger is effective means for reducing postoperative nausea and vomiting: Meta-analysis
.CONCLUSIONS: This meta-analysis demonstrates that a fixed dose at least 1 g of ginger is more effective than placebo for the prevention of postoperative nausea and vomiting and postoperative vomiting. Use of ginger is an effective means for reducing postoperative nausea and vomiting.
Chaiyakunapruk N et al The efficacy of ginger for the prevention of postoperative nausea and vomiting: a meta-analysis. Am J Obstet Gynecol. 2006 Jan;194(1):95-9
Obstetric Characteristics Predict Risk of Sudden Infant Death Syndrome
CONCLUSIONS: A model that uses maternal characteristics and outcome at birth is predictive of the risk for SIDS. This model is presented in a simple form that allows calculation of the individual risk for SIDS.
Smith GC, White IR. Predicting the risk for sudden infant death syndrome from obstetric characteristics: a retrospective cohort study of 505,011 live births. Pediatrics. 2006 Jan;117(1):60-6.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd
=Retrieve&db=pubmed&dopt=Abstract&list_uids=16396861&query_hl
Correlates of intake of folic acid-containing supplements among pregnant women
CONCLUSION: This study identifies correlates of folic acid supplement intake, which may contribute to the design of interventions to improve intake during early pregnancy.
Carmichael SL et al. Correlates of intake of folic acid-containing supplements among pregnant women. Am J Obstet Gynecol. 2006 Jan;194(1):203-10.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd
=Retrieve&db=pubmed&dopt=Abstract&list_uids=16389033
Treatment of Vaginal Infections During Pregnancy
Bacterial vaginosis and infection with Trichomonas vaginalis have been associated with preterm labor and preterm birth. Although the mechanism is unclear, it has been suggested that the infection may spread from the vagina to the uterus. Three meta-analyses have recommended that women at high risk for preterm birth be screened and appropriately treated for bacterial vaginosis and T. vaginalis infection.
The authors conclude that antibiotic therapy appears to reduce bacterial vaginosis but does not reduce the risk of preterm birth or other adverse outcomes. Similarly, they conclude that antibiotic treatment of T. vaginalis infection is not beneficial and that the use of metronidazole may be harmful. Killing the organisms may cause inflammation or release a virus that increases the risk of preterm birth.
Okun N, et al. Antibiotics for bacterial vaginosis or Trichomonas vaginalis in pregnancy: a systematic review. Obstet Gynecol April 2005;105:857-68.
Newborn screening educational gap: what prenatal care providers do vs what is expected
CONCLUSION: Pregnant women and state professionals rely on prenatal care providers to educate pregnant women about newborn screening; however, many providers do not appear to view it as part of their responsibility. Therefore, the state needs to improve communication with both providers and the public about newborn screening.
Faulkner LA, et al The newborn screening educational gap: what prenatal care providers do compared with what is expected. Am J Obstet Gynecol. 2006 Jan;194(1):131-7.
Spirometry is related to perinatal outcomes in pregnant women with asthma
CONCLUSION: Lower pulmonary function during pregnancy is associated with increased gestational hypertension and prematurity in the pregnancies of women with asthma, which may be due to inadequate asthma control or factors that are associated with increased asthma severity.
Schatz M, et al Spirometry is related to perinatal outcomes in pregnant women with asthma. Am J Obstet Gynecol. 2006 Jan;194(1):120-6.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd
=Retrieve&db=pubmed&dopt=Abstract&list_uids=16389020
Preeclampsia Associated With Later Kidney Problems in Mother
Pregnant women who develop preeclampsia and who have a low birth weight infant seem to be at increased risk of later kidney problems, according to a report in the January 18th online issue of the Journal of the American Society of Nephrology. The risk of kidney disease is highest in women with both factors.
It is well known that preeclampsia is associated with later cardiovascular disease in the mother. Our study is the first to document a strong relationship between preeclampsia and low birth weight offspring and later clinical kidney disease in the mother.
Conclusion: Women who have preeclampsia and give birth to offspring with low birth weight and short gestation have a substantially increased risk for having a later kidney biopsy.
Vikse BE, et al Adverse Perinatal Outcome and Later Kidney Biopsy in the Mother. J Am Soc Nephrol. 2006 Jan 18;
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd
=Retrieve&db=pubmed&dopt=Abstract&list_uids=16421228&query_hl
The Fidgety Fetus Hypothesis
RESULTS —Phase I confirmed that there is little variability in fetal movements (i.e., fetal kicks did not significantly deviate from one another on a day-to-day basis). In phase II, the fetal monitoring strips illustrated that the active fetuses (defined as 
4 FHR accelerations in a 20-min period) were always active, and the inactive fetuses were always inactive. The mean birth weight percentile, corrected for gestational age, in the active group was 37 vs. 63% in the inactive group (P = 0.05). In phase III, the fetal monitoring strips showed an inverse correlation between the mean number of FHR accelerations and the birth weight of the fetus, corrected for gestational age. The mean birth weight percentile in the active group was 37 vs. 62% in the inactive group (P = 0.0017).
