• Elevated Serum Uric Acid Predicts Metabolic Syndrome in Adolescents
• Adding Zinc to Antibiotics Reduces Treatment Failures
• Is Lower Salt Intake Dangerous?
• USPSTF Draft Recommendation: No Vitamin D, Calcium Supplementation for
Healthy Postmenopausal Women
• WHO Group Classifies Diesel Fumes as Carcinogenic
• The Higher the Body-Mass Index, the Higher the Risk for Adenoma
• The Incremental Relation Between Fasting Glucose and Glycosylated Hemoglobin
• Ramifications of Breast-Conserving Surgery for Ductal Carcinoma in Situ
• Statin Use Linked to Fatigue in Randomized Trial
• Meta-Analysis: Viscosupplementation for Knee Osteoarthritis Ineffective
• It's Never Too Late to Quit Smoking
• Lens or Lentil-Shaped Lipid Vesicles May Target Drugs to Stenotic Vessels
• Trillions of BFFs (Bacterial Friends Forever)
• Keep Washing Those Hands
• Per Capita Radiation Dose Doubled from 1996 to 2010
• Effect of Induction on Course of Labor
• Balancing Positive and Negative Effects of Antidepressants During Pregnancy
• Hormonal Contraceptives Showed Increased Risks for Stroke, MI
MM: Wouldn’t it be great if we could use a single, simple blood test that would identify children at unusually high risk for metabolic syndrome? Well, it appears that we now have one. By testing uric acid levels in a standard battery of tests that could be added to a child’s school physical or ‘wellness visit” to their pediatrician its possible tyo perform pro-active instead of re-active medicine. Unfortunately, this does not necessaarily mean that parents will universally initiate healthy lifestyles: eating, physical activity or food portions and choices, but at least it could be a start.
J Pediatr 2012 May 11
Elevated Serum Uric Acid Predicts Metabolic Syndrome in Adolescents
Male adolescents with the highest uric acid levels at baseline were 6 times more likely to develop metabolic syndrome after 3 years than those with the lowest levels.
Elevated uric acid (UA) is one of a number of clinical abnormalities associated with the metabolic syndrome in adults and children. To examine this association in adolescents, researchers followed 613 randomly selected male adolescents (age range, 10–15 years) from a health screening center in Taiwan for a mean of 2.7 years. Baseline UA, waist circumference, blood pressure (BP), body-mass index (BMI), fasting plasma glucose, and cholesterol levels were measured at baseline and follow-up. Adolescents with metabolic syndrome, type 1 diabetes, hypertension, or hyperlipidemia at baseline were excluded.
Adolescents were divided into quartiles according to UA levels, ranging from lowest (mean, 5.2 mg/dL) to highest (mean, 8.9 mg/dL). Nineteen adolescents (3.1%) developed metabolic syndrome as defined by the International Diabetes Federation consensus criteria (>3 of the following: abdominal obesity, triglycerides 
150 mg/dL, high-density lipoprotein cholesterol <40 mg/dL, hypertension, and fasting plasma glucose 
100 mg/dL). Age, waist circumference, BMI, BP, high-density lipoprotein cholesterol, and triglycerides were significantly associated with baseline UA. Risk for developing metabolic syndrome was significantly greater in adolescents in the highest UA quartile than in those in the lowest quartile (odds ratio, 6.39). The positive predictive value of a baseline UA value of 7.6 mg/dL for developing metabolic syndrome was 79% and the negative predictive value was 94%. Higher UA, waste circumference, and BP were independently predictive of metabolic syndrome at follow-up.
Comment: Uric acid is hypothesized to be an endothelial toxin and to play a role in the genesis of hypertension and metabolic syndrome. Although this is a relatively small study and the serum uric acid levels are surprisingly high, serum UA appears to be a marker in adolescents for developing metabolic syndrome.
