Volume 6, No. 12, December 2008/January 2009
Hot Topics
Obstetrics | Gynecology | Child Health | Chronic Disease and Illness
Obstetrics
Excess gestational weight gain: modifying fetal macrosomia risk associated with maternal glucose
OBJECTIVE: To estimate how maternal weight gain
and maternal glucose relate to fetal macrosomia risk (greater than 4,000 g) among
a population universally screened for gestational diabetes mellitus (GDM).
METHODS: Between 1995 and 2003, 41,540 pregnant women in two regions (Northwest/Hawaii)
of a large U.S. health plan had GDM screening using the 50-g glucose challenge
test; 6,397 also underwent a 3-hour, 100-g oral glucose tolerance test. We assessed
the relationship between level of maternal glucose with glucose screening and
fetal macrosomia risk after adjustment for potential confounders, including maternal
age, parity, and ethnicity and sex of the newborn. We stratified by maternal
weight gain (40 lb or fewer compared with more than 40 lb) because excessive
maternal weight gain modified results.
RESULTS: Among women with both normal and abnormal GDM screenings, increasing
level of maternal glucose was linearly related to macrosomia risk (P<.001
for trend in all groups). Women with excessive weight gain (more than 40 lb)
had nearly double the risk of fetal macrosomia for each level of maternal glucose
compared with those with gestational weight gain of 40 lb or fewer. For example,
among women with normal post-glucose challenge test glucose levels (less than
95 mg/dL) and excessive weight gain, 16.5% had macrosomic newborns compared with
9.3% of women who gained 40 lb or fewer. Moreover, nearly one third of women
(29.3%) with GDM who gained more than 40 lb had a macrosomic newborn compared
with only 13.5% of women with GDM who gained 40 lb or fewer during pregnancy
(P=.018).
CONCLUSION: Excessive pregnancy weight gain nearly doubles the risk of fetal
macrosomia with each increasing level of maternal glucose, even among women with
GDM.
Hillier TA, Pedula KL, Vesco KK, Schmidt MM, Mullen JA, LeBlanc ES, Pettitt DJ. Excess gestational weight gain: modifying fetal macrosomia risk associated with maternal glucose. Obstet Gynecol. 2008 Nov;112(5):1007-14. http://www.ncbi.nlm.nih.gov/pubmed/18978099
Gestational weight gain and gestational diabetes mellitus: perinatal outcomes
OBJECTIVE: To examine the association between gestational weight
gain and perinatal outcome in women with gestational diabetes mellitus (GDM).
METHODS: This is a retrospective cohort study of women with nonanomalous singleton
pregnancies with GDM enrolled in the Sweet Success California Diabetes and Pregnancy
Program between 2001 and 2004. Gestational weight gain, calculated from prepregnancy
weight and weight at last prenatal Sweet Success visit, was subgrouped into below,
within, and above the Institute of Medicine (IOM) weight-gain guidelines. Perinatal
outcomes were examined using chi2 test and multivariable regression analysis
with 15-35-lb weight gain as the reference group. RESULTS: There were 31,074
women meeting study criteria. Compared with women with gestational weight gain
within the IOM guidelines, women who gained above the guidelines had higher odds
of having large for gestational age neonates (adjusted odds ratio [aOR] 1.72,
95% confidence interval [CI] 1.53-1.93, number needed to harm 10), preterm delivery
(aOR 1.30, 95% CI 1.14-1.48, number needed to harm 32), and primary cesarean
delivery (aOR 1.52, 95% CI 1.26-1.83, number needed to harm 10). Women who gained
below the guidelines had higher odds of having small for gestational age neonates
(aOR 1.39, 95% CI 1.01-1.90) and maintaining diet-controlled GDM (aOR 1.47, 95%
CI 1.34-1.63) and lower odds of having large for gestational age neonates (aOR
0.60, 95% CI 0.52-0.67).
CONCLUSION: Women diagnosed with GDM who had gestational weight gain above the
IOM guidelines have higher risk of undesirable outcomes, including preterm delivery,
having macrosomic neonates, and cesarean delivery. Women who gained below guidelines
are more likely to remain on diet control but have small for gestational age
neonates.
Cheng YW, Chung JH, Kurbisch-Block I, Inturrisi M, Shafer S, Caughey AB. Gestational weight gain and gestational diabetes mellitus: perinatal outcomes. Obstet Gynecol. 2008 Nov;112(5):1015-22. http://www.ncbi.nlm.nih.gov/pubmed/18978100
Pregnancy and fertility following bariatric surgery: a systematic review
CONTEXT: Use of bariatric surgery has increased dramatically
during the past 10 years, particularly among women of reproductive age.
OBJECTIVES: To estimate bariatric surgery rates among women aged 18 to 45 years
and to assess the published literature on pregnancy outcomes and fertility after
surgery.
EVIDENCE ACQUISITION: Search of the Nationwide Inpatient Sample (1998-2005) and
multiple electronic databases (Medline, EMBASE, Controlled Clinical Trials Register
Database, and the Cochrane Database of Reviews of Effectiveness) to identify
articles published between 1985 and February 2008 on bariatric surgery among
women of reproductive age. Search terms included bariatric procedures, fertility,
contraception, pregnancy, and nutritional deficiencies. Information was abstracted
about study design, fertility, and nutritional, neonatal, and pregnancy outcomes
after surgery.
