The European Cerebral Palsy Study Group looked at the correlation of MRI findings and clinical outcomes. MRI scans plus detailed clinical assessments were carried out on over 400 children from the age of 2 years on and it was found that the scans could provide information about the timing and extent of their lesions (Bax et al JAMA 2006;296:1602-8).
The commonest finding was that of white matter damage of immaturity with nearly 90% of the subjects having defined structural abnormalities which would allow clear prognoses to be made. The authors strongly advocate MRI scan for all children with CP.
The possibility of obstetric mishaps being the cause of CP in their study group was small which is in keeping with all similar studies. The most frequent cause was infection which obstetrically is associated with preterm labour and placental damage. When this leads to preterm delivery, the hypoxic insult can result in white matter damage. This mechanism is also thought to account for the cortical damage of those born at term with CP, the infection being either clinical or sub-clinical at an early stage of the pregnancy. Multiple pregnancies are an at-risk group accounting at least 10%, with the same numbers attributable to cerebral malformations and genetic or metabolic disorders.
Only 20% of those born after 34 weeks gestation could be considered to have CP on the basis of an intrapartum mishap. Such mishaps are unlikely to be the result of obstetric mismanagement and the proportion amenable to intervention low. The authors agree with previous findings that asphyxiated encephalopathic infants are not necessarily the result of labour malpractice or lack of vigilance in pregnancy. They suggest the treatment of infections in pregnancy, the reduction in assisted reproduction twin pregnancies and the better, earlier diagnoses of CP are the preventative measures that will reduce the burden of CP. See also the editorial by Msall (pp 1650-2).
22 December, 2006
18 December, 2006
Cord blood collection
Should cord blood be collected for the future benefit of the child? The current debate about stem cell research has focused attention on cord blood and commercial firms are cashing in by offering to collect and store cord blood for future purposes.
Companies are advertising collection as a biological insurance whereby the blood is kept for possible transfusion if the child develops leukaemia or some metabolic disease. Claims, which are presently speculative, suggest that future medical advances will use the blood to cure diseases such as diabetes, breast cancer, ovarian and testicular cancer, melanoma, rheumatoid arthritis or for the regeneration of damaged heart valves. More accurate predictions would be that better treatments for childhood leukaemias will be found that do not require autologous cells. In any event, donor cord blood can be used.
The scientific arguments are in fact pseudoscience in that they talk about future “yet to be discovered” developments. Maybe there will be inventions that will need the patient's own cord blood, but research will be extremely difficult as trials testing “own versus other” blood will be a recruiting nightmare. At present, the likelihood of stored blood being used is very low - quoted at between 1 in 1 400 and 1 in 20 000 (Edozien BMJ 2006;333:801-4).
The Royal College of O&G says storage cannot be recommended because of insufficient scientific evidence and logistic problems. The American and Canadian Colleges are also critical of the process, as are midwifery, paediatric and ethical bodies. There are also medico-legal issues, like whose responsibility is it to take the blood, ensure it is free of contamination, correctly consent its collection, labelling, storage and testing for viral and other dangers? To whom does the blood belong - mother or child? Does the collection process take priority over other labour ward procedures?
It is clear that it cannot be a routine practice, but should those with sufficient resources be advised to pay for it? Parents-to-be want the best for their unborn child and can be considered vulnerable to promotion of this “just in case” philosophy. Yes, personal cord blood may be useful in future situations but at present it is more likely that other measures will overtake autologous transfusions. Medical science says “no” right now but there are other sciences and other beliefs, so it is up to individuals to decide whether recommending cord collection is medical paternalism or sound advice.
Companies are advertising collection as a biological insurance whereby the blood is kept for possible transfusion if the child develops leukaemia or some metabolic disease. Claims, which are presently speculative, suggest that future medical advances will use the blood to cure diseases such as diabetes, breast cancer, ovarian and testicular cancer, melanoma, rheumatoid arthritis or for the regeneration of damaged heart valves. More accurate predictions would be that better treatments for childhood leukaemias will be found that do not require autologous cells. In any event, donor cord blood can be used.