— F. Bruder Stapleton, MD Published in Journal Watch Pediatrics and Adolescent Medicine June 13, 2012
Citation(s): Wang J-Y et al. Predictive value of serum uric acid levels for the diagnosis of metabolic syndrome in adolescents. J Pediatr 2012 May 11; [e-pub ahead of print].
(http://dx.doi.org/10.1016/j.jpeds.2012.03.036)
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MM: talk about relatively easy and inexpensive fixes to big problems, this is just such a potential fix. Will adding zinc to every child’s regimen show a marked improvement to infectious situations/ Probably not. But moderate amounts presented to a child’s diet should do no harm, is very inexpensive and shows outstanding potential benefit.
Lancet 2012 Jun 2; 379:2072
Adding Zinc to Antibiotics Reduces Treatment Failures
Among infants with probable bacterial infection, adjunctive zinc decreased the need to change therapy, the need for intensive care, and the risk for death.
Bacterial infections are responsible for more than a quarter of neonatal deaths in India. Might the addition of zinc improve treatment outcomes, given findings of beneficial effects in animals and in children?
To find out, researchers conducted a double-blind trial involving infants aged 7 to 120 days who were treated for probable serious bacterial infection (based on clinical findings and elevated C-reactive protein levels) at any of three hospitals in New Delhi. The infants were randomized to receive 10 mg of oral zinc or placebo daily, along with standard antibiotic therapy.
Treatment failure (defined as need to change therapy within 7 days, need for intensive care, or death within 21 days; assessable in 655 infants) occurred significantly less frequently in the zinc group than in the placebo group (10% vs. 17%; relative risk reduction, 40%). The death rate was nonsignificantly lower in the zinc group than in placebo group (5% vs. 3%). Tests of zinc levels done at study entry showed that 44% of study infants had low baseline levels (<9.2 µmol/L).
Comment: The authors and editorialists note the importance of zinc in immune function, through mechanisms such as reducing expression of cytokines and increasing CD4 cells. Results of previous studies of zinc in diarrheal disease have been sufficiently robust for WHO and UNICEF to recommend its use in childhood diarrhea. This study broadens potential areas of benefit to other common, serious infections. Whether zinc treatment would be beneficial in populations of infants with normal zinc levels is unknown.
Zinc is inexpensive. Its use could potentially decrease mortality in infants with serious infections in developing countries and reduce the proportion of infants needing second-line antibiotics because of treatment failure.
— Mary E. Wilson, MD Published in Journal Watch Infectious Diseases June 13, 2012
Citation(s): Bhatnagar S et al. Zinc as adjunct treatment in infants aged between 7 and 120 days with probable serious bacterial infection: A randomised, double-blind, placebo-controlled trial. Lancet 2012 Jun 2; 379:2072.
http://www.ncbi.nlm.nih.gov/pubmed/22656335?dopt=Abstract
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MM: Dr Peter Rosi, MD is gonna love this analysis. He has been preaching the gospel of “No Low Sodium Diets for decades” Low sodium incereases gastrointestinal issues and now it appears that those sodium phobes who stayed clear of the stuff because they thought they were being protective of their cardiovascular systems may have been looking at the wrong side of the evidence-based sodium restriction data.
JAMA 2011 May 4; 305:1777
Is Lower Salt Intake Dangerous?
In a controversial study, low-salt diets were associated with elevated cardiovascular disease mortality.
Salt intake has been correlated directly with blood pressure (BP) in short-term intervention trials. These data inform the premise that decreased salt intake should substantially prevent cardiovascular disease (CVD). Belgian investigators tested this theory among 3681 patients without CVD (26% with hypertension) who were assessed for CVD outcomes in two European prospective cohort studies (median follow-up, 8 years).
In the overall cohort, a significant but inverse relation was noted between urinary sodium excretion and fatal or nonfatal CVD events. For example, the CVD death rate was 4.1% versus 0.8% in the lowest versus highest tertiles of sodium excretion.