EVIDENCE SYNTHESIS: Of 260 screened articles, 75 were included. Women aged 18
to 45 years accounted for 49% of all patients undergoing bariatric surgery (>50,000
cases annually for the 3 most recent years). Three matched cohort studies showed
lower maternal complication rates after bariatric surgery than in obese women
without bariatric surgery, or rates approaching those of nonobese controls. In
1 matched cohort study that compared maternal complication rates in women after
laparoscopic adjustable gastric band surgery with obese women without surgery,
rates of gestational diabetes (0% vs. 22.1%, P < .05) and preeclampsia (0%
vs. 3.1%, P < .05) were lower in the bariatric surgery group. Findings were
supported by 13 other bariatric cohort studies. Neonatal outcomes were similar
or better after surgery compared with obese women without laparoscopic adjustable
gastric band surgery (7.7% vs. 7.1% for premature delivery; 7.7% vs. 10.6% for
low birth weight, P < .05; 7.7% vs. 14.6% for macrosomia, P < .05). No
differences in neonatal outcomes were found after gastric bypass compared with
nonobese controls (26.3%-26.9% vs. 22.4%-20.2% for premature delivery, P = not
reported [1 study] and P = .43 [1 study]; 7.7% vs. 9.0% for low birth weight,
P = not reported [1 study]; and 0% vs. 2.6%-4.3% for macrosomia, P = not reported
[1 study] and P = .28 [1 study]). Findings were supported by 10 other studies.
Studies regarding nutrition, fertility, cesarean delivery, and contraception
were limited.
CONCLUSION: Rates of many adverse maternal and neonatal outcomes may be lower
in women who become pregnant after having had bariatric surgery compared with
rates in pregnant women who are obese; however, further data are needed from
rigorously designed studies.
Maggard MA, Yermilov I, Li Z, Maglione M, Newberry S, Suttorp M, Hilton L, Santry HP, Morton JM, Livingston EH, Shekelle PG. Pregnancy and fertility following bariatric surgery: a systematic review. JAMA. 2008 Nov 19;300(19):2286-96. http://www.ncbi.nlm.nih.gov/pubmed/19017915
Perinatal outcomes in the setting of active phase arrest of labor
OBJECTIVE: To examine the association between active phase arrest and perinatal outcomes. METHODS: This was a retrospective cohort study of women with term, singleton, cephalic gestations diagnosed with active phase arrest of labor, defined as no cervical change for 2 hours despite adequate uterine contractions. Women with active phase arrest who underwent a cesarean delivery were compared with those who delivered vaginally, and women who delivered vaginally with active phase arrest were compared with those without active phase arrest. The association between active phase arrest, mode of delivery, and perinatal outcomes was evaluated using univariable and multivariable logistic regression models. RESULTS: We identified 1,014 women with active phase arrest: 33% (335) went on to deliver vaginally, and the rest had cesarean deliveries. Cesarean delivery was associated with an increased risk of chorioamnionitis (adjusted odds ratio [aOR] 3.37, 95% confidence interval [CI] 2.21-5.15), endomyometritis (aOR 48.41, 95% CI 6.61-354), postpartum hemorrhage (aOR 5.18, 95% CI 3.42-7.85), and severe postpartum hemorrhage (aOR 14.97, 95% CI 1.77-126). There were no differences in adverse neonatal outcomes. Among women who delivered vaginally, women with active phase arrest had significantly increased odds of chorioamnionitis (aOR 2.70, 95% CI 1.22-2.36) and shoulder dystocia (aOR 2.37, 95% CI 1.33-4.25). However, there were no differences in the serious sequelae associated with these outcomes, including neonatal sepsis or Erb's palsy. CONCLUSION: Efforts to achieve vaginal delivery in the setting of active phase arrest may reduce the maternal risks associated with cesarean delivery without additional risk to the neonate.
Henry DE, Cheng YW, Shaffer BL,
Kaimal AJ, Bianco K, Caughey AB. Perinatal outcomes in the setting of active
phase arrest of labor. Obstet Gynecol. 2008 Nov;112(5):1109-15.
http://www.ncbi.nlm.nih.gov/pubmed/18978113
Association between Vitamin D Deficiency and Primary Cesarean Section
Background:
At the turn of the 20th century, women commonly died in childbirth due to "rachitic
pelvis". Although rickets virtually disappeared with
the discovery of the hormone "vitamin" D, recent reports suggest vitamin
D deficiency is widespread in industrialized nations. Poor muscular performance
is an established symptom of vitamin D deficiency. The current US cesarean birth
rate is at an all-time high of 30.2%. We analyzed the relationship between maternal
serum 25-hydroxyvitamin D [25(OH)D] status, and prevalence of primary cesarean
section.
Methods: Between 2005 and 2007, we measured maternal and infant serum 25(OH)D
at birth, and abstracted demographic and medical data from the maternal medical
record, at an urban teaching hospital in Boston, USA, with 2,500 births per year.
We enrolled 253 women, of whom 43 (17%) had a primary cesarean.
Results: There was an inverse association with having a cesarean section and
serum 25(OH)D levels. We found that 28% of women with serum 25(OH)D <37.5
nmol/L had a cesarean section, compared to only 14% of women with 25(OH)D >/=37.5nmol/L
(p=0.012). In multivariable logistic regression analysis controlling for race,
age, education level, insurance status, and alcohol use, women with 25(OH)D <37.5
nmol/L were almost 4 times as likely to have a cesarean than women with 25(OH)D >/=37.5
nmol/L (AOR 3.84; 95% CI 1.71 to 8.62).
Interpretation: Vitamin D deficiency was associated with increased odds of primary
cesarean section.
