From Medscape Medical News
News Author: Laurie Barclay, MD
CME Author: Désirée Lie, MD, MSEd
April 17, 2009 — Novel risk factors for sudden infant death syndrome (SIDS) include sleeping outside the parental home, in the living room, or prone on a sheepskin, according to the results of a population-based, case-control study reported in the April issue of Pediatrics.
"A number of case-control studies in the late 1980s and early 1990s identified prone sleeping as a major risk factor for SIDS," write Mechtild M. Vennemann, MD, PD, MPH, from the University of Münster in Münster, Germany, and colleagues from the German Sudden Infant Death Syndrome Study Group.
"Following advice to put infants only on their back for sleeping, the rates in all developed countries for SIDS have decreased dramatically."
The purpose of this study, which took place from 1998 to 2001 in Germany, was to identify risk factors for SIDS in the sleep environment for a population in which few infants sleep prone because of widespread education campaigns.
During the study period, there were 333 SIDS cases and 998 matched controls. Only 4.1% of the infants were placed in a prone position to sleep, but the risk for SIDS was increased in those infants. The risk was very high in those infants who were unaccustomed to sleeping prone or who were turned to prone.
Factors associated with an increased risk for SIDS were bed sharing, particularly for infants younger than 13 weeks; use of duvets; sleeping prone on a sheepskin; sleeping in the house of a friend or a relative vs sleeping in the parental home; and sleeping in the living room vs in the parental bedroom.
Pacifier use during the last sleep was associated with a significantly decreased risk for SIDS.
Limitations of this study include small numbers of cases in groups with some of the novel risk factors.
Pediatrics. 2009;123:1162-1170.
Clinical Context
SIDS is the leading cause of death in infants younger than 1 year in developed countries. Sleeping in a prone position has been identified as a significant risk, leading to the Back to Sleep campaign, which resulted in a reduction in SIDS mortality rates in many countries. Since that campaign was initiated, other risk factors such as sleep environment have not been fully examined.
This is a population-based case-control study conducted in a part of Germany with more than 50% of its live births to determine risk factors associated with SIDS during a 3-year period (1998-2001).
Thursday, December 31, 2009
Wednesday, December 30, 2009
Clinical Risk Factors May Predict Depression During Pregnancy
From Medscape Medical News
Laurie Barclay, MD
December 30, 2009 — Clinical risk factors that may be easily identified during routine obstetric examination may help predict depression during pregnancy, according to the results of a review of 57 studies reported in the January 2010 issue of the American Journal of Obstetrics & Gynecology.
"Prenatal care providers are uniquely suited to address antepartum depression," write Christie A. Lancaster, MD, MS, from the University of Michigan in Ann Arbor, and colleagues. "First of all, providers have already captured their target population, because most women will use obstetric services at some point during their pregnancies. Providers also have multiple opportunities to assess, treat, and follow-up with patients, as obstetric visits are recurring during a several-month span."
Based on an English-language search of the literature from 1980 through 2008, the reviewers aimed to examine risk factors for antepartum depressive symptoms that could be detected in routine obstetric care. Selection criteria were studies evaluating the association between antepartum depressive symptoms and 1 or more risk factors. Two masked, independent reviewers assessed the overall trend of evidence for each potential risk factor.
There were 57 studies identified that met selection criteria.
Factors associated with a greater likelihood of antepartum depressive symptoms in bivariate analyses were maternal anxiety, life stress, history of depression, lack of social support, unintended pregnancy, Medicaid insurance, domestic violence, lower income, lower education, smoking, single status, and poor relationship quality.
In multivariate analyses, factors that continued to show a significant association with depressive symptoms were life stress, lack of social support, and domestic violence.
"Our results demonstrate several correlates that are consistently related to an increased risk of depressive symptoms during pregnancy," the review authors write.
"Our results are important for practicing clinicians because they identify risk factors that can be assessed during routine obstetric care," they add.
"For current practice, providers should especially consider the likelihood of depressive symptoms in women with these risk factors, such as report of domestic violence or a lack of social support during pregnancy."
Limitations of the studies reviewed include significant heterogeneity among studies; lack of diagnostic assessments for depression; use of different cutoff points on screening tools; limited sample size; and observational, cross-sectional design in most studies. Limitations of the data analysis include possible publication bias, review of only studies published in English, and subjective assessment of quality.
"Future work should address how well our current obstetric screening forms capture these constructs and how we can use risk factor identification to improve screening efficiency and accuracy and to enhance our clinical assessments during pregnancy," the study authors conclude.
"For example, future research studies could evaluate the likelihood of major depressive disorder in women with positive depression screens that do or do not have these additional risk factors."
The Robert Wood Johnson Clinical Scholars Program supported this study.
Am J Obstet Gynecol. 2010;202:5-14.
Laurie Barclay, MD
December 30, 2009 — Clinical risk factors that may be easily identified during routine obstetric examination may help predict depression during pregnancy, according to the results of a review of 57 studies reported in the January 2010 issue of the American Journal of Obstetrics & Gynecology.
"Prenatal care providers are uniquely suited to address antepartum depression," write Christie A. Lancaster, MD, MS, from the University of Michigan in Ann Arbor, and colleagues. "First of all, providers have already captured their target population, because most women will use obstetric services at some point during their pregnancies. Providers also have multiple opportunities to assess, treat, and follow-up with patients, as obstetric visits are recurring during a several-month span."
Based on an English-language search of the literature from 1980 through 2008, the reviewers aimed to examine risk factors for antepartum depressive symptoms that could be detected in routine obstetric care. Selection criteria were studies evaluating the association between antepartum depressive symptoms and 1 or more risk factors. Two masked, independent reviewers assessed the overall trend of evidence for each potential risk factor.
There were 57 studies identified that met selection criteria.
Factors associated with a greater likelihood of antepartum depressive symptoms in bivariate analyses were maternal anxiety, life stress, history of depression, lack of social support, unintended pregnancy, Medicaid insurance, domestic violence, lower income, lower education, smoking, single status, and poor relationship quality.
In multivariate analyses, factors that continued to show a significant association with depressive symptoms were life stress, lack of social support, and domestic violence.
"Our results demonstrate several correlates that are consistently related to an increased risk of depressive symptoms during pregnancy," the review authors write.
"Our results are important for practicing clinicians because they identify risk factors that can be assessed during routine obstetric care," they add.
"For current practice, providers should especially consider the likelihood of depressive symptoms in women with these risk factors, such as report of domestic violence or a lack of social support during pregnancy."
Limitations of the studies reviewed include significant heterogeneity among studies; lack of diagnostic assessments for depression; use of different cutoff points on screening tools; limited sample size; and observational, cross-sectional design in most studies. Limitations of the data analysis include possible publication bias, review of only studies published in English, and subjective assessment of quality.
"Future work should address how well our current obstetric screening forms capture these constructs and how we can use risk factor identification to improve screening efficiency and accuracy and to enhance our clinical assessments during pregnancy," the study authors conclude.
"For example, future research studies could evaluate the likelihood of major depressive disorder in women with positive depression screens that do or do not have these additional risk factors."
The Robert Wood Johnson Clinical Scholars Program supported this study.
Am J Obstet Gynecol. 2010;202:5-14.
Saturday, December 26, 2009
Antiviral Medications in Pregnancy
From Centers for Disease Control and Prevention (CDC): Expert Commentary
CDC Commentary: 2009 H1N1
Sonja A. Rasmussen, MD
http://www.medscape.com/viewarticle/711570
CDC Commentary: 2009 H1N1
Sonja A. Rasmussen, MD
http://www.medscape.com/viewarticle/711570
Friday, December 18, 2009
Breast-Feeding May Protect the Mother From Metabolic Syndrome CME
From MedscapeCME Clinical Briefs
News Author: Laurie Barclay, MD
CME Author: Charles P. Vega, MD
December 17, 2009 — Breast-feeding may protect the nursing mother from the metabolic syndrome, according to the results of a prospective, observational cohort study reported in the December 3 Online First issue of Diabetes.
"The Metabolic Syndrome is a clustering of risk factors related to obesity and metabolism that strongly predicts future diabetes and possibly, coronary heart disease during midlife and early death for women," lead author Erica Gunderson, PhD, from Kaiser Permanente's Division of Research in Oakland, California, said in a news release. "Because the Metabolic Syndrome affects about 18 to 37 percent of U.S. women between ages 20-59, the childbearing years may be a vulnerable period for its development. Postpartum screening of risk factors for diabetes and heart disease may offer an important opportunity for primary prevention."
The multicenter, population-based, US cohort used for this study consisted of 1399 nulliparous women (39% black, aged 18 - 30 years) enrolled in the ongoing Coronary Artery Risk Development in Young Adults Study. Participants were free of the metabolic syndrome at baseline from 1985 to 1986 and before subsequent pregnancies. At 7, 10, 15, and/or 20 years after baseline, participants were re-examined, and National Cholesterol Education Program criteria were used to identify incident cases of metabolic syndrome.
Of 704 parous women, 84 had gestational diabetes and 620 did not. During 9993 person-years, there were 120 incident cases of metabolic syndrome, yielding an overall crude incidence rate of 12.0 per 1000 person-years (10.8 for nongestational diabetes and 22.1 for gestational diabetes). Increasing duration of lactation was associated with lower crude incidence rates of metabolic syndrome from 0 to 1 month through 9 months or more of breast-feeding (P < .001).
"The findings indicate that breastfeeding a child may have lasting favorable effects on a woman's risk factors for later developing diabetes or heart disease," Dr. Gunderson said.
Risk reductions associated with longer duration of lactation were greater among women with gestational diabetes (fully adjusted relative hazards range, 0.14 - 0.56; P = .03) vs those without gestational diabetes (fully adjusted relative hazards range, 0.44 - 0.61; P = .03).
Limitations of this study include observational design and possible residual confounding.
"Longer duration of lactation was associated with lower incidence of the metabolic syndrome years post-weaning among women with a history of GDM [gestational diabetes mellitus] and without GDM controlling for preconception measurements, BMI [body mass index], socio-demographic and lifestyle traits," the study authors conclude. "Further investigation is needed to elucidate the mechanisms through which lactation may influence women's cardiometabolic risk profiles, and whether lifestyle modifications, including lactation duration, may affect development of coronary heart disease and type 2 diabetes, particularly among high-risk groups such as women with a history of GDM."
The National Institutes of Health (the National Heart, Lung, and Blood Institute; the National Institute of Diabetes, Digestive and Kidney Diseases) and the American Diabetes Association supported this study. The study authors have disclosed no relevant financial relationships.
Diabetes. Published online December 3, 2009. Abstract
News Author: Laurie Barclay, MD
CME Author: Charles P. Vega, MD
December 17, 2009 — Breast-feeding may protect the nursing mother from the metabolic syndrome, according to the results of a prospective, observational cohort study reported in the December 3 Online First issue of Diabetes.
"The Metabolic Syndrome is a clustering of risk factors related to obesity and metabolism that strongly predicts future diabetes and possibly, coronary heart disease during midlife and early death for women," lead author Erica Gunderson, PhD, from Kaiser Permanente's Division of Research in Oakland, California, said in a news release. "Because the Metabolic Syndrome affects about 18 to 37 percent of U.S. women between ages 20-59, the childbearing years may be a vulnerable period for its development. Postpartum screening of risk factors for diabetes and heart disease may offer an important opportunity for primary prevention."
The multicenter, population-based, US cohort used for this study consisted of 1399 nulliparous women (39% black, aged 18 - 30 years) enrolled in the ongoing Coronary Artery Risk Development in Young Adults Study. Participants were free of the metabolic syndrome at baseline from 1985 to 1986 and before subsequent pregnancies. At 7, 10, 15, and/or 20 years after baseline, participants were re-examined, and National Cholesterol Education Program criteria were used to identify incident cases of metabolic syndrome.
Of 704 parous women, 84 had gestational diabetes and 620 did not. During 9993 person-years, there were 120 incident cases of metabolic syndrome, yielding an overall crude incidence rate of 12.0 per 1000 person-years (10.8 for nongestational diabetes and 22.1 for gestational diabetes). Increasing duration of lactation was associated with lower crude incidence rates of metabolic syndrome from 0 to 1 month through 9 months or more of breast-feeding (P < .001).
"The findings indicate that breastfeeding a child may have lasting favorable effects on a woman's risk factors for later developing diabetes or heart disease," Dr. Gunderson said.
Risk reductions associated with longer duration of lactation were greater among women with gestational diabetes (fully adjusted relative hazards range, 0.14 - 0.56; P = .03) vs those without gestational diabetes (fully adjusted relative hazards range, 0.44 - 0.61; P = .03).
Limitations of this study include observational design and possible residual confounding.
"Longer duration of lactation was associated with lower incidence of the metabolic syndrome years post-weaning among women with a history of GDM [gestational diabetes mellitus] and without GDM controlling for preconception measurements, BMI [body mass index], socio-demographic and lifestyle traits," the study authors conclude. "Further investigation is needed to elucidate the mechanisms through which lactation may influence women's cardiometabolic risk profiles, and whether lifestyle modifications, including lactation duration, may affect development of coronary heart disease and type 2 diabetes, particularly among high-risk groups such as women with a history of GDM."
The National Institutes of Health (the National Heart, Lung, and Blood Institute; the National Institute of Diabetes, Digestive and Kidney Diseases) and the American Diabetes Association supported this study. The study authors have disclosed no relevant financial relationships.
Diabetes. Published online December 3, 2009. Abstract
Tuesday, November 24, 2009
Govt issues record 2.1M recall for dropside cribs
By JENNIFER C. KERR, Associated Press
WASHINGTON – More than 2.1 million drop-side cribs by Stork Craft Manufacturing are being recalled, the biggest crib recall in U.S history, following reports of four infant suffocations.
The Consumer Product Safety Commission said late Monday the recall involves 1.2 million cribs in the United States and almost 1 million in Canada, where Stork Craft is based. Sales of the cribs being recalled go back to 1993.
Nearly 150,000 of the cribs carry the Fisher-Price logo.
The CPSC said it is aware of four infants who suffocated in the drop-side cribs, which have a side that moves up and down to allow parents to lift children from the cribs more easily. The agency also said there have been 110 incidents of drop-sides detaching from the cribs.
The Stork Craft cribs have had problems with their hardware, which can break, deform or become missing after years. CPSC said there can also be problems with assembly mistakes by the crib owner. These problems can cause the drop-side to detach, creating a dangerous space between the drop-side and the crib mattress, where a child can become trapped.
The commission is urging parents to stop using the cribs until receiving a free repair kit from Stork Craft. The kit will convert the drop-side into a fixed side.
The cribs, which were manufactured and distributed between January 1993 and October 2009, were sold at major retailers including BJ's Wholesale Club, Sears and Wal-Mart stores and online through Target and Costco. They sold for between $100 and $400, and were made in Canada, China and Indonesia.
Calls to Stork Craft were not immediately returned.
This is the second big recall this year for the company. It recalled about 500,000 cribs in January because of problems with the metal brackets that support the mattress. Some of the same models in the earlier recall were also part of Monday's announcement, CPSC said.
Consumer advocates have complained for years about drop-side cribs. More than 5 million of them have been recalled over the past two years alone — recalls that were associated with the deaths of a dozen young children.
ASTM International, an organization that sets voluntary industry safety standards for everything from toys to the steel used in commercial buildings, approved a new standard last week that requires four immovable, or fixed, sides for full-size cribs — essentially eliminating the manufacture of drop-side cribs.
CPSC is also considering new rules for making cribs safer and could adopt the ASTM voluntary standard as a mandatory one, outright banning the cribs.
Nancy Cowles, executive director of Chicago-based Kids In Danger, said the agency must include more rigorous testing for crib durability. "Parents should be able to trust that their child is safe in their crib," said Cowles.
Toys"R"Us started phasing out drop-side cribs earlier this year and will no longer carry them next month.
In the Stork Craft recall, the manufacture date, model number, crib name, country of origin, and the firm's name, address and contact information are located on the assembly instruction sheet attached to the mattress support board. The firm's insignia "storkcraft baby" or "storkling" is inscribed on the drop-side teething rail of some cribs.
Consumers can contact the company, 877-274-0277, to order the free repair kit, or log on to http://www.storkcraft.com.
WASHINGTON – More than 2.1 million drop-side cribs by Stork Craft Manufacturing are being recalled, the biggest crib recall in U.S history, following reports of four infant suffocations.
The Consumer Product Safety Commission said late Monday the recall involves 1.2 million cribs in the United States and almost 1 million in Canada, where Stork Craft is based. Sales of the cribs being recalled go back to 1993.
Nearly 150,000 of the cribs carry the Fisher-Price logo.
The CPSC said it is aware of four infants who suffocated in the drop-side cribs, which have a side that moves up and down to allow parents to lift children from the cribs more easily. The agency also said there have been 110 incidents of drop-sides detaching from the cribs.
The Stork Craft cribs have had problems with their hardware, which can break, deform or become missing after years. CPSC said there can also be problems with assembly mistakes by the crib owner. These problems can cause the drop-side to detach, creating a dangerous space between the drop-side and the crib mattress, where a child can become trapped.
The commission is urging parents to stop using the cribs until receiving a free repair kit from Stork Craft. The kit will convert the drop-side into a fixed side.
The cribs, which were manufactured and distributed between January 1993 and October 2009, were sold at major retailers including BJ's Wholesale Club, Sears and Wal-Mart stores and online through Target and Costco. They sold for between $100 and $400, and were made in Canada, China and Indonesia.
Calls to Stork Craft were not immediately returned.
This is the second big recall this year for the company. It recalled about 500,000 cribs in January because of problems with the metal brackets that support the mattress. Some of the same models in the earlier recall were also part of Monday's announcement, CPSC said.
Consumer advocates have complained for years about drop-side cribs. More than 5 million of them have been recalled over the past two years alone — recalls that were associated with the deaths of a dozen young children.
ASTM International, an organization that sets voluntary industry safety standards for everything from toys to the steel used in commercial buildings, approved a new standard last week that requires four immovable, or fixed, sides for full-size cribs — essentially eliminating the manufacture of drop-side cribs.
CPSC is also considering new rules for making cribs safer and could adopt the ASTM voluntary standard as a mandatory one, outright banning the cribs.
Nancy Cowles, executive director of Chicago-based Kids In Danger, said the agency must include more rigorous testing for crib durability. "Parents should be able to trust that their child is safe in their crib," said Cowles.
Toys"R"Us started phasing out drop-side cribs earlier this year and will no longer carry them next month.
In the Stork Craft recall, the manufacture date, model number, crib name, country of origin, and the firm's name, address and contact information are located on the assembly instruction sheet attached to the mattress support board. The firm's insignia "storkcraft baby" or "storkling" is inscribed on the drop-side teething rail of some cribs.
Consumers can contact the company, 877-274-0277, to order the free repair kit, or log on to http://www.storkcraft.com.
Sunday, November 22, 2009
Pain Control Recommended for Newborns
From Medscape Medical News CME
News Author: Laurie Barclay, MD
CME Author: Penny Murata, MD
November 11, 2009 — Feeding and breast-feeding newborns are found to be the most effective methods of pain relief during heel-lancing, according to the results of a prospective study reported in the November issue of Pediatrics.
"Pain experience can alter clinical outcome, brain development, and subsequent behavior in newborns, primarily in preterm infants," write Amir Weissman, MD, from Technion-Israel Institute of Technology in Haifa, Israel, and colleagues. "The aims of this study were (1) to evaluate several simple, commonly used methods for pain control in newborns and (2) to evaluate the concordance between behavioral and autonomic cardiac reactivity to pain in term neonates during heel-lancing."
During heel-lancing for routine neonatal screening of phenylketonuria and hypothyroidism, 180 term newborn infants were randomly selected to 1 of 6 groups: (1) control (no intervention for pain relief); (2) sucking without feeding; (3) holding by mother; (4) ingestion of oral glucose solution; (5) feeding with oral formula; or (6) breast-feeding. Response to pain was assessed with the Neonatal Facial Coding System score; duration of crying; and autonomic variables determined from spectral analysis of heart rate variability before, during, and after heel-lancing.