CONCLUSIONS —The fetus appears to play a role in determining its own destiny. Increased fetal activity may minimize the impact of hyperglycemia on subsequent birth weight. The inactive fetus appears to be at a higher risk for glucose-mediated macrosomia.
Zisser H, Jovanovic L et al The Fidgety Fetus Hypothesis: Fetal activity is an additional variable in determining birth weight of offspring of women with diabetes
Diabetes Care 2006 29: 63-67.
All patients in labor should be considered at risk for the development of shoulder dystocia
Knowledge of the maneuvers used for the alleviation of shoulder dystocia is relevant not only for obstetric residents and attending house staff but also for family practitioners, nurses, and nurse midwives. The performance of shoulder dystocia "drills" can be helpful not only to coordinate a teamwork approach to this obstetric emergency but also to provide an opportunity to practice the maneuvers. Shoulder dystocia continues to represent an immense area of clinical interest because it typically occurs without prediction. All patients in labor should be considered at risk for the development of shoulder dystocia.
Gherman RB. Shoulder dystocia: prevention and management. Obstet Gynecol Clin North Am. 2005 Jun;32(2):297-305,
Relationship between social support and alcohol use in pregnant women
In this sample of well-educated and employed pregnant women and their partners, social support was not predictive of prenatal alcohol use.
* Characteristics that increased overall maternal social support were the woman's being married, having more education, and having a job that was more prestigious than her partner's.
* Characteristics that decreased overall maternal social support were first pregnancy and increased woman's age.
* Social support was not predictive of prenatal alcohol use or birthweight.
* Early pregnancy drinking prior to study enrollment was the most predictive of subsequent consumption, whether measured by quantity or frequency.
* Marital status predicted prenatal drinks per day, whereas lifetime alcohol use predicted percentage of prenatal drinking days.
Prior use and early pregnancy drinking were the most predictive of subsequent prenatal consumption, underscoring the importance of screening pregnant women for drinking.
McNamara TK, Orav J, Wilkins-Haug L, et al. 2006. Social support and prenatal alcohol abuse. Journal of Women?s Health 25(1):70-76 http://www.liebertonline.com/doi/abs/10.1089/jwh.2006.15.70
Partnership focuses on maintenance of health weight among women of childbearing age
Promoting Healthy Weight Among Women of Reproductive Age outlines factors that influence weight, demographics of weight among women of reproductive age, and the impact of overweight and obesity on perinatal outcomes. The paper was produced by the Association of Maternal and Child Health Programs and CityMatCH Women's Health Partnership, a project to build state and local capacity to promote safe motherhood and enhance women's health before, during, and after pregnancy. A description of the theoretical frameworks underpinning the AMCHP/CityMaTCH project efforts are presented, along with resources and community-based interventions for assisting women of reproductive age to maintain a healthy weight. The paper is available at http://www.amchp.org/aboutamchp/publications/Healthy%20Weight.pdf
AmniSure rapid immunoassay versus standard methods for rupture of membranes
The purpose of this study was to compare the AmniSure rapid immunoassay with standard methods for diagnosing rupture of fetal membranes. Patients presenting with signs/symptoms of membrane rupture between 15 and 42 weeks of gestation were invited to participate. Standard/control methods were performed to establish a diagnosis and compare it with AmniSure results. AmniSure performance metrics and their 95% confidence intervals were calculated. A total of 203 patients agreed to participate. Discrepancies between the control method and AmniSure were noted in seven cases. In these cases, true positives and negatives were determined by retesting with the control method and AmniSure and by noting sonographic evidence of low amniotic fluid. In the final analysis, the AmniSure diagnostic test demonstrated a sensitivity of 98.9%, specificity of 100%, positive predictive value of 100%, and a negative predictive value of 99.1%. AmniSure is highly accurate in diagnosing fetal membrane rupture
Cousins LM, et al AmniSure placental alpha microglobulin-1 rapid immunoassay versus standard diagnostic methods for detection of rupture of membranes. Am J Perinatol. 2005 Aug;22(6):317-20 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd
=Retrieve&db=pubmed&dopt=Abstract&list_uids=16118720&query_hl
and
Technical Innovations in Clinical Obstetrics, Contemporary OB/GYN, September 15, 2005, Vol 50
http://www.contemporaryobgyn.net/obgyn/issue/issueDetail.jsp?id=6950
Gynecology
Superiority of Liquid-Based Cytology for Cervical Screening Questioned
INTERPRETATION: We saw no evidence that liquid-based cytology reduced the proportion of unsatisfactory slides, or detected more high-grade lesions in high-quality studies, than conventional cytology. This review does not lend support to claims of better performance by liquid-based cytology. Large randomised controlled trials are needed.