The scientific arguments are in fact pseudoscience in that they talk about future “yet to be discovered” developments. Maybe there will be inventions that will need the patient's own cord blood, but research will be extremely difficult as trials testing “own versus other” blood will be a recruiting nightmare. At present, the likelihood of stored blood being used is very low - quoted at between 1 in 1 400 and 1 in 20 000 (Edozien BMJ 2006;333:801-4).
The Royal College of O&G says storage cannot be recommended because of insufficient scientific evidence and logistic problems. The American and Canadian Colleges are also critical of the process, as are midwifery, paediatric and ethical bodies. There are also medico-legal issues, like whose responsibility is it to take the blood, ensure it is free of contamination, correctly consent its collection, labelling, storage and testing for viral and other dangers? To whom does the blood belong - mother or child? Does the collection process take priority over other labour ward procedures?
It is clear that it cannot be a routine practice, but should those with sufficient resources be advised to pay for it? Parents-to-be want the best for their unborn child and can be considered vulnerable to promotion of this “just in case” philosophy. Yes, personal cord blood may be useful in future situations but at present it is more likely that other measures will overtake autologous transfusions. Medical science says “no” right now but there are other sciences and other beliefs, so it is up to individuals to decide whether recommending cord collection is medical paternalism or sound advice.
06 December, 2006
Magnesium sulphate and eclampsia
Magnesium sulphate is given intravenously to prevent initial or subsequent eclamptic fits in peripartum women. Its efficacy in fit prophylaxis is unquestioned but when it should be commenced and stopped are challenging questions. Two American surveys help in the decision making process in high-risk hypertensive patients.
Alexander et al from Texas (Obstet Gynecol 2006;826-32) reviewed their unit's records when changing from an intramuscular to an intravenous regime and at the same time from treating all hypertensive women to treating only those qualifying for treatment according to strict criteria which would label them as severe preeclamptics. The criteria used were
* BP of 140/90 in a previously normotensive woman
* proteinuria of 2+ or greater on a catheter specimen
* serum creatinine more than 1.2mg/dl or platelets less than 100 000/ml
* aspartate transaminase of double the upper limit of normal
* persistent headache or visual disturbances
* persistent epigastric or right upper-quadrant pain.
As expected, the selective rather than broad spectrum use of magnesium resulted in more eclamptic fits but the numbers needed to treat and the side effects of magnesium therapy make an optimal policy difficult to set. If the net is too fine, it cannot be dragged through the water, and the authors speak of an “irreducible minimum” of unpreventable cases.
A second study from Ohio looked at the duration of magnesium treatment postpartum in mild preeclamptics. Ehrenberg & Mercer (pp833-8) randomly allocated women receiving prophylactic magnesium sulphate but who did not have severe disease, to have 12 or 24 hours of postpartum treatment. Women whose condition deteriorated after being selected to one or other arm of the trial were immediately excluded. Incidentally they found that chronic hypertensive and insulin-dependent diabetics were the most at-risk groups for such deterioration.
Of those not showing progressive disease, it seemed that 12 hours of treatment was sufficient and that carrying on the magnesium for a total of 24 hours had no advantage. Of course, lesser duration of treatment means fewer intensive nursing hours, less chance of side-effects and less maternal mobility, so this article provides useful practical information.
Alexander et al from Texas (Obstet Gynecol 2006;826-32) reviewed their unit's records when changing from an intramuscular to an intravenous regime and at the same time from treating all hypertensive women to treating only those qualifying for treatment according to strict criteria which would label them as severe preeclamptics. The criteria used were
* BP of 140/90 in a previously normotensive woman
* proteinuria of 2+ or greater on a catheter specimen
* serum creatinine more than 1.2mg/dl or platelets less than 100 000/ml
* aspartate transaminase of double the upper limit of normal
* persistent headache or visual disturbances
* persistent epigastric or right upper-quadrant pain.
