Volume 6, No. 11, November 2008
Hot Topics
Obstetrics | Gynecology | Child Health | Chronic Disease and Illness
Obstetrics
Alcohol Use Screening for FASD Prevention among a Cohort of American Indian Women
ABSTRACT:
INTRODUCTION: The purpose of the study was to compare three sequential pregnancies of American Indian women who have children with FAS or children with incomplete FAS with women who did not have children with FAS.
METHODS: Two retrospective case-control studies were conducted of Northern Plains American Indian children with fetal alcohol syndrome (FAS) (Study 1) or incomplete FAS (Study 2) in 1981–1993. Three successive pregnancies ending in live births of 43 case mothers who had children with FAS, and 35 case mothers who had children with incomplete FAS were compared to the pregnancies of 86 and 70 control mothers who did not have children with FAS, respectively, in the two studies. Prenatal records were abstracted for the index child (child with FAS or incomplete FAS) and siblings born just before and just after the index child, and comparable prenatal records for the controls.
RESULTS: Compared to the controls, significantly more case mothers used alcohol before and after all three pregnancies and during pregnancy with the before sibling and the index child. Mothers who had children with FAS reduced their alcohol use during the pregnancy following the birth of the index child. All Study 1 case mothers (100%) and 60% of Study 2 case mothers used alcohol during the pregnancy with the index child compared to 20 and 9% of respective control mothers. More study 1 case mothers experienced unintentional injuries (OR 9.50) and intentional injuries during the index pregnancy (OR 9.33) than the control mothers. Most case mothers began prenatal care in the second trimester.
CONCLUSIONS: Alcohol use was documented before, during and after each of the three pregnancies. Women of child-bearing age should be screened for alcohol use whenever they present for medical services. Mothers who had a child with FAS decreased their alcohol consumption with the next pregnancy, a finding that supports the importance of prenatal screening throughout pregnancy. Women who receive medical care for injuries should be screened for alcohol use and referred for appropriate treatment. Protective custody, case management and treatment services need to be readily available for women who use alcohol.
Kvigne VL, Leonardson GR, Borzelleca J, Brock E, Neff-Smith M, and Welty TK. Alcohol Use, Injuries, and Prenatal Visits During Three Successive Pregnancies Among American Indian Women on the Northern Plains Who have Children with Fetal Alcohol Syndrome or Incomplete Fetal Alcohol Syndrome. Maternal and Child Health Journal. Volume 12, Supplement 1 / July, 2008. pp 37-45. http://www.springerlink.com/content/dj5203723n2l7l34/
Prevention of Diabetes in Women with a History of Gestational Diabetes: Effects of Metformin and Lifestyle Interventions
CONTEXT: A past history of gestational diabetes mellitus (GDM) confers a very high risk of post-partum development of diabetes, particularly type 2 diabetes.
OBJECTIVE: The Diabetes Prevention Program (DPP) sought to identify individuals with impaired glucose tolerance (IGT) and intervene in an effort to prevent or delay their progression to diabetes. This analysis examines the differences between women enrolled in DPP with and without a reported history of GDM.
DESIGN: The DPP was a randomized, controlled clinical trial.
SETTING: The study was a multicenter, NIH-sponsored trial carried out at 27 centers including academic and Indian Health Services sites.
PATIENTS: 2190 women were randomized into the DPP and provided information for past history of GDM. This analysis addresses the differences between those 350 women providing a past history of GDM and those 1416 women with a previous live birth, but no history of GDM.
INTERVENTIONS: Subjects were randomized to either standard lifestyle and placebo or metformin therapy, or to an intensive lifestyle intervention.
MAIN OUTCOMES: The primary outcome was the time to development of diabetes ascertained by semi-annual fasting plasma glucose and annual oral glucose tolerance testing. Assessments of insulin secretion and insulin sensitivity were also performed.
RESULTS: While entering the study with similar glucose levels, women with a history of GDM randomized to placebo had a crude incidence rate of diabetes 71% higher than that of women without such a history. Among women reporting a history of GDM, both intensive lifestyle and metformin therapy reduced the incidence of diabetes by approximately 50% compared with the placebo group, whereas this reduction was 49% and 14%, respectively in parous women without GDM. These data suggest that metformin may be more effective in women with a GDM history as compared to those without.
CONCLUSIONS: Progression to diabetes is more common in women with a history of GDM compared to those without GDM history despite equivalent degrees of IGT at baseline. Both intensive lifestyle and metformin are highly effective in delaying or preventing diabetes in women with IGT and a history of GDM.
