Volume 5, No. 8, September 2007
Hot Topics
Obstetrics | Gynecology | Child Health | Chronic Disease and Illness
Obstetrics
Low-dose aspirin has benefits when used for prevention of pre-eclampsia
AUTHORS' CONCLUSIONS: Antiplatelet agents, largely low-dose aspirin, have moderate benefits when used for prevention of pre-eclampsia and its consequences. Further information is required to assess which women are most likely to benefit, when treatment is best started, and at what dose.
Duley L et al Antiplatelet agents for preventing pre-eclampsia and its complications. Cochrane Database Syst Rev. 2007; (2):CD004659
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17443552
OB/GYN CCC Editorial comment:
Just cut and paste this into your facility’s guidelines
After 12 weeks GA consider prophylactic low dose ASA 81 mg po every day to prevent or decrease severe pre-eclampsia and/or IUGR. Indicated if:
-Chronic hypertension
-Past severe preeclampsia
-Renal Disease
-Pre-existing diabetes
Guidelines for management of hypertensive disorders in pregnancy
http://www.ihs.gov/NonMedicalPrograms/NC4/Documents/HYPERT12004.doc
Oral Antidiabetic Agents in Pregnancy and Lactation: A Paradigm Shift
CONCLUSIONS: Neither glyburide nor metformin has caused developmental toxicity in humans. Glyburide has been used for the treatment of gestational diabetes, and metformin has been used in women with PCOS who eventually became pregnant. Additional trials are needed to better define the benefits and risks of oral antidiabetic agents in pregnancy. Metformin, glyburide, and glipizide appear to be compatible with breast-feeding.
Feig DS, Briggs GG, Koren G. Oral antidiabetic agents in pregnancy and lactation: a paradigm shift? Ann Pharmacother. 2007 Jul;41(7):1174-80
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17535842
OB/GYN CCC Editorial comment:
Glyburide is first line agent, while metformin is awaiting more data
Studies of glyburide and glipizide have found little or no transfer of these drugs across the placenta, whereas metformin and rosiglitazone cross readily. Animal studies have found no evidence to suggest that glyburide, glipizide, metformin, or rosiglitazone are teratogenic. In gestational diabetes, glyburide was safe and efficacious; however, 16-19% of women failed to achieve optimal glucose control. No developmental toxicity in infants was observed when metformin was used before and throughout pregnancy in women with polycystic ovarian syndrome (PCOS). Some of the studies involving patients with type 2 diabetes had methodological problems. A randomized controlled trial using metformin for gestational diabetes in the third trimester is underway. The human information is inadequate to evaluate the risk of glipizide or the thiazolidinediones in pregnancy. In breast milk, 3 studies measured nonsignificant amounts of metformin and one study was unable to detect either glyburide or glipizide.
Preventive Approach to Cutting Cesarean Delivery Rates Appears Feasible
CONCLUSIONS: A preventive approach to reducing cesarean deliveries may be possible. This study found that practitioners who often used risk-guided, prostaglandin-assisted labor induction had a lower cesarean delivery rate without increases in rates of other adverse birth outcomes. Randomized controlled trials of this method of care are warranted.
Nicholson JM, Yeager DL, Macones G. A preventive approach to obstetric care in a rural hospital: association between higher rates of preventive labor induction and lower rates of cesarean delivery. Ann Fam Med. 2007 Jul-Aug;5(4):310-9.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17664497
No advantage to bulking agent after primary repair of obstetric anal sphincter injury
RESULTS: Pain scores were similar in the two treatment groups; but incontinence in the immediate postnatal period was more frequent with the two preparations compared with lactulose alone (32.86% versus 18.18%, P = 0.03).
CONCLUSIONS: This study does not support routine prescribing of a stool-bulking agent in addition to a laxative in the immediate postnatal period for women who have sustained anal sphincter injury at vaginal delivery.
Eogan M et al Randomised clinical trial of a laxative alone versus a laxative and a bulking agent after primary repair of obstetric anal sphincter injury. BJOG. 2007; 114(6):736-40
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17516966
Prepregnancy obesity, overweight raise risk of birth defects
CONCLUSIONS: To our knowledge, this is the first population-based study of its scale to examine prepregnancy obesity and a range of structural birth defects. These results suggest a weak to moderate positive association of maternal obesity with 7 of 16 categories of birth defects and a strong inverse association with gastroschisis. The mechanisms underlying these associations are not yet understood but may be related to undiagnosed diabetes.