As expected, the selective rather than broad spectrum use of magnesium resulted in more eclamptic fits but the numbers needed to treat and the side effects of magnesium therapy make an optimal policy difficult to set. If the net is too fine, it cannot be dragged through the water, and the authors speak of an “irreducible minimum” of unpreventable cases.
A second study from Ohio looked at the duration of magnesium treatment postpartum in mild preeclamptics. Ehrenberg & Mercer (pp833-8) randomly allocated women receiving prophylactic magnesium sulphate but who did not have severe disease, to have 12 or 24 hours of postpartum treatment. Women whose condition deteriorated after being selected to one or other arm of the trial were immediately excluded. Incidentally they found that chronic hypertensive and insulin-dependent diabetics were the most at-risk groups for such deterioration.
Of those not showing progressive disease, it seemed that 12 hours of treatment was sufficient and that carrying on the magnesium for a total of 24 hours had no advantage. Of course, lesser duration of treatment means fewer intensive nursing hours, less chance of side-effects and less maternal mobility, so this article provides useful practical information.
New JASS out
This month we have a focus on American health.If you are wondering about JASS' highlighting of American reproductive health, then reflect on the fact that the US spends more on health than the GNP of most developing countries. Their pharma behemoths dictate where drug research spending is directed - on which much of the rest of the world depends. Their administration's stance on drugs is vital - especially in women's health, but let's hope their moral lead is not one we all have to follow.
Our own government's policies on contraception, abortion, HIV, violence against women and obesity are all issues that directly affect our practice. We seem less and less able to influence political dictates which is leading to frustration and lowered morale.
It is good that the journals are speaking out for the profession rather than siding with our political masters.
There are practical summaries too. What to do about cord blood collection, acute uterine bleeding in gynaecology and postpartum, as well as facts to support our patients who wish to eat fish - and stay slim!
Our own government's policies on contraception, abortion, HIV, violence against women and obesity are all issues that directly affect our practice. We seem less and less able to influence political dictates which is leading to frustration and lowered morale.
It is good that the journals are speaking out for the profession rather than siding with our political masters.
There are practical summaries too. What to do about cord blood collection, acute uterine bleeding in gynaecology and postpartum, as well as facts to support our patients who wish to eat fish - and stay slim!
05 December, 2006
03 November, 2006
October JASS is out
A snippet from the just released October JASS:
Tea and olive oil
Tea is made from the leaves of the Camellia sinensis plant. There are basically three kinds of tea - green, oolong and black tea - three billion kilograms of which are consumed each year which makes tea the most popular beverage in the world.
Green tea contains polyphenols which have a theoretical role in the prevention of cardiovascular disease, but it is unclear if this has any effect on tea drinkers in the real world. To test the effects, Kuriyama et al (JAMA 2006;296:1255-65) followed 40 000 Japanese adults for a decade and related their mortality rates from cardiovascular disease to their tea consumption.
They found the more green tea people drank, the lower their risk of dying from cardiovascular disease. There was a “dose-related” response and the effect was more marked in women. The strongest association was with a decrease in stroke mortality. There was no link with cancer mortality.
And while on the subject of polyphenols, it appears that virgin olive oil is better than refined olive oil when it comes to raising your high-density lipoproteins and decreasing your oxidative stress markers. Covacs et al (Ann Int Med 2006;145:333-41) showed that taking an unrefined olive oil supplement as opposed to a refined olive oil one, positively affected serum markers of good cardio-vascular health. These effects were in addition to olive oil being a monounsaturated fat, so it seems the Mediterranean diet using virgin olive oil is underpinned by solid science.