Ratner RE, Christophi CA, Metzger BE, Dabelea D, Bennett PH, Pi-Sunyer X, Fowler S, Kahn SE; The Diabetes Prevention Program Research Group. Prevention of Diabetes in Women with a History of Gestational Diabetes: Effects of Metformin and Lifestyle Interventions. J Clin Endocrinol Metab. 2008 Sep 30. [Epub ahead of print] http://www.ncbi.nlm.nih.gov/pubmed/18826999
Perinatal outcomes in low-risk term pregnancies: do they differ by week of gestation?
OBJECTIVE: The objective of the study was to examine whether the risk of perinatal complications increases with increasing gestational age among term pregnancies.
STUDY DESIGN: This is a retrospective cohort study of low-risk women with term, singleton births in 2003 in the United States. Gestational age was subgrouped into 37, 38, 39, 40, and 41 completed weeks. Statistical comparison was performed using chi(2) test and multivariable logistic regression models, with 39 weeks' gestation as the referent.
RESULTS: There were 2,527,766 women meeting study criteria. Compared with 39 weeks, delivery at 37 or 38 weeks had lower risk of febrile morbidity but slightly higher risk of cesarean delivery. Delivery at 40 or 41 weeks was also associated with higher overall maternal morbidity. For neonates, delivery at 40 or 41 weeks had higher risk of birthweight greater than 4500 g, neonatal injury (40 weeks: adjusted odds ratio [aOR] 1.11 [95% confidence interval (CI), 1.05-1.18]; 41 weeks: aOR 1.27 [95% CI, 1.17-1.37]) and meconium aspiration (40 weeks: aOR 1.55 [95% CI, 1.43-1.69]; 41 weeks: aOR 2.12 [95% CI, 1.91-2.35]). Delivery at 37 or 38 weeks had higher risk of hyaline membrane disease (37 weeks: aOR 3.12 [95% CI, 2.90-3.38]); 38 weeks: aOR 1.30 [95% CI, 1.19-1.43]) but lower risk of meconium aspiration.
CONCLUSION: The risk of cesarean delivery and neonatal morbidity in low-risk women increases at 40 weeks and beyond, whereas the odds of serious neonatal pulmonary disease were highest at 37 weeks. Recognition of such variation in term outcomes should lead providers to avoid iatrogenic morbidity and consider interventions to prevent complications of late-term pregnancy.
Cheng YW, Nicholson JM, Nakagawa S, Bruckner TA, Washington AE, Caughey AB. Perinatal outcomes in low-risk term pregnancies: do they differ by week of gestation? Am J Obstet Gynecol. 2008 Oct;199(4):370.e1-7. http://www.ncbi.nlm.nih.gov/pubmed/18928977
Effect on birth outcomes of a formalised approach to care in hospital labour assessment units: international, randomised controlled trial
OBJECTIVE: To determine if a complex nursing and midwifery intervention in hospital labour assessment units would increase the likelihood of spontaneous vaginal birth and improve other maternal and neonatal outcomes.
DESIGN: Multicentre, randomised controlled trial with prognostic stratification by hospital. SETTING: 20 North American and UK hospitals.
PARTICIPANTS: 5002 nulliparous women experiencing contractions but not in active labour; 2501 were allocated to structured care and 2501 to usual care.
INTERVENTIONS: Usual nursing or midwifery care or a minimum of one hour of care by a nurse or midwife trained in structured care, consisting of a formalised approach to assessment of and interventions for maternal emotional state, pain, and fetal position.
MAIN OUTCOME MEASURES: Primary outcome was spontaneous vaginal birth. Other outcomes included intrapartum interventions, women's views of their care, and indicators of maternal and fetal health during hospital stay and 6-8 weeks after discharge.
RESULTS: Outcome data were obtained for 4996 women. The rate of spontaneous vaginal birth was 64.0% (n=1597) in the structured care group and 61.3% (n=1533) in the usual care group (odds ratio 1.12, 95% confidence interval 0.96 to 1.27). Fewer women allocated to structured care (n=403, 19.5%) rated staff helpfulness as less than very helpful than those allocated to usual care (n=544, 26.4%); odds ratio 0.67, 98.75% confidence interval 0.50 to 0.85. Fewer women allocated to structured care (n=233, 11.3%) were disappointed with the amount of attention received from staff than those allocated to usual care (n=407, 19.7%); odds ratio 0.51, 98.75% confidence interval 0.32 to 0.70. None of the other results met prespecified levels of statistical significance.
CONCLUSION: A structured approach to care in hospital labour assessment units increased satisfaction with care and was suggestive of a modest increase in the likelihood of spontaneous vaginal birth. Further study to strengthen the intervention is warranted.
