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Volume 5, No. 5, May 2007
Hot Topics
Obstetrics | Gynecology | Child Health | Chronic Disease and Illness
Obstetrics
More stillbirths after previous cesarean delivery
CONCLUSIONS: Pregnancies in women following a pregnancy delivered by caesarean section are at an increased risk of stillbirth. In our study, the risk appears to be mainly concentrated in the subgroup of explained stillbirths. However, there are sufficient inconsistencies in the developing literature about stillbirth risk that further research is needed.
Gray R; Quigley MA; Hockley C; Kurinczuk JJ; Goldacre M; Brocklehurst P Caesarean delivery and risk of stillbirth in subsequent pregnancy: a retrospective cohort study in an English population. BJOG. 2007; 114(3):264-70
Pregnant Moms' Weight Affects Toddlers
RESULTS: Greater weight gain was associated with higher child body mass index z-score (0.13 units per 5 kg [95% CI, 0.08, 0.19]), sum of subscapular and triceps skinfold thicknesses (0.26 mm [95% CI, 0.02, 0.51]), and systolic blood pressure (0.60 mm Hg [95% CI, 0.06, 1.13]). Compared with inadequate weight gain (0.17 units [95% CI, 0.01, 0.33]), women with adequate or excessive weight gain had children with higher body mass index z-scores (0.47 [95% CI, 0.37, 0.57] and 0.52 [95% CI, 0.44, 0.61], respectively) and risk of overweight (odds ratios, 3.77 [95% CI: 1.38, 10.27] and 4.35 [95% CI: 1.69, 11.24]). CONCLUSION: New recommendations for gestational weight gain may be required in this era of epidemic obesity.
Oken E, et al Gestational weight gain and child adiposity at age 3 years. Am J Obstet Gynecol. 2007 Apr;196(4):322.e1-8
Neonatal Pneumothorax Risk Increased After Early Elective Cesarean Delivery
CONCLUSIONS: The timing of elective cesarean section influences the pneumothorax risk. A reduction in neonatal iatrogenic pneumothorax would result if elective deliveries were performed after the 39 completed weeks of pregnancy
Zanardo V, et al The influence of timing of elective cesarean section on risk of neonatal pneumothorax. J Pediatr. 2007 Mar;150(3):252-5
Walking is popular, practical: Predictors of physical activity during and after pregnancy
Declines were observed in total physical activity during pregnancy that persisted to some degree at 6 months postpartum. Physical activity during and following pregnancy may have beneficial effects on postpartum weight and related health outcomes.
The authors found that
* The mean age of women at enrollment was 32.5, 34% were overweight or obese before pregnancy, and 24% were nonwhite. Approximately 8%-9% of the women were depressed during either time period.
* The percentage of women working equal to or greater than 35 hours per week was 60% during the second trimester and 30% at 6 months postpartum. Nearly two-thirds of the sample reported that insufficient time was a very important barrier to physical activity at 6 months postpartum.
* Physical activity decreased during pregnancy from 9.6 to 6.9 hours per week and rebounded to 8.0 hours per week during the postpartum period. This decrease was accounted for by the sustained drop in light-to-moderate and vigorous physical activity, not including walking.
* Prevalence of insufficiently active lifestyle increased from 12.6% pre-pregnancy to 21.6% during pregnancy, and remained at 21.7% during the postpartum period.
* The odds ratio for becoming insufficiently active during pregnancy was 1.58 in women with at least one child already in the home compared to women with no children yet in the home.
* Predictors of insufficient activity between pregnancy and 6 months postpartum included postpartum weight retention, working longer hours during pregnancy and postpartum, and reporting that child care was a barrier to physical activity.
The authors conclude that "walking is popular, practical -- it can be most easily worked into the daily routine (e.g., pushing child in stroller) -- and efficacious in reducing disease risks. Thus, walking appears to be a relevant targeted activity for interventions during and following pregnancy."
Pereira MA , Rifas-Shiman SL, Kleinman KP, et al. 2007. Predictors of change in physical activity during and after pregnancy: Project Viva.
American Journal of Preventive Medicine 32(4):312-319.
Preterm low birth weight and maternal periodontal status: A likely association
RESULTS: The literature search revealed 17 articles that met the inclusion criteria. Seven thousand one hundred fifty-one women participated in the studies, 1056 of whom delivered a preterm and/or low birthweight infant. The overall odds ratio was 2.83 (95% CI: 1.95-4.10, P < .0001). This pooled value needed to be interpreted cautiously because there appeared to be a clear trend for the better quality studies to be of lower association strength.