Waller DK, et al Prepregnancy obesity as a risk factor for structural birth defects. Arch Pediatr Adolesc Med. 2007 Aug;161(8):745-50
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17679655
Stillbirth: A risk marker for premature mortality among parous women
RESULTS: During the study period, 78 (13.1%) mothers with stillbirths died, compared with 1,518 (6.2%) women without stillbirth (crude hazard ratio 2.08, 95% confidence interval [CI] 1.65-2.61). The mortality risk remained significantly increased after adjustments for sociodemographic variables, maternal diseases at pregnancy, placental abruption, and preeclampsia (hazard ratio 1.40, 95% CI 1.11-1.77). Stillbirth was associated with an increased risk of death from coronary heart disease (adjusted hazard ratio 2.00, 95% CI 1.02-3.93), all circulatory (adjusted hazard ratio 1.70, 95% CI 1.02-2.84) and renal (adjusted hazard ratio 4.70, 95% CI 1.47-15.0) causes. Stratifying by country of origin, an increased risk was evident particularly among women of North African origin (all-cause mortality, adjusted hazard ratio 2.47, 95% CI 1.69-3.63).
CONCLUSION: Stillbirth may be a risk marker for premature mortality among parous women.
Calderon-Margalit R et al Late stillbirths and long-term mortality of mothers. Obstet Gynecol. 2007; 109(6):1301-8
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17540801
ACOG Releases Guidelines on the Use of SSRIs During Pregnancy
Depression is common among women of reproductive age, and approximately one in 10 women will have major or minor depression during pregnancy and the postpartum period. Selective serotonin reuptake inhibitors (SSRIs) are commonly used to treat depression. Recently, however, there have been concerns that the use of paroxetine (Paxil) during the first trimester of pregnancy may increase the risk of congenital cardiac malformations. Additionally, transient neonatal complications, including mild respiratory distress, transient tachypnea of the newborn, a weak cry, and poor tone, have been associated with SSRI use late in pregnancy. To address this risk, the American College of Obstetricians and Gynecologists (ACOG) has released a committee opinion on the use of SSRIs during pregnancy, which was published in the December 2006 issue of Obstetrics & Gynecology.
Although the benefits of paroxetine may outweigh the risks, physicians should consider whether a patient could have a relapse of depression if treatment is discontinued. Left untreated, depression could increase the risk of low weight gain, sexually transmitted diseases, and alcohol and substance abuse.
Therefore, ACOG recommends that the use of SSRIs and selective norepinephrine reuptake inhibitors be individualized in pregnant women. If possible, however, paroxetine should be avoided in patients who are pregnant or want to become pregnant. If a patient is exposed to paroxetine in early pregnancy, fetal echocardiography should be considered.
The committee recommends that treatment decisions involve the expertise of a mental health professional to assess the benefits. Ideally, this shared decision making would occur before the patient becomes pregnant. However, because nearly 50 percent of pregnancies are unplanned, preconception care for women with depression may not always occur.
When discontinuing paroxetine, patients should follow the instructions outlined in the prescribing information, because abrupt discontinuation may lead to withdrawal symptoms.
Treatment with selective serotonin reuptake inhibitors during pregnancy. ACOG Committee Opinion No. 354. American College of Obstetricians and Gynecologists. Obstet Gynecol 2006;108:1601–3.bstet Gynecol 2006;108:1597–99 Practice Guideline Briefs
http://www.aafp.org/afp/20070815/practice.html
Cesarean Delivery Rate Hits All-time High
Nearly one in three live births in the United States in 2005 was a cesarean delivery, marking the highest U.S. total cesarean rate ever reported. Since 1996, the total cesarean rate has increased by 46 percent, driven by an increase in the percentage of women having a first cesarean delivery and a decrease in the percentage of women delivering vaginally after a previous cesarean delivery. Cesarean rates vary considerably among states but tend to be lower in the Western mountain states and upper Midwest, and higher in the Southeast and East.
QuickStats: Percentage of All Live Births by Cesarean Delivery --- National Vital Statistics System, United States, 2005 MMWR April 20, 2007 / 56(15);373
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5615a8.htm
Antibiotics for asymptomatic bacteriuria in pregnancy reduces pyelonephritis
AUTHORS' CONCLUSIONS: Antibiotic treatment is effective in reducing the risk of pyelonephritis in pregnancy. A reduction in low birthweight is consistent with current theories about the role of infection in adverse pregnancy outcomes, but this association should be interpreted with caution given the poor quality of the included studies.