Davey E et al Effect of study design and quality on unsatisfactory rates, cytology classifications, and accuracy in liquid-based versus conventional cervical cytology: a systematic review. Lancet. 2006 Jan 14;367(9505):122-32.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd
=Retrieve&db=pubmed&dopt=Abstract&list_uids=16413876&query_hl
LEEP: Treatment of Cervical Neoplasia Linked to Preterm Births
CONCLUSION: Women with a history of LEEP, cold knife conization, and cryotherapy all independently have shorter cervical lengths than low-risk controls and similar lengths to women with previous spontaneous preterm birth. Loop electrosurgical excision procedure and cold knife conization are associated with spontaneous preterm birth less than 37 weeks, and transvaginal ultrasonography predicts preterm birth in women who have had LEEP. LEVEL OF EVIDENCE: II-2. Crane JM, et al Transvaginal Ultrasonography in the Prediction of Preterm Birth After Treatment for Cervical Intraepithelial Neoplasia. Obstet Gynecol. 2006 Jan;107(1):37-44.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd
=Retrieve&db=pubmed&dopt=Abstract&list_uids=16394037&query_hl
OB/GYN CCC Editorial comment:
This is a recurrent finding. The CCC Corner has reported the same finding as recently as September 2004. To repeat…
For young women who have not yet completed reproduction, LEEP may not be the best therapeutic option for treating CIN, especially of low malignant potential. Women who clearly require surgical intervention may be better served with other procedures, such as cryotherapy, or observation.
LEEP - not the best for treating young women who have not completed reproduction
http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN0904_HT.cfm#gyn
Treatment for cervical intraepithelial neoplasia and risk of preterm delivery
http://www.ihs.gov/MedicalPrograms/MCH/M/OBGYN0904_HT.cfm#ob
Preterm Labor and PPROM: Perinatology Corner (see Background)
http://www.ihs.gov/MedicalPrograms/MCH/M/PTL_2.cfm
Restricted activities after gynecologic surgery: No greater impact than rising from a chair
RESULTS: Median peak abdominal pressures ranged from 48 (lifting 8 lb from a counter) to 150 (lifting 35 lb from the floor), with much variation. Many activities did not raise the intra-abdominal pressure more than simply getting out of a chair, including lifting 8, 13, and 20 lb from a counter, lifting 8 or 13 lb from the floor, climbing stairs, walking briskly, or doing abdominal crunches. Body mass index and abdominal circumference each correlated positively with peak, but not net, pressures. Age and grip strength were not associated with abdominal pressure.
CONCLUSION: Some activities commonly restricted postoperatively have no greater effect on intra-abdominal pressures than unavoidable activities like rising from a chair. How lifting is done impacts intra-abdominal pressure. Many current postoperative guidelines are needlessly restrictive. Further research is needed to determine whether increased intra-abdominal pressure truly promotes pelvic floor disorders. LEVEL OF EVIDENCE: III
Weir LF, et al Postoperative Activity Restrictions: Any Evidence? Obstet Gynecol. 2006 Feb;107(2):305-309.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd
=retrieve&db=pubmed&list_uids=16449116&dopt=Abstract
Continued frequent screening of women with normal pap: Costly and benefits limited
CONCLUSION: As the number of prior normal Pap tests increases, the costs per life-year saved increase substantially. Resources should be prioritized for screening those never or rarely screened women. LEVEL OF EVIDENCE: II-2.
Kulasingam SL et al Cost-effectiveness of Extending Cervical Cancer Screening Intervals Among Women With Prior Normal Pap Tests. Obstet Gynecol. 2006 Feb;107(2):321-328.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd
=retrieve&db=pubmed&list_uids=16449119&dopt=Abstract
Protective Effect of Progesterone or Estrogen: Ovarian Cancer
Ovarian carcinoma (OCa) continues to be the leading cause of death due to gynecologic malignancies and the vast majority of OCa is derived from the ovarian surface epithelium (OSE) and its cystic derivatives. Epidemiological evidence strongly suggests that steroid hormones, primarily estrogens and progesterone, are implicated in ovarian carcinogenesis. However, it has proved difficult to fully understand their mechanisms of action on the tumorigenic process. New convincing data have indicated that estrogens favor neoplastic transformation of the OSE while progesterone offers protection against OCa development. Specifically, estrogens, particularly those present in ovulatory follicles, are both genotoxic and mitogenic to OSE cells. In contrast, pregnancy-equivalent levels progesterone are highly effective as apoptosis inducers for OSE and OCa cells. In this regard, high-dose progestin may exert an exfoliation effect and rid an aged OSE of pre-malignant cells. A limited number of clinical studies has demonstrated efficacies of antiestrogens, aromatase inhibitors, and progestins alone or in combination with chemotherapeutic drugs in the treatment of OCa. As a result of increased life expectancy in most countries, the number of women taking hormone replacement therapies (HRT) continues to grow. Thus, knowledge of the mechanism of action of steroid hormones on the OSE and OCa is of paramount significance to HRT risk assessment and to the development of novel therapies for the prevention and treatment of OCa. Ho SM. Estrogen, progesterone and epithelial ovarian cancer.Reprod Biol Endocrinol. 2003 Oct 7;1:73.