CONCLUSION: These findings indicate a likely association, but it needs to be confirmed by large, well-designed, multicenter trials.
Vergnes JN; Sixou M Preterm low birth weight and maternal periodontal status: a meta-analysis. Am J Obstet Gynecol. 2007; 196(2):135.e1-7
High-Fat Dairy Intake Reduces Risk for Anovulatory Infertility
CONCLUSIONS High intake of low-fat dairy foods may increase the risk of anovulatory infertility whereas intake of high-fat dairy foods may decrease this risk. Further, lactose (the main carbohydrate in milk and dairy products) may not affect fertility within the usual range of intake levels in humans.
Chavarro JE, et al A prospective study of dairy foods intake and anovulatory infertility. Hum Reprod. 2007 Feb 28
CDC Issues Guidelines for Preconception Care of Women
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 et al National recommendations for preconception care: the essential role of the family physician. J Am Board Fam Med. 2007 Jan-Feb;20(1):81-4
Postterm delivery and short term risk for epilepsy in childhood
We found no evidence for the association between postterm delivery and risk for epilepsy beyond the first year of life.
CONCLUSIONS: Prolonged gestation is a risk factor for early epilepsy; the added increase in risk for instrument-assisted and cesarean deliveries could be attributable to factors that are related to both birth complications and epilepsy.
Ehrenstein V et al Postterm delivery and risk for epilepsy in childhood. Pediatrics. 2007; 119(3):e554-61
Fetal movement counting for assessment of fetal wellbeing
AUTHORS' CONCLUSIONS: This review does not provide enough evidence to influence practice. In particular, no trials compared fetal movement counting with no fetal movement counting. Robust research is needed in this area .
Mangesi L; Hofmeyr G Fetal movement counting for assessment of fetal wellbeing. Cochrane Database Syst Rev. 2007; (1):CD004909
Management of HSV-2 during pregnancy may enhance mother-to-child HIV-1 prevention
CONCLUSION: Herpes simplex virus type 2 is the leading cause of genital ulcers among women in sub-Saharan Africa and was highly prevalent in this cohort of pregnant women receiving prophylactic zidovudine. After adjusting for plasma HIV-1 RNA levels, genital ulcers were associated with increased risk of intrapartum HIV-1 transmission. These data suggest that management of HSV-2 during pregnancy may enhance mother-to-child HIV-1 prevention efforts. LEVEL OF EVIDENCE: II
Drake AL et al Herpes simplex virus type 2 and risk of intrapartum human immunodeficiency virus transmission. Obstet Gynecol. 2007; 109(2 Pt 1):403-9
Eating disorders: Higher risk of miscarriages and significantly lower birth weight
RESULTS: The group with bulimia nervosa had significantly higher rates of past miscarriages (relative risk ratio 2.0, P=0.01) and the group with anorexia nervosa delivered babies of significantly lower birth weight than the general population (P=0.01), which was mainly explained by lower pre-pregnancy body mass index. Preterm delivery rates were comparable across groups
CONCLUSIONS: Women with a history of eating disorders are at higher risk of major adverse obstetric outcomes. Antenatal services should be aware of this higher risk.
Micali N; Simonoff E; Treasure J Risk of major adverse perinatal outcomes in women with eating disorders. Br J Psychiatry. 2007; 190:255-9
Short courses of antiretroviral drugs effective for reducing transmission of HIV
Authors' conclusions: Short courses of antiretroviral drugs are effective for reducing mother-to-child transmission of HIV and are not associated with any safety concerns in the short-term. A combination of ZDV and 3TC given to mothers in the antenatal, intrapartum and postpartum periods and to babies for a week after delivery or a single dose of NVP given to mothers in labour and babies immediately after birth may be most effective. Where HIV infected women present late for delivery, post-exposure prophylaxis with a single dose of NVP immediately after birth plus ZDV for the first 6 weeks of life is beneficial. The long term implications of the emergence of resistant mutations following the use of these regimens require further study
Volmink J et al Antiretrovirals for reducing the risk of mother-to-child transmission of HIV infection. Cochrane Database Syst Rev. 2007; (1):CD003510
Reduction in caffeine intake in pregnancy has no effect on birth weight or gestational age
RESULTS: After adjustment for length of gestation, parity, prepregnancy body mass index, and smoking at entry to the study the mean birth weight of babies born to women in the decaffeinated group was 16 g (95% confidence interval -40 to 73) higher than those born to women in the caffeinated group. The adjusted difference (decaffeinated group-caffeinated group) of length of gestation was -1.31 days (-2.87 to 0.25).