Compared with newborns in any of the 5 intervention groups, those in the control group with no pain intervention had the greatest levels of pain manifestation. Breast-feeding or feeding with oral formula appeared to be most effective vs all other groups, based on the lowest increase in heart rate (21 and 23 beats per minute, respectively, vs 36 beats per minute; P < .01), neonatal facial score (2.3 and 2.9, respectively, vs 7.1; P < .001), cry duration (5 and 13 seconds, respectively, vs 49 seconds; P < .001), and the lowest decrease in parasympathetic tone (–2 and –2.4, respectively, vs 1.2; P < .02).
"Any method of pain control is better than none," the study authors write. "Feeding and breast-feeding during heel-lancing were found to be the most effective methods of pain relief."
Limitations of this study include low sensitivity of the pain assessment methods, large variability of newborn response to painful stimuli, and the subjective nature of interpreting these data.
"Neonatal pain prevention is the expectation of the parents and should be the goal of the medical staff; therefore, family members or staff may be recruited to help during these procedures, and nursing mothers should be encouraged to breastfeed during the procedure," the study authors conclude. "If family members believe that they cannot withstand the procedure, hear their infant crying, or see the heel-lancing, then bottle-feeding seems to be a good alternative."
The study authors have disclosed no relevant financial relationships.
Pediatrics. 2009;124:e921-e926.
News Author: Laurie Barclay, MD
CME Author: Penny Murata, MD
November 11, 2009 — Feeding and breast-feeding newborns are found to be the most effective methods of pain relief during heel-lancing, according to the results of a prospective study reported in the November issue of Pediatrics.
"Pain experience can alter clinical outcome, brain development, and subsequent behavior in newborns, primarily in preterm infants," write Amir Weissman, MD, from Technion-Israel Institute of Technology in Haifa, Israel, and colleagues. "The aims of this study were (1) to evaluate several simple, commonly used methods for pain control in newborns and (2) to evaluate the concordance between behavioral and autonomic cardiac reactivity to pain in term neonates during heel-lancing."
During heel-lancing for routine neonatal screening of phenylketonuria and hypothyroidism, 180 term newborn infants were randomly selected to 1 of 6 groups: (1) control (no intervention for pain relief); (2) sucking without feeding; (3) holding by mother; (4) ingestion of oral glucose solution; (5) feeding with oral formula; or (6) breast-feeding. Response to pain was assessed with the Neonatal Facial Coding System score; duration of crying; and autonomic variables determined from spectral analysis of heart rate variability before, during, and after heel-lancing.
Compared with newborns in any of the 5 intervention groups, those in the control group with no pain intervention had the greatest levels of pain manifestation. Breast-feeding or feeding with oral formula appeared to be most effective vs all other groups, based on the lowest increase in heart rate (21 and 23 beats per minute, respectively, vs 36 beats per minute; P < .01), neonatal facial score (2.3 and 2.9, respectively, vs 7.1; P < .001), cry duration (5 and 13 seconds, respectively, vs 49 seconds; P < .001), and the lowest decrease in parasympathetic tone (–2 and –2.4, respectively, vs 1.2; P < .02).
"Any method of pain control is better than none," the study authors write. "Feeding and breast-feeding during heel-lancing were found to be the most effective methods of pain relief."
Limitations of this study include low sensitivity of the pain assessment methods, large variability of newborn response to painful stimuli, and the subjective nature of interpreting these data.
"Neonatal pain prevention is the expectation of the parents and should be the goal of the medical staff; therefore, family members or staff may be recruited to help during these procedures, and nursing mothers should be encouraged to breastfeed during the procedure," the study authors conclude. "If family members believe that they cannot withstand the procedure, hear their infant crying, or see the heel-lancing, then bottle-feeding seems to be a good alternative."
The study authors have disclosed no relevant financial relationships.
Pediatrics. 2009;124:e921-e926.
Bottled Water a Risk Factor for Early Childhood Caries
From Medscape Medical News
Crina Frincu-Mallos, PhD
November 18, 2009 (Philadelphia, Pennsylvania) — Drinking bottled water was the only modifiable risk factor related to early childhood caries (ECC) in a retrospective investigation presented here at the American Public Health Association 137th Annual Meeting by Rosalia A. Mendoza, MD, MPH, assistant professor in the Department of Family and Community Medicine at the University of California at San Francisco.
The study was prompted by the fact that 62% of children referred to an oral health clinic in the San Francisco area had caries by the age of 2 years. More than half of them drank bottled water, from which fluoride is usually removed, together with impurities, by reverse osmosis.
Currently, 69% of the American population lives in communities served by fluoridated public water supply systems, according to the Centers for Disease Control and Prevention.
"There appears to be a protective effect of drinking the fluoridated tap water over drinking bottled water" (odds ratio [OR], 0.59; P = .07), Dr. Mendoza reported.
In their retrospective analysis, Dr. Mendoza and colleagues aimed to identify risks and protective factors associated with untreated ECC at an urban San Francisco Family Health Center, which serves more than 8000 children 5 years and younger annually. ECC seem to be more prevalent among African American and Latino children in the San Francisco area.
Living in Fluoridated Communities Does Not Translate Into Fluoride Exposure
Between June 2006 and April 2009, 239 children (114 girls and 125 boys), 70% of whom were Latino, were referred to the oral health screening clinic at a San Francisco Family Health Center by family medicine physicians. The physicians had identified cavitated and noncavitated caries. They also interviewed parents about the oral health status of the child and the child's behavior. The investigators looked for ECC risk factors, such as more than 3 sugary snacks or drinks consumed per day, and ECC protective factors, such as whether the parent sees a dentist regularly, the child's teeth are brushed with fluoride toothpaste, and the child drinks tap water.
Drinking bottled water was "the only associated and modifiable risk factor" that the investigators found.
Family medicine physicians have an "important role during the early screening and referral to dentists," said Dr. Mendoza in an interview with Medscape Public Health & Prevention. "Frequent visits in the first and second year of life, following the vaccine schedule for preventive care," can be used to incorporate early regular oral care.
"We are very successful [in] detecting some of the modifiable risk behaviors and protective behaviors," said Dr. Mendoza. For instance, bottled water vs tap water preferences and practices are currently not part of state surveys.
Interestingly, "there also appears to be an association between a dental home and caries prevalence in this community," Dr. Mendoza observed.
At-Home Water Filtration Recommended
Dr. Mendoza and colleagues are trying to assess how well immigrant families understand the importance of fluoride. "Do they know that fluoride is part of their tap water, the municipal water, which is free?" she said. Her team wants to find out what the barriers are "that we need to overcome in our health promotion to facilitate greater tap water consumption in this community."
Most families believed that milk or water is a healthier choice than juice, she said, but "they chose to use bottled water, not water from the tap, to add to formula milk or to aguas frescas."
At the core of the practice of giving bottled water to children seems to be the perception that "the water [in the United States] is not safe. If you do live in a rental property, if you know there is sediment in the tap water or if you don't like the taste, how do you address that?" asked Dr. Mendoza: "You use a filter!"
Need for Monitoring of Tap Water Drinking Habits
Next, the researchers are going to "push the importance of bottled water preferences and practice into our national and state surveys," said Dr. Mendoza.
"In our local community, we are going to be looking at ways that we can do successful public health promotion around these identified areas in immigrant practices and beliefs around bottled water," she added.
"It was interesting to see how family physicians can deliver the message that fluoridated water can help protect teeth from caries," said Jeffrey Johnston, public health analyst in the Office of Operations, Health Resources and Services Administration in Rockville, Maryland, who attended the meeting. "Hopefully, now we can implement some service-delivery changes," he concluded.
Dr. Mendoza and Mr. Johnston have disclosed no relevant financial relationships.
American Public Health Association (APHA) 137th Annual Meeting: Abstract 204297. Presented November 8, 2009.
Crina Frincu-Mallos, PhD
November 18, 2009 (Philadelphia, Pennsylvania) — Drinking bottled water was the only modifiable risk factor related to early childhood caries (ECC) in a retrospective investigation presented here at the American Public Health Association 137th Annual Meeting by Rosalia A. Mendoza, MD, MPH, assistant professor in the Department of Family and Community Medicine at the University of California at San Francisco.
The study was prompted by the fact that 62% of children referred to an oral health clinic in the San Francisco area had caries by the age of 2 years. More than half of them drank bottled water, from which fluoride is usually removed, together with impurities, by reverse osmosis.
Currently, 69% of the American population lives in communities served by fluoridated public water supply systems, according to the Centers for Disease Control and Prevention.
"There appears to be a protective effect of drinking the fluoridated tap water over drinking bottled water" (odds ratio [OR], 0.59; P = .07), Dr. Mendoza reported.
In their retrospective analysis, Dr. Mendoza and colleagues aimed to identify risks and protective factors associated with untreated ECC at an urban San Francisco Family Health Center, which serves more than 8000 children 5 years and younger annually. ECC seem to be more prevalent among African American and Latino children in the San Francisco area.
Living in Fluoridated Communities Does Not Translate Into Fluoride Exposure
Between June 2006 and April 2009, 239 children (114 girls and 125 boys), 70% of whom were Latino, were referred to the oral health screening clinic at a San Francisco Family Health Center by family medicine physicians. The physicians had identified cavitated and noncavitated caries. They also interviewed parents about the oral health status of the child and the child's behavior. The investigators looked for ECC risk factors, such as more than 3 sugary snacks or drinks consumed per day, and ECC protective factors, such as whether the parent sees a dentist regularly, the child's teeth are brushed with fluoride toothpaste, and the child drinks tap water.
Drinking bottled water was "the only associated and modifiable risk factor" that the investigators found.
Family medicine physicians have an "important role during the early screening and referral to dentists," said Dr. Mendoza in an interview with Medscape Public Health & Prevention. "Frequent visits in the first and second year of life, following the vaccine schedule for preventive care," can be used to incorporate early regular oral care.
"We are very successful [in] detecting some of the modifiable risk behaviors and protective behaviors," said Dr. Mendoza. For instance, bottled water vs tap water preferences and practices are currently not part of state surveys.
Interestingly, "there also appears to be an association between a dental home and caries prevalence in this community," Dr. Mendoza observed.
At-Home Water Filtration Recommended
Dr. Mendoza and colleagues are trying to assess how well immigrant families understand the importance of fluoride. "Do they know that fluoride is part of their tap water, the municipal water, which is free?" she said. Her team wants to find out what the barriers are "that we need to overcome in our health promotion to facilitate greater tap water consumption in this community."
Most families believed that milk or water is a healthier choice than juice, she said, but "they chose to use bottled water, not water from the tap, to add to formula milk or to aguas frescas."
At the core of the practice of giving bottled water to children seems to be the perception that "the water [in the United States] is not safe. If you do live in a rental property, if you know there is sediment in the tap water or if you don't like the taste, how do you address that?" asked Dr. Mendoza: "You use a filter!"
Need for Monitoring of Tap Water Drinking Habits
Next, the researchers are going to "push the importance of bottled water preferences and practice into our national and state surveys," said Dr. Mendoza.
"In our local community, we are going to be looking at ways that we can do successful public health promotion around these identified areas in immigrant practices and beliefs around bottled water," she added.
"It was interesting to see how family physicians can deliver the message that fluoridated water can help protect teeth from caries," said Jeffrey Johnston, public health analyst in the Office of Operations, Health Resources and Services Administration in Rockville, Maryland, who attended the meeting. "Hopefully, now we can implement some service-delivery changes," he concluded.
Dr. Mendoza and Mr. Johnston have disclosed no relevant financial relationships.
American Public Health Association (APHA) 137th Annual Meeting: Abstract 204297. Presented November 8, 2009.
Thursday, November 19, 2009
New Breast Cancer Screening Guidelines Opposed by Societies
From Medscape Medical News
Laurie Barclay, MD
November 19, 2009 — Several professional organizations and expert groups have voiced their objections to new recommendations for breast cancer screening issued by the US Preventive Services Task Force (USPSTF) and published in the November 17 issue of the Annals of Internal Medicine.
"[The American Cancer Society] continues to recommend [mammography] screening annually for women 40 to 49 years of age," Victor G. Vogel, MD, MHS, FACP, national vice president for research at the American Cancer Society (ACS) in Atlanta, Georgia, told Medscape Medical News. "Clinicians should recognize that very few agencies, including the ACS, are altering their screening guidelines based on the USPSTF modeling results, which simply reanalyze previously published data."
Based on an evidence review, the updated USPSTF guidelines recommend against routine mammography screening for women before age 50 years, suggest that screening end at age 74 years, and recommend changing the screening interval from 1 year to 2 years.
In addition to the ACS, the American College of Radiology (ACR), the American College of Obstetricians and Gynecologists (ACOG), and several other expert groups recommend that clinicians and patients continue to follow earlier guidelines (see Table below for a detailed comparison with ACS guidelines). The ACS recommendations call for annual mammograms starting at age 40 years and continuing for as long as a woman is in good health; ACS has no specific upper age at which mammography screening should be discontinued. The society suggests that the decision to stop regular mammography screening should be individualized based on patient-specific, potential benefits and risks of screening within the context of overall health and estimated lifespan.
ACOG's recommendations are similar, except that mammography is recommended every 1 to 2 years from ages 40 to 49 years.
"We would urge primary care clinicians to continue to observe the ACR and ACS mammography guidelines and to talk with their patients regarding the benefits of mammography and any concerns their patients may have," M. Shawn Farley, ACR's director of public affairs, told Medscape Medical News.
Supporting Evidence
Dr. Vogel cited several lines of evidence supporting the ACS position, including evidence that early detection of breast cancer saves lives or improves survival (JAMA. 1995;273[2]:149–154).
"If the USTSF recommendations are adopted as policy — particularly if Medicare and private insurers try to use them as an excuse to cut cost — many women will die unnecessarily from breast cancer," Mr. Farley said. "The treatment costs associated with the disease may rise because cancers would be found at a more advanced stage. For those women diagnosed at a later stage, they may experience more invasive techniques to remove the cancers because the disease is more advanced."
http://www.medscape.com/viewarticle/712720?sssdmh=dm1.558850&src=nldne&uac=71630FV
Laurie Barclay, MD
November 19, 2009 — Several professional organizations and expert groups have voiced their objections to new recommendations for breast cancer screening issued by the US Preventive Services Task Force (USPSTF) and published in the November 17 issue of the Annals of Internal Medicine.
"[The American Cancer Society] continues to recommend [mammography] screening annually for women 40 to 49 years of age," Victor G. Vogel, MD, MHS, FACP, national vice president for research at the American Cancer Society (ACS) in Atlanta, Georgia, told Medscape Medical News. "Clinicians should recognize that very few agencies, including the ACS, are altering their screening guidelines based on the USPSTF modeling results, which simply reanalyze previously published data."
Based on an evidence review, the updated USPSTF guidelines recommend against routine mammography screening for women before age 50 years, suggest that screening end at age 74 years, and recommend changing the screening interval from 1 year to 2 years.
In addition to the ACS, the American College of Radiology (ACR), the American College of Obstetricians and Gynecologists (ACOG), and several other expert groups recommend that clinicians and patients continue to follow earlier guidelines (see Table below for a detailed comparison with ACS guidelines). The ACS recommendations call for annual mammograms starting at age 40 years and continuing for as long as a woman is in good health; ACS has no specific upper age at which mammography screening should be discontinued. The society suggests that the decision to stop regular mammography screening should be individualized based on patient-specific, potential benefits and risks of screening within the context of overall health and estimated lifespan.
ACOG's recommendations are similar, except that mammography is recommended every 1 to 2 years from ages 40 to 49 years.
"We would urge primary care clinicians to continue to observe the ACR and ACS mammography guidelines and to talk with their patients regarding the benefits of mammography and any concerns their patients may have," M. Shawn Farley, ACR's director of public affairs, told Medscape Medical News.
Supporting Evidence
Dr. Vogel cited several lines of evidence supporting the ACS position, including evidence that early detection of breast cancer saves lives or improves survival (JAMA. 1995;273[2]:149–154).
"If the USTSF recommendations are adopted as policy — particularly if Medicare and private insurers try to use them as an excuse to cut cost — many women will die unnecessarily from breast cancer," Mr. Farley said. "The treatment costs associated with the disease may rise because cancers would be found at a more advanced stage. For those women diagnosed at a later stage, they may experience more invasive techniques to remove the cancers because the disease is more advanced."
http://www.medscape.com/viewarticle/712720?sssdmh=dm1.558850&src=nldne&uac=71630FV
Monday, November 2, 2009
Drugs to treat urinary infections could cause heart, brain problems
Nov. 2, 2009 Associated Press
CHICAGO - Researchers studying antibiotics in pregnancy have found a surprising link between common drugs used to treat urinary infections with birth defects. Reassuringly, the most-used antibiotics in early pregnancy — penicillins — appear to be the safest.
Bacterial infections themselves can cause problems for the fetus if left unchecked, experts said, so pregnant women shouldn't avoid antibiotics entirely. Instead, women should discuss antibiotics choices with their doctors.
The new study is the first large analysis of antibiotic use in pregnancy. It found that mothers of babies with birth defects were more likely than mothers with healthy babies to report taking two types of antibiotics during pregnancy: sulfa drugs (brand names include Thiosulfil Forte and Bactrim) and urinary germicides called nitrofurantoins (brand names include Furadantin and Macrobid).
It was the first time an association had been seen between urinary tract treatments and birth defects, said lead author Krista Crider, a geneticist with the Centers for Disease Control and Prevention, which funded the research. "Additional studies are going to need to be done to confirm these findings."
Before rigorous safety testing
Used for many decades, the antibiotics in question predate the Food and Drug Administration and its requirements for rigorous safety testing. The FDA now grades all drugs for safety to the fetus based on available research, but rigorous studies are so lacking in many cases, that no antibiotics get the highest grade of "A."
Sulfa drugs are the oldest antibiotics and some animal studies have found harm during pregnancy. Nitrofurantoins previously have been viewed by doctors as safe to treat urinary tract infections during pregnancy.
The study, appearing in November's Archives of Pediatrics and Adolescent Medicine, may cause doctors to change the drugs they choose to treat pregnant women with infections. The findings were released Monday.
Dr. Susan Mehnert-Kay, a family practice doctor in Tulsa, Okla., who has written about diagnosing and managing urinary tract infections, said the research is "very interesting" and would cause her to reconsider antibiotic choices in early pregnancy.
The study is important because it looked at drugs that have been used for decades without large studies of their safety in pregnant women, said Dr. Michael Katz of the March of Dimes.
"Some physicians are not as attuned to this as they ought to be, so patients have the right to ask questions," Katz said.
The researchers analyzed data from more than 13,000 mothers whose infants had birth defects and nearly 5,000 women who lived in the same regions with healthy babies.
The women were interviewed by phone from six weeks to two years after their pregnancies. Those who remembered taking antibiotics during the month before conception through the first three months of pregnancy were identified as exposed to antibiotics.
The women's memories could have been faulty, a substantial weakness of the study, which the authors acknowledged. About one-third of the women who took antibiotics couldn't remember the specific type of drug they took.
It's also unclear whether the birth defects were caused by the drugs or by the underlying infections being treated, Crider said.
Birth defects linked to sulfa drugs included rare brain and heart problems, and shortened limbs. Those linked to nitrofurantoins included heart problems and cleft palate. The drugs seemed to double or triple the risk, depending on the defect.
"These defects are rare. Even with a threefold increase in risk, the risk for the individual is still quite low," Crider said.
CHICAGO - Researchers studying antibiotics in pregnancy have found a surprising link between common drugs used to treat urinary infections with birth defects. Reassuringly, the most-used antibiotics in early pregnancy — penicillins — appear to be the safest.
Bacterial infections themselves can cause problems for the fetus if left unchecked, experts said, so pregnant women shouldn't avoid antibiotics entirely. Instead, women should discuss antibiotics choices with their doctors.