Smaill F; Vazquez JC Antibiotics for asymptomatic bacteriuria in pregnancy. Cochrane Database Syst Rev. 2007; (2):CD000490
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17443502
Gynecology
Human papillomavirus, vaccines and women's health: questions and cautions
This will be part of an issue of the CMAJ that will feature other articles on HPV as well. There is also a larger policy paper available (19 pages) -- casting a critical lens on the HPV vaccine -- now available on the CWHN website: www.cmaj.ca
Human papillomavirus, vaccines and women's health: questions and cautions
by A. Lippman PhD, R. Melnychuk PhD, C. Shimmin BJ, and colleagues (August 1, 2007)
http://www.cmaj.ca/cgi/rapidpdf/cmaj.070944v1
HPV, Vaccines, and Gender: Policy Considerations
This paper reflects data available to us as of June 2007. Studies about HPV
vaccines -- their efficacy, safety, place in women's health care -- and research
on the implications of initiating vaccination programs continue to evolve. They
will be adding new references and links to some of this work as best we can in
the future.
http://www.cwhn.ca/resources/cwhn/hpv-brief.html
Liquid prep no more accurate than conventional cytology, RCT
CONCLUSION: Liquid based cytology showed no statistically significant difference in sensitivity to conventional cytology for detection of cervical intraepithelial neoplasia of grade 2 or more. More positive results were found, however, leading to a lower positive predictive value. A large reduction in unsatisfactory smears was evident
Ronco G et al Accuracy of liquid based versus conventional cytology: overall results of new technologies for cervical cancer screening: randomised controlled trial. BMJ. 2007; 335(7609):28
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17517761
Laparoscopically guided minilaparotomy reduces intraperitoneal spillage
CONCLUSION: Laparoscopically guided minilaparotomy, when compared with laparoscopy, is able to reduce intraperitoneal spillage in patients with presumably benign large adnexal masses, with minimal increase in patient short- and long-term discomfort. Because data regarding the importance of intraperitoneal spillage during surgery for benign and malignant pathologies, as well as rupture rates during traditional laparotomy, are scarce, traditional laparotomy still represents the standard treatment. In women desiring a minimally invasive strategy for large cysts, laparoscopically guided minilaparotomy should be considered. LEVEL OF EVIDENCE: I.
Panici PB, et al Laparoscopy compared with laparoscopically guided minilaparotomy for large adnexal masses: a randomized controlled trial. Obstet Gynecol. 2007 Aug;110(2 Pt 1):241-8
Quadrivalent HPV Recombinant Vaccine (Gardasil) for the Prevention of Cervical Cancer
Bottom Line
The HPV vaccine is safe and effective in preventing genital warts and cervical changes that may lead to cervical cancer, and it is recommended as part of the vaccination series in females 11 to 12 years of age. It can be given to females as young as 9 or 10 years of age, and catch-up vaccination is recommended for those who are 13 to 26 years of age.
STEPS New Drug Reviews http://www.aafp.org/afp/20070815/steps.htmlChild Health
Educate parents about new pre-adolescent vaccine recommendations
The 2007 Pre-Teen Vaccine Campaign was recently launched to increase awareness among parents and health professionals of three new vaccine recommendations for 11- and 12-year-olds. The campaign, launched on August 1, 2007, by the Centers for Disease Control and Prevention (CDC) to coincide with National Immunization Month, also encourages parents to schedule a routine check-up for their children in this age group, as recommended by the American Academy of Pediatrics, the American Academy of Family Physicians, and CDC. The campaign provides educational materials (including posters and flyers in English and in Spanish) about vaccines to protect children from meningitis, tetanus, diphtheria, whooping cough, and cervical cancer. It also includes outreach to mainstream and ethnic media, as well as information on the creation of partnerships with national and state organizations that reach parents and health professionals. http://www.cdc.gov/vaccines/spec-grps/preteens-adol/07gallery/default.htm
Fact sheet focus on adolescent HPV vaccination issues and opportunities
The HVP Vaccine: Background, Coverage & Benefits presents selected information for state public health leaders and others on the risk imposed by genital human papillomavirus (HPV) infection and the vaccine manufactured to protect against it. The fact sheet, produced by the Association of Maternal and Child Health Programs, provides statistics on HPV infection and adverse health outcomes, recent research to test the efficacy of the HPV vaccine, and recommendations for health care practice. Other topics include (1) HPV vaccine administration and coverage for costs and (2) controversies surrounding legislation to mandate the HPV vaccine as a school-entrance requirement. Opportunities offered by the introduction of the HPV vaccine in addressing the more comprehensive health needs of adolescents are also discussed. http://www.amchp.org/aboutamchp/publications/HPV.pdf
Tobacco Smoke Exposure During Pregnancy Increases Blood Pressure in Infants
Infant offspring of mothers who had smoked during pregnancy had 5.4 mm Hg (95% CI: 1.2 to 9.7; P=0.01) higher systolic blood pressure levels than offspring of mothers who were not exposed to tobacco smoke in pregnancy, taking account of birth weight, infant age, gender, nutrition, and age of mother. No associations were found between maternal exposure to tobacco smoke in pregnancy and diastolic blood pressure. A positive association between maternal exposure to tobacco smoke and heart rate was largely explained by confounding. It can be concluded that maternal exposure to tobacco smoke in pregnancy has a substantial increasing effect on systolic blood pressure in early infancy.