CONCLUSION: A moderate reduction in caffeine intake in the second half of pregnancy has no effect on birth weight or length of gestation.
Bech BH; Obel C; Henriksen TB; Olsen J Effect of reducing caffeine intake on birth weight and length of gestation: randomised controlled trial. BMJ. 2007; 334(7590):409
Immunoglobulin increased the rates of live birth in secondary recurrent miscarriage
CONCLUSIONS: IVIG increased the rates of live birth in secondary recurrent miscarriage, but there was insufficient evidence for its use in primary recurrent miscarriage.
Hutton B et al Use of intravenous immunoglobulin for treatment of recurrent miscarriage: a systematic review. BJOG. 2007; 114(2):134-42
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=17166218
Gynecology
Young women with CIN: Any treatment increases the risk of preterm delivery - LEEP
CONCLUSION: Any treatment for CIN, including loop electrosurgical excision procedure, increases the risk of preterm delivery. It is important to emphasize this when treating young women with CIN. LEVEL OF EVIDENCE: II.
Jakobsson M et al Preterm delivery after surgical treatment for cervical intraepithelial neoplasia. Obstet Gynecol. 2007; 109(2 Pt 1):309-13
Women with C. glabrata show higher mycological cure with boric acid
RESULTS: C. glabrata was isolated in 68 (61.3%) and C. albicans in 32 (28.8%) of 111 subjects. Patients with C. glabrata vulvovaginal candidiasis.( VVC) showed higher mycological cure with boric acid compared with fluconazole in the ITT (21 of 33, 63.6% vs. 10 of 35, 28.6%; P = 0.01) and PP analyses (21 of 29, 72.4% vs. 10 of 30, 33.3%; P = 0.01). The secondary efficacy outcomes were not significantly different in the two treatment arms in the ITT and PP analyses. CONCLUSIONS: Diabetic women with C. glabrata VVC show higher mycological cure with boric acid vaginal suppositories given for 14 days in comparison with single-dose oral 150-mg fluconazole.
Ray D; Goswami R; Banerjee U; Dadhwal V; Goswami D; Mandal P; Sreenivas V; Kochupillai NPrevalence of Candida glabrata and its response to boric acid vaginal suppositories in comparison with oral fluconazole in patients with diabetes and vulvovaginal candidiasis. Diabetes Care. 2007; 30(2):312-7
Is Pelvic Organ Prolapse Caused by Vaginal Delivery?
Results: The nulliparous women did not differ from the parous women in any significant variable. For both groups, the mean age was 60 years and the mean BMI was 28 kg per m2. Hysterectomy was reported in 27 percent of parous women and in 24 percent of nulliparous women. Ten of the nulliparous women and 24 of the parous women reported previous vaginal surgery. The average parity for the parous women was three.
There was no pelvic organ prolapse in 82.2 percent of the nulliparous women and in 43.6 percent of the parous women. Nevertheless, a statistically significant familial association was observed. The concordance in prolapse stage between sisters ranged from 74.3 percent for the anterior compartment to 91.1 percent for the apical compartment. In the 25 pairs of sisters with discordant findings, the prolapse was more advanced in the parous sister in all but three pairs.
Measures of pelvic support showed that at least two thirds of the sister pairs had similar measurements (within 1 cm) except at the cervix or vaginal cuff. In the remaining one third of pairs, the parous sister had greater descent in 80 percent of cases. Statistical analysis showed a twofold increase in risk of posterior wall prolapse and a threefold increase in risk of anterior wall prolapse with each vaginal birth. Other factors, including BMI, were not associated with risk of prolapse.
Conclusion: The authors conclude that familial factors are highly significant in the development of pelvic organ prolapse. Parity appears to confer a small additional risk of severe prolapse.
Buchsbaum GM, et al. Pelvic organ prolapse in nulliparous women and their parous sisters. Obstet Gynecol December 2006;108:1388-93.