Merewood A, Mehta SD, Chen TC, Bauchner H, Holick MF. Association between Vitamin D Deficiency and Primary Cesarean Section. J Clin Endocrinol Metab. 2008 Dec 23. [Epub ahead of print] http://www.ncbi.nlm.nih.gov/pubmed/19106272
Gynecology
Clinical practice guidelines on vaginal graft use from the society of gynecologic surgeons
OBJECTIVE: To develop guidelines regarding whether
graft or native tissue repair should be done in transvaginal repair of anterior,
posterior, or apical pelvic organ prolapse.
METHODS: The Society of Gynecologic Surgeons formed a work group to develop evidence-based
guidelines. Published data from 1950 to November 27, 2007, from the companion
systematic review were reviewed to develop guidelines on biologic and synthetic
graft use compared with native tissue repair in vaginal prolapse repair. The
work group formulated guidelines based on its overall assessment of the evidence.
The approach to grading the quality of evidence and the strength of recommendations
was based on a modification of the Grades for Recommendation Assessment, Development,
and Evaluation system.
RESULTS: It is suggested that native tissue repair remains appropriate when compared
with biologic graft use. Nonabsorbable synthetic graft use may improve anatomic
outcomes of anterior vaginal wall repair, but there are trade-offs in regard
to additional risks. The group suggests issues that should be included in the
preoperative counseling of patients in whom clinicians propose to use a vaginally
placed graft.
CONCLUSION: Based on the overall low quality of evidence, only weak recommendations
could be provided. This highlights the need for practitioners to fully explain
the relative merits of each alternative and carefully consider patients' values
and preferences to arrive at an appropriate decision. Future research is likely
to change the estimates in the net benefit and risk and the confidence around
these assessments.
Murphy M; Society of Gynecologic Surgeons Systematic Review Group. Clinical practice guidelines on vaginal graft use from the society of gynecologic surgeons. Obstet Gynecol. 2008 Nov;112(5):1123-30. http://www.ncbi.nlm.nih.gov/pubmed/18978115
FDA Public Health Notification: Serious Complications Associated with Transvaginal
Placement of Surgical Mesh in Repair of Pelvic Organ Prolapse and Stress Urinary
Incontinence
http://www.fda.gov/cdrh/safety/102008-surgicalmesh.html
Probability of hysterectomy after endometrial ablation
OBJECTIVE:
To investigate risk factors for hysterectomy after endometrial ablation.
METHODS: This was a retrospective cohort analysis of data from Kaiser Permanente
Northern California members, aged 25-60 years undergoing endometrial ablation
from 1999 to 2004 and collected through 2007. Risk factors assessed included
age, presence of leiomyomas, setting of procedure (inpatient or outpatient),
and type of endometrial ablation procedure (first generation, radio frequency,
hydrothermal, or thermal balloon). Univariable and survival analyses were performed
to identify risk factors and estimate probability of hysterectomy.
RESULTS: From 1999 to 2004, 3,681 women underwent endometrial ablation at 30
Kaiser Permanente Northern California facilities. Hysterectomy was subsequently
performed in 774 women (21%), whereas 143 women (3.9%) had uterine-conserving
procedures. Age was a significant predictor of hysterectomy (P<.001). Cox
regression analysis found that compared with women aged older than 45 years,
women aged 45 years or younger were 2.1 times more likely to have hysterectomy
(95% confidence interval 1.8-2.4). Hysterectomy risk increased with each decreasing
stratum of age and exceeded 40% in women aged 40 years or younger. Overall, type
of endometrial ablation procedure, setting of endometrial ablation procedure,
and presence of leiomyomas were not predictors of hysterectomy. In analysis of
individual procedure types, concomitant myomectomy was associated with a decreased
risk of hysterectomy for patients receiving first-generation endometrial ablation
(P=.002), and outpatient location for hydrothermal endometrial ablation increased
hysterectomy risk (P<.001).
CONCLUSION: Age is more important than type of procedure or presence of leiomyomas
in predicting subsequent hysterectomy after endometrial ablation. Women undergoing
endometrial ablation at younger than 40 years of age are at elevated risk of
hysterectomy, and rather than plateauing within several years of endometrial
ablation, hysterectomy risk continues to increase through 8 years of follow-up.
Longinotti MK, Jacobson GF, Hung YY, Learman LA. Probability of hysterectomy after endometrial ablation. Obstet Gynecol. 2008 Dec;112(6):1214-20. http://www.ncbi.nlm.nih.gov/pubmed/19037028
A protocol of dual prophylaxis for venous thromboembolism prevention in gynecologic cancer patients
OBJECTIVE: To evaluate a quality improvement protocol for venous thromboembolism
prevention in postoperative gynecologic cancer patients.
METHODS: On January 1, 2006, we initiated a universal protocol of dual prophylaxis
with sequential compression devices and three times daily heparin (or daily low
molecular weight heparin) until discharge in gynecologic cancer patients having
major surgery. Patients with both malignancy and age over 60 years (or history
of prior clot) were discharged on 2 weeks of anticoagulant. Before January 2006,
all patients were given sequential compression devices starting before the induction
of anesthesia, continuing until discharge from the hospital. Records of gynecologic
cancer service patients admitted in 2005 and 2006 were reviewed, excluding patients
with a history of heparin-induced thrombocytopenia or those admitted on an anticoagulant.
Any pulmonary embolism or deep vein thrombosis diagnosed within 6 weeks of surgery
was identified. We performed chi2 and Wilcoxon rank sum tests as well as multivariable
regression analysis for confounders.
RESULTS: Six of the 311 women meeting inclusion criteria in 2006 (1.9%) and 19
of 294 (6.5%) in 2005 had venous thromboembolism (odds ratio 0.33, 95% confidence
interval 0.12-0.88, multivariable analysis adjusting for baseline differences
between the groups). Heparin was given to 98.1% of patients in the hospital in
2006, and 91.1% of those meeting high-risk criteria were discharged on an anticoagulant.