Hodnett ED, Stremler R, Willan AR, Weston JA, Lowe NK, Simpson KR, Fraser WD, Gafni A; SELAN (Structured Early Labour Assessment and Care by Nurses) Trial Group. Effect on birth outcomes of a formalised approach to care in hospital labour assessment units: international, randomised controlled trial. BMJ. 2008 Aug 28;337:a1021. doi: 10.1136/bmj.a1021. http://www.ncbi.nlm.nih.gov/pubmed/18755762
Free full text:
http://www.bmj.com/cgi/content/full/337/aug28_1/a1021
Peripartum Clostridium difficile infection
Clostridium difficile infection (CDI) in nonhospitalized patients has been reported with increased frequency. An association between CDI and pregnancy has not been stressed. This review will report 4 cases of peripartum CDI with characterization of the infecting strain and a literature review. A PubMed search identified 24 recorded cases of peripartum CDI; information was available for 14 cases. Most patients (91%) received prophylactic antibiotics during delivery or for treatment of bacterial infections (50%). All patients reported diarrhea. Two of our reported cases without known risk factors were found by polymerase chain reaction analysis to be infected with an epidemic and hypervirulent C difficile strain. These cases demonstrate the need for clinicians to consider CDI in patients with severe diarrhea, even if they do not have the traditional risk factors for CDI, such as antibiotic use or concurrent hospitalizations. Further research into the scope and risk factors for peripartum CDI is warranted.
Garey KW, Jiang ZD, Yadav Y, Mullins B, Wong K, Dupont HL. Peripartum Clostridium difficile infection: case series and review of the literature. Am J Obstet Gynecol. 2008 Oct;199(4):332-7. Epub 2008 Jul 17. http://www.ncbi.nlm.nih.gov/pubmed/18639213
Gynecology
Pregnancy outcome in women before and after cervical conisation
OBJECTIVES: To examine the consequences of cervical conisation in terms of adverse outcome in subsequent pregnancies.
DESIGN: Population based cohort study.
DATA SOURCES: Data on cervical conisation derived from the Cancer Registry of Norway and on pregnancy outcome from the Medical Birth Registry of Norway, 1967-2003. 15 108 births occurred in women who had previously undergone cervical conisation and 57 136 who subsequently underwent cervical conisation. In the same period there were 2 164 006 births to women who had not undergone relevant treatment (control).
RESULTS: The proportion of preterm delivery was 17.2% in women who gave birth after cervical conisation versus 6.7% in women who gave birth before cervical conisation and 6.2% in women who had not undergone cervical conisation. The relative risk of a late abortion (<24 weeks' gestation) was 4.0 (95% confidence interval 3.3 to 4.8) in women who gave birth after cervical conisation compared with no cervical conisation. The relative risk of delivery was 4.4 (3.8 to 5.0) at 24-27 weeks, 3.4 (3.1 to 3.7) at 28-32 weeks, and 2.5 (2.4 to 2.6) at 33-36 weeks. The relative risk of preterm delivery declined during the study period and especially of delivery before 28 weeks' gestation.
CONCLUSION: Cervical conisation influences outcome in subsequent pregnancies in terms of an increased risk of preterm delivery, especially in the early gestational age groups in which the clinical significance is highest. A careful clinical approach should be taken in the selection of women for cervical conisation and in the clinical care of pregnancies after a cervical conisation.
Albrechtsen S, Rasmussen S, Thoresen S, Irgens LM, Iversen OE. Pregnancy outcome in women before and after cervical conisation: population based cohort study. BMJ. 2008 Sep 18;337:a1343. doi: 10.1136/bmj.a1343. http://www.ncbi.nlm.nih.gov/pubmed/18801869
Free Full Text: http://www.bmj.com/cgi/content/full/337/sep18_1/a1343
FDA Public Health Notification: Serious Complications Associated with Transvaginal Placement of Surgical Mesh in Repair of Pelvic Organ Prolapse and Stress Urinary Incontinence
The FDA has informed healthcare professionals of serious complications
associated with transvaginal placement of surgical mesh in repair of pelvic organ
prolapse (POP) and stress urinary incontinence (SUI). Over the past three years,
FDA has received over 1,000 reports from nine surgical mesh manufacturers of
complications that were associated with surgical mesh devices used to repair
POP and SUI. The most frequent complications included erosion through vaginal
epithelium, infection, pain, urinary problems, and recurrence of prolapse and/or
incontinence. There were also reports of bowel, bladder, and blood vessel perforation
during insertion. In some cases, vaginal scarring and mesh erosion led to a significant
decrease in patient quality of life due to discomfort and pain, including dyspareunia.
FDA provided recommended actions for both physicians and patients to reduce the
risks.
Additional information is available at:
http://www.fda.gov/cdrh/safety/102008-surgicalmesh.html
The role of Lactobacillus casei rhamnosus Lcr35 in restoring the normal vaginal flora after antibiotic treatment of bacterial vaginosis
OBJECTIVE: To evaluate the efficacy of additional topical Lactobacillus casei rhamnosus (Lcr35) subsequent to antibiotic treatment of bacterial vaginosis (BV) to restore the normal vaginal flora.