Tea and olive oil
Tea is made from the leaves of the Camellia sinensis plant. There are basically three kinds of tea - green, oolong and black tea - three billion kilograms of which are consumed each year which makes tea the most popular beverage in the world.
Green tea contains polyphenols which have a theoretical role in the prevention of cardiovascular disease, but it is unclear if this has any effect on tea drinkers in the real world. To test the effects, Kuriyama et al (JAMA 2006;296:1255-65) followed 40 000 Japanese adults for a decade and related their mortality rates from cardiovascular disease to their tea consumption.
They found the more green tea people drank, the lower their risk of dying from cardiovascular disease. There was a “dose-related” response and the effect was more marked in women. The strongest association was with a decrease in stroke mortality. There was no link with cancer mortality.
And while on the subject of polyphenols, it appears that virgin olive oil is better than refined olive oil when it comes to raising your high-density lipoproteins and decreasing your oxidative stress markers. Covacs et al (Ann Int Med 2006;145:333-41) showed that taking an unrefined olive oil supplement as opposed to a refined olive oil one, positively affected serum markers of good cardio-vascular health. These effects were in addition to olive oil being a monounsaturated fat, so it seems the Mediterranean diet using virgin olive oil is underpinned by solid science.
13 October, 2006
Spelling
Putting JASS online has made us acutely aware of trans-atlantic spelling issues. The most important of these is 'gynaecology' (the UK spelling obviously) and 'gynecology' (the American spelling). Both are of course, correct. For instance, articles from AJOG will use the 'gynecology' spelling, and BMJ, we'll use 'gynaecology'. We have been using 'gynaecology' , but are considering adding the American spelling when used by the journal article being summarized.
03 October, 2006
Wound closure
There is little hard evidence as to which is the best way to close the subcutaneous layer of incisions. With the increasing prevalence of obesity, the question of what to do when the fat layer is 3cm or more will be asked more frequently.
Cardosi et al from Florida (AJOG 2006;195:607-16) randomly allocated obese patients to three ways of dealing with the subcutaneous layer following vertical midline incisions for gynaecological procedures. The three methods were suturing the layer closed with an absorbable stitch, no stitching but placing a suction drain in situ, or no intervention.
All incisions had staples for skin closure that were left in place for at least 7 days. All patients received pre-operative antibiotic prophylaxis and the wounds were diligently observed in hospital and at 2 and 6 weeks post-operatively.
In the over 200 patients in the trial, the method of closure made no difference in terms of disruption, cellulitis, seroma or haematoma formation or abscess occurrence. It seems subcutaneous technique is irrelevant in these circumstances, so preference and resources can dictate practice.
Cardosi et al from Florida (AJOG 2006;195:607-16) randomly allocated obese patients to three ways of dealing with the subcutaneous layer following vertical midline incisions for gynaecological procedures. The three methods were suturing the layer closed with an absorbable stitch, no stitching but placing a suction drain in situ, or no intervention.
All incisions had staples for skin closure that were left in place for at least 7 days. All patients received pre-operative antibiotic prophylaxis and the wounds were diligently observed in hospital and at 2 and 6 weeks post-operatively.
In the over 200 patients in the trial, the method of closure made no difference in terms of disruption, cellulitis, seroma or haematoma formation or abscess occurrence. It seems subcutaneous technique is irrelevant in these circumstances, so preference and resources can dictate practice.
19 September, 2006
Tailpiece
More and more women of childbearing age are sporting lumbar tattoos. Irrespective of your attitude to the practice, does this preclude her from having an epidural in labour?
Kuczkowski from California, where a fifth of the population have some “epidermal enhancement” believe a lumbar tattoo is not a contraindication to neuraxial analgesia (Arch Gynecol Obstet 2006;274:310-2). It is suggested that pigmented areas are best avoided and Touhy needles used routinely to circumvent possible tattoo puncture-related complications.