Chance of woman undergoing a hysterectomy can now be accurately predicted
The findings confirm a widely held, but untested, belief in gynecology that the more symptoms of discomfort a woman has, as well as the longer she has tried alternative therapies unsuccessfully, the more likely she is to have a hysterectomy. CONCLUSIONS: For women with common pelvic problems, three easily measured clinical characteristics (symptom combination, degree of resolution, and earlier use of a gonadotropin-releasing hormone agonist) predict the likelihood of subsequent hysterectomy and can be used to inform counseling about the likely success of alternative treatments.
Learman LA, et al Predictors of hysterectomy in women with common pelvic problems: a uterine survival analysis. J Am Coll Surg. 2007 Apr;204(4):633-41
Insulin-sensitising drugs versus the combined oral contraceptive pill for PCOS
CONCLUSIONS: Up to 12-months treatment with the OCP is associated with an improvement in menstrual pattern and serum androgen levels compared with metformin; but metformin treatment results in a reduction in fasting insulin and lower triglyceride levels than with the OCP. Side-effect profiles differ between the two drugs. There is either extremely limited or no data on important clinical outcomes such as the development of diabetes, cardiovascular disease, or endometrial cancer. There are no data comparing ISDs other than metformin (that is rosiglitazone, pioglitazone, and D-chiro-inositol) versus OCPs (alone or in combination).
Costello M; Shrestha B; Eden J; Sjoblom P; Johnson N Insulin-sensitising drugs versus the combined oral contraceptive pill for hirsutism, acne and risk of diabetes, cardiovascular disease, and endometrial cancer in polycystic ovary syndrome. Cochrane Database Syst Rev. 2007 Jan 24;(1):CD005552
Anal sphincter gaps on US: Common with sphincter tear and severity of fecal incontinence
RESULTS: Thirty-five percent of the sphincter tear group exhibited internal sphincter gaps compared with 3% of vaginal controls (odds ratio [OR] 18.4, 95% confidence interval [CI] 5.5-62.1) and 10% of cesarean controls. External sphincter gaps were identified in 51% of the tear group compared with 31% of vaginal controls (OR 2.3, 95% CI 1.3-4.0) and 28% of cesarean controls. In the tear group, fecal incontinence severity was greater in those with internal sphincter gaps compared with those with no internal sphincter gaps (Fecal Incontinence Severity Index score 6.6+/-8.3 compared with 3.3+/-6.1, P=.02), as well as in those with external sphincter gaps (6.1+/-8.4 compared with 2.7+/-5.0, P=.01), and greatest in those with both internal and external sphincter gaps compared with at least one gap not present (7.2+/-8.1 compared with 3.4+/-6.4, P=.003). CONCLUSION: Anal sphincter gaps detected by ultrasonography are prevalent in postpartum primiparous women with a history of sphincter tear and are associated with fecal incontinence severity. LEVEL OF EVIDENCE: II-2.
Richter HE et al Endoanal ultrasound findings and fecal incontinence symptoms in women with and without recognized anal sphincter tears. Obstet Gynecol. 2006; 108(6):1394-401
Interventions to reduce haemorrhage during myomectomy for fibroids
AUTHORS' CONCLUSIONS: There is limited evidence from a few RCTs that misoprostol, vasopressin, bupivacaine plus epinephrine, tourniquet and mesna may reduce bleeding during myomectomy. There is no evidence that oxytocin and morcellation have an effect on intraoperative blood loss. There is need for adequately powered RCTs to shed more light on the effectiveness, safety and costs of different interventions in reducing blood loss during myomectomy.
Kongnyuy E; Wiysonge C Interventions to reduce haemorrhage during myomectomy for fibroids. Cochrane Database Syst Rev. 2007; (1):CD005355
Risk of Advanced Cervical Lesions After a Diagnosis of CIN 1 or Less
Results: There were 3,791 participants in the study, and the mean follow-up period was 26.3 months. Of the women who had CIN 1 or less on colposcopy, 1.9 percent were subsequently diagnosed with CIN 3 or cancer. The presence of high-risk HPV on the initial examination was more likely to be associated with subsequent CIN 3 and cancer. Women who were 30 years or older were more likely to have subsequent CIN 3 or cancer than younger women.