The new study is the first large analysis of antibiotic use in pregnancy. It found that mothers of babies with birth defects were more likely than mothers with healthy babies to report taking two types of antibiotics during pregnancy: sulfa drugs (brand names include Thiosulfil Forte and Bactrim) and urinary germicides called nitrofurantoins (brand names include Furadantin and Macrobid).
It was the first time an association had been seen between urinary tract treatments and birth defects, said lead author Krista Crider, a geneticist with the Centers for Disease Control and Prevention, which funded the research. "Additional studies are going to need to be done to confirm these findings."
Before rigorous safety testing
Used for many decades, the antibiotics in question predate the Food and Drug Administration and its requirements for rigorous safety testing. The FDA now grades all drugs for safety to the fetus based on available research, but rigorous studies are so lacking in many cases, that no antibiotics get the highest grade of "A."
Sulfa drugs are the oldest antibiotics and some animal studies have found harm during pregnancy. Nitrofurantoins previously have been viewed by doctors as safe to treat urinary tract infections during pregnancy.
The study, appearing in November's Archives of Pediatrics and Adolescent Medicine, may cause doctors to change the drugs they choose to treat pregnant women with infections. The findings were released Monday.
Dr. Susan Mehnert-Kay, a family practice doctor in Tulsa, Okla., who has written about diagnosing and managing urinary tract infections, said the research is "very interesting" and would cause her to reconsider antibiotic choices in early pregnancy.
The study is important because it looked at drugs that have been used for decades without large studies of their safety in pregnant women, said Dr. Michael Katz of the March of Dimes.
"Some physicians are not as attuned to this as they ought to be, so patients have the right to ask questions," Katz said.
The researchers analyzed data from more than 13,000 mothers whose infants had birth defects and nearly 5,000 women who lived in the same regions with healthy babies.
The women were interviewed by phone from six weeks to two years after their pregnancies. Those who remembered taking antibiotics during the month before conception through the first three months of pregnancy were identified as exposed to antibiotics.
The women's memories could have been faulty, a substantial weakness of the study, which the authors acknowledged. About one-third of the women who took antibiotics couldn't remember the specific type of drug they took.
It's also unclear whether the birth defects were caused by the drugs or by the underlying infections being treated, Crider said.
Birth defects linked to sulfa drugs included rare brain and heart problems, and shortened limbs. Those linked to nitrofurantoins included heart problems and cleft palate. The drugs seemed to double or triple the risk, depending on the defect.
"These defects are rare. Even with a threefold increase in risk, the risk for the individual is still quite low," Crider said.
Friday, October 30, 2009
Longer lactation reduces risk of later CVD
Lactation increases energy expenditure, promotes post-partum weight loss and improves glucose tolerance and lipid metabolism. It may also have long-term beneficial effects on glucose metabolism. Now data from the US Women’s Health Initiative study have linked prolonged breastfeeding with lower postmenopausal cardiovascular risk.
Data were analysed from 139,681 postmenopausal women (median age, 63 years) who had had at least one live birth. A lifetime history of >12 months of lactation was associated with significant reductions of 12% in hypertension, 20% in diabetes, 19% in hyperlipidaemia and 9% in cardiovascular disease (CVD). There was no reduction in the prevalence of obesity. Over an average of 8 years of follow-up, there was a significant 28% reduction in incidence of CVD among women who had had a single live birth and breastfed for 7–12 months compared with similar women who did not breastfeed.
Prolonged breastfeeding may protect against later CVD.
Schwarz EB, et al. Duration of lactation and risk factors for maternal cardiovascular disease. Obstet Gynecol 2009;113:974–982.
http://www.mims.com/Page.aspx?menuid=RecentHL&RecentHeaderID=353
Data were analysed from 139,681 postmenopausal women (median age, 63 years) who had had at least one live birth. A lifetime history of >12 months of lactation was associated with significant reductions of 12% in hypertension, 20% in diabetes, 19% in hyperlipidaemia and 9% in cardiovascular disease (CVD). There was no reduction in the prevalence of obesity. Over an average of 8 years of follow-up, there was a significant 28% reduction in incidence of CVD among women who had had a single live birth and breastfed for 7–12 months compared with similar women who did not breastfeed.
Prolonged breastfeeding may protect against later CVD.
Schwarz EB, et al. Duration of lactation and risk factors for maternal cardiovascular disease. Obstet Gynecol 2009;113:974–982.
http://www.mims.com/Page.aspx?menuid=RecentHL&RecentHeaderID=353
Postnatal Depression
Health visitor delivered psychotherapy for post-natal depression
Depression affects about 13% of women in the year after delivery. Now a UK trial in general practice has shown benefit from interventions by health visitors.
A total of 2,749 women were enrolled antenatally at 101 general practices and randomized
(2:1) to intervention or control groups. In the intervention group, specially trained health visitors identified symptoms of depression using the Edinburgh post-natal depression scale (EPDS) and clinical assessment, and provided therapy (either cognitive behavioural therapy or person-centred therapy) in sessions lasting for an hour, each week for 8 weeks. The control group had usual care. At 6 weeks after delivery, 595 women had an EPDS score of at least 12. Of 418 of these women reassessed at 6 months, 93/271 (34%) in the intervention group and 67/147 (46%) in the control group had a score of at least 12, a significant 38% reduction in prevalence in the intervention group. In the total cohort, the prevalence of a score of at least 12 at 6 months was 12.4% (intervention) versus 16.7% (control), a significant 33% difference. The benefit was maintained at 12 months. There was no difference in outcome with cognitive behavioural or person-centred therapy.
Therapy provided by trained health visitors was successful.
Morrell CJ, et al. Clinical effectiveness of health visitor training in psychologically informed approaches for depression in postnatal women: pragmatic cluster randomised trial in primary care. BMJ 2009;338:276– 280; Dennis C-L. Preventing and treating postnatal depression. Ibid:246– 247 (editorial).
http://www.mims.com/Page.aspx?menuid=RecentHL&RecentHeaderID=352
Depression affects about 13% of women in the year after delivery. Now a UK trial in general practice has shown benefit from interventions by health visitors.
A total of 2,749 women were enrolled antenatally at 101 general practices and randomized
(2:1) to intervention or control groups. In the intervention group, specially trained health visitors identified symptoms of depression using the Edinburgh post-natal depression scale (EPDS) and clinical assessment, and provided therapy (either cognitive behavioural therapy or person-centred therapy) in sessions lasting for an hour, each week for 8 weeks. The control group had usual care. At 6 weeks after delivery, 595 women had an EPDS score of at least 12. Of 418 of these women reassessed at 6 months, 93/271 (34%) in the intervention group and 67/147 (46%) in the control group had a score of at least 12, a significant 38% reduction in prevalence in the intervention group. In the total cohort, the prevalence of a score of at least 12 at 6 months was 12.4% (intervention) versus 16.7% (control), a significant 33% difference. The benefit was maintained at 12 months. There was no difference in outcome with cognitive behavioural or person-centred therapy.
Therapy provided by trained health visitors was successful.
Morrell CJ, et al. Clinical effectiveness of health visitor training in psychologically informed approaches for depression in postnatal women: pragmatic cluster randomised trial in primary care. BMJ 2009;338:276– 280; Dennis C-L. Preventing and treating postnatal depression. Ibid:246– 247 (editorial).
http://www.mims.com/Page.aspx?menuid=RecentHL&RecentHeaderID=352
Eating during labour
It is common practice to discourage food intake during labour. Now a study in London, England, has suggested that a light diet does no harm.
The study included 2,426 nondiabetic nulliparae in labour at term with a singleton, cephalic-presenting fetus and at least 5 cm cervical dilatation. Randomization was to light (low fat, low residue) diet or water only. The rate of normal vaginal delivery was 44% in each group. Duration of labour was similar in the two groups (597 minutes with food, 612 minutes with water only). There were no significant differences in rates of instrumental or Caesarean delivery, maternal vomiting, or use of epidural analgesia or oxytocin. There were no cases of aspiration. Apgar scores and rates of admission to neonatal intensive care were similar.
Allowing women to eat in labour caused no harm.
O’Sullivan G, et al. Effect of food intake during labour on obstetric outcome: randomised controlled trial. BMJ 2009;338:880; Downe S. Eating a light diet during labour. Ibid: 842–843 (editorial).
MIMS Online http://www.mims.com/Page.aspx?menuid=RecentHL&RecentHeaderID=354
The study included 2,426 nondiabetic nulliparae in labour at term with a singleton, cephalic-presenting fetus and at least 5 cm cervical dilatation. Randomization was to light (low fat, low residue) diet or water only. The rate of normal vaginal delivery was 44% in each group. Duration of labour was similar in the two groups (597 minutes with food, 612 minutes with water only). There were no significant differences in rates of instrumental or Caesarean delivery, maternal vomiting, or use of epidural analgesia or oxytocin. There were no cases of aspiration. Apgar scores and rates of admission to neonatal intensive care were similar.
Allowing women to eat in labour caused no harm.
O’Sullivan G, et al. Effect of food intake during labour on obstetric outcome: randomised controlled trial. BMJ 2009;338:880; Downe S. Eating a light diet during labour. Ibid: 842–843 (editorial).
MIMS Online http://www.mims.com/Page.aspx?menuid=RecentHL&RecentHeaderID=354
Thursday, October 29, 2009
Stages of Pregnancy in Pictures
view pictures of fetus in utero
http://www.emedicinehealth.com/slideshow_stages_of_pregnancy_pictures/article_em.htm
http://www.emedicinehealth.com/slideshow_stages_of_pregnancy_pictures/article_em.htm
Wednesday, October 28, 2009
Breastfeeding Recommended for Low-Income Mothers
From Medscape Medical News
Crina Frincu-Mallos, PhD
October 28, 2009 (Washington, DC) — Despite the recommendation from the World Health Organization that all women exclusively breastfeed for the first 6 months for optimal infant growth and development, data from 198 primiparous women in Tennessee show that even women intending to nurse give up after the first 2 months. The findings were reported here at the American Academy of Pediatrics 2009 National Conference and Exhibition.
More than half of low-income first-time mothers start breastfeeding, but only 13% continue up to 6 months, partly because of the availability of free infant formula provided by the Special Supplemental Nutrition Program for Women, Infants, and Children, known as the WIC program, researchers told meeting attendees.
Mother's Milk Is Best . . . and Free
"We did our research in first-time mothers in the South, which has the lowest rates of breastfeeding," said Stephanie M. Reich, PhD, assistant professor in the Department of Education at University of California at Irvine.
"We found that if they were getting free formula from their pediatrician, they were more than twice as likely to quit breastfeeding," Dr. Reich said in an interview with Medscape Pediatrics.
The 198 women in the study were interviewed at home during the third trimester of their pregnancy. Of these, 168 women were interviewed after they gave birth, and again at 2, 4, 6, 9, 12, and 18 months postpartum. Study participants were African American (n = 125), white (n = 62), Hispanic (n = 16), and Asian (n = 2). Most women in study were single mothers (n = 154). Pregnancy was planned in only 40 cases (20%).
In terms of education, 58 first-time mothers were high-school graduates, 57 attended college, 52 attended high school, 21 had associate and/or bachelors degrees, and 10 were in graduate school. In terms of annual income, 31 first-time mothers had incomes higher than $26,000, 29 had incomes lower than $8000, and the rest fell within this range.
Good Intentions but Negative Impact of Free Infant Formula
"Giving new mothers formula gives them the idea that formula, in some way, might be preferable to breast milk, which it is not," noted Paula Brinkley, MD, a pediatrician in private practice in Berkeley, California, who was attending the meeting. "In order to maximize breastfeeding, it's preferable not to make formula too easy to obtain," Dr. Brinkley, who was not involved with the study, told Medscape Pediatrics in an interview.
"Keep formula companies from giving free formula to hospitals, which they often do, suggested Dr. Brinkley, "and, as a pediatrician, don't give formula to mothers, don't offer it as a perk, unless it's necessary," she advised.
There are other factors that contribute to a new mother's decision to stop breastfeeding, yet all mothers "were more likely to give it up if they were given free formula," explained Dr. Reich. "If you are frustrated with breastfeeding, it's 1 more step to have to go and buy formula and decide, but if you can open a cabinet and do that, it's easier. Formula is expensive, but if you get it for free, you don't have the cost barrier that a lot of other women face," she said.
Breastfeeding Decision Is Influenced by Parents, Physicians
Most women in the study (71%) planned to breastfeed their infants and even more (99%) knew about the health benefits of mother's milk. Those not intending to breastfeed felt it would be a hassle and were more likely to be receiving WIC, said Dr. Reich.
The study results indicate that the obstetrician's influence regarding a new mother's decision to breastfeed is relatively high, compared with the pediatrician's influence (23% vs 9%). However, "family members were very influential in their decision to breastfeed," noted Dr. Reich, "so if their parents were against breastfeeding (46%), they didn't at all, but if their parents were supportive, they were more likely to try it."
Interestingly, looking at postnatal practices, the results show that of the first-time mothers who said during the initial interview that they intend to breastfeed, 89% actually did. However, of those who intended to use free formula, none breastfed.
Dr. Reich added that "a lot of them did not intend to breastfeed for very long, only planned to breastfeed for 1 month, which doesn't give as many of the benefits, but gives all the discomforts — the discouragement, the soreness, . . . the rest of it, but they don't have enough education about breastfeeding to know that it's easier downstream."
"Women who know more about breastfeeding," she remarked, "know more about the benefits of breastfeeding, the protective factor, and do continue breastfeeding."
"This is part of a larger study in which we are trying to educate women by providing educational information through baby books, so as women read to their children, they learn more about child development and intervention," explained Dr. Reich. "We are studying these infants for the first 18 months of their lives and [by now] we know that books work, we know that moms know more after reading them. Then we look at whether that changes any of their behaviors, if it increases their interaction with their babies, and do they provide nutritional benefits."
"We started with breastfeeding," Dr. Reich said, "but we look at other feeding practices, safety in their home, the quality of their interactions, [and] language and cognitive development in the babies."
Knowing the benefits of breast milk is not sufficient for inducing low-income first-time mothers to breastfeed their babies for at least 6 months. Understanding the reasons for never starting or discontinuing early and the role that family and doctors play in this decision could help with implementing breastfeeding practices, concluded Dr. Reich.
Dr. Reich and Dr. Brinkley have disclosed no relevant financial relationships.
American Academy of Pediatrics (AAP) 2009 National Conference and Exhibition: Abstract 7890. Presented October 18, 2009.
Crina Frincu-Mallos, PhD
October 28, 2009 (Washington, DC) — Despite the recommendation from the World Health Organization that all women exclusively breastfeed for the first 6 months for optimal infant growth and development, data from 198 primiparous women in Tennessee show that even women intending to nurse give up after the first 2 months. The findings were reported here at the American Academy of Pediatrics 2009 National Conference and Exhibition.
More than half of low-income first-time mothers start breastfeeding, but only 13% continue up to 6 months, partly because of the availability of free infant formula provided by the Special Supplemental Nutrition Program for Women, Infants, and Children, known as the WIC program, researchers told meeting attendees.
Mother's Milk Is Best . . . and Free
"We did our research in first-time mothers in the South, which has the lowest rates of breastfeeding," said Stephanie M. Reich, PhD, assistant professor in the Department of Education at University of California at Irvine.
"We found that if they were getting free formula from their pediatrician, they were more than twice as likely to quit breastfeeding," Dr. Reich said in an interview with Medscape Pediatrics.
The 198 women in the study were interviewed at home during the third trimester of their pregnancy. Of these, 168 women were interviewed after they gave birth, and again at 2, 4, 6, 9, 12, and 18 months postpartum. Study participants were African American (n = 125), white (n = 62), Hispanic (n = 16), and Asian (n = 2). Most women in study were single mothers (n = 154). Pregnancy was planned in only 40 cases (20%).
In terms of education, 58 first-time mothers were high-school graduates, 57 attended college, 52 attended high school, 21 had associate and/or bachelors degrees, and 10 were in graduate school. In terms of annual income, 31 first-time mothers had incomes higher than $26,000, 29 had incomes lower than $8000, and the rest fell within this range.
Good Intentions but Negative Impact of Free Infant Formula
"Giving new mothers formula gives them the idea that formula, in some way, might be preferable to breast milk, which it is not," noted Paula Brinkley, MD, a pediatrician in private practice in Berkeley, California, who was attending the meeting. "In order to maximize breastfeeding, it's preferable not to make formula too easy to obtain," Dr. Brinkley, who was not involved with the study, told Medscape Pediatrics in an interview.
"Keep formula companies from giving free formula to hospitals, which they often do, suggested Dr. Brinkley, "and, as a pediatrician, don't give formula to mothers, don't offer it as a perk, unless it's necessary," she advised.
There are other factors that contribute to a new mother's decision to stop breastfeeding, yet all mothers "were more likely to give it up if they were given free formula," explained Dr. Reich. "If you are frustrated with breastfeeding, it's 1 more step to have to go and buy formula and decide, but if you can open a cabinet and do that, it's easier. Formula is expensive, but if you get it for free, you don't have the cost barrier that a lot of other women face," she said.
Breastfeeding Decision Is Influenced by Parents, Physicians
Most women in the study (71%) planned to breastfeed their infants and even more (99%) knew about the health benefits of mother's milk. Those not intending to breastfeed felt it would be a hassle and were more likely to be receiving WIC, said Dr. Reich.
The study results indicate that the obstetrician's influence regarding a new mother's decision to breastfeed is relatively high, compared with the pediatrician's influence (23% vs 9%). However, "family members were very influential in their decision to breastfeed," noted Dr. Reich, "so if their parents were against breastfeeding (46%), they didn't at all, but if their parents were supportive, they were more likely to try it."
Interestingly, looking at postnatal practices, the results show that of the first-time mothers who said during the initial interview that they intend to breastfeed, 89% actually did. However, of those who intended to use free formula, none breastfed.
Dr. Reich added that "a lot of them did not intend to breastfeed for very long, only planned to breastfeed for 1 month, which doesn't give as many of the benefits, but gives all the discomforts — the discouragement, the soreness, . . . the rest of it, but they don't have enough education about breastfeeding to know that it's easier downstream."
"Women who know more about breastfeeding," she remarked, "know more about the benefits of breastfeeding, the protective factor, and do continue breastfeeding."
"This is part of a larger study in which we are trying to educate women by providing educational information through baby books, so as women read to their children, they learn more about child development and intervention," explained Dr. Reich. "We are studying these infants for the first 18 months of their lives and [by now] we know that books work, we know that moms know more after reading them. Then we look at whether that changes any of their behaviors, if it increases their interaction with their babies, and do they provide nutritional benefits."
"We started with breastfeeding," Dr. Reich said, "but we look at other feeding practices, safety in their home, the quality of their interactions, [and] language and cognitive development in the babies."
Knowing the benefits of breast milk is not sufficient for inducing low-income first-time mothers to breastfeed their babies for at least 6 months. Understanding the reasons for never starting or discontinuing early and the role that family and doctors play in this decision could help with implementing breastfeeding practices, concluded Dr. Reich.
Dr. Reich and Dr. Brinkley have disclosed no relevant financial relationships.
American Academy of Pediatrics (AAP) 2009 National Conference and Exhibition: Abstract 7890. Presented October 18, 2009.
Tuesday, October 27, 2009
Pregnant? Stop Smoking or Risk having a Psychotic Teen
From Medscape Medical News CME
Maternal Smoking in Pregnancy Linked to Increased Risk for Psychotic Symptoms in Adolescents
Deborah Brauser & Laurie Barclay,
October 16, 2009 — The maternal use of tobacco while pregnant is associated with an increased risk for psychotic symptoms such as hallucinations and delusions in their children, with evidence of a dose-response effect, according to results from a large cohort study published in the October issue of the British Journal of Psychiatry.
"These findings indicate that the risk factors for development of non-clinical psychotic experiences may operate during early development," write Stanley Zammit, PhD, clinical senior lecturer in psychiatric epidemiology in the Department of Psychological Medicine at Cardiff University in Wales and the University of Bristol in the United Kingdom, and colleagues.
"This is the only study to really try and tease out to what extent this association is causal rather than being confounded or explained by other factors," Dr. Zammit told Medscape Psychiatry.