Congenital Adrenal Hyperplasia in Adults: Medical, Surgical and Psychological Issues
Our knowledge of the experience of adults with congenital adrenal hyperplasia (CAH) as they pass through life is only now emerging. In this review we gather medical, surgical and psychological literature pertaining to adults with CAH and consider this alongside practical experience gained from a dedicated adult CAH clinic. There is increasing awareness for the need for multidisciplinary teams who have knowledge of CAH particularly with respect to gynaecological surgery and clinical psychology for women. Routine management of CAH comprises adjustment of glucocorticoid and mineralocorticoid treatment according to individual needs balancing biochemical markers, compliance and long term risks. Bone density is one such long term concern and is not greatly reduced in most individuals with CAH. More recently, attention has turned to cardiovascular risk factors and catecholamine deficiency in adults with CAH. Women with CAH require access to an experienced gynaecologist, specialised pregnancy care and psychosexual support. The very low fertility rates for women with CAH previously reported appear to be improving with time.
Ogilvie CM, et al Congenital adrenal hyperplasia in adults: a review of medical, surgical and psychological issues. Clin Endocrinol (Oxf). 2006 Jan;64(1):2-11.
Laparoscopic Excision of Endometrioma Leaves Ovarian Reserve
CONCLUSION: Laparoscopic excision of endometriomas is associated with a quantitative but not a qualitative damage to ovarian reserve.
Ragni G, et al Damage to ovarian reserve associated with laparoscopic excision of endometriomas: a quantitative rather than a qualitative injury. Am J Obstet Gynecol. 2005 Dec;193(6):1908-14.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd
=Retrieve&db=pubmed&dopt=Abstract&list_uids=16325591
Advantages Seen With Artery Embolization Over Myomectomy for Uterine Fibroids
CONCLUSION(S): The uterine fibroid quality of life score was significantly improved in both groups. No significant differences were observed in bleeding improvement, uterine volume reduction, uterine fibroid quality of life score improvement, and overall quality of life score improvement between groups. Patients receiving UAE required fewer days off work, fewer hospital days, and experienced fewer adverse events.
Goodwin SC et al Uterine artery embolization versus myomectomy: a multicenter comparative study. Fertil Steril. 2006 Jan;85(1):14-21.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd
=Retrieve&db=pubmed&dopt=Abstract&list_uids=16412720&query_hl
Toremifen a Feasible Therapy for Moderate to Severe Mastalgia
CONCLUSIONS: Toremifen effectively relieves moderate and severe cyclical mastalgia and tends to exert a positive therapeutic effect on noncyclical mastalgia. In addition, toremifen therapy does not increase the incidence of intolerable adverse event. Therefore, it is a feasible therapy for mastalgia, especially cyclical mastalgia.
Gong C, et al A double-blind randomized controlled trial of toremifen therapy for mastalgia. Arch Surg. 2006 Jan;141(1):43-7.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd
=Retrieve&db=pubmed&dopt=Abstract&list_uids=16415410&query_hl
Sexual Dysfunction After Pelvic Surgery
Pelvic surgeries are among the most common causes of organic sexual dysfunction in men and women. The impact of nerve-sparing surgery on potency has been well documented in radical prostatectomy. However, its impact on potency needs to be evaluated in other pelvic surgeries. Sexual dysfunction is highly prevalent even after multiple technical advances in the field of oncological surgeries. The prevalence varies from 8 to 82%, depending on the type of pelvic surgery. In females, sexual dysfunction has not been evaluated adequately using validated questionnaires. However, in subspecialized circles, treatment for female sexual dysfunction is becoming routine. Currently, physicians have several options for the treatment of erectile dysfunction (ED) in men. Since the introduction of oral PDE-5 inhibitors, oral therapy has become the first-line treatment option for ED, irrespective of etiology. Currently available treatment options for the female sexual dysfunction include estrogens, androgens, phosphodiesterase inhibitors, and dopamine receptor antagonists. Initial reports regarding the role of early rehabilitation are encouraging and may become the part of routine practice in the management of ED after pelvic surgery. In this article, we summarize the sexual dysfunction following pelvic surgeries and their management.
Zippe C, et al Sexual dysfunction after pelvic surgery. Int J Impot Res. 2006 Jan-Feb;18(1):1-18.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd
=Retrieve&db=pubmed&dopt=Abstract&list_uids=15988545&query_hl
Child Health
Broad-spectrum antibiotics during labor linked to late-onset serious infections in infants
Group B Streptococcus (GBS) infection can cause a life-threatening blood infection and meningitis in newborns. Over one-third of women receive antibiotics during labor to prevent the transmission of GBS from themselves to their newborns. Intrapartum antibiotics (IPA) have been very successful in preventing early-onset (first week of life) neonatal GBS infection. However, a new study shows a relationship between exposure to broad-spectrum IPA and occurrence of late-onset (7-90 days after birth) serious bacterial infections (SBIs). Infants with late-onset SBI were more likely to have been exposed to IPA than uninfected infants. Also, pathogens that caused late-onset SBIs were more likely to be resistant to ampicillin, if the mother was treated with ampicillin. Thus, penicillin, an antibiotic that treats a narrow range of bacteria, is recommended for IPA to prevent GBS instead. The researchers compared the use of IPA and antibiotic-resistant strains of bacteria in 90 previously healthy full-term infants hospitalized for late-onset SBI (case infants) with 92 healthy full-term infants, who were known not to have an SBI in the first 90 days (control infants).