STUDY DESIGN: Single-centre, randomised, observer blinded study.
SETTING: Population-based study in Vienna over 1 year.
SAMPLE: 190 women were enrolled in the study.
METHODS: Women with Nugent scores between 7 and 10 on initial vaginal swab were randomised to the one of two groups. All women were treated with standard antibiotic therapy for 7 days. Only women in the intervention group received vaginal capsules containing 10(9) colony-forming units of live Lcr35 for 7 days after antibiotic treatment. Final vaginal swabs for Nugent scoring were taken 4 weeks after the last administration of the study medication.
MAIN OUTCOME MEASURES: The primary efficacy variable was a change in the Nugent score between the baseline and the end of the study of at least 5 grades in each individual woman.
RESULTS: Sixty-nine of the 83 women (83%) in the intervention group and 31 of the 88 women (35%) in the control group showed a reduction of the Nugent score by at least 5 grades. The difference in the number of women with improvement was highly significant (P < 0.001). The median difference in Nugent scores between initial and final swabs was 6.61 in the intervention group and 4.13 in the control group (P < 0.001).
CONCLUSION: Our data show that the restoration of the vaginal flora after antibiotic treatment of BV can be significantly enhanced by exogenously applied lactobacilli.
Petricevic L, Witt A. The role of Lactobacillus casei rhamnosus Lcr35 in restoring the normal vaginal flora after antibiotic treatment of bacterial vaginosis. BJOG. 2008 Oct;115(11):1369-74. http://www.ncbi.nlm.nih.gov/pubmed/18823487
Hormone therapy and the risk of breast cancer in BRCA1 mutation carriers
BACKGROUND: Hormone therapy (HT) is commonly given to women to alleviate the climacteric symptoms associated with menopause. There is concern that this treatment may increase the risk of breast cancer. The potential association of HT and breast cancer risk is of particular interest to women who carry a mutation in BRCA1 because they face a high lifetime risk of breast cancer and because many of these women take HT after undergoing prophylactic surgical oophorectomy at a young age. METHODS: We conducted a matched case-control study of 472 postmenopausal women with a BRCA1 mutation to examine whether or not the use of HT is associated with subsequent risk of breast cancer. Breast cancer case patients and control subjects were matched with respect to age, age at menopause, and type of menopause (surgical or natural). Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated with conditional logistic regression. Statistical tests were two-sided.
RESULTS: In this group of BRCA1 mutation carriers, the adjusted OR for breast cancer associated with ever use of HT compared with never use was 0.58 (95% CI = 0.35 to 0.96; P = .03). In analyses by type of HT, an inverse association with breast cancer risk was observed with use of estrogen only (OR = 0.51, 95% CI = 0.27 to 0.98; P = .04); the association with use of estrogen plus progesterone was not statistically significant (OR = 0.66, 95% CI = 0.34 to 1.27; P = .21). CONCLUSION: Among postmenopausal women with a BRCA1 mutation, HT use was not associated with increased risk of breast cancer; indeed, in this population, it was associated with a decreased risk.
Eisen A, Lubinski J, Gronwald J, Moller P, Lynch HT, Klijn J, et al. Hormone therapy and the risk of breast cancer in BRCA1 mutation carriers. J Natl Cancer Inst. 2008 Oct 1;100(19):1361-7. Epub 2008 Sep 23. http://www.ncbi.nlm.nih.gov/pubmed/18812548
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http://jnci.oxfordjournals.org/cgi/content/full/100/19/1361
Child Health
Prevention of Rickets and Vitamin D Deficiency in Infants, Children, and Adolescents
ABSTRACT
Rickets in infants attributable to inadequate vitamin D intake and decreased
exposure to sunlight continues to be reported in the United States. There are
also concerns for vitamin D deficiency in older children and adolescents. Because
there are limited natural dietary sources of vitamin D and adequate sunshine
exposure for the cutaneous synthesis of vitamin D is not easily determined for
a given individual and may increase the risk of skin cancer, the recommendations
to ensure adequate vitamin D status have been revised to include all infants,
including those who are exclusively breastfed and older children and adolescents.
It is now recommended that all infants and children, including adolescents, have
a minimum daily intake of 400 IU of vitamin D beginning soon after birth. The
current recommendation replaces the previous recommendation of a minimum daily
intake of 200 IU/day of vitamin D supplementation beginning in the first 2 months
after birth and continuing through adolescence. These revised guidelines for
vitamin D intake for healthy infants, children, and adolescents are based on
evidence from new clinical trials and the historical precedence of safely giving
400 IU of vitamin D per day in the pediatric and adolescent population. New evidence
supports a potential role for vitamin D in maintaining innate immunity and preventing
diseases such as diabetes and cancer. The new data may eventually refine what
constitutes vitamin D sufficiency or deficiency.
