What’s new in the other journals?
These snippets are exacts from a monthly service called the journal Article Summary Service (JASS). It is a service that summarises all that is new in obstetrics and gynaecology over the preceding month. If you would like to know the details of how to subscribe, please email the editor Athol Kent at email@example.com or visit the website http://www.jassonline.com.
The wealthy well
GPs often allude to patients seeking reassurance as the ‘worried well’. There is another group emerging in the UK dubbed the ‘wealthy well’ who present themselves for privateer screening sessions. For £152 punters can have a series of biophysical and biochemical tests run on themselves by a team of technicians in a local venue chosen for the screening extravaganza.
There is a delightful vignette by a retired neurologist who buys in to the process out of curiosity (Warlow BMJ 2009;338:1274). It describes the ECG, aortic aneurysm screen, carotid ultrasonography and other components carried out by a vascular screening company in a parish church. Although amusing it does raise issues of dealing with equivocal results or indeed abnormalities that then cost more money (state or privately funded) to resolve.
Screening is big business and its marketing is based on fear not necessity. The NHS runs established screening programmes and still fear-mongers thrive. Other countries are less lucky and their citizens more vulnerable (Spence BMJ 2009;338:1394).
Women in the UK do avail themselves of breast and cervical screening programmes with over 90% of eligible women participating in each programme (Moser et al. BMJ 2009;338:1480–4). Most – more than 80%– women have both tests and the researchers’ data showed that attendance for mammography is related to income and for cervical cytology to ethnicity. Only 3% of women report having neither test done.
Antiemetics in early pregnancy
Metoclopramide is the antiemetic of choice in early pregnancy in many European countries. In the US it is used in severe cases but it is not ‘labeled’ for treating gestational nausea and vomiting and there is surprisingly little evidence of it safety. To remedy the dearth of data concerning its use in the first trimester Matok et al. (NEJM 2009;360:2528–35) from Israel looked into its track record in over 80 000 pregnancies.
About 5% of those whose records were scrutinised used metoclopramide in the first 13 weeks of gestation but the children exposed had the same rate of congenital abnormalities as those not exposed; around 5%. The rates for perinatal mortality, premature delivery and low birth weight were also comparable. Although the study was observational it is likely that prescribed medications were fulfilled and taken so it appears that metoclopramide is safe to use in early pregnancy.
Thalidomide caused a drug debacle with many children being born with limb deformities after maternal ingestion during embryogenesis. Only now has the pathology it caused become unravelled. Therapontos et al. (Proc Natl Acad Sci USA 2009;106:8573–8) have shown in experimental animals that thalidomide inhibits angiogenesis in early gestation and the loss of immature blood vessels that should supply limbs leads to stunted growth from nutritional deprivation. This explanation, rather than through inflammatory or metabolic mechanisms, clarifies the specificity of thalidomide embryopathy and has significant implications for its therapeutic application.
Monitoring osteoporosis therapy
Treating osteoporotic postmenopausal women with bisphosphonates is effective therapy. It slows down bone resorption and reduces the risk of fractures in the vast majority of patients, but it is a long-term process and whatever antiresorptive medication is used, it needs to be persevered with for at least 5 years which is demanding. By committing to such adherence and cost it could be argued that monitoring the outcomes would be a good idea, but although bone mineral density and fracture risk do correspond, the question remains whether serial bone mineral density (BMD) measurements are useful.
Bone mineral density is measured by dual energy X-ray absorptiometry (DXA) which is used to diagnose osteoporosis but should it be used to monitor alendronate or other therapies? Compston (BMJ 2009;338:1511–3) says DXA is not precise enough to detect changes in BMD in less than 3 years so there is little point in annual measurements. She also says that BMD is a poor indicator of alteration in fracture risk which is the ultimate aim of therapy.
A study by Bell et al. (BMJ 2009;338:1553) on over 6000 women corroborates these data showing wide ranges of BMD changes on alendronate therapy which did not correlate with the fracture reduction which they found. They deem DXA unhelpful in monitoring bisphosphonate treatment of osteoporosis. Whether DXA monitoring will prove useful in assessing other forms of antiresorptive therapies is unproven but probably it will not.
Group B streptococcal screening
Group B streptococcal disease occurs commonly in infants during their first week of life. It is acquired by the neonate if the microorganism is a commensal of the mother’s genital tract and she has a vaginal delivery. Effective screening for Group B streptococcal status is readily available but it must be carried out prior to labour and the results must be available so treatment can be instituted before delivery. Medication is cheap and effective so the potential savings and scope for preventative medicine are considerable.