Geerts CC, et al Tobacco Smoke Exposure of Pregnant Mothers and Blood Pressure in Their Newborns. Results from the Wheezing Illnesses Study Leidsche Rijn Birth Cohort. Hypertension. 2007 Jul 30
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17664395
Body composition, physical activity and insulin sensitivity in adolescents
The study shows that in a community sample of African American adolescents, both adiposity [percentage of total body fat] and lack of PEPA [play-equivalent physical activity] are independent statistical determinants of low insulin sensitivity and high insulin secretion, both of which have been identified as precursors of type 2 diabetes..
The authors found that
* The models with BMI z score and time spent in PEPA as the sole determinants of insulin sensitivity explained 21% of the variance in insulin sensitivity and 18% of the variance in insulin secretion. Models in which BMI z score was replaced by other measures of adiposity (BMI, percentage of total body fat, or percentage of abdominal fat) provided an almost identical fit.
* When PEPA was replaced by mean daily activity counts (to evaluate the importance of cumulative activity rather than intensity), insulin sensitivity was no longer significantly correlated with activity but only with BMI z score. Insulin secretion, on the other hand, was correlated with mean daily activity counts and BMI z score.
* Neither PEPA nor BMI z score was a significant independent determinant of DI.
In our study, both adiposity and level of physical activity were significant, independent determinants of insulin sensitivity and secretion, such that a high degree of adiposity and a small proportion of time spent in PEPA were associated with low insulin sensitivity and high insulin secretion.
Snitker S, Le KY, Hager E, et al. 2007. Association of physical activity and body composition with insulin sensitivity in a community sample of adolescents. Archives of Pediatrics & Adolescent Medicine 161(7):677-683. http://archpedi.ama-assn.org/cgi/content/abstract/161/7/677?etoc
Updated AAP Guidelines on Newborn Screening and Tx for Congenital Hypothyroidism
Unrecognized congenital hypothyroidism leads to mental retardation. Newborn screening and thyroid therapy started within 2 weeks of age can normalize cognitive development. The primary thyroid-stimulating hormone screening has become standard in many parts of the world. However, newborn thyroid screening is not yet universal in some countries. Initial dosage of 10 to 15 µg/kg levothyroxine is recommended. The goals of thyroid hormone therapy should be to maintain frequent evaluations of total thyroxine or free thyroxine in the upper half of the reference range during the first 3 years of life and to normalize the serum thyroid-stimulating hormone concentration to ensure optimal thyroid hormone dosage and compliance.
Improvements in screening and therapy have led to improved developmental outcomes in adults with congenital hypothyroidism who are now in their 20s and 30s. Thyroid hormone regimens used today are more aggressive in targeting early correction of thyroid-stimulating hormone than were those used 20 or even 10 years ago. Thus, newborn infants with congenital hypothyroidism today may have an even better intellectual and neurologic prognosis. Efforts are ongoing to establish the optimal therapy that leads to maximum potential for normal development for infants with congenital hypothyroidism.
Remaining controversy centers on infants whose abnormality in neonatal thyroid function is transient or mild and on optimal care of very low birth weight or preterm infants. Of note, thyroid-stimulating hormone is not elevated in central hypothyroidism. An algorithm is proposed for diagnosis and management.