Considering all types of IPA, nearly twice as many case infants (41 percent) than control infants (27 percent) had been exposed to IPA, after controlling for hospital of delivery and other factors. The association was much stronger when IPA was with broad-spectrum antibiotics. Bacteria that were isolated from infected infants who had been exposed to IPA were nearly 6 times more likely to exhibit ampicillin resistance, but not resistance to other antibiotics commonly used to treat SBI in infants. The researchers recommend that clinicians find out infants' exposure to IPA when they are seen for late-onset SBI, so that they can gauge which antibiotics will be more effective for treatment.
Glasgow TS, et al. Association of intrapartum antibiotic exposure and late-onset serious bacterial infections in infants. Pediatrics September 2005, 116(3): 696-702.
Over Bundling: Winter and SIDS
The National Institute of Child Health Development Releases an Alert to Parents to Winter SIDS Risk and Updated AAP Recommendations According to the National Institute of Child Health and Human Development (NICHD), the number of infants who die from Sudden Infant Death Syndrome, or SIDS, increases in the cold winter months. During these colder months, parents often place extra blankets or clothes on infants, hoping to provide them with more warmth. In fact, the extra material may actually increase infants' risk for SIDS.
http://www.nih.gov/news/pr/jan2006/nichd-18.htm
Your female patient athletes: Treatment of stress fractures: the fundamentals
This article is an introduction to the fundamentals of stress fracture management. Extrinsic and intrinsic factors, that may play a role in the development of stress fractures, are discussed and incorporated as possible treatment options. Different treatment modalities including ultrasound and electromagnetic fields are addressed, with an emphasis on literature support.
Raasch WG, Hergan DJ.Treatment of stress fractures: the fundamentals.
Clin Sports Med. 2006 Jan;25(1):29-36, vii.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd
=Retrieve&db=pubmed&dopt=Abstract&list_uids=16324971&query_hl
Screening and Counseling for Obesity in Children
Fifteen percent of patients six to 19 years of age are considered to be overweight or obese as defined by percentile growth charts. Although guidelines and surveys have suggested that physicians discuss weight control with overweight patients at most visits, the rate of treatment has been low. Cook and associates conducted a study of a nationally representative sample of well-child visits to determine the frequency and quality of obesity evaluation and counseling.
The authors conclude that because increased screening for obesity is associated with increased diagnosis and counseling rates, programs should target methods that will increase screening rates. They also suggest that insurance and race discrepancies should be corroborated by other studies and actively addressed. Because the actual charts were not reviewed in the study, the reasoning behind the coding or its absence was not apparent. For example, physicians may have discussed obesity without coding for it. The authors speculate that lack of time and inadequate reimbursement also may be barriers to obesity counseling.
This study, which documents the underdiagnosis of childhood obesity at office visits, does not acknowledge the problem of treatment. Does office-based, primary care intervention for obesity reduce obesity in children? According to the U.S. Preventive Services Task Force, the evidence is insufficient to recommend for or against routine screening for overweight children. 1 First, physicians must demonstrate that their time counseling families of obese children is well spent. If so, then they will want to make sure that, in terms of diagnosis, no child is left behind.
http://www.aafp.org/afp/20060201/tips/6.html
Resources:
Cook S, et al. Screening and counseling associated with obesity diagnosis in a national survey of ambulatory pediatric visits. Pediatrics July 2005;116:112-6.
U.S. Preventive Services Task Force. Screening and interventions for overweight in children and
adolescents: recommendation statement. Pediatrics 2005;116:205-9.
AAP Recommendations for Treating Children After a Disaster
The American Academy of Pediatrics (AAP) has released a clinical report recommending a course of action in treating children who have experienced or witnessed a disaster, "Psychosocial Implications of Disaster or Terrorism on Children: A Guide for the Pediatrician".
The report outlines several studies that were conducted after the Sept. 11, 2001, terrorist attacks in New York and Washington, D.C. Three months after the attacks, some children were deeply dependent on parents for emotional and psychological support. The studies found that parents' moods and behaviors after traumatic events may add to a child's fears. Parents also may not recognize symptoms of their child's stress.
After a disaster, children may experience a range of symptoms, from mild stress reactions to more severe cases of post-traumatic stress disorder (PTSD). A child with adverse stress reactions lasting longer than one month after a disaster may be at higher risk of developing PTSD or violent behaviors later in life. Boys generally display higher rates of symptoms and require more time to recover than girls. Shy, fearful, or poorly supported children are at greater risk of developing negative mental reactions after trauma. Children with indirect exposure to a disaster on television also face the same risk as those witnessing it directly.
Physicians treating children after a traumatic event should be aware of patients who are at risk of adverse reactions or the development of symptoms of PTSD, and they should educate and counsel parents about the range of normal emotional and behavioral reactions of children to disaster. Physicians should help parents recognize the potential deleterious effects of indirect disaster exposure from news media and educate them about the importance of helping children understand information at a developmentally appropriate level.