Two subgroups were created. In the first subgroup, 2096 patients who were normotensive at baseline were followed for incident hypertension; no association was found between urinary sodium excretion and incident hypertension, which was roughly 26%–27% in all tertiles. In the second subgroup, 1499 patients who were not receiving antihypertensive treatment were followed to assess the association of urinary sodium excretion and BP; greater sodium excretion was associated with a significant but small increase in systolic BP.
Comment: Not unexpectedly, this study has been criticized by many investigators and for many reasons, as reported in the May 3, 2011, New York Times. Two criticisms are that participants were relatively young (mean age, 40) and that the number of CVD events was relatively small. However, the results are not inconsistent with those of other studies. No clinical recommendations can be drawn from the study, but it is certainly provocative and worthy of discussion.
— Thomas L. Schwenk, MD Published in Journal Watch General Medicine May 17, 2011
Citation(s): Stolarz–Skrzypek K et al. Fatal and nonfatal outcomes, incidence of hypertension, and blood pressure changes in relation to urinary sodium excretion. JAMA 2011 May 4; 305:1777. (http://dx.doi.org/10.1001/jama.2011.574)
http://www.ncbi.nlm.nih.gov/pubmed/21540421?dopt=Abstract
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MM: To paraphrase Forrest Gump, “Stupid is, as stupid does…” That is what this position on REDUCING the recommended daily intake of vitamin D. This is a myopic approach looking at a single outcome that takes years to appropriately measure and assess. It completely ignores the welll-documented benfits of vitamin D. My advice: don’t decrease daily intake, inccrease it until blood levels reach the upper, rather than the lower blood levels of the vitamin D range.
USPSTF Draft Recommendation: No Vitamin D, Calcium Supplementation for Healthy Postmenopausal Women
Healthy postmenopausal women should not take daily low-dose vitamin D and calcium supplements to prevent fracture (grade D recommendation), the U.S. Preventive Services Task Force said on Tuesday in a draft recommendation statement.
The group says that 400 IU of vitamin D3 and 1000 mg of calcium carbonate taken daily don't reduce osteoporotic fractures and slightly increase the risk for kidney stones.
In addition, the USPSTF determined there was not enough evidence to make recommendations for or against the following:
- Vitamin D and calcium supplementation to prevent fractures in men or premenopausal women
- Higher doses of vitamin D for fracture prevention in healthy postmenopausal women
- Vitamin D — with calcium or alone — for cancer prevention in adults
http://www.uspreventiveservicestaskforce.org/draftrec3.htm
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WHO Group Classifies Diesel Fumes as Carcinogenic
Diesel engine exhaust is a human carcinogen, the WHO's International Agency for Research on Cancer announced on Tuesday. An IARC working group found "sufficient evidence" that such exhaust causes lung cancer and limited evidence that it's associated with increased risk for bladder cancer.
The announcement updates the IARC's 1988 classification of diesel exhaust as probably carcinogenic.
Dr. Christopher Portier, chairman of the working group, said: "The scientific evidence was compelling and the [group's] conclusion was unanimous: diesel engine exhaust causes lung cancer in humans."
http://press.iarc.fr/pr213_E.pdf
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Gastroenterology 2012 Apr; 142:762
The Higher the Body-Mass Index, the Higher the Risk for Adenoma
A 5-unit increase in BMI was associated with a 19% increased risk for colorectal adenoma.
Obesity is considered a risk factor for colon cancer and adenomas. However, study results have been mixed on the magnitude of risk and whether it is limited to men. Now, researchers have conducted a meta-analysis to clarify the link between body-mass index (BMI) and colorectal adenoma.