Physicians must not relinquish their clinical judgment and experience in the face of normal newborn thyroid test results. Hypothyroidism can be acquired after the newborn screening. When clinical symptoms and signs suggest hypothyroidism, regardless of newborn screening results, serum free thyroxine and thyroid-stimulating hormone determinations should be performed
Newborn Screening for Congenital Hypothyroidism: Recommended Guidelines
Pediatrics 91: 1203-1209. http://pediatrics.aappublications.org/cgi/content/abstract/117/6/2290
Chronic Disease and Illness
Exposing the Great Bottled Water Scam
This University of Alaska at Anchorage Newsletter issue tackles their first environmental health topic: Americans’ addiction to bottled water, and it’s ramifications for the environment. I think you will be as shocked as I was when you learn more about the size and speed of growth of this social phenomenon. It’s hard to believe we are drinking more bottled water than milk, coffee or beer; only carbonated soft drinks are more popular!
http://consortiumlibrary.org/hsis/about/newsletters/Jul07.pdf
Soda consumption linked with metabolic syndrome
CONCLUSIONS: In middle-aged adults, soft drink consumption is associated with a higher prevalence and incidence of multiple metabolic risk factors.
Dhingra R, et al Soft drink consumption and risk of developing cardiometabolic risk factors and the metabolic syndrome in middle-aged adults in the community. Circulation. 2007 Jul 31;116(5):480-8.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17646581
Antiretroviral Prophylaxis for Occupational Exposure to HIV
Clinical Question : Cochrane for Clinicians
Should health care workers with occupational exposure to human immunodeficiency virus (HIV) receive postexposure antiretroviral prophylaxis?
Evidence-Based Answer
There are no controlled trials of postexposure prophylaxis for persons with occupational exposure to body fluids potentially infected with HIV. Based on one case-control study, individually selected antiretroviral therapy, initiated soon after exposure, is recommended. Treatment should continue for four weeks or until the source body fluid tests HIV negative.
Practice Pointers
The Centers for Disease Control and Prevention (CDC) defines occupational HIV exposure as a percutaneous injury (e.g., a needlestick, cut from a sharp object) or contact of mucous membranes or nonintact skin (e.g., skin that is chapped, abraded, or affected by dermatitis) with blood, tissue, or other body fluids that are potentially infected with HIV.1 Potentially infectious fluids include cerebrospinal, synovial, pleural, peritoneal, pericardial, and amniotic fluids. Feces, nasal secretions, saliva, sputum, sweat, tears, urine, and vomit are not considered infectious unless visibly bloody. The risk of HIV transmission is approximately 0.3 percent after percutaneous exposure to infected blood and 0.9 percent after mucous membrane exposure. The risk of transmission varies with the type of exposure and infected fluid.1
The authors of this Cochrane review searched the literature from 1985 to May 2005. They found no controlled trials of postexposure prophylaxis, but found one case-control study. Participants were health care workers with occupational, percutaneous exposure to HIV-infected blood. Patients in the case group had HIV seroconversion temporally associated with the exposure and no other reported concurrent exposure to HIV. Participants in the control group remained seronegative six months after exposure.
An increased risk of HIV transmission was associated with deep injury, visible blood on the device, procedures involving a needle placed in the source patient's blood vessel, and terminal illness in the source patient. Zidovudine (Retrovir) use after exposure was associated with a lower risk of HIV transmission. Most patients took at least 1,000 mg of zidovudine per day starting within four hours of exposure.
Of 58 health care workers who received postexposure prophylaxis, 71 percent had adverse effects, including nausea (24 percent), fatigue (22 percent), emotional distress (13 percent), and headache (9 percent). Although patients who received a three-drug regimen reported more adverse effects, the drop-out rate in these patients was similar to that in patients who received fewer drugs.
The CDC recommends postexposure prophylaxis for health care workers who have occupational exposure to blood infected with HIV, and it recommends considering prophylaxis for health care workers with percutaneous injuries from sources with unknown HIV status who have risk factors or who are from settings where HIV exposure is likely.1 Prophylaxis should be initiated as soon as possible, ideally within hours, not days, of exposure. Therapy should continue for four weeks or until the source blood tests HIV negative. Selection of prophylactic medication should be determined in consultation with an expert in antiretroviral therapy and HIV transmission.1
Young TN, Arens FJ, Kennedy GE, Laurie JW, Rutherford G. Antiretroviral post-exposure prophylaxis (PEP) for occupational HIV exposure. Cochrane Database Syst Rev 2007;(1):CD002835.