Carol L. Wagner, MD, Frank R.
Greer, MD, and the Section on Breastfeeding and Committee on Nutrition. Prevention
of Rickets and Vitamin D Deficiency in Infants, Children, and Adolescents.
Pediatrics 2008;122:1142–1152. http://www.aap.org/new/VitaminDreport.pdf
Interventions in primary care to promote breastfeeding: an evidence review for the U.S. Preventive Services Task Force
BACKGROUND: Evidence suggests that breastfeeding decreases the risk for many diseases in mothers and infants. It is therefore important to evaluate the effectiveness of breastfeeding interventions.
PURPOSE: To systematically review evidence for the effectiveness of primary care-initiated interventions to promote breastfeeding with respect to breastfeeding and child and maternal health outcomes.
DATA SOURCES: Electronic searches of MEDLINE, the Cochrane Central Register of Controlled Trials, and CINAHL from September 2001 to February 2008 and references of selected articles, restricted to English-language publications.
STUDY SELECTION: Randomized, controlled trials of primary care-initiated interventions to promote breastfeeding, mainly in developed countries.
DATA EXTRACTION: Characteristics of interventions and comparators, study setting, study design, population characteristics, the proportion of infants continuing breastfeeding by different durations, and infant or maternal health outcomes were recorded.
DATA SYNTHESIS: Thirty-eight randomized, controlled trials (36 in developed countries) met eligibility criteria. In random-effects meta-analyses, breastfeeding promotion interventions in developed countries resulted in significantly increased rates of short- (1 to 3 months) and long-term (6 to 8 months) exclusive breastfeeding (rate ratios, 1.28 [95% CI, 1.11 to 1.48] and 1.44 [CI, 1.13 to 1.84], respectively). In subgroup analyses, combining pre- and postnatal breastfeeding interventions had a larger effect on increasing breastfeeding durations than either pre- or postnatal interventions alone. Furthermore, breastfeeding interventions with a component of lay support (such as peer support or peer counseling) were more effective than usual care in increasing the short-term breastfeeding rate.
LIMITATIONS: Meta-analyses were limited by clinical and methodological heterogeneity. Reliable estimates for the isolated effects of each component of multicomponent interventions could not be obtained.
CONCLUSION: Evidence suggests that breastfeeding interventions are more effective than usual care in increasing short- and long-term breastfeeding rates. Combined pre- and postnatal interventions and inclusion of lay support in a multicomponent intervention may be beneficial.
Chung M, Raman G, Trikalinos T, Lau J, Ip S. Interventions in primary care to promote breastfeeding: an evidence review for the U.S. Preventive Services Task Force. Ann Intern Med. 2008 Oct 21;149(8):565-82. http://www.ncbi.nlm.nih.gov/pubmed/18936504
Full Text: http://www.ahrq.gov/clinic/uspstf08/breastfeeding/brfeedart.pdf
Use of a fan during sleep and the risk of sudden infant death syndrome
OBJECTIVE: To examine the relation between room ventilation during sleep and risk of sudden infant death syndrome (SIDS).
DESIGN: Population-based case-control study.
SETTING: Eleven California counties.
PARTICIPANTS: Mothers of 185 infants with a confirmed SIDS diagnosis and 312 randomly selected infants matched on county of residence, maternal race/ethnicity, and age.
INTERVENTION: Fan use and open window during sleep.
MAIN OUTCOME MEASURE: Risk of SIDS.
RESULTS: Fan use during sleep was associated with a 72% reduction in SIDS risk (adjusted odds ratio [AOR], 0.28; 95% confidence interval [CI], 0.10-0.77). The reduction in SIDS risk seemed more pronounced in adverse sleep environments. For example, fan use in warmer room temperatures was associated with a greater reduction in SIDS risk (AOR, 0.06; 95% CI, 0.01-0.52) compared with cooler room temperatures (0.77; 0.22-2.73). Similarly, the reduction associated with fan use was greater in infants placed in the prone or side sleep position (AOR, 0.14; 95% CI, 0.03-0.55) vs supine (0.84; 0.21-3.39). Fan use was associated with a greater reduction in SIDS risk in infants who shared a bed with an individual other than their parents (AOR, 0.15; 95% CI, 0.01-1.85) vs with a parent (0.40; 0.03-4.68). Finally, fan use was associated with reduced SIDS risk in infants not using pacifiers (AOR, 0.22; 95% CI, 0.07-0.69) but not in pacifier users (1.99; 0.16-24.4). Some differences in the effect of fan use on SIDS risk did not reach statistical significance.