Investigators identified 36 studies (16 case-control, 13 cross-sectional, and 7 cohort or nested case-control) appropriate for the meta-analysis. A 5-unit increase in body-mass index (BMI) was associated with a 19% increased risk for colorectal adenoma regardless of patient sex, study region (U.S., Europe, or Asia), or adjustment for physical activity, smoking, caloric intake, alcohol use, and nonsteroidal anti-inflammatory drug use in a subset of studies. In a meta-analysis based on BMI categories, obese patients (BMI 
30) but not overweight patients (BMI 
25 and <30) had an increased risk for colorectal adenoma compared with patients with normal BMI (<25). A subanalysis of 11 studies found that increased BMI was associated with increased risk for colon adenoma but not rectal adenoma.
Comment: This meta-analysis firms up the association between body-mass index and colon adenomas. Increased BMI has also been linked with increased risk for cancer of the colon but not the rectum. Current guidelines do not recommend adjustment of screening or surveillance intervals based on BMI.
— Douglas K. Rex, MD Published in Journal Watch Gastroenterology April 27, 2012
Citation(s): Ben Q et al. Body mass index increases risk for colorectal adenomas based on meta-analysis. Gastroenterology 2012 Apr; 142:762.
http://www.ncbi.nlm.nih.gov/pubmed/22245665?dopt=Abstract
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Diabetes Care 2012 Apr; 35:749
The Incremental Relation Between Fasting Glucose and Glycosylated Hemoglobin
The relation is affected, in part, by the degree of fasting hyperglycemia and use of oral antidiabetes drugs.
Sometimes glycosylated hemoglobin (HbA1c) test results don't seem consistent with patients' reported blood glucose levels. In this study, researchers sought to determine whether ethnicity, geographic region, or oral antidiabetes drug use affects the relation between HbA1c and fasting plasma glucose (FPG) levels. The study involved 12,500 patients worldwide with type 2 diabetes, impaired glucose tolerance, or impaired fasting glucose; none were using insulin.
Results were as follows:
- At FPG levels between 100 and 162 mg/dL, an FPG increment of 18 mg/dL was associated with a mean HbA1c increment of 0.43% in patients who weren't taking oral antidiabetes drugs, and 0.26% in patients who were taking oral antidiabetes drugs
- At FPG levels >162 mg/dL, an FPG increment of 18 mg/dL was associated with a mean HbA1c increment of 0.21% in patients who weren't taking oral antidiabetes drugs, and 0.10% in patients who were taking oral antidiabetes drugs
The above-noted results were not affected by type of oral antidiabetes drug (metformin or sulfonylurea), geographic location (North America, South America, Europe, or Pacific Rim) or ethnicity (white, Latino, Asian, or black)
Comment: We know that HbA1c can be affected by hemoglobin structure, erythrocyte lifespan, and lability of blood glucose levels (JW Gen Med Sep 13 2011). This study provides additional insights: (1) as FPG increases above 162 mg/dL, HbA1c does not rise as steeply as it does for FPG increments below that threshold; and (2) at any given level of FPG, HbA1c will likely be lower in patients who take oral antidiabetes drugs, compared with untreated patients. Finally, note that these findings apply to fasting glucose levels and not to 24-hour average glucose levels.
— Allan S. Brett, MD Published in Journal Watch General Medicine April 26, 2012
Citation(s):Ramachandran A et al. Relationship between A1C and fasting plasma glucose in dysglycemia or type 2 diabetes: An analysis of baseline data from the ORIGIN trial. Diabetes Care 2012 Apr; 35:749.
(http://dx.doi.org/10.2337/dc11-1918)
http://www.ncbi.nlm.nih.gov/pubmed/22323416?dopt=Abstract
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J Natl Cancer Inst 2012 Apr 18; 104:614
Ramifications of Breast-Conserving Surgery for Ductal Carcinoma in Situ
Ten-year follow-up shows high rates of subsequent invasive procedures.