Physicians should screen for anxiety in all patient encounters after a disaster. A simple question and expression of concern is an effective, brief intervention. For many children with supportive families, peers, and teachers, the reaction to traumatic experience resolves in a few months. A follow-up screening four to six months after the disaster would be appropriate to identify children with continuing symptoms who may need referral for additional services.
http://pediatrics.aappublications.org/cgi/content/full/116/3/787
Chronic Disease and Illness
Dietary intervention alone of little benefit in preventing disease
CONCLUSIONS: Over a mean of 8.1 years, a dietary intervention that reduced total fat intake and increased intakes of vegetables, fruits, and grains did not significantly reduce the risk of CHD, stroke, or CVD in postmenopausal women and achieved only modest effects on CVD risk factors, suggesting that more focused diet and lifestyle interventions may be needed to improve risk factors and reduce CVD risk.
Howard BV et al Low-fat dietary pattern and risk of cardiovascular disease: the Women's Health Initiative Randomized Controlled Dietary Modification Trial.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd
=Retrieve&db=pubmed&dopt=Abstract&list_uids=16467234
OB/GYN CCC Editorial comment:
This study does not prove that diet has no impact on cardiovascular disease. Rather than total calories of fat consumed, we should monitor other the type of fat, e .g.. trans fats vs monounsaturated fats. In addition we should address other issues like total calories, and other modifiable lifestyle changes, e. g., exercise, smoking. Here are some thoughts for experts in the field.
“It would be easy to misinterpret the results of this study, and it is important that we get it right," Dr. Robert H. Eckel, president of the American Heart Association, said in a press statement. "Reducing the risk of cardiovascular disease is about following an integrated lifestyle program, rather than concentrating solely on dietary composition."
"To achieve a significant public health impact on CVD events, a greater magnitude of change in multiple macronutrients and micronutrients and other behaviors that influence CVD risk factors may be necessary," Dr. Howard's group writes.
In a related editorial, Dr. Cheryl A. M. Anderson and Lawrence J. Appel from Johns Hopkins University in Baltimore remark that the WHI study did not address dietary measures that might have had a greater impact in reducing CVD, such as reducing salt and saturated fats and increasing potassium and polyunsaturated fats. Even though most of the participants were overweight or obese, the trial did not focus on lifestyle interventions that could have had an influence, including weight loss, physical activity, and avoiding tobacco exposure.
Cardiovascular Disease in American Indians and Alaska Natives
Sunday, March 5, 8:00 am - 12:00, Phoenix.
This special program will review the science of translating epidemiology and clinical trial results into practice in these special populations. The national program is being offered as part of the American Heart Association 46th Annual Conference on Cardiovascular Disease Epidemiology and Prevention which is scheduled for March 2-5 at the Pointe Hilton Squaw Peak Resort.
http://www.americanheart.org/downloadable/heart/113502046449146EpiAdvPrg
Cold Sores: Famciclovir for the Treatment of Recurrent Genital and Labial Herpes Lesions
Famciclovir (Famvir, Novartis) is an effective treatment for herpes zoster and herpes simplex. Two separate studies recently examined the effectiveness of single high doses of famciclovir for treating recurrent genital herpes and labial herpes (cold sores). In the randomized, placebo-controlled studies, patients initiated treatment at the first onset of symptoms. For the treatment of genital herpes, a 1,000 mg b.i.d. dose of famciclovir had significant advantages over the placebo, reducing the time required to heal the lesions, preventing the development of lesions beyond the papule stage, and improving the time to resolution of all symptoms. For the treatment of labial herpes, a single 1,500 mg dose of famciclovir shortened the lesion healing time, shortened the time to normal skin, and resulted in faster resolution of pain and tenderness.
Langley RG. Famciclovir for the treatment of recurrent genital and labial herpes lesions. Skin Therapy Lett. 2005 Dec-2006 Jan;10(10):5-7.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd
=Retrieve&db=pubmed&dopt=Abstract&list_uids=16408140&query_hl
Percentage of Persons Aged >18 Years Reporting Severe Headache or Migraine
In 2004, the percentage of adults who experienced a severe headache or migraine during the preceding 3 months decreased with age, from 18% among persons aged 18-44 years to 6% among persons aged >75 years. In every age group, the proportion of women who experienced severe headache or migraine was greater than that of men.
Percentage of Persons Aged ≥ 18 years Reporting Severe Headache or Migraine During the Preceding 3 Months, by Sex and Age Group — United States, 2004
Substandard preventive care for diabetes more likely: Multiple low priority visits
Patients who attend relatively few outpatient visits or who attend more frequent visits for predominantly lower-priority conditions are more likely to receive substandard preventive care for diabetes. Fenton JJ et alQuality of Preventive Care for Diabetes: Effects of Visit Frequency and Competing Demands Annals of Family Medicine 4:32-39 (2006)
http://www.annfammed.org/cgi/content/full/4/1/32
Herbal Therapies to Relieve Pain: Efficacy and Adverse Effects
To find holistic treatment with effective pain relief and few side effects, Americans spend billions of dollars annually on complementary and alternative medicine, including herbal therapies. Despite extensive use, the lack of regulatory scrutiny of these herbal supplements contributes to the paucity of reliable clinical data assessing their efficacy and safety. This review summarizes the existing studies investigating the efficacy of herbal therapies as a treatment for pain. Possible side effects, potential drug-herb interactions, and information about common herbal therapies are also summarized. Uses, dosages, routes of administration, and side effects were summarized. Strength of empirical evidence also was evaluated. This review found few well-controlled clinical studies. Furthermore, these studies documented limited efficacy of herbal therapies to treat pain. The information presented here may be used to further educate nurses and patients on the use of herbal therapies as well as direct future research efforts.