"There could still be confounding, of course, but this makes us a bit more confident that the association may be due to the effects of nicotine on the developing brain in the uterus," he added.
Smoking While Pregnant Common in the United Kingdom
"In the [United Kingdom], 15-20% of women continue to smoke throughout their pregnancy, and although cannabis use is less common, some alcohol intake during pregnancy is reported by most women," write the study authors.
They note that past studies have shown an association between maternal smoking and, to a lesser extent, maternal cannabis and alcohol use and adverse long-term effects on their offspring, including reduced cognitive ability and increased incidence of both attention-deficit/hyperactivity disorder and conduct disorder during childhood and adolescence.
However, the authors report that there have been very few epidemiological studies showing causal inference between maternal substance abuse and childhood psychopathology.
"Our aim [in this study] was to investigate, in a longitudinal design, whether maternal tobacco, cannabis, or alcohol use during pregnancy were independently associated with risk of the offspring developing psychotic symptoms during early adolescence," write the study authors.
"I'm interested in the effects of substance use on mental health outcomes," explained Dr. Zammit. "In animals, there is good evidence that nicotine in utero can disrupt the normal development/function of the fetal brain, so it seems very plausible that this could happen in humans and have subtle effects that are not noticeable early on in life but are only expressed later during development."
The investigators examined data from the Avon Longitudinal Study of Parents and Children, including 14,062 adolescents born between April 1991 and December 1992.
Dr. Zammit and his team focused their evaluation on a cohort of 6356 adolescents, all 12 years of age, who participated in a semistructured interview for psychosis-like symptoms (PLIKS). This interview included 12 core questions, which covered hallucinations, delusions, and experiences of thought interference during the past 6 months.
Data on parental substance use were obtained from self-report postal questionnaires completed by the mother at 8, 18, and 32 weeks of pregnancy and at 2, 21, 33, and 47 months after giving birth, and from the father at 18 weeks of pregnancy and at 2, 8, and 21 months after birth.
Of these mothers, 1219 (19.3%) smoked tobacco, 4372 (70.0%) drank alcohol, and 157 (2.5%) used cannabis at least once during pregnancy.
Maternal Tobacco Use Increased Risk for PLIKS
At the end of this cohort study, a total of 734 of the children (11.6%) were rated as having suspected or definite PLIKS, and 300 of these children (4.7%) had definite symptoms.
The investigators found that maternal tobacco use during pregnancy was strongly associated with an increased risk for suspected or definite PLIKS in their offspring (adjusted odds ratio [OR], 1.20; 95% confidence interval [CI], 1.05 – 1.37; P = .007). This risk further increased based on frequency of tobacco use.
In addition, "the offspring of mothers who used tobacco only in their third trimester had a greater risk of developing any suspected or definite PLIKS than offspring whose mothers smoked only in the first trimester (OR, 2.1; 95% CI, 0.96-4.59; P = 0.063)," report the authors.
After adjusting for confounders and maternal smoking during pregnancy, paternal smoking during pregnancy, maternal smoking postpregnancy, or maternal cannabis use were not associated with any suspected or definite PLIKS.
Although maternal alcohol use did show a nonlinear association with psychotic symptoms, this effect was found almost exclusively in the offspring of the 25 women who drank more than 21 units weekly.
Future Studies Needed
"Maternal smoking during pregnancy was associated with an increased risk of psychotic symptoms in the children, with evidence of a dose-response effect whereby risk of PLIKS was highest in the offspring of mothers who smoked most heavily," write the study authors.
"If our results are non-biased and truly reflect a causal relationship, we can estimate that about 20% of adolescents in this cohort would not have developed psychotic symptoms if their mothers had not smoked," they add.
Study limitations included missing data resulting from attrition and wave nonresponse, as well as possible underreporting of substance use (including cannabis, which is illegal in the United Kingdom).
"Hopefully this will encourage more research into the effects of tobacco on brain development in utero, and increase understanding of how any disruptions of brain development can impact risk of psychosis," Dr. Zammit concluded.
This study was supported by the Wellcome Trust Grant, with additional funding to Dr. Zammit through a Clinician Scientist Award from the National Assembly for Wales. The other study authors have disclosed no relevant financial relationships.
Br J Psychiatry. 2009;195:294–300. Abstract
Additonal Resource
More information on tobacco use and pregnancy is available on the Centers for Disease Control and Prevention's Web site.
Maternal Smoking in Pregnancy Linked to Increased Risk for Psychotic Symptoms in Adolescents
Deborah Brauser & Laurie Barclay,
October 16, 2009 — The maternal use of tobacco while pregnant is associated with an increased risk for psychotic symptoms such as hallucinations and delusions in their children, with evidence of a dose-response effect, according to results from a large cohort study published in the October issue of the British Journal of Psychiatry.
"These findings indicate that the risk factors for development of non-clinical psychotic experiences may operate during early development," write Stanley Zammit, PhD, clinical senior lecturer in psychiatric epidemiology in the Department of Psychological Medicine at Cardiff University in Wales and the University of Bristol in the United Kingdom, and colleagues.
"This is the only study to really try and tease out to what extent this association is causal rather than being confounded or explained by other factors," Dr. Zammit told Medscape Psychiatry.
"There could still be confounding, of course, but this makes us a bit more confident that the association may be due to the effects of nicotine on the developing brain in the uterus," he added.
Smoking While Pregnant Common in the United Kingdom
"In the [United Kingdom], 15-20% of women continue to smoke throughout their pregnancy, and although cannabis use is less common, some alcohol intake during pregnancy is reported by most women," write the study authors.
They note that past studies have shown an association between maternal smoking and, to a lesser extent, maternal cannabis and alcohol use and adverse long-term effects on their offspring, including reduced cognitive ability and increased incidence of both attention-deficit/hyperactivity disorder and conduct disorder during childhood and adolescence.
However, the authors report that there have been very few epidemiological studies showing causal inference between maternal substance abuse and childhood psychopathology.
"Our aim [in this study] was to investigate, in a longitudinal design, whether maternal tobacco, cannabis, or alcohol use during pregnancy were independently associated with risk of the offspring developing psychotic symptoms during early adolescence," write the study authors.
"I'm interested in the effects of substance use on mental health outcomes," explained Dr. Zammit. "In animals, there is good evidence that nicotine in utero can disrupt the normal development/function of the fetal brain, so it seems very plausible that this could happen in humans and have subtle effects that are not noticeable early on in life but are only expressed later during development."
The investigators examined data from the Avon Longitudinal Study of Parents and Children, including 14,062 adolescents born between April 1991 and December 1992.
Dr. Zammit and his team focused their evaluation on a cohort of 6356 adolescents, all 12 years of age, who participated in a semistructured interview for psychosis-like symptoms (PLIKS). This interview included 12 core questions, which covered hallucinations, delusions, and experiences of thought interference during the past 6 months.
Data on parental substance use were obtained from self-report postal questionnaires completed by the mother at 8, 18, and 32 weeks of pregnancy and at 2, 21, 33, and 47 months after giving birth, and from the father at 18 weeks of pregnancy and at 2, 8, and 21 months after birth.
Of these mothers, 1219 (19.3%) smoked tobacco, 4372 (70.0%) drank alcohol, and 157 (2.5%) used cannabis at least once during pregnancy.
Maternal Tobacco Use Increased Risk for PLIKS
At the end of this cohort study, a total of 734 of the children (11.6%) were rated as having suspected or definite PLIKS, and 300 of these children (4.7%) had definite symptoms.
The investigators found that maternal tobacco use during pregnancy was strongly associated with an increased risk for suspected or definite PLIKS in their offspring (adjusted odds ratio [OR], 1.20; 95% confidence interval [CI], 1.05 – 1.37; P = .007). This risk further increased based on frequency of tobacco use.
In addition, "the offspring of mothers who used tobacco only in their third trimester had a greater risk of developing any suspected or definite PLIKS than offspring whose mothers smoked only in the first trimester (OR, 2.1; 95% CI, 0.96-4.59; P = 0.063)," report the authors.
After adjusting for confounders and maternal smoking during pregnancy, paternal smoking during pregnancy, maternal smoking postpregnancy, or maternal cannabis use were not associated with any suspected or definite PLIKS.
Although maternal alcohol use did show a nonlinear association with psychotic symptoms, this effect was found almost exclusively in the offspring of the 25 women who drank more than 21 units weekly.
Future Studies Needed
"Maternal smoking during pregnancy was associated with an increased risk of psychotic symptoms in the children, with evidence of a dose-response effect whereby risk of PLIKS was highest in the offspring of mothers who smoked most heavily," write the study authors.
"If our results are non-biased and truly reflect a causal relationship, we can estimate that about 20% of adolescents in this cohort would not have developed psychotic symptoms if their mothers had not smoked," they add.
Study limitations included missing data resulting from attrition and wave nonresponse, as well as possible underreporting of substance use (including cannabis, which is illegal in the United Kingdom).
"Hopefully this will encourage more research into the effects of tobacco on brain development in utero, and increase understanding of how any disruptions of brain development can impact risk of psychosis," Dr. Zammit concluded.
This study was supported by the Wellcome Trust Grant, with additional funding to Dr. Zammit through a Clinician Scientist Award from the National Assembly for Wales. The other study authors have disclosed no relevant financial relationships.
Br J Psychiatry. 2009;195:294–300. Abstract
Additonal Resource
More information on tobacco use and pregnancy is available on the Centers for Disease Control and Prevention's Web site.
Monday, October 26, 2009
New-Onset Breast Tenderness During Hormone Therapy Linked to Increased Breast Cancer Risk
From Medscape Medical News CME
Laurie Barclay, MD
Charles P. Vega, MD
October 21, 2009 — New-onset breast tenderness during conjugated equine estrogens plus medroxyprogesterone acetate (CEE+MPA) hormonal therapy is linked to increased breast cancer risk, according to an analysis of data from a randomized controlled trial reported in the October 12 issue of the Archives of Internal Medicine.
"To our knowledge, no prior published studies have addressed whether there is an association between CEE+MPA–induced new-onset breast tenderness and breast cancer risk," lead author Carolyn J. Crandall, MD, MS, from the David Geffen School of Medicine at University of Southern California, Los Angeles, said in a news release.
In the Women's Health Initiative (WHI) Estrogen Plus Progestin Trial, postmenopausal women with an intact uterus were randomly assigned to receive daily CEE+MPA (0.625/2.5 mg; n = 8506) or placebo (n = 8102). Mammography and clinical breast examination were performed at baseline and once yearly, and self-reported breast tenderness was evaluated at baseline and at 12 months. During follow-up (mean duration, 5.6 years), medical record review allowed confirmation of invasive breast cancer incidence.
Among 14,538 women who did not report breast tenderness at baseline, new-onset breast tenderness after 12 months occurred in 36.1% of those randomly assigned to CEE+MPA vs 11.8% of those in the placebo group (P < .001). Among women receiving CEE+MPA, those with new-onset breast tenderness had significantly higher breast cancer risk vs those without self-reported tenderness (hazard ratio, 1.48; 95% confidence interval, 1.08 - 2.03; P = .02).
"Is it because the hormone therapy is causing breast-tissue cells to multiply more rapidly, which causes breast tenderness and at the same time indicates increased cancer risk?" Dr. Crandall said. "We need to figure out what makes certain women more susceptible to developing breast tenderness during hormone therapy than other women."
Breast cancer risk was not significantly associated with new-onset breast tenderness in the placebo group (P = .97).
Limitations of this study include annual vs more frequent assessment of breast tenderness, relatively high rates of discontinuation of combination therapy and of crossover from placebo to active therapy, and lack of generalizability to other types of hormonal therapy.
"New-onset breast tenderness during conjugated equine estrogens plus medroxyprogesterone therapy was associated with increased breast cancer risk," the study authors write. "The sensitivity and specificity of the association between breast tenderness and breast cancer were similar in magnitude to those of the Gail model."
The National Heart, Lung, and Blood Institute, National Institutes of Health, US Department of Health and Human Services supported the WHI. Dr. Crandall's work was supported by the National Institute on Aging, National Institutes of Health, and the Tarlow-Eisner-Moss Research Endowment of the Iris Cantor–UCLA Women's Health Center. Wyeth-Ayerst Research Laboratories supplied the active study drug and placebo. One of the study authors (Dr. Chlebowski) has disclosed various financial relationships with Astra-Zeneca, Eli Lilly & Co, Novartis International AG, Wyeth Pharmaceuticals, and Pfizer Inc.
Arch Intern Med. 2009;169:1684-1691.
Additional Resources
More information on breast cancer and hormone therapy is available on the Women's Health Inititaive's Web site and also on the National Cancer Institute's Web site.
Clinical Context
Women with increased breast density on mammography results have a higher risk for breast cancer, and a previous study suggests that breast symptoms in women during menopause may predict the degree of breast density. In another study by Crandall and colleagues, which was published in the August 14-28 issue of the Archives of Internal Medicine, middle-aged and older women with new-onset breast discomfort had a significant 3.9% increase in total breast density vs women who did not have discomfort. Although participants in this research were enrolled in a trial of postmenopausal hormone therapy, the positive relationship between breast density and breast discomfort was present whether they were receiving active treatment or placebo.
Postmenopausal hormone therapy can increase breast density, and breast discomfort as a marker may be useful to identify women with a higher risk for breast cancer. The current study examines the relationship between breast discomfort and breast cancer using data from the WHI.
Laurie Barclay, MD
Charles P. Vega, MD
October 21, 2009 — New-onset breast tenderness during conjugated equine estrogens plus medroxyprogesterone acetate (CEE+MPA) hormonal therapy is linked to increased breast cancer risk, according to an analysis of data from a randomized controlled trial reported in the October 12 issue of the Archives of Internal Medicine.
"To our knowledge, no prior published studies have addressed whether there is an association between CEE+MPA–induced new-onset breast tenderness and breast cancer risk," lead author Carolyn J. Crandall, MD, MS, from the David Geffen School of Medicine at University of Southern California, Los Angeles, said in a news release.
In the Women's Health Initiative (WHI) Estrogen Plus Progestin Trial, postmenopausal women with an intact uterus were randomly assigned to receive daily CEE+MPA (0.625/2.5 mg; n = 8506) or placebo (n = 8102). Mammography and clinical breast examination were performed at baseline and once yearly, and self-reported breast tenderness was evaluated at baseline and at 12 months. During follow-up (mean duration, 5.6 years), medical record review allowed confirmation of invasive breast cancer incidence.
Among 14,538 women who did not report breast tenderness at baseline, new-onset breast tenderness after 12 months occurred in 36.1% of those randomly assigned to CEE+MPA vs 11.8% of those in the placebo group (P < .001). Among women receiving CEE+MPA, those with new-onset breast tenderness had significantly higher breast cancer risk vs those without self-reported tenderness (hazard ratio, 1.48; 95% confidence interval, 1.08 - 2.03; P = .02).
"Is it because the hormone therapy is causing breast-tissue cells to multiply more rapidly, which causes breast tenderness and at the same time indicates increased cancer risk?" Dr. Crandall said. "We need to figure out what makes certain women more susceptible to developing breast tenderness during hormone therapy than other women."
Breast cancer risk was not significantly associated with new-onset breast tenderness in the placebo group (P = .97).
Limitations of this study include annual vs more frequent assessment of breast tenderness, relatively high rates of discontinuation of combination therapy and of crossover from placebo to active therapy, and lack of generalizability to other types of hormonal therapy.
"New-onset breast tenderness during conjugated equine estrogens plus medroxyprogesterone therapy was associated with increased breast cancer risk," the study authors write. "The sensitivity and specificity of the association between breast tenderness and breast cancer were similar in magnitude to those of the Gail model."
The National Heart, Lung, and Blood Institute, National Institutes of Health, US Department of Health and Human Services supported the WHI. Dr. Crandall's work was supported by the National Institute on Aging, National Institutes of Health, and the Tarlow-Eisner-Moss Research Endowment of the Iris Cantor–UCLA Women's Health Center. Wyeth-Ayerst Research Laboratories supplied the active study drug and placebo. One of the study authors (Dr. Chlebowski) has disclosed various financial relationships with Astra-Zeneca, Eli Lilly & Co, Novartis International AG, Wyeth Pharmaceuticals, and Pfizer Inc.
Arch Intern Med. 2009;169:1684-1691.
Additional Resources
More information on breast cancer and hormone therapy is available on the Women's Health Inititaive's Web site and also on the National Cancer Institute's Web site.
Clinical Context
Women with increased breast density on mammography results have a higher risk for breast cancer, and a previous study suggests that breast symptoms in women during menopause may predict the degree of breast density. In another study by Crandall and colleagues, which was published in the August 14-28 issue of the Archives of Internal Medicine, middle-aged and older women with new-onset breast discomfort had a significant 3.9% increase in total breast density vs women who did not have discomfort. Although participants in this research were enrolled in a trial of postmenopausal hormone therapy, the positive relationship between breast density and breast discomfort was present whether they were receiving active treatment or placebo.
Postmenopausal hormone therapy can increase breast density, and breast discomfort as a marker may be useful to identify women with a higher risk for breast cancer. The current study examines the relationship between breast discomfort and breast cancer using data from the WHI.
Wednesday, October 7, 2009
Rate of Postpartum Diabetes Screening May Be Low
From Medscape Medical News
Laurie Barclay, MD Charles P. Vega, MD
Diabetes Care. Published online September 9, 2009. Abstract
Clinical Context
Gestational diabetes is associated with an increased risk for the subsequent development of type 2 diabetes, and a previous systematic review by Kim and colleagues explored this relationship. Their findings, which were published in the October 2002 issue of Diabetes Care, suggested that the lifetime incidence of type 2 diabetes among women with a history of gestational diabetes could be more than 70%. The risk for incident diabetes is highest in the first 5 years after delivery and plateaus by 10 years. An elevated fasting glucose level was the most important factor in predicting the risk for incident diabetes.
Nonetheless, many women at risk for incident diabetes do not receive testing for hyperglycemia in the postpartum period. The current study examines the prevalence of such testing and compares oral glucose tolerance testing vs fasting glucose testing in diagnosing hyperglycemia.
Study Highlights
The study design was a retrospective cohort review of cases from 1 hospital in Canada. The researchers focused on women with a history of gestational diabetes or impaired glucose tolerance during pregnancy.
Gestational diabetes was diagnosed after a 50-g oral glucose tolerance test result of 10.3 mmol/L or more at 1 hour, or after an abnormal 2-hour glucose tolerance test result after an equivocal 1-hour result. Impaired glucose tolerance was defined as a fasting plasma glucose level of 5.3 mmol/L or more, a 1-hour result of 10.6 mmol/L or more, or a 2-hour result of 8.9 mmol/L or more after a 75-g oral glucose tolerance test.
Women with a history of hyperglycemia before pregnancy were excluded from study analysis.
Researchers examined the prevalence of screening for diabetes postpartum and compared oral glucose tolerance testing vs fasting plasma glucose testing in diagnosing hyperglycemia.
Diabetes was defined as a fasting plasma glucose level of 7 mmol/L or more, or a 2-hour glucose level of at least 11.1 mmol/L after a 75-g oral glucose tolerance test. Impaired glucose tolerance was defined as a 2-hour glucose level of 7.8 to 11.1 mmol/L after a 75-g oral glucose tolerance test. Impaired fasting glucose was defined as a glucose level between 6.1 and 6.9 mmol/L.
909 women underwent analysis. The mean age of subjects was 31.7 years, and two thirds of the cohort had a family history of diabetes. A total of 61% of women had used insulin during pregnancy.
Only 438 (48.2%) of women underwent postpartum testing, of whom 21 completed only a fasting plasma glucose test.
Women with a higher parity and who did not use insulin were less likely to receive postpartum glucose testing.
14 women were diagnosed with type 2 diabetes at the postpartum visit, whereas 15 had impaired fasting glucose, 57 had impaired glucose tolerance, and 3 had both impaired glucose tolerance and impaired fasting glucose.
Results of the fasting plasma glucose test and oral glucose tolerance test were abnormal in 5.7% and 21.3% of women, respectively. Fasting glucose testing alone would have missed 72% of women with an abnormal glucose result.