CONCLUSION: Fan use may be an effective intervention for further decreasing SIDS risk in infants in adverse sleep environments.
Coleman-Phox K, Odouli R, Li DK. Use of a fan during sleep and the risk of sudden infant death syndrome. Arch Pediatr Adolesc Med. 2008 Oct;162(10):963-8. http://www.ncbi.nlm.nih.gov/pubmed/18838649
Support for Comprehensive Sexuality Education: Perspectives from Parents of School-Age Youth
PURPOSE: Controversy about school-based sexuality education in public schools has continued over the past decade, despite mounting evidence that comprehensive sexuality education effectively promotes sexual health and that parents support these programs in public schools. The present study replicates and expands upon previous findings regarding public views on school-based sexuality education.
METHODS: One thousand six hundred five parents of school-age children in Minnesota responded to telephone surveys in 2006-2007 (63% participation rate), including items regarding general sexuality education, 12 specific topics, the grade level at which each should be taught, and attitudes toward sexuality education.
RESULTS: The large majority of parents supported teaching about both abstinence and contraception (comprehensive sexuality education [CSE]; 89.3%), and support was high across all demographic categories of parents. All specific sexuality education topics received majority support (63.4%-98.6%), even those often viewed as controversial. Parents believed most topics should first be taught during the middle school years. Parents held slightly more favorable views on the effectiveness of CSE compared to abstinence-only education, and these views were strongly associated with support for CSE (odds ratio [OR](CSE) = 14.3; OR(abstinence) = 0.11).
CONCLUSIONS: This study highlights a mismatch between parents' expressed opinions and preferences, and actual sexuality education content as currently taught in the majority of public schools. In light of broad parental support for education that emphasizes multiple strategies for prevention of pregnancy and sexually transmitted infections (including abstinence), parents should be encouraged to express their opinions on sexuality education to teachers, administrators, and school boards regarding the importance of including a variety of topics and beginning instruction during middle school years or earlier.
Eisenberg ME, Bernat DH, Bearinger LH, Resnick MD. Support for comprehensive sexuality education: perspectives from parents of school-age youth. J Adolesc Health. 2008 Apr;42(4):352-9. Epub 2007 Dec 26. http://www.ncbi.nlm.nih.gov/pubmed/18346660
First-trimester maternal alcohol consumption and the risk of infant oral clefts
Although alcohol is a recognized teratogen, evidence is limited on alcohol intake and oral cleft risk. The authors examined the association between maternal alcohol consumption and oral clefts in a national, population-based case-control study of infants born in 1996-2001 in Norway. Participants were 377 infants with cleft lip with or without cleft palate, 196 with cleft palate only, and 763 controls. Mothers reported first-trimester alcohol consumption in self-administered questionnaires completed within a few months after delivery. Logistic regression was used to calculate odds ratios and 95% confidence intervals, adjusting for confounders. Compared with nondrinkers, women who reported binge-level drinking (>or=5 drinks per sitting) were more likely to have an infant with cleft lip with or without cleft palate (odds ratio = 2.2, 95% confidence interval: 1.1, 4.2) and cleft palate only (odds ratio = 2.6, 95% confidence interval: 1.2, 5.6). Odds ratios were higher among women who binged on three or more occasions: odds ratio = 3.2 for cleft lip with or without cleft palate (95% confidence interval: 1.0, 10.2) and odds ratio = 3.0 for cleft palate only (95% confidence interval: 0.7, 13.0). Maternal binge-level drinking may increase the risk of infant clefts.
DeRoo LA, Wilcox AJ, Drevon CA, Lie RT. First-trimester maternal alcohol consumption and the risk of infant oral clefts in Norway: a population-based case-control study. Am J Epidemiol. 2008 Sep 15;168(6):638-46. Epub 2008 Jul 30. http://www.ncbi.nlm.nih.gov/pubmed/18667525
Chronic Disease and Illness
Patients and Caregivers Benefit from End-of-Life Discussions
CONTEXT: Talking about death can be difficult. Without evidence that end-of-life discussions improve patient outcomes, physicians must balance their desire to honor patient autonomy against a concern of inflicting psychological harm.
OBJECTIVE: To determine whether end-of-life discussions with physicians are associated with fewer aggressive interventions.
DESIGN, SETTING, AND PARTICIPANTS: A US multisite, prospective, longitudinal cohort study of patients with advanced cancer and their informal caregivers (n = 332 dyads), September 2002-February 2008. Patients were followed up from enrollment to death, a median of 4.4 months later. Bereaved caregivers' psychiatric illness and quality of life was assessed a median of 6.5 months later.