When patients were diagnosed with CIN 3 or cancer, 97.8 percent had high-risk HPV present and 91.3 percent had abnormal cervical cytology. Women with normal cervical cytology and high-risk HPV were significantly less likely to be diagnosed with subsequent CIN 3 or cancer than those with abnormal cervical cytology and high-risk HPV.
Conclusion: Annual cytology and HPV testing is appropriate for women who have been diagnosed with CIN 1 or less. If high-risk HPV is present and cervical cytology is abnormal, patients should have colposcopy. If high-risk HPV is present and cervical cytology is normal, patients should have colposcopy at least every two years. Women with subsequent normal cytology and a negative high-risk HPV test for two consecutive years can return to a routine screening schedule.
Pretorius RG, et al. Subsequent risk and presentation of cervical intraepithelial neoplasia (CIN) 3 or cancer after a colposcopic diagnosis of CIN 1 or less. Am J Obstet Gynecol November 2006;195:1260-5. http://www.aafp.org/afp/20070401/tips/15.html
Child Health
Public Opinion vs. Science Concerning Sex Education
Results: The study population included 1,096 participants with a mean age of 46.8 years. The race/ethnicity of the respondents was similar to other nationally representative surveys. The percentage of individuals supporting a combined abstinence and contraception educational program was 82 percent. Support for teaching of proper condom use was about 68 percent. An abstinence-only program was supported by 36 percent of the respondents and received the highest level of opposition. Most individuals in each political ideology group supported abstinence plus contraception programs, with the conservative group agreeing 70.0 percent of the time, the moderate group 86.4 percent, and the liberal group 91.6 percent.
Conclusion: Public opinion supports the combination of abstinence plus contraception education programs in schools. This support demonstrates that the scientific community and the public do not support the federal policy of abstinence-only programs.
Bleakley A, et al. Public opinion on sex education in US schools. Arch Pediatr Adolesc Med November 2006;160:1151-6.
Young Native-American Children at Higher Risk of Fatal Accidents
Despite years of largely successful public campaigns to reduce the number of deadly childhood accidents, new research suggests those efforts haven't had the desired effect for American Indian/Alaskan Native children.
Statistics from 2003 show that young black children were 63 percent more likely to die from an unintentional injury than white children, and young American Indian and Alaskan Native children were more than two times more likely to die.
CONCLUSIONS: These findings identify injury areas in which disparities narrowed, improvement occurred with maintenance or widening of disparities, and little or no progress was evident. This study further suggests specific mechanisms whereby new strategies and approaches to address areas that are recalcitrant to improvement in absolute rates and/or narrowing of disparities are needed and where increased dissemination of proven efficacious injury prevention efforts to high-risk populations are indicated.
Pressley JC, et al Twenty-year trends in fatal injuries to very young children: the persistence of racial disparities. Pediatrics. 2007 Apr;119(4):e875-84
What fluoride varnish are you using? Please respond
-Duraphat®: http://www.colgateprofessional.com/app/cop/jsp/products/productHome.jsp?prodcode=011400100
(multi-use tube)
-Duraflor®: http://www.medicom.com/faq.ch2 (available in unit-dose package)
-CavityShield®: http://www.omniipharma.com/cavityshield.asp (available in unit-dose package)
-VarnishAmerica™: http://www.medicalproductslaboratories.com/products/varnishamerica/varnishamerica.html
(available in unit-dose package)
Judith Thierry, Rockville , MarylandJudith.Thierry@ihs.gov Voice: 301-443-5070
New Guidelines Recommend Against Drug Testing of Teens in School, Home
The American Academy of Pediatrics continues to believe that adolescents should not be drug tested without their knowledge and consent. Recent US Supreme Court decisions and market forces have resulted in recommendations for drug testing of adolescents at school and products for parents to use to test adolescents at home. The American Academy of Pediatrics has strong reservations about testing adolescents at school or at home and believes that more research is needed on both safety and efficacy before school-based testing programs are implemented. The American Academy of Pediatrics also believes that more adolescent-specific substance abuse treatment resources are needed to ensure that testing leads to early rehabilitation rather than to punitive measures only.
Committee on Substance Abuse, American Academy of Pediatrics. Testing for drugs of abuse in children and adolescents: addendum--testing in schools and at home. Pediatrics. 2007 Mar;119(3):627-30.
Association between adolescent dieting behaviors and weight gain over time
This analysis provides insight into why dieting is associated with weight gain over time.