As more women undergo screening mammography, the number who receive diagnoses of ductal carcinoma in situ (DCIS) has risen. Breast-conserving surgery (BCS) is a reasonable alternative to mastectomy for DCIS, as both approaches yield similar long-term mortality outcomes (JW Oncol Hematol Apr 19 2011); however, the recurrence risk associated with BCS necessitates ongoing surveillance. In a report based on 10-year follow-up of women enrolled in three U.S. integrated health care systems who were treated for DCIS with BCS between 1990 and 2001, investigators assessed the frequency of diagnostic mammograms and ipsilateral invasive procedures.
During a median follow-up of 4.8 years in 2948 evaluable women (mean age at diagnosis, 58), ipsilateral recurrence was diagnosed in 11% of participants (6% DCIS and 5% invasive disease). Diagnostic mammograms were performed in 7.3% of women during the first 6 months of follow-up and subsequently at an annual rate of 4.3%; during 10 years, 30.8% of women underwent such imaging. About half (51.5%) of women underwent at least one ipsilateral invasive procedure during the first 6 months; thereafter, the annual rate of invasive procedures was 3.1%. The 10-year incidence of invasive procedures was 61.5%.
Comment: Although increasing numbers of women with ductal carcinoma in situ are choosing mastectomy, breast-conserving surgery remains the most common surgical treatment for this disease. The high rate of ipsilateral invasive procedures during the 6 months following BCS is noteworthy and probably reflects reexcision to obtain clear margins. Nonetheless, the use of invasive diagnostic procedures may increase with the growing use of breast magnetic resonance imaging in high-risk patients. In making informed choices about treatment of DCIS, women and clinicians should take into account the risk for subsequent invasive procedures.
— Andrew M. Kaunitz, MD Published in Journal Watch Women's Health April 26, 2012
Citation(s):Nekhlyudov L et al. Ten-year risk of diagnostic mammograms and invasive breast procedures after breast-conserving surgery for DCIS. J Natl Cancer Inst 2012 Apr 18; 104:614.
http://www.ncbi.nlm.nih.gov/pubmed/22491230?dopt=Abstract
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Statin Use Linked to Fatigue in Randomized Trial
Statin use leads to decreased energy and increased fatigue with exertion, especially among women, according to a randomized trial published in the Archives of Internal Medicine.
Researchers randomized some 1000 adults with elevated LDL cholesterol — and without cardiovascular disease or diabetes — to simvastatin (20 mg/day), pravastatin (40 mg/day), or placebo. At 6 months, statin use was associated with significant worsening in energy and exertional fatigue, with simvastatin accounting for most of the ill effects. Women seemed particularly affected.
The authors say this is the "first randomized evidence affirming unfavorable statin effects" on these outcomes. They conclude that such effects "merit consideration when prescribing or contemplating use of statins, particularly in groups without expected net morbidity/mortality benefit."
http://click.jwatch.org/cts/click?q=227%3B67689359%3B%2FSbAOubO252F8pG%2
B6tvBYKJxsHn4WtonB7djn6KHq3c%3D
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Meta-Analysis: Viscosupplementation for Knee Osteoarthritis Ineffective
Viscosupplementation, the intra-articular injection of hyaluronic acid, offers few benefits for knee osteoarthritis but can lead to serious adverse events, according to an Annals of Internal Medicine analysis.
Examining 89 trials comprising over 12,000 adults, researchers found "a small, clinically irrelevant effect" on pain from viscosupplementation. At the same time, treatment was associated with increased risk for overall serious adverse events (for example, those resulting in significant disability or inpatient hospitalization).
The researchers criticize the methodological and reporting quality of many of the studies, and the fact that safety data were often not reported at all. Nonetheless, they conclude that "the administration of these preparations should be discouraged."
http://annals.org/article.aspx?doi=10.7326/0003-4819-157-3-201208070-00473
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It's Never Too Late to Quit Smoking
Smoking is linked to increased mortality even among adults older than 80 — but quitting can reduce this risk — according to a meta-analysis in the Archives of Internal Medicine.