Kuczkowski from California, where a fifth of the population have some “epidermal enhancement” believe a lumbar tattoo is not a contraindication to neuraxial analgesia (Arch Gynecol Obstet 2006;274:310-2). It is suggested that pigmented areas are best avoided and Touhy needles used routinely to circumvent possible tattoo puncture-related complications.
Tamoxifen and infertility
Tamoxifen citrate is sometimes used empirically in the treatment of unexplained infertility. The rationale for using an anti-oestrogen is unclear but rebound endogenous ovarian stimulation has been suggested, unencumbered by scientific proof.
Now a study by Shokeir (Arch Gynecol Obstet 2006;274:279-83) shows that tamoxifen has no benefit in improving pregnancy rates in infertile women. In fact, there was a statistically significant decrease in conception rates in those taking tamoxifen compared to placebo. This effect may have been mediated by altered cervical mucus or endometrial suppression - either way tamoxifen for infertility is bad news.
Now a study by Shokeir (Arch Gynecol Obstet 2006;274:279-83) shows that tamoxifen has no benefit in improving pregnancy rates in infertile women. In fact, there was a statistically significant decrease in conception rates in those taking tamoxifen compared to placebo. This effect may have been mediated by altered cervical mucus or endometrial suppression - either way tamoxifen for infertility is bad news.
The Journals in August
The articles pouring out of the American journals are impressive. There seems a flood of data on lifestyle, diet, exercise and smoking. There is also a serious self-examination of their public health needs and their ability to provide these.
There is a strong tension between the medical profession, the legislation and big pharma. There seems no resolution in sight. The UK NHS is also being seriously re-examined, with private care being more and more debated as a “partner” in providing the needs of its citizens, while the medical governing bodies are realigning themselves.
JASS tries to keep out of politics but doesn't always manage to do so!
One point about the hormonal replacement trials. The differences that are being uncovered are exceedingly small. The RUTH trial summarised this month confirms this. We are talking in points of one percent differences in outcomes. What concerns me is the lack of data from women starting HRT at their menopause and then continuing - not women aged 68 on a trial. And what about quality of life measures? I know the problems of global scores, but that is what it's all about in the end.
Please visit www.jassonline.com for information about JASS for GPs or tell your Family Physician friends about it.
There is a strong tension between the medical profession, the legislation and big pharma. There seems no resolution in sight. The UK NHS is also being seriously re-examined, with private care being more and more debated as a “partner” in providing the needs of its citizens, while the medical governing bodies are realigning themselves.
JASS tries to keep out of politics but doesn't always manage to do so!
One point about the hormonal replacement trials. The differences that are being uncovered are exceedingly small. The RUTH trial summarised this month confirms this. We are talking in points of one percent differences in outcomes. What concerns me is the lack of data from women starting HRT at their menopause and then continuing - not women aged 68 on a trial. And what about quality of life measures? I know the problems of global scores, but that is what it's all about in the end.
Please visit www.jassonline.com for information about JASS for GPs or tell your Family Physician friends about it.
02 August, 2006
In silico ?
For those at the cutting edge of computers and parturition, there is a gem of an article by Errol Norwitz from Yale (AJOG 2006;194:1510-2). It is about how computers can extract patterns from data fed into them and recognise sequences that are too complex to be picked up by standard computer programmes or our brains. This artificial intelligence resembles human intelligence but can hold and connect more variables simultaneously than can our innate software.
The multi-factorial initiation of labour may yield to such scrutiny and the unravelling may have already begun. These sophisticated programmes make in silico redictions - a term Norwitz uses to describe the complex solutions the computers come up with, as compared to in vitro or in vivo evidence. Presumably in silico will take its place in our new lexicon, so drop it into a ward round casually to impress non JASS readers.
For those needing to be conversant with the modern views of the onset of labour, this editorial is highly recommended.