Previous research has demonstrated a strong longitudinal association between dieting behaviors and weight gain in adolescents. However, the question as to how dieting leads to weight gain remains unanswered. The article builds on previous analysis from Project EAT, a 5-year longitudinal study of eating and weight in adolescents, and explores possible mechanisms for the association between dieting behaviors and weight gain over time in adolescents.
They found that
* Among female adolescents, dieting at Time 1 strongly predicted binge eating and breakfast skipping at Time 2.
* Among male adolescents, dieting at Time 1 strongly predicted binge eating and lower levels of physical activity at Time 2.
* The behaviors most strongly associated with weight gain over time in female adolescents (i.e., higher levels of binge eating, lower levels of breakfast consumption, and lower levels of fruit and vegetable intake) were, in general, the same behaviors most strongly predicted by dieting in female adolescents.
* The behaviors most strongly associated with weight gain over time in male adolescents (i.e., higher levels of binge eating and decreased
MVPA) were the same behaviors most strongly predicted by dieting in male adolescents.
* In both female and male adolescents, the association between dieting and BMI change was weakened, but remained statistically significant, after the eating and activity behaviors were included in the model. This finding suggests that there may be other factors contributing to the association between dieting and weight gain over time.
"Findings from our study suggest that dieting places adolescents at risk for unhealthful eating and physical behaviors. Adolescents will need skills and support to avoid dieting behaviors that may be counterproductive to their aims for weight management and, instead, adopt eating and physical activity behaviors that would be effective in promoting health and preventing excess weight gain over time.
Neumark-Sztainer D, Wall M, Haines J, et al. 2007. Why does dieting predict weight gain in adolescents? Findings from Project Eat-II: A 5-year longitudinal study. Journal of the American Dietetic Association 107(3):448-455. http://www.adajournal.org/article/PIIS0002822306026800/abstract
Advanced Parental Age Predicts Risk for Autism Spectrum Disorder in Children
Advanced maternal and paternal ages are independently linked with risk for autism spectrum disorder (ASD) in children, according to the results of a historical birth cohort study
CONCLUSION: Advanced maternal and paternal ages are independently associated with ASD risk. Croen LA, et al Maternal and paternal age and risk of autism spectrum disorders. Arch Pediatr Adolesc Med. 2007 Apr;161(4):334-40
Patient Education Improves Adherence to Antidepressants
Conclusion: The authors conclude that, although physicians commonly mention the medication's name, purpose, and adverse effects when prescribing an antidepressant, other important information is mentioned less often. Physicians also tend to provide more information to less severely depressed patients. The authors conclude that adherence to antidepressant medications might be improved by developing better patient education strategies, especially those focusing on anticipated duration of therapy and the need to wait several weeks before symptom improvement will be noticeable.
Young HN, et al. Types of information physicians provide when prescribing antidepressants. J Gen Intern Med November 2006;21:1172-7.
Certain types of severe abdominal injury may signal child abuse in young children
http://www.ahrq.gov/research/mar07/307RA7.htm
Chronic Disease and Illness
Smoking Ban Has Health Benefits for Workers
Conclusion: The authors conclude that, although the participants had been bar workers for an average of nine years, health improvements were apparent just one month after a smoking ban, as measured by objective and subjective symptoms. The most marked improvements occurred in participants with asthma. An accompanying editorial notes that mandating smoke-free workplaces also results in higher rates of smoking cessation. However, there still is a high rate of exposure to secondhand smoke, especially among children and non-Hispanic blacks.
Menzies D, et al. Respiratory symptoms, pulmonary function, and markers of inflammation among bar workers before and after a legislative ban on smoking in public places. JAMA October 11, 2006;296:1742-8, and Eisner MD. Banning smoke in public places: time to clear the air [Editorial]. JAMA 2006;296:1778-9.
New Guideline for Screening Mammography for Women 40 to 49 Years of Age
-Recommendations encourage women to become part of the decision-making process
The American College of Physicians (ACP) released a new clinical practice guideline for screening mammography for women 40 to 49 years of age
Breast cancer is one of the most common causes of death for women in their
40s in the United States. Individualized risk assessment plays an important role
when making decisions about screening mammography, especially for women 49 years
of age or younger. The purpose of this guideline is to present the available
evidence for screening mammography in women 40 to 49 years of age and to increase
clinicians' understanding of the benefits and risks of screening mammography.