Non-Caucasian ethnicity, previous gestational diabetes, and higher pregnancy oral glucose tolerance testing values were all predictors of a higher risk for an abnormal postpartum glucose testing result.
Clinical Implications
A previous systematic review found that the lifetime incidence of type 2 diabetes among women with a history of gestational diabetes may exceed 70%.
The rate of new cases of diabetes was highest in the first 5 years after delivery. Although a high fasting glucose test result during pregnancy was found to be an important predictor of the risk for type 2 diabetes, race alone was not.
Less than half of women with abnormal glucose testing results during pregnancy received postpartum glucose screening in the current study. Oral glucose tolerance testing was more sensitive than fasting plasma glucose testing in diagnosing postpartum glucose abnormalities.
Laurie Barclay, MD Charles P. Vega, MD
Diabetes Care. Published online September 9, 2009. Abstract
Clinical Context
Gestational diabetes is associated with an increased risk for the subsequent development of type 2 diabetes, and a previous systematic review by Kim and colleagues explored this relationship. Their findings, which were published in the October 2002 issue of Diabetes Care, suggested that the lifetime incidence of type 2 diabetes among women with a history of gestational diabetes could be more than 70%. The risk for incident diabetes is highest in the first 5 years after delivery and plateaus by 10 years. An elevated fasting glucose level was the most important factor in predicting the risk for incident diabetes.
Nonetheless, many women at risk for incident diabetes do not receive testing for hyperglycemia in the postpartum period. The current study examines the prevalence of such testing and compares oral glucose tolerance testing vs fasting glucose testing in diagnosing hyperglycemia.
Study Highlights
The study design was a retrospective cohort review of cases from 1 hospital in Canada. The researchers focused on women with a history of gestational diabetes or impaired glucose tolerance during pregnancy.
Gestational diabetes was diagnosed after a 50-g oral glucose tolerance test result of 10.3 mmol/L or more at 1 hour, or after an abnormal 2-hour glucose tolerance test result after an equivocal 1-hour result. Impaired glucose tolerance was defined as a fasting plasma glucose level of 5.3 mmol/L or more, a 1-hour result of 10.6 mmol/L or more, or a 2-hour result of 8.9 mmol/L or more after a 75-g oral glucose tolerance test.
Women with a history of hyperglycemia before pregnancy were excluded from study analysis.
Researchers examined the prevalence of screening for diabetes postpartum and compared oral glucose tolerance testing vs fasting plasma glucose testing in diagnosing hyperglycemia.
Diabetes was defined as a fasting plasma glucose level of 7 mmol/L or more, or a 2-hour glucose level of at least 11.1 mmol/L after a 75-g oral glucose tolerance test. Impaired glucose tolerance was defined as a 2-hour glucose level of 7.8 to 11.1 mmol/L after a 75-g oral glucose tolerance test. Impaired fasting glucose was defined as a glucose level between 6.1 and 6.9 mmol/L.
909 women underwent analysis. The mean age of subjects was 31.7 years, and two thirds of the cohort had a family history of diabetes. A total of 61% of women had used insulin during pregnancy.
Only 438 (48.2%) of women underwent postpartum testing, of whom 21 completed only a fasting plasma glucose test.
Women with a higher parity and who did not use insulin were less likely to receive postpartum glucose testing.
14 women were diagnosed with type 2 diabetes at the postpartum visit, whereas 15 had impaired fasting glucose, 57 had impaired glucose tolerance, and 3 had both impaired glucose tolerance and impaired fasting glucose.
Results of the fasting plasma glucose test and oral glucose tolerance test were abnormal in 5.7% and 21.3% of women, respectively. Fasting glucose testing alone would have missed 72% of women with an abnormal glucose result.
Non-Caucasian ethnicity, previous gestational diabetes, and higher pregnancy oral glucose tolerance testing values were all predictors of a higher risk for an abnormal postpartum glucose testing result.
Clinical Implications
A previous systematic review found that the lifetime incidence of type 2 diabetes among women with a history of gestational diabetes may exceed 70%.
The rate of new cases of diabetes was highest in the first 5 years after delivery. Although a high fasting glucose test result during pregnancy was found to be an important predictor of the risk for type 2 diabetes, race alone was not.
Less than half of women with abnormal glucose testing results during pregnancy received postpartum glucose screening in the current study. Oral glucose tolerance testing was more sensitive than fasting plasma glucose testing in diagnosing postpartum glucose abnormalities.
Friday, October 2, 2009
Regular Exercise During Pregnancy May Lower Risk for Excessive Birth Weight
From Medscape Medical News CME
Laurie Barclay, Désirée Lie,
Obstet Gynecol. 2009;114:770-776.
Clinical Context
Macrosomia, defined as birth weight of 4000 or 4500 g regardless of birth length, has increased in frequency in the past decades and is associated with increased perinatal and neonatal morbidity and mortality rates. Although exercise has been shown to be beneficial in pregnancy, the frequency and intensity of exercise decrease as pregnancy progresses.
This is a prospective cohort study of pregnant women in Norway to examine the association between self-reported exercise before and during pregnancy and the risk for excessive newborn birth weight.
Study Highlights
The data were derived from the Norwegian Mother and Child Cohort Study, a nationwide cohort linked to the Medical Birth Registry of Norway.
Included were women from 50 of 52 maternity units in Norway who received a routine ultrasound examination at 17 weeks, delivered at 37 weeks of gestation or later, and who completed 3 questionnaires during pregnancy, 2 at 17 weeks, and 1 at 30 weeks of gestation.
Excluded were women with multiple pregnancies or with unknown birth dates of their infants.
1 questionnaire administered at 17 weeks asked about lifestyle, including exercise before and during pregnancy, and the other was a food frequency questionnaire.
The third questionnaire administered at 30 weeks focused on maternal outcomes during pregnancy and followed up on some items from the first questionnaire.
For all exercises, women were asked about type and frequency of exercise, with degree of frequency from "never" to "three or more times a week."
For prepregnancy exercise, women were asked at week 17 for their frequency and type of exercise 3 months before the current pregnancy.
Primary outcome was excessive birth weight, defined as equal or above the 90th percentile (4170 g for nulliparous women and 4362 g for multiparous women).
There were 16,064 nulliparous and 20,805 multiparous women.
Mean energy intake was 9600 kcal daily, mean total gestational weight gain was 9300 g, and two thirds of women had a normal prepregnancy body mass index.
At week 17, a total of 10% were smokers.
Mean birth weight was 3683 g, and 10.9% of infants had excessive birth weight.
A greater number of infants with excessive birth weight were born to multiparous vs nulliparous women.
Nulliparous and multiparous women did not differ in age, smoking, height, diabetes, or education, but nulliparous women were younger, had lower energy intake, and gained more weight.
The highest proportion of overweight women, nonexercisers, and excessive newborn weight was found in the multiparous group.
Regular exercise performed 3 months before the current pregnancy did not decrease the risk for high newborn birth weight in nulliparous or multiparous women.
Nulliparous women who reported exercising 3 times or more weekly in week 17 were less likely to have a newborn with excessive birth weight (P for trend = .008); this was not affected by adjustment for diabetes and preeclampsia.
Nulliparous women who reported exercising 1 to 2 times weekly in week 30 were also at lower risk of having a newborn with excessive birth weight.
Walking (aOR, 0.86) and running (aOR, 0.63) in nulliparous women in week 17 and walking in week 30 (aOR, 0.84) were negatively associated with excessive newborn weight.
Multiparous women who participated in dancing in week 17 were less likely to deliver an infant with excessive weight (aOR, 0.75).
Low-impact aerobics (aOR, 0.68) and dancing (aOR, 0.69) at week 30 were associated with a lower risk for excessive newborn birth weight in multiparous women.
However, weight training in fitness centers in week 17 and swimming in week 30 in multiparous women were associated with a higher risk for excessive birth weight.
The authors concluded that exercise during pregnancy, but not before pregnancy, was associated with a lower risk for excessive newborn birth weight; they suggested that this benefit may be the result of the effect of exercise on glucose tolerance.
Clinical Implications
Self-reported exercise before pregnancy is not associated with a lower risk for excessive newborn birth weight in nulliparous or multiparous women.
Self-reported exercise during pregnancy is associated with a lower risk for excessive newborn birth weight in nulliparous and multiparous women.
Laurie Barclay, Désirée Lie,
Obstet Gynecol. 2009;114:770-776.
Clinical Context
Macrosomia, defined as birth weight of 4000 or 4500 g regardless of birth length, has increased in frequency in the past decades and is associated with increased perinatal and neonatal morbidity and mortality rates. Although exercise has been shown to be beneficial in pregnancy, the frequency and intensity of exercise decrease as pregnancy progresses.
This is a prospective cohort study of pregnant women in Norway to examine the association between self-reported exercise before and during pregnancy and the risk for excessive newborn birth weight.
Study Highlights
The data were derived from the Norwegian Mother and Child Cohort Study, a nationwide cohort linked to the Medical Birth Registry of Norway.
Included were women from 50 of 52 maternity units in Norway who received a routine ultrasound examination at 17 weeks, delivered at 37 weeks of gestation or later, and who completed 3 questionnaires during pregnancy, 2 at 17 weeks, and 1 at 30 weeks of gestation.
Excluded were women with multiple pregnancies or with unknown birth dates of their infants.
1 questionnaire administered at 17 weeks asked about lifestyle, including exercise before and during pregnancy, and the other was a food frequency questionnaire.
The third questionnaire administered at 30 weeks focused on maternal outcomes during pregnancy and followed up on some items from the first questionnaire.
For all exercises, women were asked about type and frequency of exercise, with degree of frequency from "never" to "three or more times a week."
For prepregnancy exercise, women were asked at week 17 for their frequency and type of exercise 3 months before the current pregnancy.
Primary outcome was excessive birth weight, defined as equal or above the 90th percentile (4170 g for nulliparous women and 4362 g for multiparous women).
There were 16,064 nulliparous and 20,805 multiparous women.
Mean energy intake was 9600 kcal daily, mean total gestational weight gain was 9300 g, and two thirds of women had a normal prepregnancy body mass index.
At week 17, a total of 10% were smokers.
Mean birth weight was 3683 g, and 10.9% of infants had excessive birth weight.
A greater number of infants with excessive birth weight were born to multiparous vs nulliparous women.
Nulliparous and multiparous women did not differ in age, smoking, height, diabetes, or education, but nulliparous women were younger, had lower energy intake, and gained more weight.
The highest proportion of overweight women, nonexercisers, and excessive newborn weight was found in the multiparous group.
Regular exercise performed 3 months before the current pregnancy did not decrease the risk for high newborn birth weight in nulliparous or multiparous women.
Nulliparous women who reported exercising 3 times or more weekly in week 17 were less likely to have a newborn with excessive birth weight (P for trend = .008); this was not affected by adjustment for diabetes and preeclampsia.
Nulliparous women who reported exercising 1 to 2 times weekly in week 30 were also at lower risk of having a newborn with excessive birth weight.
Walking (aOR, 0.86) and running (aOR, 0.63) in nulliparous women in week 17 and walking in week 30 (aOR, 0.84) were negatively associated with excessive newborn weight.
Multiparous women who participated in dancing in week 17 were less likely to deliver an infant with excessive weight (aOR, 0.75).
Low-impact aerobics (aOR, 0.68) and dancing (aOR, 0.69) at week 30 were associated with a lower risk for excessive newborn birth weight in multiparous women.
However, weight training in fitness centers in week 17 and swimming in week 30 in multiparous women were associated with a higher risk for excessive birth weight.
The authors concluded that exercise during pregnancy, but not before pregnancy, was associated with a lower risk for excessive newborn birth weight; they suggested that this benefit may be the result of the effect of exercise on glucose tolerance.
Clinical Implications
Self-reported exercise before pregnancy is not associated with a lower risk for excessive newborn birth weight in nulliparous or multiparous women.
Self-reported exercise during pregnancy is associated with a lower risk for excessive newborn birth weight in nulliparous and multiparous women.
Maternal Obesity, Overweight Linked to Congenital Heart Defects
From Medscape Medical News
Laurie Barclay, MD
October 2, 2009 — Maternal obesity and overweight before pregnancy are linked to congenital heart defects (CHDs) in the offspring, according to the results of a large case-control study reported in the October issue of the American Journal of Obstetrics & Gynecology.
"Congenital heart defects are the most common types of birth defect, and among all birth defects, they are a leading cause of illness, death, and medical expenditures," Dr. Edwin Trevathan, director of the US Centers for Disease Control and Prevention's (CDC) National Center on Birth Defects and Developmental Disabilities, said in a news release. "Women who are obese and who are planning a pregnancy could benefit by working with their physicians to achieve a healthy weight before pregnancy."
The goal of this analysis from the National Birth Defects Prevention Study (NBDPS) was to evaluate associations between prepregnancy body mass index (BMI) and CHDs in the offspring. Case infants with CHDs (n = 6440) were compared vs 5673 liveborn control infants without birth defects enrolled in the NBDPS from 1997 to 2004.
For all CHDs combined, adjusted odds ratios were 1.16 for overweight status (95% confidence interval [CI], 1.05 - 1.29), 1.15 for moderate obesity (95% CI, 1.00 -1.32), and 1.31 for severe obesity (95% CI, 1.11 - 1.56). Phenotypes of CHD associated with maternal BMI of at least 25.0 kg/m2 were conotruncal defects (tetralogy of Fallot), total anomalous pulmonary venous return, hypoplastic left heart syndrome, right ventricular outflow tract (RVOT) defects (pulmonary valve stenosis), and septal defects (secundum atrial septal defect).
The study authors concluded that these findings supported those from previous research and also highlighted new associations between obesity and conotruncal defects and RVOT defects.
"These results support previous studies, as well as provide additional evidence, that there is an association between a woman being overweight or obese before pregnancy and certain types of heart defects," said lead author Suzanne M. Gilboa, PhD, epidemiologist at CDC's National Center on Birth Defects and Developmental Disabilities. "This provides another reason for women to maintain a healthy weight. In addition to the impact on a woman's own health and the known pregnancy complications associated with maternal obesity, the baby's health could be at risk."
Limitations of this study include BMI calculated from self-reported weight and height, some missing data for prepregnancy BMI, 70% response rate in the NBDPS, and inability to determine any causal relationship between maternal body weight and CHDs. In addition, study centers in Massachusetts and New Jersey did not ascertain case infants among pregnancy terminations, and New York began ascertaining pregnancy terminations only in the year 2000.
The NBDPS is funded by the CDC. The views expressed in the journal article are those of the study authors and do not necessarily represent the official position of the CDC.
Am J Obstet Gynecol. Published online October 1, 2009.
Laurie Barclay, MD
October 2, 2009 — Maternal obesity and overweight before pregnancy are linked to congenital heart defects (CHDs) in the offspring, according to the results of a large case-control study reported in the October issue of the American Journal of Obstetrics & Gynecology.
"Congenital heart defects are the most common types of birth defect, and among all birth defects, they are a leading cause of illness, death, and medical expenditures," Dr. Edwin Trevathan, director of the US Centers for Disease Control and Prevention's (CDC) National Center on Birth Defects and Developmental Disabilities, said in a news release. "Women who are obese and who are planning a pregnancy could benefit by working with their physicians to achieve a healthy weight before pregnancy."
The goal of this analysis from the National Birth Defects Prevention Study (NBDPS) was to evaluate associations between prepregnancy body mass index (BMI) and CHDs in the offspring. Case infants with CHDs (n = 6440) were compared vs 5673 liveborn control infants without birth defects enrolled in the NBDPS from 1997 to 2004.
For all CHDs combined, adjusted odds ratios were 1.16 for overweight status (95% confidence interval [CI], 1.05 - 1.29), 1.15 for moderate obesity (95% CI, 1.00 -1.32), and 1.31 for severe obesity (95% CI, 1.11 - 1.56). Phenotypes of CHD associated with maternal BMI of at least 25.0 kg/m2 were conotruncal defects (tetralogy of Fallot), total anomalous pulmonary venous return, hypoplastic left heart syndrome, right ventricular outflow tract (RVOT) defects (pulmonary valve stenosis), and septal defects (secundum atrial septal defect).
The study authors concluded that these findings supported those from previous research and also highlighted new associations between obesity and conotruncal defects and RVOT defects.
"These results support previous studies, as well as provide additional evidence, that there is an association between a woman being overweight or obese before pregnancy and certain types of heart defects," said lead author Suzanne M. Gilboa, PhD, epidemiologist at CDC's National Center on Birth Defects and Developmental Disabilities. "This provides another reason for women to maintain a healthy weight. In addition to the impact on a woman's own health and the known pregnancy complications associated with maternal obesity, the baby's health could be at risk."
Limitations of this study include BMI calculated from self-reported weight and height, some missing data for prepregnancy BMI, 70% response rate in the NBDPS, and inability to determine any causal relationship between maternal body weight and CHDs. In addition, study centers in Massachusetts and New Jersey did not ascertain case infants among pregnancy terminations, and New York began ascertaining pregnancy terminations only in the year 2000.
The NBDPS is funded by the CDC. The views expressed in the journal article are those of the study authors and do not necessarily represent the official position of the CDC.
Am J Obstet Gynecol. Published online October 1, 2009.
Sunday, September 27, 2009
Regular Exercise During Pregnancy May Lower Risk for Excessive Birth Weight
From Medscape Medical News
Laurie Barclay, MD
September 23, 2009 —- Regular exercise during pregnancy may lower the risk for excessive birth weight, according to the results of a cohort study reported in the October issue of Obstetrics & Gynecology.
"Despite extensive literature on the relationship between regular exercise during pregnancy and mean birth weight, the results are ambiguous and lack consistency," write Katrine Mari Owe, MSci, from Norwegian School of Sport Sciences in Oslo, Norway, and colleagues. "Both a positive and negative association with newborn birth weight have been suggested....The aim of the present study was to estimate, in a prospective cohort of pregnant women, the association of regular exercise, performed before and during pregnancy, with excessive newborn birth weight."
This analysis included data from 36,869 singleton pregnancies lasting at least 37 weeks among participants in the Norwegian Mother and Child Cohort Study. Two questionnaires administered during pregnancy weeks 17 and 30 provided data on regular exercise, and linkage to the Medical Birth Registry of Norway provided information regarding newborn birth weight. Excessive newborn birth weight, defined as birth weight at or above the 90th percentile, was the primary endpoint of the study. Associations were estimated separately for nulliparous (n = 16,064) and multiparous (n = 20,805) women with use of logistic regression analyses.
Of 4033 newborns (10.9%) with excessive birth weight, 2263 (56.1%) were born to multiparous women. Regular exercise (at least 3 times per week) in pregnancy weeks 17 and 30 was inversely associated with excessive newborn birth weight in nulliparous women (adjusted odds ratio [aOR], 0.72; 95% confidence interval [CI], 0.56 - 0.93 and aOR, 0.77; 95% CI 0.61 - 0.96, respectively).
"Regular exercise performed before pregnancy did not affect the probability of delivering newborns with an excessive birth weight in nulliparous or multiparous women," the study authors write.
"Regular exercise during pregnancy reduces the odds of giving birth to newborns with excessive birth weight by 23–28%."
Limitations of this study include indirect assessment of regular exercise with use of self-administered questionnaires, low response rate in the Norwegian Mother and Child Cohort Study, and possible confounding factors.
"Although our results indicate a protective effect of regular exercise during pregnancy, there seems to be an urgent need for randomized controlled trials with high methodological and interventional quality to be carried out to study the causal relationship between regular exercise in pregnancy and excessive newborn birth weight," the study authors conclude.
The Norwegian Mother and Child Cohort Study is supported by the Norwegian Ministry of Health, National Institutes of Health/National Institute of Environmental Health Sciences, National Institutes of Health/National Institute of Neurological Disorders and Stroke, and the Norwegian Research Council/Functional Genomics Project (FUGE). The study authors have disclosed no relevant financial relationships.
Obstet Gynecol. 2009;114:770-776.