No differences in major bleeding complications were seen between years.
CONCLUSION: A protocol of dual prophylaxis with prolonged prophylaxis in high-risk
patients was successfully implemented and was associated with a significant reduction
in the rate of venous thromboembolism without increasing bleeding complications.
Einstein MH, Kushner DM, Connor JP, Bohl AA, Best TJ, Evans MD, Chappell RJ, Hartenbach EM. A protocol of dual prophylaxis for venous thromboembolism prevention in gynecologic cancer patients. Obstet Gynecol. 2008 Nov;112(5):1091-7. http://www.ncbi.nlm.nih.gov/pubmed/18978110
Effectiveness of tension-free vaginal tape compared with transobturator tape in women with stress urinary incontinence and intrinsic sphincter deficiency: a randomized controlled trial
OBJECTIVE: To compare efficacy of transobturator
tape with tension-free vaginal tape (TVT) in the treatment of stress urinary
incontinence in women with intrinsic sphincter deficiency. METHODS: One hundred
sixty-four women diagnosed with urodynamic stress incontinence and intrinsic
sphincter deficiency with or without concomitant pelvic organ prolapse repair
were randomized to receive TVT or transobturator tape. The primary outcome was
the presence or absence of urodynamic stress incontinence at 6 months postoperatively.
Secondary outcomes were the rate of operative complications, symptomatic stress
incontinence requiring further surgery, and quality-of-life questionnaires.
RESULTS: Of 180 women eligible to participate, 164 were enrolled and underwent
surgery. Of the 138 patients assessed at 6 months with urodynamic studies, 14
of 67 (21%) had urodynamic stress incontinence in the TVT group compared with
32 of 71 (45%) in the transobturator tape group (P=.004), with nine women in
the transobturator tape group having repeat sling surgery compared with none
in the TVT group. In the intention-to-treat analysis, the incident rate difference
for request of repeat surgery was 9.7% (95% confidence interval [CI] 0-19.9);
repeat surgery would be requested in one of every six transobturator tape procedures
compared with 1 of every 16 TVT procedures. The risk ratio of repeat surgery
was 2.6 (95% CI 0.9-9.3) times higher in the transobturator tape group.
CONCLUSION: Retropubic TVT is a more effective operation than the transobturator
tape sling in women with urodynamic stress incontinence and intrinsic sphincter
deficiency.
Schierlitz L, Dwyer PL, Rosamilia A, Murray C, Thomas E, De Souza A, Lim YN, Hiscock R. Effectiveness of tension-free vaginal tape compared with transobturator tape in women with stress urinary incontinence and intrinsic sphincter deficiency: a randomized controlled trial. Obstet Gynecol. 2008 Dec;112(6):1253-61. http://www.ncbi.nlm.nih.gov/pubmed/19037033
A 12-month prospective evaluation of transcervical sterilization using implantable polymer matrices (Essure)
OBJECTIVE: To
evaluate placement efficacy and reliability of an intratubal occlusion device
for permanent contraception and to assess tolerability and overall satisfaction.
METHODS: Seven hundred seventy women with known parity were recruited to participate
in a prospective, multicenter study. Bipolar, low-level radiofrequency energy
delivery and porous silicon inserts were used. Inserts were placed bilaterally
in the fallopian tube lumen. Subsequent bilateral occlusion was assessed with
hysterosalpingography.
RESULTS: Overall, bilateral placement success was achieved in 611 of 645 women
(95%). Bilateral occlusion was confirmed in 570 of 645 (88.4%). The 1-year pregnancy
prevention rate as derived with life-table methods was 98.9%.
CONCLUSION: This transcervical sterilization system offers an effective contraceptive
method, which was well tolerated and had a high satisfaction rate.
Vancaillie TG, Anderson TL, Johns DA. A 12-month prospective evaluation of transcervical sterilization using implantable polymer matrices. Obstet Gynecol. 2008 Dec;112(6):1270-7.
http://www.ncbi.nlm.nih.gov/pubmed/19037035Child Health
Increased Risk of Adverse Neurological Development for Late Preterm Infants
OBJECTIVE: To assess the risks of moderate prematurity
for cerebral palsy (CP), developmental delay/mental retardation (DD/MR), and
seizure disorders in early childhood.
STUDY DESIGN: Retrospective cohort study using hospitalization and outpatient
databases from the Northern California Kaiser Permanente Medical Care Program.
Data covered 141 321 children >/=30 weeks born between Jan 1, 2000, and June
30, 2004, with follow-up through Jun 30, 2005. Presence of CP, DD/MR, and seizures
was based on International Classification of Diseases, Ninth Revision codes identified
in the encounter data. Separate Cox proportional hazard models were used for
each of the outcomes, with crude and adjusted hazard ratios calculated for each
gestational age group.
RESULTS: Decreasing gestational age was associated with increased incidence of
CP and DD/MR, even for those born at 34 to 36 weeks gestation. Children born
late preterm were >3 times as likely (hazard ratio, 3.39; 95% CI, 2.54-4.52)
as children born at term to be diagnosed with CP. A modest association with DD/MR
was found for children born at 34 to 36 weeks (hazard ratio, 1.25; 95% CI, 1.01-1.54),
but not for children in whom seizures were diagnosed. CONCLUSIONS: Prematurity
is associated with long-term neurodevelopmental consequences, with risks increasing
as gestation decreases, even in infants born at 34 to 36 weeks.