The analysis included 17 longitudinal studies assessing the effects of cigarette smoking on mortality in people aged 60 and older. Overall, current smokers had nearly twice the risk for death as those who never smoked. When analyzed according to age group, smoking was significantly associated with mortality even among those aged 80 and older. And among former smokers, as the time since quitting increased, the risk for death decreased; again, this finding was significant among the oldest individuals.
The authors write: "Even older people who smoked for a lifetime without negative health consequences should be encouraged and supported to quit." And a commentator calculates: "the statement that about 1 in 2 smokers will be killed by smoking is true even for elderly smokers."
http://archinte.jamanetwork.com/article.aspx?articleid=1182214
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Lens or Lentil-Shaped Lipid Vesicles May Target Drugs to Stenotic Vessels
A lipid-based nanoparticle that can deliver cardiovascular drugs specifically to diseased constricted arteries and spare normal arteries from unwanted drug therapy has been developed. Intravenous injections of vasodilators results in the dilation of both stenotic and normal blood vessels, which can lead to significant side-effects. The new lenticular (lentil-shaped) liposomes effectively target only diseased stenotic vessels because the increased shear stress forces within the narrowed lumens is enough to cause transient break points in the particles that let the drugs out, whereas in healthy vessels, the liposomes continue their journey.
http://www.genengnews.com/gen-news-highlights/scientists-develop-lentil-shaped-lipid-vesicles-that-target-drugs-to-stenotic-vessels/81246882/
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Trillions of BFFs (Bacterial Friends Forever)
It may not be time to revert to bloody smocks in the operating room, but bacteria and other microbes are having a moment in the spotlight.
A federal project concentrating on the human microbiome (and noticed by the New York Times) is trying to characterize the microbial genomes of some 250 healthy people. The Times reports an estimate of 100 trillion bacteria reside in each of us. A news release about the project says that there are 10 times as many microbial cells in and on our bodies as there are human cells. Who knew?
http://www.nytimes.com/2012/06/14/health/human-microbiome-project-decodes-our-100-trillion-good-bacteria.html?_r=1&hpw
http://www.ploscollections.org/article/browseIssue.action?issue=info:doi/10.1371/issue.pcol.v01.i13
http://www.genome.gov/27549144
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J Infect Dis 2012 Jun 1; 205:1639
Keep Washing Those Hands
The leading cause of gastroenteritis worldwide can survive on fomites for weeks.
Many infectious microbes have become media stars in recent years, but noroviruses remain relatively unknown, even though they cause more diarrheal disease in this country than any other pathogen (and are estimated to cause half of all gastroenteritis outbreaks worldwide.) A small outbreak among members of a girls' soccer team illustrates just how contagious these viruses are.
The index patient, a teenage girl, developed vomiting and diarrhea one night while at an out-of-town hotel for a tournament and, then, went home the next morning without any further contact with the rest of her group. Three days later, seven additional team members became ill. Investigators determined that illness was associated with eating grapes or packaged snacks that had been stored in a reusable grocery bag in the index patient's hotel bathroom. Swabs from the grocery bag (obtained 2 weeks after the outbreak) and all three stool specimens from ill individuals were positive for norovirus of the same genotype.
Comment: An editorialist calls noroviruses "the perfect human pathogens": A tiny dose causes infection, huge quantities of virions are shed in feces and vomit, and infection brings no lasting immunity. This case illustrates how important fomites are in transmission — they can contaminate both hands and food of secondary cases. Further, because norovirus infections can be acquired by ingestion of aerosolized particles, even assiduous handwashing might not have saved this team.
— Abigail Zuger, MD Published in Journal Watch General Medicine June 14, 2012
Citation(s): Repp KK and Keene WE. A point-source norovirus outbreak caused by exposure to fomites. J Infect Dis 2012 Jun 1; 205:1639.
(http://dx.doi.org/10.1093/infdis/jis250)
http://www.ncbi.nlm.nih.gov/pubmed/22573873?dopt=Abstract
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JAMA 2012 Jun 13; 307:2400
Per Capita Radiation Dose Doubled from 1996 to 2010
Growing use of diagnostic imaging could lead to more cancers in the future.