Laurie Barclay, MD
September 23, 2009 —- Regular exercise during pregnancy may lower the risk for excessive birth weight, according to the results of a cohort study reported in the October issue of Obstetrics & Gynecology.
"Despite extensive literature on the relationship between regular exercise during pregnancy and mean birth weight, the results are ambiguous and lack consistency," write Katrine Mari Owe, MSci, from Norwegian School of Sport Sciences in Oslo, Norway, and colleagues. "Both a positive and negative association with newborn birth weight have been suggested....The aim of the present study was to estimate, in a prospective cohort of pregnant women, the association of regular exercise, performed before and during pregnancy, with excessive newborn birth weight."
This analysis included data from 36,869 singleton pregnancies lasting at least 37 weeks among participants in the Norwegian Mother and Child Cohort Study. Two questionnaires administered during pregnancy weeks 17 and 30 provided data on regular exercise, and linkage to the Medical Birth Registry of Norway provided information regarding newborn birth weight. Excessive newborn birth weight, defined as birth weight at or above the 90th percentile, was the primary endpoint of the study. Associations were estimated separately for nulliparous (n = 16,064) and multiparous (n = 20,805) women with use of logistic regression analyses.
Of 4033 newborns (10.9%) with excessive birth weight, 2263 (56.1%) were born to multiparous women. Regular exercise (at least 3 times per week) in pregnancy weeks 17 and 30 was inversely associated with excessive newborn birth weight in nulliparous women (adjusted odds ratio [aOR], 0.72; 95% confidence interval [CI], 0.56 - 0.93 and aOR, 0.77; 95% CI 0.61 - 0.96, respectively).
"Regular exercise performed before pregnancy did not affect the probability of delivering newborns with an excessive birth weight in nulliparous or multiparous women," the study authors write.
"Regular exercise during pregnancy reduces the odds of giving birth to newborns with excessive birth weight by 23–28%."
Limitations of this study include indirect assessment of regular exercise with use of self-administered questionnaires, low response rate in the Norwegian Mother and Child Cohort Study, and possible confounding factors.
"Although our results indicate a protective effect of regular exercise during pregnancy, there seems to be an urgent need for randomized controlled trials with high methodological and interventional quality to be carried out to study the causal relationship between regular exercise in pregnancy and excessive newborn birth weight," the study authors conclude.
The Norwegian Mother and Child Cohort Study is supported by the Norwegian Ministry of Health, National Institutes of Health/National Institute of Environmental Health Sciences, National Institutes of Health/National Institute of Neurological Disorders and Stroke, and the Norwegian Research Council/Functional Genomics Project (FUGE). The study authors have disclosed no relevant financial relationships.
Obstet Gynecol. 2009;114:770-776.
Monday, September 14, 2009
FDA Approves Blood Test That Helps Detect Ovarian Cancer
From Medscape Medical News
Yael Waknine
September 14, 2009 — The US Food and Drug Administration (FDA) has approved a novel blood test (OVA1, Vermillion Inc and Quest Diagnostics) to help detect ovarian cancer in adult women with pelvic tumors that are known to need surgery.
The test consolidates immunoassay results for 5 proteins known to change with ovarian cancer, rating the likelihood of malignancy on a scale of 1 to 10.
"OVA1 is the first FDA-cleared laboratory test that can indicate the likelihood of ovarian cancer with high sensitivity prior to biopsy or exploratory surgery, even if radiological test results fail to indicate malignancy," the company said in a news release.
Identifying potentially malignant cases before surgery allows involvement of a gynecologic oncologist, which can improve patient outcome.
According to the FDA, ovarian cancer patients have demonstrated improved survival when the surgery is performed by gynecologic oncologists rather than general gynecologists or surgeons.
"Tests such as OVA1 personalize and improve public health by providing patients and health care providers with more information to support medical decisions that impact survival rates and reduce surgical complications," noted Jeffrey Shuren, MD, JD, acting director of the FDA's Center for Devices and Radiological Health.
OVA1 should only be used to compliment other diagnostic and clinical procedures; the test is not indicated for screening purposes or to achieve a definite diagnosis of ovarian cancer.
Yael Waknine
September 14, 2009 — The US Food and Drug Administration (FDA) has approved a novel blood test (OVA1, Vermillion Inc and Quest Diagnostics) to help detect ovarian cancer in adult women with pelvic tumors that are known to need surgery.
The test consolidates immunoassay results for 5 proteins known to change with ovarian cancer, rating the likelihood of malignancy on a scale of 1 to 10.
"OVA1 is the first FDA-cleared laboratory test that can indicate the likelihood of ovarian cancer with high sensitivity prior to biopsy or exploratory surgery, even if radiological test results fail to indicate malignancy," the company said in a news release.
Identifying potentially malignant cases before surgery allows involvement of a gynecologic oncologist, which can improve patient outcome.
According to the FDA, ovarian cancer patients have demonstrated improved survival when the surgery is performed by gynecologic oncologists rather than general gynecologists or surgeons.
"Tests such as OVA1 personalize and improve public health by providing patients and health care providers with more information to support medical decisions that impact survival rates and reduce surgical complications," noted Jeffrey Shuren, MD, JD, acting director of the FDA's Center for Devices and Radiological Health.
OVA1 should only be used to compliment other diagnostic and clinical procedures; the test is not indicated for screening purposes or to achieve a definite diagnosis of ovarian cancer.
Friday, September 11, 2009
Elective Induction of Labor at 41 Weeks or Longer May Reduce Risk for Cesarean Delivery
From Medscape Medical News
Laurie Barclay, MD
August 17, 2009 — Elective induction of labor at 41 weeks of gestation or later is associated with a decreased risk for cesarean delivery and meconium-stained amniotic fluid, according to the results of a systematic review reported in the August 18 issue of the Annals of Internal Medicine. However, the reviewers warn against translating these findings to actual practice.
"The rates of induction of labor and elective induction of labor are increasing," write Aaron B. Caughey, MD, MPP, MPH, PhD, from Stanford University in California, and colleagues. "Whether elective induction of labor improves outcomes or simply leads to greater complications and health care costs is commonly debated in the literature."
The goal of this review was to compare the benefits and harms of elective induction of labor with those of expectant management of pregnancy. The reviewers searched Medline through February 2009; Web of Science, CINAHL, and the Cochrane Central Register of Controlled Trials through March 2009; reference lists of retrieved studies; and previously published systematic reviews for English-language articles describing experimental and observational studies of elective induction of labor.
Two of the reviewers abstracted information regarding study design, patient characteristics, methodologic quality, and outcomes including cesarean delivery and maternal and neonatal morbidity. Of 6117 articles identified, 36 met inclusion criteria, of which 11 were randomized controlled trials (RCTs) and 25 were observational studies.
Compared with elective induction of labor, expectant management of pregnancy was associated in 9 RCTs with a higher odds ratio (OR) of cesarean delivery (OR, 1.22; 95% confidence interval [CI], 1.07 – 1.39; absolute risk difference, 1.9 percentage points; 95% CI, 0.2 – 3.7 percentage points). Risk for cesarean delivery was higher in women at or beyond 41 completed weeks of gestation who were managed expectantly (OR, 1.21; 95% CI, 1.01 – 1.46). However, this difference was not statistically significant in women at less than 41 completed weeks of gestation (OR, 1.73; 95% CI, 0.67 – 4.5).
Compared with women who had elective induction of labor, those who were managed expectantly were more likely to have meconium-stained amniotic fluid (OR, 2.04; 95% CI, 1.34 – 3.09).
"RCTs suggest that elective induction of labor at 41 weeks of gestation and beyond is associated with a decreased risk for cesarean delivery and meconium-stained amniotic fluid," the review authors write. "There are concerns about the translation of these findings into actual practice; thus, future studies should examine elective induction of labor in settings where most obstetric care is provided."
Limitations of this review include that there were no recent RCTs of elective induction of labor at less than 41 weeks of gestation. The 2 studies conducted at less than 41 weeks of gestation were of poor quality, and the findings could not be generalized to current practice.
In an accompanying editorial, George A. Macones, MD, MSCE, from Washington University in St. Louis School of Medicine in Missouri, notes the need for well-designed RCTs of induction vs expectant management at 39 to 41 weeks that are sufficiently powered to evaluate critical subgroups, such as parity and cervical examination at randomization. In addition to studying rates of cesarean delivery, he also recommends studying the effect of new strategies on healthcare utilization and costs.
"Elective inductions are on the rise," Dr. Macones writes. "This development may not be as bad as obstetricians have traditionally believed. I hope that Caughey and colleagues' excellent systematic review will spur obstetricians to rethink and, more important, to more carefully research the role of elective induction of labor at and beyond 39 weeks."
Ann Intern Med. 2009;151:252–263, 281–282.
Laurie Barclay, MD
August 17, 2009 — Elective induction of labor at 41 weeks of gestation or later is associated with a decreased risk for cesarean delivery and meconium-stained amniotic fluid, according to the results of a systematic review reported in the August 18 issue of the Annals of Internal Medicine. However, the reviewers warn against translating these findings to actual practice.
"The rates of induction of labor and elective induction of labor are increasing," write Aaron B. Caughey, MD, MPP, MPH, PhD, from Stanford University in California, and colleagues. "Whether elective induction of labor improves outcomes or simply leads to greater complications and health care costs is commonly debated in the literature."
The goal of this review was to compare the benefits and harms of elective induction of labor with those of expectant management of pregnancy. The reviewers searched Medline through February 2009; Web of Science, CINAHL, and the Cochrane Central Register of Controlled Trials through March 2009; reference lists of retrieved studies; and previously published systematic reviews for English-language articles describing experimental and observational studies of elective induction of labor.
Two of the reviewers abstracted information regarding study design, patient characteristics, methodologic quality, and outcomes including cesarean delivery and maternal and neonatal morbidity. Of 6117 articles identified, 36 met inclusion criteria, of which 11 were randomized controlled trials (RCTs) and 25 were observational studies.
Compared with elective induction of labor, expectant management of pregnancy was associated in 9 RCTs with a higher odds ratio (OR) of cesarean delivery (OR, 1.22; 95% confidence interval [CI], 1.07 – 1.39; absolute risk difference, 1.9 percentage points; 95% CI, 0.2 – 3.7 percentage points). Risk for cesarean delivery was higher in women at or beyond 41 completed weeks of gestation who were managed expectantly (OR, 1.21; 95% CI, 1.01 – 1.46). However, this difference was not statistically significant in women at less than 41 completed weeks of gestation (OR, 1.73; 95% CI, 0.67 – 4.5).
Compared with women who had elective induction of labor, those who were managed expectantly were more likely to have meconium-stained amniotic fluid (OR, 2.04; 95% CI, 1.34 – 3.09).
"RCTs suggest that elective induction of labor at 41 weeks of gestation and beyond is associated with a decreased risk for cesarean delivery and meconium-stained amniotic fluid," the review authors write. "There are concerns about the translation of these findings into actual practice; thus, future studies should examine elective induction of labor in settings where most obstetric care is provided."
Limitations of this review include that there were no recent RCTs of elective induction of labor at less than 41 weeks of gestation. The 2 studies conducted at less than 41 weeks of gestation were of poor quality, and the findings could not be generalized to current practice.
In an accompanying editorial, George A. Macones, MD, MSCE, from Washington University in St. Louis School of Medicine in Missouri, notes the need for well-designed RCTs of induction vs expectant management at 39 to 41 weeks that are sufficiently powered to evaluate critical subgroups, such as parity and cervical examination at randomization. In addition to studying rates of cesarean delivery, he also recommends studying the effect of new strategies on healthcare utilization and costs.
"Elective inductions are on the rise," Dr. Macones writes. "This development may not be as bad as obstetricians have traditionally believed. I hope that Caughey and colleagues' excellent systematic review will spur obstetricians to rethink and, more important, to more carefully research the role of elective induction of labor at and beyond 39 weeks."
Ann Intern Med. 2009;151:252–263, 281–282.
Depression and Pregnancy: New Report Weighs Treatment Options
From Medscape Medical News
Deborah Brauser
August 21, 2009 — A joint report from the American Psychiatric Association (APA) and the American College of Obstetricians and Gynecologists (ACOG) aims to provide a new resource for clinicians who care for pregnant women who either have or are at risk of developing major depressive disorder.
"In terms of birth outcomes, the literature suggests that it's likely that both depression as well as antidepressant treatment confer risks and may be associated with adverse birth outcomes. However, the data looking at both of these together are insufficient at this point," Dr. Yonkers added.
In addition, the authors write that available research has not yet adequately controlled for other factors that may influence birth outcomes, including maternal illness or problematic health behaviors. The use of multiple medications during pregnancy also makes it difficult to assess the effect of a single compound, such as an antidepressant, on maternal and fetal outcomes.
According to the report, between 14% and 23% of pregnant women experience depressive symptoms, and approximately 13% of women in 2003 took an antidepressant at some time during pregnancy. "Thus, clinicians and patients need up-to-date information to assist with decisions about depression treatment during pregnancy," the authors write.
At the end of the review, the investigators found that although both depressive symptoms and antidepressant exposure are associated with fetal growth changes and shorter gestation periods, the majority of the studies that evaluated antidepressant risks were unable to control for the possible effects of a depressive disorder.
The researchers also found that:
Neonates born to mothers with a depressive disorder have an increased risk for irritability, less activity and attentiveness, and fewer facial expressions compared with those born to mothers without depression.
Several studies report fetal malformations in association with first-trimester antidepressant exposure, but there is no specific pattern of defects for individual medications or class of agents.
The association between paroxetine and cardiac defects is more often found in studies that included all malformations, rather than clinically significant malformations.
Late gestational use of selective serotonin reuptake inhibitor antidepressants is associated with transitory neonatal signs and an increased risk for persistent pulmonary hypertension in the newborn.
Most of the studies did not show an association between tricyclic antidepressant use in pregnancy and structural malformations, but tricyclic antidepressants are associated with increased perinatal complications such as jitteriness, irritability, and convulsions in neonates.
The report also recommends several treatment algorithms. These common scenarios include the following.
Women Thinking About Getting Pregnant
Tapering and discontinuing medication for those with mild or no depressive symptoms for 6 months or longer.
This discontinuation may not be appropriate for women with a history of severe or recurrent depression (or who have psychosis, bipolar disorder, other psychiatric illness requiring medication, or a history of suicide attempts).
Pregnant Women Currently on Medication for Depression
After a consultation between their psychiatrist and obstetrician/gynecologist (to discuss risks), psychiatrically stable women who prefer to stay on medication may be able to do so.
For those who want to discontinue medication and are not experiencing symptoms, tapering and discontinuation may be attempted. However, women with a history of recurrent depression are at a high risk for relapse.
Those with recurrent depression or symptoms despite their medication may benefit from psychotherapy to replace or augment medication.
Women with severe depression should remain on medication. If a patient refuses, alternative treatment and monitoring should be in place, preferably before discontinuation.
Pregnant Women Not Currently on Medication for Depression
For those who want to avoid antidepressant medication, psychotherapy may be beneficial.
For those who prefer taking medication, risks and benefits of treatment choices should be evaluated and discussed.
In addition, regardless of circumstances, any pregnant woman with suicidal or psychotic symptoms should seek an immediate consultation with a psychiatrist for treatment.
"In the past, reproductive health practitioners have felt ill equipped to treat these patients because of the lack of available guidance concerning the management of depressed women during pregnancy. Many people — physicians and women alike — will be glad to know that their choices go beyond medication or nothing," ACOG President Gerald F. Joseph, Jr, MD, said in a statement.
Limitations of this report are that only a minority of the studies reviewed included information on maternal psychiatric illness. Studies with detailed information regarding diagnoses and antidepressant use were usually smaller and had limited power to find important associations.
In addition, confounding factors that influence birth outcomes, such as poor prenatal care and drug, alcohol, and nicotine use, were variably controlled.
"This is a report intended to reach out to psychiatrists as well as obstetrician-gynecologists," said Dr. Yonkers. "We developed algorithms which I think reflect the fact that there are multiple issues to consider and [that] there should be no knee-jerk response in managing a woman who is depressed and pregnant or contemplating pregnancy. Psychiatric history and a woman's preference are among the important features that should be taken into consideration."
Gen Hosp Psychiatry. 2009;31(5):403–413.
Obstet Gynecol. 2009;114(3):703–713.
Deborah Brauser
August 21, 2009 — A joint report from the American Psychiatric Association (APA) and the American College of Obstetricians and Gynecologists (ACOG) aims to provide a new resource for clinicians who care for pregnant women who either have or are at risk of developing major depressive disorder.
"In terms of birth outcomes, the literature suggests that it's likely that both depression as well as antidepressant treatment confer risks and may be associated with adverse birth outcomes. However, the data looking at both of these together are insufficient at this point," Dr. Yonkers added.
In addition, the authors write that available research has not yet adequately controlled for other factors that may influence birth outcomes, including maternal illness or problematic health behaviors. The use of multiple medications during pregnancy also makes it difficult to assess the effect of a single compound, such as an antidepressant, on maternal and fetal outcomes.
According to the report, between 14% and 23% of pregnant women experience depressive symptoms, and approximately 13% of women in 2003 took an antidepressant at some time during pregnancy. "Thus, clinicians and patients need up-to-date information to assist with decisions about depression treatment during pregnancy," the authors write.
At the end of the review, the investigators found that although both depressive symptoms and antidepressant exposure are associated with fetal growth changes and shorter gestation periods, the majority of the studies that evaluated antidepressant risks were unable to control for the possible effects of a depressive disorder.
The researchers also found that:
Neonates born to mothers with a depressive disorder have an increased risk for irritability, less activity and attentiveness, and fewer facial expressions compared with those born to mothers without depression.
Several studies report fetal malformations in association with first-trimester antidepressant exposure, but there is no specific pattern of defects for individual medications or class of agents.
The association between paroxetine and cardiac defects is more often found in studies that included all malformations, rather than clinically significant malformations.
Late gestational use of selective serotonin reuptake inhibitor antidepressants is associated with transitory neonatal signs and an increased risk for persistent pulmonary hypertension in the newborn.
Most of the studies did not show an association between tricyclic antidepressant use in pregnancy and structural malformations, but tricyclic antidepressants are associated with increased perinatal complications such as jitteriness, irritability, and convulsions in neonates.
The report also recommends several treatment algorithms. These common scenarios include the following.
Women Thinking About Getting Pregnant
Tapering and discontinuing medication for those with mild or no depressive symptoms for 6 months or longer.
This discontinuation may not be appropriate for women with a history of severe or recurrent depression (or who have psychosis, bipolar disorder, other psychiatric illness requiring medication, or a history of suicide attempts).
Pregnant Women Currently on Medication for Depression
After a consultation between their psychiatrist and obstetrician/gynecologist (to discuss risks), psychiatrically stable women who prefer to stay on medication may be able to do so.
For those who want to discontinue medication and are not experiencing symptoms, tapering and discontinuation may be attempted. However, women with a history of recurrent depression are at a high risk for relapse.
Those with recurrent depression or symptoms despite their medication may benefit from psychotherapy to replace or augment medication.
Women with severe depression should remain on medication. If a patient refuses, alternative treatment and monitoring should be in place, preferably before discontinuation.
Pregnant Women Not Currently on Medication for Depression
For those who want to avoid antidepressant medication, psychotherapy may be beneficial.
For those who prefer taking medication, risks and benefits of treatment choices should be evaluated and discussed.
In addition, regardless of circumstances, any pregnant woman with suicidal or psychotic symptoms should seek an immediate consultation with a psychiatrist for treatment.
"In the past, reproductive health practitioners have felt ill equipped to treat these patients because of the lack of available guidance concerning the management of depressed women during pregnancy. Many people — physicians and women alike — will be glad to know that their choices go beyond medication or nothing," ACOG President Gerald F. Joseph, Jr, MD, said in a statement.
Limitations of this report are that only a minority of the studies reviewed included information on maternal psychiatric illness. Studies with detailed information regarding diagnoses and antidepressant use were usually smaller and had limited power to find important associations.