The multi-factorial initiation of labour may yield to such scrutiny and the unravelling may have already begun. These sophisticated programmes make in silico redictions - a term Norwitz uses to describe the complex solutions the computers come up with, as compared to in vitro or in vivo evidence. Presumably in silico will take its place in our new lexicon, so drop it into a ward round casually to impress non JASS readers.
For those needing to be conversant with the modern views of the onset of labour, this editorial is highly recommended.
27 July, 2006
JASS expanding
We are pleased to report that JASS continues to grow in circulation. We are also expanding the range of JASS with introduction of JASS for GPs. JASS for General Practitioners is aimed at GPs and physicians who are not O&G specialists. JASS for GPs is now available for subscription on the website.
JASS for Nurses will be coming soon! In addition, we also plan to offer podcasts with discussion of the latest from the journals. Imagine being able to listen to the most-to-date research anywhere you like - quite a thought.
JASS for Nurses will be coming soon! In addition, we also plan to offer podcasts with discussion of the latest from the journals. Imagine being able to listen to the most-to-date research anywhere you like - quite a thought.
07 July, 2006
Clotting and flying
Much debate has arisen around a link between flying and thrombosis. Long-haul flights do expose us to prolonged periods of relative hypoxia at low pressure, combined with inactivity, but does the combination make thrombosis more likely – even if we have no risk factors?
It seems not. Toff et al (JAMA 2006;295:2251-61) simulated an 8-hour flight by placing volunteers in an oxygen chamber set to commercial aircraft conditions, then at ground settings and checked their clothing factors. It appears that lowering the environment to hyperbaric and hypoxia flight levels makes little difference to laboratory testable thrombosis propensity. If you are a Factor V Leiden positive or taking oral contraceptives, then take extra precautions, otherwise keep well hydrated, flex and extend your ankles and knees and walk around the cabin as often as you can.
It seems not. Toff et al (JAMA 2006;295:2251-61) simulated an 8-hour flight by placing volunteers in an oxygen chamber set to commercial aircraft conditions, then at ground settings and checked their clothing factors. It appears that lowering the environment to hyperbaric and hypoxia flight levels makes little difference to laboratory testable thrombosis propensity. If you are a Factor V Leiden positive or taking oral contraceptives, then take extra precautions, otherwise keep well hydrated, flex and extend your ankles and knees and walk around the cabin as often as you can.
28 June, 2006
Gross statistics
In the last quarter of a century the prevalence of obesity in the United States has doubled. Officially one third of the US population is now obese being defined as having a Body Mass Index of greater than 30.
7% are morbidly obese with a BMI above 40. There seems little likelihood of the figures growing smaller in the immediate future as 17% of adolescents are overweight – a significant increase over the last 5 years (Ogden et al JAMA 2006;295:1549-55).
7% are morbidly obese with a BMI above 40. There seems little likelihood of the figures growing smaller in the immediate future as 17% of adolescents are overweight – a significant increase over the last 5 years (Ogden et al JAMA 2006;295:1549-55).
Over-assisted reproduction?
2% of babies born in Europe are the result of assisted reproduction. This has helped countries of the European Union raise their birth rates but these are still nowhere near population replacement levels (Int J Andr 2006;29:12-6).
Surely one of the most bizarre stories about assisted reproduction must be that of Mrs Z from Russia, reported by the appropriately named Mr Leidig in the BMJ (2006;332:627). She is a 55-year old headmistress whose son was dying of cancer, so she persuaded doctors to freeze some of his semen before treatment was started. This was done and two years after his eventual demise she requested his sperm be used to fertilise a donor egg and be implanted into a surrogate mother.
The child, Mrs Z’s grandson, was born alive and well but the Russian authorities say she is too old to adopt him. The situation is further complicated by the fact that the sperm donor died two years ago and cannot be legally registered as the father. Since the oocyte was donated, the baby doesn’t have a mother either, and since he has no parents he does not officially exist. The Registry Office wants to take him away from Mrs Z and place him in an orphanage. The case is going to court.