The rising use of diagnostic imaging is associated with more radiation exposure. In this study, researchers used data from six U.S. healthcare systems and associated insurance plans that enrolled 1 to 2 million patients annually from 1996 to 2010. The overall rate of imaging was similar across the six plans (range, 1218–1680 imaging procedures/1000 enrollees/year), but specific modalities varied widely across sites (e.g., comparing highest to lowest plan, magnetic resonance imaging [MRI] varied by 1.6-fold; angiography/fluoroscopy varied by 4.5-fold).
Use of plain radiography rose by only 1% annually from 1996 to 2010, but use of computed tomography (CT) rose by 8% annually, MRI rose by 10% annually, ultrasound rose by 4% annually, and positron emission tomography rose by 57% annually. Nuclear medicine rates declined by 8% annually. Per capita radiation exposure roughly doubled from 1996 to 2010, as did the proportion of enrollees who received high or very high radiation exposure. CT use accounted for most of the increase, with 30% of radiation exposure attributable to CT in 1996 versus 68% in 2010.
Comment: Radiation exposure from imaging at current rates is predicted to be responsible for 2% of future cancers — this figure could be an underestimate, if rates of imaging continue to increase. These six plans had few co-payment or decision-support mechanisms in place during most of the study period, and both might help limit inappropriate use of imaging. However, keep in mind that predicted cancer risks from diagnostic imaging are just estimates and not direct observations.
— Thomas L. Schwenk, MD Published in Journal Watch General Medicine June 13, 2012
Citation(s): Smith-Bindman R et al. Use of diagnostic imaging studies and associated radiation exposure for patients enrolled in large integrated health care systems, 1996–2010. JAMA 2012 Jun 13; 307:2400. (http://dx.doi.org/10.1001/jama.2012.5960)
O'Connor GT and Hatabu H. Lung cancer screening, radiation, risks, benefits, and uncertainty. JAMA 2012 Jun 13; 307:2434. (http://dx.doi.org/10.1001/jama.2012.6096)
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Obstet Gynecol 2012 Jun; 119:1113
Effect of Induction on Course of Labor
Extended latent phase may not indicate need for cesarean delivery.
In 2007, a substantially higher proportion of births involved induction of labor than in 1990 (23% vs. 9%). Researchers at one institution conducted a 4-year retrospective cohort study in which the courses of induced versus spontaneous term labors were compared in 5388 women with singleton pregnancies and vertex presentations. Results were analyzed by parity.
In all, 2021 participants (38%) presented in spontaneous labor, 1647 (31%) were induced, and 1720 (32%) were augmented after an initial diagnosis of spontaneous labor. Induced labors lasted significantly longer than spontaneous labors (median time to progress from 4- to 10-cm cervical dilation, 5.5 hours vs. 3.8 hours in nulliparous women; 4.4 hours vs. 2.4 hours in multiparous women). Progression of cervical dilation from 4 cm to 6 cm (latent phase) took longer in the induced group than in the spontaneous group, but after 6-cm dilation (active phase), women in both groups advanced to 10 cm at similar rates. Patterns of progression were similar for induced and augmented labor. Overall patterns among multiparous women were similar to those in nulliparous women across the three groups. Excluding those women who had undergone artificial rupture of membranes — sometimes considered a form of augmentation — from the spontaneous group did not affect the results.
Comment: This study should make us rethink whether rigid definitions of active phase arrest are applicable when labor is induced. Although women with induced or augmented labors took longer to reach full dilation, their progression after 6-cm dilation was comparable to that of women in spontaneous labor. Therefore, longer times should be allowed for such labors. Any diagnosis of arrest of labor before 6-cm dilation — particularly if the labor has been induced — must be made cautiously to avoid unnecessary cesarean deliveries.