If expert consultation is not immediately possible, more information on prophylactic regimens is available at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5409a1.htm and http://www.ucsf.edu/hivcntr/Hotlines/PEPline.html
Does Consuming Red Meat Increase Risk of Breast Cancer?
Results: Of the 90,659 participants, 1,021 were diagnosed with invasive premenopausal breast carcinoma. Although a high intake of red meat was weakly associated with an overall increased risk of breast cancer, there was a strong association between the intake of red meat and the risk of hormone-receptor-positive breast cancer. Consuming red meat was not associated with an increased risk of hormone-receptor-negative breast cancer. Compared with participants who ate three or fewer servings of red meat per week, women who had four to five servings per week had a relative risk of breast cancer of 1.14. Those who consumed more than 1.5 servings per day had a relative risk of 1.97.
Conclusion: Red meat intake was associated with a higher risk of hormone-receptor-positive breast cancer in premenopausal women. Moreover, a higher consumption of red meat during the study increased the risk of invasive hormone-receptor-positive breast cancer. Because few breast cancer risk factors are modifiable, the authors add that these findings have potential health implications in preventing breast cancer.
Cho E, et al. Red meat intake and risk of breast cancer among premenopausal women. Arch Intern Med November 13, 2006;166:2253-9. http://www.aafp.org/afp/20070801/tips/3.html
AHA Releases Statement on Physical Activity Interventions
Sedentary behavior is a common but preventable cause of death, and an inverse linear relationship exists between all-cause mortality and volume of physical activity. Further, regular physical activity decreases the risk of type 2 diabetes, osteoporosis, obesity, cardiovascular disease, breast cancer, depression, colon cancer, and falls in older adults. Because of these numerous health benefits, various public health guidelines have been published on the recommended volume and intensity of physical activity. Therefore, the American Heart Association (AHA) has released a summary statement on physical activity interventions, which appears in the December 12, 2006, issue of Circulation.
The AHA's aim was to provide an overview of the population-wide impact of physical activity interventions. Along with the U.S. Surgeon General, the Centers for Disease Control and Prevention, and the American College of Sports Medicine, the AHA recommends at least 30 minutes a day of at least moderate-intensity physical activity on most, and preferably all, days of the week. However, despite the known benefits of physical activity, only 32 percent of adults and 66 percent of children and adolescents actively pursue leisure-time physical activity. It is imperative that interventions be designed to promote the adoption and maintenance of active lifestyles in large numbers of the population.
In older adults, behaviorally oriented approaches have shown short-term effectiveness, but long-term maintenance is not as strong. However, even brief interventions (three to 10 minutes) in health care settings have been shown to increase physical activity in patients over a short-term follow-up. Written prescriptions as well as verbal advice may also enhance the effectiveness of interventions. However, interventions that include behavioral strategies (e.g., goal setting, self-monitoring, feedback, problem solving) and supervised exercise are more effective than advice alone.
Adults spend most of their time at work, so the workplace has been examined as a setting for physical activity interventions. Although the evidence supporting workplace interventions is mixed, stronger evidence suggests that individually tailored behavior-change programs sent through e-mail or the Internet are effective. Incentives for positive behavior that do not undermine work productivity also may be considered.
Interventions delivered through the television, the telephone, the Internet, or in print have produced short-term behavioral change among adults, and they may be effective in the longer term. Creating new opportunities for physical activity for recreational and transportation purposes (e.g., improving sidewalks, creating bike trails) may also prove to be valuable.
Research on physical activity interventions has grown, but employing these transdisciplinary efforts will be important for promoting physical activity among children and adults. The AHA notes that, to be successful, these efforts must be collaborative in theory development, hypothesis generation, study design, implementation, and analysis
http://circ.ahajournals.org/cgi/content/full/114/24/2739
Western diet linked to colon cancer recurrence
CONCLUSIONS: Higher intake of a Western dietary pattern may be associated with a higher risk of recurrence and mortality among patients with stage III colon cancer treated with surgery and adjuvant chemotherapy. Further studies are needed to delineate which components of such a diet show the strongest association.