Petrini JR, Dias T, McCormick MC, Massolo ML, Green NS, Escobar GJ. Increased Risk of Adverse Neurological Development for Late Preterm Infants. J Pediatr. 2008 Dec 8. [Epub ahead of print] http://www.ncbi.nlm.nih.gov/pubmed/19081113
Risk factors for unintentional injuries in children: are grandparents protective?
OBJECTIVE: We sought to identify sociodemographic and familial
correlates of injury in children aged 2 to 3 years.
METHODS: The Healthy Steps data set describes 5565 infants who were enrolled
at birth in 15 US cities in 1996-1997 and had follow-up until they were 30 to
33 months of age. Data were linked to medical claims reporting children's medically
attended office visits by age 30 to 33 months. Each claim was accompanied by
a reason for the visit. An analytical sample of 3449 was derived from the children
who could be effectively followed up and linked to medical charts. Missing data
were imputed by using multiple imputation with chained equations. The analytical
sample showed no systematic evidence of sample selection bias. Multivariate logistic
regression was used to determine the odds ratios of injury events.
RESULTS: Odds of medically attended injuries were decreased for children who
received care from grandparents. Odds were increased for children who lived where
fathers did not co-reside or in households where the parents never married. Statistical
results were robust to the addition of a variety of covariates such as income,
education, age, gender, and race.
CONCLUSIONS: Children are at higher risk for medically attended injury when their
parents are unmarried. Having grandparents as caregivers seems to be protective.
Household composition seems to play a key role in placing children at risk for
medically attended injuries.
Bishai D, Trevitt JL, Zhang Y, McKenzie LB, Leventhal T, Gielen AC, Guyer B. Risk factors for unintentional injuries in children: are grandparents protective? Pediatrics. 2008 Nov;122(5):e980-7. http://www.ncbi.nlm.nih.gov/pubmed/18977965
Effect of breastfeeding duration on lung function at age 10 years: a prospective birth cohort study
INTRODUCTION: The protective effects
of breastfeeding on early life respiratory infections are established, but there
have been conflicting reports on protection from asthma in late childhood. The
association of breastfeeding duration and lung function was assessed in 10-year-old
children.
METHODS: In the Isle of Wight birth cohort (n = 1456), breastfeeding practices
and duration were prospectively assessed at birth and at subsequent follow-up
visits (1 and 2 years). Breastfeeding duration was categorised as "not
breastfed" (n = 196); "<2 months" (n = 243); "2 to <4
months" (n = 142) and ">or=4 months" (n = 374). Lung function
was measured at age 10 years (n = 1033): forced vital capacity (FVC), forced
expiratory volume in 1 s (FEV(1)), FEV(1)/FVC ratio and peak expiratory flow
(PEF). Maternal history of asthma and allergy was assessed at birth. The effect
of breastfeeding on lung function was analysed using general linear models, adjusting
for birth weight, sex, current height and weight, family social status cluster
and maternal education. RESULTS: Compared with those who were not breastfed,
FVC was increased by 54.0 (SE 21.1) ml (p = 0.001), FEV(1) by 39.5 (20.1) ml(p
= 0.05) and PEF by 180.8 (66.1) ml/s (p = 0.006) in children who were breastfed
for at least 4 months. In models for FEV(1) and PEF that adjusted for FVC, the
effect of breastfeeding was retained only for PEF (p = 0.04).
CONCLUSIONS: Breastfeeding for at least 4 months enhances lung volume in children.
The effect on airflow appears to be mediated by lung volume changes. Future studies
need to elucidate the mechanisms that drive this phenomenon.
Ogbuanu IU, Karmaus W, Arshad SH, Kurukulaaratchy RJ, Ewart S. Effect of breastfeeding duration on lung function at age 10 years: a prospective birth cohort study. Thorax. 2009 Jan;64(1):62-6. Epub 2008 Nov 10. http://www.ncbi.nlm.nih.gov/pubmed/19001004
Parental alcohol screening in pediatric practices
OBJECTIVES:
Pediatricians are in an ideal position to screen parents of their patients for
alcohol use. The objective of this study was to assess parents' preferences regarding
screening and intervention for parental alcohol use during pediatric office visits
for their children.
METHODS: A descriptive multicenter study that used 3 pediatric primary care clinic
sites (rural, urban, suburban) was conducted between June 2004 and December 2006.
Participants were a convenience sample of consecutively recruited parents who
brought children for medical care. Parents completed an anonymous questionnaire
that contained demographics; 2 alcohol-screening tests (TWEAK and Alcohol Use
Disorders Identification Test); and items that assessed preferences for who should
perform alcohol-screening, acceptance of screening, and preferred interventions
if the screening result was positive.
RESULTS: A total of 929 of 1028 eligible parents agreed to participate, and 879
of 929 completed surveys that yielded sufficient data for analysis. Most participants
were mothers. A total of 101 of 879 parents screened positive on either the TWEAK
or the Alcohol Use Disorders Identification Test. Parents with a negative alcohol
screen (alcohol-negative) were more likely than parents with a positive alcohol
screen (alcohol-positive) to report that they would agree to being asked about
their alcohol use. There were no significant differences in preferences within
alcohol-positive and alcohol-negative groups for screening by the pediatrician
or computer-based questionnaire. Most preferred interventions for the alcohol-positive
group were for the pediatrician to initiate additional discussion about drinking
and its effect on their child, give educational materials about alcoholism, and
refer for evaluation and treatment. Alcohol-positive men were more accepting
than alcohol-positive women of having no intervention.