Wirth JH, et al Use of herbal therapies to relieve pain: a review of efficacy and adverse effects. Pain Manag Nurs. 2005 Dec;6(4):145-67.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd
=Retrieve&db=pubmed&dopt=Abstract&list_uids=16337563&query_hl
Aspirin prevents cardiovascular disease in healthy adults
CONCLUSIONS: For women and men, aspirin therapy reduced the risk of a composite of cardiovascular events due to its effect on reducing the risk of ischemic stroke in women and MI in men. Aspirin significantly increased the risk of bleeding to a similar degree among women and men.
Berger JS, et al Aspirin for the primary prevention of cardiovascular events in women and men: a sex-specific meta-analysis of randomized controlled trials. JAMA. 2006 Jan 18;295(3):306-13.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd
=Retrieve&db=pubmed&dopt=Abstract&list_uids=16418466&query_hl
Increased cancer-related mortality with type 2 diabetes who use sulfonylureas or insulin
CONCLUSIONS: Patients with type 2 diabetes exposed to sulfonylureas and exogenous insulin had a significantly increased risk of cancer-related mortality compared with patients exposed to metformin. It is uncertain whether this increased risk is related to a deleterious effect of sulfonylurea and insulin or a protective effect of metformin or due to some unmeasured effect related to both choice of therapy and cancer risk.
Bowker SL, et al Increased cancer-related mortality for patients with type 2 diabetes who use sulfonylureas or insulin. Diabetes Care. 2006 Feb;29(2):254-8.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd
=Retrieve&db=pubmed&dopt=Abstract&list_uids=16443869&query_hl
Breast Cancer Screening and Socioeconomic Status
The Centers for Disease Control and Prevention (CDC) has released a report on breast cancer screening for women in 35 major metropolitan areas in 2000 and 2002. Data for the report were collected from surveillance surveys and the 2000 U.S. Census.
More than 250,000 women 18 years and older were interviewed to determine general demographic status and were asked if they had ever had a mammogram. Those who answered yes were asked the date of their last mammogram. Analyses for this report focused on women 40 years or older. Of these women, 9.6 percent had household incomes of less than $15,000 per year, and 23.7 percent had incomes of $15,000 to $34,999 per year. Overall, 78.5 percent reported having a mammogram during the two years preceding the study. Among women who reported annual household incomes of less than $15,000, 68.4 percent received a mammogram in the preceding two years; 75.3 percent of women with household incomes of $15,000 to $34,999 and 82.5 percent of women with household incomes of more than $50,000 had received a mammogram in the preceding two years. Women who did not complete high school or were never married and women who had no health insurance had lower mammography rates than those who were college graduates or had married, or who had health insurance.
The report shows that women with household incomes of less than $15,000 per year were less likely to have had a breast cancer screening test in the past two years than wealthier women, especially those living in affluent areas. Women with less education also were less likely to have had a mammogram.
The CDC suggests that women not eligible for Medicaid who do not have employer-sponsored health care may receive breast and cervical cancer screening through the CDC's National Breast and Cervical Cancer Early Detection Program (http://www.cdc.gov/cancer/nbccedp).
October 7, 2005, Morbidity and Morality Weekly
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5439a2.htm
Are there any important differences between available nonsteroidal anti-inflammatory drugs (NSAIDs)?
trade-off between benefits and harms
Choice Between Different NSAIDs. Systematic reviews showed no important differences in effectiveness between different NSAIDs for the symptoms of musculoskeletal disorders. Systematic reviews showed that cyclooxygenase-2 (COX-2) inhibitors reduced symptomatic ulcers compared with older NSAIDs. However, the COX-2 inhibitor rofecoxib was withdrawn from the market in 2004 after it was found to increase the risk of myocardial infarction, and there is good evidence that other COX-2 inhibitors also may increase cardiovascular risk.
unlikely to be beneficial
NSAIDs in Increased Doses. Systematic reviews showed that the benefits of NSAIDs increased towards a maximum value at high doses. Recommended doses are close to creating the maximum benefit. In contrast, three systematic reviews showed no ceiling for adverse effects, which increased in an approximately linear fashion with dose.