In the US there have been guidelines for screening for a decade and it is illuminating to follow the course of the disease as the universal screening has taken effect (Van Dyke et al. NEJM 2009;360:2626–36). The rates of screening have increased from 50% of women 10 years ago to over 85%. This detection together with almost 90% of those testing positive receiving antibiotic cover has resulted in meaningful reductions in affected infants. Fifteen years ago 1.7 per 1000 were infected compared to the latest figures of 0.3 per 1000.
One of the challenges remains the screening in preterm deliveries where the anticipation of delivery is not possible and where an infectious component triggering labour cannot be ruled out. Nevertheless this programme has demonstrated that ‘public health policy can be translated into action’ and all credit to the Americans for this significant advance in their perinatal care.
Prevention is better than cure
Prevention means just that. Preventing the condition – not detecting it early or in its treatable stages – but stopping it from occurring in the first place. This self-evident fact is confused with screening and normal aging. As those in the forefront of family planning we embrace preventative medicine but the ‘next big thing’ will be the prevention of obesity with its looming threat of the metabolic syndrome.
Type II diabetes prevalence is rising alarmingly, especially in Asian countries for example from 1% to 6% in China over the last 20 years so it seems personal pollution is going hand in hand with environmental pollution (JAMA 2009;301:2129–40).
Lest you think this is for youngsters only, a large study was carried out in a group of men and women over 65 years old that looked at exercise, healthy eating, smoking, alcohol and BMI. Those who had low risk factors were considerably less likely to develop Type II diabetes leading the authors to conclude ‘Overall 9 out of 10 new cases of diabetes appeared attributable to these five lifestyle factors’ (Mozaffarian et al. Arch Intern Med 2009;169:798–807).
Check diet, exercise and other habits but don’t forget to laugh. Laughter decreases pulse wave velocity which is an index of arterial stiffness (Psycho-somatic Med 2009; 71:446–53). So hold it lightly – or else!
Women and alcohol
Little is known about the effects of alcohol intake and cancer in women. Only in breast cancer are there accurate data on alcohol consumption and the incidence of malignancy. This dearth of information is remedied in an article exploring the relationship between drinking and malign disease in UK women (J Nat Can Inst 2009;101:296–305).
Tapping into the Million Women Study the authors produced the following facts. Seventy-five percent of the respondents reported drinking alcohol with 98% of women consuming <3 drinks per day, the average being one drink per day.
Increasing intake was associated with increasing risks of some cancers, namely breast, oral cavity and pharynx, rectum, oesophagus, larynx and liver. Other types of cancer did not have increased incidences with increasing alcohol intake. Overall, in women up to the age of 75 years, moderate alcohol intake gives a total of 1.5% excess malignancies compared with nondrinkers.
Quitting smoking in pregnancy
Smoking in pregnancy is associated with increased rates of preterm birth, small for gestational age babies and other complications. Many women quit smoking when they discover they are pregnant, possibly because they know the harm it can cause their child, possibly because of bonding with their fetus or possibly in response to peer or health-provider pressure.
There are numerous advantages to booking by 10 weeks gestation and the opportunity of being motivated to cease smoking is one of them. McCowen et al. (BMJ 2009;338:1552) from New Zealand observed the outcomes of pregnancies where women never smoked, quit smoking prior to 15 weeks gestation or continued smoking. Almost 80% of the study group were nonsmokers, 10% stopped by 15 weeks and 10% kept smoking. Those quitting had the same outcomes of preterm births (4%) and small for gestational age infants (10%) as never smokers whereas the same figures for those continuing to smoke were 10% and 17% respectively.
Unsurprisingly those who continued to smoke were heavier smokers, younger, less well educated, had higher unemployment levels and used alcohol more than the never-smokers or quitters. How one wins trust, educates and changes behaviour, literally across generations, remains the challenge.
US sex education policy
Many have been critical of the US Federal Government’s stand on sex education for teenagers. Under the previous administration the only funded programmes were abstinence-only instruction with purity covenants and virginity pledges as part of the package. Despite congressional commissions concluding that these policies did not work, $1.3 billion was squandered on them between 2001 and 2008 (Tanne, BMJ 2009;338:1232).
The Obama team budget has reversed the legislation and provided extra funds for evidence-based instruction promoting abstinence while providing medically accurate, age-appropriate information to young people who are sexually active.
Preaching abstinence before marriage clearly has not worked in the US which still has – by far – the highest teenage pregnancy rate of any developed country. In addition the latest statistics show that 40% of women giving birth are unmarried – more than double the figure in 1980 (http://www.cdc.gov/nchs/data/databriefs/db18.pdf).