CONCLUSIONS: A majority of parents would agree to being screened for alcohol
problems in the pediatric office. Regardless of their alcohol screen status,
parents are accepting of being screened by the pediatrician, a computer-based
questionnaire, or a paper-and-pencil survey. Parents who screen positive prefer
that the pediatrician discuss the problem further with them and present options
for referral.
Wilson CR, Harris SK, Sherritt L, Lawrence N, Glotzer D, Shaw JS, Knight JR. Parental alcohol screening in pediatric practices. Pediatrics. 2008 Nov;122(5):e1022-9. http://www.ncbi.nlm.nih.gov/pubmed/18977952
Early antiretroviral therapy and mortality among HIV-infected infants
BACKGROUND:
In countries with a high seroprevalence of human immunodeficiency virus type
1 (HIV-1), HIV infection contributes significantly to infant mortality. We investigated
antiretroviral-treatment strategies in the Children with HIV Early Antiretroviral
Therapy (CHER) trial.
METHODS: HIV-infected infants 6 to 12 weeks of age with a CD4 lymphocyte percentage
(the CD4 percentage) of 25% or more were randomly assigned to receive antiretroviral
therapy (lopinavir-ritonavir, zidovudine, and lamivudine) when the CD4 percentage
decreased to less than 20% (or 25% if the child was younger than 1 year) or clinical
criteria were met (the deferred antiretroviral-therapy group) or to immediate
initiation of limited antiretroviral therapy until 1 year of age or 2 years of
age (the early antiretroviral-therapy groups). We report the early outcomes for
infants who received deferred antiretroviral therapy as compared with early antiretroviral
therapy.
RESULTS: At a median age of 7.4 weeks (interquartile range, 6.6 to 8.9) and a
CD4 percentage of 35.2% (interquartile range, 29.1 to 41.2), 125 infants were
randomly assigned to receive deferred therapy, and 252 infants were randomly
assigned to receive early therapy. After a median follow-up of 40 weeks (interquartile
range, 24 to 58), antiretroviral therapy was initiated in 66% of infants in the
deferred-therapy group. Twenty infants in the deferred-therapy group (16%) died
versus 10 infants in the early-therapy groups (4%) (hazard ratio for death, 0.24;
95% confidence interval [CI], 0.11 to 0.51; P<0.001). In 32 infants in the
deferred-therapy group (26%) versus 16 infants in the early-therapy groups (6%),
disease progressed to Centers for Disease Control and Prevention stage C or severe
stage B (hazard ratio for disease progression, 0.25; 95% CI, 0.15 to 0.41; P<0.001).
Stavudine was substituted for zidovudine in four infants in the early-therapy
groups because of neutropenia in three infants and anemia in one infant; no drugs
were permanently discontinued. After a review by the data and safety monitoring
board, the deferred-therapy group was modified, and infants in this group were
all reassessed for initiation of antiretroviral therapy.
CONCLUSIONS: Early HIV diagnosis and early antiretroviral therapy reduced early
infant mortality by 76% and HIV progression by 75%.
Violari A, Cotton MF, Gibb DM, Babiker AG, Steyn J, Madhi SA, Jean-Philippe P, McIntyre JA; CHER Study Team. Early antiretroviral therapy and mortality among HIV-infected infants. N Engl J Med. 2008 Nov 20;359(21):2233-44. http://www.ncbi.nlm.nih.gov/pubmed/19020325
Free Full Text: http://content.nejm.org/cgi/content/full/359/21/2233
Chronic Disease and Illness
Use of prescription and over-the-counter medications and dietary supplements among older adults in the United States
CONTEXT: Despite concerns about
drug safety, current information on older adults' use of prescription and over-the-counter
medications and dietary supplements is limited.
OBJECTIVE: To estimate the prevalence and patterns of medication use among older
adults (including concurrent use), and potential major drug-drug interactions.
DESIGN, SETTING, AND PARTICIPANTS: Three thousand five community-residing individuals,
aged 57 through 85 years, were drawn from a cross-sectional, nationally representative
probability sample of the United States. In-home interviews, including medication
logs, were administered between June 2005 and March 2006. Medication use was
defined as prescription, over-the-counter, and dietary supplements used "on
a regular schedule, like every day or every week." Concurrent use was defined
as the regular use of at least 2 medications.
MAIN OUTCOME MEASURE: Population estimates of the prevalence of medication use,
concurrent use, and potential major drug-drug interactions, stratified by age
group and gender. RESULTS: The unweighted survey response rate was 74.8% (weighted
response rate, 75.5%). Eighty-one percent (95% confidence interval [CI], 79.4%-83.5%)
used at least 1 prescription medication, 42% (95% CI, 39.7%-44.8%) used at least
1 over-the-counter medication, and 49% (95% CI, 46.2%-52.7%) used a dietary supplement.
Twenty-nine percent (95% CI, 26.6%-30.6%) used at least 5 prescription medications
concurrently; this was highest among men (37.1%; 95% CI, 31.7%-42.4%) and women
(36.0%; 95% CI, 30.2%-41.9%) aged 75 to 85 years. Among prescription medication
users, concurrent use of over-the-counter medications was 46% (95% CI, 43.4%-49.1%)
and concurrent use of dietary supplements was 52% (95% CI, 48.8%-55.5%). Overall,
4% of individuals were potentially at risk of having a major drug-drug interaction;
half of these involved the use of nonprescription medications. These regimens
were most prevalent among men in the oldest age group (10%; 95% CI, 6.4%-13.7%)
and nearly half involved anticoagulants. No contraindicated concurrent drug use
was identified.
CONCLUSIONS: In this sample of community-dwelling older adults, prescription
and nonprescription medications were commonly used together, with nearly 1 in
25 individuals potentially at risk for a major drug-drug interaction.