In addition, confounding factors that influence birth outcomes, such as poor prenatal care and drug, alcohol, and nicotine use, were variably controlled.
"This is a report intended to reach out to psychiatrists as well as obstetrician-gynecologists," said Dr. Yonkers. "We developed algorithms which I think reflect the fact that there are multiple issues to consider and [that] there should be no knee-jerk response in managing a woman who is depressed and pregnant or contemplating pregnancy. Psychiatric history and a woman's preference are among the important features that should be taken into consideration."
Gen Hosp Psychiatry. 2009;31(5):403–413.
Obstet Gynecol. 2009;114(3):703–713.
Thursday, September 10, 2009
First Trial of H1N1 Vaccine for Pregnant Women to Begin This Week
From Medscape Medical News
Martha Kerr
September 10, 2009 — The first clinical trial of a 2009 influenza A (H1N1) candidate vaccine for pregnant women will launch this week, according to the National Institute of Allergy and Infectious Diseases (NIAID).
"Data indicate that pregnant women are at higher risk for complications from the 2009 H1N1 influenza virus . . . so this trial will provide critical information for public-health planning," NIAID director Anthony S. Fauci, MD, said in an NIAID announcement.
Centers for Disease Control and Prevention (CDC) figures show that 45 deaths from H1N1 influenza occurred between mid-April and mid-June of this year. Of these, 6 (13%) were in pregnant women. During the first month of the H1N1 influenza outbreak this year, pregnant women were 4 times more likely to be hospitalized with the flu than the general population.
"Women are at higher risk of developing severe illness if they become infected with influenza virus while pregnant, which is why they are strongly encouraged to receive the seasonal influenza vaccine every year," Dr. Fauci said.
The CDC's Advisory Committee on Immunization Practices has recommended that pregnant women be among the top-priority groups and receive the H1N1 vaccine as soon as one becomes available.
The trial will involve up to 120 pregnant women, aged 18 and 39 years, who are between 14 and 34 weeks' gestation.
Subjects will receive either 15 or 30 µg of a vaccine manufactured by Sanofi Pasteur. It will be administered in 2 doses, given 21 days apart, using the same trial design as that for the H1N1 vaccine that began in August.
The vaccine contains inactivated virus and has no thimerosal or adjuvant added.
Safety will be monitored continuously, as will immune response to the vaccine, including antibody production. Umbilical cord blood will be collected at delivery to assess the transfer of maternal antibodies to the infant.
The NIAID-funded national network of Vaccine and Treatment Evaluation Units (VTEUs) is conducting the trial at 6 sites: Baylor College of Medicine VTEU in Houston, Texas; Group Health Cooperative Center for Health Studies VTEU in Seattle, Washington; Saint Louis University VTEU, in Missouri; Vanderbilt University VTEU in Nashville, Tennessee; Duke University in Durham, North Carolina; and Scott and White Memorial Hospital and Clinic in Temple, Texas.
The NIAID is also planning to conduct trials in pregnant women of other candidate 2009 H1N1 influenza vaccines made by other manufacturers.
Detailed information about this study can be found on the ClinicalTrials.gov Web site.
Martha Kerr
September 10, 2009 — The first clinical trial of a 2009 influenza A (H1N1) candidate vaccine for pregnant women will launch this week, according to the National Institute of Allergy and Infectious Diseases (NIAID).
"Data indicate that pregnant women are at higher risk for complications from the 2009 H1N1 influenza virus . . . so this trial will provide critical information for public-health planning," NIAID director Anthony S. Fauci, MD, said in an NIAID announcement.
Centers for Disease Control and Prevention (CDC) figures show that 45 deaths from H1N1 influenza occurred between mid-April and mid-June of this year. Of these, 6 (13%) were in pregnant women. During the first month of the H1N1 influenza outbreak this year, pregnant women were 4 times more likely to be hospitalized with the flu than the general population.
"Women are at higher risk of developing severe illness if they become infected with influenza virus while pregnant, which is why they are strongly encouraged to receive the seasonal influenza vaccine every year," Dr. Fauci said.
The CDC's Advisory Committee on Immunization Practices has recommended that pregnant women be among the top-priority groups and receive the H1N1 vaccine as soon as one becomes available.
The trial will involve up to 120 pregnant women, aged 18 and 39 years, who are between 14 and 34 weeks' gestation.
Subjects will receive either 15 or 30 µg of a vaccine manufactured by Sanofi Pasteur. It will be administered in 2 doses, given 21 days apart, using the same trial design as that for the H1N1 vaccine that began in August.
The vaccine contains inactivated virus and has no thimerosal or adjuvant added.
Safety will be monitored continuously, as will immune response to the vaccine, including antibody production. Umbilical cord blood will be collected at delivery to assess the transfer of maternal antibodies to the infant.
The NIAID-funded national network of Vaccine and Treatment Evaluation Units (VTEUs) is conducting the trial at 6 sites: Baylor College of Medicine VTEU in Houston, Texas; Group Health Cooperative Center for Health Studies VTEU in Seattle, Washington; Saint Louis University VTEU, in Missouri; Vanderbilt University VTEU in Nashville, Tennessee; Duke University in Durham, North Carolina; and Scott and White Memorial Hospital and Clinic in Temple, Texas.
The NIAID is also planning to conduct trials in pregnant women of other candidate 2009 H1N1 influenza vaccines made by other manufacturers.
Detailed information about this study can be found on the ClinicalTrials.gov Web site.
Risk for Breast Cancer Recurrence Decreased by Lifestyle Changes
From Medscape Medical News
Roxanne Nelson
September 9, 2009 — Breast cancer survivors might be able to reduce their risk for contralateral breast cancer by making lifestyle modifications. A new study published online September 8 in the Journal of Clinical Oncology has found that obesity, alcohol use, and smoking all significantly increase the risk for second primary invasive contralateral breast cancer among breast cancer survivors.
Researchers from the Fred Hutchinson Cancer Research Center in Seattle, Washington, found that obese women had a 50% increased risk for contralateral breast cancer, and those who consumed 7 or more alcoholic drinks per week had a 90% increased risk. Survivors who currently smoked had a 120% increased risk of developing a second breast cancer.
The risk was particularly high in women who were current smokers and who consumed at least 1 alcoholic beverage a day. The authors found that this subgroup of women had a 7.2-fold (95% confidence interval [CI], 1.9 to 26.5) elevated risk for contralateral breast cancer.
Limited Data on Role of Lifestyle in Preventing Second Cancer
There is substantial evidence that modifiable lifestyle factors play a significant role in the risk for primary breast cancer. As recently reported by Medscape Oncology, an updated version of the American Institute for Cancer Research/World Cancer Research Fund's report, Food, Nutrition, Physical Activity, and the Prevention of Cancer: A Global Perspective, reaffirmed that factors such as maintaining a healthy weight, exercising regularly, and limiting consumption of alcoholic beverages can reduce the risk of developing breast cancer.
However, information on lifestyle factors and their role in preventing contralateral disease in survivors is more limited. The authors point out that although adjuvant hormone therapy can lower the risk by 47%, little is known about other factors that are within the patient's control.
Reducing the risk for a second cancer is of considerable concern, they note, because breast cancer survivors have a risk of developing a contralateral breast cancer that is 2 to 6 times greater than that of women in the general population developing a first breast cancer. Therefore, identifying potentially modifiable risk factors is of public-health relevance and of individual importance to breast cancer survivors, the authors note.
"But 1 issue in our study was that while some of the smokers stopped smoking, few of the drinkers changed their drinking habits, and few of the obese women lost weight, so we could not directly assess the impact that changing these habits had on reducing risk of a second breast cancer," lead author Christopher I. Li, MD, PhD, associate member of the Public Health Sciences Division at the Hutchinson Center, told Medscape Oncology.
"That said, the evidence regarding obesity and alcohol use and risk of a first breast cancer does suggest that reducing body weight and reducing alcohol consumption does lower risk of first breast cancer, so I would expect that changing these things could also reduce the risk of second breast cancer," he added.
Obesity, Alcohol Use, and Smoking Increase Risk
In this study, Dr. Li and colleagues evaluated the effect of obesity, alcohol consumption, and smoking on risk for second primary invasive contralateral breast cancer among breast cancer survivors.
The cohort consisted of 365 women who were diagnosed with an estrogen-receptor (ER)-positive first primary invasive breast cancer and a second primary contralateral invasive breast cancer, and 726 matched controls who were diagnosed with only an ER-positive first primary invasive breast cancer.
Information regarding obesity, alcohol use, and smoking was acquired from medical-record reviews and from interviews with the participants. The researchers then used conditional logistic regression to assess the association of these 3 factors and the risk for a second cancer.
They found that compared with women who had a body mass index (BMI) lower than 25.0 kg/m2, those with a BMI of 30.0 kg/m2 or above had a higher risk for contralateral breast cancer (odds ratio [OR], 1.4; 95% CI, 1.0 to 2.1).
The consumption of alcohol was also positively related to an increased risk for a second cancer (OR, 1.9; 95% CI, 1.1 to 3.2) when evaluated at both the first diagnosis of breast cancer and during the interval between first breast cancer diagnosis and reference date.
In similar fashion, current smokers had an elevated risk for contralateral breast cancer (OR, 2.2; 95% CI, 1.2 to 4.0) at first breast cancer diagnosis and at reference date, compared with women who had never smoked. The association between smoking and cancer risk did not vary by pack-years, the authors note. A small number of women were smokers at the time of their first diagnosis but quit by their reference date (14 patients and 29 control subjects), and this did not seem to influence the risk of developing a second breast cancer.
This observation suggests that recent smoking is the most relevant to risk, the authors note. "There were also too few women who were exsmokers and who started smoking again after their first breast cancer diagnosis for us to be able to assess this aspect," said Dr. Li.
Impact of Hormone Therapy Unclear
Despite having ER-positive primary cancers, 30% of the control women and 39.5% of the patients with contralateral disease were not treated with adjuvant hormone therapy. However, the researchers explain that this cohort included patients who received their first breast cancer diagnosis nearly 2 decades ago. At that time, the use of hormone therapy differed from what it is now, and as a result, fewer women received this type of treatment or for the amount of time needed for it to confer maximal clinical benefit.
But given the low rates of hormonal therapy use in this cohort, "it is reasonable to ask whether the relationship between weight and alcohol use seen in this study would be maintained in women with ER-positive tumors treated according to current adjuvant therapy guidelines," writes Jennifer A. Ligibel, MD, from the Dana-Farber Cancer Institute, Harvard Medical School, in Boston, Massachusetts, in an editorial.
"Thus, further work is needed to define the impact of modifiable factors on the risk of second primary breast cancers from modern observational data sets including women treated with modern hormonal therapy regimens," she notes.
The study was funded by a grant from the National Cancer Institute. The study authors and editorialist have disclosed no relevant financial relationships.
J Clin Oncol. Published online before print September 8, 2009.
Roxanne Nelson
September 9, 2009 — Breast cancer survivors might be able to reduce their risk for contralateral breast cancer by making lifestyle modifications. A new study published online September 8 in the Journal of Clinical Oncology has found that obesity, alcohol use, and smoking all significantly increase the risk for second primary invasive contralateral breast cancer among breast cancer survivors.
Researchers from the Fred Hutchinson Cancer Research Center in Seattle, Washington, found that obese women had a 50% increased risk for contralateral breast cancer, and those who consumed 7 or more alcoholic drinks per week had a 90% increased risk. Survivors who currently smoked had a 120% increased risk of developing a second breast cancer.
The risk was particularly high in women who were current smokers and who consumed at least 1 alcoholic beverage a day. The authors found that this subgroup of women had a 7.2-fold (95% confidence interval [CI], 1.9 to 26.5) elevated risk for contralateral breast cancer.
Limited Data on Role of Lifestyle in Preventing Second Cancer
There is substantial evidence that modifiable lifestyle factors play a significant role in the risk for primary breast cancer. As recently reported by Medscape Oncology, an updated version of the American Institute for Cancer Research/World Cancer Research Fund's report, Food, Nutrition, Physical Activity, and the Prevention of Cancer: A Global Perspective, reaffirmed that factors such as maintaining a healthy weight, exercising regularly, and limiting consumption of alcoholic beverages can reduce the risk of developing breast cancer.
However, information on lifestyle factors and their role in preventing contralateral disease in survivors is more limited. The authors point out that although adjuvant hormone therapy can lower the risk by 47%, little is known about other factors that are within the patient's control.
Reducing the risk for a second cancer is of considerable concern, they note, because breast cancer survivors have a risk of developing a contralateral breast cancer that is 2 to 6 times greater than that of women in the general population developing a first breast cancer. Therefore, identifying potentially modifiable risk factors is of public-health relevance and of individual importance to breast cancer survivors, the authors note.
"But 1 issue in our study was that while some of the smokers stopped smoking, few of the drinkers changed their drinking habits, and few of the obese women lost weight, so we could not directly assess the impact that changing these habits had on reducing risk of a second breast cancer," lead author Christopher I. Li, MD, PhD, associate member of the Public Health Sciences Division at the Hutchinson Center, told Medscape Oncology.
"That said, the evidence regarding obesity and alcohol use and risk of a first breast cancer does suggest that reducing body weight and reducing alcohol consumption does lower risk of first breast cancer, so I would expect that changing these things could also reduce the risk of second breast cancer," he added.
Obesity, Alcohol Use, and Smoking Increase Risk
In this study, Dr. Li and colleagues evaluated the effect of obesity, alcohol consumption, and smoking on risk for second primary invasive contralateral breast cancer among breast cancer survivors.
The cohort consisted of 365 women who were diagnosed with an estrogen-receptor (ER)-positive first primary invasive breast cancer and a second primary contralateral invasive breast cancer, and 726 matched controls who were diagnosed with only an ER-positive first primary invasive breast cancer.
Information regarding obesity, alcohol use, and smoking was acquired from medical-record reviews and from interviews with the participants. The researchers then used conditional logistic regression to assess the association of these 3 factors and the risk for a second cancer.
They found that compared with women who had a body mass index (BMI) lower than 25.0 kg/m2, those with a BMI of 30.0 kg/m2 or above had a higher risk for contralateral breast cancer (odds ratio [OR], 1.4; 95% CI, 1.0 to 2.1).
The consumption of alcohol was also positively related to an increased risk for a second cancer (OR, 1.9; 95% CI, 1.1 to 3.2) when evaluated at both the first diagnosis of breast cancer and during the interval between first breast cancer diagnosis and reference date.
In similar fashion, current smokers had an elevated risk for contralateral breast cancer (OR, 2.2; 95% CI, 1.2 to 4.0) at first breast cancer diagnosis and at reference date, compared with women who had never smoked. The association between smoking and cancer risk did not vary by pack-years, the authors note. A small number of women were smokers at the time of their first diagnosis but quit by their reference date (14 patients and 29 control subjects), and this did not seem to influence the risk of developing a second breast cancer.
This observation suggests that recent smoking is the most relevant to risk, the authors note. "There were also too few women who were exsmokers and who started smoking again after their first breast cancer diagnosis for us to be able to assess this aspect," said Dr. Li.
Impact of Hormone Therapy Unclear
Despite having ER-positive primary cancers, 30% of the control women and 39.5% of the patients with contralateral disease were not treated with adjuvant hormone therapy. However, the researchers explain that this cohort included patients who received their first breast cancer diagnosis nearly 2 decades ago. At that time, the use of hormone therapy differed from what it is now, and as a result, fewer women received this type of treatment or for the amount of time needed for it to confer maximal clinical benefit.
But given the low rates of hormonal therapy use in this cohort, "it is reasonable to ask whether the relationship between weight and alcohol use seen in this study would be maintained in women with ER-positive tumors treated according to current adjuvant therapy guidelines," writes Jennifer A. Ligibel, MD, from the Dana-Farber Cancer Institute, Harvard Medical School, in Boston, Massachusetts, in an editorial.
"Thus, further work is needed to define the impact of modifiable factors on the risk of second primary breast cancers from modern observational data sets including women treated with modern hormonal therapy regimens," she notes.
The study was funded by a grant from the National Cancer Institute. The study authors and editorialist have disclosed no relevant financial relationships.
J Clin Oncol. Published online before print September 8, 2009.
Saturday, September 5, 2009
Osteoporosis Risk in Premenopausal Women
From Pharmacotherapy
Sheryl E Vondracek, Pharm.D., FCCP; Laura B. Hansen, Pharm.D., FCCP; Michael T. McDermott, M.D.
Abstract
Although clinically significant bone loss and fractures in healthy premenopausal women are rare, more women are seeking evaluation for osteoporosis from their health care providers. As pharmacists are in an ideal position to influence the management of premenopausal women with osteoporosis, it is important that pharmacists understand the available data on bone loss, fractures, and risk factors and secondary causes for osteoporosis, as well as when to recommend testing and treatment in premenopausal women. Limited data are available; therefore, we conducted a MEDLINE search of the literature from January 1993-August 2008.
Studies evaluating bone loss, fractures, and fracture risk in healthy premenopausal women were targeted and summarized; most recommendations are based on expert opinion. A small but statistically significant loss in bone mineral density of 0.25-1%/year by dual-energy x-ray absorptiometry is seen healthy premenopausal women; the clinical significance of this is unknown.
Whereas absolute fracture risk is low, premenopausal fractures appear to increase postmenopausal fracture risk by 1.5-3-fold. Risk factors for low bone density appear to be similar between pre- and postmenopausal women.
Bone density screening in healthy premenopausal women is not recommended, but bone mineral density testing is advisable for those who have conditions or who receive drug therapy that may cause secondary bone loss.
Lifestyle modification emphasizing bone-healthy habits such as adequate calcium and vitamin D nutrition, regular exercise, limitation of caffeine and alcohol consumption, and avoidance of tobacco are essential to the management of osteoporosis risk.
The efficacy and safety of osteoporosis drugs have not been adequately demonstrated in premenopausal women. Therefore, pharmacologic interventions cannot be recommended in young women with low bone mass but may be considered in those having a more significant fracture risk, such as those with a previous low-trauma fracture or an identified secondary cause for bone loss.
Sheryl E Vondracek, Pharm.D., FCCP; Laura B. Hansen, Pharm.D., FCCP; Michael T. McDermott, M.D.
Abstract
Although clinically significant bone loss and fractures in healthy premenopausal women are rare, more women are seeking evaluation for osteoporosis from their health care providers. As pharmacists are in an ideal position to influence the management of premenopausal women with osteoporosis, it is important that pharmacists understand the available data on bone loss, fractures, and risk factors and secondary causes for osteoporosis, as well as when to recommend testing and treatment in premenopausal women. Limited data are available; therefore, we conducted a MEDLINE search of the literature from January 1993-August 2008.
Studies evaluating bone loss, fractures, and fracture risk in healthy premenopausal women were targeted and summarized; most recommendations are based on expert opinion. A small but statistically significant loss in bone mineral density of 0.25-1%/year by dual-energy x-ray absorptiometry is seen healthy premenopausal women; the clinical significance of this is unknown.
Whereas absolute fracture risk is low, premenopausal fractures appear to increase postmenopausal fracture risk by 1.5-3-fold. Risk factors for low bone density appear to be similar between pre- and postmenopausal women.
Bone density screening in healthy premenopausal women is not recommended, but bone mineral density testing is advisable for those who have conditions or who receive drug therapy that may cause secondary bone loss.
Lifestyle modification emphasizing bone-healthy habits such as adequate calcium and vitamin D nutrition, regular exercise, limitation of caffeine and alcohol consumption, and avoidance of tobacco are essential to the management of osteoporosis risk.
The efficacy and safety of osteoporosis drugs have not been adequately demonstrated in premenopausal women. Therefore, pharmacologic interventions cannot be recommended in young women with low bone mass but may be considered in those having a more significant fracture risk, such as those with a previous low-trauma fracture or an identified secondary cause for bone loss.