Surely one of the most bizarre stories about assisted reproduction must be that of Mrs Z from Russia, reported by the appropriately named Mr Leidig in the BMJ (2006;332:627). She is a 55-year old headmistress whose son was dying of cancer, so she persuaded doctors to freeze some of his semen before treatment was started. This was done and two years after his eventual demise she requested his sperm be used to fertilise a donor egg and be implanted into a surrogate mother.
The child, Mrs Z’s grandson, was born alive and well but the Russian authorities say she is too old to adopt him. The situation is further complicated by the fact that the sperm donor died two years ago and cannot be legally registered as the father. Since the oocyte was donated, the baby doesn’t have a mother either, and since he has no parents he does not officially exist. The Registry Office wants to take him away from Mrs Z and place him in an orphanage. The case is going to court.
25 June, 2006
24 June, 2006
UK statistics on O&G popularity
In the UK the popularity of our speciality is falling fast. Ten years ago 5% of all graduates wanted to specialise in O&G but this dropped to 3% in 2002 and is now estimated at 2%. This is way below the numbers required to maintain staffing levels, especially with consultants becoming increasingly required on labour wards.
Long hours and the exercising of “patients’ rights” in declining students’ presence are noted by the Royal College as disincentives to choosing O&G. Foreign doctors are being looked to as numbers dwindle (Brettingham BMJ 2006;332:323).
Long hours and the exercising of “patients’ rights” in declining students’ presence are noted by the Royal College as disincentives to choosing O&G. Foreign doctors are being looked to as numbers dwindle (Brettingham BMJ 2006;332:323).
Herbs for menopausal symptoms
Most herbal remedies for menopausal symptoms give under-whelming results – in fact, most research shows they are no better than placebo. There is always a placebo effect in these trials so any claims at improvements must show a reduction in symptoms well below possible “suggestion or Hawthorne” effects.
At last one such study has appeared (Uebelhack et al Obstet Gynecol 2006;107:247-55) from Germany using black cohosh plus St John’s wort. Black cohosh extract in the dosage of 1mg triterpene glycoside, the active ingredient, is said to relieve symptoms of hot flushes, night sweats and sleep disturbances without exerting oestrogenic effects. St John’s wort has proved effective in the treatment of depression and mood disorders at a dose of 0.25 mg hypericine, so the combination of the two herbs was tested against placebo in the hope of relieving menopausal physiological and psychological symptoms without the side effects of oestrogens or selective serotonin reuptake inhibitors.
Over a 16 week trial period, the women’s menopause rating scores were reduced by 50% in the active ingredient group and by 20% in the placebo group. In the depression rating scale treatment resulted in a 40% reduction in symptoms with a 12% placebo effect. The authors claim the relatively low placebo effect was due to a single investigator being employed who did not accentuate the psychotherapeutic approach.
The side effects were minimal and it appears that the combination of a fixed dose of black cohosh and St John’s wort has a place in the management of climacteric complaints with a pronounced psychological component.
At last one such study has appeared (Uebelhack et al Obstet Gynecol 2006;107:247-55) from Germany using black cohosh plus St John’s wort. Black cohosh extract in the dosage of 1mg triterpene glycoside, the active ingredient, is said to relieve symptoms of hot flushes, night sweats and sleep disturbances without exerting oestrogenic effects. St John’s wort has proved effective in the treatment of depression and mood disorders at a dose of 0.25 mg hypericine, so the combination of the two herbs was tested against placebo in the hope of relieving menopausal physiological and psychological symptoms without the side effects of oestrogens or selective serotonin reuptake inhibitors.
Over a 16 week trial period, the women’s menopause rating scores were reduced by 50% in the active ingredient group and by 20% in the placebo group. In the depression rating scale treatment resulted in a 40% reduction in symptoms with a 12% placebo effect. The authors claim the relatively low placebo effect was due to a single investigator being employed who did not accentuate the psychotherapeutic approach.