Qato DM, Alexander GC, Conti RM, Johnson M, Schumm P, Lindau ST. Use of prescription and over-the-counter medications and dietary supplements among older adults in the United States. JAMA. 2008 Dec 24;300(24):2867-78. http://www.ncbi.nlm.nih.gov/pubmed/19109115
General and abdominal adiposity and risk of death in Europe
BACKGROUND:
Previous studies have relied predominantly on the body-mass index (BMI, the weight
in kilograms divided by the square of the height in meters) to assess the association
of adiposity with the risk of death, but few have examined whether the distribution
of body fat contributes to the prediction of death.
METHODS: We examined the association of BMI, waist circumference, and waist-to-hip
ratio with the risk of death among 359,387 participants from nine countries in
the European Prospective Investigation into Cancer and Nutrition (EPIC). We used
a Cox regression analysis, with age as the time variable, and stratified the
models according to study center and age at recruitment, with further adjustment
for educational level, smoking status, alcohol consumption, physical activity,
and height.
RESULTS: During a mean follow-up of 9.7 years, 14,723 participants died. The
lowest risks of death related to BMI were observed at a BMI of 25.3 for men and
24.3 for women. After adjustment for BMI, waist circumference and waist-to-hip
ratio were strongly associated with the risk of death. Relative risks among men
and women in the highest quintile of waist circumference were 2.05 (95% confidence
interval [CI], 1.80 to 2.33) and 1.78 (95% CI, 1.56 to 2.04), respectively, and
in the highest quintile of waist-to-hip ratio, the relative risks were 1.68 (95%
CI, 1.53 to 1.84) and 1.51 (95% CI, 1.37 to 1.66), respectively. BMI remained
significantly associated with the risk of death in models that included waist
circumference or waist-to-hip ratio (P<0.001). CONCLUSIONS: These data suggest
that both general adiposity and abdominal adiposity are associated with the risk
of death and support the use of waist circumference or waist-to-hip ratio in
addition to BMI in assessing the risk of death.
Pischon T, Boeing H, Hoffmann
K, Bergmann M, Schulze MB, Overvad K, et al.,
General and abdominal adiposity and risk of death in Europe. N Engl J Med. 2008
Nov 13;359(20):2105-20. http://www.ncbi.nlm.nih.gov/pubmed/19005195
Free Full Text: http://content.nejm.org/cgi/content/full/359/20/2105
National Heart, Lung, and Blood Institute Guidelines on managing overweight
and obesity:
http://www.nhlbi.nih.gov/guidelines/obesity/prctgd_c.pdf
Metformin, sulfonylureas, or other antidiabetes drugs and the risk of lactic acidosis or hypoglycemia: a nested case-control analysis
OBJECTIVE:
Lactic acidosis has been associated with use of metformin. Hypoglycemia is a
major concern using sulfonylureas. The aim of this study was to compare the risk
of lactic acidosis and hypoglycemia among patients with type 2 diabetes using
oral antidiabetes drugs. RESEARCH DESIGN AND METHODS: This study is a nested
case-control analysis using the U.K.-based General Practice Research Database
to identify patients with type 2 diabetes who used oral antidiabetes drugs. Within
the study population, all incident cases of lactic acidosis and hypoglycemia
were identified, and hypoglycemia case subjects were matched to up to four control
patients based on age, sex, practice, and calendar time.
RESULTS: Among the study population of 50,048 type 2 diabetic subjects, six cases
of lactic acidosis during current use of oral antidiabetes drugs were identified,
yielding a crude incidence rate of 3.3 cases per 100,000 person-years among metformin
users and 4.8 cases per 100,000 person-years among users of sulfonylureas. Relevant
comorbidities known as risk factors for lactic acidosis could be identified in
all case subjects. A total of 2,025 case subjects with hypoglycemia and 7,278
matched control subjects were identified. Use of sulfonylureas was associated
with a materially elevated risk of hypoglycemia. The adjusted odds ratio for
current use of sulfonylureas was 2.79 (95% CI 2.23-3.50) compared with current
metformin use. CONCLUSIONS: Lactic acidosis during current use of oral antidiabetes
drugs was very rare and was associated with concurrent comorbidity. Hypoglycemic
episodes were substantially more common among sulfonylurea users than among users
of metformin.
Bodmer M, Meier C, Krähenbühl S, Jick SS, Meier CR. Metformin, sulfonylureas, or other antidiabetes drugs and the risk of lactic acidosis or hypoglycemia: a nested case-control analysis. Diabetes Care. 2008 Nov;31(11):2086-91. Epub 2008 Sep 9. http://www.ncbi.nlm.nih.gov/pubmed/18782901
Effect of fibre, antispasmodics, and peppermint oil in the treatment of irritable bowel syndrome: systematic review and meta-analysis
OBJECTIVE:
To determine the effect of fibre, antispasmodics, and peppermint oil in the treatment
of irritable bowel syndrome.
DESIGN: Systematic review and meta-analysis of randomised controlled trials.
DATA SOURCES: Medline, Embase, and the Cochrane controlled trials register up
to April 2008. Review methods Randomised controlled trials comparing fibre, antispasmodics,
and peppermint oil with placebo or no treatment in adults with irritable bowel
syndrome were eligible for inclusion. The minimum duration of therapy considered
was one week, and studies had to report either a global assessment of cure or
improvement in symptoms, or cure of or improvement in abdominal pain, after treatment.
A random effects model was used to pool data on symptoms, and the effect of therapy
compared with placebo or no treatment was reported as the relative risk (95%
confidence interval) of symptoms persisting.