Qaseem
A et al Screening mammography for women 40 to 49 years of age: a clinical
practice guideline from the American College of Physicians. Ann
Intern Med. 2007 Apr 3;146(7):511-5.
MRI Detects Breast Cancer Missed by Mammography
RESULTS: MRI detected clinically and mammographically occult breast cancer in the contralateral breast in 30 of 969 women who were enrolled in the study (3.1%). The sensitivity of MRI in the contralateral breast was 91%, and the specificity was 88%. The negative predictive value of MRI was 99%. A biopsy was performed on the basis of a positive MRI finding in 121 of the 969 women (12.5%), 30 of whom had specimens that were positive for cancer (24.8%); 18 of the 30 specimens were positive for invasive cancer. The mean diameter of the invasive tumors detected was 10.9 mm. The additional number of cancers detected was not influenced by breast density, menopausal status, or the histologic features of the primary tumor. CONCLUSIONS: MRI can detect cancer in the contralateral breast that is missed by mammography and clinical examination at the time of the initial breast-cancer diagnosis.
Lehman CD, et al MRI evaluation of the contralateral breast in women with recently diagnosed breast cancer. N Engl J Med. 2007 Mar 29;356(13):1295-303
Low-Dose Aspirin Linked to Lower Risk for All-Cause Mortality in Women
CONCLUSIONS: In women, low to moderate doses of aspirin are associated with significantly lower risk of all-cause mortality, particularly in older women and those with cardiac risk factors. A significant benefit is evident within 5 years for cardiovascular disease, whereas a modest benefit for cancer is not apparent until after 10 years of use
Chan AT, et al Long-term aspirin use and mortality in women. Arch Intern Med. 2007 Mar 26;167(6):562-72
Intensive Smoking Cessation Intervention Reduces Mortality in High-Risk Smokers
CONCLUSION: Hospitalized smokers, especially those with cardiovascular disease, should undergo treatment with a structured intensive cessation intervention. The duration of the initial treatment should be 3 months.
Mohiuddin SM, et al Intensive smoking cessation intervention reduces mortality in high-risk smokers with cardiovascular disease. Chest. 2007 Feb;131(2):446-52
Orlistat Facilitates Weight Loss After a Very Low Energy Diet in Obese Patients
Orlistat added to lifestyle intervention was linked to an additional 2.4 kg of weight loss after a very low-energy diet in obese patients, and this loss was maintained for up to 3 years, according to the results of a 3-year randomized, placebo-controlled study
CONCLUSIONS: The addition of orlistat to lifestyle intervention was associated with maintenance of an extra 2.4 kg weight loss after VLED for up to 3 years in obese subjects. The combination of orlistat and lifestyle intervention was associated with a reduced occurrence of type 2 diabetes.
Richelsen B et al Effect of orlistat on weight regain and cardiovascular risk factors following a very-low-energy diet in abdominally obese patients: a 3-year randomized, placebo-controlled study. Diabetes Care. 2007 Jan;30(1):27-32.
AHA Publishes Guidelines on CVD Prevention in Women
lifestyle interventions
Cigarette Smoking. Counseling women against smoking is recommended, as is nicotine replacement or another indicated pharmacotherapy combined with participation in a behavioral or formal smoking cessation program. Women should also try to avoid secondhand smoke.
Physical Activity. Women at risk of CVD should aim for a minimum of 30 minutes of moderate exercise (e.g., brisk walking) on most, and preferably all, days of the week and 60 to 90 minutes of daily moderate exercise for those who need to lose weight or sustain weight loss.
Weight Maintenance. To maintain or lose weight, it is recommended that women find an appropriate balance of physical activity and caloric intake. Body mass index should be between 18.5 and 24.9 kg per m2, and waist circumference should not exceed 35 inches.
Dietary Intake. A high intake of fruits and vegetables is recommended for women at risk. Selecting whole-grain, high-fiber foods and consuming oily fish at least twice a week is recommended. Dietary cholesterol should be less than 300 mg per day, and saturated fat should make up no more than 7 to 10 percent of the diet; women at risk of hypercholesterolemia should have diets with less than 7 percent saturated fat and less than 200 mg of cholesterol each day.
In conjunction with diet, omega-3 fatty acids in capsule form may be considered for women with coronary heart disease (CHD).