What are the effects of cotreatments on reducing the risk of the adverse gastrointestinal effects of NSAIDs?
trade-off between benefits and harms
Misoprostol in Persons Who Cannot Avoid NSAIDs. One systematic review showed that misoprostol reduced serious gastrointestinal complications and symptomatic ulcers compared with placebo. The review did not assess adverse effects of misoprostol. However, another systematic review showed that misoprostol increased withdrawals caused by adverse events, mainly diarrhea and abdominal pain, compared with placebo. Randomized controlled trials (RCTs) provided insufficient evidence to compare the effects of misoprostol with proton pump inhibitors (PPIs) or histamine H 2 blockers.
unknown effectiveness
H2 Blockers in Persons Who Cannot Avoid NSAIDs. One systematic review provided insufficient evidence about the effects of H 2 blockers on serious gastrointestinal complications and symptomatic ulcers. It showed that H 2 blockers reduced endoscopically diagnosed ulcers compared with placebo, but the clinical relevance of this finding is uncertain. RCTs provided insufficient evidence to compare the effects of H 2 blockers with misoprostol or PPIs.
PPIs in Persons Who Cannot Avoid NSAIDs. One systematic review provided insufficient evidence regarding the effects of PPIs compared with placebo on serious gastrointestinal complications and symptomatic ulcers. Another systematic review showed that PPIs reduced endoscopically diagnosed ulcers compared with placebo, but the clinical relevance of this finding is uncertain. RCTs provided insufficient evidence to compare the effects of PPIs with misoprostol or H 2 blockers.
What are the effects of topical NSAIDs?
likely to be beneficial
Topical NSAIDs (For Up to Two Weeks). One systematic review that included persons with acute musculoskeletal pain conditions showed limited evidence that topical NSAIDs reduced pain compared with placebo at one week. One systematic review that included persons with osteoarthritis showed limited evidence that topical NSAIDs reduced pain compared with placebo at two weeks but showed no significant difference between treatments at four weeks.
unknown effectiveness
Topical NSAIDs (For Longer than Two Weeks). One systematic review that included persons with osteoarthritis showed no significant difference between topical NSAIDs and placebo at four weeks. The review showed no evidence regarding the effects of topical NSAIDs compared with placebo for longer than four weeks.
Topical vs. Systemic NSAIDs or Alternative Analgesics. Two systematic reviews showed insufficient evidence to compare topical with oral NSAIDs for pain in acute musculoskeletal pain conditions or osteoarthritis. We found no systematic review or RCT comparing topical NSAIDs with paracetamol for musculoskeletal conditions.
Definition
NSAIDs have anti-inflammatory, analgesic, and antipyretic effects, and they inhibit platelet aggregation. This chapter focuses on the use of NSAIDs for the treatment of the symptoms of musculoskeletal conditions. NSAIDs have no documented effect on the course of musculoskeletal diseases such as osteoarthritis. NSAIDs inhibit the enzyme COX, which has two known isoforms, COX-1 and COX-2. NSAIDs often are categorized according to their ability to inhibit the individual isoforms; newer NSAIDs predominantly inhibit the COX-2 isoform, and older NSAIDs often are less specific inhibitors.
Incidence
NSAIDs are widely used. Almost 10 percent of persons in the Netherlands used a nonaspirin NSAID in 1987, and the overall use was 11 defined daily doses per 1,000 persons. In Australia in 1994, overall use was 35 defined daily doses per 1,000 persons, with 36 percent receiving NSAIDs for osteoarthritis, 42 percent for sprain and strain or low back pain, and 4 percent for rheumatoid arthritis. Thirty-five percent of the persons receiving NSAIDs were older than 60 years.
Paracetamol is called acetaminophen in the United States.
Gøtzsche PC. Non-steroidal anti-inflammatory drugs. Clin Evid Concise 2005;14:388-9.
http://www.aafp.org/afp/20060201/bmj.html
ACSM Recommendations for Endurance Athletes
The American College of Sports Medicine (ACSM) has released evidence-based recommendations for athletes to prevent hyponatremia and dehydration during sporting events..
The study reinforces the importance of managing hyponatremia and dehydration in persons who participate in endurance events such as races and marathons. The ACSM recommends the following procedures to help prevent these conditions:
• Work to minimize the risk of hyponatremia and dehydration. Hyponatremia occurs when the athlete drinks too much liquid, causing the body's sodium levels to dilute. The condition is rare and usually affects athletes participating in running events lasting longer than four hours. Dehydration occurs much more frequently, and the ACSM recommends avoiding over- or underdrinking when running.
• Drink on a schedule to match fluid loss. Athletes should know their body's average hourly sweat rate and drink the appropriate amount of fluids to replace what was lost each hour. The study also recommends drinking early and at regular intervals during a race rather than all at once. Drinking constantly over a set period of time rehydrates more effectively than rapid fluid replacement.
• Consume salty foods and beverages. Eating foods with high levels of sodium helps stimulate fluid intake and promote fluid retention. The ACSM recommends that endurance athletes ingest salty snacks and fluids to help offset the loss of salt in sweat and prevent hyponatremia
June 2005 issue of Current Sports Medicine Reports
http://www.aafp.org/afp/20060201/practice.html
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OB/GYN
Dr. Neil Murphy is the Obstetrics and Gynecology Chief Clinical Consultant (OB/GYN C.C.C.). Dr. Murphy is very interested in establishing a dialogue and/or networking with anyone involved in women's health or maternal child health, especially as it applies to Native or indigenous peoples around the world. Please don't hesitate to contact him by e-mail or phone at 907-729-3154.