RESULTS: 12 studies compared fibre with placebo or no treatment in 591 patients
(relative risk of persistent symptoms 0.87, 95% confidence interval 0.76 to 1.00).
This effect was limited to ispaghula (0.78, 0.63 to 0.96). Twenty two trials
compared antispasmodics with placebo in 1778 patients (0.68, 0.57 to 0.81). Various
antispasmodics were studied, but otilonium (four trials, 435 patients, relative
risk of persistent symptoms 0.55, 0.31 to 0.97) and hyoscine (three trials, 426
patients, 0.63, 0.51 to 0.78) showed consistent evidence of efficacy. Four trials
compared peppermint oil with placebo in 392 patients (0.43, 0.32 to 0.59).
CONCLUSION: Fibre, antispasmodics, and peppermint oil were all more effective
than placebo in the treatment of irritable bowel syndrome.
Ford AC, Talley NJ, Spiegel BM, Foxx-Orenstein AE, Schiller L, Quigley EM, Moayyedi P. Effect of fibre, antispasmodics, and peppermint oil in the treatment of irritable bowel syndrome: systematic review and meta-analysis. BMJ. 2008 Nov 13;337:a2313. doi: 10.1136/bmj.a2313. http://www.ncbi.nlm.nih.gov/pubmed/19008265
Free Full Text: http://www.bmj.com/cgi/content/full/337/nov13_2/a2313
Genotype score in addition to common risk factors for prediction of type 2 diabetes
BACKGROUND: Multiple genetic loci have been convincingly
associated with the risk of type 2 diabetes mellitus. We tested the hypothesis
that knowledge of these loci allows better prediction of risk than knowledge
of common phenotypic risk factors alone.
METHODS: We genotyped single-nucleotide polymorphisms (SNPs) at 18 loci associated
with diabetes in 2377 participants of the Framingham Offspring Study. We created
a genotype score from the number of risk alleles and used logistic regression
to generate C statistics indicating the extent to which the genotype score can
discriminate the risk of diabetes when used alone and in addition to clinical
risk factors.
RESULTS: There were 255 new cases of diabetes during 28 years of follow-up. The
mean (+/-SD) genotype score was 17.7+/-2.7 among subjects in whom diabetes developed
and 17.1+/-2.6 among those in whom diabetes did not develop (P<0.001). The
sex-adjusted odds ratio for diabetes was 1.12 per risk allele (95% confidence
interval, 1.07 to 1.17). The C statistic was 0.534 without the genotype score
and 0.581 with the score (P=0.01). In a model adjusted for sex and self-reported
family history of diabetes, the C statistic was 0.595 without the genotype score
and 0.615 with the score (P=0.11). In a model adjusted for age, sex, family history,
body-mass index, fasting glucose level, systolic blood pressure, high-density
lipoprotein cholesterol level, and triglyceride level, the C statistic was 0.900
without the genotype score and 0.901 with the score (P=0.49). The genotype score
resulted in the appropriate risk reclassification of, at most, 4% of the subjects.
CONCLUSIONS: A genotype score based on 18 risk alleles predicted new cases of
diabetes in the community but provided only a slightly better prediction of risk
than knowledge of common risk factors alone.
Meigs JB, Shrader P, Sullivan LM, McAteer JB, Fox CS, Dupuis J, et al., Genotype score in addition to common risk factors for prediction of type 2 diabetes. N Engl J Med. 2008 Nov 20;359(21):2208-19. http://www.ncbi.nlm.nih.gov/pubmed/19020323
Clinical risk factors, DNA variants, and the development of type 2 diabetes
BACKGROUND: Type 2 diabetes mellitus is thought to develop
from an interaction between environmental and genetic factors. We examined whether
clinical or genetic factors or both could predict progression to diabetes in
two prospective cohorts.
METHODS: We genotyped 16 single-nucleotide polymorphisms (SNPs) and examined
clinical factors in 16,061 Swedish and 2770 Finnish subjects. Type 2 diabetes
developed in 2201 (11.7%) of these subjects during a median follow-up period
of 23.5 years. We also studied the effect of genetic variants on changes in insulin
secretion and action over time.
RESULTS: Strong predictors of diabetes were a family history of the disease,
an increased body-mass index, elevated liver-enzyme levels, current smoking status,
and reduced measures of insulin secretion and action. Variants in 11 genes (TCF7L2,
PPARG, FTO, KCNJ11, NOTCH2, WFS1, CDKAL1, IGF2BP2, SLC30A8, JAZF1, and HHEX)
were significantly associated with the risk of type 2 diabetes independently
of clinical risk factors; variants in 8 of these genes were associated with impaired
beta-cell function. The addition of specific genetic information to clinical
factors slightly improved the prediction of future diabetes, with a slight increase
in the area under the receiver-operating-characteristic curve from 0.74 to 0.75;
however, the magnitude of the increase was significant (P=1.0x10(-4)). The discriminative
power of genetic risk factors improved with an increasing duration of follow-up,
whereas that of clinical risk factors decreased. CONCLUSIONS: As compared with
clinical risk factors alone, common genetic variants associated with the risk
of diabetes had a small effect on the ability to predict the future development
of type 2 diabetes. The value of genetic factors increased with an increasing
duration of follow-up.
Lyssenko V, Jonsson A, Almgren P, Pulizzi N, Isomaa B, Tuomi T, Berglund G, Altshuler D, Nilsson P, Groop L. Clinical risk factors, DNA variants, and the development of type 2 diabetes. N Engl J Med. 2008 Nov 20;359(21):2220-32. http://www.ncbi.nlm.nih.gov/pubmed/19020324
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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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