Rehabilitation. Women who have had a recent cerebrovascular event; acute coronary syndrome or coronary intervention; peripheral arterial disease; new-onset or chronic angina; or symptoms of heart failure should be offered a comprehensive risk-reduction regimen (e.g., physician-guided community- or home-based exercise training program, cardiovascular or stroke rehabilitation).
Depression. Screening for depression in women with CHD should be considered.
http://www.aafp.org/afp/20070401/practice.html#p2 (Scroll down to find)
Intensive Smoking Cessation Intervention Reduces Mortality in High-Risk Smokers
CONCLUSION: Hospitalized smokers, especially those with cardiovascular disease, should undergo treatment with a structured intensive cessation intervention. The duration of the initial treatment should be 3 months.
Mohiuddin SM, et al Intensive smoking cessation intervention reduces mortality in high-risk smokers with cardiovascular disease. Chest. 2007 Feb;131(2):446-52
Are Opioids Effective in the Treatment of Neuropathic Pain?
Clinical Scenario
A 70-year-old woman with poorly controlled type 2 diabetes presents with burning, bilateral pain in her legs that is worsening; she requests medication to relieve her symptoms.
Clinical Question
Are opioids safe and effective for the treatment of neuropathic pain?
Evidence-Based Answer
Eight to 60 days of opioid therapy for the treatment of neuropathic pain effectively reduces pain scores as measured by a visual analog scale. A lack of response to opioids in the first 24 hours should not be used to predict whether longer-term opioid therapy might be beneficial. There are no controlled clinical trials that include patients receiving opioids for more than 70 days. Adverse effects (e.g., nausea, vomiting, constipation, drowsiness, dizziness) are common. Tolerance and addiction were not addressed in this Cochrane review.
Cochrane for Clinicians: Putting Evidence into Practice
Eisenberg E, McNicol E, Carr DB Opioids for neuropathic pain The Cochrane Database of Systematic Reviews 2007 Issue 1
http://www.cochrane.org/reviews/en/ab006146.html
Peppermint leaf and peppermint oil: Use for digestive disorders
Peppermint leaf and peppermint oil have a long history of use for digestive disorders. Recent evidence suggests that enteric-coated peppermint oil may be effective in relieving some of the symptoms of irritable bowel syndrome. A combination product including peppermint oil and caraway oil seems to be moderately effective in the treatment of non-ulcer dyspepsia. Topical application of peppermint oil may be effective in the treatment of tension headache. Because of its relaxing effects on smooth muscle, peppermint oil given via enema has been modestly effective for relief of colonic spasm in patients undergoing barium enemas. Peppermint oil is well tolerated at the commonly recommended dosage, but it may cause significant adverse effects at higher dosages. Am Fam Physician 2007;75:1027-30.
http://www.aafp.org/afp/20070401/1027.html
Outpatient Management of Anticoagulation Therapy
The Seventh American College of Chest Physicians (ACCP) Conference on Antithrombotic and Thrombolytic Therapy provides guidelines for outpatient management of anticoagulation therapy. The ACCP guidelines recommend short-term warfarin therapy, with the goal of maintaining an International Normalized Ratio (INR) of 2.5 ± 0.5, after major orthopedic surgery. Therapy for venous thromboembolism includes an INR of 2.5 ± 0.5, with the length of therapy determined by associated conditions. For patients with atrial fibrillation, the INR is maintained at 2.5 ± 0.5 indefinitely; for most patients with mechanical valves, the recommended INR is 3.0 ± 0.5 indefinitely. Use of outpatient low-molecular-weight heparin (LMWH) is as safe and effective as inpatient unfractionated heparin for treatment of venous thromboembolism. The ACCP recommends starting warfarin with unfractionated heparin or LMWH for at least five days and continuing until a therapeutic INR is achieved. Because patients with venous thromboembolism and cancer who have been treated with LMWH have a survival advantage that extends beyond their venous thromboembolism treatment, the ACCP recommends beginning their therapy with three to six months of LMWH. When invasive procedures require the interruption of oral anticoagulation therapy, recommendations for bridge therapy are determined by balancing the risk of bleeding against the risk of thromboembolism. Patients at higher risk of thromboembolization should stop warfarin therapy four to five days before surgery and start LMWH or unfractionated heparin two to three days before surgery. Am Fam Physician 2007;75:1031-42. http://www.aafp.org/afp/20070401/1031.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.