MAIN OUTCOME MEASURES: Aggressive medical care (eg, ventilation, resuscitation) and hospice in the final week of life. Secondary outcomes included patients' mental health and caregivers' bereavement adjustment.
RESULTS: One hundred twenty-three of 332 (37.0%) patients reported having end-of-life discussions before baseline. Such discussions were not associated with higher rates of major depressive disorder (8.3% vs 5.8%; adjusted odds ratio [OR], 1.33; 95% confidence interval [CI], 0.54-3.32), or more worry (mean McGill score, 6.5 vs 7.0; P = .19). After propensity-score weighted adjustment, end-of-life discussions were associated with lower rates of ventilation (1.6% vs 11.0%; adjusted OR, 0.26; 95% CI, 0.08-0.83), resuscitation (0.8% vs 6.7%; adjusted OR, 0.16; 95% CI, 0.03-0.80), ICU admission (4.1% vs 12.4%; adjusted OR, 0.35; 95% CI, 0.14-0.90), and earlier hospice enrollment (65.6% vs 44.5%; adjusted OR, 1.65;95% CI, 1.04-2.63). In adjusted analyses, more aggressive medical care was associated with worse patient quality of life (6.4 vs 4.6; F = 3.61, P = .01) and higher risk of major depressive disorder in bereaved caregivers (adjusted OR, 3.37; 95% CI, 1.12-10.13), whereas longer hospice stays were associated with better patient quality of life (mean score, 5.6 vs 6.9; F = 3.70, P = .01). Better patient quality of life was associated with better caregiver quality of life at follow-up (beta = .20; P = .001). CONCLUSIONS: End-of-life discussions are associated with less aggressive medical care near death and earlier hospice referrals. Aggressive care is associated with worse patient quality of life and worse bereavement adjustment.
Wright AA, Zhang B, Ray A, Mack JW, Trice E, Balboni T, Mitchell SL, Jackson VA, Block SD, Maciejewski PK, Prigerson HG. Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjustment. JAMA. 2008 Oct 8;300(14):1665-73. http://www.ncbi.nlm.nih.gov/pubmed/18840840
Comparative Effectiveness and Safety of Premixed Insulin Analogues in Type 2 Diabetes
BACKGROUND: Evidence comparing premixed insulin analogues (a mixture of rapid-acting and intermediate-acting insulin analogues) with other antidiabetic agents is urgently required to guide appropriate therapy.
PURPOSE: To summarize the English-language literature on the effectiveness and safety of premixed insulin analogues compared with other antidiabetic agents in adults with type 2 diabetes.
DATA SOURCES: The authors searched MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials from inception to February 2008 and sought unpublished data from the U.S. Food and Drug Administration, European Medicines Agency, and industry.
STUDY SELECTION: Studies with control groups that compared premixed insulin analogues with another antidiabetic medication in adults with type 2 diabetes.
DATA EXTRACTION: 2 reviewers using standardized protocols performed serial abstraction.
DATA SYNTHESIS: Evidence from clinical trials was inconclusive for clinical outcomes, such as mortality. Therefore, the review focused on intermediate outcomes. Premixed insulin analogues were similar to premixed human insulin in decreasing fasting glucose levels, hemoglobin A(1c) levels, and the incidence of hypoglycemia but were more effective in decreasing postprandial glucose levels (mean difference, -1.1 mmol/L; 95% CI, -1.4 to -0.7 mmol/L [-19.2 mg/dL; 95% CI, -25.9 to -12.5 mg/dL]). Compared with long-acting insulin analogues, premixed insulin analogues were superior in decreasing postprandial glucose levels (mean difference, -1.5 mmol/L; CI, -1.9 to -1.2 mmol/L [-27.9 mg/dL; CI, -34.3 to -21.5 mg/dL]) and hemoglobin A(1c) levels (mean difference, -0.39% [CI, -0.50% to -0.28%]) but were inferior in decreasing fasting glucose levels (mean difference, 0.7 mmol/L; CI, 0.3 to 1.0 mmol/L [12.0 mg/dL; CI, 6.0 to 18.1 mg/dL]) and were associated with a higher incidence of hypoglycemia. Compared with noninsulin antidiabetic agents, premixed insulin analogues were more effective in decreasing fasting glucose levels (mean difference, -1.1 mmol/L; CI, -1.7 to -0.6 mmol/L [-20.5 mg/dL; CI, -29.9 to -11.2 mg/dL]), postprandial glucose levels (mean difference, -2.1 mmol/L; CI, -3.4 to -0.8 mmol/L [-37.4 mg/dL; CI, -61.0 to -13.7 mg/dL]), and hemoglobin A(1c) levels (mean difference, -0.49% [CI, -0.86% to -0.12%]) but were associated with a higher incidence of hypoglycemia. Limitations: The literature search was restricted to studies published in English. Data on clinical outcomes were limited. The small number of studies for each comparison limited assessment of between-study heterogeneity.