— Diane J. Angelini, EdD, CNM, FACNM, FAAN, NEA-BC Published in Journal Watch Women's Health June 14, 2012
Citation(s): Harper LM et al. Normal progress of induced labor. Obstet Gynecol 2012 Jun; 119:1113.
http://www.ncbi.nlm.nih.gov/pubmed/22569121?dopt=Abstract
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Am J Psychiatry 2012 Jun 1; 169:616
Balancing Positive and Negative Effects of Antidepressants During Pregnancy
Auditory sensory gating was impaired in infants whose mothers had prenatal anxiety but not in those whose mothers used antidepressants during pregnancy.
Maternal antidepressant (AD) use occurs during at least 8% of pregnancies in the U.S. and has been associated with psychopathology in offspring (e.g., autism; JW Psychiatry Aug 29 2011). In this study, researchers assessed the effects of maternal anxiety and AD use during pregnancy on infant auditory sensory gating, a measure of attentional function. Electroencephalographic responses to sequentially paired clicks were recorded, and response amplitudes to the first and second stimuli were measured (in normal gating, the second stimulus elicits a lower-amplitude response).
The participants were 242 mother–infant pairs (mean infant age, 76 days). Fourteen mothers had current or past anxiety disorders and used ADs while pregnant, 13 had no histories of anxiety but used ADs during pregnancy, 46 had anxiety but did not use ADs during pregnancy, and 169 had no anxiety and no AD use.
Infants of mothers who used ADs had sensory gating within the normal range, whereas infants of mothers with anxiety disorders but no AD use had impaired gating: Responses to second stimuli were not as diminished. Findings in treated women with anxiety disorders did not remain significant after controlling for multiple comparisons. Exploratory analyses suggested that postnatal AD use was not a significant variable.
Comment: Although the findings did not hold up to multiple comparisons, they are salient because sensory gating defects are associated with multiple major psychopathologies (e.g., JW Psychiatry Oct 29 2007). Thus, these preliminary data warrant consideration when making decisions aimed at balancing risks and benefits in treatment of anxiety disorders in pregnant women. Future sensory gating studies that control for treatment with nonpharmacologic interventions, such as cognitive-behavioral therapy, will be especially useful.
— Barbara Geller, MD Published in Journal Watch Psychiatry June 11, 2012
Citation(s): Hunter SK et al. Antidepressants may mitigate the effects of prenatal maternal anxiety on infant auditory sensory gating. Am J Psychiatry 2012 Jun 1; 169:616.
(http://dx.doi.org/10.1176/appi.ajp.2012.11091365)
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Hormonal Contraceptives Showed Increased Risks for Stroke, MI
Hormonal contraceptives raise relative risks for thrombotic stroke and myocardial infarction, although the absolute risks are low, according to a New England Journal of Medicine study.
Using Danish national registries, researchers followed 1.6 million women (aged 15 to 49) from 1995 through 2009. Compared with women not using hormonal contraceptives, those currently using combined oral contraceptives containing 30 to 40 μg of ethinyl estradiol had increased relative risks for stroke (RRs ranged from 1.5 to 2.2) and MI (RRs, 1.3 to 2.3). Those using formulations with 20 μg of ethinyl estradiol had somewhat lower risks. Overall, differences in risk according to progestin type were small.
Progestin-only products (e.g., levonorgestrel-releasing IUD and subcutaneous implants) did not raise risks significantly. However, contraceptive patches increased relative risks for stroke (RR, 3.2), as did vaginal rings (RR, 2.5). Data on MI were too sparse to evaluate patch use, and the risk for vaginal rings didn't reach statistical significance.
An editorialist estimates that the number of excess arterial thrombotic events attributable to these contraceptives is about 1 to 2 per 10,000 women per year and that "for an individual woman, the probability of an event is quite small."
http://www.nejm.org/doi/full/10.1056/NEJMoa1111840
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