Meyerhardt JA, et al Association of dietary patterns with cancer recurrence and survival in patients with stage III colon cancer. JAMA. 2007 Aug 15;298(7):754-64
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17699009
Herbal and Dietary Supplements for Treatment of Anxiety Disorders
Use of complementary and alternative medicine has increased over the past decade. A variety of studies have suggested that this use is greater in persons with symptoms or diagnoses of anxiety and depression. Data support the effectiveness of some popular herbal remedies and dietary supplements; in some of these products, particularly kava, the potential for benefit seems greater than that for harm with short-term use in patients with mild to moderate anxiety. Inositol has been found to have modest effects in patients with panic disorder or obsessive-compulsive disorder. Physicians should not encourage the use of St. John's wort, valerian, Sympathyl, or passionflower for the treatment of anxiety based on small or inconsistent effects in small studies. Although the evidence varies depending on the supplement and the anxiety disorder, physicians can collaborate with patients in developing dietary supplement strategies that minimize risks and maximize benefits. Am Fam Physician 2007;76:549-56.
http://www.aafp.org/afp/20070815/549.html
Fibromyalgia
Fibromyalgia is an idiopathic, chronic, nonarticular pain syndrome with generalized tender points. It is a multisystem disease characterized by sleep disturbance, fatigue, headache, morning stiffness, paresthesias, and anxiety. Nearly 2 percent of the general population in the United States suffers from fibromyalgia, with females of middle age being at increased risk. The diagnosis is primarily based on the presence of widespread pain for a period of at least three months and the presence of 11 tender points among 18 specific anatomic sites. There are certain comorbid conditions that overlap with, and also may be confused with, fibromyalgia. Recently there has been improved recognition and understanding of fibromyalgia. Although there are no guidelines for treatment, there is evidence that a multidimensional approach with patient education, cognitive behavior therapy, exercise, physical therapy, and pharmacologic therapy can be effective. Am Fam Physician 2007;76:247-54.
http://www.aafp.org/afp/20070715/247.html
Home Monitoring of Glucose and Blood Pressure (see Patient Education)
Home monitoring of blood glucose and blood pressure levels can provide patients and physicians with valuable information in the management of diabetes mellitus and hypertension. Home monitoring allows patients to play an active role in their care and may improve treatment adherence and clinical outcomes. Glucose meters currently on the market produce results within 15 percent of serum blood glucose readings and offer a variety of features. Although the data are somewhat conflicting, home glucose monitoring has been associated with improved glycemic control and reduced long-term complications from diabetes. These effects are more pronounced in patients who take insulin. Home blood pressure values predict target organ damage and cardiovascular outcomes better than values obtained in the office. Home blood pressure measurements are also effective at detecting borderline hypertension and monitoring the effectiveness of antihypertensive drugs. Validated arm cuffs are the preferred blood pressure devices for home use. Information from home monitoring should always be used in conjunction with that from regular office visits and other data to make appropriate therapeutic decisions. Am Fam Physician 2007;76:255-60, 261, 262.
http://www.aafp.org/afp/20070715/255.html
Cytochrome P450 Metabolism on Drug Response, Interactions, and Adverse Effects
Cytochrome P450 enzymes are essential for the metabolism of many medications. Although this class has more than 50 enzymes, six of them metabolize 90 percent of drugs, with the two most significant enzymes being CYP3A4 and CYP2D6. Genetic variability (polymorphism) in these enzymes may influence a patient's response to commonly prescribed drug classes, including beta blockers and antidepressants. Cytochrome P450 enzymes can be inhibited or induced by drugs, resulting in clinically significant drug-drug interactions that can cause unanticipated adverse reactions or therapeutic failures. Interactions with warfarin, antidepressants, antiepileptic drugs, and statins often involve the cytochrome P450 enzymes. Knowledge of the most important drugs metabolized by cytochrome P450 enzymes, as well as the most potent inhibiting and inducing drugs, can help minimize the possibility of adverse drug reactions and interactions. Although genotype tests can determine if a patient has a specific enzyme polymorphism, it has not been determined if routine use of these tests will improve outcomes. Am Fam Physician 2007;76:391-6
http://www.aafp.org/afp/20070801/391.html
From Your Colleagues ‹ Previous | Next › Features
OB/GYN
Dr. Neil Murphy is the Obstetrics and Gynecology Chief Clinical Consultant (OB/GYN C.C.C.). Dr. Murphy is very interested in establishing a dialogue and/or networking with anyone involved in women's health or maternal child health, especially as it applies to Native or indigenous peoples around the world. Please don't hesitate to contact him by e-mail or phone at 907-729-3154.