The side effects were minimal and it appears that the combination of a fixed dose of black cohosh and St John’s wort has a place in the management of climacteric complaints with a pronounced psychological component.
Fibroid embolisation outcomes
The long-term outcomes of fibroid embolisation look promising. The FIBROID Registry in the US is a voluntary multi-centre database that chronicles the results of fibroid embolisation. There are records of over 2000 women and they have a unique symptom score method which allows quality-of-life measurements to be made and compared prospectively.
The results are available for the first year after embolisation and 95% of patients had significantly improved symptoms and quality-of-life scores. Only 3% underwent hysterectomy within a year of treatment. The results are remarkable with the best outcomes being achieved when the fibroids were small, submucosal and presented with heavy menstrual loss (Spies et al Obstets Gynecol 2005;106:1309-18).
The results are available for the first year after embolisation and 95% of patients had significantly improved symptoms and quality-of-life scores. Only 3% underwent hysterectomy within a year of treatment. The results are remarkable with the best outcomes being achieved when the fibroids were small, submucosal and presented with heavy menstrual loss (Spies et al Obstets Gynecol 2005;106:1309-18).
Ultimate sex discrimination
There are more boys than girls born in India. The discrepancy is becoming more marked with every census, and is greater in urban than rural areas and amongst higher socio-economic groups. It is not a natural process as there are more male than female stillbirths and infant mortality ratios are equal.
The situation is even more apparent in households where the first-born is a girl – the next child is much more likely to be a boy – rather than another girl. In other words, the sex of the existing child or children affects the sex of the next born.
Jha et al (Lancet 2006;367:211-8) traced these trends by conducting interviews in over one million households. They postulate that prenatal sex testing with abortion of female fetuses is the most likely explanation which fits with India’s common ideology. Although illegal and officially condemned (Sheth pp 135-6) the practice of ultrasonic or amniocentesis sex determination is widespread and it is calculated that in that country alone 10 million female fetuses have been aborted in the last two decades. China is also suspected of having a similarly discriminatory attitude, and the world figure of “missing presumed dead” female babies is estimated at 100 million.
The situation is even more apparent in households where the first-born is a girl – the next child is much more likely to be a boy – rather than another girl. In other words, the sex of the existing child or children affects the sex of the next born.
Jha et al (Lancet 2006;367:211-8) traced these trends by conducting interviews in over one million households. They postulate that prenatal sex testing with abortion of female fetuses is the most likely explanation which fits with India’s common ideology. Although illegal and officially condemned (Sheth pp 135-6) the practice of ultrasonic or amniocentesis sex determination is widespread and it is calculated that in that country alone 10 million female fetuses have been aborted in the last two decades. China is also suspected of having a similarly discriminatory attitude, and the world figure of “missing presumed dead” female babies is estimated at 100 million.
Oestrogens only and breast cancer
Part of the Women’s Health Initiative study of hormonal replacement therapy in the late 1990s included a group of hysterectomised women who received oestrogen alone. Over 10 000 post-menopausal women were randomised to 0.625mg of conjugated equine oestrogen (CEE) daily or placebo over a period of seven years before the trial was stopped because of an increase in stroke incidence without cardiovascular benefit.
14 June, 2006
Some interesting links
This is an interesting link of a journal-club search.
The Public Library of Science has an open-access medical journal.
The Cochrane Centre for evidence-based medicine
Center for Evidence-based medicine at Oxford.
The Public Library of Science has an open-access medical journal.
The Cochrane Centre for evidence-based medicine
Center for Evidence-based medicine at Oxford.
06 June, 2006
Welcome
Welcome to the JASS blog. This is where the editor-in-chief of the Journal Article Summary Service will be recording his thoughts on state of the art in obstetrics and gynaecology research. Posts will include opinion on the latest research and practice, as well as what is happening in the leading journals.
Your feedback is always welcome.
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