CONCLUSION: Premixed insulin analogues provide glycemic control similar to that of premixed human insulin and may provide tighter glycemic control than long-acting insulin analogues and noninsulin antidiabetic agents.
Qayyum
R, Bolen S, Maruthur N, Feldman L, Wilson LM, Marinopoulos SS, Ranasinghe P,
Amer M, Bass EB. Systematic Review: Comparative Effectiveness and Safety of Premixed
Insulin Analogues in Type 2 Diabetes. Ann Intern Med. 2008 Sep 15. [Epub ahead
of print]
http://www.ncbi.nlm.nih.gov/pubmed/18794553
Modified Insulin Most Effective for Controlling Post-Meal Blood Sugar Levels. Press Release, September 15, 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/press/pr2008/modinspr.htm
Smoking cessation interventions for hospitalized smokers: a systematic review
BACKGROUND: A hospital admission provides an opportunity to help people stop smoking. Providing smoking cessation advice, counseling, or medication is now a quality-of-care measure for US hospitals. We assessed the effectiveness of smoking cessation interventions initiated during a hospital stay.
METHODS: We searched the Cochrane Tobacco Addiction Review Group's register for randomized and quasirandomized controlled trials of smoking cessation interventions (behavioral counseling and/or pharmacotherapy) that began during hospitalization and had a minimum of 6 months of follow-up. Two authors independently extracted data from each article, with disagreements resolved by consensus.
RESULTS: Thirty-three trials met inclusion criteria. Smoking counseling that began during hospitalization and included supportive contacts for more than 1 month after discharge increased smoking cessation rates at 6 to 12 months (pooled odds ratio [OR], 1.65; 95% confidence interval [CI], 1.44-1.90). No benefit was found for interventions with less postdischarge contact. Counseling was effective when offered to all hospitalized smokers and to the subset admitted for cardiovascular disease. Adding nicotine replacement therapy to counseling produced a trend toward efficacy over counseling alone (OR, 1.47; 95% CI, 0.92-2.35). One study added bupropion hydrochloride to counseling, which had a nonsignificant result (OR, 1.56; 95% CI, 0.79-3.06).
CONCLUSIONS: Offering smoking cessation counseling to all hospitalized smokers is effective as long as supportive contacts continue for more than 1 month after discharge. Adding nicotine replacement therapy to counseling may further increase smoking cessation rates and should be offered when clinically indicated, especially to hospitalized smokers with nicotine withdrawal symptoms.
Rigotti NA, Munafo MR, Stead LF. Smoking cessation interventions for hospitalized smokers: a systematic review. Arch Intern Med. 2008 Oct 13;168(18):1950-60. http://www.ncbi.nlm.nih.gov/pubmed/18852395
Free Full Text:
http://archinte.ama-assn.org/cgi/content/full/168/18/1950
Patients with Coronary Heart Disease Benefit from Screening for Depression
ABSTRACT
Depression is commonly present in patients with coronary heart disease (CHD)
and is independently associated with increased cardiovascular morbidity and mortality.
Screening tests for depressive symptoms should be applied to identify patients
who may require further assessment and treatment. This multispecialty consensus
document reviews the evidence linking depression with CHD and provides recommendations
for healthcare providers for the assessment, referral, and treatment of depression.
Lichtman JH, Bigger JT Jr, Blumenthal JA, Frasure-Smith N, Kaufmann PG, Lespérance F, Mark DB, Sheps DS, Taylor CB, Froelicher ES. Depression and Coronary Heart Disease. Recommendations for Screening, Referral, and Treatment. A Science Advisory From the American Heart Association Prevention Committee of the Council on Cardiovascular Nursing, Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Interdisciplinary Council on Quality of Care and Outcomes Research. Circulation. 2008 Sep 29. [Epub ahead of print]. http://www.ncbi.nlm.nih.gov/pubmed/18824640
Free full text:
http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.108.190769v2
Resources for Depression Screening:
The McArthur Initiative on Depression and
Primary Care:
http://www.depression-primarycare.org/clinicians/toolkits/
Sample PHQ2:
http://www.commonwealthfund.org/usr_doc/PHQ2.pdf
Sample PHQ9:
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OB/GYN
Jean Howe, MD, MPH is the Obstetrics and Gynecology Chief Clinical Consultant (OB/GYN C.C.C.). Dr. Howe is very interested in establishing a dialogue and/or networking with anyone involved in women's health or maternal child health, especially as it applies to American Indian and Alaska Native women and also indigenous peoples around the world. Please don't hesitate to contact her by e-mail (jean.howe@ihs.gov) or phone at (928) 674-7422.
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