Friday, September 4, 2009
New Data Confirm Lifestyle Changes Can Dramatically Reduce Risk for Breast Cancer
From Medscape Medical News
Roxanne Nelson
September 3, 2009 — New data have confirmed that lifestyle factors play a significant role in the risk for breast cancer. An updated version of the American Institute for Cancer Research/World Cancer Research Fund's (AICR/WCRF) report, Food, Nutrition, Physical Activity, and the Prevention of Cancer: A Global Perspective, reaffirms that factors such as maintaining a healthy weight, breastfeeding, exercising regularly, and limiting consumption of alcoholic beverages can reduce the risk for breast cancer.
The 2007 report is considered to be the most comprehensive scientific analysis of cancer prevention and causation ever undertaken, as previously reported by Medscape Oncology. The original paper reviewed 873 studies on breast cancer, and since that time, information from 81 new breast-cancer-related studies has been added to the database.
"This study represents the clearest picture we have ever had on how lifestyle affects a woman's risk of breast cancer," said Martin Wiseman, MD, medical and scientific adviser for AICR and WCRF, in a statement.
By maintaining a healthy weight, being physically active, and limiting the amount of alcohol they drink, women can dramatically reduce their risk.
"We are now more certain than ever that by maintaining a healthy weight, being physically active, and limiting the amount of alcohol they drink, women can dramatically reduce their risk," he added.
An AICR policy report issued in February 2009 estimated the percentage of cancers that could be prevented by incorporating the recommendations of the 2007 report. Overall, the report concluded that about one third of the most common cancers could be prevented by following AICR recommendations on body weight, physical activity, and diet.
They reported that 38% of cases of breast cancer in the United States could be prevented through diet, activity, and healthy weight. Based on figures from the American Cancer Society, that percentage extrapolates to about 70,000 new cases of breast cancer prevented each year.
Continuous Update Project Adds to Research
The report on breast cancer is part of the Continuous Update Project, the long-term goal of which is to continuously update the findings of the AICR/WCRF 2007 report. "When we published our 2007 report, we knew that we wanted to keep it a living document, so that its recommendations could always reflect the latest science without going out of date," explained Glen Weldon, director of communications at AICR. "That's what the Continuous Update Project is about."
For the Continuous Update Project, a smaller expert panel will collect and analyze new reports and combine the new data with the those from studies already in the database. "This will be done on a cancer-by-cancer basis," Mr. Weldon told Medscape Oncology. "Breast cancer was the most studied cancer in the years since the 2007 report, so that was the one we started with."
An independent systematic literature-review team identified an additional 81 breast cancer studies that met the criteria for inclusion. The expert panel then reviewed the new data, combined evidence, and determined that the new data only strengthened the 2007 report's conclusions.
Breast Feeding, Body Weight, Alcohol Consumption Affect Risk
In the updated chapter on breast cancer, the panel reached several conclusions regarding lifestyle/diet and breast cancer risk. They found "convincing evidence" that:
lactation protects against breast cancer at all ages
alcoholic drinks are a cause of breast cancer at all ages, and
body fatness is a cause of postmenopausal breast cancer.
In addition, there is convincing evidence that factors that lead to greater attained adult height or its consequences are a cause of postmenopausal breast cancer. The authors clarify that although adult attained height is unlikely to directly modify the risk for cancer, it is "a marker for genetic, environmental, hormonal, and nutritional factors affecting growth during the period from preconception to completion of linear growth."
Physical activity probably protects against postmenopausal breast cancer, and there is limited evidence suggesting that it protects against premenopausal breast cancer, the experts note.
Based on these conclusions, the AICR recommends the following for reducing the risk for breast cancer:
Because of the link between excess body fat and cancer, the goal is to be as lean as possible within the normal range of body weight.
Be physically active as part of everyday life.
Limit alcohol consumption to 1 drink per day for women (2 drinks for men).
Mothers should breastfeed exclusively for up to 6 months and then add other liquids and foods. Evidence is convincing that mothers who breastfeed reduce their risk for breast cancer, and there is also probable evidence that children who are breastfed have a lower risk of gaining excess weight as they grow.
World Cancer Research Fund/American Institute for Cancer Research. The Second Expert Report, Food, Nutrition, Physical Activity, and the Prevention of Cancer: A Global Perspective. Washington, DC: AICR; 2009.
Roxanne Nelson
September 3, 2009 — New data have confirmed that lifestyle factors play a significant role in the risk for breast cancer. An updated version of the American Institute for Cancer Research/World Cancer Research Fund's (AICR/WCRF) report, Food, Nutrition, Physical Activity, and the Prevention of Cancer: A Global Perspective, reaffirms that factors such as maintaining a healthy weight, breastfeeding, exercising regularly, and limiting consumption of alcoholic beverages can reduce the risk for breast cancer.
The 2007 report is considered to be the most comprehensive scientific analysis of cancer prevention and causation ever undertaken, as previously reported by Medscape Oncology. The original paper reviewed 873 studies on breast cancer, and since that time, information from 81 new breast-cancer-related studies has been added to the database.
"This study represents the clearest picture we have ever had on how lifestyle affects a woman's risk of breast cancer," said Martin Wiseman, MD, medical and scientific adviser for AICR and WCRF, in a statement.
By maintaining a healthy weight, being physically active, and limiting the amount of alcohol they drink, women can dramatically reduce their risk.
"We are now more certain than ever that by maintaining a healthy weight, being physically active, and limiting the amount of alcohol they drink, women can dramatically reduce their risk," he added.
An AICR policy report issued in February 2009 estimated the percentage of cancers that could be prevented by incorporating the recommendations of the 2007 report. Overall, the report concluded that about one third of the most common cancers could be prevented by following AICR recommendations on body weight, physical activity, and diet.
They reported that 38% of cases of breast cancer in the United States could be prevented through diet, activity, and healthy weight. Based on figures from the American Cancer Society, that percentage extrapolates to about 70,000 new cases of breast cancer prevented each year.
Continuous Update Project Adds to Research
The report on breast cancer is part of the Continuous Update Project, the long-term goal of which is to continuously update the findings of the AICR/WCRF 2007 report. "When we published our 2007 report, we knew that we wanted to keep it a living document, so that its recommendations could always reflect the latest science without going out of date," explained Glen Weldon, director of communications at AICR. "That's what the Continuous Update Project is about."
For the Continuous Update Project, a smaller expert panel will collect and analyze new reports and combine the new data with the those from studies already in the database. "This will be done on a cancer-by-cancer basis," Mr. Weldon told Medscape Oncology. "Breast cancer was the most studied cancer in the years since the 2007 report, so that was the one we started with."
An independent systematic literature-review team identified an additional 81 breast cancer studies that met the criteria for inclusion. The expert panel then reviewed the new data, combined evidence, and determined that the new data only strengthened the 2007 report's conclusions.
Breast Feeding, Body Weight, Alcohol Consumption Affect Risk
In the updated chapter on breast cancer, the panel reached several conclusions regarding lifestyle/diet and breast cancer risk. They found "convincing evidence" that:
lactation protects against breast cancer at all ages
alcoholic drinks are a cause of breast cancer at all ages, and
body fatness is a cause of postmenopausal breast cancer.
In addition, there is convincing evidence that factors that lead to greater attained adult height or its consequences are a cause of postmenopausal breast cancer. The authors clarify that although adult attained height is unlikely to directly modify the risk for cancer, it is "a marker for genetic, environmental, hormonal, and nutritional factors affecting growth during the period from preconception to completion of linear growth."
Physical activity probably protects against postmenopausal breast cancer, and there is limited evidence suggesting that it protects against premenopausal breast cancer, the experts note.
Based on these conclusions, the AICR recommends the following for reducing the risk for breast cancer:
Because of the link between excess body fat and cancer, the goal is to be as lean as possible within the normal range of body weight.
Be physically active as part of everyday life.
Limit alcohol consumption to 1 drink per day for women (2 drinks for men).
Mothers should breastfeed exclusively for up to 6 months and then add other liquids and foods. Evidence is convincing that mothers who breastfeed reduce their risk for breast cancer, and there is also probable evidence that children who are breastfed have a lower risk of gaining excess weight as they grow.
World Cancer Research Fund/American Institute for Cancer Research. The Second Expert Report, Food, Nutrition, Physical Activity, and the Prevention of Cancer: A Global Perspective. Washington, DC: AICR; 2009.
Shampoos
From Dermatitis
Matthew Zirwas; Jessica Moennich
Abstract
Shampoos are used almost universally in developed countries to wash the hair on a daily basis. A number of known contact allergens are used as ingredients in shampoos, and contact allergy due to shampoos is a well known entity. Patch testing can be used to identify ingredients to which patients are allergic, after which the physician can help the patient to find a shampoo that is free of the ingredients to which they are allergic. The ingredients used in shampoos have not been systematically reviewed in recent years in the United States. We use a database of products sold at a major drug store to quantify the most frequent allergens used in shampoos.
The allergens most commonly present, in order of prevalence are as follows: fragrance, cocamidopropyl betaine, ethylchloroisothiazolinone/methylisothiazolinone, formaldehyde releasers, propylene glycol, vitamin E, parabens, benzophenones, iodopropynyl butylcarbamate, and methyldibromoglutaronitrile/phenoxyethanol.
Introduction
Shampoo is the most commonly used product on the hair and scalp, and as a result, many different formulations are marketed on the basis of consumer-specific concerns such as hair manageability, problems associated with age and gender, and certain scalp problems such as dandruff and psoriasis. Shampoos are typically composed of 10 to 30 ingredients although products with as few as four ingredients are available, as are products with many more than 30 ingredients. Several types of ingredients are particularly important, including "surfactants" that aid in cleansing and lathering, "conditioners" and "active ingredients" that affect the hair and scalp, and "additives" that stabilize the product, add consumer appeal, and modify the effect of the surfactant.[1]
Although generally well tolerated, allergic contact dermatitis (ACD) due to ingredients in shampoo is a well-known entity.[2] ACD from shampoo can present as eyelid dermatitis, facial dermatitis, neck dermatitis, scalp dermatitis, dermatitis of the upper back, or dermatitis in more than one of these areas, often leading to difficulty in clinical diagnosis. Another confounding factor is that because of significant similarities in the ingredients of one shampoo to those of another, a patient who suspects shampoo allergy and thus changes products may change to another product that also contains the ingredient to which he or she is allergic and thus experience no improvement after the switch. This history often leads patients (and sometimes physicians) to erroneously assume that because the dermatitis did not improve following a change in shampoo, shampoo allergy is not the etiologic factor in the dermatitis.
Patch-testing for shampoo allergy can be challenging. Many of the relevant allergens are also irritants, which leads to possible false-positive results on patch testing.[3] Also, numerous allergens in shampoos are not included in current screening series, which makes it necessary to test with additional panels and to consider testing with the patient's own shampoo.[4] However, patch-testing directly with shampoos is fraught with difficulty because there may not be a dilution that is dilute enough to avoid false-positive irritant reactions while still being concentrated enough to avoid false-negative reactions.
Following a positive patch-test result, finding shampoos that are free of the detected allergens can be problematic for patients owing to the widespread use of a number of common allergens in many shampoos. We sought to systematically evaluate the potentially allergenic ingredients currently used in shampoos that are widely available in the United States. This information should be helpful to clinicians who detect allergy to substances that may be shampoo ingredients by allowing them to better assess the likelihood of past, present, and future exposure to these allergens in shampoos.
for detailed article see:
http://www.medscape.com/viewarticle/706406_5
Matthew Zirwas; Jessica Moennich
Abstract
Shampoos are used almost universally in developed countries to wash the hair on a daily basis. A number of known contact allergens are used as ingredients in shampoos, and contact allergy due to shampoos is a well known entity. Patch testing can be used to identify ingredients to which patients are allergic, after which the physician can help the patient to find a shampoo that is free of the ingredients to which they are allergic. The ingredients used in shampoos have not been systematically reviewed in recent years in the United States. We use a database of products sold at a major drug store to quantify the most frequent allergens used in shampoos.
The allergens most commonly present, in order of prevalence are as follows: fragrance, cocamidopropyl betaine, ethylchloroisothiazolinone/methylisothiazolinone, formaldehyde releasers, propylene glycol, vitamin E, parabens, benzophenones, iodopropynyl butylcarbamate, and methyldibromoglutaronitrile/phenoxyethanol.
Introduction
Shampoo is the most commonly used product on the hair and scalp, and as a result, many different formulations are marketed on the basis of consumer-specific concerns such as hair manageability, problems associated with age and gender, and certain scalp problems such as dandruff and psoriasis. Shampoos are typically composed of 10 to 30 ingredients although products with as few as four ingredients are available, as are products with many more than 30 ingredients. Several types of ingredients are particularly important, including "surfactants" that aid in cleansing and lathering, "conditioners" and "active ingredients" that affect the hair and scalp, and "additives" that stabilize the product, add consumer appeal, and modify the effect of the surfactant.[1]
Although generally well tolerated, allergic contact dermatitis (ACD) due to ingredients in shampoo is a well-known entity.[2] ACD from shampoo can present as eyelid dermatitis, facial dermatitis, neck dermatitis, scalp dermatitis, dermatitis of the upper back, or dermatitis in more than one of these areas, often leading to difficulty in clinical diagnosis. Another confounding factor is that because of significant similarities in the ingredients of one shampoo to those of another, a patient who suspects shampoo allergy and thus changes products may change to another product that also contains the ingredient to which he or she is allergic and thus experience no improvement after the switch. This history often leads patients (and sometimes physicians) to erroneously assume that because the dermatitis did not improve following a change in shampoo, shampoo allergy is not the etiologic factor in the dermatitis.
Patch-testing for shampoo allergy can be challenging. Many of the relevant allergens are also irritants, which leads to possible false-positive results on patch testing.[3] Also, numerous allergens in shampoos are not included in current screening series, which makes it necessary to test with additional panels and to consider testing with the patient's own shampoo.[4] However, patch-testing directly with shampoos is fraught with difficulty because there may not be a dilution that is dilute enough to avoid false-positive irritant reactions while still being concentrated enough to avoid false-negative reactions.
Following a positive patch-test result, finding shampoos that are free of the detected allergens can be problematic for patients owing to the widespread use of a number of common allergens in many shampoos. We sought to systematically evaluate the potentially allergenic ingredients currently used in shampoos that are widely available in the United States. This information should be helpful to clinicians who detect allergy to substances that may be shampoo ingredients by allowing them to better assess the likelihood of past, present, and future exposure to these allergens in shampoos.
for detailed article see:
http://www.medscape.com/viewarticle/706406_5
Thursday, September 3, 2009
Adjuvant Hormonal Therapy for Breast Cancer May Affect Contralateral Breast Cancer Risk
From Medscape Medical News
Laurie Barclay, MD
September 1, 2009 — Long-term adjuvant hormonal therapy for breast cancer may affect the risk for contralateral estrogen receptor (ER)–positive or ER-negative tumors, according to the results of a population-based, nested case-control study reported in the August 25 online issue of Cancer Research.
"Compared with the breast cancer risk women in the general population have, breast cancer survivors have a substantially higher risk of developing a second primary contralateral breast cancer," write Christopher I. Li, MD, PhD, from the Fred Hutchinson Cancer Research Center in Seattle, Washington, and colleagues. "Adjuvant hormonal therapy reduces this risk, but preliminary data indicate that it may also increase risk of hormone receptor–negative contralateral tumors."
The study sample consisted of 367 women diagnosed with both first primary ER-positive invasive breast cancer and second primary contralateral breast cancer (case patients) and 728 matched women diagnosed only with a first breast cancer (control subjects). Telephone interviews and medical record review allowed collection of data on adjuvant hormonal therapy, other treatments, and breast cancer risk factors. Associations between adjuvant hormonal therapy and the risk for hormone receptor–specific subtypes of contralateral breast cancer were measured with two-sided statistical tests with use of conditional logistic regression.
Among case patients, 303 had ER-positive breast cancer and 52 had ER-negative breast cancer. Women who used adjuvant tamoxifen for at least 5 years had a lower risk for ER-positive contralateral breast cancer (odds ratio [OR], 0.4; 95% confidence interval [CI], 0.3 - 0.7) but a 4.4-fold (95% CI, 1.03 - 19.0) increased risk for ER-negative contralateral breast cancer vs women not treated with hormonal therapy. Tamoxifen use for less than 5 years did not appear to affect the risk for contralateral ER-negative breast cancer.
"Although adjuvant hormonal therapy has clear benefits, risk of the relatively uncommon outcome of ER-negative contralateral breast cancer may now need to be tallied among its risks," the study authors write. "This is of clinical concern given the poorer prognosis of ER– compared with ER+ tumors."
Limitations of the study include recall bias, possibly insufficient statistical power to determine a dose-response relationship for the relatively rare outcome of an ER-negative second primary contralateral tumor, relatively small sample size, and lack of generalizability to users of other types of hormonal therapy.
"The considerable benefits of adjuvant hormonal therapy for women with hormone receptor–positive breast cancer are clear as they confer substantially reduced risks of breast cancer recurrence, contralateral breast cancer, and mortality," the study authors conclude. "Nevertheless, risk of a hormone receptor–negative contralateral breast cancer may now need to be tallied among the risks of treatment with tamoxifen, and further studies are needed to determine if other hormonal therapies and the increasingly used aromatase inhibitors in particular, also carry this risk."
The National Cancer Institute supported this study. The study authors have disclosed no relevant financial relationships.
Cancer Res. Published online August 25, 2009. Abstract
Laurie Barclay, MD
September 1, 2009 — Long-term adjuvant hormonal therapy for breast cancer may affect the risk for contralateral estrogen receptor (ER)–positive or ER-negative tumors, according to the results of a population-based, nested case-control study reported in the August 25 online issue of Cancer Research.
"Compared with the breast cancer risk women in the general population have, breast cancer survivors have a substantially higher risk of developing a second primary contralateral breast cancer," write Christopher I. Li, MD, PhD, from the Fred Hutchinson Cancer Research Center in Seattle, Washington, and colleagues. "Adjuvant hormonal therapy reduces this risk, but preliminary data indicate that it may also increase risk of hormone receptor–negative contralateral tumors."
The study sample consisted of 367 women diagnosed with both first primary ER-positive invasive breast cancer and second primary contralateral breast cancer (case patients) and 728 matched women diagnosed only with a first breast cancer (control subjects). Telephone interviews and medical record review allowed collection of data on adjuvant hormonal therapy, other treatments, and breast cancer risk factors. Associations between adjuvant hormonal therapy and the risk for hormone receptor–specific subtypes of contralateral breast cancer were measured with two-sided statistical tests with use of conditional logistic regression.
Among case patients, 303 had ER-positive breast cancer and 52 had ER-negative breast cancer. Women who used adjuvant tamoxifen for at least 5 years had a lower risk for ER-positive contralateral breast cancer (odds ratio [OR], 0.4; 95% confidence interval [CI], 0.3 - 0.7) but a 4.4-fold (95% CI, 1.03 - 19.0) increased risk for ER-negative contralateral breast cancer vs women not treated with hormonal therapy. Tamoxifen use for less than 5 years did not appear to affect the risk for contralateral ER-negative breast cancer.
"Although adjuvant hormonal therapy has clear benefits, risk of the relatively uncommon outcome of ER-negative contralateral breast cancer may now need to be tallied among its risks," the study authors write. "This is of clinical concern given the poorer prognosis of ER– compared with ER+ tumors."
Limitations of the study include recall bias, possibly insufficient statistical power to determine a dose-response relationship for the relatively rare outcome of an ER-negative second primary contralateral tumor, relatively small sample size, and lack of generalizability to users of other types of hormonal therapy.
"The considerable benefits of adjuvant hormonal therapy for women with hormone receptor–positive breast cancer are clear as they confer substantially reduced risks of breast cancer recurrence, contralateral breast cancer, and mortality," the study authors conclude. "Nevertheless, risk of a hormone receptor–negative contralateral breast cancer may now need to be tallied among the risks of treatment with tamoxifen, and further studies are needed to determine if other hormonal therapies and the increasingly used aromatase inhibitors in particular, also carry this risk."
The National Cancer Institute supported this study. The study authors have disclosed no relevant financial relationships.
Cancer Res. Published online August 25, 2009. Abstract
Subscribe to:
Posts (Atom)
.jpg)
